MaineCare pays for medically necessary services based on your coverage group, which is determined by your income, age, medical needs, and if you need help with Activities of Daily Living (ADLs).
What services are covered?
Some examples of services that may be covered include:
- Doctor visits
- Prescription medications
- Behavioral health services
- X-rays and labs
- Emergency and hospital visits
What services are not covered?
Some examples of services that are not covered include:
- Acupuncture
- Cosmetic surgery
- Experimental procedures or drugs
- Health club memberships, such as the YMCA
- Massage therapy
How do I find out if a service is covered?
Talk with your health care provider or call MaineCare Member Services at 1-800-977-6740. TTY users, dial 711 (Maine Relay). To see if your medication is covered, call the Pharmacy Help Desk at -866-796-2463, TTY: 711.
Do I have to pay for MaineCare coverage?
You may have to pay a copayment, premium, or cost of care for MaineCare services depending on what coverage group you have.
Copayments
You may need to pay for part of the cost of some MaineCare services. What you pay is called a copayment, or copay.
Members do not have a copay for the following:
- Services provided in Indian Health Service Centers
- Family Planning services and supplies
- Emergency Department services
- Hospice services
- All oxygen and oxygen equipment services
- Tobacco cessation services and products
For details about services that may require a copay and members who are responsible for copays, see the MaineCare Member Handbook (PDF). To see what you may pay for a copay for services and prescription drugs, see the MaineCare Member Copayments (PDF).
Premiums
A premium is a fee that some members pay to have MaineCare coverage. For some MaineCare programs, if you are over the income level for MaineCare, you may have the option to pay a premium for MaineCare coverage. You will know if you must pay a premium for coverage because you will get a letter. Examples of programs with members who are responsible for premiums are the Katie Beckett program and the Children’s Health Insurance Program (CHIP).
Cost of Care
If you live in a medical facility, you may have to pay for a portion of your care. The Cost of Care is the amount you pay towards your care at the medical facility. Members who pay a cost of care usually live in a nursing facility, residential care facility, cost-reimbursed boarding home, or an adult family care home.
What is a Prior Authorization?
Before you can get some services or equipment, MaineCare must approve it. This approval is called Prior Authorization (PA). Your provider sends a form to MaineCare and we will send you and your provider a letter to let you know if the service or medical equipment is approved. If you get the service or the medical equipment without MaineCare’s approval, you may have to pay the bill.
Examples of services and medical equipment that need PA:
- Some prescription drugs
- Some mental health services
- Some surgeries
- Most medical supplies and medical equipment that cost over $699.99
- Hearing aids
- Most out-of-state services
- Some eye care services
- Some dental services, especially for adults
- All services to straighten teeth
- Some physical therapy, occupational therapy, and speech therapy
- Inpatient treatment at an in-state psychiatric hospital
- Out-of-state and some in-state transportation services
- Some home care services
- Some ambulance services
For questions about a PA for a prescription drug, call the Pharmacy Help Desk at Pharmacy Help Desk at 1-866-796-2463. Call MaineCare Member Services at 1-800-977-6740 for questions about all other services.
How do I find out more about covered services?
See the MaineCare Options to learn more about your coverage group.