A global pandemic was not top of mind 10 years ago when the Patient Protection and Affordable Care Act (ACA) came into being. But Maryland and many other places are vastly better positioned today because of it.

A decade ago, 12 out of every 100 Marylanders lacked health coverage. Today, it’s about 6 out of every 100. That’s the best ever recorded by the Census Bureau. An estimated 59,000 children in Maryland did not have health insurance in 2013 when this state and others launched their health insurance marketplaces under the ACA. Three years later, that total had dropped 24% to 45,000.¹

Communities that had lacked health insurance at higher rates prior to the ACA — young adults, African-Americans, Latinos — began closing that gap. Since 2015, consumers who identified as African-American when they enrolled in coverage through Maryland Health Connection have increased by 20% to more than 27,000. Enrollees self-identified as Hispanic tripled during that same period, up to 18,000 in 2020.

And because more people have health insurance, they have been able to get care and treatment for conditions that might have made them even more vulnerable in the current environment.

• The percentage of Marylanders who reported not having a doctor declined from 21% in 2013 to 16% in 2018², which was 10th best in the nation.
• By expanding Medicaid eligibility, Maryland extended smoking cessation coverage to about 70,000 adults not previously eligible for Medicaid³.
• A study of 69,000 patients found a 60% increase in the use of rehabilitation by young adult trauma patients due to expanded coverage⁴.

Enrollment in health coverage in Maryland has been so successful, in part, due to the 600+ trained navigators, insurance brokers and others who have provided free, expert assistance to help hundreds of thousands enroll in coverage. Health care affordability continues to be a priority in the country. In 2018,Maryland was able to provide $744 million to reduce premiums for 120,000 residents. The state continues to enact laws like a reinsurance program, which helped thousands of people save dramatically on their 2018 and 2019 premiums. 

Footnotes

1.  Georgetown University Health Policy Institute, “Nation’s Uninsured Rate for Children Drops to Another Historic Low in 2016,” September 2017
2.  State Health Access Data Assistance Center (SHADAC), University of Minnesota School of Public Health, State Health Compare
3.  Centers for Disease Control and Prevention (CDC), “State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage — United States, 2016,” December 9, 2016 
4. JAMA Surgery, “Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients,” December 21, 2016

When you’re shopping for a health insurance plan, you can choose from several options. It’s important to understand the difference between plans, so you can choose the one that’s right for your lifestyle. Let’s take a look at what makes these plan types different from each other. 

What is an HMO plan?

An HMO (Health Maintenance Organization) is a health insurance plan that establishes a network of health care doctors, facilities, and hospitals to provide health care services to consumers. With an HMO plan, you pick one primary care doctor. All care goes through that doctor. This means you’ll need to ask your doctor for a referral to a specialist before you can see any other health care professional, except in an emergency. HMOs often focus on preventative and wellness care. u To avoid unexpected medical expenses, you should always confirm that a specialist is in-network with your HMO. HMO plans generally have lower premiums due to the managed care, in-network provider model.

What is a PPO plan?

A PPO (Preferred Provider Organization) is a type of health plan that establishes a network of doctors, facilities, and hospitals that will provide health care services at a determined rate. PPO plans provide some flexibility. For example, you  can see any health care professional you want without a referral—inside or outside of your network. Choosing a specialist in your network means smaller copays and full coverage. If you choose to seek treatment from a specialist who does not participate in your network, you'll have higher out-of-pocket costs, and not all services may be covered.

PPOs often have a set fee or rate that they will pay an out-of-network provider. If the care provided costs more than the set fee established between the the doctor and the insurance company, then the consumer will be required to pay the difference. A PPOgenerally has a higher monthly premium cost than that of an HMO due to the increased flexibility a PPO offers.

Key takeaways:

• Out-of-network services usually are not covered under an HMO.
• Seeing a specialist usually requires a referral from your doctor with anHMO.
• You usually must select a primary care provider under an HMO.
• PPOs and HMOs have a network and costs tend to be lower when receiving in-network care.
• Premium and out-of-pocket costs tend to be lower with an HMO.

