§ 31-113

Maryland § 31-113

• Jurisdiction: Maryland
• Article gin: Insurance
• Title: 31

Text

(a) (1) There is a navigator program for the Individual Exchange.

(2) The navigator program for the Individual Exchange shall be:

(i) administered by the Individual Exchange; and

(ii) regulated by the Commissioner.

(3) In administering the navigator program, the Individual Exchange shall consult with the Commissioner and the Maryland Department of Health to ensure consistency and compliance with all laws, regulations, and policies governing:

(i) the sale, solicitation, and negotiation of health insurance; and

(ii) the Maryland Medical Assistance Program and the Maryland Children’s Health Program.

(4) In regulating the navigator program, the Commissioner shall enter into one or more memoranda of understanding with the Exchange and the Maryland Department of Health to facilitate enforcement of this section.

(5) The Commissioner may require the Individual Exchange to:

(i) make available to the Commissioner all records, documents, data, and other information relating to the navigator program, including the authorization of Individual Exchange connector entities and the certification of Individual Exchange navigators; and

(ii) submit a corrective plan to take appropriate action to address any problems or deficiencies identified by the Commissioner in the Individual Exchange connector entity authorization process or the Individual Exchange navigator certification process.

(6) The Commissioner, in the Commissioner’s role as a member of the Board, may not participate in any matter that involves the Individual 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 Individual Exchange’s navigator program.

(b) The navigator program for the Individual Exchange shall:

(1) focus outreach efforts and services on individuals without health insurance coverage;

(2) use Individual Exchange connector entities that:

(i) have expertise in working with vulnerable and hard–to–reach populations; and

(ii) conduct outreach and provide enrollment support for these populations; and

(3) enable the Individual Exchange to:

(i) comply with the Affordable Care Act by providing seamless entry into the Maryland Medical Assistance Program, the Maryland Children’s Health Program, and qualified plans;

(ii) assist individuals who, due to former incarceration or other circumstances, transition between the types of coverage described in item (i) of this item or have lapsed enrollment; and

(iii) meet consumer needs and demands for health insurance coverage while maintaining high standards of quality assurance and consumer protection.

(c) To carry out its purposes and in compliance with the Affordable Care Act, the Individual Exchange navigator program, with respect only to the Maryland Medical Assistance Program, the Maryland Children’s Health Program, and qualified plans offered in the Exchange, shall provide comprehensive consumer assistance services, including:

(1) conducting education and outreach to individuals;

(2) distributing information about:

(i) the Individual Exchange, including eligibility requirements for applicable federal premium subsidies and cost–sharing assistance;

(ii) eligibility requirements for the Maryland Medical Assistance Program and the Maryland Children’s Health Program; and

(iii) procedures for enrolling in the Maryland Medical Assistance Program, the Maryland Children’s Health Program, or qualified plans offered in the Individual Exchange;

(3) with respect to qualified plans, facilitating:

(i) plan selection, based on the needs of the individual seeking to enroll;

(ii) assessment of tax implications and premium and cost–sharing requirements; and

(iii) application, enrollment, renewal, and disenrollment processes;

(4) facilitating eligibility determinations for the Maryland Medical Assistance Program and the Maryland Children’s Health Program, selection of managed care organizations, and application, enrollment, and disenrollment processes;

(5) conducting eligibility determinations and redeterminations for premium subsidies and cost–sharing assistance;

(6) 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, questions, or the need for other social services;

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

(8) providing ongoing support with respect to issues relating to eligibility, enrollment, renewal, and disenrollment in the Maryland Medical Assistance Program, the Maryland Children’s Health Program, and qualified plans offered in the Individual Exchange.

(d) (1) The consumer assistance services described in subsection (c) of this section that must be provided by an Individual Exchange navigator are those services that involve the sale, solicitation, and negotiation of qualified plans offered in the Individual Exchange, including:

(i) examining or offering to examine a qualified plan for the purpose of giving, or offering to give, advice or information about the terms, conditions, benefits, coverage, or premium of a qualified plan;

(ii) facilitating:

1. qualified plan selection;

2. the application of premium tax subsidies to selected qualified health plans;

3. plan application, enrollment, renewal, and disenrollment processes; and

(iii) providing ongoing support with respect to issues relating to qualified plan enrollment, application of premium tax subsidies, renewal, and disenrollment.

