You asked how Maine’s new universal health program differs from Connecticut’s SAGA medical assistance program in terms of eligibility, services, and funding.

We are attaching a copy of OLR report 2003-R-0494, which summarizes Maine’s program in more detail.

SUMMARY

The Maine universal health care program, Dirigo Health, is the state’s comprehensive plan to offer health care to its uninsured residents. The program made two major changes: a Medicaid (MaineCare) expansion and an insurance plan, primarily for small employers and self-employed people that offers comprehensive coverage, and subsidies to individuals and families with incomes under 300% of the federal poverty level (FPL) who do not qualify for MaineCare. It is designed primarily to help uninsured, working adults under age 65. (Most adults aged 65 and older qualify for Medicare and many, especially those with lower incomes, also qualify for Medicaid. ) Federal and state funds pay for the Medicaid expansion and a combination of sources will help subsidize the non-Medicaid, Dirigo Choice health plan, which the state has negotiated with Anthem Blue Cross Blue Shield of Maine. A recent press release from Maine’s Governor’s Office reports that enrollment in the plan will begin on January 1, 2005.

SAGA medical assistance is a totally state-funded program that provides health care coverage to the state’s poorest citizens who do not qualify for Medicaid. Most services are covered but several are not, including nonemergency transportation. It is primarily aimed at single adults under the age of 65.

SAGA and Dirigo both offer publicly funded health care coverage. But the two programs differ in a number of other ways. In addition to their funding source, MaineCare offers more services than SAGA medical assistance. But it also charges co-payments, albeit minimal ones, where SAGA does not.

We could not get information about the Dirigo Choice benefit plan. We requested but are still waiting for information on the various options and cost-sharing requirements. We will forward these to you once we receive them.

DIRIGO AND SAGA MEDICAL ASSISTANCE COMPARISON

Eligibility

SAGA. SAGA provides health care coverage to the state’s uninsured individuals who are not eligible for Medicaid. (Connecticut’s Medicaid program covers non-elderly or -disabled adults only if they are the caretakers of children enrolled in HUSKY A and have income no greater than 100% of the federal poverty level (FPL) or $ 15,670 for a family of three. ) It is entirely state-funded. To qualify, a single person cannot have more than $ 1,000 of liquid assets and monthly income greater than $ 476 (after deducting up to $ 150 in earnings), which is about 61% of the FPL.

MaineCare. Unlike Connecticut’s Medicaid program, MaineCare covers parents and childless adults. Three categories of uninsured adults can get MaineCare coverage; each has different income caps. The following table shows these groups and how the 2003 law that created the Dirigo plan expanded this coverage:

Table 1: MaineCare Coverage for Adults

There is no asset test for children under age 18. Adults generally cannot have more than $ 2,000 in liquid assets.

Dirigo Choice. Individuals who work for small businesses or themselves, and unemployed residents, will soon be able to get health coverage through insurance plans that the state has negotiated with Anthem/Blue Cross. Coverage is subsidized for residents with incomes below 300% of the FPL ($ 47,010 annually for a family of three in 2004). Even those with higher incomes can participate and stand to benefit since the state is pooling the groups to negotiate the best prices. Employers generally pay 60% of the employee-only costs of care plus an annual program fee ($ 150 to $ 300 per year, depending on the size of their workforce).

Services

SAGA and MaineCare cover most of the same services, as shown in Table 2. The principal difference is that SAGA does not pay for nonemergency transportation.

Table 2: Comparison of SAGA and MaineCare Coverage

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[1] Includes oral exams, x-rays, filling, fluoride, oral surgery, sealants, bridge and crown, root canals, full and partial dentures, extractions, and orthodontia for patients under age 21.

[2] Pregnancy termination is limited and must be consistent with DSS policy.

[3] Not covered if provided by an independent practitioner.

Most SAGA medical assistance recipients now receive their services from federally qualified health centers. The services are less generous than those available under both Connecticut Medicaid and Dirigo. SAGA does not cover non-emergency transportation, unless it is for cancer treatment or dialysis. Nor does it pay for podiatrists, optometrists, chiropractors, naturopaths, or independent therapists (e. g. , audiologists, physical therapists, licensed audiologists and speech pathologists).

MaineCare covers all of the mandatory Medicaid services as well as many optional services. Employees of employers who participate in Dirigo Choice who are eligible for MaineCare can get coverage for services that Medicaid covers but the plan does not. Employer payments for these individuals are pooled (see 2003 report) and a portion goes to the MaineCare program, for which the state will receive a federal matching payment.

We were unable to ascertain what the specific benefit package will be, but the Dirigo Choice plan promises to offer a comprehensive package of services. The Dirigo website touts the program’s offer of 100% coverage for wellness and prevention and a $ 100 reward to enrollees who complete a health needs questionnaire and meet goals that they identify with their physician. It will apparently not be as generous as MaineCare’s service package.

Funding

The SAGA medical assistance program is funded entirely with state General Fund appropriations. (State law requires the DSS commissioner to explore the possibility of getting Medicaid coverage for this population, possibly through a waiver. As of yet, she has not done so. )

Dirigo Health is funded in a few ways. Its first year of costs are being paid with $ 53 million in one-time enhanced federal Medicaid matching funds that all states received in 2003. (Connecticut’s enhanced match went directly into the General Fund and was not earmarked for a specific purpose. ) For subsequent years, the state will use “savings offsets” it receives from the state’s insurance companies and the employee and individual payments. (See the 2003 OLR report for a detailed explanation of the offsets. )

Cost Sharing

SAGA medical assistance recipients are not required to share the cost of the services they receive.

Most MaineCare recipients have to make minimal co-payments, although certain individuals, including pregnant and post-partum women and children under age 21, are exempt from these payments. The co-payments range from $ . 50 to $ 3 for both services and prescriptions. For example, laboratory work and x-rays require a $ 1 co-payment, while $ 2 is required for chiropractors, mental health clinics, and opticians, among other services. Clients pay $ 2 for each generic drug and $ 3 for brand-name ones.

Under the Dirigo Choice plan, cost sharing will depend on the participant’s income and the health plan option he chooses. The program’s discounts will provide help to individuals and families with incomes under 300% of the FPL.

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