Maryland Health Benefit Exchange:
Individual Appeals
of Eligibility Determinations
Karen Rohrbaugh, AAG
October 29, 2013
A service of the Maryland Health Benefit Exchange
Reasonable Compatibility
Reasonable Compatibility Methods, 42
C.F.R. § 435.952
There are three ways to determine whether what an
applicant attests to is reasonably compatible with the data
from electronic data sources:
simple income comparison
detailed income comparison
reasonable explanation
– Medicaid only
3
Simple Income Comparison
If both the attested and electronic income are above
the applicable income standard, the individual is
income ineligible
If both the attested and electronic income are at or
below the applicable income standard, then the
individual is determined to be eligible
If the attestation is above the Medicaid standard and
the electronic income is below the Medicaid standard,
the applicant is ineligible for Medicaid but may still be
eligible for an APTC/CSR
4
Detailed Income Comparison
5
Reasonable Explanation
For Medicaid only, there are times when the attested
information will be accepted, without additional
verification, if the applicant provides a reasonable
explanation, such as:
– employment was seasonal
– recent unemployment
The Medicaid Verification Plan is located at:
http://www.medicaid.gov/AffordableCareAct/MedicaidMoving-Forward-2014/Eligibility-VerificationPolicies/Downloads/Maryland-Verification-Plan-TemplateFINAL.pdf
6
Inconsistencies,
45 C.F.R. § 155.315(f)
If the information on the application – e.g., residency,
income, citizenship status – is still not reasonably
compatible with the data from the electronic data
sources, or the electronic data is not available, the
applicant is notified that the information cannot be
verified
MHBE will then contact the applicant to confirm the
accuracy of the information submitted and attempt to
identify and resolve the cause of the inconsistency
7
Inconsistency Period,
45 C.F.R. § 155.315(f)
If those efforts to resolve the inconsistency are
unsuccessful, MHBE will provide notice to the applicant of
the inconsistency
The applicant has 90 days to either present satisfactory
documentation or otherwise resolve the inconsistency
– The 90 day period may be extended if the applicant
demonstrates that a good faith effort has been made to
obtain the required documentation
8
Inconsistency Period,
45 C.F.R. § 155.315(f)
During this Inconsistency Period, MHBE gives the applicant the
benefit of the doubt and determines eligibility based on the
information provided by the applicant
– An APTC will only be provided if the applicant attests that he
or she understands that the APTC is subject to
reconciliation.
Upon the expiration of the Inconsistency Period, if the
applicant’s information cannot be verified, MHBE must:
– determine the applicant’s eligibility based on the info from
the data sources
– send the applicant an eligibility determination indicating that
MHBE is unable to verify the attestation.
9
Reasonable Compatibility Flow
10
Eligibility Determinations
Eligibility Determinations, 45 C.F.R.
§ 155.515 and Interim Procedure .04(A)
All eligibility determinations include:
– a statement of the action MHBE intends to take
– the specific laws or regulations that support the action
– an explanation of the applicant’s appeal rights, and a
description of the procedures to request an appeal
– information on the applicant’s right to be represented by
legal counsel or to designate an authorized representative
– an explanation of the circumstances under which the
appellant's eligibility may be maintained or reinstated
pending the appeal decision
– an explanation that an appeal decision for one household
member may result in a change in eligibility for other
household members, resulting in a redetermination of
eligibility for the affected members
12
Medicaid Eligibility Determinations,
Interim Procedure .04(B)
Pursuant to Medicaid rules, determinations involving
Medicaid must also:
– include an explanation of the circumstances under
which assistance is continued if a fair hearing is
requested
– to the extent required by law, state that expenses
incurred in connection with a fair hearing, such as
transportation and baby-sitting costs, shall be paid by
DHMH when incurred by the appellant and may be
paid when incurred by the appellant's witnesses
13
Redeterminations,
45 C.F.R. §§ 155.330 and 155.335
In addition to initial eligibility determinations, MHBE will also issue
redeterminations
Redeterminations will be done:
– annually
– during the year for changes in circumstances
• Enrollees are required to report changes in eligibility factors
to MHBE within 30 days
– This is particularly important for individuals who are
receiving APTC (due to the IRS reconciliation)
• Periodic data searches are conducted to confirm continued
eligibility
Inconsistency Period applies to redeterminations as well
14
Appeals
Right to Appeal
Section 1411(f) of the ACA guarantees individuals the right
to appeal an eligibility determination
45 C.F.R. § 155.535(c) and the Interim Procedures require
MHBE to give an appellant an evidentiary hearing
MHBE is delegating these appeals of individual eligibility
determinations to OAH pursuant to:
– 45 C.F.R. §§ 155.505(c)(1) and 155.110(a)
– Ins. § 31-106(a) and (b)
– State Govt. § 10-205(a)(1)(ii)
– Intergovernmental Cooperation Act of 1968
16
Bases of Appeal, 45 C.F.R. §§ 155.505(b) and
155.520(b) and Interim Procedures .03(A) and .05(D)
An appellant has 90 days to appeal on the basis that:
there has been an incorrect determination or
redetermination of eligibility
e.g.:
– enrollment in a QHP
– eligibility for Medicaid/MCHP Premium
– eligibility for APTC/CSR
MHBE failed to provide timely notice of an eligibility
determination or redetermination
17
Bases of Appeal, 45 C.F.R. § 155.505(b)
(cont.)
