Health Care Resources for the Uninsured and Underinsured

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CONTENTS

MaineCare Programs
Medicare
Prescription Drugs
Other Resources
Get More Information


MaineCare

Full benefit MaineCare (formerly called Medicaid and Cub Care) covers most health care needs for both adults and children who meet the eligibility requirements. Most people do not pay a premium (some families pay a small premium for their children's coverage). Children do not have co-payments, but some adults pay small co-payments for some services. There is no asset test for children and pregnant women. For most adults, assets are counted, but many assets (such as home or car or some savings) are not counted.

There are different income limits depending on the "category" of eligibility (i.e. child, parent, senior). These income limits for MaineCare benefit packages are linked to the Federal Poverty Level (FPL) Guidelines. The Census Bureau publishes these figures and they change every year. Remember that there are income and asset deductions and exclusions in most benefit packages, so you may be eligible, even if your income or assets are higher than the figures listed in the eligibility charts. Get more details on income and asset limits

When in doubt…apply! Even if you are ineligible for full benefit MaineCare, the Department of Health & Human Services (DHHS) will check to see if you are eligible for other benefits, such as coverage for prescription drugs. DHHS will try to select the best benefit package for you, based on your individual situation. For an application, call:

DHHS posts some of its most common application forms. If you know which form you need, you may be able to download an application.

Medically Needy benefit. This benefit is for people who are over-income for full benefit MaineCare, have limited income and very high medical bills (usually thousands of dollars). You must also be:

  • 65 or older;
  • disabled;
  • 20 or younger;
  • pregnant; or
  • the parent of a minor child.

When you apply for the Medically Needy benefit, DHHS will tell you what your deductible (also called "spend down") is. The deductible is the amount of medical bills you have to incur before being eligible for full benefit MaineCare. Usually the deductible amount is very high. You do not need to have paid this amount in medical costs, just owe the money. You will need to provide documentation of your expenses to DHHS. Usually the deductible is calculated for a six-month period. When you meet the deductible, you will be eligible for full benefit MaineCare for the rest of that six month period. At the end of six-months, you will need to be recertified and, again, meet the deductible for the following six-month period. Get more details

The Katie Beckett Option. Children with disabilities may be eligible for full benefit MaineCare, even if their family is over-income. The Katie Beckett option is for children with serious physical or mental health conditions. Eligibility is based on the child's own financial situation, not the family's (currently, the child can have up to $2,022 in income). The child must also meet the Social Security rules for disability and must otherwise need institutional level of care. When you fill out the MaineCare application, if you have a child with a disability, be sure to check off the box that asks if anyone in your household has a disability.

Working Disabled benefit. Many people under age 65 with disabilities who work may be eligible for full benefit MaineCare through the working disabled benefit (sometimes called the "Medicaid Buy-In" program). If you have a disability (based only on the medical disability part of the Social Security standard) and you work, you will be eligible for full benefit MaineCare if:

  • You have countable unearned income at or below 100% of the federal poverty level; and
  • Your total countable (earned and unearned) income isn't over 250% of the poverty level (remember, not all income counts!); and
  • Your countable assets are not over $8,000 for one person or $12,000 for a couple. (many assets don't count toward this limit, including your home, up to two vehicles, and some savings).

If your monthly countable income is over 150% of the poverty level, you will need to pay a small monthly premium for your benefits. See table below.

Poverty Guidelines

Nursing Home and Home and Community Benefit for the Elderly or Adults with Disabilities Benefit. In order to receive MaineCare coverage for nursing home care or equivalent care at home, you must need the level of medical care given in a nursing home. There are other MaineCare programs that offer different levels of care in the home depending on your needs. You must also meet the income and asset limits. The income limits are higher than for full benefit MaineCare.

To learn more, call your local Area Agency on Aging or 1-877-ELDERS1 (1-877-353-3771).

If you are looking for a care facility in Maine, try using Assisted Living Facilities Search, posted by DHHS's Office of Elder Services.

The Medicare Savings Program (MSP). Medicare doesn't pay the full cost of your health care, including deductibles, co-payments and premiums. MaineCare has a benefit that will help pay these costs, the Medicare Buy-In benefit - which includes:

  • Qualified Medicare Beneficiaries (QMB);
  • Specified Low Income Medicare Beneficiaries (SLMB) and
  • Qualified Individuals (QI).

These benefits are sometimes called the "Medicare Savings Program" or "dual eligible" benefits. People may be eligible if they:

  • are eligible for Medicare, and
  • have income that is higher than for full benefit MaineCare

Assets are not counted in these programs. Here is a chart with the different Medicare Buy-In benefits and the income limits and coverage for each one.

 
QMB
SLMB/QI

Income Limits

Individual

Couple

Couple, with only one spouse getting MSP benefit


$1,437

$1,939

$2,276


$1,754

$2,368

$2,705

Benefits

Part B premium

Copays

Deductibles

 

yes

yes

yes

 

yes

no

no

Important Note:
If you have earned income, you may get work-related income deductions. This means that your income can be higher than shown on this chart.


Medicare

The Social Security Administration is responsible for determining eligibility for Social Security retirement benefits, Social Security Disability Insurance (SSDI), and Supplemental Security Income (SSI). Here is how Social Security benefits are linked with Medicare and MaineCare:

  • People eligible to get Social Security retirement benefits are also eligible for Medicare.
  • People under age 65 getting Social Security Disability (SSDI) benefits are eligible for Medicare after getting SSDI benefits for 24-months.
  • People eligible to get Supplemental Security Income or the State Supplement because their SSDI or Social Security retirement benefits are very low are eligible for both Medicare and full benefit MaineCare.
  • People eligible to get SSI only are eligible for full benefit MaineCare.

