Plan designs (HMO, PPO, POS, indemnity, HDHP with an HSA), cost sharing, and the federal ACA rules are covered in the national Medical Plans guide. Maryland adds its own definition of an HMO, a grievance and complaint process run through the Maryland Insurance Administration, prompt-pay rules, and several mandated benefits. Group continuation is in the Maryland group health guide. Individual policy provisions are in the Maryland individual accident and health provisions guide.

HMOs and nonprofit plans

• A Maryland HMO must provide at least physician, hospital, laboratory, x-ray, emergency and preventive services, plus out-of-area coverage. Apart from copays and deductibles, it is paid only on a predetermined periodic rate (Health-Gen. § 19-701(g)).
• A complying nonprofit health service plan is a tax-exempt public benefit corporation whose mission is affordable, accessible coverage (Ins. § 14-102).
• Selling HMO, dental plan or nonprofit health service plan contracts for pay requires a producer license (Ins. § 1-101(u)).

Grievances and complaints (Ins. Title 15, Subtitle 10A)

Internal grievances (§ 15-10A-02):

• Every carrier must have an internal grievance process.
• Nonemergency grievances are decided in writing within 30 working days.
• Emergency grievances are decided within 24 hours.

Complaints to the Commissioner (§ 15-10A-03):

• After a carrier's adverse decision, a member may file a complaint with the Commissioner within 4 months.
• The Commissioner decides nonemergency complaints within 45 days, and emergency cases within 24 hours.

Help filing. The Health Education and Advocacy Unit in the Attorney General's Consumer Protection Division helps members file grievances.

Prompt payment (§ 15-1005)

• A carrier pays a clean claim, or explains why it isn't paying, within 30 days of receipt.
• Providers get at least 180 days from the date of service to submit claims.

Mandated benefits and offers

• Morbid obesity surgery (§ 15-839). Plans must cover surgical treatment of morbid obesity that meets NIH guidelines. Morbid obesity means a BMI over 40, or 35 or more with a comorbid condition such as diabetes.
• Alzheimer's care (§ 15-801). Group expense-incurred policies must offer the policyholder optional benefits for nursing home and custodial care for Alzheimer's disease. This is a mandated offer, not a mandated benefit.
• Newborns and adopted children (§ 15-401). They are covered from birth, or from adoption. Adoption coverage starts when custody is assumed, if that comes before the decree. If extra premium is needed, the policy may require notice and payment within 31 days.
• Grandchildren (§ 15-403). Dependent coverage must be extended, on request, to a grandchild in the insured's court-ordered custody.
• Disabled children (§ 15-402). A child incapable of self-support stays covered past the limiting age.
• Medical child support (§ 15-405). A child covered under a support order can't be refused because they don't live with the parent, were born out of wedlock, or are eligible for Medicaid.

Underwriting limits

• Genetic information (§ 27-909). Health carriers may not use genetic tests or information to deny, rate or cancel coverage. This rule doesn't apply to life, annuity, LTC or disability insurance.
• Domestic violence status may not be used to refuse or rate health coverage (§ 27-504).

Common exam traps

• Nonemergency grievances are decided in 30 working days, and emergencies in 24 hours.
• A member has 4 months to complain to the Commissioner, who decides in 45 days.
• Clean claims are paid in 30 days. Providers have 180 days to submit claims.
• Alzheimer's care is a mandated offer for group policies.
• The genetic information ban doesn't cover life, annuity, LTC or disability insurance.