Health Insurance Tips Know the Details When You Shop for Health

Health Insurance Tips

Maryland Insurance Administration • 800-492-6116 • www.insurance.maryland.gov 1

Health Insurance Edition

If you are looking for health insurance,

you may be able to purchase it through

your employer (or your spouse’s or

parents’ employer), a private insurer, an

insurance producer, or the Maryland

Health Connection.

If you are considering a traditional

insurance plan, the Maryland Insurance

Administration’s Health Insurance

Shopping Tool is a good way for you to

compare the features of the insurance,

including coverage, deductibles, and

copayments.

Here is the link to the publication:

https://tinyurl.com/y6hm98j4

Know the Details When You Shop for Health Insurance Coverage

Shopping for ways to pay for medical treatment can be extremely confusing because there are so many

options to pay for medical treatment, from traditional health insurance, to short-term policies, to special

membership programs. Before you make your purchase, it is important that you understand:

 whether you are purchasing insurance, a discount plan or some other type of arrangement;

 how much the coverage you are purchasing will cost. The fees you pay can include any

combination of the following expenses: program fee, premium, deductibles, copays, mandatory

and/or voluntary contributions, administrative fees, and/or coinsurance;

 how much the coverage you are purchasing will cover. This includes limits on amounts it will

pay, when it will pay, and any other restrictions. the rights you have if it does not pay, for

example, can you appeal the decision and to whom? And which provider, medical

devices/equipment and hospital services will be covered.

You can compare and

enroll in private health plans, Medicaid, or dental

coverage through the Maryland Health Connection,

the state’s health insurance marketplace under the

Patient Protection and Affordable Care Act of 2010

(ACA). The Maryland Health Connection is also the

only place to qualify for financial help to make

coverage more affordable.

If you have questions about your application, call the

Maryland Health Connection at 1-855-642-8572

(TTY: 1-855-642-8573) or find free, in-person help

near you. You can also download the free Enroll

MHC mobile app to shop, enroll, find local help, view

notices and upload documents.

Health Insurance Tips

Maryland Insurance Administration • 800-492-6116 • www.insurance.maryland.gov 2

Health Insurance Edition

Some health plans help pay the cost of covered prescription medicines.

These plans use a “formulary” that determines how much of the cost

you’ll pay. A formulary usually has different tiers. Prescription medicines

listed in one tier may cost you more than those in another tier. Always

show your pharmacy your health insurance card. If your health

insurance provides prescription drug coverage, typically, the amount

you pay for a covered medication will count toward your annual

out-of-pocket maximum.

To find out which prescriptions your plan covers, visit your insurer’s

website to find your online health plan formulary, or check your

insurance policy or certificate to learn more about your formulary.

You can find a link to your plan’s formulary in the plan’s “Summary of

Benefits Coverage”. This summary appears in the “Common Medical Events” section in the row labeled “if

you need drugs to treat your illness or condition.” If you need help, call your insurer directly to find out

what’s covered.

Tier 1—Generic drugs. These are lower-cost drugs.

Tier 2—Preferred, brand-name drugs. These drugs

cost more because they’re unique, and just one drug

company makes them.

Tier 3—Non-preferred, brand-name drugs. These are

also brand-name drugs, but they may cost you more

than other brand name drugs that treat the same

condition.

Tier 4—Some plans use this tier for specialty drugs.

Other plans have a separate “specialty” tier. These

are high-cost drugs that treat rare or complex

diseases.

It’s a good idea to talk with your providers about the best, affordable medications for you, based on your

plan. If the pharmacy says that your plan doesn’t cover a prescription drug you’ve been taking, you may

want to check with your insurer to make sure. It is also a good idea to talk with your provider about other

options, including whether the provider can ask your health plan for an exception. Providers may be

willing to ask for an exception, for example, when all other drugs the plan covers haven’t worked or won’t

work as well as the drug the provider prescribed, or all other drugs the plan covers have caused or could

cause harmful side effects. If your insurer approves an exception, prescription medicine that your plan

doesn’t normally cover will be covered, at least in part. You may need to request approval for an

exception each time you get a new prescription or refill so be sure to ask your insurer if it requires special

authorization each time the prescription is filled.

Your health plan may not cover all of the health care services that you may need. For example, there

may be limits on the number of visits for physical therapy, or the number of days covered in a skilled nursing facility.

Even if your doctor says you still need these services, if your health plan has a limit, it will not pay for the treatment

beyond the limits specified in your policy. Also, covered services may require cost sharing such as a copay,

co-insurance, and/or deductible.

You can avoid unexpected costs for health services by becoming familiar with the specifics of your health insurance

plan and planning a budget. When planning a budget, make sure to consider premium payments, co-payments and

any charges that will not be covered by your insurance, including amounts above your policy limit.

Health Insurance Tips

Maryland Insurance Administration • 800-492-6116 • www.insurance.maryland.gov 3

Health Insurance Edition

LARRY HOGAN

Governor

BOYD K. RUTHERFORD

Lt. Governor

KATHLEEN A. BIRRANE

Commissioner

JAY COON

Deputy Commissioner

This consumer guide should be used for educational purposes only. It is not

intended to provide legal advice or opinions regarding coverage under a specific

insurance policy or contract; nor should it be construed as an endorsement of any

product, service, person, or organization mentioned in this guide. Please note that

policy terms vary based on the particular insurer and you should contact your

insurer or insurance producer (agent or broker) for more information.

This publication has been produced by the Maryland Insurance Administration (MIA)

to provide consumers with general information about insurance-related issues

and/or state programs and services. This publication may contain copyrighted

material which was used with permission of the copyright owner. Publication herein

does not authorize any use or appropriation of such copyrighted material without

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All publications issued by the MIA are available free of charge on the MIA’s website

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name and contact information must remain clearly visible, and no other name,

including that of the insurer or insurance producer reproducing the publication, may

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the prior written consent of the MIA.

Persons with disabilities may request this document in an alternative format.

Requests should be submitted in writing to the Director of Communications at

the address listed on this page.

Maryland Insurance Administration

200 St. Paul Place, Suite 2700

Baltimore, MD 21202

410-468-2000 or 800-492-6116

800-735-2258 TTY