The draft of Maine’s State Health Plan, November 2005 states:
• “Maine has the highest rate of uninsured citizens in New England. About 136,000 (17%) of non-elderly Maine residents spent part of 2002 uninsured, and on any given day, roughly 1 in 8 non-elderly Mainers were uninsured. 80% of the uninsured work – of those who do work 73% work in small businesses or are self-employed.”
As a member of the fishing community, how do you protect your assets if you or your family needs medical care? According to Heather Lewis whose husband, Troy, fishes out of Southwest Harbor, some families decide that one adult will work in a job that provides health insurance benefits. But what are the options if you’re on your own? This is the first of a series of articles that will help you answer those questions.
Do You Need Health Insurance Coverage?
Many Mainers, including those of us at the Fisherman’s Voice, have experienced the loss of a loved one to cancer. According to www.statehealthfacts.org, Maine’s cancer rate is the 2nd highest in the nation. Unfortunately, we take first place nationwide with chronic obstructive pulmonary disease or COPD, which can be caused from smoking and poor air quality.
Dartmouth Hitchcock Medical Center in Lebanon, NH puts the charge for an average 5.6 day hospital stay in 2005 at $26,320; a figure way beyond the budget of most Maine households.
Prevention is always the best strategy, but when you or your loved ones fall victim to injury or disease healing and treatment should be foremost in your mind, rather than financial stress.
Dirigo Health Plan
First, let’s take a look at DirigoChoice, Maine’s own health plan, which is provided through the Anthem insurance company—the old Blue Cross & Blue Shield of Maine.
In his speech on March 15, 2006, Governor Baldacci highlighted the progress of the Dirigo Health Plan, stating that 15,000 Mainers are insured through the program. The total membership at the end of March 2006 was 9473; comprised of 30% sole proprietors (self-employed), 32% individuals (not self-employed) and 38% small business groups, as reported in the Maine Medical Association’s Weekly Update.
How DirigoChoice Works
You may purchase DirigoChoice as long as you:
• Have no access to an employer health plan
• Are not eligible for Medicare (65 years old or disabled)
• Are not eligible for MaineCare (Maine’s no-cost health insurance)
• Have resided in Maine for at least the last 60 days
Dirigo charges individuals or self-employed people $150 a year membership fee which is added to your monthly premium.
Your monthly premium rate (cost for the plan) will take into account your age and where you live. You may fill out financial statements to see if you qualify for a discounted premium. There are four levels of discounts available. Below I have listed only the highest and lowest incomes that will qualify you for a discount and the approximate rates for households with one to three persons. The annual income amounts in the chart below are based on NET income (your income after expenses).
The Benefits
This is where things spin into “insurance speak.” Bear with me. The benefits vary a lot from situation to situation so it’s best to call Dirigo for your personal quote.
Three Deductible* Levels, depending on your income:
Individual/ Family - $500/ $1000
Individual/ Family - $1450/$2900
Individual/ Family - $1750/$3500
*A deductible is an initial uncovered amount each year. For example, a $1000 deductible means that the first $1000 of your health care costs beginning each January will be payable by you. Note: In the DirigoChoice plan, no deductible applies to Preventative services such as physical exams or immunizations. But there are special billing instructions, so if your claim is denied call your doctor. Your adult annual physical exam claim needs to be billed with a special procedure code of 99420 in order to be paid. This is a number code that your doctor’s office puts on the claim form that it sends to Anthem and is special to only Dirigo claims.
Contractual Write-offs:
If you have health insurance, in most cases your doctor or hospital has a contractual agreement with your health insurance company to accept only a “usual & customary fee” for your care. Any charge that exceeds this amount is written off. So even if you’re billed the balance because a deductible applies, you pay less than if you would pay if you had no coverage at all. Additionally, your claim runs through the claim paying system and is scanned for errors, so you get a bill that is fair and accurate.
Medicines
Everybody gets a prescription drug card, so you can get your medicines with the following co-payments (amount payable by you at the pharmacy):
$10 generic/ $25 brand name/ $40 optional brand
Will Dirigo Cover You If You’re Already Ill?
An important feature of DirigoChoice is that it has no pre-existing condition clause. This means that after the time it takes you to sign up for the program (usually less than two months), any illness process that you are involved in will be covered. This is not the case with other plans, some of which have a two or three year waiting period before treatment of pre-existing illnesses will be paid. Note: If you are switching from one health insurance plan to another, with no break in coverage, pre-existing conditions are covered.
If I Qualify For A Reduced Rate, How Do I Get My Discount?
Premiums need to be paid by check, up front, by the first of the month. Dirigo provides you with a Debit Card account, which is credited on the first day of each month with the amount of your discount. Your debit card is valid for withdrawals of cash from ATM machines. Once you have been with the program three months, you may elect to have this amount direct deposited into your bank account and forego the debit card arrangement.
The state employees at the Skowhegan-based Dirigo Health Agency office that handles payments report that this debit and direct deposit system is working very well and there have been no complaints.
For more information or to receive an application packet and quote without obligation, call Anthem at 1-800-934-3233, and select #3 to reach a sales agent. If you’re interested in information about all the plans offered by Anthem, call 1-800-585-0099.
Bottom Line:
If you qualify for a discount and/or are currently involved in a major illness process, DirigoChoice may be a good plan for you. However, if you have to pay full premium rates, there may be a better deal out there.
Other Options:
In future articles, we’ll investigate some of the other commercial plans such as:
• Aetna
• John Alden
• United Healthcare
• Cigna
• Great West Life
• Mega Life (formerly NASE)
And we’ll outline Health Savings Accounts (HSAs) so you can see if this way of socking away tax-free cash to pay for health care would work for you.
Susan Whittaker is a certified professional medical coder and is currently the Coding Specialist for the Health Centers of MDI Hospital in Bar Harbor. She has been a medical insurance ‘geek’ for over 20 years and offers private consultations to physician practices and individuals. Reach her at codermd@netzero.com.
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