LEWISTON — Mainers who want to buy health insurance through the Affordable Care Act’s upcoming health insurance exchange likely will have two insurance companies to choose from.

But only if both are federally approved.

The 2010 Patient Protection and Affordable Care Act created health insurance exchanges, or marketplaces, through which individuals and small groups can buy coverage. Individuals who meet income and other guidelines can receive federal subsidies to help pay for insurance purchased through the exchange. People who don’t meet guidelines can still buy insurance there, but they won’t get a subsidy to do so. Employers can buy small-group insurance for their workers through an exchange.

Nearly 800,000 Mainers are covered by Medicare, MaineCare, military, veteran, self-insured or large-group plans. They would not need the exchange. 

About 124,500 Mainers have individual or small-group health insurance plans, and another 133,000 have no insurance. Those 257,500 people are the ones likely to be affected by the exchange, by choosing it for themselves or working for an employer who might choose it.

Enrollment is expected to begin in October. Insurance coverage would be effective Jan. 1, 2014.

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So far, only two companies have applied to have plans included in the exchange for Maine. One is Anthem Blue Cross Blue Shield, the state’s largest health insurance company. The other is Maine Community Health Options, a nonprofit co-op insurance program based in Lewiston. Since it is new, that company does not yet have a track record for sales.

Each company can apply to have more than one insurance plan on the exchange. Maine Community Health Options said it has proposed “a handful.” An Anthem spokesman could not say Thursday how many plans Anthem has proposed.

The Maine Bureau of Insurance is considering applications from both companies. Once reviewed, the proposed plans will be forwarded to the U.S. Department of Health and Human Services. It will approve the plans it deems qualified.

Plans that aren’t qualified may still be offered in Maine, but not through the exchange.

The bureau said it was not aware of any other Maine companies that want in on the exchange. The bureau must review proposals by July 31.

It is possible that multi-state, or cross-state, insurance companies may also want to offer insurance to Mainers through the exchange. A spokesman for the Maine Bureau of Insurance said the federal government has indicated one company is interested, but the bureau hasn’t received confirmation and doesn’t have any details about it.

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Trish Riley, senior fellow in health policy and politics at the University of Southern Maine’s Muskie School of Public Service and former chairwoman of the governor’s Affordable Care Act steering committee, said the federal government is looking at phasing in multi-state insurance sales over four years. It was unclear whether Maine would be included in that phase-in sooner or later. 

She said the limited choice available to Mainers through the exchange mirrors the limited market Mainers now have for health insurance. Only a few companies are currently responsible for the bulk of coverage. She believes that’s largely due to the size, scope and nature of health care in Maine.

“Maine is a teeny market,” Riley said. “You’ve got 1.3 million people stretched across a huge geography. You could go to a neighborhood in Philadelphia for that.” Riley was the director of the Governor’s Office of Health Policy and Finance under former Gov. John Baldacci.

Earlier this week, lawyers for the bureau and Anthem told a judge time was of the essence in his consideration of a lawsuit brought by Central Maine Healthcare of Lewiston against the bureau. That suit centers on Anthem’s insurance proposal for the exchange and plan information that has been kept confidential.

The lawyers said there is concern the state won’t meet its July 31 deadline to review Anthem’s proposal and Mainers will end up with only one insurance company on the exchange.

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