Bulletin #3102, Health Insurance Coverage: What Mainers Need to Know

Print Friendly, PDF & Email

Adapted by Jane Conroy, Associate Extension Professor, University of Maine Cooperative Extension

For information about UMaine Extension programs and resources, visit extension.umaine.edu.
Find more of our publications and books at extensionpubs.umext.maine.edu.

stethoscopeTable of Contents

According to the U.S. Department of Health and Human Services, there are 144,958 (13%) uninsured Maine residents who are eligible for coverage through the Health Insurance Marketplace. Of those, 81% have a full-time worker in the family, 56% are male, and 32% are 19-34 years old.

This fact sheet provides tips and resources to help you navigate health insurance plans so that you and your family are better prepared to make decisions.

Affordable health insurance can give you and your family peace of mind, protect your financial future, and give you access to health and wellness services and programs to improve your overall health.

Understanding health insurance coverage will increase your confidence to find, review, and evaluate information about health plans. You will then be able to select the best plan for you and your family. As part of your monthly budgeting, consider health and medical cost options, as well as preventative health choices, to save you and your family money.

By March 31, 2014, all Maine residents must be enrolled in a health plan or face a penalty. If you don’t have coverage in 2014, you will be required to pay a penalty fee of $95 per adult, $47.50 per child, or 1% of your income (whichever is higher). This fee will increase every year. Some people may qualify for an exemption to the fee. For more information on fees, visit HealthCare.gov.

So, where to start?

You can start by reviewing your current medical needs and practices. How often are you seeing your doctor now? Do you have chronic health issues such as diabetes? Are you overweight? Or are you relatively healthy and want to remain that way?

Next, learn how various health insurance plans can save you money when selecting health care providers, using generic versus brand name drugs, or going to walk-in care centers versus an emergency room.

Most plans commonly cover basic health, dental, preventative services, vision, mental health, substance abuse services, maternity coverage, and prescription drugs.

Wellness programs offer additional opportunities. Making healthier lifestyle choices a regular part of your life can reduce your risk of chronic and serious health conditions. If your employer offers a wellness component to your plan, be sure you understand the benefits and take advantage of them — to improve your health and increase your savings.

Be sensitive to the language in your plan’s contract, important dates, and enrollment or reimbursement deadlines.

Some common terms to know

Allowable charge: Sometimes known as the “allowed amount,” “maximum allowable,” and “usual, customary, and reasonable (UCR)” charge, this is the dollar amount considered by a health insurance company to be a reasonable charge for medical services or supplies based on the rates in your area.

Benefit: The amount payable by the insurance company to a plan member for medical costs.

Claim: A request by a plan member, or a plan member’s health care provider, for the insurance company to pay for medical services.

Coinsurance: The amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

Copayment: A shared payment for your medical costs. You pay a flat fee for certain medical expenses (for example, $25 for every visit to the doctor), while your insurance company pays the rest.

Deductible: The amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.

Dependent: Any individual, either spouse or child, that is covered by the primary insured member’s plan.

Exclusion or limitation: Any specific situation, condition, or treatment that a health insurance plan does not cover.

Explanation of benefits: The health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.

Health maintenance organization (HMO): A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific, in-network plan providers.

Health savings account (HSA): A personal savings account that allows participants to pay for medical expenses with pre-tax dollars. HSAs are designed to complement a special type of health insurance called an HSA-qualified high-deductible health plan (HDHP). HDHPs typically offer lower monthly premiums than traditional health plans. With an HSA-qualified HDHP, members can take the money they save on premiums and invest it in the HSA to pay for future qualified medical expenses.

In-network provider: A health care professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.

Network: The group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.

Out-of-network provider: A health care professional, hospital, or pharmacy that is not part of a health plan’s network of preferred providers. You will generally pay more for services received from out-of-network providers.

Out-of-pocket maximum: The most money you will pay during a year for coverage. The out-of-pocket maximum includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.

