Covered Services & Benefits

MaineCare pays for medically necessary services based on your coverage group, which is determined by your income, household size, age, medical needs, and if you need help with Activities of Daily Living. Each coverage group has different covered services and benefits, and there are limits or special rules for most covered services.

This page provides information about:

• What services MaineCare does and does not cover
• Pharmacy Benefits
• How to find out if a service is covered by MaineCare
• Examples of coverage groups
• Prior Authorizations
• Cost sharing

What services are covered?

Some examples of services that may be covered by MaineCare include:

• Doctor visits
• Prescription medications
• Behavioral health services
• Gender affirming care services, such as hormone therapy or surgery
• X-rays and labs
• Emergency and hospital visits
• Dental services
• Annual physical exams
• Immunizations, also called vaccines or shots (including COVID-19 vaccines)
• Pap smears
• Mammograms
• Prostate screenings
• Eye exams

To learn more about covered services, visit our MaineCare Options page.

Examples of Covered Preventive Service

Children and Young Adults

Well-Child Exams

Well-Child Exams are covered by MaineCare. Your child’s health care provider will check to see if your child is healthy, and give immunizations (also called vaccines or shot) and tests (like lead screenings) if needed. Children can also get optional treatment services. Optional treatment services are medically necessary services or equipment that may be needed to prevent illness or injury to a child. For more detail, see the Well-Child Visit Pamphlet (PDF).

Oral Health

MaineCare covers preventive dental care for children. Your child’s teeth and gums are checked to make sure they are healthy. Your child should go to the dentist for well-child visits starting by age one or younger. Examples of preventative dental care include:

• Teeth cleanings and routine checkups
• Twice a year X-rays and fillings
• Fluoride treatments
• Other care the dentist says is necessary

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program

Children and young adults who are under age 21 who have MaineCare are part of the EPSDT program. EPSDT is designed to ensure children and young adults receive early detection and treatment to address health problems as soon as possible. For more details, please visit our Children’s webpage.

Adult Dental Services

As of July 1, 2022, all individuals over age 21 years old have access to comprehensive dental coverage.

What services may be covered?

• Diagnostic services, such as oral evaluations and X-rays
• Preventive services, such as cleanings, flouride, and tobacco and substance use counseling
• Restorative services, such as fillings and crowns
• Endodontic services, such as root canals
• Periodontic services, such as various gum surgeries and cleanings that occur below the gums
• Complete, partial, and immediate dentures and denture repairs
• Oral surgeries, such as tooth extractions and removal of tumors and lesions
• Adjunctive services, such as sedation and night guards

To find a dental provider that accepts MaineCare, please call MaineCare Member Services at 1-800-977-6740.

Quitting Tobacco

If you want to quit tobacco, MaineCare can help!

MaineCare may cover these services to help you quit:

Tobacco treatment counseling services Nicotine replacement options like the nicotine patch or gum Doctor visits

See the Tobacco Cessation (PDF) for more information about how we can help.

• Tobacco treatment counseling services
• Nicotine replacement options like the nicotine patch or gum
• Doctor visits

If you're ready to quit, you can call or visit

• The Maine QuitLink at 1-800-QUIT-NOW or mainequitlink.com to get free help with your quit plan.
• Your doctor for help finding services and determining which products might be best for you.

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 1-866-796-2463. TTY users, dial 711 for Maine Relay.

Pharmacy Benefits

When you have full MaineCare coverage, you can get prescription drugs paid for with your pharmacy benefit.

Preferred Drug List

See https://www.mainecarepdl.org for a list of medications your doctor can prescribe. Drugs listed as “Preferred” generally do not need a PA. Drugs listed as “Non-Preferred” will need a PA from your provider.

Copayments

You may need to pay for part of the cost of your prescription drug. What you pay is called a copayment, or copay.

For more information about PAs, see the "What is a Prior Authorization?" section below. To see what you may pay for a copay for your prescription drug, see the "Copayments" section below.

Mail Order Pharmacies

You can get brand name or generic drugs from mail order pharmacies that are approved by MaineCare. Mail order saves you time and money. You can get a 90-day supply of most generic and brand name drugs delivered to your mailbox. When you order drugs through the mail you will not be charged a copay.

If you have prescription drug questions, please contact the Pharmacy Help Desk: 1-866-796-2463. TTY users dial 711.

Discount Drug Programs

To apply for one of the below discount drug programs, complete an application online with the Office for Family Independence at MyMaineConnection.gov. You can also visit one of the District Offices and apply in person.

Drugs for the Elderly and Disabled

This discount drug program is for individuals who are age 62 and older or have a disability and are over the income level for MaineCare. You may get up to 80% off the cost of your prescription drugs. You may also have to pay a $2.00 copayment.

Maine Rx Plus

If you are over the income level for MaineCare, you may get a discount on some prescription drugs. If you are eligible, you may save up to 60% on generic drugs and up to 15% on name brands.

Questions

For prescription drug benefits, medication PAs, and Medicare Part D questions, call the Pharmacy Help Desk: 1-866-796-2463. TTY users dial 711.

Coverage Groups

MaineCare offers coverage options for:

• Adults
• Children
• Older Adults and Adults with Disabilities
• People who require Limited Benefits

For more information about all available coverage options, visit the Office for Family Independence’s Health Care Assistance webpage.

Coverage for Individuals without Citizenship

Beginning July 1, 2022, people who are pregnant or under 21, with or without citizenship, are now eligible for full MaineCare coverage. This Frequently Asked Questions (FAQ) document provides more information about MaineCare coverage for individuals with or without citizenship documentation.

Postpartum Coverage

Effective August 1, 2022, MaineCare extended postpartum coverage to 12 months after the pregnancy ends. This coverage is automatically applied to current MaineCare members and ensures that no one loses access to care during the postpartum period. For more detail, see the Postpartum Coverage Flyer (PDF).

What is a Prior Authorization?

Before you can get some services or equipment, MaineCare must approve it. This approval is called a 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 1-866-796-2463. Call MaineCare Member Services at 1-k800-977-6740 for questions about all other services.

Will 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 your prescription drug. What you pay is called a copayment, or copay.

For more information about PAs, see the “What is a Prior Authorization?” section below. To see what you may pay for a copay for your prescription drug, see the “Copayments” section below.

Premiums

A premium is a monthly 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 to pay a premium for MaineCare coverage. You will know if you must pay a premium for coverage because you will get a letter from the Office for Family Independence. And example of a program with members who are responsible for premiums is the Katie Beckett program.

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 toward 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.