Who counts as a household member for MaineCare eligibility?
Executive summary
Household membership for children-and-pregnant-people">MaineCare is determined primarily by MAGI-based (Modified Adjusted Gross Income) rules that group people by tax-filing relationships and who lives together for purposes of counting income and household size, but Maine also applies different constructions for specific categories like pregnant people, children, transitional MaineCare, and long‑term care where different household definitions or asset tests may apply [1] [2] [3]. Applicants should expect that whether a person is a tax filer, is claimed on another’s taxes, or was included in a prior MAGI eligibility determination will materially change whose income and needs are counted [1] [2] [3].
1. MAGI-based households: the baseline rule that governs most adults and families
For most MaineCare coverage groups, household size and income are defined under MAGI rules, meaning the “household” is built from tax relationships — who files taxes together or who is claimed as a dependent — and countable income is assigned to that MAGI assistance unit when deciding eligibility and premiums [1] [2]. State guidance and the Department of Health and Human Services confirm that household composition and tax filing status must be considered to determine eligibility for each person applying, so an adult who files taxes separately from a spouse or who is not claimed by parents may be evaluated on individual income while others are grouped [1] [4].
2. Tax filers, non‑filers, and people “not claimed” — how income gets allocated
Maine’s rules instruct eligibility workers to categorize applicants by whether they are tax filers, are claimed as dependents, or are “not claimed” on another’s return; a person who is a household of one has only their own income counted, whereas those who are part of a tax household have combined incomes considered for MAGI categories [2] [5]. Advocacy materials and eligibility guides emphasize that an applicant’s household size is not always the physical people living under one roof but is constructed for assistance unit purposes, which can result in different household sizes for different coverage groups [2] [5].
3. Pregnant people and fetuses: explicit counting that raises the household size
Pregnancy changes the household calculus: income guidelines for pregnant people are higher and the fetus or fetuses are explicitly counted as household members for determining household size and income eligibility under pregnancy categories [6] [7]. Consumers for Affordable Health Care and Maine’s eligibility tables note that pregnancy increases the applicable household size for income thresholds, producing different income limits than for non‑pregnant adults [6] [7].
4. Children, young adults, and immigration‑status exceptions
Children and young adults under 21 have separate, often more generous household income thresholds and in many cases can qualify regardless of immigration status, with guidance indicating that family income and household composition still play a role but that special rules expand coverage for youth [8] [6]. Maine’s outreach and legal‑aid resources explain that children’s eligibility can be evaluated at higher family income levels than adults and that unclaimed young adults may apply using only their own income in some situations [8] [6].
5. Transitional MaineCare and carry‑over household membership
When MAGI coverage ends, Transitional MaineCare (TM) relies on the household composition used at the time of MAGI eligibility; TM household membership includes those whose needs and income were included in the MAGI determination at closing, meaning prior inclusion can persist for continuity purposes [3]. The state regulation cited clarifies that TM households are determined using MAGI household composition rules and that members included at termination remain part of the TM unit even amid other changes [3].
6. Long‑term care and non‑MAGI categories: different constructions and asset considerations
Long‑term care MaineCare and other non‑MAGI categories (for example, elderly or disabled institutional care) use different financial tests — including asset limits and “spend down” rules — and household membership for those programs can be governed by separate rules that focus on the applicant and sometimes the spouse’s resources rather than MAGI tax units [9] [10]. External guidance and long‑term care overviews highlight that for nursing home or ABD (aged, blind, disabled) coverage, asset and income rules — including allowable personal needs allowances and spousal calculations — drive eligibility rather than MAGI household composition [9] [10].
7. Practical implications and where to get authoritative determinations
Because MaineCare applies different household constructions across MAGI categories, pregnancy, youth, transitional coverage, and long‑term care, claimants should expect that the same person could be counted differently depending on which program is at issue, and the Office for Family Independence is the authority that processes applications and determines eligibility [1] [4] [3]. For case‑specific answers, Maine publishes detailed eligibility guidelines and state helplines and legal aid groups (Consumers for Affordable Health Care, Maine Equal Justice, Pine Tree Legal) provide assistance and worksheets to calculate household size and countable income [1] [8] [11].