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Published by:

The Maine Bureau of Insurance
34 State House Station
Augusta ME 04333
(207) 624-8475
(800) 300-5000
http://maineinsurancereg.org

John Elias Baldacci
Governor

Alessandro A. Iuppa
Superintendent

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). This brochure is intended to help you to understand your options and to 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 any individual who applies. If you already have a policy, but want to replace it 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. If you have a small business, ask for our publication, "What Maine Small Employers Should Know About Health Insurance." A self-employed individual with no employees is considered a small employer. Companies who sell both small group policies and individual policies must offer coverage to self-employed individuals. However, companies that offer both types of policies can choose which one to offer to self-employed individuals.

What is Available?

Insurers offer a variety of policies. Policies may vary 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, the insured 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 medical providers who agree to accept lower fees and/or to control utilization. The insured receives a higher lever of benefits if they go to a preferred provider than if they go to a non-preferred provider.
  • Health Maintenance Organization (HMO) - People enrolled in this plan must choose a primary care physician from a list of participating doctors. For any non-emergency hospital or specialty care, you must get a referral from your primary care physician.

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..

  • You may be subject to a pre-existing condition exclusion of up to 12 months. This means that any health condition that you had before the effective date of the new policy will not be covered for 12 months. 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 the "continuity law." This law requires insurers to waive pre-existing condition exclusions that otherwise would be used, to the extent you would have been eligible for benefits under the old policy. For example, if your old policy included coverage for physical therapy and the new policy also includes these benefits, you can receive benefits for physical therapy under the new policy without a pre-existing condition exclusion. However, if the old policy did not include physical therapy benefits and the new policy does, you could be subject to a pre-existing condition exclusion before you can receive benefits for this service.

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 cannot be subjected to pre-existing condition exclusions regardless of the level of benefits you had under an old health insurance policy:

  1. You are not eligible for other coverage such as Medicare, Medicaid, or group coverage through an employer.
  1. 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.
  1. You have at least 18 months of prior coverage. This may be entirely under your most recent coverage or may be combined with earlier coverage as long as there was not a gap of more than 63 days when you had no coverage.
  1. If 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 health insurance plan available to small employers and individuals through Anthem Blue Cross and Blue Shield of Maine. Participation is voluntary. Everyone is eligible, and those with incomes less than three times the federal poverty level qualify for reduced premiums and deductibles. Further information is available on the Dirigo web site at http://dirigohealth.maine.gov/dhlp02.html or from Anthem at 1-800-409-7520 (1-888-671-4333 TTY).

What are HSAs?

An HSA, or Health Savings Account, combines a high-deductible health insurance policy with an investment account from which you can withdraw money tax-free for medical care until you meet your deductible or for medical care not covered by health insurance. Otherwise, the money accumulates with tax-free interest until retirement, when you can withdraw for any purpose and pay normal income taxes. The tax benefits apply to federal income tax only, not to Maine state income tax. The high-deductible health insurance policy must meet standards set in federal tax law. Some policies are designed specifically for this purpose. Other high-deductible policies may qualify, but you or your tax adviser should check the federal standards carefully to be sure.

How Much Does It Cost?

Insurers and HMOs cannot charge different rates based on gender, health status, claims experience, or policy duration. Rates may vary based on age, tobacco use, industry, 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.

The chart below shows the monthly individual community rates for all available carriers. The rates shown are current as of March 1, 2005. After this date, you can check for updated rates for this brochure on our Internet home page at MaineInsuranceReg.org 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.

Standardized Major Medical Plans

 

Plans Standard Plan A Standard Plan B
Individual Deductible   $250 $500 $1,000 $1,500 $250 $500 $1,000 $1,500
Anthem Blue Cross & Blue Shield Telephone Number* 800-585-0099
Single
Premium
  $685.37 $672.27 $646.07 $619.86 $595.07 $581.96 $555.76 $529.55
Family
Premium
  $1,816.23 $1,781.52 $1,712.09 $1,642.63 $1,576.94 $1,542.19 $1,472.76 $1,403.31
MEGA Life & Health Insurance Co.
 
