Maryland health insurance overview
- Maryland will seek federal funding for reinsurance to stabilize premiums in 2019
- SB387 will impose fee on insurers in 2019, in place of suspended federal fee
- Exchange board decided to postpone the implementation of standardized plans
Open enrollment in Maryland’s exchange for 2018 coverage began on November 1, 2017, and continued until December 22, 2017. This was a one-week extension, announced in mid-December. Open enrollment had previously been scheduled to end December 15, but Maryland Health Connection ultimately joined most of the other state-run exchanges in issuing an extension. All plans purchased during open enrollment were effective January 1, 2018. By the end of open enrollment, 153,571 people had enrolled, which was about 2.6 percent lower than the year before — not surprising, given the shorter open enrollment period and the sharp increase in premiums for the minority of enrollees who don’t qualify for premium subsidies.
In 2018, under the terms of the Contraceptive Equity Act, Maryland began requiring all fully insured plans (ie, not including self-insured group plans) to fully cover vasectomies, with no cost-sharing for the patient. This is similar to the federal requirement that all plans cover female contraception in full, but coverage for male contraception is not addressed in federal regulations (so under federal rules, female sterilization, which is more expensive than male sterilization, is covered in full, but vasectomies do not have to be covered at all). This was welcome news for consumer advocates, but it also meant that HSA-qualified plans in Maryland might no longer be in compliance with IRS rules, since the IRS mandates that HSA-qualified plans cannot provide any benefits before the deductible, with the exception of preventive care — and the IRS doesn’t consider vasectomies to be preventive care. To get around this issue, lawmakers in Maryland passed HB135/SB137 in 2018, to exempt HSA-qualified plans from the requirement to cover vasectomies.
In Maryland, access to healthcare and health insurance is above average, and the state consistently ranks well for these measures. With a state-based health insurance exchange and Medicaid expansion under the Affordable Care Act, the number of Marylanders who go uninsured has declined substantially — from 10.2 percent in 2013, to 6.1 percent in 2016, according to US Census data.
This guide provides an overview of the healthcare landscape in Maryland, including public health rankings, ACA implementation, legislation, and other factors. Use the following links to see how Maryland is moving on specific health measures, and read how efforts around healthcare reform might be pushing the state in a positive direction.
Maryland health ratings
In the Commonwealth Fund’s 2015 Scorecard on State Health System Performance, Maryland ranked 18th based on scoring for five categories: Access, Prevention & Treatment, Avoidable Hospital Use & Costs, Healthy Lives, and Equity. But in the 2017 ranking, Maryland tied with New York for 10th place.
Access was Maryland’s highest-scoring category (fifth place) due to lower than average uninsured rates, few adults who went without a routine doctor visit, few adults who went without healthcare due to cost, and only 1 percent of individuals under age 65 with high out-of-pocket medical costs relative to their annual household income. See the most recent Maryland scorecard (2017 version) for more details.
The Old Line State placed 18th in United Health Foundation’s America’s Health Rankings for 2015, and climbed slightly, to 16th place, in 2017. Again, the state fared well in measures related to access to healthcare, and to healthy behaviors.
For more even information about health in Maryland, see Key Health Data About Maryland from the 2016 edition of Trust for America’s Health.
Finally, the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin break down public health rankings at the county level.
How has Obamacare helped Maryland?
Maryland experienced a significant drop in its uninsured rate after the ACA’s individual mandate went into effect. According to US Census data, 10.2 percent of Maryland residents were uninsured in 2013, and that had fallen to 6.1 percent in 2016. Nationwide, the average uninsured rate was 14.5 percent in 2013, and had fallen to 8.6 percent by 2016.
2018 enrollment rates and carriers
CareFirst and Kaiser are continuing to offer coverage in Maryland’s exchange for 2018, but Cigna withdrew from the exchange at the end of 2017 (they only had about 700 members, so their exit did not have a substantial effect). Evergreen Health, an ACA-created CO-OP, did not offer individual market plans in Maryland for 2017, but they had planned to start offering exchange plans again for 2018. That plan did not come to fruition, however, as Evergreen was placed in receivership and is no longer offering coverage at all.
So CareFirst and Kaiser are the only two insurers offering plans through the Maryland exchange for 2018. But they already had by far the bulk of the market share for plans purchased through the exchange.
Maryland enrollment in qualified health plans
Despite the challenges of a malfunctioning website, as was the case for many exchanges early on, 67,757 Marylanders enrolled in qualified health plans (QHPs) through Maryland Health Connection during 2014 open enrollment. More than 90 percent of those enrolling in QHPs for 2014 coverage selected plans offered by CareFirst BlueCross BlueShield. By August 13, 2015, effectuated enrollment in QHPs through Maryland’s exchange was substantially improved at 123,673 with 94 percent receiving financial assistance.
In 2016, Maryland Health Connection launched a pilot program in which customers who called the exchange were transferred to brokers for assistance. The program was intended to reduce call-center hold times and allow customers to receive plan selection advice, which only licensed agents and brokers can provide. If deemed successful, the program will return with additional brokers for the 2017 open enrollment period, which begins November 1, 2016.
