10-144-332 Me. Code R. § 3-4

Current through 2024-51, December 18, 2024

Section 144-332-3-4 - TRANSITIONAL MAINECARE

Transitional MaineCare (TM) is MaineCare coverage that is available to families who become ineligible for MAGI-based coverage due to increased earnings or hours of employment of the parent or caretaker relative (as defined by Section 2.2 in this Part), or because of receipt of or increase in alimony.

Section 4.1:General Requirements

Section 4.1.1:Covered Individuals

TM is available to individuals who were eligible for MAGI-based MaineCare coverage in either the Children Under 18, or the Parent/Caretaker groups (except Expansion Adults with income above 100% FPL).

TM households are determined on an individual basis using MAGI household composition rules. Some individuals may be granted TM while others may continue in MAGI coverage groups.

Membership in a TM household includes those individuals whose needs and income were included in determining eligibility for the MAGI coverage group at the time of closing.

The following individuals may also be added to a TM household:

I. a parent/caretaker relative who returns home whose needs and income would be considered in determining coverage under MAGI, and whose earnings/alimony, either alone or added to other income of the household, result in the loss of MAGI coverage;

II. a child or parent/caretaker relative who moves into the home after TM has started;

III. a child who is born after TM has started; or

IV. a pregnant individual who was included in a MAGI household and loses coverage after the end of the pregnancy, if the individual's spouse and/or dependent children are receiving TM.

Section 4.1.2:Conditions of Eligibility

At least one member must have been eligible for and receiving coverage under an eligibility group for which MAGI-based methodology applies in one of the three months immediately preceding ineligibility. Retroactive coverage under an eligibility group for which MAGI-based methodology applies will be counted for this purpose even if there is only one month of retroactive coverage and no current eligibility under an eligibility group for which MAGI-based methodology applies.

Example

A family applies in July and requests retroactive coverage for one month. The family is covered under an eligibility group for which MAGI-based methodology applies for June (the retroactive month) and is ineligible for coverage in July due to increased earnings. TM eligibility exists starting in July.

An individual is not eligible for TM if:

I. The State makes a finding that, at any time during the last 6 months the individual was ineligible for Medicaid because of fraud; or

II. Information is received which indicates the household was incorrectly determined eligible for MAGI-based coverage.

Individuals receiving TM must continue to assign their rights to payment for medical care from any third party (See Part 2, Section 6). The custodial parent is not required to cooperate in obtaining medical support or payments from the non-custodial parent.

Section 4.2:Eligibility for Transitional Medicaid: Individuals Who Become Ineligible for Coverage under MAGI-Based Coverage Due to Increased Earnings

Section 4.2.1:Computation of Transition Period

Individuals who lose eligibility in a coverage group for which MAGI-based methodology applies due to the earnings of a parent/caretaker relative may remain eligible for Medicaid for up to 12 months. The scope of services will be the same as those provided to those eligible under an eligibility group for which MAGI-based methodology applies.

The 12-month count begins the month after the individual becomes ineligible for MAGI coverage.

Example:

A family reports an increase in the parent's earnings on April 5. The parent is now ineligible in April. The first month for TM is May.

Section 4.2.2:Termination of TM

TM will be closed with timely and adequate notice when:

I. A child no longer resides within the household. The TM household must include a child who resides in the household. This child must be under the age of 18 or between the ages of 18 and 19, and a student regularly attending a secondary school on a full-time basis (or in the equivalent level of vocational or technical training at the high school level) and reasonably expected to complete the program prior to their 19^th birthday.

II. The parent/caretaker relative is no longer employed. Note: good cause reasons will be requested for lack of employment and established by the Department. Some reasons for good cause for lack of employment include but are not limited to:

A. dismissal/termination by the employer;

B. illness of employed individual;

C. care of other ill family members who are residing within the household;

D. loss of transportation;

E. harassment;

F. risk to health and safety;

G. loss of child care if there is not any other adequate replacement; or

H. other reasons which indicate the action was not deliberate or willful.

III. The household moves out of state or the recipient's whereabouts are unknown and Departmental mail has been returned.

IV. The member becomes eligible in another comparable MaineCare category.

A determination of whether the individual is potentially eligible for any other MaineCare categories must be made prior to the termination of Transitional Medicaid.

In situations when the intended Department action is to terminate coverage, timely and adequate notice must be given to the recipient as described in Part 2, Section 15.

Section 4.2.3:Client Reporting Responsibilities

The family must report when a child no longer resides within its household or when there are any other changes in the family composition. All changes must be reported within the time frames outlined in Part 2, Section 12.2.

Section 4.2.4:Department Notice Requirements

At the time of the closing under MAGI-Based rules, a determination must be made for the individual's eligibility for Transitional Medicaid and a notice must be sent informing the individual of the following:

I. The individual's eligibility for the extension and a medical card which lists all eligible members; and

II. The conditions under which the initial extension may be terminated.

A review is due in the 12th month. It is used to determine continuing eligibility for MaineCare coverage when TM ends.

Section 4.3:Eligibility for Transitional Medicaid: Individuals Who Become Ineligible for MAGI Based Coverage Due to Increased Alimony

Transitional Medicaid coverage for persons with increased alimony is limited to 4 months; it continues irrespective of other changes in household income or composition.

Coverage under a MAGI-based eligibility group must have been closed solely because of an increase in the amount of alimony being received by an individual in the household.

The individual must have been eligible under a MAGI-based eligibility group for three of the six months prior to the month they are determined ineligible.

The four-month count for extended Medicaid begins the first month after the individual became ineligible for MAGI coverage.

Example

A client reports in May that their alimony has increased and now the countable income exceeds program standards. The four-month extension begins in June.

At the end of the four-month period, the individual's coverage is to be reviewed for potential future coverage. If eligibility does not exist, coverage is to be ended following timely and adequate notice procedures (Part 2 Section 15).

10-144 C.M.R. ch. 332, § 3-4