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Rights – Laws


Health insurance in Maryland is backed by many laws including several that benefit the consumer more so than in other states. Interestingly, the majority of health plans tend to be the same cost for both male and female applicants, though technically anyone can still be subject to rate changes based on gender, according to the Kaiser Family Foundation. Laws that are in place to protect the insured include guaranteed renewal, and a set of mandatory health benefits to be covered by all insurers. Otherwise, there are many protections on the other side of the coin, helping Maryland insurers stay in business.

In addition to the regulations keeping health insurance afloat in Maryland, the insured individual has a few rights if any problems should arise. Anyone whose claim is denied is able to file a formal appeal, should his or her plan fail to cover a certain type of service. As health insurance is an important investment for the individuals and families who pay for their plans, it is equally essential to know your rights as a policyholder.

 

Guaranteed Renewal

Those who purchase a health plan have guaranteed renewal to protect them from losing coverage. This law requires Maryland insurance companies to offer to renew your plan for another term before your coverage runs out. The same law makes it possible for insured individuals to keep their health plans even if they acquire an illness during the course of their plan year. Insurers cannot cancel your benefits if you suddenly come down with some kind of sickness or condition that would usually result in a decline, as you are already paying for your plan and were in acceptable health when you enrolled.

Unless you have committed some fraudulent act in regards to your health plan, or have not been paying your premiums regularly, you will be eligible for guaranteed renewal. This law is in place to make sure insured people maintain their coverage continuously. Being aware of guaranteed renewal is helpful to Maryland residents who buy an individual health plan, in the rare case that you do get sick and notice that your coverage is no longer working.

 

Pre-Existing Conditions

Children with pre-existing conditions in Maryland must be accepted by all individual health insurance plans. Their rates may increase based on the seriousness of the condition, but they cannot be declined. This is different for Maryland residents between age 19 and 65, as insurers can most certainly decline adults based on having a pre-existing condition. Health plans in Maryland judge conditions by the objective standard, which is any health condition a person has received medical treatment or advice for prior to enrollment.

Maryland’s maximum look-back period is 12 months, which gives insurers the right to dig up your past year of medical records to decide if you have a qualifying condition. If you do have such a condition, you may not be accepted for coverage depending on your condition and the company. For conditions that are not quite as expensive to treat or life threatening, an applicant could be accepted and will likely see a rate increase. Rate increases vary by insurer, as well. Maryland insurers can also issue an exclusion period of up to 12 months for pre-existing conditions.

 

Mandatory Benefits

Maryland health insurers follow a list of required benefits to be covered by every health plan in the state with the exception of HMOs. If an insurer does not offer these benefits or mention a specific exclusion for a service, they are subject to fines or sanctions. Those who buy an individual health insurance plan will receive these benefits for preventive care and other areas of coverage for special health needs. The current set of mandatory benefits offers more than the health care law requires, though it varies based on the plan. These covered services are applicable to those enrolled in most Maryland individual plans:

 

  • Anesthesia for dental care
  • Autism care
  • Blood products
  • Breast cancer screening
  • Child wellness care
  • Chlamydia screening
  • Cleft palate/lip
  • Clinical trials
  • Colorectal cancer screening
  • Contraceptives
  • Diabetic supplies and equipment
  • Emergency care
  • Extension of benefits
  • Gynecological care
  • Habilitative services
  • Hearing aids
  • Home health care
  • HPV screening
  • Infertility benefits
  • Mammograms
  • Mastectomies
  • Medical foods (PKU/Formula)
  • Mental health/substance abuse care
  • Morbid obesity treatment
  • Osteoporosis prevention
  • Prescriptions
  • Prostate cancer screenings
  • Prosthetics
  • Reconstructive breast surgery
  • Smoking cessation
  • Testicular cancer surgery
  • TMJ treatment

 

For more information, view the Maryland Insurance Administration’s Consumer’s Guide to Health Insurance.

 

 

Sources:

 

1. Maryland Insurance Administration. “Consumer’s Guide to Health Insurance”. pp 26-39.

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