MaineCare Eligibility

Low Cost or Free Health Care Coverage

A Joint Project of Consumers for Affordable Health Care and Maine Equal Justice Partners

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Table of Contents

Introduction

Section 1 -- Coverage and Eligibility

1.1 Health care services covered by full-benefit MaineCare
1.2 Who can get MaineCare?
1.3 What counts as income for MaineCare?
1.4 Calculating income eligibility / Monthly gross income eligibility chart
1.5 Rules about assets
1.6 Pregnant women
1.7 Katie Beckett for Disabled Children

Section 2 -- The Application Process

2.1 How to apply
2.2 Citizenship and identity verification requirement
2.3 How long it takes DHHS to review an application?
2.4 When will coverage start? Can back bills be paid?
2.5 Length of enrollment
2.6 Other rules about how long enrollment will last
2.7 Options for members when their income goes over the guidelines
(Full Cost Purchase Option and Transitional MaineCare)

Section 3 -- Managed Care

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 4 -- Other Important Information

4.1 What if the applicant already has private health insurance?
4.2 Two groups of children aren't eligible for CHIP MaineCare (children who pay a monthly premium)
4.3 What happens if CHIP premiums aren't paid?
4.4 How to appeal a DHHS decision

Section 5 -- MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "non-Cats"

5.1 Introduction
5.1 Who can get MaineCare?
5.2 What counts as income for MaineCare?
5.3 Calculating income eligibility: deductions
5.4 Rules about assets
5.5 When will coverage start? Can back bills be paid?
5.6 Options for members when their income goes over the guidelines
5.7 Home & Community Benefit and Nursing Home Benefit
5.8 Managed Care

Section 6 -- Additional MaineCare Benefit for Seniors and Adults with Disabilities-the Medicare Savings Program (MSP)

6.1 What is the Medicare Savings Program (MSP)?
6.2 Medicare Savings Program (MSP)eligibility
6.3 What are the benefits of the Medicare Savings Program (MSP)?
6.4 How to apply to the Savings Program (MSP)
6.5 Does the Estate Recovery Program try to recoup benefits from the Medicare Savings Program (MSP)?
6.6 The appeals process for the Medicare Savings Program (MSP)
6.7 Medicare Savings Program (MSP) resources

Section 7 -- Appendices (Links to more important information)

Tips for the applicant
Regional DHHS offices
Federally Qualified Health Centers (FQHC's)
Maine's Medical Assistance Benefits: Who's Covered?
Current Federal Poverty Levels (FPL's)
Transportation Agencies

Link to MaineCare Eligibility Manual (official program rules)
Link to MaineCare Benefits Manual (official program rules)

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Introduction

A Guide to MaineCare

This guide is about MaineCare, which is Maine's Medicaid program. MaineCare also includes Maine's State Children's Health Insurance Program (CHIP), which provides the same MaineCare coverage benefits to children in families with a higher income range; this program used to be called Cub Care. MaineCare provides health insurance benefits to specific groups, or categories, of low-income people: children, their parents, 19- and 20-year-olds, pregnant women, adults with disabilities, seniors age 65 and older, and "non-categorical" adults (who do not fit into any of the categories of coverage-they are adults age 21 to 64 who do not have dependent children living in their household and who are not disabled). For a brief overview of all covered groups, see:  Maine's Medical Assistance Programs:  Who's Covered and Who's Not.

This guide focuses on full-benefit MaineCare for children and their parents, 19- and 20-year-olds, and pregnant women. However, Sections 5 and 6 include information on MaineCare coverage for adults with disabilities, seniors age 65 and older, and the non-cats, as well as the Medicare Savings Program, which is a partial-benefit MaineCare program.

MaineCare Highlights

For working and unemployed parents. Even if one or two parents work, they and their children can still enroll.

Good coverage. The full benefit package includes doctor visits, hospital care, prescriptions, lab work, x-rays, mental health services, and much more.

No asset limits for children and pregnant women. For children and pregnant women, only family income is counted. For parents and 19 and 20-year olds, assets are counted, but many assets (including a home, car[s], and some savings) are not counted.

Easy to apply. The application form for families with children and pregnant women is only two pages long. You can get it by:

• Calling the Department of Health and Human Services (DHHS) on their statewide toll free number: 1-877-543-7669;
• Calling the local DHHS office
• Printing a form from the DHHS website ("MaineCare for Children and Pregnant Women" form is the shortest and easiest to use)
• Calling the Consumers for Affordable Health Care HelpLine at 1-800-965-7476
• Faxing the DHHS supply room at 626-5555 to request a bulk order of applications (500 per box). Be sure to include your mailing address, the application form you want (the green family MaineCare application), and the number of applications you would like to receive.

The application can be returned to DHHS by mail or dropped off at a local DHHS office. Be sure to include proof of income along with the application.

If applicants prefer, they can also call their local DHHS office and apply over the telephone. (It is not possible at this time to apply online.)

Easy to get help and information.

• Consumers for Affordable Health Care HelpLine: The HelpLine will answer questions about MaineCare and help eligible people enroll. The HelpLine is answered by Consumers for Affordable Health Care, a non-profit agency, not by DHHS. Any information given to the HelpLine staff is confidential and will not be shared with DHHS, without permission. The HelpLine toll-free number is 1-800-965-7476. If you are deaf or hard of hearing and have a TTY machine, the number is the same.
• MaineCare Member Services: 1-800-977-6740 (TTY 1-800-977-6741), for coverage questions or for help getting bills paid or finding a provider.
• MaineCare Provider Services: 1-800-321-5557 (option 9), for assistance for MaineCare providers.
• Department of Health and Human Services (DHHS) regional offices: Call or visit a local DHHS office to apply to MaineCare or to ask questions about eligibility. Statewide toll-free number: 1-877-543-7669.
• Maine Equal Justice: 626-7058; 1-866-626-7059 (TTY is the same). Maine Equal Justice, a non-profit agency, provides a range of health care information on this website. Staff are also available to help with problems or concerns regarding MaineCare or other public benefit programs.
• Pine Tree Legal Assistance (PTLA): PTLA can assist with MaineCare denials, terminations, and appeals, both in terms of eligibility for MaineCare and also for covered services (e.g., they handle cases when MaineCare denies coverage of a drug or denies a service, such as orthodontics). Find a local PTLA office. PTLA does not help with cases related to MaineCare long-term care for seniors age 60 and older; Legal Services for the Elderly (LSE) will help with this (LSE HelpLine: 1-800-750-5353).
• Disability Rights Center: provides information about rights and service systems, referrals to appropriate services, representation of individuals at meetings and hearings and legal representation of individuals or groups. Call 1-800-452-1948.
• Legal Services for the Elderly (LSE) Helpline: 1-800-750-5353
• Further information about options for dental care:
  List of free and low-cost dental service providers
  Map of Federally Qualified Health Centers that offer dental care
  

