MaineCare Application Information

MaineCare, previously known as Medicaid, is a program that gives health care assistance to people who have limited income. It is a joint program between the federal government and the state of Maine that helps its residents with medical payments.

MaineCare is administered by the Office of MaineCare Services (OMS) under the Department of Health and Human Services (DHHS). OMS manages the programs and ensures that they are consistent with the goals of the DHHS and the orders of the federal government.

In the MaineCare program, there are a number of different benefit packages. A benefit package is a set of covered medical services that depends on various factors including age, income, medical needs, and whether assistance is needed with activities of daily living (ADL). The package you get may be altered if there is a change in your age, income, the size of your household, or health.

There are three ways to acquire the medical services under MaineCare:

  1. Managed care services
  2. DirigoChoice
  3. Fee-for-service

There are some services, equipment, and medications that need Prior Authorization (PA) from MaineCare before you can acquire them. For such situations, the provider will send a form to MaineCare asking for PA. MaineCare will then send a letter to you and to the provider to inform you if you have PA for a certain medical equipment, service, or medication. If there is no approval, you might need to pay the cost.

The examples of medical services and equipment that need Prior Authorization include, but are not limited to, the following:

  • Certain surgeries
  • Certain medications
  • Hearing aid services
  • Medical equipment and supplies that cost more than $499.99
  • Certain eye care services
  • Certain dental services (particularly for adults)
  • Orthodontia services
  • Transportation services
  • Long-term in-patient care in psychiatric hospitals in the state
  • Certain home care services
  • Certain ambulance services

Once you become a MaineCare member, you will receive a permanent MaineCare card that only you can use. It is illegal to let others use it, even if they are your relatives. Every member of your family who qualifies as a member must use their own card.

You should always have your MaineCare card with you wherever you go because medical providers may refuse to see you if you are not carrying it. In case you can't find your card, contact your eligibility specialist immediately at the nearest DHHS office. It is advisable to keep your card even if your eligibility is lost since you will be able to use it once you become eligible to receive benefits again.

As a MaineCare member, you must report any changes in your household such as your address, income, assets, or medical condition to your DHHS eligibility specialist within a period of ten days.

Eligibility Requirements

To qualify for MaineCare, there are certain eligibility requirements you have to meet. Eligibility is determined by the Office of Integrated Access and Support (OIAS) of the DHHS.

The general requirements of the program include the following:

  • You must be a resident of Maine
  • You must be a U.S. citizen, a legal alien, or a permanent resident
  • You must be in need of health care assistance
  • Your income must be considered low

The MaineCare program is available to the following people who meet the general eligibility requirements:

  • Newborn babies up to children who are 20 years old
  • Individuals age 21 and up who have children living in their homes
  • Disabled
  • People who have autism or mental retardation, or any other developmental disabilities
  • Pregnant women
  • Elderly
  • Inmates in jails
  • People who have AIDS/HIV
  • Individuals who are living in residential care facilities
  • People living in nursing homes

There are a number of benefit packages under the MaineCare program; each has its own covered services and eligibility requirements. What package you will get depends on your age, income, and medical needs. You cannot get several benefit packages at once - you only get one at a time. If you are not sure what package is right for you, you may call the MaineCare Member Services at 1-800-977-6740 or TTY 1-800-977-6741.

MaineCare Application Instructions

To apply for MaineCare, you need to fill out an application form that you can get from your local DHHS office or by calling the Member Services of OMS at 1-800-977-6740. You may also download it by clicking here. After you have completed the application, you should return it to your local DHHS office.

You may visit your local Department of Health & Human Services (DHHS) where you will meet with an eligibility specialist. He/She will determine if you are eligible for the program and will answer your questions regarding the application process.

Here's a list of some of the documents you may need to provide (if available) when applying for MaineCare:

  • Resources and the amounts of your household income (except income from Social Security and SSI)
  • Documentation of the value for property that is not your residence
  • Copy of your health insurance cards such as Medicare (if any)
  • Your life insurance policies and/or your spouse's
  • Annuity contract
  • Trust agreement in which you are a beneficiary or a grantor
  • Prepaid burial contracts
  • Documentation of liquid assets that you presently own and/or those owned currently by your spouse such as savings bonds, IRA, deposits, statement of checking and savings accounts, any investments, and the like.

If there are still documents that you do not have, you should not put off your application because you can submit them later during the interview process.

Some few members of MaineCare pay a premium. This is what you pay every month for the insurance coverage. Once your application has been approved, the notice of decision of your eligibility in the program will notify you if you must pay a monthly premium. You will receive a coupon every month you owe if you are required to pay. Return it, along with your payment when it's due. Do not disregard this since you may lose your coverage if you do not pay.

There are services and prescription drugs that have co-payments. How much you need to pay is based on the amount MaineCare pays for the medical service or drugs (unless you are exempted). Once you have paid 5% of the income you have each month, you no longer need to make additional co-payments.

The following are the services that have co-payments:

  • Non-emergency services
  • Chiropractor
  • Durable medical supplies and equipment
  • Ambulance
  • Consumer directed attendant
  • Home health services
  • Federally qualified health centers
  • Laboratory
  • Hospital (outpatient and/or inpatient)
  • Optometrists
  • Opticians
  • Occupational therapy
  • Prescription drugs
  • Podiatrist
  • Physical therapy
  • Speech
  • Rural health center
  • Private duty nursing
  • Medical imaging and x-rays
  • Behavioral health services

Here are the services where you do not have to make a co-payment:

  • Emergency cases
  • Family planning services and supplies
  • Services given in Indian Health Service Centers
  • Oxygen and oxygen equipment services
  • Hospice services

Certain MaineCare members are exempted – they do not have to pay a co-payment. These include members who are:

  • Pregnant (exempted until three months after pregnancy ends)
  • Below age 21
  • Under state guardianship In state custody
  • In hospitals, nursing facilities, or any other long term care facilities and are paying for part of the services as established by the OMS/DHHS