If you disagree with a decision made by Maryland Health Connection, you may request a case review. During the case review, Maryland Health Connection will review your information and the decision to make sure it is correct. If the case review shows that the decision is incorrect, Maryland Health Connection will fix it.

If you are still dissatisfied after the case review, you may request a hearing before the Office of Administrative Hearings. If you have any questions about this information, contact the Call Center at 1-855-642-8572 (Deaf and hard of hearing use Relay service).

Decisions you can challenge

You can challenge the following kinds of decisions:

• Whether you’re eligible to buy a plan through Maryland Health Connection
• Whether you can enroll in a Maryland Health Connection plan outside of the regular open enrollment period
• Whether you’re eligible for lower plan premiums or reduced out-of-pocket costs with your plan (tax credits and cost-sharing reductions)
• Whether you’re eligible for Medicaid or Maryland Children’s Health Program (MCHP)

Decisions you cannot challenge

• Decisions relating to Managed Care Organization (MCO) enrollment, selection, or change. For assistance with MCO disputes, contact the HealthChoice Help Line at 1-800-284-4510
• Decisions relating to claims paid or not paid by your carrier or the date your plan was terminated. For assistance with these disputes, contact your carrier.

How to request a case review

You can request a case review by phone, mail or e-mail. Please include your Maryland Health Connection application ID# on all requests.

By Mail: Complete the Request for Case Review form or write a request to:

Maryland Health Connection
P.O. Box 857
Lanham, MD 20703-0857
or:
Office of Administrative Hearings
11101 Gilroy Road
Hunt Valley, MD 21031

By Email: Complete and scan the Request for Case Review form and send an email to: MHBE.Appeals@maryland.gov

By Phone: Call Maryland Health Connection at 1-855-642-8572 (Deaf and hard of hearing use Relay service)

After the case review is completed, you will receive a notice explaining how to request a hearing at the Office of Administrative Hearings if you are still dissatisfied with Maryland Health Connection’s decision.

Important information about the process

• You may be able to keep your eligibility for coverage while your case review and appeal is pending.
• The outcome of your case review or appeal could change the eligibility of other members of your household.
• You can have someone else file or participate in the case review and appeal. That person can be a friend, relative, lawyer, or any other person. Or you can handle it yourself.

For assistance with challenging your eligibility to buy a health plan through Maryland Health Connection, or your eligibility for lower plan premiums or reduced out-of-pocket costs, you can contact the Office of the Attorney General’s Health Education and Advocacy Unit (HEAU) online at www.MarylandCares.org or by phone at 410-528-1840 or toll free at 877-261-8807. The HEAU can assist you in preparing your case but cannot represent you at the hearing.

Your rights when your health insurer or HMO will not pay for health care services

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If your health care provider tells you that a certain health care service is needed, but your health insurer or HMO disagrees, you have the right to appeal that decision and have it reviewed by an independent medical expert. A health care provider includes your doctor, a hospital or a person that is licensed to provide health care services, such as a psychologist, chiropractor, or physical therapist.

You can get free help if your new health plan refuses to cover all or part of your care, or if you have trouble using your plan. Contact the Maryland Attorney General’s Health Education and Advocacy Unit (HEAU). The HEAU can also help you with:

• medical billing (including surprise medical bills);
• medical equipment;
• medical records; and
• hospital financial assistance disputes.

Visit www.marylandcares.org or call 410-528-1840 for more information.

You may skip to Step 4 below and file a complaint directly with the Maryland Insurance Administration before receiving the health insurer or HMO’s decision if the health insurer or HMO waives its requirement that you first appeal to it, if the health insurer or HMO does not follow any part of its internal appeal process, or if you show a compelling reason, such as showing that a delay could result in your death, serious impairment to a bodily function, serious dysfunction of a bodily organ, or could cause you to be a threat to yourself or others.

Here’s how the process works:

• Step 1: You will receive a letter from your health insurer or HMO notifying you of its decision.
• Step 2: Follow the instructions in the first denial letter you receive from your health insurer or HMO to ask your health insurer or HMO to reconsider its decision. If you would like some help, contact the Health Education and Advocacy Unit in the Attorney General’s Office at 877-261-8807 for assistance. Your health care provider, or someone else you authorize to help you, can also do this for you.
• Step 3: If your health insurer or HMO upholds its original decision to deny payment for the health care service, you may have your case reviewed by an independent medical expert, who will decide if the health care service your health care provider recommended is medically necessary. The Health Education and Advocacy Unit can help you with this too.
• Step 4: If your policy allows you to file a complaint with the Maryland Insurance Administration (MIA), the MIA will send your case to an independent medical expert. The MIA will send you a copy of the opinion of the independent medical expert. If your policy does not allow you to file a complaint with the MIA, your health insurer or HMO will send your case to an independent medical expert. Your letter from your health insurer or HMO will tell you if you can file a complaint with the Maryland Insurance Administration. There are time limits for filing a complaint, so please carefully read your letter.
• Step 5: If the independent medical expert finds the health care service recommended by your health care provider is medically necessary, the Insurance Commissioner, after considering all the facts of your case, may order your health insurer or HMO to pay for the health care service in accordance with your policy.

You have the right to appeal other coverage decisions made by your health insurer or HMO but those appeals may not necessarily be reviewed by an independent medical expert.

How to File a Complaint with the Maryland Insurance Administration:

Complaints must be received in writing and include a signed consent form.

Contact the MIA to learn how to submit a complaint:

Maryland Insurance Administration
Attn: Consumer Complaint Investigation Life and Health/Appeals and Grievance
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Telephone: 410-468-2000 or 800-492-6116
TTY: 1-800-735-2258
Fax: 410-468-2270 or 410-468-2260 (Life and Health/Appeals and Grievance)
Online at www.insurance.maryland.gov.

How to Contact the Health Education and Advocacy Unit:

Office of the Attorney General Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
Telephone: 410-528-1840 or 877-261-8807
Fax: 410-576-6571
Online at www.oag.state.md.us/consumer/heau.htm