Medicare in Maine

Medicare is a federal health insurance program for individuals aged 65+ and younger adults with qualifying disabilities. Its core components are Parts A and B, with the former focusing on critical services and the latter on outpatient care. Part A provides coverage for emergency care, inpatient treatments and skilled care within nursing homes and the beneficiary’s home. Part B provides coverage for essential outpatient care services, diagnostic testing, medical transportation and vital medical supplies and equipment. Most adults who satisfy Part A’s eligibility requirements don’t pay for coverage, while Part B carries a monthly premium of $164.90. In 2021, Medicare cost the state of Maine approximately 1.7 billion dollars.

Medicare Advantage, also known as Part C, combines the coverage provided by Parts A and B, excluding hospice care. As of 2023, there were 54 Medicare Advantage Plans in Maine, down from 57 the previous year. Premiums start at 0%, but, because beneficiaries add extra coverage options, such as vision and dental, the median monthly premium is $11.25. Medicare Part D exclusively covers prescription drug expenses. Premiums vary because numerous factors have an influence, including the individual’s prescribed medications and the tier assigned to their drugs. To help manage out-of-pocket expenses, such as deductibles and copayments, seniors can sign up for a Medicare Supplement Plan, also known as Medigap. 

The Centers for Medicare and Medicaid Services (CMS) administers Original Medicare, while approved private insurance companies oversee Medicare Advantage. As of July 2023, Maine was displaying a gradual shift toward Medicare Advantage. Of seniors eligible for the program, 55% have adopted a plan, an increase from the previous year’s 51% and above the national average of 48%. There is evidence this trend is continuing. Another 2.7% of Maine’s residents became eligible for Medicare Advantage in 2023, while the take-up increased by 7.73% from 2022’s figures.

This guide provides a comprehensive review of Medicare in Maine. It covers options available to the state’s seniors and additional resources to help them learn more about the state health insurance. Also, there’s information about how they can make Medicare more affordable. 

Options for Medicare Coverage in Maine

Original Medicare provides basic coverage that meets some seniors’ needs, but more people are discovering they need more comprehensive health insurance coverage. Maine residents have several options to help limit out-of-pocket expenses, save money on prescription drugs and provide savings on wellness programs that may help them lead healthier lives throughout their retirement. 

Original Medicare (Parts A & B)

Original Medicare provides identical coverage across the nation, whether the individual resides in Maine or is relocating or visiting another state. However, Medicare very rarely pays for coverage outside the United States. As a precautionary measure, the U.S. Department of State strongly advises Americans traveling abroad to secure health insurance for their specific destinations. 

Within Original Medicare, seniors are responsible for settling their health care costs upon receipt of services. Medicare covers 80% of the eventual fees, with the remaining 20% covered by the recipient. As of 2023, Part A’s annual deductible is $1,600, while Part B’s is $226.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

While Original Medicare offers a rigid form of coverage, Medicare Advantage offers choice. It’s a flexible option for seniors who need more coverage than Original Medicare provides. There are five distinct types of Medicare Advantage Plans:

• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Private Fee-for-Service plans (PFFS)
• Special Needs Plans (SNPs)
• Medicare Savings Account (MSA)

Each type of plan caters to different requirements. For example, seniors wanting access to a wider network of health care specialists may consider a PFFS plan, while those happy with a restricted network for potentially lower premiums may opt for an HMO plan.

Who Should Consider Medicare Advantage

An Advantage plan is an ideal choice for people who:

• Are generally healthy, so may benefit from lower premiums

• Need coverage not provided by Original Medicare
• Want more control over their out-of-pocket expenses
• Are comfortable with managed care, and seeing doctors in a provider network

The Top Medicare Advantage Plans in Maine

Maine residents can choose from plenty of Medicare Advantage plans in the state. The following table displays the top-rated plans based on enrollment data, satisfaction ratings and plan costs as of August 2023. More information on Medicare Advantage plans is available on the Medicare Advantage Plans in Maine page. 

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later. Most Medicare Advantage plans include prescription drug coverage (Part D).

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2023 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Maine

It may feel confusing or difficult for seniors to navigate the Medicare enrollment process or to search for Advantage plans that offer the coverage they desire, but thankfully, there are several resources and programs available that provide assistance. The following programs provide Medicare education, one-on-one assistance with applying for benefits and information to help seniors protect themselves from fraud or scams.