2013 Maryland Code
INSURANCE
§ 31-101 - Definitions [Effective January 1, 2014].


MD Ins Code § 31-101 (2013) What's This?

§31-101.

(a) In this title the following words have the meanings indicated.

(b) “Board” means the Board of Trustees of the Exchange.

(c) “Carrier” means:

(1) an insurer authorized to sell health insurance;

(2) a nonprofit health service plan;

(3) a health maintenance organization;

(4) a dental plan organization; or

(5) any other entity providing a plan of health insurance, health benefits, or health services authorized under this article or the Affordable Care Act.

(d) “Coverage level” means a level of coverage, as defined in § 1302 of the Affordable Care Act and as determined in regulations adopted by the Secretary, for a qualified health plan.

(e) (1) “Exchange” means the Maryland Health Benefit Exchange established as a public corporation under § 31-102 of this title.

(2) “Exchange” includes:

(i) the Individual Exchange; and

(ii) the Small Business Health Options Program (SHOP Exchange).

(f) “Fund” means the Maryland Health Benefit Exchange Fund established under § 31-107 of this subtitle.

(g) (1) “Health benefit plan” means a policy, contract, certificate, or agreement offered, issued, or delivered by a carrier to an individual or small employer in the State to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

(2) “Health benefit plan” does not include:

(i) coverage only for accident or disability insurance or any combination of accident and disability insurance;

(ii) coverage issued as a supplement to liability insurance;

(iii) liability insurance, including general liability insurance and automobile liability insurance;

(iv) workers’ compensation or similar insurance;

(v) automobile medical payment insurance;

(vi) credit-only insurance;

(vii) coverage for on-site medical clinics; or

(viii) other similar insurance coverage, specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act, under which benefits for health care services are secondary or incidental to other insurance benefits.

(3) “Health benefit plan” does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the plan:

(i) limited scope dental or vision benefits;

(ii) benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; or

(iii) such other similar limited benefits as are specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act.

(4) “Health benefit plan” does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether the benefits are provided under any group health plan maintained by the same plan sponsor:

(i) coverage only for a specified disease or illness; or

(ii) hospital indemnity or other fixed indemnity insurance.

(5) “Health benefit plan” does not include the following if offered as a separate policy, certificate, or contract of insurance:

(i) Medicare supplemental insurance (as defined under § 1882(g)(1) of the Social Security Act);

(ii) coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)); or

(iii) similar supplemental coverage provided to coverage under a group health plan.

(h) “Individual Exchange” means the division of the Exchange that serves the individual health insurance market.

(i) “Individual Exchange navigator” means an individual who:

(1) holds an Individual Exchange navigator certification; and

(2) provides the services described in § 31-113(d)(1) of this title for an Individual Exchange navigator entity.

(j) “Individual Exchange navigator certification” means a certificate issued by the Individual Exchange that authorizes an individual to act as an Individual Exchange navigator.

(k) “Individual Exchange navigator entity” means a community-based organization or other entity or a partnership of entities that:

(1) is authorized by the Individual Exchange under § 31-113(f) of this title; and

(2) employs or engages Individual Exchange navigators to provide the services described in § 31-113(d)(1) of this title.

(l) “Individual Exchange navigator entity authorization” means a grant of authority from the Individual Exchange to an Individual Exchange navigator entity under § 31-113(f) of this title.

(m) “Insurance producer authorization” means a permit issued by the SHOP Exchange or Individual Exchange to allow an insurance producer to sell qualified plans in the SHOP Exchange or Individual Exchange.

(n) “Managed care organization” has the meaning stated in § 15-101 of the Health - General Article.

(o) “Maryland Health Care Reform Coordinating Council” means the joint executive-legislative council established and expanded by Executive Orders 01.01.2010.07 and 01.01.2011.10.

(p) “Qualified dental plan” means a dental plan certified by the Exchange that provides limited scope dental benefits, as described in § 31-108(b)(2) of this title.

(q) “Qualified employer” means a small employer that elects to make its full-time employees and, at the option of the employer, some or all of its part-time employees eligible for one or more qualified health plans offered through the SHOP Exchange, provided that the employer:

(1) has its principal place of business in the State and elects to provide coverage through the SHOP Exchange to all of its eligible employees, wherever employed; or

(2) elects to provide coverage through the SHOP Exchange to all of its eligible employees who are principally employed in the State.

(r) “Qualified health plan” means a health benefit plan that has been certified by the Exchange to meet the criteria for certification described in § 1311(c) of the Affordable Care Act and § 31-115 of this title.

(s) “Qualified individual” means an individual, including a minor, who at the time of enrollment:

(1) is seeking to enroll in a qualified health plan offered to individuals through the Exchange;

(2) resides in the State;

(3) is not incarcerated, other than incarceration pending disposition of charges; and

(4) is, and reasonably is expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States.

