10-144-332 Me. Code R. § 2-13

Current through 2024-51, December 18, 2024
Section 144-332-2-13 - ELIGIBILITY PERIODS/REVIEWS

An individual's eligibility period is based on the month the application is received. Eligibility for the prospective period is determined for 12 months for all MaineCare programs except for Medically Needy and Maine Rx Plus. Eligibility for Medically Needy is determined for a six-month period. Eligibility for Maine Rx Plus is determined for a 24-month period.

The eligibility period begins on the first day of the application month unless temporary coverage is being given. (See "45-Day Processing Standard", Section 12.3.1 of this Part). In some instances, the individual is not eligible for coverage during the month of application but is eligible for the following month. In this situation, the length of the eligibility period remains the same (6, 12 or 24 months), depending on the type of coverage.

A review is a re-determination of eligibility. Reviews may be completed online through the My Maine Connection website or by using the review form provided by OFI. If the recipient is determined no longer eligible a timely and adequate notice of the adverse action must be sent (See Section 15 of this Part). Recipients are provided at least 30 days from the date of the renewal form to respond and provide any necessary information to determine ongoing eligibility. If the completed review form is not received by the Department by the end of the month in which it is due coverage will end.

If the completed review form and/or required verifications are submitted within 90 days after the date of termination, a new application for MaineCare coverage will not be required. If found eligible, the individual's coverage will be reinstated back to the date of termination.

Section 13.1:Changes within the Eligibility Period

Changes reported by recipients during the eligibility period must be reviewed to determine the effect of the change on the individual's eligibility.

If the new information results in a change in the level of coverage, timely and adequate notice of the change of level or termination of benefits must be provided (See Section 15 of this Part.).

Certain categorically eligible individuals have a continuous period of eligibility even if changes occur. These groups are:

I.Newborns

If the newborn's mother is receiving Medicaid (or is covered as part of the retroactive period) on the date the baby is born, the baby is eligible regardless of the income of the assistance unit. The mother must be fully covered by Medicaid on the day of the baby's birth. If mother meets the deductible amount on the day of the baby's birth and is partially responsible for any medical bills on that date, the newborn is not eligible in this group.

Coverage continues for one year without regard to changes in income or other household changes. Coverage under this category ends effective the last day of the month in which the child reaches age one.

II.Children Under Age 19

Any categorically eligible child is continuously eligible for full benefits for 12 months after eligibility is determined by application or review without regard to changes in income or composition of the assistance unit. This provision includes a child on newborn coverage as well as children found eligible for an SSI-Related coverage group even if the SSI or State Supplemental benefits or disability determination end prior to the next MaineCare review. It does not apply to those receiving coverage under Transitional MaineCare. The 12-month period begins with the month of application or review. Eligibility within the 12-month period will end:

A. at the end of the month the child turns 19;
B. if the child ceases to be a state resident; or
C. if mail addressed to the child or child's household is returned as undeliverable.
III.Pregnant Individual
A. Effective August 1, 2022, pregnant individuals who are found eligible for MaineCare under Part 3, Section 2.3(I) are continuously eligible for 12 months beyond the date the pregnancy ends.
B. Effective December 1, 2023, pregnant individuals who are found eligible for the Children's Health Insurance Program (CHIP), and enrolled in CHIP while pregnant, under Part 3, Section 2.3(III) are continuously eligible for 12 months beyond the date the pregnancy ends.
Section 13.2:Medically Needy Eligibility Periods

Medically Needy recipients have a six-month eligibility period. Most must meet a deductible to gain eligibility. The only time the six-month deductible period is shortened is in situations when:

I. The individual, age 20, will turn 21 in less than six months;
II. The individual dies;
III. The individual becomes eligible for categorical coverage including coverage in nursing care status; or
IV. The individual voluntarily withdraws from the program. If the individual voluntarily withdraws and reapplies, new deductible periods (both retroactive and prospective) are established based on the new application. Some months of the retroactive coverage period from the first application may not be included in the new retroactive period which is established with the reapplication.

Medically Needy coverage begins on the day of the month that the deductible is met. The individual may have some responsibility for bills for medical services incurred on that day. If there is no deductible or the deductible is met with uncovered medical expenses, coverage begins on the first day of the month of eligibility.

Once the date of eligibility is established, unless there is a change in income which changes the deductible amount, or the individual becomes ineligible for Medicaid, coverage continues to the end of the deductible period. These individuals are entitled to review and timely and adequate notice as described in Section 13 of this part.

Although individuals who are eligible for Medically Needy coverage are in a deductible for six months, if their income is stable and is between the Categorically Needy income levels and the Protected Income Level (PIL) - (See Chart 5), a complete review is necessary once every 12 months rather than once every six months.

Section 13.3:Changes within the Medically Needy Eligibility Period

Changes that impact eligibility are required to be reported and can result in a change in coverage or deductible amount. The Department shall review reported changes to determine the effect on the amount of the deductible or coverage. If the deductible amount or coverage changes, the recipient is provided timely and adequate notice of the change. (See Section 15 of this Part.)

Section 13.4:Retroactive Period

An applicant for Medicaid may receive retroactive coverage of up to three months prior to the application month. The exception to this rule is when the individual is only eligible for the Qualified Medicare Beneficiary (QMB) Buy-In group for the retroactive period.

I. Eligibility for retroactive coverage must be determined separately from prospective coverage. It is possible for an individual to be covered as Medically Needy during the retroactive period and Categorically Needy prospectively or vice versa.
II. The individual must meet basic eligibility requirements for any month during which coverage is received. For example, a person who turned age 65 in the month of application cannot be covered retroactively under an SSI- Related category unless SSI-Related disability criteria are met during the retroactive period. The individual does not have to be eligible in the month of application to be eligible for retroactive coverage.

The entire three-month period may be covered if the individual is eligible for all three months. Medicaid will not cover the third month prior to the application month without including the first and second months unless the individual is ineligible due to basic eligibility requirements or excess assets during the intervening months.

Examples

1. The individual applies in August and has medical expenses incurred in May. There are no medical expenses for June or July. The individual has a deductible of $300 per month.

To cover the expenses incurred in May, the deductible is $900 for three months, not $300 for one month. June and July could be covered with a deductible of $600, or only July could be covered with a deductible of $300. Coverage must be continuously retroactive from the application month.

2. The individual applies in March and incurred medical expenses in December, January and February. They met basic eligibility and asset requirements for December and February, but not January. Expenses incurred in the month of January cannot be covered by Medicaid as the individual was not eligible. The person's deductible for December and February are added together. Expenses incurred in January for which the individual is still responsible can be used as non-covered items toward meeting the deductible. (See Part 10.)

The individual who has a deductible period may withdraw from the program and reapply for retroactive coverage. If an individual voluntarily withdraws, a new prospective period begins with the month of the new application and retroactive eligibility can be determined for up to three months prior to the month of the new application. In determining eligibility for the retroactive period, income received during that period is used.

Individuals who are determined to be eligible for SSI benefits and who indicate on their SSI application that they have medical expenses for the three months prior to their application for SSI do not need to make a separate application for retroactive Medicaid coverage.

If the individual meets the non-financial criteria and the Department has enough information in the case record about the individual's financial situation to determine eligibility for the retroactive period, the individual will be sent a notice of eligibility for MaineCare. If there is not enough information in the case record, or no case record exists, the Department will contact the individual in writing to request verification of specific information.

Individuals who are determined to be eligible for SSI and who indicate on the application for SSI that they do not have medical expenses for the three months prior to their application for SSI will be sent a notice of denial for the three-month period.

10-144 C.M.R. ch. 332, § 2-13