MaineCare is Maine’s Medicaid service, providing free and low-cost health insurance to Mainers who meet certain requirements, based on household composition and income. This page discusses what and how MaineCare provides coverage for for transgender Mainers who qualify for this program.
In 2018, Governor Mills removed exclusions to transgender care from MaineCare, and MaineTransNet participated in the rules-making for the changes in 2019. These changes bring MaineCare policy into alignment with the professional medical community and into compliance with both state and federal law, including the Affordable Care Act.
Under the new rule, medical providers will be reimbursed for providing MaineCare covered services to treat patients with gender dysphoria, a clinical diagnosis. Coverage for medically necessary surgical services related to gender dysphoria will require prior authorization. Gender dysphoria is a conflict between a person’s gender identity and the sex assigned to that person at birth. The American Psychiatric Association says it is often accompanied by extreme distress, which can interfere with the ability to function in everyday life.
The relevant portion of Maine law that determines this coverage can be found here.
What is Covered
Criteria for determining medically necessary care is based on consensus professional medical standards, such as the Standards of Care (SOC) of the World Professional Association for Transgender Health (WPATH).
Actually Covered
- Hormone Replacement Therapy (HRT).
- “Bottom Surgeries” such as Hysterectomy, orchiectomy, neovaginalplasty, phalloplasty, metoidioplasty.
- “Top” Surgeries such as mastectomy and breast augmentation.
Theoretically Covered
As the policy uses WPATH guidelines, if you can theoretically argue for the medical necessity of a procedure using those guidelines, you are welcome to try and can reach out to us to talk about possible paths. Some common procedures that are theoretically covered are: Facial Feminization Surgery (FFS), Tracheal Shave, Body Contouring, Vocal Chord Augmentation.
Electrolysis is often required for surgeries, but is not explicitly or actually covered under MaineCare right now. Some people have had success pursuing surgeries at Mass General or at Dartmouth Hitchcock, which have included the required Electrolysis for a procedure into the billable costs to MaineCare.
Prior Authorization
All surgeries covered through MaineCare require Prior Authorization with MaineCare from the surgeon’s office. In addition, the documents for referral are collected and sent through the referring provider, such as your Primary Care Practitioner. You need a Primary Care Practitioner on file at the MaineCare office for this to work.
Out-of-State Care and MaineCare
In the case of a covered procedure not available by any specialists in Maine, MaineCare will theoretically cover the costs of surgeons out-of-state who do them, as long as they are willing to file the paperwork with MaineCare. In this case, the Pre-Authorization paperwork is filled out by the out-of-state surgeon’s office, but the referring provider (like your PCP), will be the one to do the actual referral. In addition to the usual MaineCare paperwork, your PCP will also need to submit an “Out-of-State Exception Request.”
This process often runs into hiccups, as MaineCare will often challenge the exception request, asking why this procedure needs to be done out-of-state. While annoying, this sort of pushback has been successfully resolved before.
Again, you need a PCP on record with MaineCare, and they need to do the referral for your surgery with MaineCare.
Appeals process for MaineCare
MaineCare has many avenues of receiving paperwork from your PCP and surgeon, such as faxing, certified mail, email, or through the MaineCare portal if being submitted by your PCP.
IF YOU RECEIVE A LETTER OF DENIAL, please know that MaineCare cannot make a permanent denial, and that a letter of denial can be viewed more as an invitation to argue the decision. If you would like help with this, please contact:
To appeal a decision by MaineCare, we suggest you follow the method laid out in the letter of denial. We also suggest that before you do that, you (or your PCP) can and should call MaineCare to inquire as to the specific details of the denial.
Paperwork Requirements and Sample Letters