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Section 1: Coverage and Eligibility

1.1 Health care services covered by full benefit MaineCare

Health care services covered by full-benefit MaineCare include:

Doctors' Visits

• Well-child check-ups
• Sick care
• Specialist care, including surgery
• Prenatal care

Dental Services: Full coverage for children (with limits for adults)

Hospital Care: In-patient, out-patient and emergency room

Long-Term Care: Coverage for care in a nursing home or other residential care. Services may also be provided in the home.

Services

• Shots to prevent illness (immunizations)
• Prescription drugs
• Mental health services
• Substance abuse services
• Lab and x-rays
• Medical equipment and supplies
• Ambulance services
• Transportation to medical and counseling appointments (Get list of Transportation Agencies)
• Chiropractic care
• Eye exams and eye glasses (with limits for adults)
• Hearing tests (with limits for adults) and hearing aids (for children age 20 and younger)
• Family planning
• School-based health centers
• Interpreters

Therapies

• Speech therapy
• Physical therapy
• Occupational therapy

Early and Periodic Screening, Diagnosis and Treatment

Federal Medicaid law requires States to cover Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children and adolescents under age 21. EPSDT covers four separate screening services—medical, vision, hearing and dental—and includes immunizations, laboratory tests (including lead blood tests), and health education. Each type of screen must be furnished at pre-set, periodic intervals (periodic screens) and when a problem is suspected (interperiodic screens).

The treatment component of EPSDT must include any necessary health care, diagnostic services, treatment, and other measures, described in section 1396d(a) of the Medicaid Act, to “correct or ameliorate” physical and mental illnesses and conditions, whether or not such services are covered for adults in the state’s Medicaid program. EPSDT also includes outreach and informing to notify children and their families of EPSDT and the importance of preventative care, and to offer appointment scheduling and transportation assistance, if needed.

If a service that a child under age 21 needs is for some reason not available under MaineCare, or if the child requires more services than MaineCare may cover, then the child’s provider can file with the Office of MaineCare Services, a request for Prior Authorization for what is called “Optional Treatment- EPSDT Services.”

And More...

This is just a partial list of services covered by full-benefit MaineCare. It is important to note that all children with MaineCare receive the same full-benefit coverage, whether their coverage is through the CHIP program (the children whose families pay a monthly premium) or through straight Medicaid, which includes the Katie Beckett benefit. For more information, 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).

Important note about copayments: Except for small copayments, doctors and other health care providers cannot charge members in addition to the payments they get from MaineCare. There are no copayments for services provided to children. If a MaineCare member cannot afford to pay a copayment, the provider must still provide the service. The provider may bill the member, but may not deny services in the future due to non-payment of copayments.

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Section 1: Coverage and Eligibility

1.2 MaineCare coverage categories explained in this guide

* Benefit packages are outlined in the MaineCare Member Handbook.

There are other groups of people who can also get MaineCare. See Sections 5 and 6 below and Maine's Medical Assistance Programs: Who's Covered and Who's Not.

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Section 1: Coverage and Eligibility

1.3 What counts as income for MaineCare?

What counts: (partial list)

• Earned income ( gross wages from an employer)
• For people who are self-employed, the "net profit and loss" line on the Schedule C (or other IRS Form 1040 self employment attachment) is divided by 12, unless other current information is provided
• Seasonal income is counted during the months worked
• Unearned income (like Social Security, unemployment benefits or Workers' Compensation)
• Child Support

See next section for important deductions that can be subtracted from gross income.

What does not count: (partial list)

• Income from other people in the household who are not the parents or guardians of the children living with the family (like grandparents, a boyfriend or girlfriend, adult brothers and sisters, or aunts and uncles). Anyone not legally responsible is not financially responsible and their income does not count. These other household members also do not count in figuring out family size. These individuals may be eligible for MaineCare in a different category and as a separate household.
• Wages of dependent children age 20 and younger do not count, as long as they are full-time students or part-time students not working full-time.
  
• Section 125 payments (cafeteria plans) do not count to the extent used to purchase benefits.

Rules about SSI: A person who gets SSI automatically gets MaineCare. However, the SSI income that person gets is not counted when determining eligibility of other family members. The person who gets SSI is also not included when determining family size.

Rules about income from stepparents
A stepparent may or may not be counted as part of the MaineCare household. DHHS will include the stepparent in the family only if it will help everyone to get MaineCare. DHHS will figure this out in the way that gives most health care to the family.

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Section 1: Coverage and Eligibility

1.4 Calculating income eligibility: deductions

Some money can be subtracted from gross income when determining eligibility for MaineCare.

To calculate the monthly countable income:

If someone receives a weekly paycheck, he or she should multiply that amount by 4.3 to determine monthly income. If someone receives a paycheck twice per month (usually on the 1st and 15th), he or she should multiply that amount by 2 to determine monthly income. If someone receives a biweekly paycheck, he or she should multiply that amount by 2.15 to determine monthly income. Remember it is gross income that counts (the full amount of taxable wages).

Note: Current income is used to establish monthly countable income. For example, if the family income changed from last year such as workers who were laid-off or the self-employed whose business income varied, he or she should report the unemployment income or current business income (not from last year’s taxes).

To find out eligibility for free MaineCare for children, 19 and 20-year-olds, parents and pregnant women, first subtract any of these expenses from the applicant’s monthly gross income:

1. The first $90/month of a family member's earned income (from work). If both parents are working, they can each deduct the first $90 of earned income, for a total of $180.
2. Child care expenses actually paid, up to $200/month (for children age 1 and younger) or $175/month per child (for children age two and older).
3. Child support payments paid by a family member to someone outside the household.
4. Up to $50/month for child support received by the household.

