Medicare Advantage Plans in Maine

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: March 31, 2021

 

Medicare Advantage plans offer Maine seniors an alternative to Original Medicare Parts A and B. Through this program, which is sometimes referred to as Medicare Part C, Medicare-approved private insurers provide healthcare and hospitalization benefits similar to those of federally managed Medicare plans, but with the option of additional coverage for vision, dental, and hearing services, and prescription drugs. Benefits, premiums, and out-of-pocket costs for physician visits, diagnostics, and other treatment services may vary by insurer and individual plan.

Key Points

  • 1 In 2019, there were 38 Medicare Advantage plans available in Maine.
  • 2 30% of the total Medicare population in Maine is enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $8,841 per beneficiary in Maine, which is 12% lower than the national average.
  • 4 Available Medicare Advantage plans range from 24 to 34 across Maine’s 16 counties.

Medicare Advantage plans can help seniors pay for medical emergencies and other unanticipated healthcare expenses by limiting out-of-pocket costs for covered services, including visits to physicians and specialists, and hospital stays. Because insurers must adhere to rules set by Medicare, plan participants can count on the rights and protections they expect from Original Medicare. Available benefits may vary by county of residence, and some policies require members to receive services from in-network practitioners. Potential enrollees should consider their individual medical and financial needs before selecting an appropriate plan.

Medicare Advantage Plans in Maine

Types of Medicare Advantage Plans

Maine seniors can choose from several types of Medicare Advantage plans, which include HMO and PPO options. Limited PFFS plans are also available, and seniors with healthcare needs related to a specific diagnosis or healthcare-related situation may opt for an SNP if one is available in their area. Seniors with eligibility, enrollment, and coverage questions related to Maine’s Medicare Advantage program may seek help through various state and local resources.

Health Maintenance Organizations (HMO)

Medicare Advantage HMO plans provide medical coverage through networks of plan-approved physicians, specialists, and hospitals. Participants must select an in-network primary care physician who can initiate treatment plans and provide referrals to specialists as needed. For enrollees who choose an HMO plan, out-of-network care is usually not covered, except in cases of emergencies, and patients who seek care from out-of-network physicians may not be reimbursed for services. HMOs are typically the most affordable type of Medicare Advantage plan thanks to their low premiums and small or no deductibles and copays. Some plans may be purchased with bundled prescription drug plans.

Preferred Provider Organizations (PPO)

PPO plans offer members more flexibility than HMOs, letting seniors seek services from both in- and out-of-network physicians and specialists. Enrollees often pay higher premiums for PPOs and often have to meet higher deductibles or incur other out-of-pocket expenses. Although PPOs typically don’t require members to choose a primary care physician, they often have an extensive list of preferred providers. Enrollees who seek services from preferred physicians have the lowest co-pays and coinsurance rates, while those who receive care from out-of-network doctors and hospitals incur higher out-of-pocket costs. Some PPO plans may come bundled with prescription drug plans.

Private Fee-For-Service Plans (PFFS)

PFFS plans typically offer participants the greatest flexibility for selecting providers, but they generally come with higher premiums. Members don’t need to choose a primary care physician and may seek services from any Medicare-approved provider who agrees to the plan’s coverage terms. Out-of-network providers have the option of refusing services to plan participants, however. Some PFFS policies may also provide a list of preferred practitioners, letting members save money by staying in-network. PFFS plans don’t require referrals for specialist visits.

Special Needs Plans (SNP)

In some geographic areas, SNPs may be available to members who have unique healthcare needs. These targeted-membership plans are open to seniors with disabling or chronic conditions such as cancer, dementia, and drug or alcohol dependence. Dual Medicare/Medicaid-eligible seniors and individuals who need long-term residential care may also be eligible to enroll in an SNP. Although members typically pay high premiums, SNPs are designed to accommodate the specific needs of participants, offering special drug formularies and tailored provider networks. Members must choose providers, including a PCP, from a designated network of healthcare professionals, and may be required to have a care coordinator to oversee all treatment. Out-of-network care is only covered during an emergency, although members with end-stage renal disease may also go out of the network if they require out-of-area dialysis. SNPs are often only available in certain areas, which may vary each year.

