Medicare Advantage Plans in Maine

What Are Medicare Advantage Plans in Maine?

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital coverage) and Part B (medical coverage), and most also include prescription drug coverage (Part D). Many Medicare Advantage (MA) plans in Maine offer additional benefits like dental, vision, hearing, telehealth, and fitness programs.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first be enrolled in Original Medicare (Parts A and B). Most people are eligible for Medicare enrollment at age 65, though earlier enrollment is possible due to disability, ALS, or ESRD. Enrollment periods include Initial, General, and Special Enrollment. Failing to enroll on time may result in late penalties or loss of premium-free benefits.

What Types of Medicare Advantage Plans Are Available in Maine?

Maine offers a variety of Medicare Advantage plans, including:

• Health Maintenance Organization (HMO): In-network care is required, and referrals are needed to see specialists.
• Preferred Provider Organization (PPO): You can see out-of-network providers (at higher cost); no referrals required.
• Private Fee-for-Service (PFFS): Use any provider who accepts plan terms. Some plans have provider networks.
• Special Needs Plans (SNPs):
  • C-SNPs: For chronic conditions like cancer or diabetes.
  • I-SNPs: For individuals in nursing homes or who need in-home care.
  • Dual Eligible Special Needs Plans (D-SNPs): For people eligible for both Medicare and Medicaid; includes extra benefits like drug coverage and care coordination.
• Medical Savings Accounts (MSAs): Combine a high-deductible health plan with a medical savings account funded by your insurer.

What Are Your Prescription Drug Options with Medicare Advantage?

Most MA plans include Part D drug coverage, with exceptions like MSA and some PFFS plans. If your MA plan doesn’t include drug coverage:

• You may be able to enroll in a standalone Part D plan (if allowed).
• You could face a late enrollment penalty if you delay getting coverage without other creditable drug coverage.

Always check the plan’s drug formulary to ensure your prescriptions are covered.

How Do You Choose a Medicare Advantage Plan?

Before choosing a plan, review Medicare Advantage costs, and consider:

• Premiums: Many plans have $0 premiums; others include monthly costs beyond the Part B premium.
• Deductibles, Coinsurance & Copays: Understand your share of costs for services.
• Out-of-Pocket Maximums: This annual cap limits how much you’ll spend on covered care.
• Extra Benefits: Look for added perks like vision, dental, fitness memberships, and telehealth access.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during specific enrollment periods:

• Initial Enrollment: 3 months before and after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop MA plans.
• General Enrollment (Jan 1–Mar 31): For those enrolling in Part B; can join an MA plan from Apr 1–Jun 30.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Triggered by events such as:
  • Moving out of your plan’s area
  • Losing employer/union coverage
  • Plan leaving Medicare
  • Qualifying for an SNP

What If You Want to Change Your Medicare Advantage Plan?

You can switch plans during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

Enroll in your new plan, and your previous plan will be automatically canceled.

What Are Medicare Resources in Maine?

• Maine SHIP (State Health Insurance Assistance Program): Free Medicare counseling. Call (877) 353-3771 or visit the ADRC website.
• Maine SMP (Senior Medicare Patrol): Helps protect against Medicare fraud. Visit the SMP Maine site.
• Maine Bureau of Insurance: Handles Medicare-related complaints and issues. Call (800) 300-5000 or email Insurance.PFR@maine.gov.
• Medicare Savings Program (Buy-In): Assists low-income residents with premiums, deductibles, and more. Call (877) 353-3771.

Learn more about the differences between Medicare and Medicaid.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

Next Steps

If a Medicare Advantage plan in Maine is right for you, compare available plans in your area. Review provider networks, out-of-pocket costs, and extra benefits—then be ready to enroll when eligible.