Health Insurance Carriers in Maine: Coverage and Benefits Explained

Maine residents have several health insurance carriers to choose from, each offering unique coverage and benefits.

Blue Cross Blue Shield of Maine is one of the largest health insurance carriers in the state, covering over 70% of Maine's residents.

Maine residents can choose from a range of health insurance plans, including HMOs, PPOs, and EPOs, each with its own set of benefits and limitations.

The state's two largest health insurance carriers, Anthem and Maine Community Health Options, offer a range of network providers and out-of-network coverage options.

If you're looking for health insurance options in Maine, you have several types of plans to choose from.

You can purchase Preferred Provider Organizations (PPOs), which allow you to see any in-network provider without a referral. Some PPOs may require a deductible before their portion of the coverage begins.

Health Maintenance Organizations (HMOs) are another option, requiring you to select a Primary Care Physician to coordinate your healthcare and provide referrals to specialists. HMOs typically charge a fixed copayment for each doctor visit and other care provided.

High-Deductible Health Plans with Health Savings Accounts (HDHP w/HSAs) offer lower monthly premiums with higher deductibles, giving you more control over your out-of-pocket expenses. These plans are often combined with HSAs that allow you to set aside interest-earning pretax funds or tax-deductible funds.

You can also consider Flexible Spending Accounts (FSAs), which allow you to make tax-free contributions up to $2,500 per year to cover out-of-pocket healthcare expenses not covered by your insurance plan.

Here are the main differences between the types of health insurance plans available in Maine:

Anthem health plans offer a range of benefits, including coverage for doctor visits, hospital care, and mental health benefits.

You can also expect $0 virtual care, 24/7, and prescription drug coverage, with some commonly-used drugs as low as $0.

All qualifying plans must offer the 10 standardized essential benefits, including ambulatory patient service, emergency services, and preventive and wellness services.

Here's a breakdown of the four metal plans available in Maine:

Maine also mandates additional benefits, such as outpatient surgery, hospice services, and routine dental services for adults.

As a member, you'll have access to a range of health plans designed to fit different needs and budgets.

Anthem's integrated approach can help improve your health and lower costs.

We make managing your benefits easier than ever, with a focus on peace of mind.

Our health plans are designed to meet the unique needs of each individual, providing a more personalized experience.

By choosing Anthem, you can enjoy improved health outcomes and reduced healthcare expenses.

You can access quality care with Anthem plans, which offer a range of choices of doctors, care centers, and hospitals.

You can choose a video visit with a doctor or therapist on your smartphone, tablet, or computer, giving you the flexibility to receive care from anywhere.

If you speak a language other than English, you can get free language assistance services by calling the Customer Service number.

Language assistance services are available in multiple languages, including Spanish, and can be reached by calling the Customer Service number (TTY: 711).

Using the Sydney Health app, you can have a virtual care visit with a board-certified doctor 24/7, with many plans offering this service at no cost to you.

The doctor can give you expert medical advice, diagnose common health issues, and send prescriptions right to your pharmacy.

Your Anthem health plan includes coverage for most generic and many brand-name prescription drugs. Some commonly-prescribed drugs are available starting as low as $0.

You can get prescription drug coverage with Anthem, which includes some commonly-used drugs as low as $0.

You'll pay a certain amount for medications, depending on the coverage tier or class of drug.

Our Smart Rewards program is a great way to stay motivated to take care of your health and wellness. You can earn rewards for completing health and wellness activities.

You can earn rewards for a digital gift card from a selection of retailers. This is a great way to treat yourself to something nice after reaching your health and wellness goals.

Our Smart Rewards program is designed to be flexible and inclusive, allowing you to earn rewards with your covered spouse or partner.

Your Anthem health plan covers annual physicals and preventive care visits with providers in your network, regardless of the deductible.

The deductible is the amount you pay each year before your plan starts to pay for covered services, but it doesn't include costs for preventive services, which are covered regardless of the deductible.

