MaineCare Eligibility
Introduction

Contents

History

This guide was created by the Covering Kids and Families Coalition (CKF) and has been adapted and maintained by Consumers for Affordable Health Care and Maine Equal Justice Partners. The CKF Coalition consisted of the Maine Department of Health and Human Services, Consumers for Affordable Health Care, Maine Equal Justice Partners, Maine Primary Care Association, and Maine Children's Alliance.

MaineCare Quick Summary

This guide is about MaineCare, Maine’s Medicaid program. MaineCare also includes Maine’s State Children’s Health Insurance Program (CHIP). CHIP 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 MaineCare for the categories above as well as the Medicare Savings Program, which is a partial-benefit MaineCare program.

Resources for Help and information.

CAHC Linkable: (Consumers for Affordable Health Care) lists websites for all the links in this list below in one place as well as other useful sites.

• Area Agency on Aging: The five Area Agencies on Aging in Maine are the central resource for elder services. They can help you either directly or by referring you to the appropriate agency in your area. Call 1-877-353-3771 from anywhere in Maine to contact the Area Agency on Aging that serves the town you live in.


• Consumers for Affordable Health Care HelpLine: The HelpLine answers 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.


• 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.


• 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 or visit the Disability Rights Center on the web.


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


• 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.


• MaineCare Rules for eligibility, setting forth who is eligible to get MaineCare are located in the MaineCare Eligibility Manual.


• MaineCare Rules for benefits, setting forth the scope of covered services for those eligible for MaineCare are found in the MaineCare Benefits Manual, with updates available here.


• 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 its website. Staff is 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).


• Further information about options for dental care:
  List of free and low-cost dental service providers
  Directory of Federally Qualified Health Centers that offer dental care
  

What’s New in MaineCare

Here are some recent changes to MaineCare coverage.

Beginning October 1, 2012

• Parent eligibility change: Parents with household income between 133% and 200% of the Federal Poverty Level (FPL) will not be eligible for MaineCare after October 1, 2012. No new applicants in this group will be enrolled. Parents enrolled now will lose coverage. This eligibility change does NOT affect children or pregnant women. Some parents between 133% and 150% FPL may be eligible for transitional MaineCare for a limited number of months, or some may be eligible for MaineCare in the disability category.

2012

• “45 Day Rule” change: if you apply for MaineCare in the disability category and DHHS sends the necessary medical documentation forms to your medical providers within 5 days, then DHHS may exceed the “45 day limit, if the medical provider fails to provide the medical information on a timely basis.” In the past, as long as applicants responded to DHHS in a timely manner, DHHS had to grant temporary coverage if an eligibility decision had not been reached within 45 days. Now it will be more important to stress to applicants the need to stay in touch with their providers to ensure that medical documentation is returned to DHHS as soon as possible. If DHHS fails to request medical documentation within 5 days or fails to respond in a reasonable time frame when medical records are received, then a temporary MaineCare card may still be provided.
• Non-categorical wait list: The waiting list for non-categoricals is frozen. Names may still be added to the wait list but no new applicants are being enrolled now. Current enrollees remain covered if they remain eligible and return review materials to DHHS as required. It is very important to stress the need for enrolled non-categoricals to respond to (usually annual) requests from DHHS for information needed to stay enrolled. It is still important that people apply and get on the wait list, because many hospitals and other programs require proof of MaineCare application. Also, if new non-categoricals become eligible again in the future, the names highest on the wait list will be enrolled first.
• Non-categorical services: After October 1, 2012, the Department may reduce or eliminate some covered services.

2011

• Legal immigrant eligibility change: Legal immigrants to the US with Lawful Permanent Resident status less than 5 years are no longer eligible for full coverage MaineCare. The exceptions are children under 21 and pregnant women. Those legal immigrants with Lawful Permanent Resident status not eligible for full coverage MaineCare may be eligible for Emergency MaineCare only. Click here for the definition for qualifying emergencies

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