10-144-332 Me. Code R. § 2-12
The individual or the individual's authorized representative is responsible for verifying information for all persons in the household whose circumstances affect the eligibility determination. If this information is not provided and cannot be verified electronically by the Department, or electronic verification is inconsistent with the individual's attestation, the Department will notify the individual or the authorized representative what items require resolution. If, following this notice, verifications are not received, the Department is not able to determine eligibility and a denial or closure notice will be issued. It is the responsibility of the Department to assist the individual in establishing eligibility for MaineCare.
Verification of information needed to determine eligibility must be requested initially from the individual. If information is requested from other sources (with the exception of public records) the individual must be informed. If collateral contacts are necessary to determine eligibility and the individual does not give consent, denial or closure must occur because the Department is unable to determine eligibility.
It is the responsibility of the individual to report changes of income, assets, household composition and any other change in circumstances which affect eligibility for MaineCare. Such change is to be reported within ten days from occurrence. For income purposes, "occurrence" will be considered the date the increased income was received. For all other purposes, "occurrence" will be considered the date the change took place. Applicants and recipients are informed of reporting responsibilities in the notice of eligibility.
Eligibility will be recalculated within 30 days of the receipt of new information which may affect the level of MaineCare coverage or cause ineligibility.
Temporary Coverage is medical coverage that is authorized because an application has not been processed, by no fault of the applicant or their representative, and an eligibility decision has not been issued, within forty-five days of the application date. As described in Section 3.3 of this part, Temporary Coverage will not be granted following the 90-day reasonable opportunity period.
The applicant must be sent a notice of eligibility no later than 45 days after the date of application. The 45-day processing standard is the result of the settlement of a court case, Polk, et al. v. Longley. The consent decree stated that all applications must be acted upon and a decision made as quickly as possible.
Documented non-cooperation by the applicant or the source of the applicant's medical information means that the case record must contain sufficient information to show that the applicant or the source of the applicant's medical information was requested to provide specific information or verification, or carry out particular activities necessary to establish eligibility and that the applicant or medical source failed or delayed in doing so within a reasonable period of time.
The consent decree filed as a result of Polk, et al. v. Longley also mandates that the Department issue a medical card no later than ten days after the applicant furnishes adequate information about incurred medical expenses in order to meet the deductible. See Part 10, Section 6 for information about verification of medical costs.
If the person is not issued a medical card within ten days of submitting the information, temporary coverage is issued, effective on the 11th day unless there is documentation that the individual is not cooperating.
If the individual is found to be eligible, Medicaid coverage will go back to the first month of eligibility. This could be a retroactive month, the month of application or the first day of eligibility.
If the applicant is found ineligible after temporary coverage has been issued, the applicant is sent a notice of denial. There is no advance notice of adverse action (See Section 15 of this Part). The applicant becomes ineligible upon the receipt of the denial notice (five days from the day the notice is mailed).
In no instance may the dates of temporary coverage be eliminated. The individual may request a hearing regarding the denial, but temporary coverage will not continue pending the hearing decision. If the decision of the Hearing Officer is to remand the case back to the regional office for a new decision, temporary coverage is reinstated back to the date that the coverage stopped.
No payment for medical services provided to the individual during the period when the applicant was eligible for temporary coverage is recoverable from the applicant.
10-144 C.M.R. ch. 332, § 2-12