(2) The consumer assistance services described in subsection (c) of this section that do not have to be provided by an Individual Exchange navigator are:

(i) conducting general education and outreach;

(ii) facilitating eligibility determinations and redeterminations for premium tax subsidies, the Maryland Medical Assistance Program, and the Maryland Children’s Health Program; and

(iii) facilitating and providing ongoing support with respect to the selection of managed care organizations, application processes, enrollment, and disenrollment for the Maryland Medical Assistance Program and the Maryland Children’s Health Program.

(e) (1) The Exchange may authorize an Individual Exchange connector entity to provide consumer assistance services that:

(i) are required to be provided by an Individual Exchange navigator; or

(ii) subject to paragraph (2)(iii) of this subsection, result in a consumer’s enrollment in the Maryland Medical Assistance Program or the Maryland Children’s Health Program.

(2) The Exchange:

(i) may limit the authorization of an Individual Exchange connector entity to the provision of a subset of services, depending on the needs of the Individual Exchange navigator program and the capacity of the Individual Exchange connector entity, provided that the navigator program overall provides the totality of services required by the Affordable Care Act and this subtitle;

(ii) pursuant to contractual agreement, may require an Individual Exchange connector entity to provide education, outreach, and other consumer assistance services in addition to the services provided under the Individual Exchange connector entity’s authorization in order to achieve all of the objectives of the navigator program; and

(iii) may not authorize an Individual Exchange connector entity to provide services that result in a consumer’s enrollment in the Maryland Medical Assistance Program or the Maryland Children’s Health Program without the approval of the Maryland Department of Health.

(f) An Individual Exchange connector entity:

(1) shall obtain authorization from the Individual Exchange to provide services that:

(i) are required to be provided by an Individual Exchange navigator; or

(ii) result in a consumer’s enrollment in the Maryland Medical Assistance Program or the Maryland Children’s Health Program;

(2) may provide:

(i) those services that are within the scope of the Individual Exchange connector entity’s authorization; and

(ii) any other consumer assistance services that:

1. are not required to be provided by an Individual Exchange navigator; or

2. do not require authorization under this subsection;

(3) to the extent the scope of its authorization includes services that must be provided by an Individual Exchange navigator, shall provide those services only through Individual Exchange navigators;

(4) in addition to the services it may provide under its authorization, may employ or engage other individuals to conduct:

(i) consumer education and outreach; and

(ii) determinations of eligibility for premium subsidies and cost–sharing assistance, the Maryland Medical Assistance Program, and the Maryland Children’s Health Program;

(5) may employ or engage individuals to perform activities that:

(i) are executive, administrative, managerial, or clerical; and

(ii) relate only indirectly to services that must be provided by an Individual Exchange navigator or result in a consumer’s enrollment in the Maryland Medical Assistance Program or the Maryland Children’s Health Program;

(6) shall comply with all State and federal laws, regulations, and policies governing the Maryland Medical Assistance Program and the Maryland Children’s Health Program;

(7) may not receive any compensation, directly or indirectly:

(i) from a carrier, an insurance producer, or a third–party administrator in connection with the enrollment of a qualified individual in a qualified health plan; or

(ii) from any managed care organization that participates in the Maryland Medical Assistance Program in connection with the enrollment of an individual in the Maryland Medical Assistance Program or the Maryland Children’s Health Program; and

(8) with respect to the insurance market outside the Exchange:

(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; and

(iii) on contact with an individual who acknowledges having existing health insurance coverage obtained through an insurance producer, shall refer the individual back to the insurance producer for information and services unless:

1. the individual is eligible for but has not obtained a federal premium subsidy and cost–sharing assistance available only through the Individual Exchange;

2. the insurance producer is not authorized to sell qualified plans in the Individual Exchange; or

3. the individual would prefer not to seek further assistance from the individual’s insurance producer.

(g) (1) The Commissioner may suspend or revoke an Individual Exchange connector entity authorization after notice and opportunity for a hearing under §§ 2–210 through 2–214 of this article if the Individual Exchange connector entity:

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

(ii) has engaged in fraudulent or dishonest practices in conducting activities under the Individual Exchange connector entity authorization;

(iii) has had any professional license or certification suspended or revoked for a fraudulent or dishonest practice;

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

(v) 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 an Individual Exchange connector entity authorization, 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 the Individual Exchange connector entity’s violation of this article.

