ACA health insurance options in 2017

First published in Landings, November, 2016.

With cold and flu season upon us, the last thing you need is to get caught without health insurance. An illness or injury can happen any day, but thankfully, you don’t have to worry about how to pay for your healthcare or medical bills. Open enrollment for Affordable Care Act (ACA) insurance began on November 1 and will go through January 31, 2017.

The ACA requires individuals to have health insurance or pay a tax penalty. The requirement can be met by having a plan with minimal essential coverage either through one’s employer or another group, or by purchasing an individual/family policy through Maine’s health insurance Marketplace.

For 2016, if an individual did not have health insurance, he or she will pay a tax penalty of 2.5% of the household income or $695 per adult and $347.50 per child up to $2,085 per household, whichever figure was greater, when the annual income tax return is filed.

In 2017, the 2.5% of household income penalty will remain for those without coverage. However, if the dollar amount is greater, then a person would have to pay the 2016 dollar amounts plus a Cost of Living Adjustment (COLA).

Either way, you don’t want to be without health insurance next year. Get covered to avoid these penalties. There are a variety of plans available to fit your needs and your budget. All the plans on Maine’s Marketplace cover doctor visits, hospital stays, prescriptions, preventive care and more.

The 2017 Marketplace offers plans from three health insurance carriers — Anthem Blue Cross and Blue Shield, Community Health Options, and Harvard Pilgrim — all of which provide coverage across the state. Maine residents can select from 33 plans for the 2017 coverage year. Consumers can browse plans within the Marketplace and compare levels of coverage. The health care plans are labelled as Bronze, Silver, and Gold, and there are catastrophic plans for those under 30.

Anthem offers quality care in 16 Maine counties with over 3,000 specialists and 1,000 primary-care physicians in its network, called “Pathway X.” Anthem splits the state into two network branches, offering eleven different plans in each network:

Northern POS (point of service) Pathway X: Aroostook, Hancock, Penobscot, Piscataquis, Somerset, and Washington Counties.

Southern HMO (health maintenance organization) Pathway X Enhanced: Androscoggin, Cumberland, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Waldo, and York Counties.

All of Anthem’s plans offer a range of programs, discounts, and tools to support health. The health and wellness resources offered are: 24/7 nurse telephone line, care support, the “myhealth advantage” program, and a member discount program. Anthem also offers online tools from their website to a mobile app. Both the website and mobile app feature tools for finding a doctor or hospital in your location, creating a virtual ID card, comparing doctor costs and quality, managing prescription benefits, and viewing claims.
Anthem also offers LiveHealth Online app which allows for members to have live video visits with a doctor 24/7. Members need a smartphone, a tablet or a computer equipped with a webcam with Internet access. This feature allows for members to get medical advice, diagnoses, proper treatment and even prescriptions in about ten minutes or less. Members also can talk to a licensed therapist or psychologist from home.

Community Health Options is a consumer operated and oriented plan (CO-OP) formed under the ACA which has a broad network of providers across the state. This Maine-based and member-led company emphasizes prevention and primary care. For 2017, it will offer nine plans: one catastrophic plan, three Bronze plans, four Silver plans, and one Gold plan. All Maine hospitals are within Community Health Options’ network; the company now offers in-network providers in New Hampshire and Massachusetts as well.
Community Health Options provides its members with a Chronic Illness Support Program (CISP) which enables reduced out-of-pocket costs for covered services related to the routine management of five major chronic conditions: asthma, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and coronary artery disease (CAD). These services do not require any cost sharing when performed by a plan provider. Examples include office visits for the condition, medications related to the condition, lab tests, self-management classes, equipment, and supplies.

Community Health Options is the only insurance company in Maine’s Marketplace that provides benefits for pediatric dental services in some of their plans. It also offers a nurse telephone line which is available to members 24/7 for assistance in making important health care decisions. In addition, it has an online wellness portal with over 6,000 health topics plus tools and videos to enable informed choices about treatment options.

Harvard Pilgrim is a nonprofit health care company that was founded by doctors and has provided health insurance in Maine since 1994. It has a multi-state provider network which includes all the hospitals in Maine, New Hampshire, and Massachusetts. The regional network offers over 30,000 providers (doctors, hospitals, and ancillary providers). Harvard Pilgrim’s individual 2017 plans in Maine use an HMO (health maintenance organization) network. In southern and central Maine, it also offers plans that have a tiered network (Maine Choice Plans). Maine Choice HMO will be offered in Androscoggin, Cumberland, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Waldo, and York Counties.

The Maine Choice Plans have discounts that range from 10% to 15% on the monthly premium and cost sharing for those who choose the insurer’s narrower network. This network is called the Preferred tier and has over 700 primary care providers, 3,000 specialists, and 12 hospitals. But members can also use the Standard tier which includes all doctors and hospitals in Harvard Pilgrim’s New England network (this option costs more than the Preferred tier).

Harvard Pilgrim also offers a Condition Management Program for members who are living with conditions such as asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, and kidney disease. Their offering includes programs for healthy eating, personal health coaches, member savings discount program, an “eat right” rewards tool, a know cost/quality comparison tool, and a $150 fitness reimbursement program. Additional benefits include world-wide emergency care covered at the “in-network” level, no referral requirements for acupuncture or chiropractic services, and a list of discounts for alternative medicine services.

Be sure to visit to see what plans are available. Please contact the MLA’s Navigator to set up an appointment at 207-967-4555 or email