What does MaineCare Cover?
Health care services covered by full-benefit MaineCare include:
- Well-child check-ups
- Sick care
- Specialist care, including surgery Prenatal care
- Full coverage for children (with limits for adults)
- In-patient, outpatient, and emergency room
- Coverage for care in a nursing home, assisted living center, or other residential care. Services may also be provided in the home.
- Speech therapy
- Physical therapy
- Occupational therapy
- Shots to prevent illness (immunizations)
- Prescription drugs
- Mental health services
- Lab tests and x-rays
- Ambulance services
- Family planning
- Eye exams and eye glasses (with limits for adults)
- Substance abuse services
- Medical equipment and supplies
- Chiropractic care
- School-based health centers
- Transportation to medical and counseling appointments
- Hearing tests (with limits for adults) and hearing aids (for children age 20 and younger)
Early and Periodic Screening, Diagnosis and Treatment:
Federal Medicaid law requires States to cover Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children and adolescents under age 21. EPSDT covers four separate screening services- medical, vision, hearing and dental- and includes immunizations, laboratory tests (including lead blood tests), and health education. Each type of screening must be furnished at pre-set, periodic intervals (periodic screens) and when a problem is suspected (interperiodic screens).
The treatment component of EPSDT must include any necessary health care, diagnostic services, treatment, and other measures, described in section 1396d(a) of the Medicaid Act, to “correct or ameliorate” physical and mental illnesses and conditions, whether or not such services are covered for adults in the state’s Medicaid program. EPSDT also includes outreach and informing to notify children and their families of EPSDT and the importance of preventative care, and to offer appointment scheduling and transportation assistance, if needed.
If a service that a child under age 21 needs is for some reason not available under MaineCare, or if the child requires more services than MaineCare may cover, then the child’s provider can file with the Office of MaineCare Services, a request for Prior Authorization for what is called “Optional Treatment- EPSDT Services.”
This is just a partial list of services covered by full-benefit MaineCare. It is important to note that all children with MaineCare receive the same full-benefit coverage, whether their coverage is through the CHIP program (the children whose families pay a monthly premium) or through straight Medicaid, which includes the Katie Beckett program. For more information, call MaineCare Member Services at 1-800-977-6740 (if you are deaf or hard of hearing and have a TTY machine, call 1-800-977-6741).
Important note about copayments: Except for small copayments, doctors and other health care providers cannot charge members in addition to the payments they get from MaineCare. There are no copayments for services provided to children. If a MaineCare member cannot afford to pay a copayment, the provider must still provide the service. The provider may bill the member, but may not deny services in the future due to non-payment of copayments.