Important terms to understand:

• In-network- a health insurance company’s group of health care providers, facilities, and hospitals it has negotiated or contracted with that will provide health care services at a fixed or reduced rate to members of a health insurance company.
• Out-of-network- health providers, facilities, or hospitals that do not have a contracted rate with a health insurance company.
• Referral- A pre-approval to receive health care services from a provider that is not your primary care provider. A referral is provided by your primary care physician.
• Primary Care Provider (PCP)- The provider designated to coordinate all of your medical needs and oversee your preventative and wellness care.

Last year the Maryland Legislature passed Senate Bill 36 establishing a Special Enrollment Period (SEP) for pregnant women. As of Jan. 1, 2020, becoming pregnant means you can enroll in a health plan or change your current plan. At Maryland Health Benefit Exchange,our mission is to reduce the uninsured rate in Maryland. With the signing of Senate Bill 36, we are working to provide coverage for  this new population.

What is a special enrollment period?

A Special Enrollment Period (SEP) allows you to enroll in a health plan through Maryland Health Connection or change your current plan outside of the annual open enrollment period. You may enroll or change plans only if you have certain life events and are otherwise eligible to enroll in coverage through Maryland Health Connection. With the passing of this bill, women will now be able to enroll in coverage when they become pregnant.

Why is this bill important?

According to UCRHealth.org, receiving prenatal care helps to catch potential concerns and reduces the risk of complications. At Maryland Health Benefit Exchange,our mission is to reduce the uninsured rate in Maryland. With the signing of Senate Bill 36, we are working to provide coverage for this new population.

Not only are pregnant women without adequate health insurance at financial risk, but if they go without necessary prenatal care, their health and the health of their babies also are at risk. Babies of mothers who don’t get prenatal care are three times more likely to have low birth weight and five times more likely to die than babies born to mothers who get adequate care. 

What are my next steps if I am pregnant? 

You have 90 days to apply after learning you are pregnant, but you should apply as soon as possible so you can receive prenatal care right away. After applying, you can choose to have your enrollment effective the first of the month you apply, or ask for coverage retroactive to the first day of the month you learned you were pregnant. In some cases, becoming pregnant may make you eligible for Medicaid, even if you weren’t eligible before.

If you are already enrolled and become pregnant, and want to select a new plan, the effective date of your new plan will follow the 15th of the first of the following month if selection is made between the 1st and the 15th of the month, or the first of the next following month if plan selection is made between the 15th and the end of the month. This SEP is effective for the pregnant member of the household and any members already enrolled.

If you become pregnant, visit marylandhealthconnection.gov to create an account and apply, or log into your existing account if you’re already enrolled. If you need assistance, we’re here to help! See a certified navigator or call 1-855-642-8572.

This week, the U.S. Department of Health and Human Services (HHS) set in motion a national program called Ready, Set, PrEP. This initiative makes pre-exposure prophylaxis (PrEP), an HIV prevention medication, accessible to those without prescription drug insurance coverage at no cost. 

Pharmacies such as CVS Health, Walgreens, and Rite Aid have donated their dispensing services to HHS. Starting no later than March 30, 2020, qualified patients can receive the PrEP medications through mail order at no cost. 

According to the Centers for Disease Control and Prevention (CDC), PrEP is for people who do not have HIV, but who are at high risk of getting HIV. The medication is taken once a day and contains two medicines. If someone becomes exposed to HIV through injection drug use or sex, this can work to keep the virus from establishing an infection.

PrEP cuts down the risk of contracting HIV from sex by about 99 percent when taken daily and can reduce the risk of HIV infection by at least 74 percent, according to the CDC. 

To see if you are eligible for the program, visit GetYourPrEP.com or call 855-447-8410. 

It’s important to have health insurance for routine and preventive care, as well as for those occasions when emergencies arise. According to U.S. Census data from 2017, Latinos experienced a higher uninsured rate than non-Hispanic whites — 18 percent vs. 6 percent — that included private and public health insurance options. However, the good news is that coverage for Latinos has improved significantly from just a few years prior when the uninsured rate was 28 percent in 2013.

