Maryland Health Insurance: Maryland Health Connection Guide

Maryland's health insurance framework is built around Maryland Health Connection — the state's own ACA marketplace — and several distinctive features: the state Premium Assistance program (recently expanded to all ages at 400% FPL), a reinsurance waiver through December 2028 that keeps Maryland's rates among the most competitive nationally, robust required health benefit mandates under Title 15, and the MD LTC tax credit creating a unique LTC-health insurance intersection. Maryland's proximity to DC makes the federal employee/FEHB transition market particularly significant. And Maryland's strong consumer protection orientation (credit history prohibitions, required benefits, mental health parity) creates a regulatory environment that rewards producers who understand state-specific health law.

Maryland Health Connection — The State Exchange

Maryland Health Connection (marylandhealthconnection.gov) is Maryland's state-based ACA marketplace — established under Md. Code, Insurance §§ 31-102-31-207 and administered by the Maryland Health Benefit Exchange (MHBE).

Key distinction: Maryland Health Connection is NOT Healthcare.gov. Maryland is one of approximately 18 states with a state-based exchange. Virginia, Tennessee, and Ohio use Healthcare.gov. Maryland, NJ (Get Covered NJ), MN (MNsure), and Colorado (Connect for Health CO) all operate their own exchanges.

2026 Maryland Health Connection facts:

255,612 enrolled for 2026 coverage (up 3% from record 2025 enrollment)

Maryland led the nation in marketplace enrollment growth for 2026 as Healthcare.gov saw a 9.2% enrollment decline nationally

5 insurers offer 2026 plans (Aetna exited end of 2025 — down from 6 in 2025; ~5,000 Aetna enrollees needed to select replacement coverage for 2026)

Average 2026 rate increase: 13.4% (before subsidies) — partly due to expiration of enhanced federal subsidies at end of 2025

Maryland's reinsurance waiver (through December 2028) has kept MD rates significantly lower than most states

Maryland State Premium Assistance Program

Expanded for 2026:

Previously available only to young adults ages 18-37

Expanded in 2026 to all ages up to 400% FPL

~177,000 enrollees receiving MD state-funded subsidies in early 2026 (up from ~65,000 prior year)

Partially offsets the expiration of enhanced federal subsidies

How Maryland subsidies work with federal APTC:

Federal APTC: available to eligible enrollees based on income

MD state Premium Assistance: additional state-funded subsidy on top of federal APTC

Maryland's state subsidies fully cover losses for enrollees at up to 200% FPL; partially cover losses for 200-400% FPL enrollees

Advisory implication: Maryland Health Connection producers should be fluent in both federal and state subsidy structures — Maryland's two-layer subsidy system (federal + state) is more complex than Healthcare.gov-only states and provides meaningful additional assistance for middle-income clients.

Maryland Medicaid (Expanded)

Maryland expanded Medicaid under the ACA. Adults up to 138% FPL qualify for Maryland Medicaid.

Coverage eligibility routing:

Below 138% FPL → Maryland Medicaid

138-400% FPL → Maryland Health Connection (with federal APTC + potential state Premium Assistance)

Above 400% FPL → Unsubsidized Maryland Health Connection or employer/other coverage

Maryland's Individual Health Insurance Mandate

Maryland does NOT have its own individual mandate. No state tax penalty for being uninsured. This distinguishes Maryland from New Jersey (which reinstated a state mandate in 2019). Maryland relies on outreach, subsidy accessibility, and the tax check-box enrollment program to maintain marketplace enrollment.

Tax return check-box enrollment: Maryland allows residents who indicate on their state tax return that they need health insurance to enroll in coverage through the Maryland Comptroller's program — over 15,000 have enrolled since 2020. Unemployment insurance applicants can also check a box to request health coverage assistance — over 25,000 enrolled since 2022. These unique enrollment pathways are specifically Maryland features.

