MENUMENU
The State of Maine works to bring medical care to its residents by offering MaineCare coverage to those who meet eligibility requirements. Families and individuals may apply for benefits after they have lived in Maine for at least six months. In 2019, MaineCare expanded to allow more individuals than ever to qualify for benefits. According to healthinsurance.org, as of June 15, 2023, 372,480 Mainers were covered by Maine Medicaid.
MaineCare covers the cost of doctor’s visits, some prescription drugs, and family planning, among other services. This guide will discuss who qualifies for MaineCare coverage, how to apply, and what MaineCare does and does not cover. In the event more coverage is required, Insurdinary can optimize an insurance plan to include a more comprehensive range of benefits and services by way of private health insurance.
MaineCare coverage is a form of Maine Medicaid that covers necessary medical needs for people who meet certain criteria.
MaineCare is funded by the state and federal government. It provides access to medical care for people who could not otherwise afford it. Mainers who are eligible for MaineCare receive free or low-cost medical coverage.
MaineCare provides assistance for disabled individuals and people with long-term illnesses. Additionally, young adults who age out of the foster care system can receive MaineCare coverage.
You may owe a copay, premium, or other cost for medical care under MaineCare. The cost depends on the service and your coverage group.
Some MaineCare members do not have a copay. You may not owe a copay if you are:
If you don’t meet any of the above qualifications, you may owe a copay depending on the amount MaineCare contributes to the exam, test, or other medical treatment. Here is an overview of the copay schedule:
| MaineCare Contribution | Your Copay Amount |
|---|---|
| $10.00 or less | $0.50 |
| $10.01 - $25.00 | $1.00 |
| $25.01 - $50.00 | $2.00 |
| $50.00 and up | $3.00 |
Additionally, some services do not require a copay. They include the following:
Your MaineCare Card will arrive with your welcome package. It has a number on it that is unique to you. You will use this number whenever you need healthcare services. Treat it like you would any other insurance card. Your primary care physician, pharmacy, and any other medical facility you visit will need your MaineCare information on file.
It’s easy to apply for Medicaid benefits with MaineCare whether you prefer to apply online, in person, or by another method. You can contact customer service with any questions every step of the way to ensure you are on the right track to receiving the coverage you need.
It’s easy to apply online through the My Main Connection website. There, you will find a prescreening tool to determine whether you are eligible and a portal to apply for benefits.
To apply in person, visit your local district office. A representative will guide you through the process.
To apply by mail, download and print the MaineCare Application and mail it to the following address:
Office for Family Independence
114 Corn Shop Lane
Farmington, ME 04938
Fax your application to 207-778-8429.
Email your application to Farmington.DHHS@Maine.gov
People are eligible for MaineCare coverage if they meet certain conditions. The preliminary requirements include:
The following groups may be determined eligible for full benefits:
Parents or guardians of a child related by blood, marriage, or formal adoption are eligible for coverage. The child must live in the home, and the parent or guardian must be the child’s primary caregiver.
If you are pregnant or gave birth within the last 60 days, you could receive full MaineCare coverage.
If you were in foster care in the State of Maine and had Medicaid until age 18, you may qualify for MaineCare if you are currently under the age of 26.
Adults between the ages of 21 and 64 who do not otherwise qualify for Medicare may qualify for full MaineCare benefits.
If you don’t qualify for full benefits, MaineCare offers limited benefits to those who need help offsetting the cost of prescription medications and dental care as well as third-party insurance premiums.
MaineCare is available to households who meet certain income requirements. When you apply, they will take a look at your gross monthly income to determine eligibility. The income amount depends on the number of adults and children in the household. You can use an online form to determine the income limits for your household.
Review the eligibility guidelines if you need medical coverage but exceed the income for your household size. You may still qualify for partial benefits or financial assistance with private insurance.
After you apply for coverage, either through My Maine Connection or via another method, a representative may contact you if they need you to submit documents proving your monthly income or if they need any more information. Once they process your application, you will receive written notice that you qualify for and have been accepted into the MaineCare program.
Your welcome packet includes a full benefit summary and a MaineCare Card with your unique member number. You should treat your MaineCare card like you would any other insurance card. Your primary care provider will need the information to bill MaineCare for your medical care.
You must also provide your card to your pharmacy, urgent care, and any other place you receive medical care.
If your MaineCare card was lost or stolen, you can request a new one by visiting the Social Security website and entering your information. To continue receiving healthcare without interruption, request a new card as soon as you discover yours is missing. It can take about 30 days to receive a replacement card.
If you need medical care before receiving your new card, check your Benefit Verification Letter in your Social Security account. You should find it there. Alternatively, you can log into the Medicare website and print an official copy of your card.
To request a replacement card over the phone, call 1-800-MEDICARE (1-800-633-4227).
You can also request a new Mainecare card by visiting your local Social Security Office.
