Maine Health Insurance Guide
Maine Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
As a resident of Maine you have a variety of private health insurance plans to choose from including individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for Maine State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
Maine is a guarantee issue state for individual policies. That means private insurance companies are forbidden by law to refuse to issue you a health care policy because of current or past health conditions, age, gender or lifestyle. Elimination riders are not permitted. However, insurance companies are permitted a 12-month look-back and exclusionary period for pre-existing conditions. Note that pregnancy is considered a pre-existing condition and can be excluded for up to 10 months. Credit for prior creditable coverage is required. Under Maine law, companies that sell individual health insurance coverage must offer a standardize policy. That means that specific benefits, co-pays and coinsurance percentages of the coverage must be identical from all carriers, although the companies are not prohibited from selling non-standardized individual policies, as well. Premiums for individual policies in Maine are limited and can’t be adjusted because of your age, gender, health, claims history or length of time you’ve had a policy. Insurance companies are allowed to vary premiums by 20% from the adjusted community rate because of where you live in the state, your age, the type of work you do and whether or not you are or have ever been a smoker.
Maine is also a guarantee issue state for group health plans issued to small businesses. If your Maine health insurance is provided through an employer, coverage cannot be denied because of the past or current health of anyone in the group. However, a 12-month exclusionary period and 6-month look-back period for pre-existing conditions can be applied if you don’t have proof of prior creditable coverage. Maine does not allow group health insurance issuers to medically underwrite policies to determine the premium they will charge the entire group. Insurers can, however, adjust rates based on age, where the business is located, the business’s work field and the smoking habits of employees, although the highest premium cannot be greater than 20% of the standard rate.
Maine is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. Insurers are also prohibited from raising the premiums on individual plans at renewal to offset the cost of any claims or new risks you represent.
Maine Mandated Health Benefits
Maine laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism and Drug Abuse Treatment
- Breast Reconstruction
- Cervical Cancer and HPV Screening and Vaccines
- Clinical Trials
- Dental Anesthesia
- Diabetes Supplies
- Emergency Services
- Hearing Aids
- Home Health Care
- Hospice Care
- Lyme Disease
- Mastectomy and Mastectomy Stays
- Maternity and Maternity Stays
- General and Parity Mental Health
- Off-Label and Prescription Drugs
- Orthotics and Prosthetics
- Prostate Cancer Screening
- Rehabilitation Services
- Smoking Cessation
- Coverage for newborns and non-custodial children under parent's policy
- Coverage for continuation/dependents under parent's policy
- Coverage for dependent students under their parent’s policy
- Coverage for domestic partners
- Coverage for continuation/employees
- Coverage for conversion to non-groups
Types Health Insurance Plans Available in Maine
The following major medical health insurance plans are generally available in Maine. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in Maine
- MaineCare is Maine's Medicaid program. It includes Maine's Children's Health Insurance Program (CHIP), which provides MaineCare coverage to children under 18 whose families have a higher household income. It also includes coverage for pregnant women whose gross monthly household income falls below specific limits. Eligibility is based on state residency. There is no waiting period and enrollment is open. Coverage is extremely comprehensive. Premiums are range from free to a maximum of $64 per month, depending on income level. Modest co-pays may be required for some services based on income.
The Maine Bureau of Insurance is responsible for regulating Maine’s health insurance industry.
Get access to Maine health insurance quotes from http://www.EINSURANCE.com/health-insurance
Bureau of Insurance
#34 State House Station
Augusta, ME 04333-0034
(207-624-8475 or (800) 300-5000
Office of MaineCare Services
11 State House Station
Augusta, ME 04333-0011
(207) 624-7539 or (800) 321-5557
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
110 William Street
New York, NY 10038