This information has been prepared by the Section on Delivery of Legal Services and the Public Awareness Committee of the Maryland State Bar Association. It is intended to inform the public and not serve as legal advice.
Many of us have access to convenient, trouble-free medical insurance coverage. However, many people experience loss of job-related medical benefits, denial or cancellation of health insurance, denial of coverage for medical services, or face a complicated application process for government programs such as Medicaid (also called Medical Assistance)
State laws that give us certain rights and impose enforceable responsibilities on insurance companies regulate the insurance industry. Extensive laws and regulations also govern government health care payment programs. In most instances, anyone experiencing a problem with coverage for health care expenses may appeal his or her case through the appropriate agency or the courts.
Traditional Health Insurance
Health insurance provided by traditional insurance companies comes in many forms. Policies that cover only accidents or specific illnesses are too limited in coverage. Before purchasing any health insurance policy, look at a variety of plans for acceptable coverage for you and your family. Be sure to ask about deductibles, co-payments, limits on coverage and types of services covered under the plan.
Once you’ve signed a policy, you obtain specific contact rights under law that limits the reasons for which an insurance company may deny coverage for a specific problem. If you are being denied benefits or are experiencing any other problems with an insurance company, contact the Maryland Insurance Division, the state agency that regulates insurance companies, at 501 St. Paul Place, Baltimore, Maryland 21202, (410) 333-6300 in Baltimore or (800) 492-6116 statewide.
If an insured worker loses or leaves a job, the loss of private medical insurance could be catastrophic to the individual and his or her dependents. State and federal law provides for continuation of health care benefits after employment ends. Eligible persons pay for continued health insurance coverage at the same group rates the employer pays. Although the coverage is for a limited time, it can be invaluable at a time when a family could be left without any health insurance. An employer who does not inform eligible individuals of their rights to continue coverage may be liable for substantial penalties.
Health Maintenance Organizations (HMOs)
An HMO is a health organization that provides health services to members through doctors, hospitals and other health care providers under a contract with the HMO. HMOs are alternatives to traditional health insurance. As with insurance companies, HMOs are regulated by the Maryland Insurance Division. HMO members have certain rights that may be enforced in court, if necessary.
Long-Term Care Insurance
Some private health insurance is available to cover nursing home care expenses. Most long-term care policies pay a fixed amount for each covered day; but certain circumstances, such as pre-existing conditions or mental illness, may be excluded. Laws enforced by the Maryland Insurance Division also regulate these policies.
Medicare is a federal health insurance program for people who are age 65 or older or disabled or blind and who receive payments from Social Security or Railroad Retirement. Medicare covers hospital care, limited skilled nursing care, home health care, hospice care, doctors’ bills, and certain other medical services and supplies. You may apply for Medicare at your local Social Security office, (410) 876-6450 or the Social Security Administration (SSA), 6401 Security Boulevard, Baltimore, Maryland 21207, (410) 965-8882. Problems with Medicare may be appealed through the SSA’s Office of Hearings and Appeals at 711 West 40th Street, Baltimore, MD 21211, (410) 962-3361, and/or the federal courts.
Medicare Supplemental Policies (Medigap)
Medigap health insurance policies are offered by private insurance companies to fill some of the “gaps” for Medicare coverage. Medigap insurance payment rates are usually based on Medicare’s “reasonable charge” determinations. They may leave the patient liable for the difference between what the doctor charges and what Medicare deems a reasonable charge. The Maryland Insurance Division enforces the laws governing Medigap insurance. For a booklet explaining how to choose a Medigap policy, contact the Maryland Office on Aging at 1004 State Office Building, 301 West Preston Street, Baltimore, Maryland 21201, (410) 225-1100.
Medical Assistance (Medicaid)
Medical Assistance is a combined federal/state health insurance program for low-income people. For people who meet the income and asset eligibility requirements, Medical Assistance covers hospital, nursing home, and home health care costs. It also pays for doctor bills, prescription medicine, and other medical services and supplies. You may apply for Medical Assistance at any Social Services Administration office or the main branch at 201 West Preston Street, Baltimore, Maryland 21201, (410) 225-1463. Complaints should be reported to the Maryland Department of Health and Mental Hygiene hearings office at 201 West Preston Street, Baltimore, Maryland 21201, (410) 225-6960, and/or the state courts.
Pharmacy Assistance Program
Pharmacy Assistance is a state program that helps people who are not eligible for Medical Assistance but cannot afford to pay for prescriptions. Participants must pay a co-payment for prescription drugs and other items. To apply, call (410) 225-5394 in Baltimore or (800) 492-1974 statewide. Complaints against the Pharmacy Assistance program should be reported to the Maryland Department of Human Resources Hearings Office at 311 West Saratoga Street, Baltimore, Maryland 21201, (410) 333-0988.
Veteran’s Administration Health Care
Veterans may obtain health care from doctors, hospitals and nursing homes through programs offered by the Veteran’s Administration. To learn more about these benefits, contact the Veteran’s Commission at (410) 333-4428
Health Benefits: What Are Your Options © 1988, MSBA, Inc. Revised 1992 All rights reserved. No part of this work may be reproduced in any form without written permission from the Maryland State Bar Association.