10-144-332 Me. Code R. § 9-4

Current through 2024-51, December 18, 2024

Section 144-332-9-4 - LIMITED FAMILY PLANNING BENEFIT (LFPB)

This coverage group is effective October 1, 2016.

The Limited Family Planning Benefit is a limited Medicaid benefit that provides coverage to individuals, regardless of gender, for family planning and related services.

Coverage is available only to individuals who have not been determined otherwise eligible for any Categorically Needy or Medically Needy coverage group. If an individual, who is eligible for this benefit, is determined eligible for any Categorically Needy or Medically Needy coverage group, they shall be moved to that coverage group. This change in coverage includes individuals who newly meet a deductible.

If an individual, enrolled in a full coverage group, becomes ineligible for that coverage (including someone who must meet a new deductible), but is eligible for Family Planning benefits, that individual can be enrolled in Family Planning coverage.

1. Basic Eligibility Requirements

Basic Non-Financial eligibility requirements for receiving MaineCare coverage identified in Part 2 apply to this group. This stipulation includes meeting the requirements for residency, citizenship, social security numbers, and assignment of rights to medical payments and support rights, as well as applying for other benefits. The Limited Family Planning Benefit has no gender or age requirements.

Pregnant individuals are not eligible for coverage under this benefit.

A. Assets

LFPB has no asset criteria.

B. Income

Individual income must be equal to or less than 209% of the Federal Poverty Level.

C. Budgeting

MAGI-based budgeting rules for Medicaid are used to determine countable income. The assistance unit only consists of the individual applying for coverage.

2. Presumptive Eligibility for the Limited Family Planning Benefit

Presumptive eligibility provides immediate, short term access to family planning services for individuals who are not otherwise enrolled in MaineCare. Eligibility for coverage is determined by qualified entities. Pursuant to a State Plan Amendment, these changes are effective October 1, 2020.

A. Limited Family Planning Benefit Provider Qualification Requirements

To become qualified to make presumptive eligibility determinations for Medicaid, a provider must-

(1) Participate as a Medicaid provider under the State of Maine's State Plan;

(2) Notify the Office for Family Independence (OFI) in writing of its intention to make presumptive determinations under this Part;

(3) Accept training, administered by OFI, for all applicable staff on relevant MaineCare eligibility rules and regulations; and

(4) Receive approval from the Department to make presumptive eligibility determinations.

B. Eligibility for Presumptive Eligibility Determinations by Qualified Providers

Limited Family Planning Benefit Presumptive Eligibility determinations must be limited to persons who meet all eligibility requirements for LFPB as listed in Section 4 of this Part.

Additionally, LFPB presumptive eligibility is limited to no more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

C. Limited Family Planning Benefit Presumptive Eligibility Determination Process

A qualified provider must use a Limited Family Planning Benefit presumptive application to establish the applicant's financial and non-financial eligibility. Applications may be accessed at the Department's website; or by contacting the MaineCare Eligibility Program Manager by mail, phone, or e-mail. If the provider determines the applicant meets all the eligibility requirements for coverage under the LFPB, the provider shall determine that the applicant is presumptively eligible for the LFPB.

If eligible the provider must-

(1) Notify the Department of the determination within five business days after the date on which the determination is made if no application for Medicaid has been filed by that date;

(2) Provide the applicant with an approved standard MaineCare application; and

(3) Inform the individual at the time the determination is made that they must complete a full application with the Department no later than the last day of the month following the month in which the presumptive determination is made to see if benefits can continue.

For individuals determined not to be presumptively eligible, the provider must notify the applicant in writing, and orally if appropriate, of the reason for the determination.

D. Limited Family Planning Benefit Presumptive Eligibility Coverage Period

Once a provider determines an individual is presumptively eligible, Limited Family Planning Benefit coverage begins immediately and continues until the later of-

(1) If a full application for Medicaid is filed prior to the last day of the month following the month presumptive eligibility was determined, the date on which the Department makes the final eligibility decision; or

(2) The last day of the month following the month in which the presumptive eligibility determination was made if no application for Medicaid has been filed by that date.

10-144 C.M.R. ch. 332, § 9-4