MaineCare, the state’s Medicaid program, covers a wide range of medically necessary health care for enrolled members: primary and preventive care, hospital and emergency services, prescription drugs, dental care for adults and children, behavioral health and substance use treatment, vision exams, hearing aids, rehabilitative therapies, long-term care, non-emergency transportation to appointments, pregnancy and family planning services, and gender-affirming care. Some services need prior approval, a short list of items is excluded outright, and copays apply to certain services depending on which coverage group you fall into. The specifics are below.
Doctor Visits, Hospital Care, and Everyday Medical Services
Members with full MaineCare benefits can see a primary care doctor for routine visits, annual physicals, and immunizations, including COVID-19 vaccines. Preventive screenings such as pap smears, mammograms, and prostate screenings are covered.1Maine DHHS. Covered Services and Benefits
Hospital services include inpatient stays, outpatient procedures, and emergency room visits. Emergency department visits carry no copay. Lab work and X-rays are covered when medically necessary.1Maine DHHS. Covered Services and Benefits
Emergency ambulance transportation to a hospital is covered, along with emergency medical services provided at the scene. Air ambulance and certain specialized transports are classified as restricted services with additional conditions.2Maine Secretary of State. MaineCare Benefits Manual, Section 5 – Ambulance Services
Telehealth visits are covered and reimbursed at the same rates as in-person visits, so you can see a provider remotely for most services your plan would otherwise cover in an office.3Maine DHHS. Billing Reminder When Services Are Rendered via Telehealth
Prescription Drugs
Full MaineCare members get prescription drug coverage. The program keeps a Preferred Drug List that splits medications into two tiers. Preferred drugs usually don’t require prior authorization. Non-preferred drugs do, meaning your prescriber must request and receive MaineCare approval before the pharmacy can fill the prescription.4MaineCare PDL. Preferred Drug Lists1Maine DHHS. Covered Services and Benefits
You can avoid prescription copays altogether by using a MaineCare-approved mail order pharmacy, which delivers 90-day supplies of most generic and brand-name medications at no cost. Picking up prescriptions in person may trigger a copay, depending on your coverage group.1Maine DHHS. Covered Services and Benefits
Dental Coverage
Children under 21 are covered for routine checkups, cleanings, fluoride treatments, X-rays twice a year, fillings, and any additional dental care a dentist deems medically necessary.1Maine DHHS. Covered Services and Benefits
Adults have had comprehensive dental coverage since July 1, 2022. Covered adult services include oral exams and X-rays, cleanings and fluoride treatments, fillings, crowns, root canals, gum surgeries, dentures (complete, partial, and immediate, plus repairs), extractions, removal of tumors or lesions, sedation, and night guards. Some adult services require prior authorization, and all orthodontic treatment must be approved before it begins.1Maine DHHS. Covered Services and Benefits
Mental Health and Substance Use Treatment
Behavioral health coverage is extensive for both adults and children. Adult services include outpatient individual, family, and group therapy; psychological assessments; medication management; partial hospitalization for mental health and substance use disorders; and inpatient psychiatric care. Community-based supports include assertive community treatment (intensive 24/7 care), community integration, rehabilitative skill development, and daily living support.5Acentra Health. Adult Behavioral Health Services
For children and youth, MaineCare covers outpatient mental health treatment, crisis services (reached at 1-888-568-1112), medication management, home and community-based treatment for youth with serious emotional disturbances, functional family therapy, multi-systemic therapy, residential treatment, and applied behavioral analysis for children with autism spectrum disorder.6Maine DHHS OCFS. MaineCare Behavioral Health Services for Children
Substance use disorder treatment is covered across the full continuum of care. That includes outpatient counseling, residential and inpatient programs, medication-assisted treatment (methadone through opioid treatment programs and buprenorphine prescribing), and withdrawal management at all clinical levels.7Medicaid.gov. Maine SUD Care Initiative Midpoint Assessment Opioid Health Homes combine medication, counseling, care coordination, drug screening, and peer recovery support for people with opioid dependency.5Acentra Health. Adult Behavioral Health Services Tobacco cessation counseling, nicotine patches, and gum are covered with no copay.1Maine DHHS. Covered Services and Benefits
Vision and Hearing Aids
Eye exams are covered. Some additional eye care services may require prior authorization.1Maine DHHS. Covered Services and Benefits
Hearing aid rules differ sharply by age. Children under 21 can receive two digital hearing aids without prior authorization and can get annual replacements if medically necessary. Adults 21 and older qualify for one hearing aid if their hearing loss is between 41 and 90 decibels. A second hearing aid is covered only if the loss is bilateral and the person is employed, enrolled in a training program, or legally blind. Adult hearing aids need prior authorization and can only be replaced every five years unless there is a documented medical reason for earlier replacement. MaineCare also covers six replacement batteries per month.8Maine Equal Justice. Getting Hearing Aids Through MaineCare
Physical, Occupational, and Speech Therapy
MaineCare covers physical therapy, occupational therapy, and speech therapy, with specific eligibility rules.
