A Guide for Maine Workers and Their Families:
What are my health care options?

Guide Contents

Contents of this page
7.1 MaineCare
7.2 Prescription drugs
7.3 Other help with health care coverage or costs
7.4 Pre-existing conditions

Getting health insurance can be a huge challenge, especially if you have been laid off or your employer doesn’t offer an insurance plan. MaineCare or one of several other resources described in this section may be of help.

7.1 MaineCare

MaineCare (which used to be called Medicaid) provides complete health insurance for low-income adults and children. Whether or not you are eligible for MaineCare depends on your income, the makeup of your family, and, sometimes, if you have assets. You can work and still be eligible for MaineCare.

The information below gives a snapshot of who is eligible. Even if you think you might not be eligible, you should still apply. Not all of your income may count toward the income eligibility guidelines. Even if you are not eligible for MaineCare, DHHS will check to see if you are eligible for other benefits.

The following groups of people are eligible if their income is less than the amount in Table 1 below:

• Children age 18 and younger;
• Parents and most other relatives caring for a child age 17 or younger (or age 18 if the child will graduate from high school before their 19th birthday); and
• Pregnant women

There is an asset limit that affects the eligibility of parents, but many assets don’t count (such as your house, up to two cars, and some savings). There are no asset limits for children age 18 and younger and pregnant women. Families must pay premiums for children if the household income is over the amount in Table 2. Premiums vary from $8 to $64 per month total, depending on your income and how many children you have.

*Children who are disabled may be eligible under the Katie Beckett option, even if their income is higher than in Table 1. For more information on coverage for children with disabilities, contact your local DHHS office.

**If you are a parent who is disabled and working, you may still be eligible for MaineCare even if your income is higher than in Table 2. For more information contact your local DHHS office or Legal Services for the Elderly at 1 (800) 750-5353.

Important! Even if your gross income is slightly higher than the amount in Table 1, you and your children may be eligible for MaineCare because of deductions. Deductions from your monthly income may include the first $90 of earned income, child care expenses up to $200/month for children age 2 or under and $175 for children over age 2, child support payments paid to someone outside the household, and up to $50 for child support received by someone inside the household. When in doubt, apply.

The income limit for 19 and 20 year olds is different. Their income has to be equal to or less than the amounts shown in the table below. If your gross income is slightly higher than the amounts shown in this table, you may still be eligible for MaineCare because of deductions. When in doubt, apply.

There are asset limits for 19- and 20-year-olds, but many assets don’t count.

• If you are disabled or 65 years old or older, you may be eligible for MaineCare if your income is less than or equal to the amounts shown in Table 3 below, after deductions.
• People who don’t fit any of these categories (adults between the ages of 21 and 64 who are not disabled and don’t have minor children living in their home) are eligible for MaineCare as “non-categorical” participants. To qualify in this group, your gross income must be below the amount in Table 3 below. There is a limit on the number of people who can enroll in MaineCare as a non-categorical member. If you are turned down because of this limit, be sure that your worker puts you on the waiting list. Covered services for non-categorical participants are limited, but still include coverage for many of the most important services.

There is also an asset limit for seniors, people with disabilities and non-categorical participants, but many assets (like your home, car and some savings) don’t count.

*If you are disabled and working, you may still be eligible for MaineCare even if your income is higher than in Table 3. Contact your local DHHS office or Legal Services for the Elderly (toll-free) at 1 (800) 750-5353 and ask about the MaineCare Option for Workers with Disabilities.

**If you are disabled or a senior 65 or older, you may be eligible for MaineCare even if your gross income is higher because of certain allowable deductions. There are no deductions for non-categoricals.

You may also be eligible for MaineCare if you:

• Have very high medical expenses (often because of a hospital stay) and your income is over the amount allowed in your ‘category’
• Have breast or cervical cancer (for more information call 1 (800) 350-5180)
• Are HIV-positive (with or without a diagnosis of AIDS)

For more detailed information on who is covered by MaineCare, visit the MEJP website. To apply for MaineCare, contact your local DHHS office.

What happens to my MaineCare if my income goes up?

You and your family will continue to be eligible unless your income is over the monthly income guidelines for your family unit (Table 1, 2 or 3 above, depending on your age, medical condition, and who is in your family).

If you have minor children (age 18 and younger), you and your children may be eligible for Transitional MaineCare for up to 6 more months, even if your income is higher than the amount in Table 1. And your children, age 18 and younger, will continue to get MaineCare until the end of their 12-month certification period, no matter how much money you make.

If your children (age 18 and younger) are no longer eligible for MaineCare because your income has gone up, you can choose to pay to continue coverage for the children up to 18 more months under the MaineCare “Full Cost Purchase Option”. The premium for the Full Cost Purchase Option is $100 per month per child. You can choose to get coverage for all of your children or for only one or more of your children.

7.2 Prescription drugs

There are several programs that may help you with the cost of prescription drugs.