Other bases of appeals are being designated to
HHS:
– Individual exemptions from the minimum
essential coverage requirement
– Appeals from an employer as to whether it
provides its employee with minimum essential
coverage that is affordable
18
Acknowledgement of Appeal, 45 C.F.R.
§ 155.520(d)(1) and Interim Procedures .05(B) and .11(A)
MHBE will send a daily report to OAH notifying it of new
(valid) appeals
OAH will send an acknowledgement to appellant that also
includes:
– information regarding the appellant’s eligibility while the
appeal is pending
– that any APTCs are subject to reconciliation
– an FTI Release form
19
Federal Tax Information (“FTI”)
One of the items accessed by HIX in making eligibility
determinations is FTI
The IRS has very strict guidelines about access to
and disclosure of FTI
– IRS Publication 1075
Under the IRS’ policy, even saying that information
was verified with FTI or through the IRS constitutes a
disclosure of FTI
No FTI will be viewed by a human being unless an
appeal is filed, and then only if a release is signed by
all adult members of the household
20
FTI Release
Along with the acknowledgement notice, an FTI Release will be
sent to the appellant
The IRS prohibits anyone from seeing FTI unless:
– an appeal is filed
– an FTI release is signed by each adult member of the household
Effects of a signed release:
– A member of MHBE’s Appeals & Grievances Unit will be able to access
the FTI used by HIX solely for the purpose of attempting to resolve the
appeal
– The FTI can be shared with the appellant
– The information can be disclosed to OAH
If the appellant and/or any adult household member(s) refuse to
sign the release(s), the FTI used by HIX cannot be viewed by
MHBE staff, the appellant, or OAH, and it will not be introduced at
the hearing
21
Eligibility Pending Appeal, 45 C.F.R.
§ 155.525 and Interim Procedures .11 and .12
There is no eligibility pending appeal for initial
determinations
On redetermination:
– Enrollment in a QHP: eligible pending appeal
– Medicaid/MCHP Premium: eligible pending appeal
– APTC/CSR: the appellant can accept eligibility pending
appeal at the level of eligibility immediately prior to the
redetermination
22
Postponements, Interim Procedure .05(C)
If the time or location of a hearing is inconvenient, an ALJ
shall designate another time or place convenient to the
parties if the moving party has sufficient reason for
requesting the change
If the appellant is employed during the periods when fair
hearings are normally held, the ALJ shall attempt to
schedule the hearing so that the appellant will not be
required to miss employment
23
Hearing Logistics
At least initially, MHBE’s hearings will be added to existing
Medicaid dockets
– Hearings will be held at local DSS offices (existing Medicaid
hearing locations)
In the future, hearings are also expected to be held at the six
regional Connector Entity locations
– Central: HealthCare Access Maryland
• 201 N. Charles Street, 7th Floor, Baltimore
– Capital: Montgomery County Department of Health
• 401 Hungerford Drive, 5th Floor, Rockville
– Southern: Calvert Healthcare Solutions
• 234 Merrimac Court, Prince Frederick
24
Hearing Logistics
– Lower Eastern Shore: Worcester County Health
Department in Snow Hill
• 424 West Market Street, Snow Hill
• 6040 Public Landing Road, Snow Hill
– Upper Eastern Shore: Seedco, Inc., in Elkton
• 216 E. Pulaski Highway, Elkton
– Western: The Door to Healthcare Western Maryland in
Columbia
• 7178 Columbia Gateway Drive, Columbia
• 8930 Stanford Boulevard, Columbia
25
Six Connector Entity Regions
Allegany
Washington
Cecil
Carroll
Garrett
Harford
Baltimore
Frederick
Baltimore
City
Kent
Howard
Anne
Arundel
Montgomery
Queen
Anne’s
Regional Key
= Western
Talbot
Prince
George’s
Caroline
= Central
= Capital
=Southern
=Upper
Eastern
Shore
=Lower
Eastern
Shore
Charles
Calvert
Dorchester
St.
