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A Consumer's Guide To Individual Health Insurance

Published by:

The Maine Bureau of Insurance
34 State House Station
Augusta ME 04333
(207) 624-8475
(800) 300-5000
http://www.maine.gov/pfr/insurance

The Maine Bureau of Insurance regulates the insurance industry to protect and to serve the public.

Paul R. LePage
Governor

Eric Cioppa
Superintendent

 

  1. Who is eligible?
  2. What is available?
  3. What about pre-existing conditions?
  4. What happens if I change my deductible?
  5. What is DirigoChoice?
  6. What is the Pre-Existing Condition Insurance Plan?
  7. What is MGARA?
  8. What are HSAs?
  9. How much does insurance cost?
  10. Rate comparison charts
  11. Benefit comparison charts

INDIVIDUAL HEALTH INSURANCE

Individual health insurance is available in Maine from Anthem Blue Cross and Blue Shield, MEGA Life & Health Insurance Company, and several health maintenance organizations (HMOs). In addition, Maine’s DirigoChoice program offers insurance to individuals with preexisting conditions.
.
This brochure is designed for individuals looking to purchase a new insurance policy. This information will help you understand your options and compare premiums. If you currently are covered by insurance, there are many issues to consider before switching plans. Please refer to the Bureau’s website, www.maine.gov/pfr/insurance, for additional information.

Who is Eligible?

Any Maine resident who is not eligible for Medicare can buy an individual health insurance policy. By law, any individual health insurance policy offered in Maine must be sold to anyone who applies.

If you are eligible for group coverage through your employment or through membership in an association, you may want to think about whether group coverage is better for you or costs less than an individual plan. If you have a small business, look at our publication, “A Consumer's Guide to Small Employers Health Insurance.” A self-employed individual with no employees is considered a small employer. In that situation, however, an insurer or HMO that offers both individual and small group policies can choose which policy to offer you.

Continued Coverage for a Dependent Child Until His/Her 26th Birthday 
Insurance carriers must offer to cover your dependent child up to his or her 26th birthday. Federal law requires health plans to provide an open enrollment period allowing dependents to join the family plan. Eligibility for extended coverage is not limited by marital status, number of dependents, or enrollment as a student; however, if your child has coverage available through their own job, they cannot be added to your plan.

What is Available?

Insurers offer many different policies, varying the services covered, the amount of benefits payable, and the type of managed care provisions included (if any). Managed care policies include provisions intended to reduce costs. Common managed care types include:

Preferred Provider Organization (PPO) - The insurer contracts with a network of doctors, hospitals, and other medical providers (called “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.

Health Maintenance Organization (HMO) - You must choose a primary care physician (the doctor you would see for your annual physical) from a list of participating doctors. For any non-emergency hospital or specialty care, you must get a referral from your primary care physician first. The insurer or HMO reviews treatment recommendations to determine whether the hospitalization is medically necessary.

What about Pre-existing Conditions?

If you do not have health insurance for a 90 day period before buying a new health insurance policy:

Health conditions you had before the start date of the new policy may not be covered for 12 months; this is known as a “pre-existing condition exclusion”. Pre-existing condition exclusions are allowed by law to encourage people to buy insurance before they are sick or hurt. No insurer could stay in business if they collected premiums only from people who sign up once they are already sick. Pre-existing condition exclusions are prohibited for children under age 19.

If you have a pre-existing condition and have been uninsured for six months or more, the Pre-existing Condition Insurance Plan may be able to help you.

If you have health insurance any time during the 90 days before buying a new policy:
You are protected by Maine’s “continuity law”. This law requires insurers to waive pre-existing condition exclusions to the extent you would have been eligible for benefits under your old policy. For example:

  • If your old policy included coverage for physical therapy and the new policy also includes these benefits, you receive benefits for physical therapy under the new policy without a pre-existing condition exclusion.
  • If your old policy did not include physical therapy benefits and the new policy does, then physical therapy for a pre-existing condition may not be covered for the first 12 months under the new policy.
  • If the old policy included physical therapy benefits and the new policy does not, then physical therapy will not be covered under the new policy.

