Health Insurance Marketplace in Maine
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Maine has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Maine’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Who can help you (the Navigators)
Western Maine Community Action, Inc. is a private non-profit community agency and is the lead for a state-wide consortium of eight community action agencies, collectively referred to as the WMCA Community Action Navigator Consortium. Funds will be used to create a statewide network of education, outreach and enrollment assistance available and accessible to every uninsured and under-insured individual in Maine.
Fishing Partnership Health Plan (FPHP) is a health plan developed that provides subsidized coverage to uninsured commercial fisherman, many of whom operate as small business owners or employees. FPHP, in collaboration with the Maine Lobstermen’s Association, will undertake a series of community health navigation activities, including: outreach; social marketing; distribution of material describing the program, the Affordable Care Act, and the health insurance enrollment process.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
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Consumer Operated and Oriented Plan Program
Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets. CO-OP in Maine:
Accountable Care Organizations in Maine
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- Trustees Of Dartmouth College ME – Health Care Innovation Award
- Innovative Oncology Business Solutions, Inc. MEME – Health Care Innovation Award
- Maine Medical Center Portland, ME – BPCI Initiative: Model 2
- The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC ME – Community-based Care Transition Program
- Fish River Rural Health Eagle Lake, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Health Access Network-Medway Medway, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- HealthReach Community Health Centers dba Bingham Area Health Center Bingham, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- HealthReach Community Health Centers dba Madison Area Health Center Madison, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- HealthReach Community Health Centers dba Mt. Abram Regional Health Center Kingfield, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- HealthReach Community Health Centers dba Rangeley Family Medicine Rangeley, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Katahdin Valley Health Center Patten, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- HealthReach Community Health Centers dba Strong Area Health Center Strong, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Sebasticook Family Doctors – Canaan Canaan, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Sebasticook Family Doctors – Dexter Dexter, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Sebasticook Family Doctors – Pittsfield Pittsfield, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- St. Croix Regional Family Health Center Princeton, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Katahdin Valley Health Center Island Falls, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- HealthReach Community Health Centers dba Western Maine Family Health Center Livermore Falls, ME – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Beacon Health, LLC Brewer, ME – Pioneer ACO
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Maine
On November 16, 2012, Governor Paul LePage (R) wrote in a letter to federal officials that Maine would not be pursuing efforts to implement a state-based health insurance exchange.1 Legislation establishing a state-run health insurance exchange failed to pass in 2011 and 2012.
Prior to ending planning efforts, the Governor created an exchange Advisory Committee in July 2011, which included representatives from small businesses, the insurance and hospital industries, and providers, to provide recommendations and suggest exchange legislation to the Governor and the Joint Standing Committee on Insurance and Financial Services (LD 1582).2 A few months later, the Governor’s Office released a memorandum in September 2011, expressing preference for an exchange to be established within the Department of Professional and Financial Regulation, under the authority of the Director of the Department.3 Soon thereafter, the Advisory Committee released final recommendations and suggested legislation which mirrored the Governor’s memorandum.4
Contracting with Plans: On March 18, 2013, Superintendent of Insurance Eric Cioppa sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) announcing Maine’s intent to perform plan management functions, despite not having entered into a state-federal partnership exchange. The Bureau of Insurance will license carriers, review rates, and verify carrier compliance with Exchange eligibility requirements, state law mandates, and essential health benefits. The Bureau also intends to resolve consumer complaints, provide technical assistance to carriers, and carry out market conduct and solvency analyses. Superintendent Cioppa attested that Maine has the legal authority and functional capacity to execute plan management activities, as required by the Affordable Care Act.5
Navigator Program: Despite the decision not to pursue a state-based exchange, on April 13, 2012, the Governor signed legislation creating a Navigator program for an exchange operating in the state (LD 1497).6 The program would allow brokers to act as Navigators in the exchange and would require others who want to serve as Navigators to register or obtain a limited license- with the criteria for certification to be determined by the superintendent of insurance.
Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. Since Maine has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Anthem (Blue Cross Blue Shield of Maine)- Blue Choice PPO.
In September 2010, the Governor’s Office of Health Policy and Finance received the federal Exchange Planning grant of $1 million. In addition, Maine is a member of the consortium of New England states that received a federal Early Innovator Grant of $36 million to develop, share, and leverage insurance exchange technology. The multi-state consortium also includes Connecticut, Rhode Island, Vermont, and Massachusetts with the University of Massachusetts Medical School as the grant holder.7 In November 2011, the Dirigo Health Authority was awarded a $5.8 million federal Level One Establishment grant to design and begin to build business operations and information technology systems for the Exchange and Medicaid.8 However, the Governor indicated in April 2012 the state would not spend the grant money.9
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
Maine is not participating in Medicaid expansion.
On March 29, 2013, Maine received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.10
For more information on Maine’s exchange planning efforts, visit: http://www.dirigohealth.maine.gov/Pages/exchange_planning.html
1. Governor LePage. Maine Issues Letter to Federal Health Officials Opting Out of Health Insurance Exchanges. November 16, 2012. http://content.govdelivery.com/bulletins/gd/MEGOV-5cfe96#.UKZvoA8Yogk
2. LD 1582. Resolve, Creating the Advisory Committee on Maine’s Health Insurance Exchange. Signed July 6, 2011. http://www.mainelegislature.org/legis/bills/display_ps.asp?LD=1582&snum=125
3. State of Maine Department of Professional and Financial Regulation. Memorandum. September 13, 2011.http://www.dirigohealth.maine.gov/Documents/Health%20Exchange%20recommendation.pdf
4. Recommendations Regarding the Maine Health Benefit Exchange. Report to the Governor and the Joint Standing Committee on Insurance and Financial Services. September 20, 2011.
5. Letter from Superintendent Cioppa to Gary Cohen. March 18, 2013.
6. H.P. 1098 – L.D. 1497. 2012 Session. An Act Relating to Navigators under Health Benefit Exchanges. http://www.mainelegislature.org/legis/bills/getPDF.asp?paper=HP1098&item=7&snum=125ME
7. Massachusetts Application for the Cooperative Agreement to Support Innovative Exchange Information Technology Systems. New England States Collaborative Insurance Exchange Systems. December 22, 2010.
8. Maine Level One Establishment grant Project Narrative. September 29, 2011.http://www.dirigohealth.maine.gov/Documents/ME_L1_Project_Narrative_09292011_FINAL.pdf
9. Letter from Governor LePage to Katherine Bryant (CCIIO). April 18, 2012. PoliticoPro.
10. Letter from Gary Cohen to Superintendent Cioppa. March 29, 2013.
Also of interest
Provided by the Henry J. Kaiser Family Foundation