Health Insurance Basics, Policy Provisions, and Maryland-Specific Requirements
Delivery systems and cost sharing
Indemnity plans reimburse; HMOs use a closed panel, a primary care gatekeeper, and capitation; PPOs allow out-of-network care at higher cost; POS and EPO plans blend these features. Cost sharing means deductible, coinsurance, copayment, and an out-of-pocket maximum. Managed-care tools include preauthorization, utilization review, case management, and formularies.
Disability and other lines
Know own-occupation versus any-occupation, the elimination period (waiting time, not benefit duration), the benefit period, and residual disability. Accidental death and dismemberment pays only for accidental losses; long-term care is triggered by inability to perform ADLs; Medigap supplements Medicare and Medicaid is needs-based.
Policy provisions
Entire contract, grace period (commonly 31 days for individual health), reinstatement, incontestability (2 years), preexisting-condition provisions, claims requirements (notice of claim, proof of loss, timely payment), legal actions, change of occupation, relation of earnings to insurance, and the renewal clauses: noncancelable, guaranteed renewable, conditionally renewable, and optionally renewable. Group coverage adds eligibility rules, COBRA (18 months; 29 with disability extension), conversion privileges, and coordination of benefits.
ACA and Maryland rules
The ACA brought guaranteed issue, no preexisting-condition exclusions, essential health benefits, dependent coverage to age 26, and medical loss ratio rebates. In Maryland the Maryland Insurance Administration oversees the market and the Maryland Health Connection is the state exchange; rate filings for individual and small-group products receive Commissioner review. Producers must hold a current appointment and satisfy continuing education - commonly cited as 24 credit hours every two years including at least 3 hours of ethics; always confirm the current MIA bulletin.
Traps: "an HMO pays for out-of-network care," "the elimination period is the benefit period," "COBRA always lasts 36 months."
Rule of thumb: for any benefit question, identify first what is covered, then when it starts, then how much it pays.