Telephone Number* 800-527-5504
Single
Premium
Nonsmoker $832.44 $817.27 $787.71 $758.14 $679.01 $666.65 $642.53 $618.41
Smoker $973.95 $956.21 $921.62 $887.02 $794.45 $779.98 $751.76 $723.54
Family
Premium
Nonsmoker $2,041.15 $2,003.97 $1,931.47 $1,858.97 $1,664.96 $1,634.63 $1,575.49 $1,516.36
Smoker $2,388.15 $2,344.65 $2,259.82 $2,175.00 $1,948.00 $1,912.52 $1,843.33 $1,774.14

 

Non-Standardized Plans

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*
800-585-0099
Individual Deductible   $2,250 $5,000 $10,000 $15,000
Single Premium   $347.14 $203.01 $150.32 $101.83
Family Premium   $919.92 $537.98 $398.35 $269.85

 

Anthem Blue Cross & Blue Shield HealthChoice High Deductible Health Plan (compatible with HSA) Telephone Number*
800-585-0099
Individual Deductible $2,600 $5,000
Single Premium $322.65 $200.98
Family Deductible $5,200 $10,000
Family Premium $513.01 $311.52
Note: Under a family policy, no benefits are payable until the family deductible is
met, either by one family member or by all family members collectively.

 

DirigoChoice (offered through
Anthem Blue Cross & Blue Shield)
Telephone Number*
800-409-7520
Premiums and deductibles vary according to your income. Call for details, or see Dirigo’s web site at http://dirigohealth.maine.gov/dhlp02.html.

 

MEGA Life & Health Insurance Co.
 
Telephone Number* 800-527-5504
  Signature Plan (High Deductible Major Medical Plan)
 
Health Choice (Basic Hospital/
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. The premiums shown here are for the options indicated at right,
 
Deductible: $3,500
Coinsurance: 80%
Deductible: $2,000
Coinsurance: 80%
Daily Hospital Room & Board Limit: $600
Miscellaneous Hospital Expense Limit: $36,000
Surgeon: $24,000
Outpatient Surgical Facility: $6,000
  Nonsmoker Smoker Nonsmoker Smoker
Single Premium1 $165.54 $196.02 $149.18 $174.54
Family Premium1 $441.79 $498.76 $365.34 $416.06
1. A one-time application fee of $95 is added to the above rates.

 

Standardized HMO Plans

 

HMOs   Standard Plan A Standard Plan B Telephone
Number*
Single Family Single Family
Aetna Health   $1,015.21 $2,772.29 $841.17 $2,297.03 800-435-8742
CIGNA Healthcare   $1,330.48 $3,625.35 $1,062.58 $2,895.37 800-642-5551
Harvard Pilgrim   $1,036.38 $3,109.15 $829.11 $2,487.32 800-208-1221
HMO Maine
(Anthem Blue Cross/Blue Shield)
  $1,011.29 $2,679.91 $821.59 $2,177.22 800-585-0099