You'll pay a fixed copay out-of-pocket for visits to in-network healthcare providers, and the amount can vary depending on the provider or services you receive.

For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you'll pay $20 for that service after your deductible is met.

The out-of-pocket maximum is the most you'll pay for covered healthcare services during the coverage year, and if you reach it, your plan pays 100% of covered benefits.

Some commonly-used prescription drugs are as low as $0 with your Anthem plan, making it easier to stay on top of your health.

If you're looking for a clear understanding of what's included in the ACA standardized benefits, you're in the right place.

All qualifying plans must offer the following 10 essential benefits:

These benefits are the foundation of any qualifying plan, and they're designed to provide essential healthcare services to individuals and families.

Note that lifetime dollar limits on these essential health benefits have been eliminated, which means you can receive the care you need without worrying about reaching a certain dollar amount.

The specific benefits and requirements may vary depending on the state you live in, but all plans must meet the basic standards set by the ACA.

There are four main types of health insurance plans available in Maine: Bronze, Silver, Gold, and Platinum. Bronze plans feature low monthly payments with a higher deductible, making them a good option for those with few doctor visits.

Bronze plans have a 60% insurer pay ratio, meaning your insurance company will cover 60% of your healthcare costs, and you'll pay 40%. Silver plans, on the other hand, have an average monthly payment and a lower deductible, making them ideal for individuals and smaller families with average healthcare needs.

Here's a quick breakdown of the plan types:

Gold plans have higher monthly payments but an even lower deductible than Silver plans, making them a good option for those with regular, ongoing healthcare needs.

Bronze plans are a great option for those who have few doctor visits and only need coverage for medical emergencies. They feature low monthly payments with a higher deductible.

These plans are best suited for individuals or couples who don't require frequent medical attention.

You have several options to choose from when it comes to health insurance plans in Maine.

There are four main types of plans: Bronze, Silver, Gold, and Platinum. Each plan has its own unique features and benefits.

Bronze plans are best for individuals or couples who have few doctor visits and only need or want coverage for medical emergencies. They feature low monthly payments with a higher deductible.

Silver plans have average monthly payments but a lower deductible than Bronze plans. These plans are ideal for individuals and smaller families with average healthcare needs, and offer cost-sharing reductions for those who qualify.

Gold plans have higher monthly payments but an even lower deductible than Silver plans. They are best for individuals or families with regular, ongoing healthcare needs, and cover most routine healthcare costs.

Platinum plans are not mentioned in the provided article sections, but based on the table in Example 4, they have the highest percentage of healthcare costs covered by the insurer, with 90% covered and 10% paid by the individual.

Here's a summary of the plans available in Maine:

Four insurers offer exchange plans in Maine for 2024 and 2025: CHO, Harvard Pilgrim, Anthem, and Taro Health.

On-exchange health insurance plans are available on coverME.gov, and financial help to lower the cost of health coverage is only available when you enroll in one.

These plans offer the same essential health benefits as off-exchange plans, but with a key difference: you can get financial assistance to make them more affordable.

You can shop and compare on-exchange plans directly on the Anthem website, making it easy to find the right fit for your needs.

Off-exchange plans, on the other hand, are available directly through Anthem outside of the exchange or marketplace.

These plans also cover the same essential health benefits as on-exchange plans, but without the option for financial assistance.

Our Health Plan Consultants can help you determine if you're eligible for financial help and find the best plan for your needs and budget.

Short-term coverage is a temporary solution for those who need health insurance quickly. In Maine, short-term health plans are available for consumers who find themselves without comprehensive coverage.

These plans provide a stopgap measure until a more permanent solution is found. Short-term plans can be a good option for people who are between jobs or waiting for their new insurance to kick in.

Short-term plans usually have a limited duration, often ranging from a few months to a year. They can be a good fit for individuals who only need coverage for a short period of time.

