2013 Maryland Code
INSURANCE
§ 31-112 - SHOP Exchange navigator program.


MD Ins Code § 31-112 (2013) What's This?

§31-112.

(a) There is a navigator program for the SHOP Exchange.

(b) The navigator program for the SHOP Exchange shall focus outreach efforts and provide health insurance enrollment and eligibility services to small employers that do not offer health insurance to their employees.

(c) (1) To carry out its purpose and in compliance with the Affordable Care Act, the SHOP Exchange navigator program, with respect only to qualified plans offered in the SHOP Exchange, shall provide comprehensive consumer assistance services, including:

(i) conducting education and outreach to small employers;

(ii) distributing information about the SHOP Exchange, including information about:

1. options with respect to employer and employee choice;

2. procedures for enrolling in qualified plans; and

3. the availability of applicable tax credits;

(iii) facilitating:

1. qualified plan selection, based on the needs of the employee;

2. application processes;

3. enrollment;

4. renewals; and

5. disenrollment;

(iv) conducting eligibility determinations and redeterminations for tax credits;

(v) providing referrals to appropriate agencies, including the Attorney General’s Health Education and Advocacy Unit and the Administration, for applicants and enrollees with grievances, complaints, or questions;

(vi) providing all information and services in a manner that is culturally and linguistically appropriate and ensures accessibility for individuals with disabilities; and

(vii) providing ongoing support with respect to the functions set forth in this section, including eligibility and enrollment and disenrollment in and renewal of qualified plans offered in the SHOP Exchange.

(2) A SHOP Exchange navigator:

(i) shall hold a SHOP Exchange navigator license issued under subsection (d) of this section;

(ii) may not be required to hold an insurance producer license;

(iii) shall be engaged by and receive compensation only through the SHOP Exchange;

(iv) may not receive compensation from or otherwise be affiliated with a carrier, an insurance producer, a third-party administrator, or any other person connected to the insurance industry; and

(v) shall complete and comply with any ongoing requirements of the training program established under subsection (h) of this section.

(3) With respect to the insurance market outside the Exchange, a SHOP Exchange navigator:

(i) may not provide any information or services related to health benefit plans or other products not offered in the Exchange, except for general information about the insurance market outside the Exchange, which shall be limited to the information provided in a consumer education document developed by the Exchange and the Commissioner;

(ii) shall refer any inquiries about health benefit plans or other products not offered in the Exchange to:

1. any resources that may be maintained by the Exchange; or

2. carriers and licensed insurance producers;

(iii) may not seek to replace any health benefit plan already offered by a small employer unless the small employer is eligible for a federal tax credit available only through the SHOP Exchange; and

(iv) shall refer to the Individual Exchange navigator program any inquiries about information or services related to:

1. qualified plans offered in the Individual Exchange; or

2. the Maryland Medical Assistance Program and the Maryland Children’s Health Program.

(d) (1) The Commissioner shall issue a SHOP Exchange navigator license to each applicant who meets the requirements of this subsection.

(2) To qualify for a SHOP Exchange navigator license, an applicant:

(i) shall be of good character and trustworthy;

(ii) shall be at least 18 years old;

(iii) shall pass a written examination given by the Commissioner under this subsection; and

(iv) may not have committed any act that the Commissioner finds would warrant suspension or revocation of a license under subsection (e) of this section.

(3) The Commissioner shall adopt regulations that govern:

(i) the scope, type, conduct, frequency, and assessment of the written examination required for a license;

(ii) the experience required for an individual applicant to be eligible to take the written examination; and

(iii) the reinstatement of an expired license.