Federal law requires pre-existing condition exclusions to be waived completely under limited circumstances. If you meet all of the following requirements, you are a “federally eligible individual” and do not have to worry about pre-existing condition exclusions regardless of the level of benefits you had under an old health insurance policy:

  • You are not eligible for other coverage such as Medicare, MaineCare, or group coverage through an employer;
  • You had prior coverage under a group health insurance policy and you apply for an individual policy within 63 days after your old coverage ends;
  • You have at least 18 months of prior coverage. This may be entirely under one policy or more than one as long as there was not a gap of more than 63 days when you had no coverage; and
  • You had an option to buy coverage under the Federal "COBRA" law or a similar state law available under your prior plan, you took that option, and the coverage has expired.

What happens if I change my deductible?

You may be able to change your plan’s deductible, but any payments that have been credited towards your original deductible amount may not carry over to the new plan. For example: if your current plan has a $3,000 deductible and you have incurred $2,800 in medical bills, increasing your plan’s deductible to $5,000 may mean that you must pay a full $5,000 before your insurer begins to pay benefits (i.e., you may not be given ‘credit’ for the $2,800 you paid towards your original deductible). If you are changing from a high deductible plan to a low deductible plan, it is important to understand that your lower deductible may not apply for up to 12 months for pre-existing conditions. Regardless of whether you have satisfied any applicable exclusionary period, the higher deductible may be imposed for health conditions existing prior to the effective date of your new, lower deductible, plan. The lower deductible would apply, however, to claims not resulting from pre-existing conditions.

What is DirigoChoice?

DirigoChoice is a PPO plan available to small employers and individuals, provided through HPHC Insurance Company, a subsidiary of Harvard Pilgrim Health Care. While there will be no new enrollment with effective dates after January 1, 2013, individual and small businesses are able to renew their policies (or add dependents or employees) through 2013.

For more information on DirigoChoice, please call toll free (877) 892-8391 or visit the Dirigo website at http://www.dirigohealth.maine.gov/.


What is the Pre-Existing Condition Insurance Plan (PCIP)?

The PCIP is offered through the DirigoChoice program in partnership with Harvard Pilgrim Health Care. The PCIP insures individuals who have been uninsured for six months or more and who have one of 48 pre-existing conditions.

Effective March 1, 2013 there will be no new enrollment in this program.

What is MGARA?

Maine’s healthcare reform law created the Maine Guaranteed Access Reinsurance Association (MGARA). MGARA allows insurance companies to share the costs of insuring individuals with more expensive medical conditions. Some policies will be automatically included in the program based on specific medical conditions, while other policyholders may receive a health statement to fill out regarding their current medical conditions.

What are HSAs?

A Health Savings Account, or HSA, combines a high-deductible health insurance policy with an investment account. There may be income tax benefits to choosing an HSA. To determine the extent of any tax benefits, contact your tax advisor, the IRS, and/or Maine Revenue Services at www.maine.gov/revenue.

How Much Does Insurance Cost?

Insurers and HMOs cannot charge different rates based on gender, health status, claims experience, or policy duration.  Rates may vary based on age, geographic area, and smoking status. The maximum rate differential due to age is a ratio of 3 to 1 beginning on July 1, 2012.  This means that the premium for a policy issued to an older individual can be up to 3 times the amount charged to someone at the youngest age for that same policy. Not all insurers use geographic factors.  When they are used, they are restricted to a ratio of 1.5 to 1. Smoking status may also be applied to the rates and is limited to a ratio of 1.5 to 1.  These factors can be used in combination with a maximum allowed ratio of (3 times 1.5 times 1.5) 6.75 to 1.
The charts below shows monthly sample rates for carriers selling policies in Maine. After July 1, 2012, you can check for updated rates for this brochure on our website at www.maine.gov/pfr/insurance. You can also call the insurance company or an independent agent for rates.

Please note that insurers showing low rates on this chart are not necessarily the lowest cost in all situations. For instance, the rates shown are for single individuals and two-parent families with two children only. Rates for one-parent families and couples without children or with a different number of children are also offered and will vary among different insurers. You can contact the company or an independent agent for these rates, for rates specific to your age, or to find out about other available options offered by the insurers. Be sure to compare benefits, exclusions and premiums carefully when considering different policies. Service is also important to consider when you shop for insurance. A company who gives superior service may be worth some additional cost.

SCAM WARNING: The best protection is prevention.

Know how to identify a scam:

  • Scammers set prices well below market rates, offering deals that are too good to be true.
  • Scammers use documents and materials that resemble those of licensed companies, and their names are often similar to those of legitimate companies.
  • Scammers advertise by fax, e-mail, phone and on the internet.
  • Scammers use confusion around insurance changes to gain access to consumers’ personal information.