Enrollment & Eligibility for Medicare Advantage Plans in Maine

Eligibility

Maine’s Medicare Advantage program maintains strict eligibility guidelines, and enrollees must qualify for Medicare A and B to be eligible. To apply for an Advantage plan, you must be a U.S. citizen or legal resident aged 65 or older, or have a qualifying disability if younger, and reside in an area where Medicare Advantage plans are available. Applicants must not currently be enrolled in Medigap insurance. Seniors with End Stage Renal Disease don’t qualify for Medicare Advantage plans, with the exception of relevant SNPs, if available.

Seniors who begin receiving Social Security or Railroad Retirement Board benefits at least four months prior to turning 65 may opt for an Advantage plan in place of automatic enrollment in Medicare Parts A and B, or they may switch covering during subsequent annual enrollment periods. Coverage start dates may vary depending on the date of enrollment.

Enrollment Periods

Seniors may join a Medicare Advantage plan during preset enrollment periods, which accommodate new applicants, individuals who wish to change plans, or enrollees who delayed their initial coverage. Each enrollment period serves a specific purpose, as outlined here:

  • During initial coverage election periods, seniors aging into the program have a seven-month time frame in which to sign up for coverage. Initial enrollment runs for three months before and after an applicant’s 65th birthday month.
  • The annual election period begins October 15th and ends December 7th each year. During this enrollment period, current Medicare Parts A and B recipients may switch to a Medicare Advantage plan. Current Medicare Advantage participants may switch to a different insurer or enroll in a prescription drug plan.
  • Medicare Advantage holds a yearly open enrollment period for current members only. At this time, participants may change insurers or plans, or switch back to Original Medicare. The open enrollment period begins on January 1st and runs through March 31st.
  • The general enrollment period is designed for seniors who have been enrolled in Medicare Part A and who’ve added Part B during the preceding open enrollment period. During this period, which runs from April 1st to June 30th, enrollees may switch from Original Medicare to Medicare Advantage.

Prescription Drug Coverage

Many Medicare Advantage plans include prescription drug coverage, with prices and specific drug coverage varying from plan to plan. These bundled plans are often referred to as Medicare Advantage Prescription Drug plans or MA-PDs. To obtain coverage, members who select an HMO or PPO must choose a plan that bundles in prescription drugs at the time of enrollment. Coverage cannot be obtained through separate Medicare Part D prescription drug plans, and enrollment in such a plan can cause forfeiture of Medicare Advantage. Some PFFS plans also offer prescription drug benefits, and if not, members may opt for coverage through a separate Medicare Part D plan. SNPs are the only Medicare Advantage plan that, by law, must include prescription drug coverage.

Medicare Advantage Resources in Maine

Maine seniors who are considering Medicare Advantage as a viable alternative to Medicare Parts A and B may find the wide variety of coverage options confusing. This can make it difficult to choose a suitable plan, particularly for first-time enrollees and seniors considering changes in coverage. State and local resources are available at no cost to help Maine seniors navigate eligibility guidelines, coverage comparisons and enrollment completion.

Maine State Health Insurance Assistance Program (SHIP)

Provided by Maine’s Department of Health and Human Services, SHIP offers free, confidential assistance to Medicare participants and individuals who will soon be enrolling. Trained health insurance counselors provide general information, answer Medicare- and Medicare Advantage-related questions, and help seniors report Medicare abuse and fraud. Counselors are knowledgeable about Medicare prescription drug coverage and non-Medicare benefits that may supplement healthcare coverage. The agency also helps seniors connect with other local, state, and government resources, as applicable.

Contact Information: Website | 877-353-3771

Southern Maine Agency on Aging (SMAA)

The SMAA’s trained health insurance counselors provide benefits counseling to help Medicare beneficiaries understand the plan choices available in their area. The organization offers an informational Welcome to Medicare seminar, which must be taken before requesting one-on-one assistance. The course focuses on navigating the Medicare.gov website and includes instructions on account creation and site tools, such as the Medicare Plan Finder. Benefits check-up programs for singles and couples are also available. Appointments are available over the phone or through face-to-face virtual meetings.

Contact Information: Website | 800-427-7411

The Bureau of Insurance

The Bureau of Insurance provides information about health insurance products to Maine consumers. Seniors may contact the agency with questions, concerns, or complaints about Original Medicare, Medicare Advantage, and Medicare Supplement plans, which are often referred to as Medigap insurance. Agency representatives may be reached by telephone, and services for individuals with hearing impairments are available through Maine Relay by dialing 711.

Contact Information: Website | 800-300-5000

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.