For adults, physical and occupational therapy are generally covered after an acute hospital stay or surgery (within six months of discharge), for people who have needed extensive help with daily activities such as eating or mobility in the past 30 days, or for maintenance care to prevent functional decline. All services must be medically necessary and the treating provider must document rehabilitation potential.9Maine Secretary of State. MaineCare Benefits Manual, Section 85 – Physical Therapy Occupational therapy sessions are capped at two hours per day.10ED Data Solutions. Section 68 OT FAQs
Speech therapy requires assessed rehabilitation potential or medical necessity to prevent significant decline in oral communication, swallowing, or chewing. Members are limited to one initial evaluation per provider per year and one reevaluation every six months. Maintenance or palliative physical and occupational therapy are limited to one visit per year for plan-of-care design or reassessment. Psychological services are capped at 16 one-hour visits per year, with the possibility of an increase to 24 visits through prior authorization.11Maine State Legislature. Title 22, Section 3174-FF
Chiropractic evaluation and management services from a licensed chiropractor are reimbursable, though existing visit limits still apply.12Maine Legislature. Public Law Chapter 421
Gender-Affirming Care
MaineCare covers medically necessary gender-affirming treatment for members with a clinical diagnosis of gender dysphoria, using the World Professional Association for Transgender Health standards to determine medical necessity. Covered services include hormone therapy, puberty blockers, electrolysis, behavioral health services, and a range of surgeries including chest surgery, facial procedures, and genital reconstruction. All gender-affirming surgeries require prior authorization and appropriate documentation from a medical or behavioral health provider. If a needed surgery isn’t available in Maine, prior authorization can facilitate out-of-state care.13OUT Maine. Gender-Affirming Care Guide
Long-Term Care and Help at Home
MaineCare pays for care in nursing facilities and residential care facilities. It also covers home and community-based services designed to help older adults and people with physical disabilities stay out of a nursing home for as long as possible.14Maine DHHS. Long-Term Care Services Home-based services include personal care, nursing services, home-delivered meals (Meals on Wheels), personal emergency response systems, respite care, assistive technology, environmental modifications, and homemaker services.15Maine DHHS. Home Care
The Section 19 waiver serves adults 18 and older who meet nursing facility level-of-care requirements but choose to stay at home. Waiver services include care coordination, personal support, home health, adult day health, transportation, emergency response systems, environmental modifications, and respite.16Cornell Law Institute. Maine Regulations, Section 19 Waiver Eligibility requires a functional assessment, which can be arranged by calling 1-833-525-5784.15Maine DHHS. Home Care
Members living in nursing homes or residential care facilities may be required to pay a portion of their care costs, called the “Cost of Care,” based on their income.1Maine DHHS. Covered Services and Benefits
Rides to Medical Appointments
MaineCare covers non-emergency transportation for members who have no other way to get to covered medical appointments. You schedule rides through a regional transportation broker, and requests should be made at least two business days before the appointment. Options include arranged rides, mileage reimbursement if you drive yourself, and standing orders for recurring appointments. Urgent appointments don’t require the two-day lead time.17Maine DHHS. MaineCare Transportation
Pregnancy, Family Planning, and Children’s Benefits
Full MaineCare members receive family planning services as part of their standard coverage, with no copay for family planning services or supplies.1Maine DHHS. Covered Services and Benefits For people who don’t qualify for full MaineCare, a Limited Family Planning Benefit is available to those earning up to 209% of the federal poverty level who are not pregnant.18Cornell Law Institute. Limited Family Planning Benefit Regulations