Then, if the income that's left is less than the total in Column B, below (Column C for parents and pregnant women), the household meets the income requirement for free coverage.

Children age 18 and younger in families with income ranging from greater than 150% to 200% of the federal poverty level (FPL) may be eligible for CHIP MaineCare (with monthly premium). To find out eligibility for children's CHIP MaineCare (with a monthly premium), take the family's total monthly gross income and subtract:

1. The first $90/month of a family member’s earned income (from work). If both parents are working, they can each deduct the first $90 of earned income, for a total of $180.
2. Up to $50/month for child support received by the household

Then, if the family’s income that's left is between the amounts listed in Column B and Column C, children age 18 and younger will be eligible for CHIP MaineCare. The family will need to pay a monthly CHIP premium for their child's coverage, which ranges from $8 to $64 per month per family.

Monthly Gross Income Eligibility Chart

Remember to deduct all expenses, as described in Section 1.4 above, before comparing adjusted gross monthly income (also called countable income) to the amounts in this table.

The federal government determines the federal poverty level (FPL) each year. The FPL increases a small amount each year, usually around February, to adjust to the rising cost of living.

*CHIP MaineCare for children in households with countable income (gross income minus any deductions) from greater than 150% to 200% FPL must pay a monthly premium that ranges from $8 to $64 per family. The amount of the CHIP premium depends on the family’s income and size. CHIP MaineCare is sometimes referred to as low-cost MaineCare, or premium MaineCare (in the past it was called Cub Care). (A premium is charged for these children because their MaineCare coverage is provided through the State Children’s Health Insurance Program [CHIP], which requires premiums.) DHHS sends a bill and a postage-paid envelope to the family to pay the premium each month, although premium costs can also be paid up to 12 months in advance or at the end of the 12-month eligibility period.

Children in households with monthly gross income of 150% FPL or lower; parents; pregnant women; 1 9- and 20-year-olds do not have a monthly premium. This is referred to as free MaineCare.

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Section 1: Coverage and Eligibility

1.5 Rules about assets

For children (age 18 and younger) and pregnant women, DHHS will not count assets. But, any income from an asset, such as interest from a bank account, will count as income.

For parents and 19 and 20 year olds, there is a $2,000 asset limit. This means a family cannot have property or other valuable items worth more than $2,000. But, many assets are not counted in the $2,000 limit.

Assets that do NOT count against the $2,000 limit:

• The family's home and surrounding lot
• Basic items used in day-to-day living, such as furniture, tools and equipment
• Two cars or trucks (the second vehicle must be necessary for employment, medical treatment, or essential daily activities, or it must have been modified for operation by a person with a disability or for the transportation of a person with a disability)
• Property used to produce income such as boats, trucks, and machinery
• Money in a savings account, CD, pension plan, or IRA: up to $8,000 for a single person, $12,000 for a family of two or more
• Real estate that is up for sale
• Loans that must be repaid
• The cash value of life insurance the family has purchased
• Up to $10,000 in a Family Development Account (FDA) that can be spent only for education, home repair or purchase, a car or truck needed for work or school, small business start up, health care, or to use for an emergency or other family need approved by DHHS
• Other less common assets listed in DHHS rules

Equity value of owned property: For property that does count against the $2,000 limit (for instance, a plot of land that is owned but not lived on by the MaineCare member/applicant), it is the equity value of the property that counts towards the asset limit. So, a family may own land worth $7,000 but have only $1,000 in equity; in this case, only the $1,000 would count toward the asset limit.

Money or gifts received: A lump sum of money (over the asset limits) which is received while a family is getting MaineCare won't count as an asset if the family spends it, within 30 days, on back bills or on assets that don't count (like a home improvement). Retroactive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) checks won't count as an asset for a longer time period. Contact Maine Equal Justice for more information.

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Section 1: Coverage and Eligibility

1.6 Pregnant Women

General eligibility rules for pregnant women:

• Eligible up to 200% of the federal poverty level (Column C)
• Household size is increased by one (or two if expecting twins)
• Marital status, assets, and cooperation with Third Party Liability (TPL) and support enforcement are not factors in determining eligibility
• In the case of unmarried parents who live together, acknowledgment of paternity cannot be made prior to the baby's birth. This means that the father's income and assets are not used in determining eligibility for the pregnant woman and he is not counted as a member of her MaineCare household
• Other people who live with the pregnant woman may also be eligible for MaineCare under separate eligibility guidelines
• Coverage can be retroactive for up to 3 months if the woman was pregnant and financially eligible during that time period
• Once a woman is found eligible for MaineCare because she is pregnant, she will continue to be eligible for 60 days beyond the day her pregnancy ends (and through the last day of the month in which the 60th day falls)
• If a woman is receiving MaineCare when the baby is born, the baby will be eligible for MaineCare for 12 if the mother notifies DHHS of the birth and applies for a Social Security number for the baby.

Who is included in the household when the pregnant woman is a minor?

If the pregnant woman does not live with her parents, regardless of her age, her parents' income will not count.

An 18- to 21-year-old who is pregnant or is a parent is an "independent child." The parents' ("grandparents") income and assets are not considered in budgeting.

In the case of a pregnant minor or minor parent who is age 17 or younger and living with her parents (the "grandparents"), DHHS will first look to see if everyone in the household can be enrolled in MaineCare based on the entire household's income and assets. Even if the grandparents are ineligible for MaineCare, the pregnant minor (or minor parent and her children) may still be eligible. Some of the grandparents' income will be considered available to the pregnant minor, but not all of it. And none of it will be considered available to the grandchildren. Even if the minor is ineligible because of the income of the grandparents, the minor parent's child (the grandchild) is likely to be eligible.

Presumptive Eligibility:

If a qualified MaineCare provider (including a Federally Qualified Health Center [FQHC] or a Family Planning office, such as Planned Parenthood, that chooses to provide presumptive eligibility) determines that the pregnant woman's income meets the MaineCare guidelines, she can receive prenatal care beginning the day she comes for services. This is called "presumptive eligibility."

Once the MaineCare provider has made a presumptive determination, the coverage will last through the last day of the month following the month in which the determination is made. In order to avoid a break in coverage, women should be encouraged to apply for on-going MaineCare coverage through the Department of Health and Human Services (DHHS) during this presumptive eligibility period.

