Maine's Medical Assistance Programs - Who's Covered, And Who's Not

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Category

Benefit Level

Income Limit


Asset Limit


Notes

Children age 0-18

Full-benefit

MaineCare

213% FPL (federal poverty level)

None

Children with income up to 161% FPL are eligible for free MaineCare; infants under 1 with income up to 196% FPL are eligible for free MaineCare. Children between 162%-213% 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 any months during the period of 18 months following termination.

19- and 20-year-olds

Full-benefit

MaineCare

161% FPL

None

If child declared a tax dependent of the parents in the household then parental income is counted in most circumstances.

Children under age 26 who were in foster care in the State of Maine at age 18

Full-benefit MaineCare

No income limit

None

Must not be eligible under any other Medicaid category. 

Parents with children age 18 and younger at home[1]

Full-benefit

MaineCare

105% FPL

None

Transitional coverage: If family income goes over 105% of FPL and the family has earnings from employment, then the family will get an additional 6 months of “Transitional MaineCare” coverage.  After the first 6 months, if income is below 185% of FPL, then the family may get another 6 months of Transitional MaineCare. If income goes over 105% of FPL and the family has income from child support, then the family will get Transitional MaineCare for 4 months.

Pregnant women

Full-benefit

MaineCare

214% 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.

Disabled adults and seniors age 65 and older

Full-benefit

MaineCare

100% FPL

 

 

$2,000
($3,000/couple)

(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, plus services that Medicare does not cover, such as transportation and long term care services. 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.

MaineCare Option for Workers with Disabilities: People with disabilities who work may be eligible for full-benefit MaineCare if their unearned income, such as Social Security 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[2]

Limited-benefit MaineCare

175% FPL

  $50,000/$75,000 liquid asset test for individual/couple

Medicare Savings Program (MSP, or “Buy In”): MaineCare will pay the Medicare Part B premiums for those below 175% of FPL. For those below 140% of FPL MaineCare will also pay the Part A & B deductibles, co-insurance/co-pays. Recipient may not be charged.

MSPs will have no Part D premium, deductible or “donut-hole.” Co-payments are limited. ($2.65/$6.60 for generics/brand name drugs.)

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/couple)

(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  who are living at home through the Home and Community Based Waiver. (Elderly, Disabled, Brain Injury, “other related conditions”, such as cerebral palsy. 

Full-benefit MaineCare

300% of the federal SSI Benefit Amount

$2,000 ($3,000/couple)

(Many assets are excluded.)

This is a gross income test.  The person will be able to keep income equaling up to 200% of the Federal Poverty Level and allowed deductions for medical costs.  All other income will be used to pay for the cost of care.  Income and assets of a non-waiver spouse do not count.

Adults living in residential care facilities, e.g. assisted living,  other than nursing facilities

Full-Benefit MaineCare

Countable Income must be below the private pay rate for the residential care facility.

$2000

($3000/couple)

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 MaineCareafter a large deductible is met

None

$2,000 ($3,000 for some couples)

(Many assets are excluded.)

The Medically Needy benefit primarily helps people with catastrophic health care expenses; participants must be in a coverable group (e.g. 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 be applied to  the deductible.

Disabled adults and seniors age 62 and older

Low Cost Drugs for the Elderly and

Disabled (DEL)

175% FPL

(income limit is increased by 25% if drug costs are high.)

None

DEL covers:

1)     80% of generic drugs costs (member pays 20% and small copay);

2)     80% of drugs costs for 14 specific health problems (member pays 20% and small copay);

3)     A small discount off the retail cost of many other medications;

4)     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.

People Who Want Family Planning Services

Limited Benefit

209% of FPL (Uses only individual, not family income)

None

Covers services such as:  Office visits for family planning; contraceptives, devices, and supplies..

Breast and pelvic exams and cancer screening; Pap smears, colposcopies, biopsies, and cryotherapies for cervical dysplasia; Treatment of genital tract and genital skin infections and disorders; diagnosis and treatment of Sexually Transmitted Infections (STIs);Testing, prevention education, counseling and referral for Human Immunodeficiency Virus (HIV); Limited pharmacy services, consisting of birth control supplies and medications, vaccines, and supplies to prevent and treat STIs and other reproductive health infections; Limited laboratory services, consisting of testing for STIs, HIV, anemia, sickle cell disease, cervical and testicular cancer screening, and pap smears. Sterilization if a properly completed sterilization consent form in accordance with federal  requirements; Provision of immunization services for STIs, including but not limited to, Hepatitis B where medically indicated.

 

Persons who do not qualify for full-benefit MaineCare

 

MaineRx 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 are approximately 15% on brand name drugs and 60% on generic drugs.



[1] Parents may be covered if 18 year old will finish high school by age 19.

 

Click Here for the 2017 MaineCare and Marketplace Income Eligibility Guidelines

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