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14.35.07.00.htm 14.35.07.00. Title 14 INDEPENDENT AGENCIES Subtitle 35 MARYLAND HEALTH BENEFIT EXCHANGE Chapter 07 Eligibility Standards for Enrollment in a Qualified Health Plan, Eligibility Standards for APTC and CSR, and Eligibility Standards for Enrollment in a Catastrophic Qualified Health Plan in the Individual Exchange Authority: Insurance Article, §31-106(c)1)iv) Annotated Code of Maryland
14.35.07.01.htm 14.35.07.01. 01 Scope.. This chapter sets forth the eligibility standards for enrollment in a qualified health plan and qualified health plans with advance payments of the premium tax credit and cost-sharing reductions in the Individual Exchange. This chapter does not address the verification of eligibility or redeterminations of eligibility for enrollment in the Individual Exchange or eligibility for enrollment in the SHOP Exchange. This chapter does not address eligibility and enrollment in q
14.35.07.02.htm 14.35.07.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) “Applicant” means an individual who submits an application through the Individual Exchange for the individual and the individual’s tax household, and is seeking eligibility for:a) Enrollment in a QHP through the Individual Exchange; or. b) Enrollment in an insurance affordability program through the Individual Exchange..
14.35.07.03.htm 14.35.07.03. 03 Applying for Coverage Through the Individual Exchange.. A. Individuals may apply to enroll in a QHP or an insurance affordability program through the Individual Exchange using the single, streamlined application form approved by the Individual Exchange.B. An individual may submit the application:. 1) By telephone;. 2) On the Individual Exchange’s internet website;. 3) Using in-person assistance, including with the provision of reasonable accommodations; or. 4) By mail..
14.35.07.04.htm 14.35.07.04. 04 Notice Requirements.. A. The Individual Exchange shall provide timely written notice to an applicant of any eligibility determination made under this chapter as set forth in 45 CFR §155.230 and a notification of the right to request a fair hearing as set forth in COMAR 14.35.11.04.B. If an employee enrolls in a QHP with APTC or CSR, the Individual Exchange shall notify the employee’s employer at the employer’s address provided by the employee to the Individual Exchange that the
14.35.07.05.htm 14.35.07.05. 05 Eligibility Requirements for Enrollment in a Qualified Health Plan Through the Individual Exchange.A. An applicant shall be determined eligible for enrollment in a QHP through the Individual Exchange if the applicant is:1) A citizen or national of the United States, a non-citizen who is lawfully present in the United States, and reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought;
14.35.07.06.htm 14.35.07.06. 06 General Eligibility Requirements ― Citizenship and Immigration Status.. For the purpose of determining eligibility for enrollment in a QHP under Regulation .05A(1) and (2) of this chapter, an individual shall be considered a citizen or national of the United States if the individual is:A. A citizen of the United States, including:. 1) An individual who was born in:. a) One of the 50 states;. b) The District of Columbia;. c) Puerto Rico;. e) The Northern Mariana Islands; or.
14.35.07.07.htm 14.35.07.07. 07 General Eligibility Requirements ― Residency in Individual Exchange Service Area.. A. For the purpose of determining eligibility for enrollment in a QHP under Regulation .05(A)2) of this chapter, an individual shall be considered a resident of the Exchange service area if:1) An individual is 21 years old or older, is not living in an institution, is capable of indicating intent, and is not receiving an optional State supplementary payment and the individual lives in th
14.35.07.08.htm 14.35.07.08. 08 Eligibility Requirements for Advance Payments of the Premium Tax Credit.. A. A tax filer shall be determined eligible for APTC if:. 1) The tax filer attests to a household income, as defined in 26 CFR §1.36B-1(e) greater than or equal to 100 percent but not more than 400 percent of the FPL for the benefit year for which coverage is requested; and2) One or more applicants for whom the tax filer attests to claiming a personal exemption deduction on the applicant’s federa
14.35.07.09.htm 14.35.07.09. 09 Eligibility Requirements for Cost ― Sharing Reductions.. A. An applicant shall be determined eligible for cost-sharing reductions if the applicant:. 1) Meets the requirements for eligibility for enrollment in a QHP through the Exchange under Regulation .05 of this chapter;2) Meets the requirements for APTC under Regulation .08 of this chapter; and. 3) Except as provided under §E of this regulation, attests to household income that does not exceed 250 percent of the FPL fo
14.35.07.10.htm 14.35.07.10. 10 Eligibility Requirements for Enrollment in a Catastrophic Plan.. A. An applicant shall be determined eligible for enrollment through the Individual Exchange in a catastrophic plan if the applicant has met the requirements for eligibility for enrollment in a QHP through the Individual Exchange under Regulation .05 of this chapter and either:1) Is younger than 30 years old before the beginning of the plan year; or. 2) Has a certification in effect for any plan year
14.35.07.11.htm 14.35.07.11. 11 Enrollment in a QHP or Insurance Affordability Program Through the Individual Exchange.. A. A qualified individual may enroll in a QHP or an insurance affordability program under Regulation .02B(12)c) and .02B(12)d) of this chapter, through the Individual Exchange only during:1) The annual open enrollment period of the Individual Exchange, or. 2) A special enrollment period for which the Individual Exchange has determined that the qualified individual is eligible.
