Maine is known for lobsters, skiing destinations and guaranteed issue health insurance. According to state laws, all individuals who live in Maine are offered a standardized health plan, regardless of health status. It is also one of the healthiest states in the nation, with many fresh foods grown locally in the clean mountain air. Maine residents have access to a variety of outdoor activities in lakes, beaches, mountains and coastline, where they can see many types of wildlife rare to much of the country. It is no wonder why Maine is such a healthy state when you consider the walkable small towns, natural assets, and abundance of local food from the ground and the water.

Residents of Maine have only a few choices when it comes to health insurance companies, including Anthem Blue Cross Blue Shield of Maine and Harvard Pilgrim Health Care. Through these companies, a variety of plans is offered, including a PPO called DirigoChoice, offered by Harvard Pilgrim to individuals, small businesses and sole proprietors. Many options are government-run given the nature of the standardized health plan and guaranteed issue laws.

 

 

Health Status

Maine is one of the the top ten healthiest states in the country, due to low air pollution, a much smaller percentage of uninsured individuals than other states (thanks in part to the guaranteed issue policy) and several other positive factors. The use of early prenatal care is frequent among Maine residents, which shows a decent emphasis on health care. There is also a moderately good number of primary care physicians available per capita, and a fairly low occurrence of infectious disease. As of 2009, 56% of the population was regularly exercising for at least 30 minutes a day, five or more days per week according to the Center for Disease Control and Prevention.

Though a variety of factors add to the state’s good overall health, there are still plenty of areas like the rest of the country that Maine residents are affected by. The amount of adults considered obese has reached over 27% of the population, or 289,000 people – which is a 4% increase in five years. There has also been a rise in diabetes among adults, now at 8.7%, or 92,000 individuals. Smoking is also an issue, though like many other states having a decrease over the years, more than 18% of adults continue to smoke. Despite the negatives, which can be treated and improved upon with lifestyle changes and use of health care, Maine still has one of the healthiest overall populations and it seems to be improving in many areas as time goes on.

 

Health Insurance Plans

 

Anthem Blue Cross Blue Shield of Maine

  • PPO plans are available in several deductible options, from $2,500 to $12,000 for individuals, and have varying coinsurance levels depending on which you choose. After you reach the deductible amount, your plan covers either 70% or 80% of major medical services including doctor’s office visits, X-ray and lab work, inpatient and outpatient hospital care and more. Once your coverage begins, you can use in-network preventive care services for no charge, or use an out-of-network provider for 40% coinsurance. There is a $1,000 deductible for prescriptions, and after it has been met, you pay 40% coinsurance for generics or brand name drugs.

 

Harvard Pilgrim Health Care

  • PPO plans come in several types from Harvard Pilgrim, mostly through employers but there is an option for individuals. Core Coverage plans have a copay before deductible on the first three physician’s office visits and behavioral health office visits, prescription drugs, emergency room and allergy tests. These plans cover inpatient and outpatient hospital care for an amount of coinsurance after deductible, and cover preventive care at 100% immediately. These plans offer low cost coverage on necessary services to those who aren’t covered by an employer.
  • DirigoChoice is a program for individuals, small businesses and self-employed persons in need of health care coverage. These PPO plans come in several types with different deductibles, and those who qualify can receive a subsidy to help pay for premiums, out-of-pocket costs and deductibles. While offered through a private health insurer, this is a public program provided jointly through Dirigo Health Agency and HPHC. As they are PPO plans, you are free to choose in-network or out-of-network care as you see fit.

 

 

Public Health Options

As mentioned above, DirigoChoice is a public health option with government subsidies available for those who are eligible, offering PPO plans to uninsured individuals, small employers and sole proprietors. There are also other programs funded by the state as health care alternative for those who have a low income or medical needs. MaineCare is the Medical Assistance or Medicaid program in the state, providing low-income pregnant women, children, families, elderly and disabled individuals with insurance. Additional programs are offered for testing and treatment of specific illnesses and conditions for uninsured Maine residents. For a comprehensive list of programs and services, visit the Maine Department of Health and Human Services.

 

 

Health Insurance Laws

Health insurance companies in Maine follow several legal regulations, including guaranteed issue and guaranteed renewability. Guaranteed issue health insurance provides individuals with health insurance through their employer regardless of their health status, and the private market is the same. No applicant can be turned away for health insurance in Maine unless they qualify for Medicare. This broadens the insurance market greatly, though prices tend to be steep.

Guaranteed renewability ensures that once a person has insurance in Maine, they get to hold onto their plan. As a result, Maine insurers must offer to renew a person’s plan when it is about to end, so they can continue to receive coverage. Insurance companies are not permitted to cancel benefits based on illness, they can only cancel your plan if you have violated the terms of your policy. This is a protection of the HIPAA law, which grants individuals the right to privacy of medical information and other insurance freedoms.

Pre-existing conditions in Maine are still regulated through insurance companies in Maine, despite the guaranteed issue law. Maine health insurance companies cannot reject any individual, but they can give them an exclusion period of up to one year – therefore not paying for any services that treat their condition. If someone who qualifies is switching plans from another company, their prior coverage can be credited towards the exclusion period and used to pay for uncovered care. Maine insurers judge pre-existing conditions by the prudent person standard, which is any condition for which a person could have (even if they did not) received treatment or medical advice before applying for a plan.

In 2014, the Affordable Care Act will make guaranteed issue widespread and will also discontinue the use of exclusion periods in Maine. Until then, the ACA set up a health plan for individuals with qualifying conditions to receive affordable health care. The Pre-Existing Condition Insurance Plan is state-run in Maine, and offers medical insurance to individuals through health care professionals throughout the state. These plans will expire when the laws change in 2014, therefore making it necessary for individuals with these plans to use a private health insurance company or state exchange.