>>Fishermen's Voice Monthly Newspaper, Gouldsboro Maine

In our last issu e, Susan Whittaker outlined Maine’s Dirigo Health plan was outlined. If you qualify for a discount or have major health concerns Dirigo is a great choice for health insurance with some premiums coming out at under $100 a month. Below the other major options available in our state for individual health plans.

Anthem
Those of us who have been around a while remember Anthem as Blue Cross & Blue Shield of Maine. We also remember when “having Blue Cross” meant you were covered. Times have changed but Anthem still offers an HMO Standard plan that comes close.
Both Plans Offer:

No deductible except $250 deductible for a hospital stay or outpatient surgery

HMO Standard
$10 Co-payment/ $50 ER
Drug Co-payment $10/15/20
Pays 100% after co-payment
Skilled Nursing covered MONTHLY COST (PREMIUM) is according to age & family size
1 person under 40 $809.03
2 persons under 40 $1618.06
With children $2143.93
HMO Basic
$25 Co-payment/ $150 ER
Drug Co-payment $20/30
Pays 80% after co-payment
Skilled Nursing NOT Covered
MONTHLY COST (PREMIUM) is according to age & family size
1 person under 40 $657.27
2 persons under 40 $1314.54
With children $1741.78
Heard enough? This is very solid coverage with a very solid price. However, Anthem offers less expensive choices, too.

Anthem Healthchoice and Healthchoice HDHP For HSA Plans
All HDHP stands for is a HIGH DEDUCTIBLE HEALTH PLAN and HSA is a Health Savings Account. According to Keith Smith, who handles health insurance for J.T. Rosborough Agency in Ellsworth, a high deductible plan, backed up with a Health Savings Account to pay medical costs with tax-free dollars, can be the best approach for many Mainers. (HSAs will be fully explained in next month’s article.)

HealthChoice deductibles range from $250 to $15000.

Monthly Costs (Premiums) for the $5000 individual/ $10000 Family Deductible:
Age 40
One Person $188.86
Two People $377.71
One w/ Family $311.62
Two with Family $500.47
Age 50
One Person $236.07 Two People $472.14 One w/ Family $389.52 Two with Family $625.59
I
n these plans, the subscriber (the first adult in the plan) must meet half the deductible before the plan pays, except for the HDHP, in which any family members can meet the deductible collectively. Anthem’s HDHP pretty much covers everything after the deductible is met. No co-payments. There is a $3 million lifetime maximum. Chiropractic & OMT adjustments are limited to 25 manipulations per year. Call Anthem at 1-800-585-0099 or your agent for a personal quote.

Aetna
The other major choice in Maine is Aetna who offers an HMO plan very similar to Anthem. Co-payments are $10 and $25 but they apply to every visit, anywhere.

Again, this is very comprehensive coverage. No deductible. No worries. High cost.

Monthly Costs/Premiums:
(Hang on to your hats.)
STANDARD PLAN $10 Co-pay
1 person under 40 $933.99
2 persons under 40 $1902.34
2 persons under 40
With children $2605.17
BASIC PLAN $25 Co-pay
1 person under 40 $773.87
2 persons under 40 $1576.21
2 persons under 40
With children $2158.56

Aetna also offers an HDHP with HSA but only to small business groups in Maine. Reach them on line or at 1-800-435-8742.

A Word About Mega Life. This coverage seems less expensive and easy to get but it has coverage gaps. Before signing on the dotted line, be sure to read the policy so you understand the limitations that may include no physician or other outpatient benefits and daily maximums coverage limits. If you do have to pay for non-covered services you would receive a discount from providers participating in PHCS (Private Healthcare Systems), which is helpful to a point.

Hurt While Working. If you are self-employed and get hurt while hauling traps or otherwise on the job, your private health plan will cover you. The rules are different if you are a sole proprietor of a small business.

Medicare is our national health plan that is meant to cover us after the age of 65 or if we become disabled. Note: There is a waiting period before receiving benefits if you do become disabled, so speak to the Social Security administration right away if you become permanently injured.

Most of us have a chunk taken out of our paycheck all our lives to pay for Medicare so it may come as a surprise that we also have to pay premiums, deductibles and coinsurance costs with Medicare. The recently rolled out drug program, called Part D, needs some serious navigation, but luckily most pharmacies and medical offices are up to speed and happy to help.

PART A – Covers Hospital Costs – Annual Deductible $952

PART B – Covers Physician & Outpatient Costs – Annual Deductible $124

PART D - Prescription Drug Plans - Coverage Gap smack in the middle

ADVANTAGE PLAN - Medicare’s HMO (lower premiums)

When I’m 65:
If you or your spouse paid in to Medicare for 40 quarters or more, PART A is free. If you didn’t (paid in less than 30 quarters), the monthly premium is $393.00 for 2006.
PART B RATE: $88.50 a month in 2006. (2005 was $78.20, 2004 was $66.60)

The Medicare premium payment is taken right out of your social security check, if you get one, or billed every 3 months. After Part B deductibles are met, 20% of costs are still billed to you, so it is advisable to have a second health insurance plan (i.e. Anthem Companion) to cover these costs. If you qualify for Mainecare, the state’s no-cost health plan, it will pick up your remaining expenses.

PART D prescription medicine coverage is optional and consists of choosing a plan with one of the companies enlisted by Medicare and paying another monthly premium.

Healthcare and getting insurance is expensive. If the information so far has left you feeling out of the loop, stay tuned after the HSA article for information on where to find low or no cost health care through public clinics & programs in our area.

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’s worked in medical practices long enough to remember when the doctor was sometimes paid with lobsters. She offers private consultations to physician practices and individuals. Reach her at codermd@netzero.com.