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Section 1: Coverage and Eligibility

1.7 Katie Beckett for Disabled Children

What is Katie Beckett?

The Katie Beckett Program for Disabled Children is health care coverage for severely disabled children 18 years old and younger. If a child qualifies for Katie Beckett, they are given full benefit MaineCare coverage.

Who can get Katie Beckett?

The parents’ income and assets do NOT count when applying for Katie Beckett. Only the income and assets of the child are looked at. In most cases, this means there is no income or assets to look at.

A child may get Katie Beckett if they:

• Are 18 years old or younger;
• Are NOT eligible for MaineCare in another category;
• Do NOT live in a medical institution; and,
• Meet the Social Security definition for disability.

You do NOT have to get a Social Security disability decision in order to apply for Katie Beckett. MaineCare’s medical review team can look at the child’s medical history to see if they meet the definition. It is hard to tell if a child will meet the disability definition until they go through the application process. If your child cannot do everyday things that children their own age can do, it may be worth applying.

What if my child has private insurance?

A child can get Katie Beckett MaineCare even if they already have private insurance. Some families choose to keep both, and other families choose to have one or the other. In some cases MaineCare will pay the premium for private insurance if the child is eligible for Katie Beckett.

Will I have to pay for Katie Beckett?

Starting on April 1, 2008 there will be low cost premiums for Katie Beckett coverage. Your monthly premium will depend on your household income and if you have private insurance with the Katie Beckett, or just have Katie Beckett.

The parents’ income is not looked at for eligibility. But, the parents' income IS looked at when figuring out the monthly premium. Katie Becket premiums are based on your household income AND if you have private insurance as well as Katie Beckett. Premiums are lower for people who have private insurance along with the Katie Beckett coverage. This is because the state pays less for people who also have private insurance paying for certain services.

Katie Beckett Program Premiums Effective April 1, 2009
Income as Percentage of Federal Poverty Level	Monthly Premium Without Other Insurance	Monthly Premium With Other Insurance
150-200%	$30	$11
201-250%	$40	$14
251-300%	$50	$18
301-350%	$60	$21
351-400%	$70	$25
401-450%	$85	$30
451-500%	4100	$35
501-550%	$115	$40
551-600%	$130	$46
601-700%	$145	$51
701-800%	$175	$61
801-900%	$205	$72
901-1000%	$240	$84
1001-1200%	$275	$96
1201-1400%	$335	$117
1401-1600%	$395	$138
1601-1800%	$455	$159
1801-2000%	$520	$182
2001-2500%	$590	$207
2501+%	$750	$263

Section 2: Application and Enrollment

2.1 How to apply

Applicants can get the form online or by calling:

• The DHHS statewide toll-free number at 1-877-543-7669
• A local DHHS office
• The Consumers for Affordable Health Care HelpLine at 1-800-965-7476

Parents, children, 19- and 20-year-olds, and pregnant women use the same form to apply. The applicant should complete the form, then mail it or bring it to a local DHHS office. Be sure he or she includes proof of income for the past 4 weeks (for example, the four most recent weekly paycheck stubs, or, if self-employed, a copy of the most recent tax form).

Tip: DHHS figures out eligibility for MaineCare based on what they think the household's income will be in the next 12 months. The proof of income provided helps them figure this out. If income is expected to go down, the applicant should attach a note to explain the change. This will help the DHHS Eligibility Specialist decide eligibility.

Note: Elderly, disabled and "non-cat" adults must use a different application form. Get online form.

Link to all DHHS online application forms

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Section 2: Application and Enrollment

2.2 Citizenship and identity verification requirement: new federal law

The citizenship and identity verification law requires people applying for or already receiving MaineCare (or Medicaid in any state) to show documents that prove their citizenship and their identity. It is no longer enough to just declare citizenship. If applicants are unable to prove their citizenship and identity, they will be allowed to get MaineCare for up to ninety (90) days. If they are not able to prove their citizenship within the 90 days, then they may lose their MaineCare. Current recipients of MaineCare also must prove their citizenship and identity.

A person will only need to prove his or her citizenship and identity once (unless he or she moves to another state). This means that if someone leaves MaineCare, but later comes back on, his or her citizenship and identity has already been proven.

Impact of the new law

Maine began enforcing this law on August 1, 2007. Many other states have already been enforcing this law. Unfortunately, tens of thousands of people from those states are no longer receiving Medicaid because they were unable to get the necessary documents that would prove their citizenship and identity. It can be very difficult - and expensive - to get the needed documents. Instead of stopping illegal immigrants from unlawfully receiving Medicaid, this law has prevented American citizens - children and adults - from getting the health insurance that they are entitled to.

We are working hard in Maine to be sure that all citizens who are entitled to MaineCare are able to get and keep this important health insurance program. DHHS is working to verify citizenship and identity information for as many MaineCare recipients and applicants as possible. DHHS will attempt to verify citizenship for all recipients and applicants born in Maine. In addition, DHHS will match names of recipients and applicants with the Bureau of Motor Vehicles to verify identity.

Exemptions from the law

There are many people who are exempt from this new law (they do not have to show documents that prove their citizenship or their identity):

• People on Medicare
• People receiving Supplemental Security Income (SSI)
• People receiving Social Security Disability Insurance (SSDI)
• Legal immigrants
• Foster children
• Newborn children born to mother who has MaineCare at the time of the birth

These groups of people are exempt because they have already had to show documents that proved their citizenship/immigration status and identity to state or federal government officials. Pregnant women can be enrolled in MaineCare and then given a reasonable amount of time to provide the required documents to prove their citizenship and identity (through presumptive eligibility).

Questions about which documents an individual needs should be directed to his or her DHHS Eligibility Specialist. Contact information for regional DHHS offices For all other questions and assistance, call: Consumers for Affordable Health Care HelpLine at 1-800-965-7476.

What documents can be used to prove citizenship and identity?

Documents must be originals, or certified copies from the issuing agency. Notarized copies are not acceptable.