Hispanic families tend to be larger and younger than other demographic groups, with extended families living within the same household. While Hispanics have a slightly higher life expectancy than non-Hispanics, about two years more on average for both men and women, the leading causes of their health concerns are no surprise — cancer, diabetes, obesity, liver and heart disease. It has long been known that prevention is much cheaper than treatment, so how can Latinos be encouraged to seek health care when faced with unknown costs, confusing types of coverage, and the added concern of language barriers?

Access to help in Spanish is key for many, along with receiving culturally competent service and care, like bilingual and bi-cultural providers and staff who can not only handle the basic needs, but can alleviate fears and build trust, while encouraging care and healthy practices. Right now, the unacculturated Latino community is fearful and uncomfortable, unwilling to reach out and participate in the available programs offered by partners like Maryland Health Connection.

I truly commend the many resources on hand at Maryland Health Connection, including bilingual support available online and in person. Spanish-speakers can feel comfortable asking questions one-on-one by phone, at local enrollment events, or by downloading the free mobile app, which offers a step-by-step process for gathering the items needed, choosing a plan, applying for coverage, and arranging payment. Health and dental plans are available for individuals and families. These plans can be accessed by many, and the state offers financial support, so folks pay less out of pocket.

To continue to serve the Latino market and other underserved communities, consistent outreach, with positive reinforcement and availability of resources is needed. Open enrollment is Nov. 1–Dec. 15, and Maryland Health Connection works with many community partners, especially in Latino-dense communities, to facilitate access and get people enrolled. This is wonderful and so important! Health insurance is not only a safety net, but an opportunity to improve our lives, ensuring we are healthy, both body and mind! And this goes for our kids and families too. Imagine the comfort of knowing our babies are vaccinated, well cared for and ready to take on the future.

Friends, being healthy doesn’t just happen. We need to be proactive, becoming informed and taking the steps needed to enact preventive wellness for ourselves and our families. Open enrollment is the perfect time for everyone to get started! So visit www.MarylandHealthConnection.gov or call 855-642-8572. Help is available in your language.

Guest blog written by Veronica Cool

Veronica Cool is founder and CEO of Cool & Associates, LLC, a consulting firm that connects the Hispanic and mainstream markets. In addition to being an entrepreneur and a Hispanic strategist, she is a leader in the Latino community in Maryland and her agency partners with Maryland Health Connection to help spread the word about health care enrollment in the state.

In a world full of specialists and urgent care, it’s tempting to overlook the most important piece of the health-care puzzle: a primary care doctor. So, what is a primary care physician and why is he or she so critical to taking care of your health?

The types of doctor identified as a primary care physician typically include family practice, internal medicine or general practice. Doctors who focus on children, called pediatricians, serve as the primary care physician for your child.

1) Coordinates and guides your care

If your medical situation begins to get complex, having a primary care doctor to help oversee your overall care is essential. Your doctor can provide recommendations on managing your care, help you focus on a central health plan, and refer you to a trustworthy specialist.

2) Knows you and your history

Primary care doctors often treat a wide range of conditions, so many people stay with their doctor through many stages in life. This helps the physician build a personal, long term relationship with you. Understanding your medical history can help in diagnosing future medical problems.

3) Navigates you through multiple medications

Certain medications can pose a high risk if taken improperly. Your primary care doctor can adjust, replace, or stop medications that are not appropriate for your condition. By assessing prescription drug interactions on a regular basis, your physician can prevent a trip to the emergency room. According to the Center for Disease Control and Prevention, more than one million people visit hospital emergency departments for adverse drug events each year in the United States.

4) Primary care doctor = Preventive care

Your doctor can help you prevent health problems by conducting tests and screenings, assisting with lifestyle changes, and administering vaccines. All Maryland Health Connection plans cover these preventive health services at no additional cost, before you pay your deductible.

5) Saves your money and your life

So, how can seeing a primary care doctor save you money? Easy! Visiting your doctor for preventive care and minor health issues means fewer emergency visits and hospital stays. According to Business Insider, an average hospital stay can cost over $10,000. With a primary care doctor overseeing your care, you can decrease your medical expenses. Early detection of health issues may save your life.