(3) 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.

(4) The Commissioner shall notify the Individual Exchange of any decision affecting the authorization of an Individual Exchange connector entity or any sanction imposed on an Individual Exchange connector entity under this subsection.

(5) A carrier is not responsible for the activities and conduct of Individual Exchange connector entities.

(h) An Individual Exchange navigator:

(1) shall hold an Individual Exchange navigator certification issued under subsection (j) of this section;

(2) may provide consumer assistance services that are required to be provided by an Individual Exchange navigator under subsection (d)(1) of this section;

(3) may not be required to hold an insurance producer or adviser license;

(4) shall be employed or engaged by an Individual Exchange connector entity or by the Exchange;

(5) shall receive compensation only through the Individual Exchange or an Individual Exchange connector entity and not from a carrier or an insurance producer;

(6) may not receive any compensation, directly or indirectly:

(i) from a carrier, an insurance producer, or a third–party administrator in connection with the enrollment of a qualified individual in a qualified health plan; or

(ii) from a managed care organization that participates in the Maryland Medical Assistance Program in connection with the enrollment of an individual in the Maryland Medical Assistance Program or the Maryland Children’s Health Program;

(7) with respect to the insurance market outside the Exchange, is subject to the same requirements applicable to Individual Exchange connector entities as set forth in subsection (f)(8) of this section; and

(8) shall comply with all State and federal laws, regulations, and policies governing the Maryland Medical Assistance Program and the Maryland Children’s Health Program.

(i) The Exchange:

(1) shall establish and administer a process for Individual Exchange navigator certification and the issuance of Consolidated Services Center employee Individual Exchange enrollment permits;

(2) in consultation with the Commissioner and the Maryland Department of Health, shall adopt regulations to implement this subsection; and

(3) may implement the process for Individual Exchange navigator certification and the issuance of Consolidated Services Center employee Individual Exchange enrollment permits with the assistance of the Commissioner and the Maryland Department of Health, in accordance with one or more memoranda of understanding.

(j) (1) The Exchange shall issue an Individual Exchange navigator certification to each applicant who meets the requirements of this subsection.

(2) To qualify for an Individual Exchange navigator certification, an applicant:

(i) shall be of good character and trustworthy;

(ii) shall be at least 18 years old;

(iii) shall complete, and comply with any ongoing requirements of, the training program established under subsection (k) of this section; and

(iv) shall comply with all applicable requirements of the Maryland Department of Health.

(3) A certification shall expire 2 years after the date it is issued unless it is renewed.

(k) (1) The Exchange, with the approval of the Commissioner and in consultation with the Maryland Department of Health, the Health Education and Advocacy Unit of the Office of the Attorney General, and stakeholders, shall develop, implement, and, as appropriate, update a training program for the certification of Individual Exchange navigators and the issuance of Individual Exchange enrollment permits for Consolidated Services Center employees.

(2) The training program shall:

(i) provide Individual Exchange navigators and Consolidated Services Center employees with the full range of skills, knowledge, and expertise necessary to meet the consumer assistance, eligibility, enrollment, renewal, and disenrollment needs of individuals:

1. eligible for the Maryland Medical Assistance Program and the Maryland Children’s Health Program; or

2. seeking qualified plans offered in the Individual Exchange;

(ii) enable the navigator program for the Individual Exchange and the Exchange’s Consolidated Services Center to provide robust protection of consumers and adherence to high quality assurance standards; and

(iii) enable the Individual Exchange to ensure that, with respect to Individual Exchange navigators and Consolidated Services Center employees who offer any form of assistance to individuals regarding the Maryland Medical Assistance Program or the Maryland Children’s Health Program, the Individual Exchange navigator certification program and Consolidated Services Center shall comply with all requirements of the Maryland Department of Health.

(3) The Individual Exchange, in consultation with the Maryland Department of Health and with the approval of the Commissioner, shall adopt regulations that govern:

(i) the scope, type, conduct, frequency, and assessment of the training required for an Individual Exchange navigator certification;

(ii) the experience requirements, if any, for an individual applicant to be eligible to participate in the training program; and

(iii) the reinstatement of an expired Individual Exchange navigator certification or the reactivation of an inactive Individual Exchange navigator certification.

