Maine's Medical Assistance Programs:
Who's Covered and Who's Not
| Category |
Benefit Level |
Income
Limit
1 |
Asset
Limit |
Notes |
| Children age 0-18 |
Full-benefit
MaineCare
|
200% FPL
(federal poverty level) |
None |
Children with income up to
150% FPL are eligible for free MaineCare; infants under 1 with income up to 185%
FPL are eligible for free MaineCare. Children between 150% and 200% FPL are eligible
for low-cost MaineCare (with a premium from $8-$64 per month, per family). Children in higher-income families
who have a serious medical condition are served under the
Katie Beckett option. For the Katie Beckett option, only the income and assets
of the child who has the disabling condition (not the parents' income or assets) are counted. There is an asset limit of $2,000
for the child for Katie Beckett coverage.
Full Cost Purchase Option allows families who lose coverage
due to increased income to buy into MaineCare at a cost of $250 per month
per child for 18 months. More information |
| 19- and 20-year-olds |
Full-benefit
MaineCare |
150% FPL |
$20002
(Many assets are excluded.) |
Income of parents in the household is counted in some
circumstances.
More information |
Parents with children age 18 and younger at
home3
|
Full-benefit
MaineCare |
200% FPL |
$2,0002
(Many assets are excluded.) |
Transitional coverage: If family income increases from under
150% to over 200% FPL due to earnings, an additional 6 months of coverage is available.
These
individuals are also eligible for transitional coverage for 4 months if
the reason for the increase in income is child support.
More information |
| Pregnant Women |
Full-benefit
MaineCare |
200% FPL |
None |
For the mother, coverage continues
for 2 months beyond the month that pregnancy ends. Coverage will continue
longer if the mother meets criteria above for parents. If the mother had
full-benefit MaineCare when the baby was born, the baby will be covered
by MaineCare for at least 1 year. More
information |
| Disabled adults and seniors age 65 and older |
Full-benefit
MaineCare |
100% FPL |
$2,000 ($3,000 for a couple)2
(Many assets are excluded.)
Workers with disabilities: $8,000 ($12,000/couple)
(Many assets are excluded.) |
Full-benefit MaineCare "wraps around" Medicare.
It covers nearly all Medicare costs. Individuals who are enrolled in Medicare
will need to be enrolled in a Medicare Part D prescription drug plan (PDP) and will get their drugs
through Part D. Call the DHHS Pharmacy Help Desk at 1-866-796-2463 for questions about Part D.
More information on Part D (large .pdf file)
MaineCare Option for Workers with Disabilities: People with disabilities who work may be eligible for full-benefit
MaineCare if their unearned income is under 100% FPL and their total income, including earnings,
is under 250% FPL. Some people may have monthly premiums.
|
| Disabled adults and seniors age 65 and older who have Medicare |
Limited-benefit
MaineCare |
185% FPL |
None |
Medicare Savings Program (MSP, or "Buy In"): MaineCare will pay the
Medicare Part B premiums for those below 185% FPL. For those below 150% FPL MaineCare will
also pay the Part A and B deductibles, co-insurance/co-pays.
MSP's will have no Part D premium, deductible or "donut hole."
Co-payments are limited. More
information on MSP
|
| "Non-Cats:" adults who do not fit into one of the "categories" for
full-benefit MaineCare |
Partial-benefit
MaineCare |
100% FPL |
$2,000 ($3,000/couple)2
(Many assets are excluded.) |
Adults age 21-64 who are not disabled and do not
have minor children
living at home may be eligible for MaineCare if their income is below 100% FPL
and they are under the asset limit. Covered services are limited. There is usually a waiting list
for this program. Individuals will be moved off of the waiting list and onto the program as spaces become
available.
|
| Adults living in Nursing Facilities |
Full-benefit
MaineCare |
Gross Income must be below the semi-private room rate of the nursing facility in which the
person resides. |
$2,000 ($3,000 for couple)2
(Many assets are excluded.) |
The person will pay most of their income toward the cost of care in the nursing facility,
unless they have a spouse at home. The Member will keep at least $40 per month for personal needs.
|
| Adults medically eligible for a Nursing Facility but who are living at home through the Home and
Community Based Waiver |
Full-benefit
MaineCare |
300% of the federal SSI Benefit Amount ($2022 in 2011) |
$2,000 ($3,000 for couple)2
(Many assets are excluded.) |
The person will be able to keep income equaling up to
125% of the Federal Poverty Level. All other income will be used to pay for the cost of care.
|
| Adults living in residential
care facilities other than nursing facilities |
Full-benefit
MaineCare |
Countable Income must be below the private pay rate for the residential care facility. |
$2,000 ($3,000 for couple)2
(Many assets are excluded.) |
The person will pay most of their income toward the cost of care in the residential care facility.
