Maryland health-insurance questions blend national medical-plan design with a layer of Maryland-specific continuation, mandated-benefit, and consumer-appeal rules. This guide reviews the building blocks every health agent needs—plan types and cost-sharing—then makes the Maryland overlay the spine: the policy provisions and grievance/external-review process the Maryland Insurance Administration enforces, state mandated benefits, group continuation and conversion rights, and how Medicaid fits in.

The national base: types of medical plans

Most health questions begin with how a plan balances cost, choice, and network:

• Indemnity / fee-for-service — pays a share of covered charges with broad provider choice; now uncommon.
• HMO (Health Maintenance Organization) — lowest cost, network-based care coordinated through a primary care physician (PCP) "gatekeeper" with referrals to specialists.
• PPO (Preferred Provider Organization) — a network with lower in-network cost but out-of-network access, usually without referrals.
• EPO (Exclusive Provider Organization) — network-only like an HMO but typically no PCP/referral requirement.
• POS (Point of Service) — a hybrid using a PCP gatekeeper like an HMO while allowing out-of-network care like a PPO.

Universal cost-sharing terms apply across all designs: the premium (what you pay to have coverage), the deductible (paid before the plan shares), the copay (a flat per-visit charge), coinsurance (a percentage split after the deductible—e.g., the plan pays 80%, you pay 20%), and the out-of-pocket (OOP) maximum / stop-loss (the annual cap after which the plan pays 100% of covered, in-network care). Providers may be paid by capitation (a set amount per member per month) or against a usual, customary, and reasonable (UCR) fee.

Coverage is also sold group (employer-sponsored, issued as a master policy with employee certificates) versus individual (now guaranteed issue under federal law). Tax-advantaged accounts round out the toolkit: an HSA (paired with a qualified high-deductible health plan), an employee-funded FSA, and an employer-funded HRA.

The ACA floor (federal minimums)

The Affordable Care Act sets a national floor every Maryland plan must meet:

• Guaranteed issue — insurers cannot decline an applicant for health reasons.
• No health rating — premiums vary only by age, geography, tobacco use, and family size, not health status.
• Pre-existing conditions covered — no exclusions or waiting periods for prior conditions.
• Essential health benefits — ten required categories (e.g., hospitalization, maternity, prescriptions, mental health, preventive care).
• Dependents to age 26 — adult children may stay on a parent's plan.

Maryland builds on top of this floor; it does not subtract from it.

Maryland mandated benefits

Like every state, Maryland requires insured (non-self-funded) health plans to include certain state-mandated benefits that may exceed the federal minimum. Treat these by category rather than memorizing specifics, which change—verify the current list with the MIA. Self-funded ERISA plans are generally exempt from state mandates, a common exam distinction.

Required policy provisions and timelines

Individual accident and health policies use a set of standard (uniform) provisions that the MIA enforces. The exam tests these by name and timeframe:

• Entire contract — the policy plus the attached application form the whole agreement; nothing can be added later by reference.
• Grace period — extra time to pay a late premium before the policy lapses.
• Reinstatement — restoring a lapsed policy; on reinstatement, sickness is typically covered only after a short waiting period (commonly 10 days), while accidents are usually covered immediately.
• Notice of claim — given within a set time (commonly 20 days or as soon as reasonably possible).
• Claim forms — if the insurer fails to furnish forms in time, the insured may submit proof in their own words.
• Proof of loss — written proof generally due within 90 days of the loss (or as soon as reasonably possible).
• Time of payment of claims — covered claims paid promptly after proof of loss.
• Legal actions — the insured generally cannot sue until 60 days after submitting proof of loss.

Renewal provisions also matter: guaranteed renewable (must renew to a stated age; rates change only by class), noncancelable (cannot cancel and cannot change the guaranteed premium), conditionally renewable, and optionally renewable.

Grievances and external review

Maryland gives consumers strong appeal rights, both enforced by the MIA:

• Health carriers must maintain an internal grievance procedure so members can appeal adverse coverage decisions.
• After internal appeals, Maryland provides an independent external review of denied claims overseen by the MIA.

A consumer with a complaint about a health insurer contacts the Maryland Insurance Administration, which also runs a market conduct examination function and a fraud unit.

Group continuation and conversion

• Federal COBRA applies to employers with 20 or more employees and allows continuation generally up to 18 months (or 36 months for certain events such as divorce, death, or a dependent aging out). Qualified beneficiaries pay the premium themselves.
• Many states fill the gap below the federal threshold with their own small-employer continuation ("mini-COBRA") law; Maryland's specific small-group continuation rights and durations should be verified with the MIA.
• Separate from continuation, group health coverage generally carries a conversion privilege: when group coverage ends, a departing member may convert to an individual policy without new evidence of insurability. On the exam, distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy).

Medicaid in Maryland

Medicaid is the joint federal-state, needs-based program for low-income individuals—distinct from Medicare (which is federal and age-based). Medicaid can help pay for long-term care for those who qualify financially. Medicaid eligibility and administration sit with the state's health/human-services agency, not the Maryland Insurance Administration—a distinction worth remembering.

Key Maryland numbers to memorize

Common exam traps

• Sending health complaints or Medicaid questions to the wrong body. Health-insurer complaints go to the MIA; Medicaid is administered by the state's health/human-services agency, not the MIA.
• Confusing continuation and conversion. Continuation keeps the group plan temporarily; conversion moves to an individual policy with no new evidence of insurability.
• Forgetting self-funded ERISA plans are usually exempt from state mandates.
• Mixing up the uniform-provision timeframes. Notice of claim (~20 days), proof of loss (~90 days), legal actions (~60-day wait)—keep them straight.
• Assuming the ACA floor can be undercut. Guaranteed issue, no health rating, and pre-existing coverage are federal minimums Maryland cannot reduce.
• Asserting exact mandate caps or durations. Treat figures as statutory and subject to change—hedge and verify.

Quick recap

Maryland medical-plan questions start with national design—HMO, PPO, EPO, POS, and indemnity—and the universal cost-sharing terms (premium, deductible, copay, coinsurance, OOP max), plus the ACA floor: guaranteed issue, no health rating, pre-existing coverage, essential health benefits, and dependents to age 26. The Maryland overlay is the spine: the uniform policy provisions the MIA enforces (entire contract, grace period, ~20-day notice of claim, ~90-day proof of loss, ~60-day legal-actions wait), a strong grievance and external-review process, state-mandated benefits (verify the list; ERISA self-funded plans exempt), and continuation/conversion rights paired with federal COBRA's 20+ rule. Remember that Medicaid is needs-based and runs through the state's health/human-services agency, and verify any specific number—and the Maryland health section becomes manageable.