3.1 Maryland Health Insurance Policy Requirements

Who Regulates Health Coverage in Maryland

The Maryland Insurance Administration (MIA) is the single state agency that licenses and regulates every form of health coverage sold in Maryland under the Insurance Article of the Annotated Code. There is no separate "department of managed care" as exists in some states. The Commissioner appointed to lead the MIA issues regulations, hears appeals, and can fine or suspend producers and insurers.

A frequent exam trap: large self-funded employer plans are governed by the federal Employee Retirement Income Security Act (ERISA), not the MIA. State mandates do not reach them. Fully insured group plans, however, ARE subject to Maryland mandates because the carrier bears the risk.

HMO-Specific Requirements

Maryland HMOs must (1) hold a certificate of authority from the MIA, (2) maintain statutory minimum net worth, (3) operate a quality-assurance program, (4) provide a member grievance and appeals process, and (5) demonstrate network adequacy so members can reach in-network providers within reasonable time and distance standards. HMO enrollees generally select a primary care physician and need referrals for specialists. Maryland law also guarantees enrollees a direct-access route to an OB/GYN without a referral and an independent external review of denied care through the MIA's appeals unit.

When a claim or coverage decision is denied, Maryland consumers may file a complaint with the MIA, which investigates and can order the carrier to pay. The MIA also licenses producers; selling health insurance requires an accident and health line of authority on the resident or non-resident license.

Maryland Health Connection and Easy Enrollment

Maryland Health Connection is the state-based health-insurance marketplace (marylandhealthconnection.gov). Maryland was one of the first states to build and keep its own exchange, so residents do NOT shop on Healthcare.gov. The marketplace sells Qualified Health Plans (QHPs) in metal tiers (bronze, silver, gold, platinum, plus catastrophic for those under 30), routes premium tax credits and cost-sharing reductions by income, and runs annual open enrollment from roughly November 1 to January 15. Outside that window, a Special Enrollment Period requires a qualifying life event (loss of coverage, marriage, birth/adoption, move).

The Easy Enrollment Program

Maryland enacted an individual coverage requirement framework but built it as Easy Enrollment rather than a flat tax penalty. Uninsured filers check a box on their state income tax return authorizing the Comptroller to share income and household data with Maryland Health Connection, which then determines eligibility for Medicaid or subsidized QHPs and reaches out. This is the modern, exam-relevant fact: do not describe Maryland as imposing a per-person fine like the old federal mandate.

Free Look Period

Maryland health and disability policies must give a 10-day free look (also called the right-to-examine period):

• Begins when the policy is delivered to the owner.
• Owner may return the policy for any reason for a 100% premium refund.
• The policy is then void from inception, as if never issued.
• LTC policies get a longer 30-day free look (covered in 3.3).

Exam tip: Health = 10-day free look from delivery; long-term care = 30 days. Test writers love this contrast.

Mandated Benefits and Consumer Protections

All ACA-compliant individual and small-group plans sold in Maryland must cover the ten Essential Health Benefits (EHBs):

1. Ambulatory (outpatient) services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive/wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Mental Health Parity

Maryland enforces federal and state mental health parity: financial requirements (copays, coinsurance, deductibles) and treatment limits applied to mental health and substance-use benefits cannot be more restrictive than those applied to comparable medical/surgical benefits. A plan cannot, for example, cap therapy visits while leaving physical-therapy visits unlimited.

Pre-existing Conditions, Guaranteed Issue, and Renewal

Worked scenario: A 40-year-old with diabetes applies during open enrollment. The insurer cannot decline her, cannot charge more for the diabetes, and cannot impose a waiting period before covering it. Premium may differ only by the allowed factors above. This is the heart of ACA reform that Maryland fully adopts.

Dependent Coverage and Conversion

Maryland requires plans that cover dependents to extend adult-child coverage to age 26, matching federal law. Group health policies must allow a terminated employee a conversion to an individual policy without evidence of insurability, and federal COBRA (or Maryland's mini-COBRA for small employers) lets a qualified beneficiary continue group coverage at up to 102% of the premium for 18 to 36 months depending on the event. These continuation rules are commonly tested alongside guaranteed renewal.

Common trap: Guaranteed issue means the insurer must SELL the policy; guaranteed renewal means it must keep the policy in force. Do not swap the two definitions on the exam.