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Consumer 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/insurance
The Maine Bureau of Insurance regulates the insurance industry to protect and to serve the public.
Paul R. LePage
Governor
Eric Cioppa
Superintendent
- Who is Eligible?
- What is Available?
- What about Pre-existing Conditions?
- What is DirigoChoice?
- What are HSAs?
- How Much Does Insurance Cost?
- Standardized Major Medical Plans
- Non-Standardized Plans
- HMO Plans
- 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 may offer subsidies to eligible individuals and small businesses. This brochure will help you understand your options and compare premiums.
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 want to replace your current policy with a different policy, you can do this at any time.
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 your situation 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. However, in that situation, an insurer or HMO that offers both individual and small group policies can choose which one to offer you.
Continued Coverage for Dependent Children up to age 25 - If you buy a policy after September 23, 2010, or continue an existing policy after January 1, 2011, it must offer to continue to cover your dependent child up to his or her 26th birthday. The new federal law requires health plans to provide an open enrollment period allowing dependents to join the family plan. Companies must provide notice of this open enrollment period. Eligibility for extended coverage is not limited by marital status, number of dependents, or enrollment as a student; however, if your dependent has coverage available through their own job, they cannot be added to your plan.
What is Available?
Insurers offer a variety of policies, varying according to the services covered, the amount of benefits payable, and the type of managed care provisions included (if any). Managed care refers to a variety of provisions intended to reduce costs. Common managed care provisions include:
- Utilization Review - Typically, you must call a toll-free number to receive approval before going into a hospital for non-emergency care. The insurer or HMO reviews treatment recommendations to determine whether the hospitalization is medically necessary.
- 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.
- Health Maintenance Organization (HMO) - You must choose a primary care physician (the doctor you’d 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.
Besides other policies they offer, all insurers and HMOs must offer “Standard Plan A” and “Standard Plan B”. These two policies have standardized benefits which are established by law. Standard Plan B pays lower benefits and is less expensive than the Standard Plan A. Insurers must offer you both plans with a choice of deductibles* ranging from $250 to $1500. Both plans cover preventive care with no deductibles or co-payments.
*Most HMOs do not use deductibles; however, they may require co-payments for specific services.
What about Pre-existing Conditions?
If you do not have health insurance 90 days before buying a new health insurance policy...
- Any health condition you had before the effective 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 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 are collecting insurance benefits.
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 passed in 1997 requires pre-existing condition exclusions to be waived completely under limited circumstances. If you meet all of the following requirements, you don’t 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 coverage under the group policy 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.
- You had an option for continuation of coverage under the Federal "COBRA" law or a similar state law available under your prior plan, you elected that option and the coverage has expired.
What is DirigoChoice?
DirigoChoice was created as part of the Dirigo Health Reform Act, which is intended to lower health care costs, increase access to health care, and ensure high quality health care. DirigoChoice is a PPO plan available to small employers and individuals, currently provided through HPHC Insurance Company, a subsidiary of Harvard Pilgrim Health Care. Everyone is eligible, and those with low incomes qualify for reduced premiums and deductibles. Coverage for individuals, self-employed and small businesses may be available through the Dirigo Health Agency. Mainers who are uninsured or underinsured and have incomes below 300 percent of the federal poverty level ($32,490 for an individual; $66,150 for a family of four) may qualify for subsidies. Assistance may also be available through:
- Health Care Tax Credits, available for workers displaced by foreign trade
- A high-risk pool for those people who are uninsured with pre-existing conditions
- Vouchers for part-time, uninsured workers to help pay for coverage from any insurance company in Maine if they work for businesses that offers it.
Enrollment may be limited - for more information on DirigoChoice or to be notified when subsidized coverage is available, please call toll free (877) 892-8391 or visit the Dirigo website at http://www.dirigohealth.maine.gov/.
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 (207-287-2076).
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 and geographic area, but no rate may be more than 20% above or below the "community rate." The "community rate" is a baseline rate set by the insurer or HMO and will be different for each insurer and for each plan of benefits. The "community rate" also changes for different types of family units. For example, there may be one rate for an individual; another rate for an individual with children; a third rate for an individual and spouse; and another rate for an individual with a spouse and children. There may also be different community rates for smokers and non-smokers.
The chart below shows the monthly individual community rates for all available carriers. The rates shown were current as of July 1, 2011. After this date, you can check for updated rates for this brochure on our website at www.maine.gov/insurance or you can call the 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 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 blast 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. |
Standardized Major Medical Plans (Community rates – actual rate may be up to 20% higher or lower based on age and geographic area)
| Plans |
Standard Plan A |
| Individual Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
| Anthem Blue Cross & Blue Shield Telephone Number* 800-547-4317 |
| Single Premium |
|
$965.35 |
$951.67 |
$924.33 |
$896.98 |
| Family Premium |
|
$2,439.44 |
$2,404.87 |
$2,335.78 |
$2,266.67 |
| Plans |
Standard Plan A |
| Individual Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
| 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. |
| Single Premium |
|
Nonsmoker |
$1,279 |
$1,268 |
$1,245 |
$1,222 |
| Smoker |
$1,497 |
$1,483 |
$1,457 |
$1,430 |
| Family Premium |
|
Nonsmoker |
$3,191 |
$3,164 |
$3,108 |
$3,052 |
| Smoker |
$3,626 |
$3,595 |
$3,531 |
$3,468 |
Sample rates are based on a community rate.
A one-time application fee of $50 is added to the above rates. |
| Plans |
Standard Plan B |
| Individual Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
| Anthem Blue Cross & Blue Shield Telephone Number* 800-547-4317 |
| Single Premium |
|
$834.68 |
$820.99 |
$793.64 |
$766.28 |
| Family Premium |
|
$2,109.24 |
$2,074.64 |
$2,005.53 |
$1,936.39 |
| Plans |
Standard Plan B |
| Individual Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
| 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. |
| Single Premium |
|
Nonsmoker |
$1,060 |
$1,049 |
$1,026 |
$1,008 |
| Smoker |
$1,240 |
$1,228 |
$1,201 |
$1,179 |
| Family Premium |
|
Nonsmoker |
$2,654 |
$2,627 |
$2,571 |
$2,526 |
| Smoker |
$3,015 |
$2,984 |
$2,920 |
$2,868 |
Sample rates are based on a community rate.
A one-time application fee of $50 is added to the above rates. |
Non-Standardized Plans (Community rates – actual rate may be up to 20% higher or lower based on age and geographic area)
Note: Benefits vary widely among policies. A comparison of benefits
is shown on the two charts at the end of this brochure.
Anthem Blue Cross & Blue Shield HealthChoice (High Deductible Major Medical Plan)
Telephone Number* 800-547-4317 |
| Individual Deductible |
|
$2,250 |
$5,000 |
$10,000 |
$15,000 |
| Single Premium |
|
$659.05 |
$462.67 |
$342.46 |
$218.25 |
| Family Premium |
|
$1,667.71 |
$1,171.46 |
$867.69 |
$553.81 |
DirigoChoice (offered through
Harvard Pilgrim) |
Telephone Number* 877-892-8391 |
| Enrollment may be limited. For more information on DirigoChoice or to be notified when subsidized coverage is available, 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. |
| Individual Deductible / Coinsurance / Coinsurance Maximum |
$3,500 / 80% /
$2,000 |
$5,000 / 80% /
$5,000 |
$7,500 / 80% /
$10,000 |
$10,000 / 50% /
$10,000 |
| Ambulatory Care (deductible)1 |
$500 |
$500 |
$1,000 |
No coverage |
| Doctor Office Visits ($50 copay)1 |
Yes |
Yes |
No coverage |
No coverage |
| Emergency Services (Copay)1 |
$250 |
$500 |
$500 |
$500 |
| Air Ambulance1 |
Yes |
Yes |
Yes |
Yes |
| Single Premium1 |
|
Nonsmoker |
$452.71 |
$405.53 |
$301.64 |
$226.60 |
| Smoker |
$520.81 |
$465.62 |
$344.08 |
$256.26 |
| Family Premium1 |
|
Nonsmoker |
$1,124.35 |
$1,005.55 |
$730.87 |
$544.23 |
| Smoker |
$1,260.55 |
$1,125.73 |
$815.75 |
$603.55 |
1 Optional rider
Sample rates are based on a community rate.
A one-time application fee of $50 is added to the above rates. |
HMO Plans (Community rates – actual rate may be up to 20% higher or lower based on age and geographic area)
| 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 |
800-234-8454 |
| Harvard Pilgrim |
Current |
$1,685.26 |
$5,055.77 |
$1,348.20 |
$4,044.61 |
800-208-1221 |
Effective
12/1/11 |
$2,003.15 |
$6,009.45 |
$1,602.52 |
$4,807.56 |
| HMO Maine (Anthem Blue Cross/Blue Shield) |
|
$1,901.48 |
$5,038.92 |
$1,544.79 |
$4,093.69 |
800-547-4317 |
* Phone numbers are current as of December 1, 2010; however, since numbers change without notice, you may have to contact a local independent agent for policy information.
Benefit Comparison Charts
The following two charts show some of the benefits that are included in the Standard plans for HMO policies (second chart) and for other policies (first chart). 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 these policies. Compare benefits carefully before choosing a policy.
| BENEFIT |
STANDARD PLAN A |
STANDARD PLAN B |
ANTHEM HEALTHCHOICE
(High Deductible Policy) |
DIRIGO CHOICE |
MEGA SIGNATURE PLAN (High Deductible Policy) |
| Deductible |
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 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. |
| Available Deductibles |
$250, $500, $1,000, $1,500 per calendar year |
$250, $500, $1,000, $1,500 per calendar year |
$2,250, $5,000, $10,000, $15,000 per calendar year |
Varies by income |
$3,500, $5,000, $7,500, $10,000 per calendar year |
Plan Coinsurance
80% to $1,000 then 100%
60% to $1,000 then 100%
None
80% to out-of-pocket limit, which varies by income, then 100%
Choice of 80% to $2,000, $5,000 or $10,000, then 100%; or 50% to $5,000, $10,000, or $20,000, then 100%. |
| Lifetime Maximum |
No limit |
No limit |
No limit |
No limit |
No limit |
| Substance Abuse |
Inpatient: calendar year maximum of 30 days.
Outpatient: calendar year maximum of $1,000. |
Inpatient: calendar year maximum of 15 days.
Outpatient: calendar year maximum of $500. |
Inpatient: 80%; limited to 31 days a year.
Outpatient: 50%; limited to 25 visits a year. |
Same as physical illness |
Not covered unless optional rider is purchased. |
| Mental Health |
Inpatient: 30 day maximum per calendar year.
Outpatient: $1,000 calendar year maximum @ 50% coinsurance. |
Inpatient: 15 day maximum per calendar year.
Outpatient: $500 calendar year maximum @ 50% coinsurance. |
Inpatient: 80%; maximum 31 days a year.
Outpatient: 50%; limited to 25 visits a year. |
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. |
Subject to policy deductible and coinsurance. |
100% after the deductible is met. |
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. |
Covered at 100%; no copayment or deductible. |
Covered at 100%; no copayment or deductible. |
| Chiropractic Care |
36 visits per calendar year; subject to policy deductible and coinsurance. |
18 visits per calendar year; subject to policy deductible and coinsurance. |
100% after the deductible is met; limit of 25 manipulations per calendar year. |
40 visits per calendar year; subject to policy deductible and coinsurance. |
Subject to policy deductible and coinsurance. |
| Prescriptions |
Subject to policy deductible and coinsurance. |
No deductible or coinsurance.
Co-payment of $20 for generic drugs and $30 for brand name drugs. |
100% after the deductible is met. |
No deductible or coinsurance.
Co-pay of $10 for generic, $25 for brand name, and $40 for optional brand name drugs. |
Not covered |
| Emergency Room Care |
Subject to $50 co-pay if not confined to the hospital. Subject to policy deductible and coinsurance. |
Subject to $75 co-pay if not confined to the hospital. Subject to policy deductible and coinsurance. |
100% after the deductible is met. |
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. |
Subject to policy deductible and coinsurance; limited to 60 days per calendar year. |
100% after the deductible is met. No limit on number of days. |
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. |
100% after the deductible is met. |
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. |
100% after the deductible is met. |
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. |
100% after the deductible is met. |
Subject to policy deductible and coinsurance. |
Subject to policy deductible and coinsurance. |
| Physician's Care While Hospitalized |
Covered subject to the policy deductible and coinsurance. |
Covered subject to the policy deductible and coinsurance. |
100% after the deductible is met. |
Subject to policy deductible and coinsurance. |
Inpatient doctor visits limited to one per day. |
| Physician's Office Visits |
Covered subject to the policy deductible and coinsurance. |
Covered subject to the policy deductible and coinsurance. |
100% after the deductible is met. |
100% after $20 copayment.
Deductible does not apply. |
Not covered unless optional rider is purchased. |
| Skilled Nursing Care |
100 days per calendar year. |
Not covered. |
100% after the deductible is met; limit 365 days (calendar year). |
100 days per calendar year; subject to policy deductible and coinsurance. |
Not covered. |
| Home Health Care |
100 visits per calendar year;
covered at 80%. |
100 visits per calendar year;
covered at 60%. |
100% after the deductible is met; limit 90 visits per calendar year. |
Subject to policy deductible and coinsurance. |
Subject to the policy deductible and coinsurance. |
| 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. |
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
Visit the Bureau's Web Site at www.maine.gov/insurance
> Return to Brochures
Last Updated:
December 8, 2011
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