Required Health Insurance Benefits (Md. Code, Insurance § 15-300 et seq.)

Maryland mandates specific health insurance benefits that state-regulated insurance products must cover:

Benefits for the elderly

Alzheimer's disease treatment

Mental illness treatment

Prescription medications

In vitro fertilization procedures

Disability from pregnancy or childbirth

Breast cancer screenings

Hospice care

Additional mandated benefits beyond ACA minimums

Mental health parity: Both federal MHPAEA and Maryland-specific parity requirements apply — mental health and substance use disorder benefits at parity with medical/surgical.

Federal Employee Health Insurance in Maryland

Maryland's proximity to DC and large federal agency workforce creates specific health insurance advisory contexts:

FEHB transition at separation: Federal employees who leave government service lose FEHB access. Temporary Continuation of Coverage (TCC) provides 18-month continuation at full cost plus 2%. After TCC: Maryland Health Connection SEP triggered by FEHB loss; potential federal and state subsidy if income qualifies.

FEHB at retirement: Federal retirees who retire with FEHB access can continue FEHB into retirement. At age 65, FEHB + Medicare coordination — FEHB typically becomes secondary to Medicare. Many federal retirees with FEHB find they don't need separate Medigap coverage because FEHB serves supplemental functions.

Maryland's large federal civilian workforce:

NIH (18,000+ campus employees): Clinical researchers, scientists, administrative professionals

FDA (~17,000 employees): Regulators and scientists in Silver Spring/White Oak

NSA (Fort Meade): Defense intelligence; exact numbers classified but substantial civilian workforce

SSA (Woodlawn): 60,000+ employees nationally; large Woodlawn, MD campus

Each agency's employees have FEHB coverage during employment; transition planning is an active advisory market at separation and retirement

5 Frequently Asked Questions

• What makes Maryland Health Connection distinctive from Healthcare.gov? Maryland operates its own state-based exchange at marylandhealthconnection.gov, administered by the Maryland Health Benefit Exchange (MHBE). Maryland offers both federal APTC and its own state Premium Assistance subsidies (expanded to all ages at 400% FPL in 2026). 255,612 enrolled for 2026 — record enrollment driven partly by Maryland's state subsidies. Healthcare.gov states (Virginia, Tennessee, Ohio) don't have these additional state-funded subsidies.
• What is Maryland's reinsurance waiver and how does it affect rates? Maryland has a federal reinsurance waiver in place through December 2028 that provides federal funds to cover a portion of high-cost claims. This reinsurance mechanism reduces the cost burden on insurers and allows them to offer lower premiums than they otherwise would. Maryland consistently has among the most competitive individual market rates nationally partly due to this waiver program.
• How does Maryland's 2026 state Premium Assistance expansion affect health advisory? Previously limited to young adults 18-37, Maryland's state Premium Assistance program now covers all ages up to 400% FPL in 2026. This means Maryland clients at 300-400% FPL who would receive no state subsidy in prior years now have access to MD state Premium Assistance — potentially making Maryland Health Connection plans significantly more affordable in 2026 than clients may expect based on past experience.
• What are Maryland's unique health insurance enrollment pathways? Maryland has two distinctive enrollment pathways: (1) State income tax return check-box — Maryland residents can indicate on their state tax return that they need health insurance, triggering enrollment assistance through the Comptroller's program; (2) Unemployment insurance check-box — those filing for unemployment can request health coverage assistance. Over 40,000 have enrolled through these programs combined since 2020.
• Does Maryland have any health insurance mandated benefits beyond ACA requirements? Yes — Maryland mandates several benefits beyond ACA minimums including Alzheimer's treatment, IVF coverage, elderly benefits, and enhanced mental health parity. These state mandates apply to state-regulated fully-insured policies (not self-insured ERISA plans). For producers advising clients on coverage adequacy, Maryland's mandated benefits create a higher floor than ACA alone in fully-insured Maryland plans.

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