Maine Health Insurance: Find Affordable Plans

Residents of Maine searching for affordable health insurance have several options. Your employer may offer private health insurance,  you may purchase insurance on your own, or you may be eligible for Medicare or Medicaid. Learn about your health care coverage options in Maine.

• Health Insurance Marketplace: You can buy affordable health insurance in Maine. Three plans are currently available on the Health Insurance Marketplace. You can purchase health coverage from any insurance company in Maine, but there is no guarantee you will receive the same benefits you get when you buy health care on the Health Insurance Marketplace.
• Enrollment: Open enrollment in the Maine Health Insurance Marketplace lasts from November 1 to January 15. The only way you can enroll in an ACA-compliant health care plan outside of these dates is if you have a qualifying life event such as getting married, having a baby, losing a job, or moving residences.
• Subsidies: The American Rescue Plan has had an impact on health care costs in Maine. In the past, when a family’s income passed the 400% federal poverty Level (FPL) limit on health care subsidies, subsidies dropped off. But that cliff has been removed so once your family’s income passes 400%, subsidies decline gradually.
• Community Health Options: Maine is one of three states in the nation that still has a co-op that sells insurance. Maine’s Community Health Options is a private, nonprofit, state-licensed health insurance carrier. Its plans are sold both on and off Maine’s Health Insurance Marketplace exchange.
• State-based marketplace: Maine runs a state-based marketplace (SMB) for healthcare. The marketplace uses the federal enrollment platform on Healthcare.gov but the state has oversight of the plans that are sold in the exchange. Starting in 2022, Maine plans to transition to a completely state-run exchange.
• Types of plans: Most residents of Maine receive health care coverage through an employer (46%), while a significant number receive health care coverage through Medicaid (20%). The next largest group is Mainers who are on Medicare (18.3%) or who have non-group insurance (5.7%). About 1.5 % receive military coverage. Currently, just over 8% of Mainers are uninsured.

If you want to enroll in a health care plan via Maine’s marketplace, you’ll need to do it on the Healthcare.gov site.

You’ll need to create an account where you’ll be asked for some information to register, including your name, place of work, Social Security number, area of residence, family income, and other relevant information. You’ll need some of this information for every member of your family you are registering.

Once your account is created, you’ll be able to examine as many as three plans at a time to compare features like premiums, coinsurance, copays, and deductibles. This will help you pick the plan that works best for your family.

Three insurance companies are available:

• Anthem
• Community Health Options
• Harvard Pilgrim

Although the process of signing up for health care remains the same whether doing it for yourself or for your family, the questions that you need to consider can be quite different. When making decisions about an individual or a family plan you’ll need to consider things like your overall health, your family’s health, how much you want to pay for a premium, and how much you want to pay out-of-pocket.

Insurance for individuals in Maine

When you’re selecting a health plan for yourself, you have a bit more flexibility than when you’re selecting one for your family. The only person whose health you need to consider is your own. Are your health care needs minimal? You can likely choose a health care plan with a low monthly premium and a high deductible. If you have a chronic condition and frequently visit your primary care physician or specialists, you may be better off selecting a plan with a higher monthly premium and a lower deductible.

The kind of plan that you choose can also make a difference in terms of your healthcare.

• A Health Maintenance Organization plan (HMO) is a good choice if you’re in good overall health because it offers lower up-front costs. The downside is that you’ll have less flexibility in how you use your plan. You’ll need to see in-network medical providers, as well as name a primary care physician, and obtain a referral any time you want to see a specialist.
• Selecting a Preferred Provider Organization (PPO) plan means a higher monthly premium but more personal control. You can use out-of-network providers, and you won’t need a referral to see a specialist or name a primary care physician.
• A Point of Service Plan (POS) offers a bit of a balance between an HMO and a PPO. You’ll need a referral to see a specialist, but you aren’t limited to in-network medical providers.

Regardless of what plan you select, you can earn premium tax credits that lower your monthly premiums if your income is between 100% to 400% of the FPL. You may also be eligible for cost-sharing reductions (CSRs) if you select a silver plan.