While Medicare does cover many medical services, it is not comprehensive insurance. For example, Medicare does not cover routine physical exams or nursing home care.

Medicare has three major parts:

  • Part A (hospital insurance),
  • Part B (medical insurance) and
  • Part D (prescription drugs).

Medicare has annual deductibles, co-payments, and premiums. There are premiums for all three parts. However, most seniors are eligible for premium-free Medicare Part A. The Medicare Part B premium is $96.40 per month in 2011. Everyone with Medicare is responsible for paying this premium. However, people who have low income may be eligible for assistance in paying for it. See Medicare Savings Program above


Prescription Drugs

The Low Cost Drug Program for the Elderly and Disabled (also known as DEL). Most people who are enrolled in both Medicare and MaineCare (or MSP) are automatically enrolled in DEL.

If you are 62 and older or at least 19 and disabled, and you are not enrolled in Medicare, you may be eligible for DEL if your income is below 185% of the federal poverty level. DEL has no asset test. For people who are not enrolled in Medicare, DEL covers approximately 80% of the cost of virtually all generic drugs and 80% of the cost of brand name drugs for 13 specific medical conditions. For other conditions, drugs may also be covered after you have spent a total of $1,000 of your own money on drugs in a year.

To get an application, call DHHS at 1-866-796-2463. If you have questions or need assistance filling out the application, call the Legal Services for the Elderly HelpLine at 1-800-750-5353.

Important Note about Prior authorization and the Preferred Drug List: Whether you get your drugs through MaineCare or are enrolled in the Low Cost Drug Program, some prescription drugs must be prior approved by DHHS in order to be covered by MaineCare. DHHS has a Preferred Drug List (PDL). If the drug you are taking, or that your doctor wants you to take, is not on the list, your doctor will need to request permission from DHHS in order for DHHS to approve coverage of your prescription. This is only required when the Department believes there is another less expensive drug on the PDL that may work just as well for you. If the Department approves your doctor's request to give you a different drug than the one DHHS recommends, you will be able to get that drug with no further delay. Which drugs are on the Preferred Drug List?

MaineRx Plus offers 15-60% savings off retail prices for preferred drugs on the MaineCare Preferred Drug List. This benefit will be available primarily to people with incomes below 350% of the federal poverty level. People with higher income who spend more than 5% of their income on prescription drugs or 15% or more of their income on all health care costs will also be eligible. For an application, contact your local DHHS office or call DHHS at 1-866-796-2463.

Drug company discount cards and prescription assistance programs. Many drug companies have discount cards or programs that offer a discount or the retail cost of prescription drugs or, in some cases, provide them for free. Each company has it's own income limits and other requirements. Most require that you don't have prescription drug coverage. For information about drug company programs for a specific drug, talk with your doctor, and go to NeedyMeds.org.


Other Health Care Resources

Community Health Centers provide a range of services on a sliding scale, based on income. Get a statewide map or call the Maine Primary Care Association at (207) 621-0677 to find out which Community Health Center is closest to you.

Hospitals: Every hospital in Maine has a Free Hospital Care program. Each hospital has its own income guidelines. If you have hospital expenses, the billing office at the hospital should give you an application and let you know if you qualify for the program. Some areas have programs that cover a wider range of services, including visits to the doctor's office and prescription drugs. These regional programs include:

CarePartners - 1-877-883-1797
CarePartners provides health care services including primary care, drugs, and hospital care to eligible residents of Lincoln County, Kennebec County and Greater Portland between the ages of 19 and 64. There is a small co-payment for services. To qualify you must be uninsured and meet the income and asset guidelines. The current income limit is 175% of the FPL.

Franklin Health Access Project - 1-888-952-2772 or 779-2772 (TTY: 779-2662)
Health Access provides many basic health care services, including primary and hospital care, to uninsured residents of Franklin County, Livermore, Livermore Falls and Vienna that meet the eligibility criteria. The current income limit is 200% of the FPL. Services are provided on a sliding-fee scale.

Community Clinical Services - 777-8899
Community Clinical Services (CCS) providers are affiliated with St. Mary's Regional Medical Center in Lewiston. Uninsured individuals that meet the income guidelines can receive medical services from participating practices in the Lewiston-Auburn area on a free or sliding-fee scale. Most CCS patients also qualify for St. Mary's free care program.

Community Health Connection - 438-9997
The mission of Community Health Connection is to support access to health services for uninsured, financially eligible individuals who live in Eliot, Kittery, Ogunquit, South Berwick, Wells and York by collaborating with the local health care community.

COBRA - Workers who lose their health insurance when they are laid off are often entitled to continue their coverage for up to 18 months at their own expense. If you qualify, you should be notified of your COBRA option within two weeks of the termination of your employer-paid coverage. Then you have 60 days to decide whether you want continued coverage, and another 45 days to begin making payments. More on COBRA


More Information

For more information about health care benefits for people with limited income, go to:

Maine Equal Justice Health Care Index
Maine Legal Services for the Elderly
Consumers for Affordable Health Care HelpLine
1-800-965-7476
Maine Primary Care Association

If you have individual questions or need assistance:

For questions about health care for children, their families, and adults under the age of 60, call the Consumers for Affordable Health Care Helpline at 1-800-965-7476.

For questions about health care for seniors, 60 and older, and people with disabilities, call the Maine Legal Services for the Elderly hotline at 1-800-750-5353.

Updated February 2011

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