Citizenship

• U.S.passport (this also proves identity)
• U.S. birth certificate
• Adoption papers
• Official military record showing a U.S. place of birth

Identity

• Passport (this also proves citizenship)
• State driver’s license or state ID
• School ID with photo
• U.S. military or draft record
• Native American tribal document
• School records (if age 15 or younger)
• Day care records (if age 15 or younger)
• Children age 15 and younger who do not have a document to prove identity can have a parent fill out an affidavit. This affidavit will prove identity for that child (or children).
• Children age 16 and 17 who do not have a document to prove identity and who attend a school that does not provide a photo ID can have a parent fill out an affidavit. This affidavit will prove identity for that child (or children).

This is not a full list of documents that will prove citizenship and identity. MaineCare Eligibility Specialists have the full list of documents, as well as staff at the DHHS Citizenship and Identity Hotline (1-800-701-1887). However, the remaining documents on the full list are uncommon documents that the majority of people are unlikely to have.

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Section 2: Application and Enrollment

2.3 How long does it take for DHHS to review an application?

Most often, DHHS will send a notice within 2 to 3 weeks after getting a MaineCare application. DHHS must make a decision within 45 calendar days from the date they get the application, if it is complete.

If DHHS does not determine eligibility within 45 calendar days due to their own delays, they must send the family a short-term medical card to use until they do decide. This occurs fairly often when DHHS reviews eligibility based upon disability. The family may begin using the short-term card on day 46 and continue to use it until DHHS makes a decision. If DHHS later denies eligibility for MaineCare, the family will not have to repay DHHS for services received while using the short-term card.

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Section 2: Application and Enrollment

2.4 When will coverage start? Can back bills be paid?

Everyone covered in this guide except CHIP children (who pay a monthly premium) may be eligible to receive coverage for up to 3 months before the month DHHS received the application. If anyone in the family had medical bills in the 3 months prior to applying, encourage them to indicate that on their application (Box 10).

CHIP children (who pay a monthly premium)will receive coverage beginning on the first day of the month that DHHS received the application.

Tip: If DHHS indicates that it will not cover medical bills for the 3 months before application, the family may want to contact the Consumers for Affordable Health Care HelpLine (1-800-965-7476).

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Section 2: Application and Enrollment

2.5 Length of enrollment

Here's the basic rule: Members must re-apply every year (12 months) for MaineCare. DHHS will send a renewal form. They will check to make sure the member still meets income and asset guidelines.

Members will remain covered if:

1. The form is returned by the deadline stated in the letter
2. Any additional information requested by DHHS, including citizenship verification, has been provided
3. Any CHIP premiums already due have been paid
4. They still meet the income and asset guidelines

Important! Children age 18 and younger who are enrolled in MaineCare are entitled to a full 12 months of coverage, regardless of any change to family income or composition.

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Section 2: Application and Enrollment

2.6 Other rules about how long enrollment will last

CHIP children (who pay a monthly premium)

Children eligible for CHIP coverage may continue receiving coverage until they turn 19 years old. As a 19- or 20-year-old, they may then be eligible for free coverage. DHHS will automatically check to see if they are eligible for MaineCare in the category of coverage for 19- and 20-year-olds, and, if so, coverage will continue seamlessly.

Section 2: Application and Enrollment

2.7 Options for members when their income goes over the guidelines

Transitional MaineCare

When earned income goes up

If parents and their children are enrolled in free MaineCare and their income goes from below the amount in Column B to over the amount in Column C (from below 150% FPL to over 200% FPL) because of increased earnings, they will be eligible for MaineCare for up to 6 more months, no matter how much their income goes up. If the children are enrolled in CHIP MaineCare (they pay a monthly premium), the parents' MaineCare will not continue. The children's eligibility will continue until the end of their annual enrollment period.

When child support goes up

If a parent and his or her children are enrolled in free MaineCare and their income goes over the amount in Column C (over 200% FPL) because of an increase in child support, they can continue to get MaineCare for 4 more months.

MaineCare coverage continues for most children

Children of parents getting these transitional benefits will continue to get MaineCare until the transitional benefits end or until the end of family's 12-month certification period, whichever is later.

For children only: The Full Cost Purchase Option

If children age 18 and younger are no longer eligible to get MaineCare because their family income exceeds the limits, the family can choose to pay to continue coverage for the children for up to 18 more months under the Full Cost Purchase Option (which used to be called the Health Insurance Purchase Option [HIPO]). Right now, it costs $100 per month per child. For more information, call Third Party Liability toll-free: 1-800-572-3839. If you are deaf or hard of hearing and have a TTY machine, call 1-800-977-6741.

For more information on transitional benefits for parents leaving TANF due to an increase in earned income, go to What Happens to my Benefits When I Get a Job and Leave TANF?

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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 below.)

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 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 PCP's) 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.

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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

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Section 3: Managed Care

3.3 Who can choose no 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 and tell them why. If you are deaf or hard of hearing and have a TTY machine, call  1-800-977-6741.

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Section 4: Other Important Information

4.1 What if the applicant already has private health insurance?

Everyone except CHIP children (who pay a monthly premium) who is eligible for MaineCare can also have private insurance:

• If the family meets the income and asset guidelines for free MaineCare, they may enroll in MaineCare even if they are covered under another health insurance policy (including Medicare). MaineCare will pay for any services covered by MaineCare that are not covered by the private policy or by Medicare.
• If the family has been paying for private insurance coverage, they may choose to drop that coverage for any family members who meet MaineCare guidelines.

For CHIP children (who pay a monthly premium):

• If the household's income is more than the amount in Column B (more than 150% FPL), the child may not be able to get MaineCare if he or she is already covered by employer-based health insurance. This does not apply if the employer offers coverage for the child, but the family hasn't taken it.
• If health insurance provided by an employer is dropped, the family may have to wait 3 months for MaineCare coverage for their child, unless they meet one of the exceptions listed below. Most families do meet one of the exceptions.

Exceptions to the 3-month rule for CHIP children (who pay a monthly premium):

• The family (employee) paid 50% or more of the cost of the child's coverage.
• The person who dropped the child's coverage did not live with the family (such as a non-custodial parent).
• The child lost coverage because of a family member's change in jobs or loss of a job for a reason that was not the family member's (employee's) fault.
• The coverage was not through an employer-based plan. For example, it was an individual policy the family bought on their own.
• The family paid over 10% of all family income for family coverage (including the child).
• The child's policy was very limited. For example, it just covered dental care or one disease, such as cancer.
• DHHS decides the family had other good cause for dropping the insurance.