Insurance for families in Maine

Health care questions become a little more complex when you’re considering individuals other than yourself and how they fit into a health care plan. You and your spouse may be healthy but perhaps you have children with health issues like asthma or a child who needs mental health care.

Healthy families can probably go with an HMO. This is a good plan if you and your family don’t make many visits to the doctor. However, if a member of your family has a chronic health issue and needs medical treatment on a regular basis, including the potential for many costly prescriptions, a PPO or a POS plan might be a better option.

Ultimately, it boils down to how much you can afford for the monthly payment versus how much you can afford for out-of-pocket expenses like copays, deductibles, and coinsurance.

Prices on the Maine health insurance marketplace in 2021 have declined by as much as 13% in some cases. The Maine marketplace uses the Healthcare.gov metal categories: Bronze, Silver, Gold, and Platinum. There is also a catastrophic level in Maine. The levels signal a difference in how much you’ll pay for premiums and deductibles.

• Bronze plans have low monthly premiums, but high deductibles. You’ll also pay a 40% coinsurance payment each time you use your plan. A Bronze plan is a good choice for you if your current health care needs are minimal. The most affordable bronze plan in Maine has a monthly premium of $372.
• Silver plans have higher premiums but lower deductibles. The coinsurance fee is 30%. However, Silver plans offer other benefits. If you qualify for cost-sharing reductions (CSRs) your deductible payments could be lowered significantly. The lowest-priced monthly Silver plan in Maine is $449.
• A Gold or a Platinum plan could be what you want If you have a lot of chronic health issues and need a plan with a low deductible. However, you will pay quite a bit more in a monthly premium for these plans. Coinsurance payments are lower (only 20% for gold and 10% for Platinum). The lowest-priced Gold plan in Maine costs $507 a month.

In Maine, Medicaid is known as MaineCare, and it also operates the Child Health Insurance Program under the title of SCHIP. These health benefits can be free or very low cost depending upon several factors. MaineCare includes doctor’s visits, emergencies, substance abuse treatment, and prescription drugs.

Medicaid in Maine

Maine expanded Medicaid in February 2019. Overall, Maine has enrolled more than 355,000 individuals in MaineCare and SCHIP.

If you apply for MaineCare, you need to be a U.S. citizen, a permanent resident, or a legal alien. You need to show that you need health insurance assistance, and that your financial situation can be categorized as low-income or very low-income. You are also eligible if you fit in one of the following categories:

• 65 or older
• Blind
• Disabled or responsible for a household member who has a disability
• Pregnant or responsible for child who is 18 years or younger

Under the expanded 2019 guidelines, any adult age 19 to 64 is eligible for MaineCare with a household income that is less than or equal to 133% of the FPL. An individual can earn no more than $18,075 a year, while a family of three is limited to $30,630 a year. Note that for households with more than eight people you can add as much as $6,038 per person to that income limit.

If you are blind or disabled, the limit is 100% of the FPL and if you are working but disabled it is 250%.

There are asset limits as well: $2,000 for an individual, $3,000 for a couple. The limit is based on income and property but does not include one home, furnishings, appliances, and one vehicle.

MaineCare SCHIP

This program provides free or cheap health insurance to families with children or pregnant women.

Eligibility depends on several factors:

• You must be a resident of Maine
• You need to be a primary caregiver who has children aged 18 or younger
• You are aged 18 or younger
• A U.S. citizen, a naturalized citizen, a permanent resident, or legal alien
• You need to be uninsured and not eligible for MaineCare
• Your family’s income must be between 158% and 208% of the FPL

Medicare is the federal government’s healthcare program for people aged 65 and older or those who are disabled. In Maine you have several options on how to receive Medicare.