(e) (1) The Commissioner may suspend, revoke, or refuse to renew or reinstate a SHOP Exchange navigator license after notice and opportunity for a hearing under §§ 2-210 through 2-214 of this article, if the licensee:

(i) has willfully violated this article or any regulation adopted under this article;

(ii) has intentionally misrepresented or concealed a material fact in the application for the license;

(iii) has obtained the license by misrepresentation, concealment, or other fraud;

(iv) has engaged in fraudulent or dishonest practices in conducting activities under the license;

(v) has misappropriated, converted, or unlawfully withheld money in conducting activities under the license;

(vi) has failed or refused to pay over on demand money that belongs to a person entitled to the money;

(vii) has willfully and materially misrepresented the provisions of a qualified plan;

(viii) has been convicted of a felony, a crime of moral turpitude, or any criminal offense involving dishonesty or breach of trust;

(ix) has failed an examination required by this article or regulations adopted under this article;

(x) has forged another’s name on an application for a qualified plan or on any other document in conducting activities under the license;

(xi) has otherwise shown a lack of trustworthiness or competence to act as a SHOP Exchange navigator; or

(xii) has willfully failed to comply with or violated a proper order or subpoena of the Commissioner.

(2) Instead of or in addition to suspending or revoking a license, the Commissioner may:

(i) impose a penalty of not less than $100 but not exceeding $500 for each violation of this article; and

(ii) require that restitution be made to any person who has suffered financial injury because of a violation of this article.

(3) If the Commissioner suspends a SHOP Exchange navigator license, the Commissioner may require the individual to pass an examination and file a new application before the suspension is lifted.

(4) The penalties available to the Commissioner under this subsection shall be in addition to any criminal or civil penalties imposed for fraud or other misconduct under any other State or federal law.

(5) The Commissioner shall notify the SHOP Exchange of any decision affecting the license of a SHOP Exchange navigator or any sanction imposed on a SHOP Exchange navigator under this subsection.

(6) The Commissioner, in the Commissioner’s role as a member of the Board, may not participate in any matter that involves the SHOP Exchange’s navigator program if, in the Commissioner’s judgment, the Commissioner’s participation might create a conflict of interest with respect to the Commissioner’s regulatory authority over the SHOP Exchange’s navigator program.

(7) A carrier is not responsible for the activities and conduct of a SHOP Exchange navigator.

(f) (1) The SHOP Exchange shall establish and administer an insurance producer authorization program.

(2) Under the program, the SHOP Exchange shall:

(i) provide an authorization to sell qualified plans to a licensed insurance producer who meets the requirements in subsection (g) of this section; and

(ii) require renewal of an authorization every 2 years.

(3) (i) Subject to the contested case hearing provisions of Title 10, Subtitle 2 of the State Government Article, the SHOP Exchange may suspend, revoke, or refuse to renew an authorization for good cause, which shall include a finding that the insurance producer holding the authorization has committed any act described in subsection (e)(1) of this section with respect to the authorization.

(ii) The SHOP Exchange shall notify the Commissioner of any decision affecting the status of an insurance producer’s authorization.

(4) The SHOP Exchange, in consultation with the Commissioner, shall adopt regulations to carry out this subsection.

(g) (1) Subject to the requirements in paragraph (2) of this subsection, an insurance producer who is licensed in the State and authorized by the Commissioner to sell, solicit, or negotiate health insurance may sell any qualified plan offered in the SHOP Exchange without being separately licensed as a SHOP Exchange navigator.

(2) To sell qualified plans in the SHOP Exchange, an insurance producer shall:

(i) register and apply for an authorization from the SHOP Exchange;

(ii) complete and comply with any ongoing requirements of the training program established under subsection (h) of this section; and

(iii) in providing assistance to a small employer seeking information about offering health insurance, inform the small employer of:

1. all qualified health plans available to employees in the SHOP Exchange; and

2. all options available to the small employer in the SHOP Exchange for offering qualified health plans to employees.

(3) An insurance producer:

(i) may not be compensated by the SHOP Exchange for the sale of a qualified plan offered in the SHOP Exchange; and

(ii) shall be compensated directly by a carrier.

(h) (1) The SHOP Exchange shall develop, implement, and, as appropriate, update training programs for:

(i) SHOP Exchange navigators; and

(ii) licensed insurance producers who seek authorization to sell qualified plans in the SHOP Exchange.

(2) The training programs shall:

(i) impart the skills and expertise necessary to perform functions specific to the SHOP Exchange, such as making tax credit eligibility determinations; and

(ii) enable the SHOP Exchange’s navigator program to provide robust protection of consumers and adherence to high quality assurance standards.

§ 31-112 - SHOP Exchange navigator program [Effective January 1, 2014].

