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Maryland Health Insurance Coverage Shopping Tips

Frequently Asked Questions

Coverage Issues

How Can I Find Individual Health Insurance?

If you are between jobs, leaving school, or starting your own business, you may find that you need an individual health insurance policy. You should consider your needs and budget carefully before applying for a policy. Policies offer different levels of coverage for different levels of premium. For some policies, you may have to prove that you are in good health. When a company reviews your health to determine if you can be insured, it is called medical underwriting.

The least expensive option for individual health insurance will be a medically underwritten policy. This option is the least expensive because insurance companies and HMOs are very selective about issuing these policies. You and your family members must be in very good health to qualify. When you fill out the application, you must be as thorough as possible in answering the questions. If the insurer finds out later that you had a medical condition that you did not tell them about on the application, they can take back the money that they have paid on your behalf, leaving you with unpaid claims. A list of carriers offering individual policies is available on the Insurance Administration's web site, www.mdinsurance.state.md.us or by calling us at 800-492-6116.

If you are leaving a group policy, you may be eligible for continuation coverage under that policy. This means that you would still be a member of the group, but you would pay your entire premium yourself. You may also be able to convert your coverage to an individual policy that does not require medical underwriting. You should read your certificate of coverage or call the insurance company to learn the details of how to take advantage of one of these options. If you are denied an individual policy for health reasons, you can enroll in the Maryland Health Insurance Plan (MHIP). For more information about MHIP, visit MHIP's website, www.marylandhealthinsuranceplan.net or call 888-444-9016.

Can My Health Plan Require That I Get A Referral Before I See A Specialist?

Not all health plans allow you direct access to specialists. Under some health plans, you must first receive a referral to a specialist from your primary care physician. However, Maryland law states that you may receive a standing referral to a specialist if:

1. the primary care physician, in consultation with the specialist, determines that you need continuing care from a specialist; AND
2. you have a condition or disease that:
   1. is life threatening, degenerative, chronic or disabling; AND
   2. requires specialized medical care.

The specialist must have expertise in treating your disease or condition; and except in special circumstances, must be part of the health plan's provider panel.

The law prohibits a carrier from requiring you to see a physician in addition to your primary care physician before you receive the standing referral.

Unless you are pregnant and receiving a standing referral to an obstetrician, you, your primary care physician and the specialist must develop a treatment plan that may:

1. limit the number of visits to the specialist;
2. limit the period of time in which visits to the specialist are authorized; and
3. require the specialist to communicate regularly with the primary care physician regarding your treatment and health status.

If you are pregnant, by law, you must receive a standing referral to an obstetrician without the need for a treatment plan. The obstetrician will have primary responsibility for the management of your pregnancy, including the issuance of referrals, in accordance with the company's policies and procedures, through the postpartum period.

If your health plan does not have a specialist in its provider panel with the professional training and expertise to treat your condition or disease, or cannot provide reasonable access to such a specialist without unreasonable delay or travel, then the carrier is required to give you a referral to a specialist outside of the provider panel. Your deductible, copayment and coinsurance will be the same as if the specialist were a member of the health plan's provider panel. The specialist may be a health care provider that is not a physician if the specialist is licensed or certified under the Maryland Health Occupation Article and is certified or trained to treat or provide health services for a specified condition or disease in a manner that is within the scope of their license or certification.