(l) (1) The Commissioner may suspend or revoke an Individual Exchange navigator certification after notice and opportunity for a hearing under §§ 2–210 through 2–214 of this article if the certified Individual Exchange navigator:

(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 Individual Exchange navigator certification;

(iii) has obtained the Individual Exchange navigator certification by misrepresentation, concealment, or other fraud;

(iv) has engaged in fraudulent or dishonest practices in conducting activities under the Individual Exchange navigator certification;

(v) has misappropriated, converted, or unlawfully withheld money in conducting activities under the Individual Exchange navigator certification;

(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 Individual Exchange navigator certification;

(xi) has otherwise shown a lack of trustworthiness or competence to act as an Individual 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 certification, 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) 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.

(4) The Commissioner shall notify the Individual Exchange and the Individual Exchange connector entity for which the Individual Exchange navigator works of any decision affecting the certification of an Individual Exchange navigator or any sanction imposed on an Individual Exchange navigator under this subsection.

(5) A carrier is not responsible for the activities and conduct of Individual Exchange navigators.

(m) (1) The Exchange shall establish and administer an insurance producer authorization process for the Individual Exchange.

(2) Under the process, the Exchange shall:

(i) provide an authorization to sell qualified plans to a licensed insurance producer who meets the requirements in subsection (n) 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 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 (l)(1) of this section with respect to the authorization.

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

(4) The Individual Exchange, with the approval of the Commissioner, shall adopt regulations to carry out this subsection.

(n) (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 Individual Exchange without being separately certified as an Individual Exchange navigator.

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

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

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

(iii) refer individuals seeking insurance who may be eligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program to the navigator program for the Individual Exchange.

(3) An insurance producer:

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

(ii) shall be compensated directly by a carrier.

(o) (1) The Exchange shall develop, implement, and, as appropriate, update a training program for insurance producers who sell qualified plans in the Individual Exchange.

(2) The training program shall:

(i) impart the skills and expertise necessary to perform functions specific to the Individual Exchange, such as making premium assistance eligibility determinations;

(ii) enable the Exchange to provide robust protection of consumers and adherence to high quality assurance standards;

(iii) impart the skills and expertise necessary to facilitate appropriate referrals of individuals and their dependents to the Maryland Medical Assistance Program, the Maryland Children’s Health Program, the appropriate Individual Exchange connector entity, an independent insurance producer, or the Consolidated Services Center; and

(iv) be approved by the Commissioner.

(p) (1) Subject to paragraphs (2) through (7) of this subsection, until January 1, 2017, a captive producer, without being separately certified as an Individual Exchange navigator, may enroll, in a qualified plan offered in the Individual Exchange by the carrier from which the captive producer has an exclusive appointment:

(i) an individual who:

1. is currently enrolled in one of the carrier’s nongroup plans; and

2. except as provided in paragraph (2) of this subsection, does not have an insurance producer of record in connection with the carrier’s nongroup plan; or

(ii) an individual who:

1. initiates contact with the captive producer or the carrier for the purpose of requesting assistance or inquiring about the carrier’s plans; and

2. except as provided in paragraph (2) of this subsection, does not acknowledge having an insurance producer in connection with any existing insurance coverage.

(2) (i) If an individual under paragraph (1) of this subsection has an insurance producer, a captive producer shall refer the individual back to the insurance producer, together with any available contact information, for information and services, unless:

1. the individual is eligible for, but has not obtained a federal premium subsidy and cost–sharing assistance, and the insurance producer is not authorized to sell qualified plans in the Individual Exchange; or

2. the individual would prefer not to seek further assistance from the individual’s insurance producer.

(ii) If a captive producer is not aware of an insurance producer of record, the captive producer shall disclose to an individual under paragraph (1) of this subsection that there may be an insurance producer of record in connection with an existing policy.

(3) (i) A carrier and its captive producers, in offering information and assistance to the carrier’s current enrollees regarding qualified plans offered in the Individual Exchange:

1. shall comply with fair marketing standards developed jointly by the Exchange and the Commissioner;

2. may not employ marketing practices or offer information and assistance only to certain enrollees in a manner that will have the effect of enrolling a disproportionate number of the carrier’s enrollees with significant health needs in qualified plans offered in the Individual Exchange; and

3. shall act in the best interest of the individual to whom the carrier and its captive producers provide assistance.