If you see an offer that seems too good to be true, it probably is.
Contact the Bureau of Insurance at (800) 300-5000 if you suspect a scam or if you have questions about a company.

 

Rate Comparisons

 

 

Anthem Blue Cross and Blue Shield

Monthly Premium Effective July 1, 2013

 HealthChoice Plus

Telephone Number* 1-800-585-0099

 

 

 

 

 

 

 

 

 

 

 

 

$2,000 Deductible

$3,500 Deductible

$5,000 Deductible

$7,500 Deductible

$12,000 Deductible

Ages

Single

Family

Single

Family

Single

Family

Single

Family

Single

Family

0 - 18

$213.31

$625.05

$186.46

$546.47

$167.90

$491.97

$138.57

$406.04

$107.00

$313.55

19 - 24

$224.80

$658.71

$196.53

$575.89

$176.94

$518.46

$146.03

$427.90

$112.76

$330.43

25 - 29

$243.50

$713.52

$212.89

$623.18

$191.66

$561.60

$158.18

$463.51

$122.15

$357.93

30 - 34

$265.82

$778.91

$232.40

$680.98

$209.22

$613.07

$172.68

$505.98

$133.34

$390.73

35 - 39

$292.40

$856.80

$255.64

$749.08

$230.15

$674.38

$189.94

$556.58

$146.68

$429.80

40 - 44

$328.17

$961.62

$286.91

$840.72

$258.30

$756.88

$213.18

$624.67

$164.62

$482.38

45 - 49

$379.04

$1,110.67

$331.38

$971.03

$298.34

$874.20

$246.22

$721.49

$190.14

$557.15

50 - 54

$455.17

$1,333.77

$397.94

$1,166.08

$358.26

$1,049.79

$295.68

$866.42

$228.33

$669.06

55 - 59

$548.70

$1,607.83

$479.71

$1,405.68

$431.88

$1,265.50

$356.44

$1,044.45

$275.24

$806.54

60+

$674.06

$1,975.17

$589.31

$1,726.84

$530.55

$1,554.63

$437.87

$1,283.07

$338.13

$990.81


DirigoChoice (offered through
Harvard Pilgrim)
Telephone Number* 877-892-8391
For more information on DirigoChoice or the PCIP, please call toll free (877) 892-8391 or visit the Dirigo web site at http://www.dirigohealth.maine.gov/.

MEGA Life & Health Insurance Co. Telephone Number* 800-527-5504, Option 1 “Insureds”. When it asks for your Insurance ID #, verbally say “Representative.” The recording will then respond by saying, “did you say representative, if so press 1”. Press 1.
Signature Plan
(Basic Medical-Surgical Expense Plan)

Benefit Options: As indicated in the Benefit Comparison Chart at the end of this brochure, these plans are available with a number of different options with respect to certain benefit levels.

**Rates listed below are for new policies effective 03/01/13**

Individual Deductible / Coinsurance / Coinsurance Maximum $5,000 / 80% /
$5,000
$7,500 / 80% /
$10,000
$10,000 / 50% /
$10,000
Ambulatory Care (deductible)1 $500 $1,000 No coverage
Doctor Office Visits ($50 copay)1 Yes No coverage No coverage
Emergency Services (Copay)1 $500 $500 $500
Air Ambulance1 Yes Yes Yes
Single Premium1   Nonsmoker $502.66 $368.70 $279.26
Smoker $579.28 $422.57 $317.91
Family Premium1   Nonsmoker $1,244.04 $892.08 $673.64
Smoker $1,397.28 $999.82 $750.94
1 Optional rider
Sample rates are based on a community rate.
A one-time application fee of $50 is added to the above rates.

HMOs   Standard Plan A Standard Plan B Telephone Number*
    Single Family Single Family
Aetna Health   $1,167.49 $3,188.13 $967.35 $2,641.58 800-435-8742
Harvard Pilgrim   $2,143.99 $6,431.98 $1,715.20 $5,145.59 800-208-1221

 

Benefit Comparison Charts

The following pages contain charts showing some of the benefits included in the Standard plans for HMO policies and for other policies. Also shown are benefits included in some non-standardized plans offered by Anthem Blue Cross & Blue Shield and by MEGA Life & Health Insurance Company. Other benefits may be available at an extra premium. 

Benefits vary widely among policies. Compare benefits carefully before choosing a policy.


