Topics on this page
- Health Insurance
- Employer-Sponsored Plan
- Individual Coverage
- Required Benefits
- Appeals of Insurance Benefit Denials
- Filing A Compliant With The State of Maryland
Health Insurance
Maryland residents have several options for obtaining health insurance, including employer-sponsored plans, individual plans, COBRA, Medicare and Medicaid. Each type of insurance is subject to different laws and regulations at the state and federal level.
Health insurance in Maryland is regulated by the Maryland Insurance Administration. The Maryland Insurance Administration (MIA) is a government agency that protects consumers by making sure insurance companies and health plans comply with the Maryland health insurance law.
Read the law: Md. Code, Insurance §§ 15-101 – 15-2102
Read the regulations: Code of Md. Regulations, Title 31, Subtitles 10 – 12
Employer-Sponsored Plans
Employers with 50 or more employees are required to provide health coverage to employees and their dependents and may face penalties for failure to do so. Employers with fewer than 50 employees are not required to provide health coverage but if they choose to do so they may qualify for a tax credit.
If you have access to employer coverage, you may still choose to purchase an individual plan, but in some cases you may not be entitled to financial assistance from the State of Maryland to cover the cost of the individual insurance.
Individual Coverage
If you are Maryland resident you may purchase an individual medical health plan through a licensed agent, directly from a health insurer or through Maryland Health Connection.
Maryland Health Connection is a marketplace for the purchase of affordable health insurance set up as a result of the Patient Protection and Affordable Care Act of 2010 (ACA), sometimes referred to as Obamacare. The Maryland Health Connection is administered by an organization called the Maryland Health Benefit Exchange. Maryland enacted the Health Benefit Exchange law to reduce the number of uninsured citizens in the State.
Read the law: Md. Code, Insurance §§ 31-102 – 31-207
Maryland law does not require individuals to obtain health insurance and does not impose a tax penalty for failure to purchase insurance.
Required Benefits
Maryland law requires health insurers to offer certain “required health insurance benefits,” including but not limited to benefits for the elderly, those individuals diagnosed with Alzheimer’s disease, treatment for mental illnesses, prescription medications, in vitro fertilization procedures, disabilities caused by pregnancy or childbirth, breast cancer screenings hospice care, and Covid-19 tests. A list of required benefits can be found in Maryland Insurance Law Title 15, Subtitle 8.
Appeals of Insurance Benefit Denials
If your insurer denies coverage for treatment, it must do so in writing. After an adverse decision or denial, your health plan must give you the details of its internal grievance or appeals process so that you can file a grievance or appeal with your health plan if you choose.
Read the law: Md. Code, Insurance § 15-10A-02 and § 15-10D-02
If you decide to file an appeal for the denial of benefits, the Maryland Attorney General's Health Education and Advocacy Unit (HEAU) may assist you, free-of-charge, in mediating with your insurance company. HEAU can also assist in the appeal of decision of the Maryland Health Connection to deny or cancel health coverage. You may reach HEAU by email at heau@oag.state.md.us or toll-free at 1-877-261-8807.
If your health insurer upholds its original decision to deny payment for the health care service, you may have the right to have your case reviewed by an independent medical expert also known as an independent review organization (IRO). The independent review will decide if the health care service your provider recommended is medically necessary. The HEAU can assist with this process.
Filing a Complaint with the State of Maryland
If you do not agree with the health insurer’s final adverse determination, you have four months to file a complaint with the Maryland Insurance Administration.
Read the law: Md. Code, Insurance § 15-10A-03
Generally you must exhaust the insurer’s internal appeals process before filing a complaint with the MIA. However, in urgent medical circumstances, the MIA may allow you to skip the internal appeal and immediately file a complaint with the MIA. The MIA may consider an immediate complaint if the delay caused by the insurer’s internal process could result in a loss of life, serious danger to an organ or bodily function, serious mental illness, dangerous use of intoxicating substances, or severe withdrawal symptoms.
Complaints can be submitted as follows:
- Online through the MIA’s secure internet portal
- Download the MIA’s complaint form and submit by email (agcomplaints.mia@maryland.gov) or by mail to:
- Maryland Insurance Administration
- Attn: Consumer Complaint Investigation
- Life and Health/Appeals and Grievance
- 200 St. Paul Place, Suite 2700
- Baltimore, MD 21202
- Contact the MIA to request a copy of the complaint form to be sent to you
- Telephone: 410-468-2000 or 1-800-492-6116 or TTY: 1-800-735-2258
- Fax: 410-468-2270 (Appeals and Grievance) or 410-468-2260 (Life and Health)