(t) “Qualified plan” means a:

(1) qualified health plan;

(2) qualified dental plan; and

(3) qualified vision plan.

(u) “Qualified vision plan” means a vision plan certified by the Exchange that provides limited scope vision benefits, as described in § 31-108(b)(3) of this title.

(v) “Secretary” means the Secretary of the federal Department of Health and Human Services.

(w) “SHOP Exchange” means the small business health options program authorized under § 31-108(b)(13) of this title.

(x) “SHOP Exchange navigator” means an individual engaged by the SHOP Exchange and authorized by the Commissioner to provide the services described in § 31-112(c)(1) of this title.

(y) “SHOP Exchange navigator license” means a license issued by the Commissioner that authorizes an individual to carry out the functions set forth in § 31-112(c) of this title in the SHOP Exchange.

(z) (1) “Small employer” means an employer that, during the preceding calendar year, employed an average of not more than:

(i) 50 employees if the preceding calendar year ended on or before January 1, 2016; and

(ii) 100 employees if the preceding calendar year ended after January 1, 2016.

(2) For purposes of this subsection:

(i) all persons treated as a single employer under § 414(b), (c), (m), or (o) of the Internal Revenue Code shall be treated as a single employer;

(ii) an employer and any predecessor employer shall be treated as a single employer;

(iii) all employees shall be counted, including part-time employees and employees who are not eligible for coverage through the employer;

(iv) if an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year; and

(v) an employer that makes enrollment in qualified health plans available to its employees through the SHOP Exchange, and would cease to be a small employer by reason of an increase in the number of its employees, shall continue to be treated as a small employer for purposes of this title as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

(aa) “State benchmark plan” means the health benefit plan designated by the State, under regulations adopted by the Secretary, to serve as the standard for the essential health benefits to be offered by:

(1) qualified health plans inside the Exchange;

(2) individual health benefit plans, except grandfathered health plans, as defined in § 1251 of the Affordable Care Act; and

(3) health benefit plans offered to small employers, except grandfathered health plans, as defined in § 1251 of the Affordable Care Act.

§ 31-101 - Definitions.

(a) In general. -- In this title the following words have the meanings indicated.

(b) Board. -- "Board" means the Board of Trustees of the Exchange.

(c) Carrier. -- "Carrier" means:

(1) an insurer authorized to sell health insurance;

(2) a nonprofit health service plan;

(3) a health maintenance organization;

(4) a dental plan organization; or

(5) any other entity providing a plan of health insurance, health benefits, or health services authorized under this article or the Affordable Care Act.

(d) Coverage level. -- "Coverage level" means a level of coverage, as defined in § 1302 of the Affordable Care Act and as determined in regulations adopted by the Secretary, for a qualified health plan.

(e) Exchange. --

(1) "Exchange" means the Maryland Health Benefit Exchange established as a public corporation under § 31-102 of this title.

(2) "Exchange" includes:

(i) the Individual Exchange; and

(ii) the Small Business Health Options Program (SHOP Exchange).

(f) Fund. -- "Fund" means the Maryland Health Benefit Exchange Fund established under § 31-107 of this subtitle.

(g) Health benefit plan. --

(1) "Health benefit plan" means a policy, contract, certificate, or agreement offered, issued, or delivered by a carrier to an individual or small employer in the State to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

(2) "Health benefit plan" does not include:

(i) coverage only for accident or disability insurance or any combination of accident and disability insurance;

(ii) coverage issued as a supplement to liability insurance;

(iii) liability insurance, including general liability insurance and automobile liability insurance;

(iv) workers' compensation or similar insurance;

(v) automobile medical payment insurance;

(vi) credit-only insurance;

(vii) coverage for on-site medical clinics; or

(viii) other similar insurance coverage, specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act, under which benefits for health care services are secondary or incidental to other insurance benefits.

(3) "Health benefit plan" does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the plan:

(i) limited scope dental or vision benefits;

(ii) benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; or

(iii) such other similar limited benefits as are specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act.

(4) "Health benefit plan" does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether the benefits are provided under any group health plan maintained by the same plan sponsor:

(i) coverage only for a specified disease or illness; or

(ii) hospital indemnity or other fixed indemnity insurance.

(5) "Health benefit plan" does not include the following if offered as a separate policy, certificate, or contract of insurance:

(i) Medicare supplemental insurance (as defined under § 1882(g)(1) of the Social Security Act);

(ii) coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)); or

(iii) similar supplemental coverage provided to coverage under a group health plan.

(h) Individual Exchange. -- "Individual Exchange" means the division of the Exchange that serves the individual health insurance market.

(i) Individual Exchange navigator. -- "Individual Exchange navigator" means an individual who:

(1) holds an Individual Exchange navigator certification; and

(2) provides the services described in § 31-113(d)(1) of this title for an Individual Exchange navigator entity.

