MaineCare Eligibility
Section 3: Managed Care

Contents

Contents of this page
3.1 How managed care works
3.2 Services that don't require PCP approval
3.3 Who can choose not to be in managed care?

Section 3: Managed Care

3.1 How managed care works

Most children, their parents, 19- and 20-year-olds, and pregnant women who get MaineCare are enrolled in managed care. This means each member must choose a Primary Care Provider (PCP) - such as a doctor, physician's assistant, nurse or health center - to meet his or her primary health care needs. The PCP manages the patient's care. Most specialty care requires a referral from the PCP. There are some MaineCare benefits that don't require going through the PCP. (You will find a list of some of these benefits in section 3.2.)

Participants who already have a family doctor, physician's assistant, or nurse can choose them as their PCP, as long as the provider is a MaineCare provider. Each family member may choose a different PCP.

Here's how a member chooses a PCP:

1. The family applies for MaineCare benefits.
2. DHHS sends a letter stating that the family can get MaineCare.
3. The family will get a package of materials with instructions to pick a PCP.
4. The family fills out and mails back the paperwork or calls MaineCare Member Services to tell them which PCP (or PCPs) the family chooses. This must be done within 27 days. Call MaineCare Member Services at 1-800-977-6740. If you are deaf or hard of hearing and have a TTY machine, call  1-800-977-6741.
5. If the family doesn't reply by mail or phone within 27 days, they will be assigned a PCP. This can be changed later, but contacting MaineCare Member Services and making a choice will avoid the hassle.

Section 3: Managed Care

3.2 Services that don't require PCP approval

Members do not need a referral from the PCP for any of these services: 

• Emergency care
• Women's exams, including most family planning services, pregnancy care or annual GYN exam
• Mental health and substance abuse services
• Dental care
• Pharmacy services
• Transportation and ambulance services
• Annual routine eye exams and eyeglass services
• Care provided in school-based health centers or well-child clinics
• A few others

Section 3: Managed Care

3.3 Who can choose not to be in managed care?

Members do not need to enroll in managed care if:

• They have a chronic disease or disability for which they have been seeing a MaineCare provider who is not part of MaineCare managed care.
• They have a terminal illness and have a provider who is not part of MaineCare managed care
• They have a language or cultural need that their MaineCare PCP cannot meet
• They have to travel more than 30 minutes to see their PCP
• They are a migrant farm worker or his or her dependent
• They are homeless
• They are in foster care
• They have Supplemental Security Income (SSI) and are under the age of 19
• They are getting hospice care at the time of enrollment
• They are living in jail or a prison
• They are living in a private non-medical institution like a residential care facility
• They are a patient in a hospital on the date they enroll. They have to enroll in MaineCare managed care when they leave the hospital

Members who feel they do not have to enroll in managed care should call MaineCare Member Services at 1-800-977-6740 (if you are deaf or hard of hearing and have a TTY machine, call  1-800-977-6741) and tell them why.

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