Mary's
Wicomico
Worcester
Somerset
26
MHBE’s Appeal Representatives
Initially, each appeal hearing will be attended by two State
representatives:
– A caseworker from a local office of either the Health
Department or the Department of Social Services
– A member of MHBE’s Appeals & Grievances Unit
• Tamara Cannida-Gunter, Manager of the Appeals &
Grievances Unit
• Nicole Edge, Appeals & Grievances Coordinator
• Wonda Oliver, Appeals & Grievances Coordinator
• Lashona Rahman, Appeals & Grievances
Coordinator
27
Authorized Representatives, 45 C.F.R.
§ 155.227 and Interim Procedure .14
Authorized representatives:
are allowed to act on an individual’s behalf during the
application, redetermination, and/or appeal, or in carrying
out other on-going communications with MHBE
can be authorized to handle all matters with MHBE, or just
certain designated functions
must be designated in a signed written document or
recorded electronically through the CSC
– Other forms of legally binding documentation, such as a
power of attorney, are also valid
must maintain the confidentiality of any information
provided by MHBE
28
Authorized Representatives, 45 C.F.R.
§ 155.227 and Interim Procedure .14
are responsible for fulfilling all of the functions for which he
or she is authorized, to the same extent as the applicant
must comply with applicable State and federal laws
concerning conflicts of interest and confidentiality of
information
An authorization remains valid until MHBE is notified of its
termination
29
Informal Resolution, 45 C.F.R. § 155.535(a)
MHBE or its partner agencies will contact the appellant in an
attempt to resolve the matters that are on appeal
– This is in addition to the efforts during the inconsistency
period
– MHBE’s Appeals & Grievances Unit will monitor the status of
informal resolution attempts
The appellant’s right to a hearing is preserved if the appellant
remains dissatisfied after the informal resolution process
If the appeal does proceed to hearing, the appellant will not be
asked to provide any duplicative information or documentation
that he or she previously provided during the application or
inconsistency process
30
Dismissals, 45 C.F.R. § 155.530
An appeal must be dismissed by OAH if the appellant:
Withdraws the appeal request in writing
Fails to appear at a scheduling hearing without good cause
Fails to submit a valid appeal request
Dies while the appeal is pending
– Except for Medicaid, when retroactive benefits are available
31
Dismissals, 45 C.F.R. § 155.530 (cont.)
Timely written notice of a dismissal must be sent by OAH to the
appellant, including:
– the reason for the dismissal
– an explanation of the dismissal's effect on the appellant's
eligibility
– an explanation of how the appellant may show good cause why
the dismissal should be vacated
A dismissal must be vacated by OAH, and the appeal allowed to
proceed, when the appellant makes a written request within 30 days
of the notice of dismissal showing good cause why the dismissal
should be vacated
– If the request is denied, timely written notice of the denial of the
request to vacate must be sent to the appellant
32
Appeal Record, 45 C.F.R. §§ 155.500
and 155.550
“Appeal record” means:
– the appeal decision
– all papers filed in the proceeding
– if a hearing was held, the transcript or recording of the
hearing testimony
– any exhibits introduced at the hearing
If requested, an appellant must have access to the appeal
record at a convenient place and time, subject to the
requirements of all applicable Federal and State laws
regarding privacy, confidentiality, disclosure, and personally
identifiable information
33
Pre-Hearing Procedures, 45 C.F.R.