BENEFIT

ANTHEM HEALTHCHOICE PLUS

DIRIGO CHOICE

MEGA SIGNATURE PLAN
(High Deductible Policy)

Deductible Network Non-Network Benefits are paid after the individual or family deductible has been met. The family deductible is met when total expenses paid for all family members exceed two times the individual deductible. Benefits are paid after the individual or family deductible has been met. The family deductible is met when three family members meet the individual deductible.
Benefits paid after the individual or family deductible is met. For family contracts, no one person contributes more than the individual deductible to the aggregate deductible.  

Non-network and network deductibles are satisfied separately.

 

Available Deductibles Individual:  $2,000—$12,000
Aggregate Family: $4,000—$24,000
Individual: $2,000—$12,000
Aggregate Family: $4,000—$24,000
Varies by income $5,000, $7,500, $10,000 per calendar year
Plan Coinsurance

30% 
(20% for  the $12,000 deductible plan)

40% 20% to out-of-pocket limit, which varies by income, then 0% Choice of 20% to $2,000, $5,000 or $10,000, then 0%; or 50% to $5,000, $10,000, or $20,000, then 0%.
Out of Pocket Limit Individual:  $6,000—$14,000
Aggregate Family: $8,000—$26,000
Individual:  $9,500—$19,500
Aggregate Family: $11,500—$31,500
Varies by income

Once Coinsurance Maximum for the calendar year is met, covered expenses for the calendar year are paid at 100%.

Note: deductibles and copayments do not count toward meeting the Coinsurance Maximum.

Network and non-network Out of Pocket Limits must be satisfied separately.
For family policies, no one person contributes more than the individual Out of Pocket Limit to the aggregate Out of Pocket Limit.
Lifetime Maximum No limit No limit No limit
Substance Abuse

Inpatient: combined (mental health and substance abuse) limit of 20 days ², subject to policy deductible ³ and coinsurance. Prior authorization is required for non-emergency inpatient admissions. Without prior authorization, preadmission penalty applies.

Outpatient: combined (mental health and substance abuse) limit of 25 days, subject to policy deductible ³ and coinsurance.

Note: Maine law requires that mental health benefits be equal to those available for physical illness when an individual has a diagnosis of schizophrenia, bipolar disorder, pervasive developmental disorder, or autism, paranoia, panic disorder, obsessive-compulsive disorder, or major depressive disorder. Benefits for the treatment or diagnosis of one of the above mental illnesses will not be subject to a limit on days of treatment.

Same as physical illness Not covered unless optional rider is purchased.
Mental Health Listed conditions: Same as physical illness.
Non-listed conditions: 80% after $150 deductible.
Not covered unless optional rider is purchased.
Maternity Subject to policy deductible and coinsurance. Prenatal services covered as preventive care. Subject to policy deductible and coinsurance. Not covered, except complications of pregnancy.
Preventive Care Covered at 100%; no copayment or deductible. Covered at 100%; no copayment or deductible. Covered at 100%; no copayment or deductible.
Chiropractic Care

15 visits per calendar year covered ³, subject to policy deductible and coinsurance.

40 visits per calendar year; subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance.
Prescriptions

Subject to $1,000 prescription deductible ³
Out of pocket limits (separate from Medical Out of Pocket Limit)
Individual: $3,500 and Family:$7,000

No deductible or coinsurance. Co-pay of $10 for generic, $25 for brand name, and $40 for optional brand name drugs. Not covered

Once annual deductible satisfied:
Retail Pharmacy (up to a 30 day supply): 40% coinsurance
Voluntary Mail Order (up to a 90 day supply): 40% coinsurance

Once annual deductible satisfied:
Retail Pharmacy (up to a 30 day supply): 50% coinsurance
Voluntary Mail Order (up to a 90 day supply): 50% coinsurance

Generic prescriptions are required if available. If a brand name drug is purchased when a generic is available, the member pays the difference between the generic and the brand name.

Emergency Room Care Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance. Only for emergency medical condition. Subject to copay of $250 or $500 and policy deductible and coinsurance. Deductible waived if optional rider purchased.
Inpatient Hospital Services

Subject to policy deductible and coinsurance. No limit on number of days. 
Prior authorization is required for non-emergency inpatient admissions. Without prior authorization, Pre-Admission Penalty applies.

