With open enrollment starting Nov. 1, insurers are competing to sign up the 75,000 or more Mainers purchasing subsidized insurance on the Affordable Care Act’s health insurance marketplace for 2016.

Community Health Options has captured about 80 percent of the individual marketplace in Maine during the first two years of the ACA’s existence. The Lewiston-based cooperative has among the most dominant market positions in any state, experts have said, especially for a nonprofit co-op that is not a traditional national insurer.

In response, Harvard Pilgrim Health Care is gunning for more market share for 2016 by offering discounted premiums to patients who select a more limited network of doctors and hospitals.

The health insurance marketplace is where those without insurance – often part-time or self-employed workers – can obtain subsidized benefits.

Harvard Pilgrim is trying to make inroads into Community Health Options’ market share by offering 10 percent to 15 percent premium reductions for patients who choose the insurer’s new narrower network. Consumers can still select Harvard Pilgrim’s traditional network, which offers a broader choice of doctors and hospitals.

Harvard Pilgrim officials said Monday the discounts are designed to persuade customers to choose their coverage for 2016. While many employers offer Harvard Pilgrim for their workers, the insurer barely made a dent in the Affordable Care Act’s individual marketplace for 2015, with about 1,000 or so Mainers choosing a Harvard Pilgrim plan. Community Health Options has about 60,000 customers, and Anthem Blue Cross Blue Shield has the balance, according to numbers released this spring, after open enrollment for 2015 ended March 31.

“We’re always cognizant of what the competition offers,” said Ed Kane, Harvard Pilgrim’s vice president for Maine.

Emily Brostek, executive director of Consumers for Affordable Health Care, an Augusta nonprofit that advocates for health care access, said Harvard Pilgrim’s prices were too expensive for 2015, and so the insurer is trying to gear up for next year’s battle for customers.

“They (Harvard Pilgrim) were by far the most expensive for this year,” Brostek said. “If they had any hope of getting people to switch or new customers to choose them, they had to be competitive on price.”

Community Health Options, the Maine-based co-op, has been a business success story, and its dominant market share has been noted numerous times by the national media. The co-ops were created under the ACA, boosted by federal loans. Community Health Options started with a $65 million federal loan, and it has since expanded into New Hampshire.

Community Health Options, Harvard Pilgrim and Anthem will be offering individual marketplace plans for 2016. Aetna was planning to enter the Maine marketplace for next year, but pulled out late last week, the Maine Bureau of Insurance confirmed on Monday. An Aetna spokeswoman couldn’t be reached Monday afternoon.

Harvard Pilgrim’s overall premium prices declined by an average of 4.8 percent for 2016 coverage. In addition, patients who choose the narrower network can save an additional 10 percent to 15 percent on premiums.

Community Health Options’ premiums rose an average of 0.5 percent, while Anthem’s plans increased by about 5 percent for 2016, according to the Bureau of Insurance.


The narrower network being offered by Harvard Pilgrim – called Maine’s Choice – will be available in 10 counties in southern, midcoast and central Maine, including Cumberland, Kennebec, Androscoggin, Sagahadoc, York, Knox, Lincoln, Oxford, Waldo and Franklin counties.

Hospitals will include Maine Medical Center, Southern Maine Health Care, MaineGeneral Medical Center, York Hospital and others. The network has about 700 primary care providers and 3,000 specialists, according to a news release.

Notably, the network excludes Mercy Hospital in Portland.

Kevin Lewis, CEO of Community Health Options, said the co-op doesn’t offer a narrow network because it’s confusing for customers and can be a financial hardship if an out-of-network doctor or hospital is used.

“Oftentimes, people are not aware of the limits of the network, so it can cause a lot of pain for the consumer,” Lewis said. “We put our focus on simplicity of design and access to health care.”

But Kane, the Harvard Pilgrim executive, said that Maine’s Choice offers patients many doctors and hospitals to choose from, and the premium reduction can generate significant savings.

“This is going to be very attractive to customers shopping on the marketplace,” Kane said. “They are going to see a substantial savings.”

Kane said Harvard Pilgrim might offer Maine’s Choice statewide in the future instead of limiting the counties where it’s available.

Brostek doesn’t object to an insurer offering a narrower network as an additional choice – as Harvard Pilgrim is doing – but she worries that some may choose such a plan based solely on price and not realize how they are limiting their choices.

In 2013, Anthem came under fire for proposing a narrower network, with officials from Central Maine HealthCare in Lewiston and others objecting to the network by accusing Anthem of building a overly restrictive network for patients. The Bureau of Insurance approved a compromise plan.


Rory Sheehan, Anthem spokesman, said they have a broad network of health care providers for consumers.

“Our exchange networks are quite comprehensive and include a majority of providers in the southern counties (Androscoggin, Cumberland, Franklin, Knox, Kennebec, Lincoln, Oxford, Sagadahoc, Waldo and York), including more than 740 primary care physicians and over 6,400 specialists, allied and other professional providers,” Sheehan said in a statement.

As for whether the Maine health insurance marketplace will grow substantially in 2016 or has plateaued, Brostek expects there will be a significant increase in new patients beyond the 75,000 Mainers currently insured through the ACA. But she said the rate of growth will likely slow for 2016. Consumers can sign up through Jan. 31 for 2016 plans, through www.healthcare.gov or www.enroll207.com.


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