§ 155.535(d) and Interim Procedure .06
MHBE will monitor the appeal to ensure that a case summary
is prepared and sent to OAH and the appellant at least six
days before the hearing
The appellant and MHBE may request the names of all
witnesses that the other party intends to call at the fair hearing
– The appellant may seek to subpoena any employee of
MHBE whose action is being contested or whose
testimony may be relevant
34
Hearing Procedures, 45 C.F.R. § 155.535(d)
and Interim Procedure .07
The appellant must be given the opportunity to:
present documentary evidence
introduce witnesses
establish all relevant facts and circumstances
present an argument without undue interference
question or refute any testimony or evidence, including the
opportunity to confront and cross-examine adverse
witnesses
35
Attendance at the Hearing,
Interim Procedure .10
The ALJ shall permit members of the public to attend the
hearing if the appellant waives, in writing, his or her
privilege of confidentiality
The ALJ may order the removal of any member of the
public whose conduct impedes the orderly progress of the
hearing, or recess the hearing until it may proceed in an
orderly fashion
If the size of the hearing room is too small to accommodate
them, the ALJ may exclude from the hearing any
individuals who have not given advance notice of their
intention to attend
36
Appeals Decisions, 45 C.F.R. §§ 155.535
and 155.545 and Interim Procedure .09(B)
All appeal decisions must:
be issued within 90 days of the date of the appeal request
– If the date of the hearing was postponed at the appellant's
request, the 90 day period is tolled by the length of the
postponement
be based solely on a de novo review of:
– the information used to determine the appellant's eligibility
– any additional relevant facts and evidence presented
during the course of the appeals process, including at the
hearing
– the eligibility requirements under 45 C.F.R. § 155.300 et
seq.
– the Medicaid and MCHP Premium eligibility requirements37
Appeals Decisions, 45 C.F.R. § 155.545
and Interim Procedure .09(A)
Summarize the facts relevant to the appeal
Identify the legal basis, including the regulations that
support the decision
State the decision, including a plain language description
of the effect of the decision on the appellant's eligibility
State the effective date of the decision
Indicate that the decision is final unless additional review is
sought, and provide an explanation of those rights
Can be based on circumstances as of the date of the
hearing, even if different than how they were at the time of
determination
38
Implementation of Appeals Decisions,
45 C.F.R. § 155.545(c) and Interim Procedure .09(C)
Appeals decisions are generally effective:
prospectively, on the first day of the month following the date of
the notice of appeal decision
at the option of the appellant, retroactively to the date the
incorrect eligibility determination was made
– however, if the appeals decision is based on facts that
occurred subsequent to the determination date, then the
decision can only be implemented prospectively
for Medicaid, if the decision is adverse to the appellant, it is
implemented immediately
An appeal decision triggers a redetermination of the eligibility of
household members whose eligibility may be affected by the
decision, even if they did not file their own appeal
39
Subsequent Appeals, 45 C.F.R § 155.505
and Interim Procedure .09(C)
An appellant may seek further review as follows:
Petition for judicial review by the Circuit Court within 30
days of the decision, State Govt. § 10-222
Appeal to HHS within 30 days of the decision, 45 C.F.R. §
155.505(c)(2)
For Medicaid appeals, the Board of Review appeal rights
remain the same for the present time, Health-Gen. § 2206(c)
40
The Future
The Appeals Module
Expected in November, 2013
ALJs will have access to HIX at all of the hearing sites
– Phone lines
– Data connection
Evidence will be downloaded from HIX
– Except FTI
Evidence brought to the hearing by the appellant will be
scanned into HIX
Decisions will be uploaded into HIX, which will
automatically notify MHBE and its partners of the decision
41
Scenarios
Scenario One
Lauren is a divorced mother who lives with her two
children, Mitchell and Patrick. Her ex-husband,
Chris, claims Mitchell on his taxes while Lauren
claims Patrick. Lauren makes $38,000 per year.
What coverage is each member of the household
eligible for?
43
Scenario One
Lauren is a divorced mother who lives with her two children, Mitchell
and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes
while Lauren claims Patrick. Lauren is a salaried employee making
$38,000 per year.
STEP 1: Determine Medicaid/MCHP Premium eligibility
For purposes of Medicaid/MCHP Premium eligibility, there are three
people in the household; the fact that Lauren does not claim Mitchell
as a deduction on her taxes does not affect the household size for
Medicaid/MCHP Premium purposes. The applicable monthly FPL is
$1,627.50, so the monthly household income of $3,166.67 is at 195%
of the FPL, making both Mitchell and Patrick eligible for MCHP.