(a) In general. -- There is a navigator program for the SHOP Exchange.

(b) Purpose. -- The navigator program for the SHOP Exchange shall focus outreach efforts and provide health insurance enrollment and eligibility services to small employers that do not offer health insurance to their employees.

(c) Duties and requirements. --

(1) To carry out its purpose and in compliance with the Affordable Care Act, the SHOP Exchange navigator program, with respect only to qualified plans offered in the SHOP Exchange, shall provide comprehensive consumer assistance services, including:

(i) conducting education and outreach to small employers;

(ii) distributing information about the SHOP Exchange, including information about:

1. options with respect to employer and employee choice;

2. procedures for enrolling in qualified plans; and

3. the availability of applicable tax credits;

(iii) facilitating:

1. qualified plan selection, based on the needs of the employee;

2. application processes;

3. enrollment;

4. renewals; and

5. disenrollment;

(iv) conducting eligibility determinations and redeterminations for tax credits;

(v) providing referrals to appropriate agencies, including the Attorney General's Health Education and Advocacy Unit and the Administration, for applicants and enrollees with grievances, complaints, or questions;

(vi) providing all information and services in a manner that is culturally and linguistically appropriate and ensures accessibility for individuals with disabilities; and

(vii) providing ongoing support with respect to the functions set forth in this section, including eligibility and enrollment and disenrollment in and renewal of qualified plans offered in the SHOP Exchange.

(2) A SHOP Exchange navigator:

(i) shall hold a SHOP Exchange navigator license issued under subsection (d) of this section;

(ii) may not be required to hold an insurance producer license;

(iii) shall be engaged by and receive compensation only through the SHOP Exchange;

(iv) may not receive compensation from or otherwise be affiliated with a carrier, an insurance producer, a third-party administrator, or any other person connected to the insurance industry; and

(v) shall complete and comply with any ongoing requirements of the training program established under subsection (h) of this section.

(3) With respect to the insurance market outside the Exchange, a SHOP Exchange navigator:

(i) may not provide any information or services related to health benefit plans or other products not offered in the Exchange, except for general information about the insurance market outside the Exchange, which shall be limited to the information provided in a consumer education document developed by the Exchange and the Commissioner;

(ii) shall refer any inquiries about health benefit plans or other products not offered in the Exchange to:

1. any resources that may be maintained by the Exchange; or

2. carriers and licensed insurance producers;

(iii) may not seek to replace any health benefit plan already offered by a small employer unless the small employer is eligible for a federal tax credit available only through the SHOP Exchange; and

(iv) shall refer to the Individual Exchange navigator program any inquiries about information or services related to:

1. qualified plans offered in the Individual Exchange; or

2. the Maryland Medical Assistance Program and the Maryland Children's Health Program.

(d) Licenses; regulations. --

(1) The Commissioner shall issue a SHOP Exchange navigator license to each applicant who meets the requirements of this subsection.

(2) To qualify for a SHOP Exchange navigator license, an applicant:

(i) shall be of good character and trustworthy;

(ii) shall be at least 18 years old;

(iii) shall pass a written examination given by the Commissioner under this subsection; and

(iv) may not have committed any act that the Commissioner finds would warrant suspension or revocation of a license under subsection (e) of this section.

(3) The Commissioner shall adopt regulations that govern:

(i) the scope, type, conduct, frequency, and assessment of the written examination required for a license;

(ii) the experience required for an individual applicant to be eligible to take the written examination; and

(iii) the reinstatement of an expired license.

(e) Denials, uspensions, revocations, or refusal to renew or reinstate license; penalties. --

(1) The Commissioner may deny, suspend, revoke, or refuse to renew or reinstate a SHOP Exchange navigator license after notice and opportunity for a hearing under §§ 2-210 through 2-214 of this article, if the licensee:

(i) has willfully violated this article or any regulation adopted under this article;

(ii) has intentionally misrepresented or concealed a material fact in the application for the license;

(iii) has obtained the license by misrepresentation, concealment, or other fraud;

(iv) has engaged in fraudulent or dishonest practices in conducting activities under the license;

(v) has misappropriated, converted, or unlawfully withheld money in conducting activities under the license;

(vi) has failed or refused to pay over on demand money that belongs to a person entitled to the money;

(vii) has willfully and materially misrepresented the provisions of a qualified plan;

(viii) has been convicted of a felony, a crime of moral turpitude, or any criminal offense involving dishonesty or breach of trust;

(ix) has failed an examination required by this article or regulations adopted under this article;

(x) has forged another's name on an application for a qualified plan or on any other document in conducting activities under the license;

(xi) has otherwise shown a lack of trustworthiness or competence to act as a SHOP Exchange navigator; or

(xii) has willfully failed to comply with or violated a proper order or subpoena of the Commissioner.

