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A Consumer's Guide To...
Individual Health Insurance In Maine
The Maine Bureau of Insurance
|Paul R. LePage
Eric A. Cioppa
Individual Health Insurance - On and Off the Market Place
The Affordable Care Act (ACA) and the federally facilitated Healthcare Marketplace has brought about changes in the insurance plans offered in the state of Maine.
The ACA’s Individual Mandate and Pre-Existing Conditions
- The ACA requires individuals to have insurance coverage by March 31, 2014,or pay a tax penalty.
- Any Maine resident not eligible for Medicare can buy an individual health insurance policy. (Individuals who need to pay for Medicare Part A can also buy an individual policy). Some people can get help with the cost of a plan on the Marketplace, depending on their income, household size, and whether they are eligible for another kind of coverage.
- For insurance issued on or after January 1, 2014, plans cannot exclude coverage for pre-existing conditions.
If you are eligible for group coverage that meets the ACA’s standards (either through your employment or your spouse’s or parents’ employment, or through membership in an association), you will not be able to get help with the cost of a plan through the Marketplace. You can still buy individual coverage on or off the Marketplace, but you will want to carefully consider whether the group coverage available to you has better benefits, or costs less.
Ten essential health benefits must now be included in all health insurance plans:
|ambulatory patient services
mental health & substance use disorder services rehabilitative and habilitative service and devices preventative/wellness services/chronic disease mgt.
maternity and newborn care
pediatric services, including dental and vision
- Preventive services: Individuals do not pay co-pays, coinsurance or deductibles for certain preventive health services that are provided by network providers. These services include routine immunizations and routine physical exams, including gynecological exams, pediatric eye exams, mammograms, digital rectal exams and routine and medically necessary colorectal cancer screenings
The ACA creates standardized levels of coverage, called “metal levels” — Bronze, Silver, Gold (and, in some states, Platinum) — which allow you to compare plans, offered by different insurance companies. In general, plans with lower cost-sharing will have higher premiums, and vice versa.
- Cost-sharing: This refers to the portion you will have to pay (or “share”) for covered services, at least until you reach the annual out-of-pocket (OOP) limit. Deductibles, co-pays and co-insurance are all types of cost-sharing. (See last page for a glossary of terms.).
||Actuarial Value* (This is the estimated % of total costs your plan will pay)
||Your Expected Cost Share
||20%, up to maximum OOP
||30%, up to maximum OOP
||40%, up to maximum OOP
||100%, up to maxium OOP
* Actuarial Value is the average amount of total cost the plan will cover for your care.
** When purchasing a Silver plan, individuals who qualify for a premium subsidy may also qualify for assistance with out-of-pocket cost-sharing.
*** Catastrophic plans are only available to individuals age 30 and younger, or to those who qualify for a “hardship exemption.”
In general, you only can purchase individual insurance during Open Enrollment periods.
Next Open Enrollment:
Start date: November 15, 2014
End date: February 15, 2015
Special Enrollment Period (SEP)
Even when Open Enrollment is closed, you can purchase a new policy if you do so within 60 days from experiencing one of these events:
· Loss of eligibility for other coverage (due to quitting a job or a lay off, a reduction in hours, loss of student health coverage upon graduation, etc.). Note: Loss due to failure to pay premiums does NOT trigger a special enrollment opportunity.
· Gaining a dependent (due to marriage, birth or adoption of a child, etc.). Note: Pregnancy does NOT trigger a special enrollment opportunity.
· Divorce or legal separation that results in loss of coverage.
· Loss of dependent status (for example, “aging off” a parents’ plan at age 26).
· Moving to another state, or within a state if you move outside of your health plan service area.
· Exhaustion of COBRA coverage.
· Losing eligibility for Medicaid or the Children’s Health Insurance Program (CHIP).
· For people enrolled in a Marketplace plan, income increases or decreases that change eligibility for subsidies.
· Change in immigration status.
· Enrollment or eligibility error made by the Marketplace or another government agency or somebody acting on behalf of the individual enrollee, such as a Marketplace Assistor.
Dependent Coverage - Young Adults:
Insurance companies generally must offer to cover your dependent child up to his or her 26th birthday. Eligibility is not limited if your dependent child is married or has his or her own dependents or files his or her own taxes. Your dependent child also is not required to be a student to qualify for coverage under your plan.
How Much Does It Cost, and Other Factors to Consider
Rates for insurance premiums vary, based on three factors: geographic area, smoking status, and age.
Benefits and Exclusions
Compare benefits, exclusions and premiums carefully when considering different policies. Service is also important to consider. A company who gives superior service may be worth some additional cost.
Some questions to consider when comparing plans:
- What medical providers are part of the network? Is my doctor & preferred hospital in the plan?
- Are out-of-state providers coverd?
- What is the formulary (cost) for different prescription drugs I may need? Are my drugs covered?
- What are the limits on services or on the number of visits to certain types of providers?
- What is the annual out-of-pocket cost?
- Is the plan compatible with a Health Savings Account (HSA)?
- Does the insurer sell their plan on the Marketplace? Am I eligible for a subsidy?
- Are some services exempted from the deductible?
- Is there a separate deductible for prescriptions?
- What is the out-of-network deductible?
- Will I be covered if I travel?
