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Questions to Ask When Shopping for Maryland Health Insurance Coverage

Questions To Ask When Shopping For Health Care Coverage

Shopping for health care coverage can be confusing because of the wide array of options available from different sources. To make an informed choice, it is important that you understand what services and conditions are covered, the premium (the price of the policy) and whether there are any fees, such as coinsurance or copays you will be responsible for paying. Below, we have identified some questions that you may want to consider when comparing different plans. But remember, when choosing a plan, you should read your plan documents carefully to make certain that you understand all of the rules and that you can afford it. You should also make sure that the covered services and supplies fit your needs.

General

1. Is this an insurance policy or a discount plan? For information about medical discount plans, see the previous section of this brochure as well as our brochure entitled "What Consumers Need To Know About Discount Medical and Discount Drug Plans."

2. Is the insurance company licensed to sell insurance in Maryland? Check our web site at www.mdinsurance.state.md.us.

3. Is the producer (agent or broker) licensed? Call us at 410-468-2000 or 800-492-6116.

4. Is this a plan offered through a trade association? If yes, you are required to pay membership dues in addition to your premium. Do the dues continue after you no longer want health coverage under the plan? Is the plan issued in Maryland? If not, the Maryland Insurance Administration may not be able to assist you with any problems.

5. What happens when I call the company's customer service number? Can I reach a real person to answer my questions?

6. What happens if I am outside of Maryland or the United States and need emergency care?

7. Has my doctor, pharmacist, or health provider had any problems with this carrier in submitting claims for other insureds?

Cost of the health coverage

8. What is the fee, or premium, for the policy? Annually? Monthly?

9. Will the rates increase? If so, how often?

10. Do you pay a charge, or "copay", to receive health care? At a doctor's office? At an emergency room? What is the amount? Is the charge dependent on the services you receive?

11. Is there a deductible? If so, how often? How much is it per person?

12. Are there any limits on how much you must pay for health care services you receive (out-ofpocket maximums)?

13. Are there any limits on the number of times you may receive a service (lifetime maximums or annual benefit caps)?

14. Does the plan have a deductible amount for each insured person? That is, the amount each person must pay out-of-pocket before benefits will be paid.

15. Is there a separate deductible for some services, such as maternity?

16. Do some services require that you pay co-insurance? for doctor office visits? for an emergency room visit if not admitted to a hospital?

17. What are the renewal conditions? Under what circumstances can the carrier increase my premium?

18. Does the plan offer any incentive if I participate in a "bona fide" wellness program?

Coverage available under the plan

19. Does the plan have different benefit levels if I use an in-network/participating provider or an out-of-network/nonparticipating provider? How easy is it to get a list of participating providers? Are my doctors, medical facilities, or pharmacies included as participating providers? How easy is it to find a local participating/in-network provider? You may want to ask your doctor directly if he or she would accept this insurance for your care.

20. Does the plan require pre-authorization or pre-certification for some procedures and/or referrals from a primary care physician? Are there penalties if I don't pre-authorize or pre-certify treatment? Who do I contact to obtain pre-authorization or pre-certification?

21. What medical and hospital services does the health coverage include? If you have a medical condition that requires a particular type of care, medication, or assistive device, does the plan cover that need?

22. Are prescription medications covered in part or in full?

23. What services does the health coverage exclude?

24. Will the health coverage pay for preventative care, maternity care, well-baby care, substance abuse treatment, organ transplants, vision care, dental care, infertility treatment, durable medical equipment, or alternative therapies such as acupuncture or chiropractic care?

25. Does Maryland law require the carrier (the term "carrier" includes insurers, HMOs and nonprofit health plans) to cover certain benefits? To learn more about what benefits are required under Maryland law, see the Mandated Benefits Section of this brochure.

26. Are there waiting periods before certain illnesses are covered? Are there any other limitations on coverage of certain illnesses?

27. How easily can I change primary-care physicians if I want to?

28. Do I need to get permission before I see a specialist?

To learn more about the options available to cover your health care, see the previous section of this brochure.