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Different Types of Maryland Group Health Insurance Plans

1. Major Medical Plans - This traditional type of policy is designed to cover and reimburse medical expenses such as hospitalization, doctor visits, surgery, diagnostic tests and prescription drugs. Traditional major medical policies usually require insureds to satisfy out-of-pocket deductibles and coinsurance provisions. These plans allow insureds to obtain medical treatment from the doctor or hospital of their choice. Benefits are typically based on Usual, Customary and Reasonable (UCR) charges. These plans generally limit the insured's annual out-of-pocket expenses. Typically, a limit is also placed on the amount of benefits payable over the insured's lifetime (e.g., $1 million, $5 million and $10 million lifetime maximum).

2. Preferred Provider Organization (PPO) Plans - Insurers that offer PPO plans contract with physicians, hospitals and other health care providers who agree to provide health care services at a discounted rate. Generally, PPO plan members may obtain care from a doctor or a hospital that is not a preferred provider if they are willing to pay additional out-of-pocket expenses. However, some PPOs are much more restrictive and only allow members to receive treatment from a participating provider unless there is an emergency or unforeseen illness, injury or condition which requires immediate care. These exclusive provider plans are similar to HMOs in that the plan may deny coverage if you do not receive treatment from a preferred provider. Also, while some PPO plans permit members to visit specialists without any prior referral or authorization, others require members to obtain a referral before seeing a specialist. If you have specific questions about your plan, you should contact your human resources department or call the plan directly.

3. Health Maintenance Organizations (HMOs) - Your employer may also offer care through a health maintenance organization (HMO). HMOs sell "open panel" and "closed panel" type plans. Under a closed panel plan, the HMO generally requires members to use only certain providers under contract with the health plan. Exceptions are given for emergencies or while the member is outside the service area. Members select a primary care provider from the list of contracted providers and pay a copayment for medical care. Members must also receive authorization from the primary care provider before they can see specialists who are also in the network. The HMO may deny coverage under the closed panel plan if care is delivered by an out-of-network provider.

HMO "open panel" plans are similar to PPO plans offered by insurers and nonprofit health service plans in that members have a choice of receiving care from both innetwork providers and out-of-network providers. When the HMO member chooses an out-of-network provider, the member generally pays more out-of-pocket than if the member were to see an in-network provider. These higher out-of-pocket costs can come in the form of higher copayments, coinsurance and deductibles.

Regardless of the type of panel the Plan offers, HMOs are prohibited by law, from excluding coverage for preexisting conditions.

In addition to these plans, your employer may also offer coverage for specific illnesses (e.g. cancer), specific types of treatment (e.g. dental), treatment in a specific place (e.g. hospital), or treatment for a specific event e.g. accident or disability).

If you have coverage under an employer's plan and you or the insured under whose policy you are enrolled becomes unemployed, you still may be able to continue your coverage for a limited time. Both federal and state law require group plans to offer continued coverage to employees, the spouse of an employee or an employee's dependent under certain conditions. While there are similarities between the federal and state laws, there are also important differences. Notably:

• Under federal law, when an employer has 20 or more employees, continued coverage under the group policy is available only if the coverage would otherwise terminate because of termination of employment, reduction in work hours, the death of the employee, divorce or legal separation, the employee qualifies for Medicare, or the dependent loses dependent status under the terms of the policy. (These conditions are referred to in the laws as "qualifying events.") To continue coverage, the employee, spouse or dependent must elect to continue coverage within 60 days of the qualifying event.
• Maryland's Continuation Coverage law applies to all employers that purchase a Maryland contract, including those with less than 20 employees, and makes continued coverage available in the event of involuntary termination of employment, death or divorce. To continue coverage, the employee, spouse or dependent must elect to continue coverage within 45 days of the qualifying event, except in the event of a divorce. In the event of a divorce, the insured employee or the divorced spouse of the insured employee shall notify the employer of the change in status within 60 days of the change in status.

Whether federal or state law applies, if an employee or a qualified dependent elects to continue coverage, the individual must pay the full premium and oftentimes, an administrative fee. The premium will likely be much higher than when subsidized by the employer. Also, the length of time the policy can be continued depends upon who is electing to continue coverage (e.g. the employee, the spouse of the dependent), the qualifying event, and whether premium payments are made on time. However, once the statutorily-required continuation period ends, you can elect to convert the group policy to an individual policy, usually at a higher premium than was available under the group or continuation coverage.

The Maryland Insurance Administration has taken the position that Maryland consumers who qualify for either state or federal protections are entitled to choose both, and that, if there are differences in qualifications or benefits, those differences are to be resolved in favor of the consumer.