- Is there one deductible for an individual and another for a family?
- Call an insurance broker or agent to compare plans and rates. Note, not all brokers and agents represent all insurers.
- Contact the insurance companies offering plans in Maine. You can call the insurance companies directly to ask questions or to buy your insurance. However, to have a subsidy applied, you must purchase your plan through the Marketplace, rather than directly from the insurance carrier. Please see insurance company contact information on the following page.
- Call the Maine Bureau of Insurance at 800-300-5000, (TTY, please use Maine Relay 711), or visit the Bureau’s website at www.maine.gov/pfr/insurance for more information about your options.
- Visit www.healthcare.gov or call 1-800-318-2596 for answers to questions about the Marketplace and subsidies, . Online chat is also available on HealthCare.gov 24 hours a day.
- Call Consumers for Affordable Health Care at 1-800-965-7476 (TTY:1-877-362-9570) for additional support in understanding the Affordable Care Act and the Marketplace, or visit www.mainecahc.org.
- Find a Marketplace “Navigator” who can help you with your application, at www.enroll207.com/locator.
1The National Association of Health Underwriters provides a list of NAHU-member agents, including those certified to sell plans on the Marketplace, at http://www.nahu.org/consumer/findagent2.cfm and use their search tool. In addition to listing Navigators, the web-based tool www.enroll207.com/locator also provides names of Market-place certified brokers. (These are provided as resources, not endorsements.)
HEALTH CARE PROVIDER NETWORKS IN MAINE
Health Care Provider Networks
The networks available to you are determined in part on where you live. The insurance companies offering plans in Maine offer the following network types:
Preferred Provider Organization (PPO) - The insurer contracts with a network of doctors, hospitals, and other medical providers (“preferred providers”) who agree to accept lower fees. You receive a higher level of benefits if you go to a preferred provider than if you go to a non-preferred provider or an out-of-network provider. Out-of-network services have separate out-of-pocket maximums.
Health Maintenance Organization (HMO) - You must choose a primary care provider (the provider you would see for your annual physical) from a list of participating providers. For any non-emergency hospital or specialty care, you must get a referral from your primary care provider first. The insurer or HMO reviews treatment recommendations to determine whether the hospitalization or treatment is medically necessary. Typically, out-of-network providers are not covered under this type of policy. Expenses for out-of-network services do not count toward your out-of-pocket maximum. Out-of-state providers are not covered.
- “Guided” HMO/POS Option - This has characteristics of both HMOs and PPOs. Like an HMO, you must choose a primary care provider from a list of participating providers, and for any non-emergency hospital or specialty care you must get a referral from your primary care provider first. Like a PPO, you can see an out-of-network provider but you will probably have to pay more than you would to see an in-network provider. Out-of-network and in-network services have separate out-of-pocket maximums. Out-of-state providers may or may not be covered.
Individual Plans Offered in Maine
For plan-specific questions and additional information, please use the phone numbers or website addresses below (current as of July 2014). You may also contact a local independent agent.
NOTE: Anthem and MCHO offer plans both on and off the Health Insurance Marketplace, so you may purchase them directly from the insurance company, from an insurance agent or broker, or through the Marketplace, where you may receive assistance with covering the cost of the premium and cost-sharing.
As always, the plans and rates insurance companies offer in Maine are reviewed and approved by the Bureau of Insurance. You are welcome to call the Bureau at 800-300-5000 with any insurance-related questions.
2014 Plans By Metal Level Offered By Each Carrier
Anthem Blue Cross Blue Shield
Guided Access HMO (South)
Guided Access POS (North)
Maine Community Health Options
Harvard Pilgrim Health Care
A Glossary of Terms
||A health insurance policy with a high deductible
||A percentage of each claim, above the deductible, that is paid by the policyholder.
||The payment that is due at the time you receive a health care service, such as a visit to a doctor’s office, or when you pick up a prescription drug. The copayment is usually a fixed amount ($10, $20, or $30, for example) and may only be part of what you will owe for the service.
||The amount that you are responsible to pay before benefits from the insurance company are payable. Choosing a plan with a higher deductible will lower your premium.
||The date on which an insurance policy coverage starts
||The date on which the policy ends.
||Once you obtain an individual policy it is renewable as long as premiums continue to be paid. If premiums are not paid the insurer can end the policy.
||A health insurance plan that has no network of providers. The insurance company pays a set amount for services and the enrollee pays the rest.
||All Maine residents who are not eligible for Medicare can buy health insurance policies for themselves and/or their families, regardless of their employment or health status.
||Maximum amount a policy will pay either overall or for a particular benefit.
||The doctors, hospitals, therapists, and other health care providers who have signed contracts to provide services to a health plan's members. Members who obtain services from providers outside the network will have to pay more.
||The amount of money an insurance company charges for insurance coverage.
|Usual And Customary Charges
||Usual and customary — also called reasonable and customary — is the fee charged by most of the providers in a given geographical area for a particular service. Most insurance companies pay claims based on a percentage of theses fees.
Other publications are available through:
Maine Bureau of Insurance
34 State House Station
Augsta, Maine 04333
(207) 624-8475 or (800) 300-5000 [in state]
TTY: Please use Maine Relay 711
Visit the Bureau’s website:
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