• Original Medicare, which includes Part A (hospitalization, home care, hospice, and skilled nursing care) and Part B (inclduding ambulance services, mental health care, doctor’s visits, and durable medical equipment). There are no out-of-pocket limits on Original Medicare’s costs. It also does not cover prescription drug costs. If you need regular prescriptions, you can get a Medicare Part D plan. The Medicare Part A deductible for inpatient hospital stays is $1,600 in 2023. Medicare Part B enrollees pay a standard monthly premium of $226 for 2023.
• Medicare Part C is also known as Medicare Advantage. Medicare Advantage offers plans from insurance companies. These plans typically offer vision, dental, and hearing coverage in addition to Original Medicare coverage. Some Medicare Advantage Plans also offer fitness memberships and prescription drug coverage. As of 2023, there are 54 Medicare Advantage Plans available in the state, however, you can only select a plan that’s available in your county.

Medicare Supplement Insurance plans cover some costs that occur with Original Medicare, such as deductibles, copays, and coinsurance. A Medicare Supplement Insurance plan will not cover dental, hearing, or long-term care. Many of these plans will provide you with health coverage if you travel outside the United States. A Medicare Supplement Insurance plan will not work with a Medicare Advantage Plan.

Eligibility

• You must be a US citizen or a permanent resident
• You must be at least 65 or have a qualifying disability
• You qualify if you have certain conditions or diseases like End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

Enrollment

If you start receiving your Social Security or Railroad Retirement Board benefits at least four months before you turn 65, you’ll be automatically enrolled in Medicare. Otherwise, you must fill out an application online or contact your local Social Security office. You can enroll in Medicare during the following periods:

• Initial enrollment: Your initial enrollment period starts three months before your 65th birthday and ends three months after your 65th birthday. If you’ve never had Medicare, you can enroll during this period. If you started receiving Medicare when you were younger, you can also make changes to your plan.
• General enrollment: Choose this enrollment period if you missed your initial enrollment period. The Medicare general enrollment period is January 1 to March 31. You can choose Original Medicare, Medicare Advantage, Medigap, or Part D.
• Medicare Advantage open enrollment: You can make changes to your Medicare Part C, also known as Medicare Advantage, from January 1 to March 31.
• Open enrollment: You can join, switch plans, or drop your coverage from October 15 to December 7 each year.
• Special enrollment periods: You may qualify for a special enrollment period if you lose your coverage or have changes to your eligibility outside the regular enrollment periods.

Medicare Resources

If you need help understanding your Medicare options, you can contact a counselor from the Maine State Health Insurance Assistance Plan (SHIP). SHIP’s trained, volunteer counselors will provide you or your caregiver with free, unbiased, and confidential guidance to better help you understand your Medicaid options. The counselors will also help you understand other health care options and if you are eligible to receive any assistance on prescription drug costs or other out-of-pocket expenses. The counselors do not sell or recommend insurance policies.

Currently, there are no short-term health care policies available in Maine.

• Benefits.gov | Maine MaineCare | Last accessed December 21, 2022
• CMS.gov | Medicare Open Enrollment | Last accessed December 21, 2022
• HealthCare.gov | Deductible | Last accessed December 21, 2022
• HealthCare.gov | Health Maintenance Organization (HMO) | Last accessed December 21, 2022
• HealthCare.gov | Preferred Provider Organization (PPO) | Last accessed December 21, 2022
• HealthCare.gov | Point of Service (POS) Plans | Last accessed December 21, 2022
• HealthCare.gov | The ‘metal’ categories: Bronze, Silver, Gold & Platinum | Last accessed December 21, 2022
• Medicare.gov | Part A & Part B sign up periods | Last accessed December 21, 2022
• Healthcare.gov | Premium Tax Credit | Last accessed December 21, 2022
• Healthcare.gov | Cost-Sharing Reduction | Last accessed December 21, 2022
• Healthcare.gov | Catastrophic Health Plans | Last accessed December 21, 2022
• KFF | Health Insurance Coverage of the Total Population | Last accessed December 21, 2022
• Maine Department of Health and Human Services | 2021 MaineCare Eligibility Guidelines | Last accessed December 21, 2022
• Maine.gov | What You Need to Know about Health Insurance | Last accessed December 21, 2022
• National Academy for State Health Policy | Maine CHIP Fact Sheet | Last accessed December 21, 2022