A total of 162,177 people enrolled in QHPs through Maryland Health Connection during 2016 open enrollment – Maryland allowed those who began the enrollment process by January 31 to finish by February 5 if they were unable to finish on time due to a snowstorm that struck the area. This was a 35 percent increase over 2015 – the third highest percentage nationwide. Maryland had also enabled online browsing of 2016 exchange plans one month ahead of open enrollment, and once open enrollment began, within the first nine days, 89 percent of enrollees had returned to the exchange to actively renew their coverage or switch plans.
For 2017 coverage, 157,832 people enrolled in plans through Maryland Health Connection. For 2018 coverage, open enrollment was much shorter than it had been in prior years, ending on December 22 instead of January 31. By the end of open enrollment, 153,571 people had purchased coverage for 2018.
Maryland and the Affordable Care Act
Maryland politics are dominated by Democrats at the state and federal level, and the Affordable Care Act has broad support among Maryland leaders.
When the ACA was passed in 2010, both Maryland Sens. Benjamin Cardin and Barbara Mikulski voted in favor of the law, as did all but one of the state’s eight U.S. Representatives. Mikulski has since been replaced by Chris Van Hollen, who is also a Democrat and supporter of the ACA.
The Maryland legislature approved a state-run health insurance marketplace, and Gov. Martin O’Malley signed the bills into law in 2011. The state marketplace, called the Maryland Health Connection, was one of the first approved by the federal government.
Despite the state’s early start, its marketplace performed poorly. So poorly, in fact, that the state abandoned its technological infrastructure and purchased the platform that Connecticut had been successfully using.
Medicaid expansion is a key ACA strategy for reducing the uninsured rate, and Maryland joined 30 other states and the District of Columbia in implementing this measure. As detailed below, Maryland has seen significant Medicaid enrollment since expansion was implemented. Medicaid signup continues year-round, so enrollment totals change monthly.
At the beginning of 2014, the Kaiser Family Foundation estimated that 756,000 nonelderly Marylanders were uninsured. When the state decided to expand Medicaid, 302,400 residents qualified for coverage through the program.
The state saw a 52 percent increase in Medicaid enrollment from 2013 to October 2017, with total enrollment reaching nearly 1.3 million. Nationwide, the average increase in Medicaid enrollment is 29 percent, so Maryland’s enrollment has increased by far more than the national average.
Maryland Medicaid signups continue throughout the year. Visit the Maryland Department of Human Resources website to learn more about the state’s Medical Assistance programs.
Other ACA reform provisions
The Consumer Operated and Oriented Plan (CO-OP) Program was created through the ACA to spur the creation of nonprofit, consumer-run health insurance companies. Evergreen Health Cooperative in Maryland was one of 24 CO-OPs to receive a federal loan.
But as was the case with most of the CO-OPs, Evergreen is no longer offering coverage. They offered small group coverage for 2017, but not individual market coverage. They had planned to switch to a for-profit entity and begin offering individual market coverage again for 2018, but by the summer of 2017 the state announced that the private investors who had planned to purchase the CO-OP had pulled out of the deal, and the CO-OP was placed in receivership.
Does Maryland have a high-risk pool?
In the individual health insurance market prior to 2014, applications were medically underwritten in nearly every state, including Maryland. Because medical history was used to determine eligibility for coverage, people with pre-existing conditions often found themselves unable to purchase comprehensive plans in the private market.
The Maryland Health Insurance Plan (which has now been phased out) had been providing coverage since 2003 for people who were denied plans in the private market because of pre-existing conditions, or offered only plans that excluded their pre-existing conditions.
Under the ACA, medical history is no longer an eligibility factor for private health insurance. The need for high-risk pools has thus been largely eliminated, but some risk pools are still operational.
In 2013, MHIP released a plan for transitioning their members to the exchange. But Maryland’s exchange was one of the more technologically challenged during the first open enrollment period, and in December 2013, the MHIP board voted to extend MHIP Standard plans until the end of 2014, and MHIP Plus plans until the end of March 2014. In January 2014, MHIP also became a temporary insurer for Maryland residents who were unable to secure coverage in the Maryland exchange because of website problems during the first few months of 2014 open enrollment. MHIP stopped providing coverage as of January 1, 2015.
Medicare enrollment in the state of Maryland
Maryland Medicare enrollment reached 930,088 in 2015 – about 16 percent of the state’s population. Nationally, 17 percent of the population is enrolled in Medicare. The state is among those with a smaller percentage of Medicare enrollees who qualify due to disability (14 percent). Eighty-six percent of Maryland Medicare recipients qualify based on age alone.
Medicare spends about $9,190 annually per Maryland enrollee and, as of 2009, the state ranks 17th in overall spending with $8.8 billion per year.
Marylanders who want additional benefits beyond what original Medicare offers can select a Medicare Advantage plan instead. A relatively small percentage of Maryland Medicare beneficiaries choose Medicare Advantage plans; in 2015, only 8 percent had done so, compared with 31 percent nationwide.
The state sees far more enrollees in Medicare Part D plans, which provide stand-alone prescription drug coverage. About 52 percent of Maryland Medicare recipients have Part D plans, while 43 percent of Medicare recipients nationwide have such Rx coverage.
State-based health reform legislation
Scroll to the bottom of this page for a summary of recent state-based legislation related to healthcare reform.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.