The Department of Health and Human Services offers a secure portal to easily pay your monthly premiums online. It cuts down on the hassle of sending payment by mail, which many patients can forget to do, especially when they have medical concerns to cope with.
For patients who prefer to send payment by mail, the option is still available. Patients who use the online portal must also pay a $2 fee for each payment.
MaineCare offers Medicaid benefits to residents of the State of Maine. It includes basic care like doctor visits, dental appointments, and more complex medical care like substance abuse treatment and hospital stays.
As of July 1, 2022, all MaineCare participants over 21 years of age have access to dental care. Some of the areas covered include:
For those who anticipate requiring more visits to the dentists, investing in private dental plans in Maine is advisable.
Participants seeking dental care must find a dental provider who accepts MaineCare. They can do so by calling 1-800-977-6740.
MaineCare provides pharmacy benefits for participants who have full coverage. Medications that fall under MaineCare’s preferred drug list do not need prior authorization. Any medications not on the list require prior authorization from your primary care provider.
Some MaineCare members may get a discount for their prescription medications, but they will still have to pay a certain percentage. In that case, they can reach out to Maine Rx Plus for assistance. Maine Rx Plus covers 15-60% of prescription drug costs.
Individuals aged 62 and up or those who have a disability and are over the income limit for MaineCare can receive prescription drug assistance through the Drugs for the Elderly and Disabled program, or DEL. The DEL program covers up to 80% of prescription drug costs. Participants may incur a $2.00 copay cost.
Individuals may qualify for extended healthcare coverage if they live in an assisted living or long-term care facility. MaineCare could cover the cost of the room, medical supplies, food, and medical care.
Those who live in a group home or an adult care facility may also qualify. MaineCare may cover all or part of the cost of the necessary assisted living resources.
Also, although Mainecaire offers some assistance for those with disabilities, it will not cover all costs related to temporary or permanent disabilities. You can purchase disability insurance to shield your household against sudden income loss due to health-related problems.
Out-of-state medical care is only covered if the provider is enrolled in MaineCare. If you encounter a medical emergency while traveling, call your primary care provider and see whether they can help you receive the care you need. Providers within 15 miles of the state line can enroll in MaineCare to provide service to eligible individuals. Always double-check that a physician is enrolled in MaineCare before scheduling an appointment — otherwise, you may end up having to pay the bill. For this reason, if you are traveling out-of-state and especially outside of the USA for leisure, invest in proper travelers insurance. Always call MaineCare member services if you receive a bill.
Most schools in the State of Maine require students to obtain health insurance as part of the acceptance and enrollment process. Obtaining health coverage depends on a few factors however. Students under age 26 can stay on their parents’ insurance plan according to the Affordable Care Act. If a student who lives outside Maine chooses to attend a college within the state, their parents’ insurance may not cover their medical care. In that case, the student should move forward with obtaining their own medical insurance through CHIP if they’re under 19 or on Maine’s Medicaid website if they’re over 19.
The federal government requires estate recovery for MaineCare patients 55 and up in long-term care facilities. Facility types may include nursing facilities, assisted living, or other community-focused residency programs.
Estate recovery means that upon their death, the state may claim available assets to total the amount paid for services by MaineCare. Services include the facilities themselves, prescription drugs, and any hospital stays.
To meet the criteria for estate recovery, a MaineCare member should:
If the individual did not receive home or community-based nursing services, they will not face estate recovery upon their death.
Working people with disabilities may not qualify for free MaineCare. The state takes into account their assets to determine what benefits they qualify for. The program provides disabled adults the opportunity to work while accessing healthcare and other means of support. You must prove you have a disability to qualify for MaineCare or Social Security Disability Insurance and Supplemental Security Income. You also need these programs in place during the qualification process for MaineCare. If you already have a determination of disability from the Social Security Administration, MaineCare will use that to help you qualify. If you don’t have a determination, you must get a disability review from the MaineCare Medical Review Team.
Basic qualifications include:
A person must have less than $8,000 in total assets if they are single and less than $12,000 if they are married. Some assets are not counted in the total amount. A savings account with $8,000 or less will not be taken into account, nor will the home a person lives in and one vehicle. If the person is married, savings of up to $12,000 are excluded.
Determining income takes a few steps. It is not as straightforward as other determining qualifications. Asset totals may contribute to deductions that reduce your income, and not all income is counted in the qualification process.
There are two steps to the income qualifications:
Step 1: The first area MaineCare will look at is your monthly Social Security benefits or other unearned income.
Step 2: The next area MaineCare examines is called your total countable monthly income. This is half of your earned income plus the full amount of your unearned income from Step 1.
If your income is under $1,823 per month or $2,465 if you’re married, you don’t have to pay for coverage. If your income is above the determined amount, whether single or married, you will owe a monthly premium of $10-$20.
If you already pay a premium for Medicare Part B, you will not owe a premium for MaineCare.
