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A Consumer's Guide to...


A Guide for Employers With 50 or Fewer Employees




A Publication of the Maine Bureau of Insurance

Eric Cioppa


The Bureau of Insurance
34 State House Station
Augusta, Maine 04333
(207) 624-8475
(800) 300-5000 (in State)
TTY - please call Maine Relay 711


Small employer health insurance is available in Maine from several insurers and health maintenance organizations (HMOs). This publication is meant to help small employers understand their options and provide information about the health insurance marketplace.

Where do I start?

It is a very good idea to contact an independent insurance producer who represents more than one health insurance company to help you shop. That agent can answer questions, evaluate your group’s coverage needs and budget, and provide quotes.

Be sure to compare benefits and premiums carefully when considering different plans. In addition to benefits and premiums, service is important to consider when shopping for insurance. A company providing superior service may be worth some additional cost. If you don’t have an agent, you can start your own research by contacting the companies listed at the end of this brochure.


Who is eligible?

A small employer is one with 50 or fewer eligible employees. Eligible employees are those who work 30 or more hours per week. At the employer’s option, part-time employees working as few as 10 hours a week may be eligible under certain circumstances. Also, at the employer’s option, retired employees may be included.

By law, any insurer or HMO in the small employer health insurance market must agree to provide coverage to any small employer who applies, as long as a sufficient percentage of eligible employees and their dependents participate. The insurer or HMO cannot require more than 75% of employees and dependents who do not have other coverage to participate.

A self-employed individual is eligible for small group health insurance. If one of the small group insurers listed in this brochure also offers individual health insurance in Maine, that insurer may offer the self-employed individual an individual policy instead of a small group policy.

Continued Coverage for Dependent Children up to age 26

Under the federal Affordable Care Act, if your business offers coverage for dependent children, that coverage must be available for adult children up to their 26th birthday on the same basis as younger children unless they can get insurance through their own jobs. This coverage must be available whether they are students or married. If the plan does not cover dependents, the company does not have to change the plan to cover adult dependents.

If you believe that you are eligible for small group health insurance but have been declined for a small group (or an individual) plan by any of the insurers shown in this brochure, please note the name of the person you spoke to at the insurance company and contact the Consumer Health Care Division of the Maine Bureau of Insurance.


Are pre-existing conditions covered?

Employees and dependents age 19 or older who had no coverage during the three months before their new coverage takes effect may be subject to a pre-existing condition exclusion of up to 12 months. This means that any health condition other than pregnancy for which medical advice, diagnosis, care, or treatment was recommended or received during the six months before the effective date will not be covered for 12 months. However, those who had coverage at any time in the prior three months are protected by Maine’s “continuity law." This law prohibits the exclusion of pre-existing conditions except to the extent they would have been excluded under the prior coverage. Starting January 1, 2014, the Affordable Care Act prohibits pre-existing condition exclusions for new health plans. The Affordable Care Act currently prohibits health plans from limiting or denying benefits or coverage for a child younger than age 19 simply because the child has a pre-existing condition.

An employee or dependent that did not enroll in the employer’s plan when first employed, but wishes to enroll later, is considered a “late entrant." Late entrants may be subject to a 12 month pre-existing condition exclusion or may be required to wait an additional 12 months before enrolling. A person will not be considered a late entrant, however, if they initially did not enroll because they had other coverage and that coverage terminates for one of several reasons specified by law. These reasons include loss of coverage through a spouse’s plan due to death, divorce, termination of employment, or termination of the group plan. Also, when an employer gains a new dependent through marriage, birth, or adoption, they have a 30 day special enrollment period during which they will not be considered a late entrant.


How much does it cost?

moneyRates cannot differ based on gender, health status, claims experience, or policy duration. Rates can vary based on tobacco use, age, industry, geography, and group size. Variations for tobacco use and geographic area are each limited to a maximum range of 1.5 to 1 from highest to lowest. Rates can vary based on age and group size, but the maximum combined rate differential is limited to a range of 2.5 to 1 for policies issued or renewed after October 1, 2012. The rate factors for each variable are applied to a base rate, which will be different for each insurer and for each plan of benefits. It will also differ for different family structures. Typically, there is one rate for individual employees, another rate for an employee with children, a third rate for an employee and his or her spouse, and another rate for an employee, spouse, and children.

