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Insurance and healthcare consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity products.

Residents of Maine searching for 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.

What to know about insurance in Maine

  • Health Insurance Marketplace: You can buy 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 December 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.

How do I enroll in Maine's health insurance marketplace?

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

How do I enroll in Maine’s individual and family insurance?

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.

How much does health insurance cost in Maine?

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.

Average premium in Maine 2018 2019 2020 2021
Most affordable bronze plan $379 $374 $384 $348
Most affordable silver plan $566 $525 $506 $435
Most affordable gold plan $641 $646 $609 $494

  • 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 $348.
  • 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 $435.
  • 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 $494 a month.
  • Catastrophic plans in Maine are only available to people under 30 or people with a hardship exemption. The lowest-priced plan is currently $206 a month.

What kind of low-income health insurance is available in Maine?

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. As of May 2021 more than 77,000 Maine residents had enrolled in this broader version of Medicaid. Overall, Maine has enrolled more than 312,000 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 $17,131 a year, while a family of three is limited to $29,207 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 low-cost 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

What are Maine’s Medicare options for seniors and people with disabilities?

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.
  • 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.

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

  • Initial Enrollment begins three months before your 65th birthday, the month of your birthday, and three months after birthday.
  • Open Enrollment takes place between October 15 and December 7. You can move from Original Medicare to a Medicare Advantage Plan, return to Original Medicare from a Medicare Advantage Plan, or switch between Medicare Advantage Plans.
  • You are eligible for a Special Enrollment Period if you move out of your county in Maine.

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.

Are there short-term health insurance plan options in Maine?

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

Maine Insurance FAQs

Does Maine require health insurance?

Although the ACA mandates health coverage, the tax penalty for not doing so was eliminated by the Supreme Court in 2019. Currently, Maine does not have its own health insurance requirement.

What types of alternative health insurance plans (like cost-sharing plans) are available in Maine?

Currently the most popular form of cost-sharing plans in Maine are religious-based health care plans. You do not have to be a member of any denomination, or even religious, to sign up for a plan. While these plans are relatively inexpensive, they are not considered to be health care plans by the federal government or the state of Maine. As a result, they remain unregulated. Unlike ACA-compliant plans, cost-sharing plans do not have to provide coverage for certain health care needs. If you are considering purchasing such a plan, make sure you confirm it provides coverage for your health concerns.

Do I need insurance if I have an FSA/HSA?

In most cases yes. It is unlikely that you will be able to save enough money using an FSA or an HSA to pay for all your health care costs. An HSA or FSA can help you with prescription drug costs, copays, and coinsurance, but do not provide coverage for serious health problems.

Do I need short-term disability coverage in Maine if I have health insurance?

It depends upon your job. Short-term disability coverage is not meant to cover health care costs. Instead it is meant to help you with household expenses like your mortgage, groceries, or car payments. If you have a job that makes injury a likelihood, then short-term disability coverage is a good idea.

Do I need long-term disability coverage in Maine if I have health insurance?

Again, it depends upon your job. Any form of disability coverage is not meant to cover long-term healthcare costs. If there is a risk of serious injury on your job, then long-term disability coverage is a good idea.

What does MaineCare SCHIP cover?

MaineCare SCHIP covers dental treatment, well-child exams, lead screenings, all necessary immunizations, and treatment for chronic health conditions or emergencies.

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