MaineCare covers medically necessary treatments and procedures. Some medical care is covered on a case-by-case basis, and some treatments are not covered at all. Areas that MaineCare does not cover include:
If you think your procedure falls under covered treatments but was denied, speak with a representative to see why it was denied and whether there is a process for requesting approval. You may reach MaineCare member services at 1-800-977-6740.
It is also important to note that MaineCare does not cover the cost of funerals. While the state offers basic resources and very limited monetary benefits towards burial costs, what is available will most definitely not cover burial costs and services. It is always wise to ensure that in the event of your passing, your family is secured with comprehensive funeral insurance.
If you are looking for even more insurance coverage beyond what MaineCare provides, such as life insurance, consider exploring your options. Visit our life insurance quote page to get personalized quotes and find a policy that suits your needs.
MaineCare covers medical services based on individual needs as well as income, age, and whether or not you need assistance with daily tasks. Here is a guide to help you determine whether or not MaineCare will cover a medical cost:
| Dental | |
|---|---|
| MaineCare covers some dental services to prevent gum disease and tooth decay. To be eligible, members must be over 21. | |
| X-Rays | Yes, if medically necessary. |
| Cleanings | Yes, if medically necessary. |
| Exams | Yes, if medically necessary. |
| Root canals | Yes, if medically necessary. |
| Fillings | Yes, if medically necessary. MaineCare covers amalgam and composite fillings. |
| Extractions | Yes, if medically necessary to relieve pain or treat infection. Wisdom teeth extraction is not covered. |
| Crowns | Yes, if medically necessary. |
| Vision | MaineCare covers eye exams and glasses for adults with some restrictions. |
|---|---|
| Eye Exams | Yes, restrictions may apply. |
| Glasses | Yes, restrictions may apply. |
| Contact lenses | Yes, restrictions may apply. Contact lenses with replacements once per year and low-vision aids for patients whose vision are 20/700 or worse. |
| Laser Eye Surgery | No |
| Surgery | Surgeries are considered on a case-by-case basis. |
|---|---|
| Appendectomy | Yes |
| Heart Surgery | Yes |
| Rhinoplasty | MaineCare does not cover these surgeries for cosmetic purposes. |
| Breast Reduction | MaineCare does not cover these surgeries for cosmetic purposes. |
| Hospital | |
|---|---|
| Hospital stays | The hospital stay for giving birth is covered. |
| Ambulance transportation | Some ambulance transportation is covered, but may need prior authorization. |
| Giving birth | The hospital stay for giving birth is covered. |
| Sexual Health | Maine has several family planning health centers providing many aspects of reproductive health care. They accept MaineCare, private insurance, or sliding scale payments to uninsured individuals. Maine’s family planning health centers accept patients of all genders and provide comprehensive care. |
|---|---|
| Gynecologist visits | Yes |
| Erectile Dysfunction | Yes |
| Birth Control | Yes (including IUDs) |
| Fertility Treatment | Yes |
| Specialist Services | Some treatments from specialists may be covered with prior authorization. If you aren’t sure whether a service is covered by MaineCare, reach out to member services by calling 1-800-977-6740. To ask about covered medications, call the Pharmacy Help Desk at 1-866-796-2463. |
|---|---|
| Dermatology | Yes |
| Physiotherapy | Yes |
| Massage Therapy | Yes |
| Podiatry and Foot Care | Yes |
| Allergy Testing | Yes |
| Sleep Physician Services and CPAP Machines | Yes |
MaineCare includes substance abuse disorder treatment as well as behavioral health services. Financial status should not prevent anyone from getting the treatment they need. MaineCare is dedicated to helping individuals and families lead healthy lives in recovery from substance abuse.
MaineCare covers medical detox to help patients take the first step toward recovery. They safely go through the drug or alcohol withdrawal process under medical supervision.
MaineCare also covers subsequent outpatient treatment to treat the cause of the addiction and provide each patient with the coping skills to adjust to sober living.
An aftercare plan helps prevent relapse as patients transition back to living independently. MaineCare offers continuing support to patients during the recovery process.
In the State of Maine, there are only six major medical programs approved for sale directly to individuals and families. These are as follows:
If you don’t qualify for MaineCare or are no longer eligible, you may qualify for subsidies that help you with the premiums for third-party medical coverage. Apply for medical coverage as soon as possible to continue getting the care you need. It can take some time for your new insurance to take effect.
The Private Health Insurance Premium program can help cover costs for your third-party health insurance. To find out whether you qualify, call PHIP at 1-800-977-6740.
Insurdinary helps individuals find the best rates for medical coverage. Our service is straightforward and free of charge. When you work with us, we will provide quotes from several insurance companies to get you the coverage you need with premiums you can afford. To begin the process of getting free quotes, browse our page to find the insurance product you require, fill out a simple quote form, and leave the rest to us!
Insurdinary, and its network of partners offer many different types of insurance. In addition to health, dental, disability, life, funeral and travel insurance as discussed on this page, you may also be interested to explore the following:
