A Consumer’s Guide to Individual Major Medical Insurance In Maine.

Any Maine resident who is not eligible for Medicare can buy an individual health insurance policy.

Tax Credits:
Some people can get help with paying for a plan that is purchased through the Marketplace, depending on their income, household size, and whether they are eligible for another kind of coverage. The assistance is provided through tax credits (and potentially through lower cost-sharing requirements). If you are eligible for insurance with minimal essential coverage through your employer or through the employer of your spouse or parents, you will not be able to get help with the cost of a plan through the Marketplace. You can still buy individual coverage on or off the Marketplace, but you will want to carefully consider whether the group coverage available to you has better benefits, or costs less.

Pre-Existing Conditions:
Major medical insurance issued on or after January 1, 2014 cannot exclude coverage for pre-existing conditions.

Essential Health Benefits:
The following ten essential health benefits must be included in major medical insurance plans:
– emergency services – ambulatory patient services (outpatient care)
– maternity and newborn care – hospitalization
– prescription drugs – mental health & substance use disorder services
– laboratory services – rehabilitative and habilitative services and devices
– pediatric services, including vision* – preventative/wellness services/chronic disease management

*Adult dental & vision coverages aren’t essential health benefits. Dental plans may be purchased separately.

Preventive Services:                                                                                                                                  Individuals do not pay co-pays, coinsurance, or deductibles for certain preventive health services that are provided by network providers, including routine immunizations and routine physical exams, such as: gynecological exams, digital rectal exams, pediatric eye exams, mammograms, and routine and medically necessary colorectal cancer screenings. Talk with your provider about whether these procedures are considered “routine” or “diagnostic” in your specific case. You will have to pay a portion of exams or procedures that are considered “diagnostic.”

Increased Coverage and Access:                                                                                                                        Beginning in 2021, the Made for Maine Health Coverage Act requires individual major medical plans to fully cover the cost of a member’s first routine primary care visit and first behavioral health visit, each year, without any out- of-pocket costs. In addition, copays for the second and third routine visits to either a primary care provider or behavioral health provider are applied before needing to meet the deductible. These new requirements do not apply to HSA or catastrophic plans.

Cost-sharing:
This refers to the portion you will have to pay (or “share”) for covered services, at least until you reach the annual maximum out-of-pocket (MOOP) limit. Deductibles, co-pays and co-insurance are all types of cost-sharing.

Make sure you know what you’re buying before you commit. The insurance described in this guide is Affordable Care Act compliant Major Medical Insurance. Short-term policies, Indemnity coverage, and other supplemental insurance can seem like a good deal, but can end up costing you much more in the long run if you actually need to make a claim. Need help understanding a policy before you purchase it? Feel free to call the Bureau’s Consumer Health Care Division at 1-800-300-5000, before you seal the deal.