Limitations on Cost-Sharing

Some MaineCare members may be required to participate in cost-sharing for covered services they receive. Consistent with federal requirements, cost-sharing incurred by all individuals in a MaineCare household may not exceed an aggregate limit of 5% of the household’s monthly income.

The Office of MaineCare Services (OMS) tracks cost-sharing expenditures to identify when a household has reached the monthly maximum. OMS will send letters to notify members when they have reached their cost-sharing maximum.

Impact on MaineCare Enrolled Providers

Providers must:

  • document the amount of copayment charged to each member regardless of whether the member made payment as required by MaineCare Benefits Manual (MBM) Chapter I, Section 1.09-1(C); and
  • refund members for any overpaid copayments.

MaineCare is currently upgrading MIHMS, its claims processing system. Until the upgrade is complete, providers who elect to request a claim adjustment due to a copayment issue have the option to submit a completed MaineCare Adjustment Request Form to the address listed on the bottom of the linked form. We will send another message when there is updated information.

Please note: Per MBM Chapter I, Section 1.09-1(B), providers may not deny services to members who cannot pay their copayment. Members remain liable for the copayments even if they cannot pay immediately.

Impact on MaineCare Members

When MaineCare members reach their monthly out-of-pocket maximum, OMS will send a letter advising them they are not subject to cost-sharing for the remainder of the month. In this letter, OMS will direct members to contact their provider for a refund of any copayments paid after they reached their out-of-pocket maximum.

This notice is sent pursuant to 42 CFR 447.56.

For questions, please contact your Provider Relations Specialist.