Maine health insurance Marketplace guide

To qualify for health coverage through the Marketplace in Maine, you must:⁵

• Be a Maine resident
• Be either a United States citizen or national, or be lawfully present
• Not be incarcerated
• Not have Medicare coverage

Eligibility for financial assistance (premium subsidies and cost-sharing reductions) will depend on your household income. In addition, to qualify for financial assistance with your Marketplace plan you must:

• Not have access to affordable employer-sponsored health insurance. If your employer offers coverage but you feel it’s too expensive, you can use our Employer Health Plan Affordability Calculator to see if you might qualify for premium subsidies in the Marketplace. 
• Not be eligible for MaineCare (Medicaid/CHIP).
• Not be eligible for premium-free Medicare Part A.⁶
• File a joint tax return with your spouse if you’re married.⁷ (with very limited exceptions)⁸
• Not be able to be claimed by someone else as a tax dependent.⁹

In Maine, the open enrollment period for individual/family health coverage on CoverME runs from November 1 to January 15. (Note that for 2024 coverage, the enrollment deadline for CoverME was extended through January 16, 2024, due to the federal holiday on the 15th.)¹⁰

Enrollments must be submitted by December 15 to have coverage effective January 1. Enrollments submitted in the final month of the open enrollment window have an effective date of February 1 instead.¹¹

Outside of open enrollment, a special enrollment period is necessary to enroll or make changes to your coverage. In most cases, a qualifying life event is necessary to trigger a special enrollment period, but some special enrollment periods don’t rely on a specific life event. Learn more in our comprehensive guide to special enrollment periods.

Maine is one of several states where pregnancy is considered a qualifying event. In most states, birth is the qualifying event and the special enrollment period begins the day the baby is born. But in Maine, the expectant mother can enroll in coverage, as the confirmation of the pregnancy is considered a qualifying life event in Maine.¹²

Maine also enacted legislation in 2022 that creates an “easy enrollment program,” allowing uninsured residents to check a box on their state tax return if they want to be contacted by the state about enrolling in health coverage. A special enrollment period will be available if the person is not eligible for Medicaid and would thus need a special enrollment period to sign up for coverage.¹³ Several other states also have easy enrollment programs.

To enroll in an ACA Marketplace plan in Maine, you can: 

• Visit CoverME.gov – Maine’s health insurance marketplace to enroll in individual and family health plans. You can contact CoverME by phone at (866) 636-0355 if you need assistance. 
• Purchase Marketplace coverage with the help of an insurance agent or broker, or a Maine Enrollment Assister.¹⁴

To locate affordable health insurance options in Maine, consumers can visit the state’s ACA Marketplace (CoverME.gov). During the open enrollment period for 2024 coverage, nearly 84% of CoverME enrollees qualified for income-based premium subsidies. These subsidies averaged $564/month and reduced the average enrollee’s premium to about $229/month. ¹⁵ Subsidies are larger and more widely available than they used to be, thanks to the American Rescue Plan, and the Inflation Reduction Act). ¹⁶

In addition to premium subsidies, the Affordable Care Act provides cost-sharing reductions (CSR) to Marketplace enrollees whose household income isn’t more than 250% of the poverty level, as long as they select a Silver-level plan. The CSR benefits result in lower out-of-pocket costs when you need medical care.¹⁷

Between the premium subsidies and cost-sharing reductions, you may find that an ACA-compliant plan obtained via Maine’s Health Insurance Marketplace plan will provide you with the best overall value.

Source: CMS.gov ¹⁸

Individual/family health plans in Maine are required to fully pay for a member’s first primary care visit and behavioral health care visit each year. The 2nd and 3rd primary care and behavioral health visits have to be covered with only a copay (no deductible or coinsurance). There is an exception for HSA-qualified high-deductible health plans, to comply with IRS rules that prohibit those plans from covering anything other than preventive care before the minimum deductible is met.¹⁹

Maine has expanded Medicaid under the ACA, so MaineCare (Medicaid) coverage is available to adults under age 65 with household income up to 138% of the federal poverty level. Children and pregnant women are eligible for MaineCare with higher household incomes.

Four insurers offer exchange plans in Maine for 2024, and all four will continue to offer plans for 2025.²⁰ CHO, Harvard Pilgrim, and Anthem all offer plans statewide. Taro Health offers plans in Cumberland, Sagadahoc, York and Lincoln counties for 2024 and 2025 (up from just Cumberland in 2023). So in those four counties, there are four insurers offering plans, while residents in the rest of the state have access to plans from three insurers.¹

Maine has one of the few remaining ACA-created CO-OPs (Community Health Options, or CHO), which is one of only three CO-OPs (nationwide) offering coverage as of 2024.

For 2025 coverage, the following average rate increases have been approved by the Maine Bureau of Insurance for the four insurers that offer individual/family health insurance through CoverME. They amount to a weighted average increase of 8.6% (before subsidies), which is significantly smaller than the 14.2% average rate increase the insurers initially proposed.⁴

Source: Maine Bureau of Insurance²¹

For three of the carriers, the approved rate increases were quite a bit smaller than the carriers had proposed, but Taro’s approved average rate increase was significantly larger than the carrier had proposed.²²

Part of the reason for the lower approved rate increases is that Maine’s federal pass-through funding for MGARA (the state’s reinsurance program) was larger than expected in 2024, allowing the state to adjust the reinsurance parameters. This allowed the carriers to refile new rates, which were generally lower than they had initially filed.⁴

Average rate changes are calculated for full-price plans, before any premium subsidies are applied. But the majority of CoverME enrollees qualify for subsidies, which change each year to keep pace with the cost of the second-lowest-cost Silver plan.

The change in net (after-subsidy) premium depends on the specific plan (each carrier’s approved rate change is an average, across all plans they offer), geographic rating area, your age, and federal premium tax credits. 

If the cost of your current plan increases, you can explore other plans in the exchange that may be less expensive and offer similar benefits.

For perspective, here’s a summary of how full-price premiums have changed in Maine over the years:

• 2015: Average decrease of 1%²³
• 2016: Average increase of 0.7%²⁴
• 2017: Average increase of 23.5%²⁵
• 2018: Average increase of 25%²⁶
• 2019: Average increase of 1%²⁷ (Reinsurance took effect)
• 2020: Average decrease of 1.6%²⁸
• 2021: Average decrease of 13.1%²⁹
• 2022: Average decrease of 2.1%³⁰
• 2023: Average increase of 11.4%³¹
• 2024: Average increase of 14.6%³²

During the open enrollment period for 2024 coverage, 62,586 people enrolled in plans through Maine’s exchange.¹⁶

In most states, enrollment numbers have been climbing in recent years, reaching significant record highs. But that hasn’t been the case in Maine, where enrollment has hovered around the same level for several years (see chart below).

Maine was the only state where 2024 enrollment was lower than 2023 enrollment had been, with a 1.3% decrease.³³ Maine officials noted³⁴ that the enrollment decrease in 2024 was due to an increase in the income limits for children and young adults to qualify for Medicaid.³⁵ As a result, some children and young adults were able to transition from CoverME plans to Medicaid starting in late 2023.

Source: 2014,³⁶ 2015,³⁷ 2016,³⁸ 2017,³⁹ 2018,⁴⁰ 2019,⁴¹ 2020,⁴² 2021,⁴³ 2022,⁴⁴ 2023,⁴⁵ 2024⁴⁶

CoverME.gov Maine’s health insurance marketplace. Can also be reached at 1-866-636-0355. 

State Exchange Profile: Maine The Henry J. Kaiser Family Foundation overview of Maine’s progress toward creating a state health insurance exchange.