* We have tried to provide current phone numbers, 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) ANTHEM HEALTH-CHOICE HIGH DEDUCTIBLE HEALTH PLAN DIRIGO CHOICE MEGA SIGNATURE PLAN (High Deductible Policy) MEGA HEALTH CHOICE
Type of Policy Major Medical Major Medical Major Medical Major Medical: Compatible with HSA Major Medical Major Medical Basic Hospital/ Medical-Surgical Expense
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. For individual plans, benefits are paid after the individual deductible has been met. For family plans, benefits are paid after the family deductible has been met. The family deductible may be met either by one family member or by all family members collectively. 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. Benefits are paid after an individual has met the deductible during a period of confinement. If the deductible is met three times in calendar year, no further deductibles will be applied that year.
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 Individual: $2,600, $5,000. Family: $5,200, $10,000. (Per calendar year) Varies by income $3,500, $5,000, $7,500, $10,000 per calendar year $1,000, $2,000, $3,000 per period of confinement
Plan Coinsurance 80% to $1,000 then 100% 60% to $1,000 then 100% None None 80% to out-of-pocket limit, which varies by income, then 100% Choice of 80% to $2,000 or
50% to $4,000, then 100%
Varies by benefit as indicated below
Lifetime Maximum $2,000,000 $1,000,000 $3,000,000 $3,000,000 No limit $1,000,000 per injury or sickness, $2,000,000 total $500,000 per injury or sickness, $1,000,000 total
Substance Abuse $25,000 lifetime maximum.
Inpatient calendar year max of 30 days, 60 day lifetime.
Outpatient calendar year max of $1,000.
$7,500 lifetime maximum.
Inpatient calendar year max of 15 days, 30 day lifetime.
Outpatient calendar year max of $500.
$25,000 combined lifetime limit with mental health.
Inpatient 80% - limited to 31 days a year.
Outpatient 50% - limited to 25 visits a year.
$25,000 combined lifetime limit with mental health.
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 purchased. Not covered unless optional rider purchased.
Mental Health $25,000 lifetime maximum.
Inpatient - 30 day calendar year maximum.
Outpatient - $1,000 calendar year maximum @ 50% coinsurance.
$7,500 lifetime maximum.
Inpatient - 15 day calendar year maximum.
Outpatient - $500 calendar year maximum @ 50% coinsurance.
$25,000 combined lifetime limit with substance abuse.
Inpatient 80% - max 31 days a year.
Outpatient 50% - limited to 25 visits a year.
$25,000 combined lifetime limit with substance abuse.
Inpatient 80% - max 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 purchased. Not covered unless optional rider purchased.
Maternity Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. 100% after the deductible is met. 100% after the deductible is met. Subject to contract deductible and coinsurance. Not covered except complications of pregnancy. Not covered except complications of pregnancy.
Prenatal, Newborn, Well Child, and Well Adult Care Covered expenses are payable at 100% subject to contract maximums. Covered expenses are payable at 100% subject to contract maximums. Pre-natal, Newborn - 100% no deductible. Well Child - max number of annual visits and max $50 benefit per exam. Well Adult Care - annual exams up to $100 per exam. Pre-natal, Newborn - 100% no deductible. Well Child - max number of annual visits and max $50 benefit per exam. Well Adult Care - annual exams up to $100 per exam. 100%, no copayment or deductible. Pre-natal, - Not covered. Newborn – Not covered except in connection with complications of pregnancy. Well Child, Well Adult Care - Not covered. Pre-natal, - Not covered. Newborn – Not covered except in connection with complications of pregnancy. Well Child, Well Adult Care - Not covered.
Chiropractic Care 36 visits per calendar year. Subject to contract deductible and coinsurance. 18 visits per calendar year. Subject to contract deductible and coinsurance. 100% after the deductible is met -
Limit 25 manipulations per calendar year.
100% after the deductible is met -
Limit 25 manipulations per calendar year.
40 visits per calendar year. Subject to contract deductible and coinsurance. Not covered Not covered
Prescriptions Subject to contract deductible and coinsurance. No deductible or coinsurance.
$20 co-payment for generic drug & $30 co-payment for brand names.
100% after the deductible is met. 100% after the deductible is met. No deductible or coinsurance.
Copay of $10 for generic drug, $25 for brand names, and $40 for optional brand names.
Not covered Not covered
Emergency Room Care Subject to $50 co-pay if not confined to the hospital. Subject to contract deductible and coinsurance. Subject to $75 co-pay if not confined to the hospital. Subject to contract deductible and coinsurance. 100% after the deductible is met. 100% after the deductible is met. Subject to contract deductible and coinsurance. Only for emergency medical condition. Subject to contract deductible and coinsurance. Only for emergency medical condition. Covered at 80%.
Inpatient Hospital Services Subject to contract deductible and coinsurance. No limit on number of days. Subject to contract deductible and coinsurance limited to 60 days per calendar year. 100% after the deductible is met. No limit on number of days. 100% after the deductible is met. No limit on number of days. Subject to contract deductible and coinsurance. No limit on number of days. Subject to contract deductible and coinsurance. No limit on number of days. Covered subject to the policy deductible. Room & Board charges are limited to daily maximum of $300, $400, $500, or $600.
Miscellaneous inpatient charges are covered at 80%, limited to 20, 40, or 60 times the daily Room & Board maximum.
Outpatient Surgical Facility Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. 100% after the deductible is met. 100% after the deductible is met. Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. Covered at 80%, limited to 10 or 15 times the daily Room & Board maximum.
Surgeon Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. 100% after the deductible is met. 100% after the deductible is met. Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. Covered at 80%, limited to 20, 40, or 60 times the daily Room & Board maximum subject to the policy deductible. Additional benefits for surgical assistant limited to 20% of amount paid to surgeon and for anesthesiologist limited to 30% of amount paid to surgeon.
Ambulance Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. 100% after the deductible is met. 100% after the deductible is met. Subject to contract deductible and coinsurance. Subject to contract deductible and coinsurance. Covered only if hospital confined, subject to the policy deductible, limited to $250 per trip.
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. 100% after the deductible is met. Subject to contract deductible and coinsurance. Inpatient doctor visits limited to one per day. Inpatient doctor visits limited to $50 per visit, one visit per day, subject to the policy deductible.
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 the deductible is met. 100% after $20 copayment,
deductible does not apply
Not covered unless optional rider purchased. Not covered unless optional rider purchased.
Skilled Nursing Care 100 days per calendar year. Not covered. 100% after the deductible is met - Limit 365 days (calendar year). 100% after the deductible is met - Limit 365 days (calendar year). 100 days per calendar year. Subject to contract deductible and coinsurance. Not covered. Not covered.
Home Health Care 100 visits per calendar year.
Max covered at 80%.
100 visits per calendar year.
Max covered at 60%.
100% after the deductible is met - Limit 90 visits per calendar year. 100% after the deductible is met - Limit 90 visits per calendar year. Subject to contract deductible and coinsurance. Maximum $50 per day. Limit 90 days per calendar year. Subject to the policy deductible and coinsurance. Covered at 80%, limited to $50 per day for a maximum of 90 days per year.

