Operations & Management

Understanding Health Care

The Affordable Care Act (ACA) was passed in March of 2010 and, as of 2014, mandates that all individuals are required to have health insurance. ACA and the federally facilitated healthcare Marketplace has brought about changes in the insurance plans offered in the state of Maine.

In 2011 and 2012, the Maine legislature considered bills to establish a state-run health insurance marketplace; however, in the end those bills were not passed. It was decided that Maine would not develop a state-run marketplace and legislation to expand Medicaid was also vetoed. It was ultimately determined that Maine would default to the federally facilitated exchange.

The ACA’s Individual Mandate and Pre-Existing Conditions

  • As of 2014 the ACA requires individuals to have health insurance or pay a tax penalty.
  • Any Maine resident not eligible for Medicare can buy an individual health insurance policy. (Individuals who need to pay for Medicare Part A can also buy an individual policy). Some people can get help with the cost of a plan on the Marketplace, depending on their income, household size, and whether they are eligible for another kind of coverage.
  • For insurance issued on or after January 1, 2014, plans cannot exclude coverage for preexisting conditions.

If you are eligible for group coverage that meets the ACA’s standards (either through your employment or your spouse’s or parents’ employment, or through membership in an association), you will not be able to get help with the cost of a plan through the Marketplace. You can still buy individual coverage on or off the Marketplace, but you will want to carefully consider whether the group coverage available to you has better benefits, or costs less.

Mandated Benefits

Ten essential health benefits must now be included in all health insurance plans:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health & substance use disorder services
  • prescription drugs
  • rehabilitative and habilitative service and devices
  • laboratory services
  • preventative/wellness services/chronic disease mgt.
  • pediatric services, including dental and vision
  • Preventive services: Individuals do not pay co-pays, coinsurance or deductibles for certain preventive health services that are provided by network providers including routine immunizations and routine physical exams, such as:
  • gynecological exams
  • pediatric eye exams
  • mammograms
  • digital rectal exams and
  • routine and medically necessary colorectal cancer screenings

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