Subject to policy deductible and coinsurance. No limit on number of days. Subject to policy deductible and coinsurance. No limit on number of days.
Outpatient Surgical Facility Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance.
Surgeon Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance.
Ambulance Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance.
Physician's Care While Hospitalized Subject to policy deductible and coinsurance. Subject to policy deductible and coinsurance. Inpatient doctor visits limited to one per day.
Physician's Office Visits Subject to policy deductible and coinsurance. 100% after $20 copayment.
Deductible does not apply.
Not covered unless optional rider is purchased.
Skilled Nursing Care

100 days per calendar year covered³ , subject to policy deductible and coinsurance.

100 days per calendar year; subject to policy deductible and coinsurance. Not covered.
Home Health Care

90 visits per calendar year covered³ , subject to policy deductible and coinsurance.

Subject to policy deductible and coinsurance. Subject to the policy deductible and coinsurance.
¹ If you use a non-network provider without Anthem’s authorization, you may be responsible for charges in excess of what Anthem will pay.
The amount you owe could be substantial.
² Two days of day treatment equals one day of inpatient care.
³ Network and non-network combined.

HMO Standard Plans A & B

BENEFIT HMO STANDARD PLAN A
(Offered by HMOs)
HMO STANDARD PLAN B
(Offered by HMOs)
Deductible Not applicable Not applicable
Plan Coinsurance Not applicable Inpatient only: 80% to $2,000 then 100%
Lifetime Maximum Not applicable Not applicable
Substance Abuse No lifetime maximum.
Inpatient: 30 day calendar year maximum.
Outpatient: $1,000 per calendar year; $10 copayment per visit.
No lifetime maximum.
Inpatient: 15 day calendar year maximum.
Outpatient: $500 calendar year; $25 copayment per visit.
Mental Health No lifetime maximum.
Inpatient: 30 day calendar year maximum.
Outpatient: $1,000 per calendar year; $10 copayment per visit.
No lifetime maximum.
Inpatient: 15 day calendar year maximum.
Outpatient: $500 calendar year; $25 copayment per visit.
Preventive Care Covered expenses are payable at 100%. Covered expenses are payable at 100%.
Chiropractic Care Subject to $10 co-payment per visit. Subject to $15 co-payment per visit.
Prescriptions $10 co-pay for generic drug and
$20 co-pay for brand name drugs.
$20 co-pay for generic drug and $30 co-pay for brand name drugs.
Emergency Room Care Subject to $50 co-pay if not confined to the hospital. Subject to $150 co-pay if not confined to the hospital.
Inpatient Hospital Services No limit on number of days.
$250 co-payment per day for first 5 days per year.
60 days per calendar year.
$250 co-payment per day.
Coinsurance: 80% to $2,000, then 100%.
Physician's Care Subject to $10 co-payment for office visits. Subject to $25 co-payment for office visits.
Skilled Nursing Care 100 days per calendar year;
$25 co-payment per day.
Not covered.
Home Health Care 100 visits per calendar year;
$10 co-payment per visit.
100 visits per calendar year;
$25 co-payment per visit.

* Phone numbers are current as of May 1, 2012; however, because numbers change without notice, you may have to contact a local independent agent for policy information.

ADDITIONAL RESOURCES

For help with finding the right health insurance for you, or just learning more about what options are available, the U.S. Department of Health and Human Services offers an online tool, at: http://finder.healthcare.gov/ .

Individual Health Insurance Carriers:
For plan-specific questions and additional information, please use the numbers below. Phone numbers are current as of May 1, 2012; however, because numbers may change without notice, you may also contact a local independent agent for policy information.

Company Telephone Number
Anthem Blue Cross and Blue Shield (800) 585-0099
Dirigo Health (877) 892-8391
MEGA Life & Health Insurance Co. (800) 527-5504
Aetna Health [HMO plan] (800) 435-8742
Harvard Pilgrim [HMO plan] (888) 333-4742


Since 1870, the Bureau of Insurance has overseen and regulated the business activities of insurance companies, producers, consultants, and adjusters in our state.

To ensure that the marketing of insurance is lawful and honest, policies and premiums are reasonable and just, and the payment of legitimate claims is dependable and timely, the Bureau is organized into the following work units: Property and Casualty, Consumer Health Care, Life and Health Actuarial, Market Conduct, Legal, Financial Examination, Financial Analysis, Alternative Risk, Research and Statistics, Licensing, and Administration.

Other publications are available through:

The Bureau of Insurance
34 State House Station
Augusta, Maine 04333
(207) 624-8475
(800) 300-5000
[in-state]

 

 


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Last Updated: September 12, 2013