Payer: The health insurance company whose plan pays to help cover the cost of your care. Also known as a carrier.

Point of Service (POS): A type of health plan in which you pay less if you use providers, hospitals, and other providers that belong to the plan’s network. POS plans may require you to get a referral from your primary care provider in order to see a specialist.

Preferred provider organization (PPO): A health insurance plan that offers greater freedom of choice than HMO (health maintenance organization) plans. Members of PPOs are free to receive care from either in-network or out-of-network (non-preferred) providers, but will receive the highest level of benefits when they use providers inside the network.

Premium: The amount you or your employer pays each month in exchange for insurance coverage.

Provider: Any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.

Specialists: A provider who focuses on a specific area of medicine or health care.

Key questions to ask yourself about your health insurance use and needs

  • What is my current plan or the one I am exploring: POS, PPO, or HMO?
  • Do ALL my current providers accept this plan?
  • Can I choose my medical providers?
  • Do I need referrals for specialists?
  • Do I need pre-authorization for procedures?
  • Does my plan accept billing or do I need to pay upfront and get reimbursed?
  • Of the services below, which are covered by my plan?
    • medical (patient services, hospitalization, emergency services)
    • prescription drugs
    • dental and vision
    • maternity and newborn care
    • mental health and substance abuse
    • preventative and wellness, and chronic disease management
  • Is there a waiting period for maternity services?
  • If I travel out-of-network, does my plan cover care out of the area?
  • Has my plan’s health insurance company received a high number of consumer complaints? (For more information, visit the Bureau of Insurance.)

Enrollment checklist

  • Review the medical, dental, and vision elections to be sure you’ve enrolled in the appropriate plan(s) that meet your needs.
  • Do you need to add or drop dependents’ coverage?
  • If you elect spouse or family coverage, are the names correct?
  • If you are adding a dependent or spouse, do you have the needed documentation (birth certificate, marriage certificate)?
  • Have you checked your beneficiary information?
  • Have you enrolled in a Flexible Spending Account plan? The IRS requires re-enrollment annually.
  • Is your mailing address correct?
  • Be sure to get a copy of your enrollment information or confirmation number.

To reduce your confusion, feel more confident, and understand and use your health plan to save money and improve your health, take action now to be more informed.

For the most accurate and up-to-date information, see the resources below.

Insurance for Maine individuals in the 2014 Marketplace:

  • Anthem
  • Maine Community Health Options

Carriers selling off the Marketplace: Anthem, Maine Community Health Options, MEGA and Harvard Pilgrim Health Care.

Additional resources

Bureau of Insurance
#34 State House Station
Augusta, ME 04333-0034
1.800.300.5000 (toll free)
TTY: 207.624.8475 (Please call Maine relay 711)

Health Insurance Literacy from eXtension’s Ask the Expert
One-to-one answers to your health insurance literacy questions from a network of experts at universities across the US.


University of Maryland Extension (August, 2013), My Smart Choice Health Insurance Consumer Workbook, College Park, MD: University of Maryland


U.S. Department of Health & Human Services

Information in this publication is provided purely for educational purposes. No responsibility is assumed for any problems associated with the use of products or services mentioned. No endorsement of products or companies is intended, nor is criticism of unnamed products or companies implied.

© 2013

Call 800.287.0274 (in Maine), or 207.581.3188, for information on publications and program offerings from University of Maine Cooperative Extension, or visit extension.umaine.edu.

The University of Maine is an EEO/AA employer, and does not discriminate on the grounds of race, color, religion, sex, sexual orientation, transgender status, gender expression, national origin, citizenship status, age, disability, genetic information or veteran’s status in employment, education, and all other programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Sarah E. Harebo, Director of Equal Opportunity, 101 North Stevens Hall, University of Maine, Orono, ME 04469-5754, 207.581.1226, TTY 711 (Maine Relay System).