Lauren, however, is not eligible for Medicaid because her income is
above the 138% income threshold.
44
Scenario One
Lauren is a divorced mother who lives with her two
children, Mitchell and Patrick. Her ex-husband, Chris,
claims Mitchell on his taxes while Lauren claims Patrick.
Lauren makes $38,000 per year.
STEP 2: Determine APTC/CSR eligibility
For purposes of APTC eligibility, Lauren’s household size
is two (since she does not claim Mitchell on her taxes).
Therefore, the applicable annual FPL is $15,510.
Lauren’s annual income is 245% of the FPL, which
qualifies her for an APTC.
Since her income is below 250% of the FPL, Lauren is
also eligible for a CSR if she enrolls in a silver level plan.
45
Scenario Two
Deepak is from India. He was lawfully admitted to the
U.S. for permanent residence in 2010. He lives alone
and works part-time while he goes to school, earning
$9,000 year.
What coverage is Deepak eligible for?
46
Scenario Two
Deepak is from India. He was lawfully admitted to the
U.S. for permanent residence in 2010. He lives alone
and works part-time while he goes to school, earning
$9,000 year.
STEP 1: Determine Medicaid/MCHP Premium
eligibility
Even though Deepak’s income is only at 78% of the
FPL, he is not eligible for Medicaid because of the
five year bar.
47
Scenario Two
Deepak is from India. He was lawfully admitted to the U.S.
for permanent residence in 2010. He lives alone and
works part-time while he goes to school, earning $9,000
year.
STEP 2: Determine APTC/CSR eligibility
Even though APTCs are usually not available for
someone earning less than 100% of the FPL, because
Deepak is a lawfully-present alien ineligible for Medicaid
because of his citizenship status, the special exception
applies. Therefore, he is eligible for an APTC, as well as
a CSR if he enrolls in a silver level plan.
48
Scenario Three
Kurt worked at an ice cream stand on the boardwalk in Ocean
City from April through September. He was previously
unemployed for over a year and did not file taxes during that
time. In December, Kurt applies online through Maryland
Health Connection and attests to an annual income of $14,000.
HIX checks the federal hub but there is no FTI available. HIX
then checks the State data sources, and MABS shows that Kurt
earned $7,000 in each of the last two quarters; HIX annualizes
that information and therefore calculates that Kurt’s annual
income is $28,000 year. Given that the difference between
Kurt’s attested income and the income annualized from MABS
is more than 10%, Kurt is asked to explain the discrepancy. He
indicates that he is a seasonal employee.
What coverage is Kurt eligible for?
49
Scenario Three
Kurt worked at an ice cream stand on the boardwalk in Ocean City
from April through September. He was previously unemployed for
over a year and did not file taxes during that time. In December, Kurt
applies online through Maryland Health Connection and attests to an
annual income of $14,000. HIX checks the federal hub but there is no
FTI available. HIX then checks the State data sources, and MABS
shows that Kurt earned $7,000 in each of the last two quarters; HIX
annualizes that information and therefore calculates that Kurt’s annual
income is $28,000 year. Given that the difference between Kurt’s
attested income and the income annualized from MABS is more than
10%, Kurt is asked to explain the discrepancy. He indicates that he is
a seasonal employee.
STEP 1: Determine Medicaid eligibility
Because Kurt’s employment is seasonal, HIX’s calculations were not
correct. The issue was resolved during the Inconsistency Period and
Kurt was determined to be eligible for Medicaid.
50
Scenario Four
Carla and Brian are married and expecting their first
child. They have a combined annual household
income of $47,000 and are both currently enrolled in
QHPs and receiving APTCs to help with their medical
expenses. Carla hears from a friend that she should
update her information with Maryland Health
Connection because she may be eligible for more
help with her medical costs, which she does.
What coverage is each member of the household
eligible for?
51
Scenario Four
Carla and Brian are married and expecting their first child. They have
a combined annual household income of $47,000 and are both
currently enrolled in QHPs and receiving APTCs to help with their
medical expenses. Carla hears from a friend that she should update
her information with Maryland Health Connection because she may
be eligible for more help with her medical costs, which she does.
STEP 1: Determine Medicaid/MCHP Premium eligibility
Carla’s unborn child is now counted towards her household size.