14.35.07.12.htm 14.35.07.12. 12 Special Enrollment Periods ― Loss of Minimum Essential Coverage or Termination of Other Specified Coverage Through the Individual Exchange.A. A qualified individual and, when specified in this regulation, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent are eligible for a special enrollment period for loss of minimum essential coverage or other specified coverage if:1) The qualified individual or the qualified individual’s dependent loses m
14.35.07.13.htm 14.35.07.13. 13 Special Enrollment Periods ― Change in Family Status Through the Individual Exchange.. A. A qualified individual, an enrollee, a qualified individual’s dependent, and an enrollee’s dependent are eligible for a special enrollment period for change in family status if the qualified individual or enrollee gains a dependent or becomes a dependent through:1) Marriage;. 2) Birth;. 3) Adoption;. 4) Placement for adoption;. 5) Placement in foster care;. 6) A child support order; or.
14.35.07.14.htm 14.35.07.14. 14 Special Enrollment Period ― Error, Misrepresentation, or Inaction through the Individual Exchange.A. Prior to January 1, 2020, a qualified individual or a qualified individual’s dependent shall be eligible for the special enrollment period set forth in 45 CFR §155.420(c)3) if the triggering event set forth in 45 CFR §155.420(d)4) occurs.B. Effective January 1, 2020, as evaluated and determined by the Individual Exchange, a qualified individual or qualified ind
14.35.07.15.htm 14.35.07.15. 15 Special Enrollment Period ― Misconduct Through the Individual Exchange.. A. Prior to January 1, 2020, a qualified individual or qualified individual’s dependent is eligible for a special enrollment period set forth in 45 CFR §155.420(c)3) if the triggering event set forth in 45 CFR §155.420(d)4) occurs.B. Effective January 1, 2020, a qualified individual or qualified individual’s dependent is eligible for a special enrollment period if:1) The Individual Exchang
14.35.07.16.htm 14.35.07.16. 16 Special Enrollment Period ― Violation of Material Provision Through the Individual Exchange.. A. Prior to January 1, 2020, an enrollee oran enrollee’s dependent shall be eligible for a special enrollment period set forth in 45 CFR §155.420(c)3) if the triggering event set forth in 45 CFR §155.420(d)5) occurs.B. Effective January 1, 2020, an enrollee or an enrollee’s dependent is eligible for a special enrollment period if the enrollee or the enrollee’s dependent:
14.35.07.17.htm 14.35.07.17. 17 Special Enrollment Period ― Exceptional Circumstances Through the Individual Exchange.. A. Prior to January 1, 2020, an individual, an enrollee or an enrollee’s dependent is eligible for a special enrollment period set forth in 45 CFR §155.420(c)3) if the triggering event set forth in 45 CFR §155.420(d)9) occurs.B. Effective January 1, 2020, a qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent is eligible for a special enrollment period if:
14.35.07.18.htm 14.35.07.18. 18 Special Enrollment Period ― Permanent Move.. A. A qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent is eligible for a special enrollment period if the qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent:1) Gains access to a new QHP as a result of a permanent move;. 2) Was enrolled in minimum essential coverage for one or more days in the 60 days prior to the move, unless the qualified ind
14.35.07.19.htm 14.35.07.19. 19 Special Enrollment Period ― Other.. A. An enrollee or an enrollee’s dependent is eligible for a special enrollment period if the enrollee or enrollee’s dependent is determined newly eligible or ineligible for APTC or has a change in eligibility for CSR. The effective date of coverage for enrollees determined eligible for a special enrollment period under this section is the first day of the month after the Individual Exchange receives the QHP selection.B. A qualified individual
14.35.07.20.htm 14.35.07.20. 20 Exemptions.. A. As set forth in 45 CFR §155.625(b) the Individual Exchange has delegated administration of all exemption determinations for Maryland residents to HHS.B. An applicant shall follow:. 1) The procedures specified by HHS to apply for an exemption set forth in 45 CFR Part 155, Subpart G; and2) The procedures specified by the Internal Revenue Service to apply for an exemption under 26 CFR §1.5000A-3.
14.35.07.21.htm 14.35.07.21. 21 Authorized Representative.. An applicant or enrollee in the Individual Exchange may designate an individual or an organization to act as the applicant or enrollee’s representative as set forth in COMAR 14.35.11.14.
14.35.07.9999.htm 14.35.07.9999. Administrative History Effective date: April 15, 2013 (40:7 Md. R. 612) ―. Regulation .01 repealed and new Regulations .01―21 adopted effective March 11, 2019 (46:5 Md. R. 307)
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