10-144-332 Me. Code R. § 3-2

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Current through 2024-51, December 18, 2024

Section 144-332-3-2 - ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES

To be eligible for MaineCare in a coverage group for which MAGI-based methodology applies, an individual must:

I. Be a covered individual;

II. Have an eligibility group;

III. Meet basic eligibility criteria in this Part and in Parts 2 and 17; and

IV. Meet income criteria.

To get Medicaid coverage under an eligibility group for which MAGI-based methodology applies, an individual must meet the criteria of at least one of the groups listed in Sections 2.1-2.4 of this part. An individual may meet the criteria of more than one group at the same time in which case they should be enrolled with the group which is the easiest way for them to get the best coverage.

Section 2.1:Children

I.Newborns

A. 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 household. The mother must be fully covered by Medicaid on the day of the baby's birth. If the 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.

B. Coverage continues for one year. This means that the baby is eligible without regard to changes in income or composition of the household.

II.Other Children Under Age One

A. Individuals under the age of one who are living with a parent/caretaker relative or with unrelated others are eligible if they meet other applicable eligibility rules in Parts 2 and 17.

B. Countable income must be equal to or less than the applicable standard in Part 4. Types of countable income are described in Part 17.

C. If the individual is receiving inpatient hospital services on the last day of the month in which the first birthday occurs, eligibility continues until the last day of the in-patient stay if the individual continues to meet all other eligibility criteria.

III.Age 1 through Age 18

A. Individuals age one up to and including age 18 (under age 19) who are living with a parent/caretaker relative or who are living alone or with unrelated others are eligible for Medicaid if they meet other applicable eligibility rules in Part 2 and Part 17.

B. Countable income must be equal to or less than the applicable income standard in Part 4. Types of countable income are described in Part 17.

C. If the individual is receiving inpatient hospital services on the last day of the month in which the 19th birthday occurs, eligibility continues until the last day of the inpatient stay if the individual continues to meet all other eligibility criteria.

IV.Age 19 or 20

A. Individuals age 19 or 20 who are living with parent/caretaker relatives or who are living alone or with unrelated others are eligible for Medicaid if they meet other applicable eligibility rules in Part 2 and Part 17.

B. Countable income must be equal to or less than the applicable income standard in Part 4. Types of countable income are described in Part 17.

C. If the individual is receiving inpatient hospital services on the last day of the month in which the 21st birthday occurs, eligibility continues until the last day of the in-patient stay if the individual continues to meet all other eligibility criteria.

V.Coverage for Noncitizens Under Age 21

A. Effective July 1, 2022, individuals under the age of 21 who would be eligible for assistance under federal Medicaid programs listed in Section 2.1(I)-(IV) of this part, but for their noncitizen status are eligible for state-funded medical assistance through MaineCare.

B. Countable income must be equal to or less than the applicable income standard in Part 4. Types of countable income are described in Part 17.

Section 2.2:Parent/Caretaker Relative

I. A parent/caretaker relative means a relative of a dependent child by blood, adoption or marriage with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for Federal income tax purposes), and who is one of the following:

A. The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;

B. The spouse of such parent or relative, even after the marriage is terminated by death or divorce; or

C. Another relative of the child based on blood (including those of half-blood), adoption or marriage.

Countable income must be equal to or less than the applicable income standard in Part 4. Types of countable income are described in Part 17.

II.Maintenance of a Home

The parent/caretaker relative must be living with a dependent child for whom a home is maintained. The child must be under age 18 or is age 18 and expects to graduate from high school prior to their 19th birthday.

The specified relative does not need to have legal custody as a result of court action in order to be considered to be maintaining a home for the child.

If the child lives part of the time with each parent, the parent with whom the child resides over 50% of the time must apply for the child.

If the child lives 50% of the time with each parent, either parent can apply for the child but not both.

If a child is living with their biological parents but the parents are not married, all three have a coverable group and are potentially eligible. Each parent has a coverable group because each is residing with their child under age 18 (or 18 and expects to graduate from high school by age 19).

