10-144-332 Me. Code R. § 9-1
The Benefit for People Living With HIV/AIDS is a section 1115 health care reform demonstration agreement between the Office of MaineCare Services and the Centers for Medicare and Medicaid Services. The Office for Family Independence determines eligibility for this benefit. This benefit provides limited MaineCare coverage to individuals with an HIV/AIDS diagnosis if they meet the medical and financial requirements identified in this section. This benefit is also known as the Special Benefit Waiver (SBW).
Individuals who do not meet the eligibility requirements for MaineCare, but who are HIV-positive and are at or below 250 percent of the federal poverty level, may be eligible for SBW. If an individual who is eligible for this benefit becomes eligible for full MaineCare coverage, they will be moved to the appropriate MaineCare full coverage group. This contingency includes someone who meets a deductible or has a reduction in income that qualifies them for full MaineCare coverage. If an individual, enrolled in a full MaineCare coverage group, becomes ineligible for that group, including someone who must meet a new deductible, but is eligible for SBW, that individual will be granted coverage through SBW. This enrollment will happen even if SBW has a wait list.
An individual cannot receive SBW coverage and the Maine Rx Plus or Low Cost Drugs for the Elderly and Disabled (DEL) programs at the same time. SBW coverage and DEL coverage can overlap when DEL is supplementing Medicare Part D.
Basic Non-Financial eligibility requirements for receiving MaineCare coverage identified in Part 2 apply to this group. This condition includes meeting the requirements for residency, citizenship, social security numbers, assignment of rights to medical payments and support rights, as well as applying for other benefits. SBW has no age requirement.
The individual must be diagnosed as HIV positive. This diagnosis is confirmed by the Maine Center for Disease Control (MCDC). The individual must also comply with a treatment regimen as defined by their licensed healthcare professional.
If an individual reports a disabling condition and is financially eligible for SSI-Related coverage, eligibility for full MaineCare coverage must be determined first. If the Social Security Administration has not completed a disability determination, this determination will be done by the Medical Review Team.
SBW has no asset criteria.
Individuals must meet the SSI - Related financial eligibility requirements as listed in Part 7 to be financially eligible for SBW. The SSI - Related rules on income exclusions, in Part 17, are applicable to this coverage group. There is no deeming of income from the spouse. There is no cost of care.
Gross income must be equal to or less than 250% of the Federal Poverty Level.
When determining MaineCare coverage for a spouse not applying for, or enrolled in, SBW, the income and assets of both individuals are used to determine eligibility for the spouse.
Premium payments are due on the first day of each month that the individual is open for MaineCare under this coverage group. Some individuals may be exempt from premiums as identified below.
The premium amount is based on gross monthly income projected for the 12-month enrollment period. Premiums are effective the month that coverage begins for the individual and end effective the month that coverage ends under the waiver. See Chart 3. 8 for premium amounts due. Premiums, when added to other payments made by the household to Cub Care or MaineCare, will not exceed five percent of that household's gross annual income.
Example: A monthly premium of $35. 93 is due during a 12-month enrollment period from January through December, and the first payment of $395. 23 is received on December first. Months one through 11 will be credited with a premium paid. The December payment is overdue.
Example A: If the enrollment period is January through December and an individual fails to pay the premium due for March, the individual has until December 31st to pay the March premium.
Example B: If the enrollment period is January through December and an individual fails to pay the premium due for December, the individual has until 60 days from December first to pay the December premium.
If the last day of the grace period falls on a weekend or holiday, the premium is due on the next business day.
Example: An individual is granted coverage for January through December. In March, coverage is changed to full MaineCare without a premium. The grace period for payment of the January premium is 60 days after January first. The grace period for payment of the February premium is 60 days after February first.
Example: The premium for the month of July is due July first. The grace period extends to 60 days after July first.
An individual is exempt from a premium if any one of the following conditions apply:
If the individual's income changes so that no premium is due, or the amount of premium increases or decreases, this change will be made as follows:
Enrollment for this benefit is capped based on expenditures. If enrollment is frozen, individuals who have been determined to be medically and financially eligible will be placed on a wait list that is maintained by the Maine Center for Disease Control and Prevention (MCDC). The rules for the wait list are in the MaineCare Benefits Manual.
When the Office for Family Independence is informed by the MCDC that an individual's coverage can start, financial eligibility will be updated before coverage for this benefit can start.
10-144 C.M.R. ch. 332, § 9-1