C.M.R. 10, 144, ch. 272, III

Current through 2024-51, December 18, 2024

Chapter III - ELIGIBILITY REQUIREMENTS

To be certified as eligible for the Coordinated Care Services for Children with Special Health Needs Program, applicants must meet all of the following requirements.

A. Reside in Maine.

B. Be under the age of 18 unless otherwise specified.

C. Diagnostic Eligibility: approval for a consultation or evaluation to establish a diagnosis or rule out a suspected disease or condition upon primary care referral and receipt of application to the C.C.S./C.S.H.N. Program.

D. Medical Eligibility: verification by the physician consultant of the following criterion as outlined in Chapter VI, "Conditions and Components of Care":

1. restricts physical functioning or causes developmental delays in accordance with C.C.S./C.S.H.N. policy;

2. requires a level of health care beyond routine and basic care;

3. requires pediatric subspecialty treatment and/or developmental therapeutic services for an extended period of time;

4. can be maintained or improved by such treatment and services; and

5. meets the specific criteria as outlined in Chapter VI, "Conditions and Components of Care".

E. Income Eligibility: determination that applicant's family self-declaration of gross annual income is equal to or less than the C.C.S./C.S.H.N. financial guidelines and that applicants comply with the following:

1. complete C.C.S./C.S.H.N. application and financial self-declaration form;

2. report annual gross income for the twelve month period prior to date of application is equal to or less than recommended financial guidelines which are based on 225% of national U.S. Department of Agriculture (U.S.D.A.) poverty guidelines;

3. provide verification of income when self-employed; and

4. Exceptions:

a. Current income will be used to determine financial eligibility when evidence exists supporting a change in income that is a more accurate reflection of the family's true financial status.

b. Family size may be increased by one when upon verification:

i. the family has a child with multiple special health needs according to C.C.S./C.S.H.N. policy (Chapter II, p. 9); or

ii. the family has more than one child with a chronic illness or physically handicapping condition in their home who is medically eligible for subspecialty treatment through the C.C.S./C.S.H.N. Program.

c. Those children at application and financial review who are receiving SSI or who have Medicaid eligibility coverage known as the Deeming (formerly Katie Beckett) option.

d. Income waiver:

Children in families whose household income falls above 225% but at or below 250% of chronic illness or physically handicapping condition that requires the national U.S.D.A. poverty guidelines and who have an eligible high cost subspecialty medical services that can be expected to exceed $5,000.00 during the upcoming six (6) months.

F. Need assistance with medical management and care coordination.

G. Date of Eligibility:

1.medically and financially eligible or the date of receipt of application, whichever is later;

2. the date of a physician direct referral to the C.C.S./C.S.H.N. Program if the application and written medical and other criteria of eligibility are received and/or can be verified with thirty days;

3. the date of referral from the Newborn Screening Program if the application and supporting medical documentation are received within thirty days; or

4. the date of referral from a C.C.S./C.S.H.N. Program supported subspecialty clinic, if the application and written medical and other criteria are received within thirty days from the date of referral.

H. Length of Eligibility:

A child is eligible for subspecialty medical services and/or care coordination on the Coordinated Care Services For Children With Special Health Needs Program for a period of one year as long as he or she and the family meet the financial and medical eligibility criteria outlined above.

Each child's eligibility for the C.C.S./C.S.H.N. Program is reviewed and updated to determine continued financial and medical eligibility, at least once a year and each succeeding year from the initial date of application to the C.C.S./C.S.H.N. Program, on a case by case basis. For all children, determination of medical eligibility is an on-going process.

I. Termination of Eligibility:

If, at any time, it becomes apparent that the child no longer meets either the medical and/or financial eligibility requirements of the C.C.S./C.S.H.N. Program, the family and authorized provider(s) will be notified in writing that the child is no longer eligible, state the reason why, and offer the opportunity for review/appeal through the administrative hearing process outlined in Chapter VIII.

C.M.R. 10, 144, ch. 272, III