What You Need to Know
Medicare Advantage plans have to provide the same basic protections as Original Medicare.
Most Medicare Advantage plans in Maine have prescription drug coverage.
You can join a Medicare Advantage plan during one of several enrollment periods each year.
If you qualify for Original Medicare, or Medicare Part A (hospital care) and Medicare Part B (outpatient care), you may be wondering if the federal program offers enough coverage. Original Medicare won’t cover all of your medical expenses. It also doesn’t cover prescription drugs or limit your out-of-pocket costs.
One option might be a Medicare Advantage (MA) plan, or Medicare Part C. These plans are provided by private insurers and offer at least the same coverage as Original Medicare except hospice care, which stays covered under Medicare Part A. Most MA plans also offer prescription drug coverage and a cap on your out-of-pocket expenses.
What Types of Medicare Advantage Plans Are Available in Maine?
Many of Maine’s Medicare Advantage plans work with networks of doctors and healthcare facilities to keep the costs of services more affordable. The most common types of plans are:
- Health Maintenance Organization (HMO): With HMO plans, you must use in-network doctors for your care. You’ll have to pick a primary care physician (PCP) and get referrals to see specialists. Except in emergencies, you’ll face high out-of-pocket costs if you go to an out-of-network doctor.1
- Preferred Provider Organization (PPO): With a PPO plan, you won’t have to choose a PCP, get referrals for specialists or be limited to in-network doctors. However, you’ll likely pay more if you go to an out-of-network doctor.2
- Special Needs Plans (SNP): SNP plans are for people with specific health conditions.3 Like other Medicare Advantage plans, SNPs are available through Medicare-approved private insurance companies. The three types of SNPs in Maine are:
- Chronic Condition SNP (C-SNP): You could be eligible for these plans if you have a chronic condition like cancer or diabetes.
- Dual Eligible SNP (D-SNP): These plans are available if you’re eligible for Medicare and either MaineCare or Medicaid.
- Institutional SNP (I-SNP): You’re eligible if you live in a nursing home or other institution or if you need in-home nursing care.
- Private Fee-for-Service (PFFS): You won’t need a PCP, and you can see any Medicare-approved healthcare provider who accepts your plan. Your plan determines how much it will pay for medical services and how much you’ll pay for care.4
- Medicare Medical Savings Account (MSA): These high-deductible private health plans are linked to special savings accounts that you use to pay for out-of-pocket expenses until you reach the deductible.5
You’ll save money with most MA plans by using in-network providers.
What Are Prescription Drug Options with Medicare Advantage?
With Original Medicare, you’ll need to buy a separate Medicare Part D plan to get prescription drug coverage in Maine. Most Medicare Advantage plans (except MSA plans and some PFFS plans) include prescription drug coverage.
When selecting a Medicare Advantage plan, be sure your prescriptions are covered by checking the plan’s list of covered drugs, known as the drug formulary. You can’t buy a separate Part D drug plan if your Medicare Advantage plan provides prescription drug coverage.
How Do You Choose Medicare Advantage Plans in Maine?
First, check if your doctors and hospitals are listed on the plans you are considering. Then compare the costs and benefits of different Medicare Advantage plans in Maine, including:
- Premiums: Your monthly cost for health insurance in addition to the Medicare Part B premium ($148.50 for most people in 2021). Zero-premium plans might be an option, but other costs under those plans (like deductibles and coinsurance) could cost more.
- Other Costs:
- Deductible: Your out-of-pocket costs for healthcare services each year before your plan starts paying.
- Coinsurance: This is your portion of the cost of a service, usually a set percentage of the total cost.
- Copayment: The fixed price you pay for a specific service.
- Out-of-pocket maximum: The total amount of out-of-pocket expenses you pay each year, except for premiums.
- Plan Benefits:
- Vision: Covers frames and eye exams.
- Dental: Covers teeth cleaning and checkups.
- Telehealth: Covers remote or virtual visits.
- Additional Perks: Many Maine Medicare Advantage plans cover part or all of your gym memberships or fitness classes.
Vision and Dental
Most Medicare Advantage plans also offer vision and dental coverage.
When and How Do You Enroll in a Medicare Advantage Plan in Maine?
- Initial Enrollment Period (IEP): You can sign up for a Medicare Advantage plan when you enroll in Original Medicare during the seven months around your 65th birthday.
- Annual Election Period (AEP), or Medicare Open Enrollment Period: You can select a Medicare Advantage plan from October 15 to December 7 each year.
- Medicare Advantage Open Enrollment Period (OEP): If you have Medicare Part C, you can change Medicare Advantage plans or switch back to Original Medicare from January 1 to March 31 each year.
- General Enrollment Period (GEP): If you didn’t sign up for Medicare during your IEP and don’t qualify for a Special Enrollment Period (see below), you can sign up between January 1 and March 31, and then join a Medicare Advantage plan between April 1 and June 30.
- Special Enrollment Period (SEP): Under certain circumstances, you might get 60 days to make changes to your Medicare Advantage plan outside of regular enrollment periods.7 Reasons include:
- You moved from the plan’s service area.
- You get your healthcare coverage from an employer or union health plan.
- You are losing your coverage, whether from a job or Medicaid.
- Your plan is being discontinued or is leaving the Medicare program.
- You need an SNP after being diagnosed with a health condition.
After signing up, you can replace Original Medicare with a Medicare Advantage plan. To qualify, you have to live within the plan’s service area and must be a legal resident of the U.S. for five years or more.
Who Has Signed up for Medicare Advantage in Maine?
Nearly 140,000 of Maine’s 380,000 Medicare-eligible seniors have signed up for Medicare Advantage plans. That is a penetration rate of about 37%, just slightly less than the national average of 39%.8 Among Maine residents, the number continues to rise every year.
How Much Do Medicare Advantage Plans Cost in Maine?
How much Medicare Advantage coverage will cost depends on your plan type and where you live. For example, one ZIP code in Portland offers 25 plans with monthly premiums ranging from $0 to $99.10 A ZIP code in Bangor has 21 available plans with the same price range.11 Be sure to consider costs like deductibles and copays as well when comparing plans.
What If You Want to Change Your Medicare Advantage Plan?
You can change your Medicare Advantage plan in Maine during any of the open enrollment periods each year. Just sign up for a new plan. When your new plan starts, your old plan will be canceled automatically.
What Are the Alternatives to Medicare Advantage?
Unlike other states, Maine doesn’t have a PACE (Programs of All-Inclusive Care for the Elderly) program or a Medicare Cost Plan.
The most common alternative to Medicare Advantage in Maine is to stay with Original Medicare.
You can cover expenses not paid by Original Medicare by buying a Medicare Supplement plan (or “Medigap”) policy from a private insurer. You’ll still need a stand-alone prescription drug plan (Medicare Part D).
What Medicare Resources Are Available in Maine?
Maine’s State Health Insurance Assistance Program (SHIP) has trained health insurance counselors who can help you navigate all aspects of Medicare and other healthcare issues. Call (877) 353-3771 or visit the Aging & Disability Resource Center (ADRC) website to learn more.
If you have Medicare, you might qualify for a Medicare Savings Program, also called Buy-In. These programs help people living on a limited income pay Medicare Part A and Part B premiums, deductibles, coinsurance and copayments. You must be eligible for Medicare Part A.12 Call (877) 353-3771 or visit the Aging & Disability Resource Center (ADRC) website for more information.
If a Medicare Advantage plan in Maine is the best option for you, compare the costs and coverage of the plans in your area. Be sure you know which plan you want once you’re eligible to sign up.