Example: Susan applies for MaineCare for her child in October. She dropped the coverage she had through work in September because she paid the entire cost and couldn't afford it. Susan's child will be able to get MaineCare when she applies in October if she meets the income guidelines.

Example: Jane also dropped her child's coverage under her employer's plan in September. But, her employer had been paying more than 50% of the cost of the child's coverage. And, their total health insurance costs were not more than 10% of family income. Jane's child will have to wait until January (3 months) for MaineCare.

Remember, because of Jane’s income level, she will need to pay a premium for her child's CHIP coverage. If her income was low enough that she did not need to pay a premium, her child would have been eligible right away, and she probably would have been eligible, too.

For more information about this 3-month rule, call the Consumer for Affordable Health Care HelpLine 1-800-965-7476. If you are deaf or hard of hearing and have a TTY machine, call the same number.

Two Important Notes:

1. Parents should not drop other insurance coverage until they find out if their children will be eligible for CHIP MaineCare.
2. If a parent does not live with his or her child and has been ordered by a court or by DHHS to provide health insurance, they may not drop that coverage. If the absent parent does drop coverage, they will have to repay any medical bills that MaineCare pays.

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Section 4: Other Important Information

4.2 Two groups of children aren't eligible for CHIP MaineCare (children who would pay a premium)

Two groups of children will not be eligible for CHIP MaineCare (remember that children with CHIP MaineCare have a family income that ranges from greater than 150% FLP to 200% FLP - between the amounts listed in Column B and Column C). These two groups are:

• Children who have access to coverage under their parent/guardian's state employee health insurance plan, even if they are not enrolled in the plan. If the state employee is a parent who does not live with the children, then this will not be a problem.
• Children who live in a public institution or an institution for mental illness.

Children in families with lower income may be eligible for free MaineCare. Even if you think one of these rules applies, encourage the family to apply!

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Section 4: Other Important Information

4.3 What happens if CHIP premiums aren't paid?

If the family can't afford to pay the MaineCare premium for children, remember:

Premium payments for months 1 through 11 can be made at the end of the child's 12 months of MaineCare eligibility. If payments have been missed at the end of the 12 months and the family has good reason, they can reapply as usual and explain their circumstances. If the family doesn't have a good reason, DHHS may make them wait up to 3 months to sign up their child in MaineCare again. If the family has lost income and can't pay the premium, they should tell DHHS. If their income is below Column B (below 150% FPL), their child will be covered by free MaineCare, and therefore won't need to pay a CHIP premium for their child's coverage.

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Section 4: Other Important Information

4.4 How to appeal a DHHS decision

If a member has a problem or complaint, encourage them to call DHHS and talk it over with their MaineCare Eligilibty Specialist. If that does not work, the next step is to talk with the supervisor of that Eligibility Specialist. Many issues can be worked out this way. In some cases, the member may request that you contact DHHS on their behalf. You will need the member’s written permission before the Eligibility Specialist can talk to you.

If the member is not satisfied with DHHS's answer, he or she has the right to appeal any DHHS decision. This includes decisions about eligibility for MaineCare and whether certain medical bills are covered.

If a member decides to appeal a MaineCare eligibility decision, it must be done within 30 calendar days of the date of the DHHS written decision. To appeal, he or she calls the regional DHHS office and asks for a fair hearing. It's good to send a dated follow-up letter asking for a fair hearing. If the 30-day limit for an appeal is missed, the applicant can reapply.

If the member gets free MaineCare and they want to appeal DHHS's decision that their coverage will end, the coverage can continue up to the time of the fair hearing, but only if they call and request a fair hearing within 12 calendar days of the date on the DHHS decision. If they miss the 12-day deadline, they can still appeal within the 30-day deadline. But, the coverage will not continue up to the hearing. If the family wins the hearing, DHHS will pay the back bills up to the hearing.

If the member gets CHIP MaineCare (children who pay a monthly premium) and he or she appeals a DHHS decision to end MaineCare, coverage will not continue up until the fair hearing. Everything else about the fair hearing process is the same.

To appeal other DHHS decisions:

The member can also appeal non-eligibility decisions made by DHHS, such as if DHHS refuses to pay a bill. The member has up to 60 calendar days from the date of the DHHS non-eligibility decision to appeal. To request this type of appeal hearing, call MaineCare Members Services.

To get legal help:

For legal advice or help, call the Consumers for Affordable Health Care HelpLine at 1-800-965-7476 (TDD/TTY is the same number). HelpLine staff will make a referral to free legal services, if necessary.

More help resources

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

You have just learned the basics of MaineCare eligibility and coverage benefits for children, their parents, 19- and 20-year-olds, and pregnant women. MaineCare also provides coverage to:

• Seniors age 65 and older
• Adults with disabilities
• "Non-cats," or non-categorical adults. These are adults who do not fit into any of the other coverage categories of MaineCare. In other words, they are age 21 to 64, they do not have dependent children living with them, and they do not have documented disabilities.

MaineCare coverage for seniors, people with disabilities, and the non-cats has some important differences. Building from your knowledge of how MaineCare works for children, their parents, 19- and 20-year-olds, and pregnant women, this section is designed to outline the major eligibility and coverage differences for seniors, people with disabilities, and the non-cats. This information is intended to supplement information already provided in the earlier sections of this guide.

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.1 Who can get MaineCare?

Refer back to Section 1.2 Who can get MaineCare?

* Benefit packages are outlined in the MaineCare Member Handbook.

It is important to note that the non-cats (adults age 21-64 without dependent children and without documented disabilities) do not receive full-benefit MaineCare. There are limits on the types of services they can receive, and there can also be limits on the number of times a service can be accessed. Also, there is often a wait list to get onto MaineCare as a non-cat. There are not wait lists for the other covered groups we have talked about in this guide (nor for seniors or adults with disabilities).

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.2 What counts as income for MaineCare?

Refer back to Section 1.3 What counts as income for MaineCare?

What counts as income

Difference: For seniors and the disabled, any child support received does not count as income for the parent.

What does not count as income

Addition: Cost of Living Adjustments (COLAs) associated with Social Security retirement benefits or Social Security Disability Insurance (SSDI) benefits do not count as income if the person currently has MaineCare (or has had MaineCare in the past 3 months). However, COLAs associated with Veterans Affairs (VA) benefits do count as income.