With a household of three, the household income of $47,000 is now at
241% of the $19,530 FPL. Therefore, Carla meets the Medicaid
threshold for pregnant women and is eligible for Medicaid while she is
pregnant and for two months after she delivers.
52
Scenario Four
Carla and Brian are married and expecting their first child.
They have a combined annual household income of
$47,000 and are both currently enrolled in QHPs and
receiving APTCs to help with their medical expenses.
Carla hears from a friend that she should update her
information with Maryland Health Connection because
she may be eligible for more help with her medical costs,
which she does.
STEP 2: Determine APTC/CSR eligibility
With a household size of two, Brian’s household income of
$47,000 is at 303% of the applicable FPL, so he remains
eligible for an APTC.
53
Scenario Four – Part B
Same scenario, except that six months later Carla
and Brian’s daughter, Maya, is born. Their household
income remains at $47,000 annually.
What coverage is each member of the household
eligible for?
54
Scenario Four – Part B
Same scenario, except that six months later Carla and Brian’s
daughter, Maya, is born. Their household income remains at
$47,000 annually.
STEP 1: Determine Medicaid/MCHP Premium eligibility
Because her mother was receiving Medicaid at the time of her
birth, Maya is a deemed newborn and is therefore automatically
enrolled in Medicaid for 13 months.
Carla remains eligible for Medicaid for 60 days after Maya’s
birth. Upon the expiration of that 60 day period, Carla will no
longer be eligible for Medicaid as the household income of
$47,000 for a family of three is at 241% of the FPL.
Brian also remains ineligible for Medicaid for the same reasons.
55
Scenario Four – Part B
Same scenario, except that six months later Carla
and Brian’s daughter, Maya, is born. Their household
income remains at $47,000 annually.
STEP 2: Determine APTC/CSR eligibility
With a household income at 241%, Carla and Brian
are both eligible for an APTC, as well as a CSR if
they enroll in a silver level plan.
56
Contact Information
L. Kristine Hoffman, Assistant Attorney General to MHBE
– Kristine.Hoffman@Maryland.gov
– (410) 547-1279
Sarah Rice, Assistant Attorney General to DHMH
– (410) 767-1879
– Sarah.Rice@Maryland.gov
Karen Rohrbaugh, Assistant Attorney General to MHBE
– Karen.Rohrbaugh@Maryland.gov
– (410) 547-7379
57
APPENDIX: Key Terms
Key Terms
Advance Payments of Premium Tax Credit (“APTC”): a
refundable tax credit that is available to qualified
individuals to help with the cost of purchasing health care
coverage through Maryland Health Connection
Cost-Sharing Reduction (“CSR”): A discount that lowers
the amount an eligible insured has to pay out-of-pocket for
deductibles, co-insurance, and co-payments for plans
purchased through MHBE
Federal Hub: a data center maintained by the U.S.
Department of Health & Human Services (“HHS”) that
allows MHBE to verify information through the Social
Security Administration, the Internal Revenue Service, the
Department of Homeland Security, and HHS
59
Key Terms
Federal Tax Information (“FTI”): includes, but is not
limited to, tax returns or any information provided to
the MHBE by the IRS that relates to a taxpayer’s
name, address, identification number, or dependents’
names; the potential liability of any person for any tax
or tax-related obligation or offense; and whether a
return was filed and/or is subject to audit,
investigation, or collection
60
Key Terms
HIX: MHBE’s electronic data system which
determines eligibility for enrollment in a qualified
health plan and for insurance affordability programs
Insurance Affordability Program (“IAP”): a program
that makes insurance more affordable for qualified
individuals, including Medicaid, MCHP Premium,
APTCs, and CSRs.
MAGI-Based Income: A methodology for computing
income based on the IRS rules for Modified Adjusted
Gross Income, as defined in 26 U.S.C. § 36B(d)(2)
61
Key Terms
Maryland Health Connection (“MHC”): the public face
of MHBE, www.MarylandHealthConnection.gov
Qualified Health Plan (“QHP”): an insurance plan that
is certified by MHBE pursuant to Ins. § 31-115 and is
available to qualified individuals through Maryland
Health Connection. To be a QHP, a plan must follow
established limits on cost-sharing and provide at least
the statutorily-designated essential health benefits
required in Ins. § 31-116
State data sources: both DLLR’s quarterly wage
information through the Maryland Automated Benefits
System (“MABS”) and DHMH/DHR benefit data
62