Member will generally keep about $70 per month for personal needs. |
| Women who have breast or cervical cancer
(or pre-cancerous condition) |
Full-benefit
MaineCare |
250% FPL |
None |
Women must be without insurance; age 40-64; have a
positive screening for breast or cervical cancer at an approved screener. For more information:
1-800-350-5180. |
| HIV-positive adults |
MaineCare
drug coverage and other limited benefits |
250% FPL |
None |
Individual must be HIV-positive
(with or without diagnosis of AIDS); coverage includes prescriptions and
physician and hospital services. There are some limitations on services;
copays are higher ($10 per prescription and per office visit) than for
full-benefit MaineCare. There is a limit on the number of individuals who
can participate in the program. |
| "Medically Needy" or "Spend Down:" persons whose income is too high for full
benefit MaineCare
|
Full-benefit MaineCare, after a large deductible is met |
None |
$2,000 ($3,000 for some couples)2
(Many assets are excluded.) |
The Medically Needy benefit helps people with catastrophic
health care expenses; participants must be in a coverable group (65 or older, disabled, 20 or younger,
pregnant, or the parent of a minor child); the deductible amount depends on income level; medical
bills and other costs associated with medical care must have been incurred, but don’t need to have
been paid; certification is usually for 6 months. Old medical bills still owed can go toward your deductible.
More information |
| Disabled adults and seniors age 62 and older |
Low Cost Drugs for the Elderly and Disabled (DEL) |
185% FPL (income limit is increased by 25%
if drug costs are high.) |
None |
DEL covers:
- 80% of generic drugs costs (member pays 20% and small
copay);
- 80% of drugs costs for 14 specific health problems
(member pays 20% and small copay);
- A small discount off the retail cost of many other medications;
- A catastrophic drug benefit covers 80% of the cost of most needed
drugs after the person incurs $1,000 out-of-pocket using their DEL card
(member pays 20% and small copay).
Some drugs require prior
authorization. Most individuals who are also enrolled in Medicare will need to be enrolled
in a Medicare Part D prescription drug plan (PDP) and will get their drugs through Part D.
Call the DHHS Pharmacy Help Desk at 1-866-796-2463
for questions on Part D.
|
| Persons who do not qualify for full-benefit MaineCare |
Maine Rx Plus |
350% FPL (see notes) |
None |
People over 350% FPL will be eligible
if they have out-of-pocket prescription drug expenses exceeding 5% of the family's income or out-of-pocket medical expenses
exceeding 15% of the family's income. Drugs listed as "preferred" on the MaineCare preferred drug list (PDL) are
covered; savings will be approximately 15% on brand name drugs and 60% on generic drugs. |
1For most MaineCare benefits, some income does not count towards these limits.
2Asset rules now exempt $8,000 for an individual and $12,000 for a household of 2 or
more in certain savings, including retirement savings!
3DHHS rules cover parents with an 18-year-old who will
finish high school by age 19.
Federal Poverty Levels
IMPORTANT NOTE: For most MaineCare benefits, some
income does not count toward these limits. Poverty levels are adjusted annually according to the Consumer Price Index.
Annual Income
|
Household
Size |
100% |
150% |
170% |
185% |
200% |
250% |
350% |
| 1 |
$11,170 |
$16,755 |
$18,989 |
$20,665 |
$22,340 |
$27,925 |
$39,095 |
| 2 |
$15,130 |
$22,695 |
$25,721 |
$27,991 |
$30,260 |
$37,825 |
$52,955 |
| 3 |
$19,090 |
$28,635 |
$32,453 |
$35,317 |
$38,180 |
$47,725 |
$66,815 |
| 4 |
$23,050 |
$34,575 |
$39,185 |
$42,643 |
$46,100 |
$57,625 |
$80,675 |
| 5 |
$27,010 |
$40,515 |
$45,917 |
$49,969 |
$54,020 |
$67,525 |
$94,535 |
| 6 |
$30,970 |
$46,455 |
$52,649 |
$57,295 |
$61,940 |
$77,425 |
$108,395 |
| Each additional person |
$3,960 |
$5,940 |
$6,732 |
$7,326 |
$7,920 |
$9,900 |
$13,860 |
Monthly Income
|
Household
Size |
100% |
150% |
170% |
185% |
200% |
250% |
350% |
| 1 |
$931 |
$1,397 |
$1,583 |
$1,723 |
$1,862 |
$2,328 |
$3,258 |
| 2 |
$1,261 |
$1,892 |
$2,144 |
$2,333 |
$2,522 |
$3,153 |
$4,413 |
| 3 |
$1,591 |
$2,387 |
$2,705 |
$2,944 |
$3,182 |
$3,978 |
$5,568 |
| 4 |
$1,921 |
$2,882 |
$3,266 |
$3,554 |
$3,842 |
$4,803 |
$6,723 |
| 5 |
$2,251 |
$3,377 |
$3,827 |
$4,165 |
$4,502 |
$5,628 |
$7,878 |
| 6 |
$2,581 |
$3,872 |
$4,388 |
$4,775 |
$5,162 |
$6,453 |
$9,033 |
| Each additional person |
$330 |
$495 |
$561 |
$611 |
$660 |
$825 |
$1,155 |
|
Disclaimer
Maine Equal Justice Partners
February 2011
We are providing this information as a public service. We try to make it accurate as of the date
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