If the only child is between the ages of 19 and 21, (or is age 18 and does not expect to graduate from high school prior to the 19th birthday), the parent or caretaker relative cannot receive Medicaid coverage unless the parent or caretaker relative is eligible in another category (e.g., a pregnant individual or meets SSI disability criteria).

Examples

A. The household consists of a single mother and her 18 year old son. In June, the boy graduates from high school. The boy may remain eligible for Medicaid since he has a coverable group (under age 21).

The mother is no longer eligible. She has no coverable group since she is not living with a dependent child covered by Medicaid and she is not pregnant and does not meet SSI disability criteria.

B. The household consists of a mother, father, and their 19 year old daughter. The daughter may be eligible, depending on the income requirements of her coverage group; however, the parents cannot be covered as a parent/caretaker relative.

C. The household consists of a mother, father, and 17 year old girl who is a sophomore in high school. On the child's 18th birthday, the parents' coverage is due to end. Discussion with the family prior to terminating the parents' coverage reveals that the mother has a condition which might meet disability criteria under the SSI program. Coverage for the girl continues. Coverage for the father is terminated. Coverage for the mother continues pending a decision from the Medical Review Team on her disability. If she does not meet criteria for SSI - Related disability (see Part 6, Section 4.3), her coverage must also end.

D. An individual, age 20, is the caretaker relative of their 18-year-old sister. When the sister graduates from high school, both can continue to receive Medicaid as both are still eligible for coverage through the infants and children under age 21 group.

III.Physical Separation

A child may be separated physically from their parent/caretaker relative and still be considered to be living with the parent/caretaker relative, provided that the parent/caretaker relative retains full and exclusive responsibility for the supervision and guidance of the child, offers a home during vacations, and any other delegation of authority to another by the parent/caretaker relative is temporary, voluntary, and revocable.

When separation occurs, it is expected that the child or parent/caretaker relative will return home at the completion of the reason for the separation. The following criteria meet the conditions for when a child or parent/caretaker relative is away from the home.

A. To secure education when high school facilities are not maintained in the place of residence or if existing facilities do not meet the child's educational or social needs. In this later instance, the assessment of needs and the development of a responsible plan must be made through the parent/caretaker relative and a recognized social service agency.

B. To secure planned supervised therapy in a private, organized treatment center such as Sweetser Home, when such is necessitated by special needs of a physical or emotional nature.

C. To attend Governor Baxter State School for the Deaf, provided that adequate resource for therapy cannot be found or developed in the child's own community.

D. To attend a vocational or technical school or college or university.

E. For care for a terminal illness which probably will prohibit eventual return to the home, although if possible, the individual would do so.

F. For other purposes, such as visiting or moving to another community and similar situations where temporary separation occurs. In such situations, the separation may not exceed four months, unless the individual can demonstrate that there is a good reason and that the separation will end as soon as possible.

IV.Reunification

MaineCare coverage may continue for parents/caretaker relatives who would otherwise lose eligibility due to a change in household size when their child is removed from the home by Child Protective Services pursuant to state law. Eligibility will continue until the parent is either:

A. No longer participating in the rehabilitation and reunification plan as required by the plan; or

B. Until the parental rights have been terminated.

If the parent/caretaker is no longer eligible for reasons other than the change in household composition (e.g., an income increase, failure to renew, etc.) MaineCare eligibility may end.

Section 2.3:Pregnant Individuals

I. Pregnant individual means an individual during pregnancy and the post-partum period, which begins on the date the pregnancy ends, and extends for 12 months beyond the month in which the pregnancy ends.

Pregnant individuals whose countable income is equal to or below the applicable income standard in Part 4 are eligible. The household size is increased by one (or by two if the individual is expecting twins). Cooperation with Third Party Liability (TPL) and Division of Support Enforcement and Recovery (DSER) is not a factor in determining eligibility.

Retroactive coverage may be granted for up to three months if the individual was pregnant and financially eligible.

If an individual is eligible as a pregnant individual in the month of application, or the retroactive period, or due to a change in ongoing eligibility, they continue to be eligible for 12 months beyond the month in which the pregnancy ends.