Maine Rx Plus

Maine Rx Plus gives many people in Maine a discount on the cost of their prescription drugs. You are eligible for Maine Rx Plus if your family’s total income is equal to or less than the amount in Table 4 below:

Even if your income is higher, you are eligible if:

• You spend more than 5% of your gross income on prescriptions; or
• You spend 15% of your total gross income on medical costs

Maine Rx Plus has no asset test. You don’t need to be a certain age or have children to be eligible.

The program provides a discount of 15% to 20% on the price of some brand name drugs and a discount of about 60% on generic drugs.

To enroll, call 1 (866) 796-2463.

Low Cost Drugs for the Elderly and Disabled (DEL)

The Low Cost Drugs for the Elderly and Disabled (DEL) program helps adults who are disabled or elderly. To qualify you must be age 62 or older, or age 19 or older and disabled. In 2009 your monthly income must be below $1,670 if you are single; $2,247 if you are married. DEL has no asset test.

The income limit for DEL is 185% of the Federal Poverty Level (FPL). These numbers increase each year, usually around February.

The program covers 80% of the cost of most generic drugs and 80% of the cost of brand name drugs for 13 specific medical conditions. If you pay more than $1,000 out of pocket for prescription drugs in a year, DEL will cover 80% of the cost of additional drugs you need that year.

To apply for the DEL program, contact your local DHHS office.

Patient Assistance Programs (PAP)

Many drug companies have their own programs that provide drugs at little or no cost to people who cannot afford to buy their drugs. Each company sets up its own rules for who is eligible. They usually won’t let people in their program if they:

• Have insurance that covers prescription drugs; and
• Are enrolled in MaineCare (or, sometimes, enrolled in the Low Cost Drugs for the Elderly and Disabled program or Medicare Part D).

Most Patient Assistance Programs (PAPs) don’t cover generic drugs.

To find out more about PAPs, talk to your doctor or visit these websites:

• RxAssist Patient Assistance Program Center
• NeedyMeds
• RxHope

7.3 Other help with health care coverage or costs

Uncompensated Care (Free Care) in Hospitals

Every hospital in Maine has a free care program. All hospitals in Maine must provide free care to people with income under the federal poverty level (FPL), but most provide help for people with higher incomes as well (more information about current FPL). If you have hospital expenses and no insurance, check with the billing office at the hospital to see if you qualify for free care.

Community Health Centers

Community health centers provide a wide variety of health care services on a sliding scale based on your income. Centers are located around the state. To find the community health center closest to you, go to the Maine Primary Care Association website or call them at (207) 621-0677.

COBRA

If you left you job and worked for an employer with 20 or more workers, you may be able to keep your health care coverage. Read more about COBRA.

Local and Regional Health Care Programs

Several other programs and services are available in local areas or regions of the state. For example, CarePartners provides health care services such as doctor’s visits, prescription drugs, and hospital services to low-income people who live in Lincoln County, Kennebec County, and the greater Portland area. They charge very small copayments. There are income limits on this program. To see if you qualify or to learn more, visit the CarePartners website or call (toll-free) 1 (877) 883-1797.

To learn more about regional programs, free clinics, dental clinics, or other questions call the Consumers for Affordable Health Care Helpline at:

Voice: (toll-free) 1 (800) 965-7476

7.4 If I enroll in a new health insurance plan, will my new plan cover medical conditions I have or have had (pre-existing conditions)?

Often, the first thing you want to know about a health insurance plan is whether it will cover a “pre-existing condition”— either an ongoing medical condition you have (like diabetes, asthma, or depression) or one for which you have received medical advice or treatment within the last 6 months. Here are some general guidelines on what an insurance plan must cover.

If you are enrolling in a new health insurance plan, your coverage should include your pre-existing condition, if:

• The condition was covered by your last health insurance plan; and
• You were covered for at least the past 18 months by your last health insurance plan (this could be MaineCare or Medicare), and you had that coverage within:
• 63 days, if you are enrolling in a self-insured group health plan, or
• 90 days, if you are enrolling in a fully insured group health plan, or
• 180 days, if you lost your last coverage because you were unemployed and you got unemployment benefits; and
• The condition is covered by your new plan.

Otherwise, your new plan may exclude coverage for a pre-existing condition for up to 12 months.

If you are trying to decide if you should enroll in a health insurance plan or if you have questions about a denial of coverage because of a pre-existing condition you can call the Consumers for Affordable Health Care Helpline at 1 (800) 965-7476.

You can read Maine law 24-A MRSA Section 2849, and 24-A MRSA Section 2850.

How long can a child stay on their parent’s health insurance plan?

Children up to age 25 (or disabled children of any age) may get health insurance coverage under their parent’s health insurance. To get this coverage, the child must be:

• Under age 25 or disabled. (A disabled child must be “dependent” on their parent); and
• Unmarried; and
• Have no dependent children of their own; and
• A resident of Maine or enrolled full time in college.

The insurance company must offer this coverage. The insurance company may charge for this coverage. An employer can refuse to pay for this coverage.

You can read Maine law 24-A MRSA §2742-B.

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