Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Created 1/1/10

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Sample Medicaid Card - Louisiana (LA)

Created 1/1/10

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Sample Medicaid Card - Maine (ME)

This card is not proof of eligibility,
Verify eligibility before providing services.

Important Information - If found, please destroy this card.

If you are a Member: Keep this card with you at all times. You must show this card to providers to get
MaineCare services. Contact your eligibility worker at the Department of Health and Human Services (DHHS)
office nearest your home if the information on this card is wrong or if this card is lost, stolen or damaged. For
questions about covered services or managed care, contact MaineCare Member Services at 1-800-977-6740,
press option 2 or if you are deaf or hard of hearing and have a TTY machine, call 1-800-977-6741.

If you are a Provider: Providers without point of service eligibility verification systems will need to call the
MaineCare member eligibility Voice Response System to verify eligibility. In Maine call 1-800-452-4694, outside
Maine call 1-207-287-3081. Office of MaineCare Services, DHHS, 11 State House Station, Augusta, Maine 04333­
0011.

Out-of-state requests require prior authorization before rendering services. For any Out-of-state emergency
services contact MaineCare’s authorized agent within one business day of providing services at 1-866-543-2387.t

Created 1/1/10

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Sample Medicaid Card - Maryland (MD)

Created 1/1/10

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Sample Medicaid Card - Massachusetts (MA)

Created 1/1/10

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Sample Medicaid Card - Michigan (MI)

Created 1/1/10

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Sample Medicaid Card - Minnesota (MN)

Created 1/1/10

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Sample Medicaid Card - Mississippi (MS)

Created 1/1/10

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Sample Medicaid Card - Missouri (MO)

Created 1/1/10

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Sample Medicaid Card - Montana (MT)