 

BENEFIT HMO STANDARD PLAN A
(Offered by HMOs)
HMO STANDARD PLAN B
(Offered by HMOs)
Deductible N/A N/A
Plan Coinsurance N/A Inpatient only - 80% to $2,000 then 100%
Lifetime Maximum N/A N/A
Substance Abuse $25,000 lifetime maximum. Inpatient - calendar year max of 30 days, 60 days lifetime. Outpatient - calendar year max of $1,000. $10 copayment per visit. $7,500 lifetime maximum. Inpatient calendar year max of 15 days, 30 day lifetime. Outpatient calendar year max of $500. $25 copayment per visit.
Mental Health $25,000 lifetime maximum.
Inpatient - 30 day calendar year maximum.
Outpatient - $1,000 per calendar year. $10 co-payment per visit.
$7,500 lifetime maximum. Inpatient - 15 day calendar year maximum.
Outpatient - $500 calendar year. $25 co-payment per visit.
Prenatal, Newborn, Well Child, and Well Adult Care Covered expenses are payable at 100% subject to contract maximums. Covered expenses are payable at 100% subject to contract maximums.
Chiropractic Care Covered - subject to $10 co-payment per visit. Covered - subject to $15 co-payment per visit.
Prescriptions $10 co-pay for generic drug &
$20 co-pay for brand names.
$20 co-pay for generic drug & $30 co-pay for brand names.
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 Covered - subject to $10 co-payment for office visits. Covered - 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 yr.,
$10 co-payment per visit.
100 visits per calendar yr.,
$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 Disability, Market Conduct, Legal, Financial Examination, Financial Analysis, Self-Insurance, Workers' Compensation, Licensing, and Administration.

Alessandro A. Iuppa
Superintendent

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 @
www.MaineInsuranceReg.org

Printed Under Appropriation No. 014 02A 3041 012
 

 

  

 

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