Only the pregnant individual is eligible under this coverage group. Other family members must be in another coverable group.

If the individual is receiving inpatient hospital services on the last day of the month in which coverage as a pregnant individual occurs, eligibility continues until the last day of the in-patient stay if the individual continues to meet all other eligibility criteria in Part 2 and Part 17.

II.Presumptive Eligibility for Pregnant Individuals

A pregnant individual is eligible to receive ambulatory prenatal care beginning on the day that a qualified Medicaid provider determines that the pregnant individual's household's countable MAGI-based income is less than the applicable income standard in Part 4. This coverage is called "presumptive eligibility".

The qualified Medicaid provider will use a presumptive eligibility application to establish the MAGI household size and income for the presumptive determination. The Medicaid provider must contact the Department within five working days after the date the presumptive determination is made to report the name, date of birth, and Social Security number of each individual determined eligible under the presumptive eligibility standards.

Once the Medicaid provider has made a presumptive determination, the individual is eligible through the last day of the month following the month in which a presumptive determination is made. If the individual applies for Medicaid during this presumptive eligibility period, presumptive eligibility ends the day that the Medicaid application is granted or denied.

Presumptive eligibility can only be determined once per pregnancy.

Example

A pregnant individual is determined presumptively eligible by the Medicaid provider on September 14. They receive coverage under presumptive eligibility through October 31. On October 31 they file an application for Medicaid. Because they applied for Medicaid within the presumptive eligibility period, the individual continues to be presumptively eligible through the day the application is granted or denied.

The Department is required to provide appropriate notices based on the standard Medicaid application, but is not required to send any notice regarding the discontinuance of the presumptive eligibility period. The individual has no appeal rights for the discontinuance of presumptive eligibility.

It is the responsibility of the Medicaid provider to:

A. provide the applicant with an approved standard MaineCare application form;

B. notify OFI of the presumptive eligibility determination within five working days from the date the determination was made;

C. notify the applicant (in writing and orally if appropriate) that if the applicant does not file a standard MaineCare application with OFI before the last day of the following month, presumptive eligibility coverage will end on that last day;

D. notify the applicant (in writing and orally if appropriate) that if the applicant files a standard MaineCare application with OFI before the last day of the following month, presumptive eligibility coverage will continue until an eligibility determination is made on the application that was filed.

III.Coverage for Pregnant Individuals for the Health of Unborn Children From Conception to End of Pregnancy and 12 Months Postpartum

Effective July 1, 2022, services are available through the Children's Health Insurance Program (CHIP) to pregnant individuals who are eligible for Medicaid but for noncitizen status. Effective December 1, 2023, if an individual is eligible as a pregnant individual, and enrolled in CHIP while pregnant, eligibility from conception to end of pregnancy extends 12 months beyond the month in which the pregnancy ends, regardless of any subsequent changes in household income.

To be covered in this category the parent of the unborn child must be:

A. Pregnant

B. A resident of the State of Maine

C. Otherwise eligible for federally funded coverage but for citizenship.

D. Uninsured. Applicants are considered to be uninsured if they do not have credible health insurance that provides coverage of prenatal care services.

E. Countable income is equal to or less than 208% FPL. Types of countable income are described in Part 17.

Section 2.4:Expansion Adults

Eligibility for this group must meet the qualifications below.

Expansion Adultsmeans an individual between the ages of 19 and 64 who meets the following qualifications:

I. Is not pregnant;

II. Is not entitled to or enrolled for Medicare benefits Part A or Part B; and

III. Is not otherwise eligible for and enrolled in mandatory MaineCare coverage.

For parents and other caretaker relatives living with a dependent child under age 21 who meet the requirements in (I) through (III) of this section and either have income above 100% FPL or don't meet the requirements for a parent/caretaker under Section 2.2 of this part, the child must receive benefits under Medicaid, CHIP, or otherwise be enrolled in minimum essential coverage as defined in 42 C.F.R. § 435.4 to be eligible as an expansion adult.

10-144 C.M.R. ch. 332, § 3-2