Changes to MaineCare

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MAINECARE ELIGIBILITY CUTS:

Two supplemental budget bills made deep cuts to MaineCare eligibility. These budgets made the following changes to the program:

Froze enrollment in the Childless Adult waiver program. Spending in the program will move from an annual budget cap of $80.3 million to $40 million. Coverage for people currently enrolled in the program will be protected, but no one from the wait list will be let onto the program at least through June 2013. Some further cuts may be made later this year if this budget target is not reached.

  • Tip: Any MaineCare recipient currently on the Childless Adult Program must be sure to complete and submit their annual recertification form on time. If someone does not recertify for the program, they WILL lose coverage and will be unable to get their MaineCare coverage back. Members who change their address should give their new address to DHHS as quickly as possible. People now have the option to recertify online using My Maine Connection.

Eliminated coverage for parents with incomes between 100% and 200% of the poverty level. As an example, a family of three with income between $19,090-38,180 per year is affected by this cut. Coverage for people with incomes between 133 and 200% of the poverty level will be terminated on October 1, 2012. (See "Important Note" below discussing why this cut may not happen for parents with incomes between 100 and 133% of the poverty level).

 

  • Tip: Parents with incomes between 133% and 150% of the poverty level whose annual recertification happens before October 1 should be sure to recertify. Parents with income between 133% FPL ($2,116 per month for family of 3) and 150% FPL ($2,387 per month for a family of 3) may be eligible for transitional MaineCare if they are working or receiving child support at the time that their MaineCare ends. Transitional MaineCare lasts for 3, 6 or 12 months after termination of eligibility, depending upon a family’s circumstance. Parents affected by this cut will only be eligible for transitional MaineCare if they are enrolled in the program on October 1st.

Eliminated coverage for 19 and 20 year olds with incomes below 150% of the poverty level. ALL 19 and 20 year olds currently covered by Maine will lose coverage unless they are pregnant or determined disabled under MaineCare rules. (See "Important Note" below discussing why this cut may not happen).

Eliminated some or all of the help that seniors and people with disabilities at certain income levels receive through the Medicare Savings Program. (See "Important Note" below discussing why this cut may not happen).

  • Seniors and people with disabilities with incomes between 175% and 185% of the poverty level will lose all help paying for Medicare Part B and Part D premiums; payments for co-insurance and deductibles; and support through the donut hole. As an example, someone living alone with income over $19,548 a year will lose help.

  • Seniors and people with disabilities with income between 140 and 150% of the poverty level will lose help paying for Medicare Part A and B deductibles and co-insurance. They will not lose help with their Part B premium, and Part D premium and other cost sharing. As an example, someone living alone with income between $15,638-16,755 a year will lose this help.

IMPORTANT NOTE ABOUT ELIGIBILITY CUTS:

These cuts in eligibility may not happen for:

  • Parents with incomes between 100 and 133% of the poverty level.
  • 19 and 20 year olds with incomes below 150% FPL; and
  • Seniors and people with disabilities on the Medicare Savings Program.

These eligibility categories are protected by a provision in the Affordable Care Act referred to as “maintenance of effort” (MOE). The U.S. Supreme Court decision did not impact the MOE requirement. Although the state recently requested that the federal government approve these eligibility cuts, we believe that the federal government will deny the request. This means that eligibility for parent coverage would remain at 133% FPL and there would be no changes for 19 and 20 year olds or for seniors and people with disabilities on the Medicare Savings Program.

MAINECARE SERVICE CUTS:

Some MaineCare services were cut. Most of these cuts have already gone into effect.

This service will still be available to members, although some providers may decide not to take as many MaineCare members. Medical providers cannot ask MaineCare members to pay them to make up for this cut.
  • Vision services: Routine eye exams will now be available once every 3 years instead of every 2 years as currently allowed;

  • Chiropractic services: Services will be limited to 12 visits per year;

  • Smoking cessation services: This service will be eliminated in August/September, 2012.

  • Methadone Clinics: The amount that DHHS pays these medical providers was reduced from $70 to $60 per week;

  • Methadone and Suboxone Treatment Services: MaineCare members receiving Methadone or Suboxone treatment will need to receive prior approval to continue treatment beyond 24 months. This means that members will have to show that it is medically necessary to continue their treatment.

  • Reimbursement rates: The amount that DHHS pays providers for the following services was reduced by 10%:
    • Occupational and physical therapy
    • Podiatry
    • Adult family Care;
  • Brand Name Prescriptions: MaineCare members will be limited to only 2 brand-name prescription drugs per month. Additional brand name drugs may be available if your medical provider says that they are medically necessary for you (the current limit is 4 per month). There is not limit on generic drugs;

  • Hospital Services: MaineCare will only pay for 5 inpatient hospital days per year per member. However, most MaineCare members are eligible for “free care” at all Maine hospitals. This means that members should still be able to get the hospital days that they need without any cost to them.

  • Certain MaineCare pain medications: A prescription for certain medications (opioids) for acute pain can now only provide for 15 days of medication. Then a face-to-face visit with the prescriber is required in order to get prior authorization for another 15-day prescription. After 45 days, if the opioid drugs are still medically necessary, a person may qualify for opioid drugs for long-term chronic pain with prior authorization. Please note: 60-day prescriptions are allowed following surgery.

Updated August 2012

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