INDIVIDUAL HEALTH INSURANCE in Maine

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.

Continued Coverage for Dependent Children up to age 25 – Effective September 20, 2007, individual health insurance policies must offer to continue coverage for a dependent child up to the age of 25 at the option of the policyholder. To qualify for the extended coverage, the dependent child must be unmarried; have no dependents; is a Maine resident or enrolled as a full time student; and not have health coverage under another policy or under a federal or state program.
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, MaineCare, or group coverage through an employer.
2. 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.
3. 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.
4. 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.

– Courtesy of the Maine Bureau of Insurance, www.maine.gov/insurance, last updated: August 6, 2009.