MaineCare Deductible: How Does it Work?

Can you explain the MaineCare Deductible?

If you are:

• elderly,
• disabled,
• pregnant,
• a minor under 21,
• a person under 26 who aged out of foster care with MaineCare, or
• a parent but your income is too high or you have too many assets for regular Maine Care,

you may be eligible for MaineCare with a deductible. This is called the “Spend Down” or “Deductible” program. 

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. These bills can be very old bills, not just new 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.

Be sure to apply for hospital free care only after you have met your MaineCare deductible. If the hospital gives you free care before you show your bill to MaineCare, then you will not meet your deductible.

Which bills will MaineCare pay?

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. Then MaineCare looks to see on which date your bills totalled $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.

Maine Consumers for Affordable Healthcare say that ‘if you expect a big bill soon, you should apply for the deductible after you get the big bill. This is called a “retroactive” deductible meaning it goes back in time. A deductible going back in time is smaller and easier to meet. But, MaineCare coverage from it ends faster than the usual MaineCare deductible.’ Read the full MCAH information sheet about MaineCare Deductibles.  

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.

How Can I have some idea of what my MaineCare Deductible will be?

Basically, MaineCare takes your monthly “countable” income and subtracts what is called the Protected Income Level or PIL. The PIL is based upon your family size. Use the chart below to see the PIL for your family size. Once they get this number, they multiply it times 6 to get a 6 month deductible.

For example, you are a household of 1 person. Your income is $1100 per month. The PIL for 1 person is $315. So, $1100 less $315 = $785. Multiply this by 6 to get a 6-month deductible or spend-down of $4710.

Protected Income Chart

Contact Pine Tree Legal Assistance if you have any questions.

Updated 1/2023
PTLA # 517