Maryland Health Insurance Policy Requirements

Maryland has comprehensive health insurance regulations with strong consumer protections. The Maryland Insurance Administration (MIA) regulates health coverage in the state under the Maryland Insurance Article.

Regulatory Structure

Maryland health coverage is regulated by a single agency:

HMO Regulation in Maryland

Maryland regulates Health Maintenance Organizations (HMOs):

• HMOs must be licensed by MIA
• Must meet net worth requirements
• Required to have quality assurance programs
• Must have grievance and appeals processes
• Must maintain adequate provider networks

Maryland Health Connection

Maryland Health Connection is the state-based health insurance marketplace:

• Maryland operates its own state-based exchange (not Healthcare.gov)
• Offers qualified health plans (QHPs)
• Open enrollment and special enrollment periods
• Premium subsidies available based on income
• Website: marylandhealthconnection.gov

Exam Tip: Maryland operates its own state-based exchange called Maryland Health Connection - it does NOT use Healthcare.gov.

Individual Mandate

Maryland has an individual mandate for health insurance:

• Residents are required to have minimum essential coverage
• Penalty for non-compliance on state tax return
• Exemptions available for financial hardship
• Maryland maintained mandate after federal penalty was reduced to zero

Free Look Period

Maryland provides free look periods for health insurance:

• Individual health insurance policies typically have a 10-day free look
• Policyholder can return for full premium refund
• Begins when policy is delivered
• No penalty for exercising this right

Required Coverage

Maryland mandates coverage for numerous benefits in accordance with ACA requirements:

Essential Health Benefits

All individual and small group ACA-compliant plans must cover:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorders
6. Prescription drugs
7. Rehabilitative services
8. Laboratory services
9. Preventive and wellness services
10. Pediatric services (including dental and vision)

Mental Health Parity

Maryland requires mental health parity in health insurance:

• Mental health benefits must be equal to medical benefits
• Same copays, deductibles, and limits apply
• Covers mental illness and substance use disorders
• Applies to group and individual plans

Covered Conditions

Mental health parity applies to conditions including:

• Major depression
• Bipolar disorder
• Schizophrenia
• Anxiety disorders
• Substance use disorders
• Eating disorders

Pre-Existing Condition Protections

Maryland prohibits pre-existing condition exclusions in ACA-compliant plans:

Guaranteed Issue and Renewal

Maryland requires for ACA-compliant plans:

Guaranteed Issue

• Insurers must accept all applicants during open enrollment
• Cannot deny coverage based on health status
• Applies to individual and small group markets

Guaranteed Renewal

• Insurers cannot cancel coverage except for:
  • Non-payment of premium
  • Fraud or misrepresentation
  • Plan discontinuation (with notice)