(ii) A carrier shall provide to the Exchange, and update as needed, a list of its current captive producers.

(4) Before providing an individual under paragraph (1) of this subsection any information or assistance with respect to qualified plans offered in the Individual Exchange, a captive producer in a manner prescribed under fair marketing standards established by the Commissioner and the Exchange, shall:

(i) disclose to the individual that:

1. the captive producer is employed by the carrier and able to provide information about and sell only qualified plans offered by the carrier; and

2. the Individual Exchange offers other qualified plans, sold by other carriers, that may meet the individual’s needs;

(ii) on the individual’s request:

1. refer the individual for further assistance to an independent insurance producer, the appropriate Individual Exchange connector entity, or the Consolidated Services Center; and

2. provide, through mail or electronic communication, written information about the Individual Exchange, the connector program, and the Consolidated Services Center; and

(iii) document that the captive producer has provided the required disclosures and the individual has acknowledged that the individual:

1. understands the disclosures;

2. does not want to be referred to an independent insurance producer, an Individual Exchange connector entity, or the Consolidated Services Center; and

3. wants to receive information and assistance from the captive producer.

(5) A record of the documentation required under paragraph (4)(iii) of this subsection shall be:

(i) retained by a captive producer for at least 3 years;

(ii) subject to the Commissioner’s review in a market conduct examination; and

(iii) provided to the Exchange on a quarterly basis.

(6) With respect to any health benefit plans or other products offered in the Individual Exchange or the insurance market outside the Individual Exchange by carriers other than the carrier with which the captive producer has an exclusive appointment, a captive producer:

(i) may not provide any information or services related to health benefit plans or other products not offered by the captive producer’s carrier; and

(ii) shall refer any inquiries about health benefit plans or other products not offered by the captive producer’s carrier to:

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

2. a licensed independent insurance producer.

(7) If a carrier or a captive producer fails to comply with the requirements of this subsection, the Exchange may:

(i) suspend, revoke, or refuse to renew the captive producer’s authorization under subsection (m)(3) of this section; and

(ii) impose sanctions against the carrier under § 31–115(j) of this subtitle.

(q) Nothing in this section shall prohibit a community–based organization or a unit of State or local government from providing the consumer assistance services described in subsection (c) of this section that are not required to be provided by an Individual Exchange navigator, if the entity providing the services and its employees do not:

(1) receive any compensation, directly or indirectly, from a carrier, an insurance producer, or a third–party administrator in connection with the enrollment of a qualified individual in a qualified health plan;

(2) receive any compensation, directly or indirectly, from a managed care organization that participates in the Maryland Medical Assistance Program or the Maryland Children’s Health Program; and

(3) identify themselves to the public as Individual Exchange connector entities or Individual Exchange navigators.

(r) (1) To the extent and in the manner permitted or required by federal law or regulation governing application counselors and other Exchange consumer assistance personnel, subject to paragraph (2) of this subsection, and depending on its needs and resources, the Exchange may:

(i) designate as an application counselor sponsoring entity under this subsection a community–based organization, health care provider, unit of State or local government, or other entity; and

(ii) certify as an application counselor any agent, employee, or volunteer of an application counselor sponsoring entity who meets the requirements for Individual Exchange navigator certification under this section.

(2) An application counselor sponsoring entity and an application counselor authorized to provide services under this subsection:

(i) may not be compensated by the Exchange;

(ii) may not impose a fee on individuals to whom they are authorized to provide services under this section for the services;

(iii) shall disclose to the Exchange and to individuals to whom they provide services any relationships they have with:

1. a carrier, an insurance producer, or a third–party administrator; or

2. a managed care organization that participates in the Maryland Medical Assistance Program and the Maryland Children’s Health Program;

(iv) shall act in the best interest of the individuals for whom they are authorized to provide services; and

(v) may not be compensated by a carrier, insurance producer, or third–party administrator for their enrollment services.

(3) An application counselor is subject to all requirements, restrictions, conflict of interest rules, and oversight applicable to:

(i) Individual Exchange connector entities and Individual Exchange navigators under this subsection and any other relevant State or federal laws; and

(ii) application counselors under federal law or regulation.

(4) The Exchange, in consultation with the Commissioner and the Maryland Department of Health, may:

(i) establish requirements for a sponsoring entity; and

(ii) adopt regulations to carry out this subsection.