Maine residents can learn more about short-term plan availability in their state by checking with insurance providers.

Premiums are the amount you pay each month to your health insurance company for your health plan. Your employer may share the cost of your premium if you have health coverage through your place of work.

Premiums can be based on your age, tobacco use, where you live, and the number of family members enrolling with you. For example, if you're older or a smoker, you might pay more for your premiums.

In Maine, the average rate increase for health insurance premiums in 2025 is 8.6% before subsidies. This is significantly smaller than the 14.2% average rate increase initially proposed by insurers.

The Maine Bureau of Insurance approved rate increases for four insurers offering individual/family health insurance through CoverME. The approved rate increases were smaller than initially proposed, except for Taro Health, which had a significantly larger approved rate increase.

Here's a summary of how full-price premiums have changed in Maine over the years:

In Maine, you have four insurers to choose from when selecting a health insurance plan through the Marketplace: CHO, Harvard Pilgrim, Anthem, and Taro Health.

CHO is one of the few remaining ACA-created CO-OPs, also known as Community Health Options.

Taro Health offers plans in Cumberland, Sagadahoc, York, and Lincoln counties, while residents in the rest of the state have access to plans from three insurers.

Here's a breakdown of the four insurers offering plans in Maine:

Four insurers offer exchange plans in Maine for 2024, and all four will continue to offer plans for 2025.

CHO, Harvard Pilgrim, and Anthem all offer plans statewide, giving residents access to a range of options.

Taro Health offers plans in Cumberland, Sagadahoc, York, and Lincoln counties for 2024 and 2025, which is an expansion from just Cumberland in 2023.

In those four counties, there are actually four insurers offering plans, while residents in the rest of the state have access to plans from three insurers.

Maine is one of the few remaining states with an ACA-created CO-OP, Community Health Options (CHO), which is one of only three CO-OPs nationwide offering coverage as of 2024.

In Maine's Marketplace, 62,586 people enrolled in plans during the open enrollment period for 2024 coverage.

Unfortunately, Maine was the only state to see a decrease in enrollment, with 1.3% fewer people enrolled in 2024 compared to 2023.

The decrease in enrollment was largely due to an increase in the income limits for children and young adults to qualify for Medicaid, allowing some to transition to Medicaid coverage starting in late 2023.

On the other hand, many states have seen enrollment numbers climb in recent years, reaching record highs.

The Patient Protection and Affordable Care Act (ACA) became law in 2010 and has been phasing in its provisions since then.

Most U.S. citizens and legal residents are required by law to have qualifying health care coverage or pay an annual tax penalty for every month they go without insurance, starting from January 1, 2014.

The penalty for not having qualifying coverage is $95 per adult and $47.50 per child or 1% of your taxable income, whichever is higher (up to $285 per family), and increases annually through 2017 and beyond.

The Patient Protection Act of 2010, also known as the Affordable Care Act, became law in 2010.

This law requires most U.S. citizens and legal residents to have qualifying health care coverage or pay an annual tax penalty for every month they go without insurance.

The individual mandate took effect on January 1, 2014, with a grace period through March 31, 2014.

The penalty for not having qualifying coverage is $95 per adult and $47.50 per child or 1% of your taxable income, whichever is higher, up to $285 per family.

The penalty increases annually through 2017 and beyond.

Under the Affordable Care Act (ACA), individuals with pre-existing conditions can't be denied coverage or charged higher premiums due to their past health history. This provision is known as Guaranteed Issue.

No look-back or waiting periods can be imposed on individuals with pre-existing conditions. This means you can enroll in a plan at any time without worrying about being penalized for past health issues.

All coverage is renewable if you choose to renew it. You can't be forced to drop your coverage unless you don't pay your premiums or commit fraud. Plans can only be canceled for non-payment of premiums or fraud.

The guaranteed issue provision applies to all non-grandfathered plans. This ensures that everyone has access to affordable health insurance, regardless of their health history.