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.3 Calculating income eligibility: deductions

Refer back to Section 1.4 Calculating income eligibility: deductions

Difference: To figure out income eligibility for MaineCare based upon being age 65 or older or disabled, there are several deductions that can be made (deductions must be made in order listed below):

1. The federal disregard of $20 first from any unearned income and then the rest from earned income of an individual’s or couple’s gross income (unless the only income received is from a need-based source, like a Veteran’s pension, or all in-kind donations)
2. $65 of any earned income
3. 50% of any remaining earned income
4. The state disregard of $55 from an individual’s remaining countable income, or $80 from a couple’s remaining countable income
5. The Cost of Living Adjustment (COLA) associated with Social Security retirement benefits and/or Social Security Disability Insurance (SSDI) benefits (if people are already on MaineCare, or if they have received MaineCare within the past 3 months)
6. Wages of dependent children
7. TANF cash benefits
8. If the elderly or disabled person has a spouse or dependent children, additional deductions may be allowed.

Difference: MaineCare with an ineligible spouse. For someone who is a senior, disabled, or a non-cat and who is living with his or her spouse, the income limit can be higher if only one spouse signs up for MaineCare. As a general rule, if the couple is $337 or less over income, check with an Eligibility Specialist regarding MaineCare with an ineligible spouse. This eligibility option disregards $337 from the ineligible spouse’s income (for the seniors and disabled, this is in addition to the seven deductions listed above. For non-cats, there are no other deductions). It also may be possible for spouses to alternate eligibility, switching their eligibility status with one another as often as once per month.

Difference: There are no deductions for non-cats for their income eligibility (except for the MaineCare with an ineligible spouse option).

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.4 Rules about assets

Refer back to Section 1.5 Rules about assets

Difference: A senior or disabled couple, or a senior or disabled individual with a child(ren), have a $3,000 asset limit. Remember that many assets are not counted in the asset limit (for example, $8,000 in savings is excluded).

Additional assets that do not count (for any MaineCare applicant/member):

• Prepaid burial contracts or mortuary trusts
• Burial spaces
• Up to $1,500 set aside in a separate account for burial expenses (including equity in burial contracts)

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.5 When will coverage start? Can back bills be paid?

Refer back to Section 2.4 When will coverage start? Can back bills be paid?

Difference: Non-cats will receive coverage beginning on the first day of the month that DHHS received the application, unless there is a waiting list. In the event of closed enrollment, a waiting list will be established, allowing applicants to submit an application. The application will be date stamped when received at DHHS and filed by date. Upon re-opening of enrollment for this group, DHHS will notify applicants in the order in which the applications were received. Coverage will begin on the first day of the month that notification is made to the applicant, as long as they still meet the eligibility requirements. There is no retroactive coverage. Back bills cannot be paid.

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.6 Options for members when their income goes over the guidelines

Refer back to Section 2.7 Options for members when their income goes over the guidelines

Addition: MaineCare Option for Workers with Disabilities

The MaineCare Option for Workers with Disabilities (sometimes called the Working Disabled Benefit or the Medicaid Buy-In) allows members to earn more and still keep their MaineCare benefits. For this benefit, he or she only needs to meet the Social Security Administration (SSA) medical standard, not the work-related standard, of a disability.

An individual may qualify for this MaineCare Option if he or she:

• Meets the Social Security guidelines for a disability, and
• Has earnings, usually from a job, and
• Meets each of the following financial guidelines:

If the individual is single:

• Unearned income: monthly income from retirement, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), or other income that is not wages from a job must be $903 (100% of the federal poverty level [FPL]) or less after deductions. (Not all income is counted—income could be as high as $978 per month.)
• Wages from a job, added to the income that is not from a job, must be $2,257 (250% FPL) or less after deductions. (Not all income is counted; income could be as high as $4,709 per month, if all income is from work.)
• Assets are $8,000 or less. (Not all assets are counted. For example, your home, car(s), and up to $8,000 in savings are not counted.)

If the individual is married:

• Monthly income from retirement, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), or other income that is not wages from a job must be $1,215 (100% FPL) or less after deductions. (Not all income is counted—income could be as high as $1,315 per month.)
• Wages from a job, added to the income that is not from a job, must be $3,036 (250% FPL) or less after deductions. (Not all income is counted—income could be as high as $6,317 per month, if all income is from work.)
• Assets are $12,000 or less. (Not all assets are counted. For example, your home, car[s], and up to $12,000 in savings are not counted.)

If someone meets the three guidelines listed above, he or she may be eligible for MaineCare. Even if income is above these amounts, he or she may still be able to get MaineCare. Not all income is counted. Contact your local Department of Health and Human Services (DHHS) office and request to fill out an application for the MaineCare Option for Workers with Disabilities.

What will it cost?

If monthly countable income is over 150% FPL, the individual will need to pay a monthly premium for his or her benefits (either $10 or $20 per month, depending on income). If married and both spouses are eligible for this benefit, they will need to pay just one premium, based on their combined income. People will not have to pay the premium if they are responsible for paying their Medicare Part B premium.

Get more details from DHHS Office of Elder Services

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.7 Home & Community Benefit and Nursing Home Benefit

In order to receive MaineCare coverage for nursing home care or equivalent care at home, an individual 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 an individual's needs. He or she must also meet income and asset limits, although the income limits are higher than for full-benefit MaineCare. Also, if the individual has a spouse, much of the spouse's income will be disregarded. To learn more about these benefits, contact your local Area Agency on Aging, or call: 1-877-ELDERS1 (1-877-353-3771).

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Section 5: MaineCare Eligibility and Benefits for Seniors, Adults with Disabilities, and the "Non-Cats"

5.8 Managed Care

Refer back to Section 3.1 How managed care works

As of October 2008, elderly, disabled and non-categorical MaineCare members will also be enrolled in Managed Care, following the same rules. However, they can't enroll in managed care if they:

• Live in a nursing or ICF-MR (Intermediate Care Facility for people with Mental Retardation)
• Have Medicare
• Have other health insurance
• Will be eligible for MaineCare for less than 3 months
• Are in the MaineCare Member Restriction Plan

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.1 What is the Medicare Savings Program (MSP)?

For an overview of the program, go to our page: Help with Medicare Costs: The Medicare Savings Program.

