In addition to the governor and legislative Republicans blocking Medicaid expansion, Maine has another health care problem: People don’t know much about the Affordable Care Act, which aims to extend health care coverage to everyone. It will be important for potential new enrollees to know details, such as which insurers will be available when they choose a required health insurance plan.
According to a Kaiser Family Foundation poll released in April, 42 percent of Americans are unaware the ACA is the law. About half of Americans say they don’t have enough information to understand how the ACA will impact their family; that sentiment increases among the uninsured and low-income adults.
Here is what Maine residents must know: Starting Oct. 1, if their employer doesn’t provide health insurance, people may enroll in a plan that’s right for them. They will be able to shop for the plan in an online marketplace, called an exchange. They, and their children, must enroll in a plan by Jan. 1, 2014 or else pay a penalty. The penalty will be based on the number of months an individual goes without coverage.
Maine will have two carriers offering different plans as part of the exchange in 2014: the large commercial insurer Anthem, which has partnered with MaineHealth, and a new, consumer-run health insurer called Maine Community Health Options.
Making a decision about which carrier to use will be a personal decision, and Anthem and Maine Community Health Options’ plan offerings available under the exchange have not yet been announced. But it’s important for Maine residents to be prepared and know how the new insurer, Maine Community Health Options, operates.
One goal of the health reform law is to increase competition among insurers and improve consumer choice. In some states, though, such as Maine, there are only a small number of insurance companies. So the law created what are called “consumer operated and oriented plans,” or CO-OP. The federal government provided $2 billion in loans to create 24 of them.
Maine Community Health Options is Maine’s CO-OP. It is a private nonprofit based in Lewiston that is currently assembling a statewide network of providers. It will serve individuals, families and businesses, with a goal of enrolling 15,000 by the end of 2014. CO-OP members will elect the governing board, and more than half of board members must belong to one of the CO-OP’s plans.
Maine Community Health Options can’t be sold or acquired, and because it is a nonprofit, it must use its profits to lower premiums, provide more benefits and pay back start-up costs. The people who participate in the CO-OP have a stake in the success of the program: If they manage their health, everyone benefits from reduced costs.
The U.S. Centers for Medicare and Medicaid services awarded the CO-OP a loan of $62.1 million, most of which is required for the purpose of sufficient reserves. In order to receive a license to operate, the Maine Bureau of Insurance verified that Maine Community Health Options’ model would support paying back that sum.
Maine Community Health Options has a strong consumer focus, but because the agency is new, it has extra work to do to successfully compete with a well-established insurer like Anthem.
It will need enough financial support for marketing — in order to draw enough members to be self-sustaining — as the government prohibits federal funds from being used for promotion. It will have to set its initial rates without detailed data about its’ members historical claims. It will also have to work well with medical providers to gain a large-enough market share to enable it to negotiate consumer-friendly payment rates.
These are all doable. But the model won’t work properly if people don’t take the time to inform themselves. Providers should learn more, in order to join the network or spread the word. Maine residents don’t have to choose Maine Community Health Options if its health insurance plans aren’t right for them, but they should, at the very least, understand their options. The success of Maine’s health care system will depend in part on the informed decisions of many individuals.