Employees may set aside pre-tax money to pay for insurance premiums or health care expenses. IRS Code Section 125 allows employees to make their employee health benefit plan premium contributions with pre-tax dollars (known as a Premium Only Plan). The employer may also set up a fund to include a Health Care or Dependent Care Reimbursement Account. Employees are then able to set aside pre-tax dollars to pay for medical expenses (that are not covered or otherwise reimbursed) and/or child care expenses. The employee decides each calendar year how much to set aside for that year and funds their account with a pre-tax contribution each pay period. The employee then makes a claim for reimbursement by submitting proof of incurring a qualifying expense. Any money left unclaimed at year end is forfeited so be cautious in committing an amount to be set aside. Anyone interested in these types of funds should contact a tax attorney, CPA, or other qualified professional.

Another alternative is a health savings account (HSA) which, unlike a Health Care Reimbursement Account, can carry over from year to year. See the section above under “What is Available” for further information on HSAs.


What is available?


magnifying glassMost insurers offer many different plans. Plans may vary as to the services covered, the level of benefits that are paid, and the extent of managed care provisions. Managed care refers to a variety of provisions intended to avoid paying for unnecessary care. The general types of plans available are:

· HMO - A “pure” HMO plan generally requires enrollees to choose a primary care physician from a list of participating doctors. Any non-emergency hospital or specialty care requires a referral from the primary care physician. With certain exceptions, no coverage is provided for doctors and hospitals that are not part of the HMO’s network.

· Point-of-Service - A point-of-service plan is another type of plan offered by HMOs. This plan is similar to a “pure” HMO plan except that services from non-network doctors or hospitals, or services obtained without a referral from the primary care physician, are covered at a lower benefit level rather than being denied.

· PPO - A PPO (preferred provider organization) plan is similar to a point-of-service plan except that it is offered by an insurance company rather than an HMO. Also, PPO plans usually do not require a referral from a primary care physician to receive the highest level of benefits for services from an in-network specialist or hospital.

· DirigoChoice - DirigoChoice was created as part of the Dirigo Health Reform Act, which is intended to lower health care costs, increase access to health care, and ensure high quality health care. DirigoChoice is a PPO plan available to small employers and individuals. Everyone is eligible, and those with incomes less than three times the federal poverty level may qualify for reduced premiums and deductibles. For more information on DirigoChoice or to be notified when subsidized coverage is available, please call toll free (877) 892-8391 or visit the Dirigo web site at:

· Indemnity - An “indemnity” or “fee-for-service” plan does not use a provider network. The same level of benefits apply to any doctor or hospital and is generally limited to the “usual and customary” charge for the service. If the doctor or hospital charges more than this amount, the patient is responsible for the extra amount. In addition, there is usually an annual deductible before benefits begin and a coinsurance provision that requires the insured to pay a percentage of the cost until an out-of-pocket limit is reached.

· HSA - An HSA, or Health Savings Account, combines a high-deductible health insurance policy with an investment account from which employees can withdraw money tax-free for medical care until they meet their deductible or for medical care not covered by health insurance. Otherwise, the money accumulates with tax-free interest until the employee’s retirement when it can be withdrawn for any purpose and will be subject to normal income taxes.

These tax benefits apply to federal income tax only, not to Maine state income tax. The investment account can be funded by the employer, by the employee, or both. The high-deductible health insurance policy must meet standards set in federal tax law. Some policies are designed specifically for this purpose. Other high-deductible policies may qualify, but you or your tax adviser should check the federal standards carefully to be sure.



Companies and Contact Information

The insurance companies listed below currently offer small employer policies. If you would like rate or benefit information, it can be obtained from the company or from a licensed producer.

COMPANY Website Telephone

Aetna Health

(800) 611-0888

Aetna Life Insurance Company

(800) 611-0888

Anthem Blue Cross & Blue Shield

(800) 585-0099

Harvard Pilgrim Health Care

(800) 208-1221

HPHC Insurance Company

(800) 208-1221

United HealthCare Insurance Company

(888) 735-5842


August 2012


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Last Updated: September 21, 2012