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MaineCare Deductible:

How Does It Work?

Can you explain the MaineCare Deductible?

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If your income is too high for regular MaineCare, you may be eligible for MaineCare with a deductible.  (This used to be called a "Medicaid spend-down.") For example, your Social Security or Veterans Benefits put you over the maximum income levels for full MaineCare coverage.

Note: "Non-categorical adults" (non-disabled without children) who are over-income cannot get this coverage.

Here is how the deductible works:

1. You will get a notice from the state telling you that you are not eligible for MaineCare.
   
2. The notice will tell you that MaineCare can help you if your medical bills for a 6-month period are over a certain amount. This is called the "deductible."

Do I actually have to spend all that money before MaineCare can help me?

No. You have to have medical bills that total at least the amount of the deductible. You do not have to have paid the bills.

Will Medicaid pay the deductible once I meet it?

No. Medicaid will not pay the deductible. That is your responsibility. Sometimes you can get "free" care or "charity" care from the hospital which can pay for your bill.

Which Bills Will MaineCare Pay for Me?

MaineCare will pay almost all the bills that any insurance, such as Medicare, does not pay. However, MaineCare will only pay those bills you have after you meet the deducible.

Here is how it works:

Let's say your MaineCare deductible is $5,000 for January 1st through June 30th. You go into the hospital on January 1st. You get out on January 8th. You then have other medical bills, like prescriptions, physical therapy, or anything else. All your bills come to $8,000.

You bring all your bills (including any old medical bills from before January 1st that are unpaid) into your MaineCare worker. MaineCare then looks to see on which date did your bills total $5,000 (your deductible amount).  Say your hospital bill shows that by January 6th your bills totaled $5,000. MaineCare will then tell you that MaineCare will pay for all your medical bills for services after January 6th. (Remember that if Medicare pays some or all of the $5,000, then MaineCare will not count that toward your deductible. If the hospital gives you "free" care, then whatever the hospital gives to you does count toward your $5,000 deductible.)

MaineCare will then pay for all your medical bills for medical services that you get from January 6th until the end of June.

What should I do if I know that I am going to have a big medical expense?

Sometimes it is better to have a MaineCare deductible for one month, instead of for 6 months. Here is how it works.

If you know that you are going into the hospital on February 1st for an operation and that you won't have any big medical expenses after the month of February, then it is usually better to reapply for MaineCare in March.

When you reapply in March you will only have a 1 month deductible (for February) which is smaller than a 6 month deductible. The only downside is that MaineCare will only cover the past medical expense (once you meet your deductible) and will not cover future medical expenses.

What Should I Do If I have Old Unpaid Medical Bills?

It is important that you tell your MaineCare worker if you have any old unpaid medical bills. These bills can sometimes be used to meet your deductible.

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The MaineCare deductible is complicated. Contact Pine Tree Legal Assistance if you have any questions!

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