MaineCare Guidance for Out-of-State Births

Oct 10, 2023

MaineCare covers births and newborn care at out-of-state hospitals in most circumstances. Please see clarification below in response to questions from out-of-state providers about the process for submitting birthing claims to MaineCare.

Births and newborn care occurring at hospitals located within 15-miles of the Maine/New Hampshire border are covered without Prior Authorization (PA) from MaineCare when the provider is enrolled in MaineCare. PAs are not required of border hospitals for any service unless the service itself requires a PA in-state. All other out-of-state providers are required to request PAs prior to supplying all services except in urgent or emergency situations.  

When there are urgent transfers, the receiving hospital should submit to MaineCare for emergency admission as soon as possible. Out-of-state MaineCare enrolled providers may submit a PA through the Health PAS portal for urgent transfers. Providers who are not already enrolled in MaineCare may contact Provider Relations for assistance. MaineCare will defer to the provider to decide if the member’s urgent needs can be met in Maine. Whenever possible, providers should refer members to in-state hospitals for care. Services delivered out-of-state are subject to medical review for medical necessity and a decision of whether the services were available in Maine. If babies are transferred out-of-state for urgent care, any follow-up care should then be provided by an enrolled provider located in Maine. 

When a member presents to an emergency room out-of-state for an unplanned delivery, this is considered an emergency admission and MaineCare will approve it as such.

If you have questions about births and newborn care, please contact your Provider Relations Specialist.