Postpartum coverage was extended to 12 months after pregnancy ends, effective August 1, 2022. Pregnant people found presumptively eligible by a health care provider get prenatal coverage for up to 60 days, during which they must apply for full MaineCare to continue coverage through the rest of the pregnancy.1Maine DHHS. Covered Services and Benefits19Maine DHHS. Limited Benefits
Children under 21 are covered through VitalCare for Kids, Maine’s version of the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. It covers well-child exams, immunizations, lead screenings, and any medically necessary equipment or services that might not normally be covered for adults. In practice this gives children a broader safety net than adult members have, since EPSDT can authorize services outside the standard benefit package when a child’s health requires it.1Maine DHHS. Covered Services and Benefits
The Katie Beckett program covers children under 19 with disabilities whose families earn too much for standard MaineCare. Only the child’s own income and assets count, and enrolled children receive full MaineCare benefits for a low-cost monthly premium.20CoverME.gov. Guide to MaineCare Programs
What MaineCare Does Not Cover
Excluded services include acupuncture, cosmetic surgery, experimental procedures or drugs, health club memberships, and massage therapy.1Maine DHHS. Covered Services and Benefits
What You May Pay Out of Pocket
Whether you owe a copay depends on your coverage group and the service. As of October 1, 2024, MaineCare reinstated certain copayments that had been suspended during the COVID-19 public health emergency.21Maine DHHS. Updates to MaineCare Member Copayments Several categories remain copay-free regardless of coverage group:
- Emergency department visits
- Family planning services and supplies
- Hospice services
- Oxygen and oxygen equipment
- Tobacco cessation services and products
- Mail-order prescriptions (90-day supply)
- Services at Indian Health Service Centers
Some members also owe a monthly premium, particularly those in the Katie Beckett program or other specific coverage groups with income above standard MaineCare thresholds.1Maine DHHS. Covered Services and Benefits
Services That Need Prior Approval
Prior authorization is required for a specific set of services, including some surgeries, inpatient psychiatric hospital stays, medical equipment costing more than $699.99, hearing aids for adults, most out-of-state services, and orthodontic treatment. If you receive a service that needed prior authorization without getting approval first, you may be personally responsible for the cost.1Maine DHHS. Covered Services and Benefits Non-preferred drugs, adult dental services beyond the basics, additional eye care, and gender-affirming surgeries also require prior authorization as described above.
Changes Coming to MaineCare
H.R.1, the federal budget reconciliation law signed on July 4, 2025, brings significant changes starting in late 2026 and into 2027. As of mid-2025, no changes had taken effect, and members were advised to continue scheduling appointments and filling prescriptions as usual.22Maine DHHS. How Recent Federal Updates Affect MaineCare Upcoming changes relevant to coverage include:
- Work requirements effective December 31, 2026, requiring roughly 90,000 expansion adults to log 80 hours per month of work, volunteering, or half-time schooling.
- Eligibility renewals shortened from annually to every six months as of January 1, 2027.
- Elimination of federal Medicaid funding for refugees, asylees, trafficking survivors, and certain parolees as of October 1, 2026. Coverage for children and pregnant individuals is unaffected.
- Retroactive coverage reduced to one month for expansion adults and two months for others, effective January 1, 2027.
Congress has also prohibited Medicaid funds from going to Planned Parenthood of Northern New England and Maine Family Planning, though both organizations were continuing to see MaineCare members in the near term as of July 2025.22Maine DHHS. How Recent Federal Updates Affect MaineCare For specific questions about what’s covered under your plan, MaineCare Member Services can be reached at 1-800-977-6740 (TTY 711), and the Pharmacy Help Desk is at 1-866-796-2463.1Maine DHHS. Covered Services and Benefits