(j) Individual Exchange navigator certification. -- "Individual Exchange navigator certification" means a certificate issued by the Individual Exchange that authorizes an individual to act as an Individual Exchange navigator.

(k) Individual Exchange navigator entity. -- "Individual Exchange navigator entity" means a community-based organization or other entity or a partnership of entities that:

(1) is authorized by the Individual Exchange under § 31-113(f) of this title; and

(2) employs or engages Individual Exchange navigators to provide the services described in § 31-113(d)(1) of this title.

(l) Individual Exchange navigator entity authorization. -- "Individual Exchange navigator entity authorization" means a grant of authority from the Individual Exchange to an Individual Exchange navigator entity under § 31-113(f) of this title.

(m) Insurance producer authorization. -- "Insurance producer authorization" means a permit issued by the SHOP Exchange or Individual Exchange to allow an insurance producer to sell qualified plans in the SHOP Exchange or Individual Exchange.

(n) Managed care organization. -- "Managed care organization" has the meaning stated in § 15-101 of the Health - General Article.

(o) Maryland Health Care Reform Coordinating Council. -- "Maryland Health Care Reform Coordinating Council" means the joint executive-legislative council established and expanded by Executive Orders 01.01.2010.07 and 01.01.2011.10.

(p) Qualified dental plan. -- "Qualified dental plan" means a dental plan certified by the Exchange that provides limited scope dental benefits, as described in § 31-108(b)(2) of this title.

(q) Qualified employer. -- "Qualified employer" means a small employer that elects to make its full-time employees and, at the option of the employer, some or all of its part-time employees eligible for one or more qualified health plans offered through the SHOP Exchange, provided that the employer:

(1) has its principal place of business in the State and elects to provide coverage through the SHOP Exchange to all of its eligible employees, wherever employed; or

(2) elects to provide coverage through the SHOP Exchange to all of its eligible employees who are principally employed in the State.

(r) Qualified health plan. -- "Qualified health plan" means a health benefit plan that has been certified by the Exchange to meet the criteria for certification described in § 1311(c) of the Affordable Care Act and § 31-115 of this title.

(s) Qualified individual. -- "Qualified individual" means an individual, including a minor, who at the time of enrollment:

(1) is seeking to enroll in a qualified health plan offered to individuals through the Exchange;

(2) resides in the State;

(3) is not incarcerated, other than incarceration pending disposition of charges; and

(4) is, and reasonably is expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States.

(t) Qualified plan. -- "Qualified plan" means a:

(1) qualified health plan;

(2) qualified dental plan; and

(3) qualified vision plan.

(u) Qualified vision plan. -- "Qualified vision plan" means a vision plan certified by the Exchange that provides limited scope vision benefits, as described in § 31-108(b)(3) of this title.

(v) Secretary. -- "Secretary" means the Secretary of the federal Department of Health and Human Services.

(w) SHOP Exchange. -- "SHOP Exchange" means the small business health options program authorized under § 31-108(b)(13) of this title.

(x) SHOP Exchange navigator. -- "SHOP Exchange navigator" means an individual engaged by the SHOP Exchange and authorized by the Commissioner to provide the services described in § 31-112(c)(1) of this title.

(y) SHOP Exchange navigator license. -- "SHOP Exchange navigator license" means a license issued by the Commissioner that authorizes an individual to carry out the functions set forth in § 31-112(c) of this title in the SHOP Exchange.

(z) Small employer. --

(1) "Small employer" means an employer that, during the preceding calendar year, employed an average of not more than:

(i) 50 employees if the preceding calendar year ended on or before January 1, 2016; and

(ii) 100 employees if the preceding calendar year ended after January 1, 2016.

(2) For purposes of this subsection:

(i) all persons treated as a single employer under § 414(b), (c), (m), or (o) of the Internal Revenue Code shall be treated as a single employer;

(ii) an employer and any predecessor employer shall be treated as a single employer;

(iii) all employees shall be counted, including part-time employees and employees who are not eligible for coverage through the employer;

(iv) if an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year; and

(v) an employer that makes enrollment in qualified health plans available to its employees through the SHOP Exchange, and would cease to be a small employer by reason of an increase in the number of its employees, shall continue to be treated as a small employer for purposes of this title as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

(aa) State benchmark plan. -- "State benchmark plan" means the health benefit plan designated by the State, under regulations adopted by the Secretary, to serve as the standard for the essential health benefits to be offered by:

(1) qualified health plans inside the Exchange;

(2) individual health benefit plans, except grandfathered health plans, as defined in § 1251 of the Affordable Care Act; and

(3) health benefit plans offered to small employers, except grandfathered health plans, as defined in § 1251 of the Affordable Care Act.

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