Medicare in Maine

Medicare is a government health insurance program for retirees over age 65 and younger adults with certain disabilities. In 2020, more than 345,000 Maine residents enrolled in Medicare, up from 263,000 only 10 years earlier. The Medicare Advantage program is becoming more popular, with enrollment in Advantage plans up by more than 460% in the last decade and fewer enrollees choosing Original Medicare in the same period. 

Original Medicare has two main parts. Part A is free to residents who contributed to Medicare through payroll taxes for a certain amount of time and covers inpatient care at hospital, skilled nursing care, home health services and hospice care. Part B covers preventative care, diagnostic testing, outpatient medical procedures, medical supplies and equipment and medical transportation services. The standard Part B premium amount costs $170.10 per month in 2022. 

The Medicare Advantage program, also referred to as Medicare Part C, allows seniors to choose a private insurance company instead of government-controlled benefits. All Advantage plans provide the same coverage found in Parts A and B, except for hospice care, but allow enrollees to choose additional coverage options to meet their needs. For example, they may add dental, vision or prescription drug coverage. 

Part D is Medicare’s prescription drug program and premiums vary by coverage level. Medicare Supplement plans, or Medigap policies, reduce seniors’ out-of-pocket expenses by covering deductibles, copays and other medical costs Medicare plans don’t cover. Private insurance companies sell and administer these plans. 

This guide offers a comprehensive review of Medicare in Maine and the options seniors can choose from when assembling custom coverage that meets their unique needs. It also provides resources and programs that assist seniors in understanding the Medicare program, enrolling for coverage and determining if they qualify for financial assistance. 

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 is administered by the Centers for Medicare & Medicaid Services (CMS) and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

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)

Medicare Advantage is an alternative to traditional Medicare coverage. Advantage plans are private insurance plans paid for in part by the federal government. Beneficiaries pay the difference in their plans’ monthly premiums. Advantage plans must provide the same benefits covered under Parts A and B (except for hospice care which remains covered by Medicare Part A) and allow enrollees to add coverage the government doesn’t traditionally offer. For example, an Advantage plan may provide dental and vision coverage, a prescription drug plan and savings on gym memberships or other wellness services. 

Advantage plans are available in four forms: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-for-Service (PFFS) and Special Needs Plans (SNPs). Program rules regarding eligibility, premiums and coinsurance all vary by plan, but most plans have annual out-of-pocket limits that help seniors on a fixed income control their expenses. 

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 10 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 April 2022. 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 2022 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.