(2) Instead of or in addition to suspending or revoking a license, the Commissioner may:

(i) impose a penalty of not less than $ 100 but not exceeding $ 500 for each violation of this article; and

(ii) require that restitution be made to any person who has suffered financial injury because of a violation of this article.

(3) If the Commissioner suspends a SHOP Exchange navigator license, the Commissioner may require the individual to pass an examination and file a new application before the suspension is lifted.

(4) The penalties available to the Commissioner under this subsection shall be in addition to any criminal or civil penalties imposed for fraud or other misconduct under any other State or federal law.

(5) The Commissioner shall notify the SHOP Exchange of any decision affecting the license of a SHOP Exchange navigator or any sanction imposed on a SHOP Exchange navigator under this subsection.

(6) The Commissioner, in the Commissioner's role as a member of the Board, may not participate in any matter that involves the SHOP Exchange's navigator program if, in the Commissioner's judgment, the Commissioner's participation might create a conflict of interest with respect to the Commissioner's regulatory authority over the SHOP Exchange's navigator program.

(7) A carrier is not responsible for the activities and conduct of a SHOP Exchange navigator.

(f) Establishment and administration of insurance producer authorization program. --

(1) The SHOP Exchange shall establish and administer an insurance producer authorization program.

(2) Under the program, the SHOP Exchange shall:

(i) provide an authorization to sell qualified plans to a licensed insurance producer who meets the requirements in subsection (g) of this section; and

(ii) require renewal of an authorization every 2 years.

(3) (i) Subject to the contested case hearing provisions of Title 10, Subtitle 2 of the State Government Article, the SHOP Exchange may suspend, revoke, or refuse to renew an authorization for good cause, which shall include a finding that the insurance producer holding the authorization has committed any act described in subsection (e)(1) of this section with respect to the authorization.

(ii) The SHOP Exchange shall notify the Commissioner of any decision affecting the status of an insurance producer's authorization.

(4) The SHOP Exchange, in consultation with the Commissioner, shall adopt regulations to carry out this subsection.

(g) Licensed insurance producer permitted to sell qualified plan offered in the SHOP Exchange. --

(1) Subject to the requirements in paragraph (2) of this subsection, an insurance producer who is licensed in the State and authorized by the Commissioner to sell, solicit, or negotiate health insurance may sell any qualified plan offered in the SHOP Exchange without being separately licensed as a SHOP Exchange navigator.

(2) To sell qualified plans in the SHOP Exchange, an insurance producer shall:

(i) register and apply for an authorization from the SHOP Exchange;

(ii) complete and comply with any ongoing requirements of the training program established under subsection (h) of this section; and

(iii) in providing assistance to a small employer seeking information about offering health insurance, inform the small employer of:

1. all qualified health plans available to employees in the SHOP Exchange; and

2. all options available to the small employer in the SHOP Exchange for offering qualified health plans to employees.

(3) An insurance producer:

(i) may not be compensated by the SHOP Exchange for the sale of a qualified plan offered in the SHOP Exchange; and

(ii) shall be compensated directly by a carrier.

(h) Training programs. --

(1) The SHOP Exchange shall develop, implement, and, as appropriate, update training programs for:

(i) SHOP Exchange navigators; and

(ii) licensed insurance producers who seek authorization to sell qualified plans in the SHOP Exchange.

(2) The training programs shall:

(i) impart the skills and expertise necessary to perform functions specific to the SHOP Exchange, such as making tax credit eligibility determinations; and

(ii) enable the SHOP Exchange's navigator program to provide robust protection of consumers and adherence to high quality assurance standards.

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