The passage of the 2010 Patient Protection and Affordable Care Act has forced all states to reconsider their existing insurance regulations in an eye toward establishing full compliance with federal statutes by 2014. There have been major initial changes involving children and insurance. Exclusions for pre-existing conditions are no longer allowed, and children may stay on their parents health policies up to age 26 regardless of their educational or marital status.
Most states, working with the federal government, have established high risk pools for people with pre-existing conditions that will remain in place until January 1, 2014, at which time health insurance exchanges will become operational.
General Insurance Regulations
Group health plans in Maine have no guarantee of renewability. Policies may be cancelled if the premiums have not been paid, if the employer has committed fraud, if there are instances of intentional misrepresentation, of if any other terms of the contract have not been met. Group insurance is guaranteed issue and can be adjusted based on the community health risk rating. There is a six-month look back period for pre-existing conditions.
Once a private insurance policy is in place, it cannot be cancelled unless the premiums are not paid. There is also a guaranteed renewability clause providing policy holders with the right to renew a policy even if a new medical condition occurs.
Group health plans in Maine have no guarantee of renewability. Policies may be cancelled if the premiums have not been paid, if the employer has committed fraud, if there are instances of intentional misrepresentation, of if any other terms of the contract have not been met. Group insurance is guaranteed issue and can be adjusted based on the community health risk rating. There is a six-month look back period for pre-existing conditions.
Currently, insurers can exclude a pre-existing condition for up to 12 months and have a 12-month look back period. Screenings must be included for breast cancer and cervical cancer and after care is required. Eating disorders also must be included.
Health Care Exchanges
Currently Maine is studying options for the formation of the health care exchange required under the Affordable Care Act. The Maine legislature introduced two bills to establish a state-run health insurance exchange in 2011, but both failed at the close of the legislative session and will be carried over to 2012.
Pre-Existing Condition Insurance
Maine’s Pre-Existing Condition Insurance Plan program is administered by Dirigo Health Agency. Benefits include hospitalization, primary and secondary care, and prescription drug coverage. Rates vary by region, but premiums average $438 to $658 a month with deductibles of $2000 or $2750. At the $2000 level the maximum out-of-pocket expense is $3500; $5600 at the $2750 deductible.
Medicaid
Eligibility for Medicaid assistance is figured on a percentage of the Federal Poverty Level. Infants under age 1 qualify at 185% FPL; children 1-5 at 133%, with 150% FPL for the Children’s CHIP-funded Medicaid Expansions. In the 6-19 age bracket the percentages are 125 and 150 respectively.
Pregnant women qualify for Medicaid at 200% FPL, parents at 200%, adults at 100%, and non-elderly disabled Social Security recipients at 74%.
Low-income residents are also covered by MaineCare, which provides assistance to families, children, pregnant women, the elderly, and other medically needy individuals. Low-income women are also eligible for free breast and cervical health screenings. If a diagnosis is made, coverage for all medical care during this period will be covered.
Medicare
Approximately 19 percent of Maine’s population received Medicare assistance, with 254,000 receiving prescription drug coverage.