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.2 Medicare Savings Program (MSP) eligibility: Important changes mean more people are eligible!

In order to get the MSP benefit, you now need to meet just two criteria:

• You must be enrolled in Medicare and have Medicare Part A coverage.
• Your "countable" income, after subtracting all the allowable disregards, must be at or below 185% FPL.

Allowable deductions (deductions must be made in order listed below)

1. Federal disregard: deduct $20 from an individual’s or couple’s gross income (unless the only income received is from a need-based source, like a Veteran's pension, or all in-kind donations).
2. Impairment-related work expenses (this deduction is only for disabled individuals/couples who are age 64 or younger and working): deduct impairment-related work expenses from an individual’s or couple’s gross income.
3. Earned income disregard (this deduction is only for people who are earning wages through employment):
   

   a. Deduct $65 from an individual’s or couple’s earned income.
   b. Deduct half of the remaining amount of earned income.

4. State disregard: deduct $55 from an individual’s gross income, or $80 from a couple’s gross income.
5. Other less common disregards (for example, for dependent children or for a couple where only one spouse is applying for MaineCare). Contact Maine Equal Justice for more information.

Because not everyone will receive the same disregards, it is difficult to give one number that represents an upper limit for income eligibility. However, in general, for people who are not working, if their income is at or below the following amounts, they will be eligible for MSP:

If single:

• $1,745 (this is $75 over 185% FPL).

If married:

• $2,347 (this is $100 over 185% FPL). If only one of you wants to enroll in MSP, your joint gross income can be up to $319 higher, which is $2,666.

Remember the earned income disregard! If you are working, your income can be even higher.

The Medicare Savings Program (MSP) has three components. The component you are eligible for depends on your countable income (after taking the deductions above):

• If you are enrolled in Medicare and your countable income is at or below 150% of the federal poverty level (FPL), you are eligible for the Qualified Medicare Beneficiaries (QMB—often called “Quimby”) portion of the MSP benefit.
• If you are enrolled in Medicare and your countable income is over 150% and equal to or less than 170% FPL, you are eligible for the Specified Low-Income Medicare Beneficiaries (SLMB—often called “Slimby”) portion of the MSP benefit.
• If you are enrolled in Medicare and your countable income is over 170% and equal to or less than 185% FPL, you are eligible for the Qualified Individual (QI) portion of the MSP benefit.

Even if you aren’t sure you are eligible, it’s a good idea to apply!

Important: When determining income eligibility, be sure to note whether you are using amounts that represent countable income (after disregards), or amounts that represent gross income (before disregards).

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.3 What are the benefits of the Medicare Savings Program (MSP)?

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.4 How to apply to the Medicare Savings Program (MSP)

You can enroll in the Medicare Savings Program (MSP) by applying to the Maine Department of Health and Human Services (DHHS), either through the DHHS regional offices or by calling 1-877-543-7669.

People are enrolled in MSP for 12 months at a time. Before the end of the 12-month enrollment period, DHHS will send you a review form. You must return the form and continue to meet applicable eligibility guidelines for continued enrollment.

Important: Most people who are found eligible for MSP will be automatically enrolled in the Low Cost Drugs for the Elderly and Disabled (DEL) benefit (and most people enrolled in DEL will be automatically enrolled in MSP). For more information about DEL, see our "Who's Covered?" chart.

MSP coverage begins the second month following your application (for instance, if you apply any time in February, you would receive coverage starting on April 1). Enrollment in the SLMB or QI portion of the MSP may be retroactive up to 3 months before the date of your application, if you were eligible during that time period.

Like all other MaineCare programs, DHHS must make an eligibility decision within 45 calendar days (or else they must temporarily provide the benefit until they are able to make a final decision). Temporary coverage after the 45th day will not happen automatically - you would need to call DHHS and note that your application has been pending for 45 days.

Because it is the Social Security Administration (SSA) that collects the Part B premiums, even if DHHS makes a decision on your MSP application within 45 days, it may be several months until SSA stops taking your Part B premium out of your Social Security retirement or Social Security Disability Insurance (SSDI) check. You will receive a lump sum check from SSA to reimburse you for any Part B premiums that were taken out of your benefit check when in fact your MSP benefit has been paying that premium.

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.5 Does the Estate Recovery Program try to recoup benefits from the Medicare Savings Program (MSP)?

The MaineCare Estate Recovery Program does not apply to the Medicare Savings Program (MSP), unless you have also received full-benefit MaineCare.

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.6 The appeals process for the Medicare Savings Program (MSP)

Each applicant for or member of the Medicare Savings Program (also for the Low Cost Drugs for the Elderly and Disabled [DEL] benefit, or Maine Rx Plus) has the right to appeal almost any Department of Health and Human Services (DHHS) decision that adversely affects eligibility or benefits. The MSP provides significant financial assistance with Part D benefits and covers the Part B premium (and for some, all of the Part A and B costs); therefore, it is of crucial importance to get or maintain membership in the MSP for all those who are eligible.

Members and applicants have the right to assistance with an appeal from an attorney, a family member, or another trusted person. Help may also be available through Pine Tree Legal Assistance or Legal Services for the Elderly (toll-free 1-800-750-5353; in the Augusta area, call 623-1797).

Appeals must be made within 30 calendar days of the date of the DHHS written decision to deny or terminate MSP. To appeal a MSP decision, call or write to the regional DHHS office and ask for a fair hearing.

If appealing a DHHS decision to end MSP benefits, the coverage can continue up to the time of the fair hearing decision, but only if the request for a fair hearing is made within 12 calendar days of the date on the DHHS decision. If the 12-day deadline is missed, an appeal within the 30-day deadline can still be filed; however, the coverage will not continue up to the hearing decision. If the person wins the hearing, then DHHS may have to pay any back bills.

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Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.7 Medicare Savings Program (MSP) resources

DHHS Pharmacy Help Desk: 1-866-796-2463 (TTY 207-287-1828)

Maine Equal Justice: 1-866-626-7059

Legal Services for the Elderly (LSE) HelpLine: 1-800-750-5353

Pine Tree Legal Assistance (PTLA) (for appeals)

Consumers for Affordable Health Care HelpLine: 1-800-965-7476
The Maine Department of Health and Human Services: 1-877-543-7669
Maine Equal Justice Partners: 1-866-626-7059