An Act To Provide Maine Children Access to Affordable Health Care
Maine Legislature, Session 129, LD 1539
Committee: Health and Human Services
Sponsors: CARNEY, MILLETT, CUDDY, FARNSWORTH, GATTINE, HANINGTON, BREEN, CLAXTON
Amends: 22 MRSA §3174-G, 22 MRSA §3174-T

Legislative Document
No. 1539
H.P. 1122
House of Representatives, April 11, 2019
An Act To Provide Maine Children Access to Affordable Health 
Care
Reference to the Committee on Health and Human Services suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative CARNEY of Cape Elizabeth.
Cosponsored by Senator MILLETT of Cumberland and
Representatives: CUDDY of Winterport, FARNSWORTH of Portland, GATTINE of 
Westbrook, HANINGTON of Lincoln, MILLETT of Waterford, Senators: BREEN of 
Cumberland, CLAXTON of Androscoggin, SANBORN, L. of Cumberland.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  22 MRSA §3174-G, sub-§1, ¶B, as repealed and replaced by PL 2007, c. 
695, Pt. C, §9, is amended to read:
B.  An infant under one year of age when the infant's family income is equal to or 
below 200% of the nonfarm income official poverty line, except that the department 
may adopt a rule that provides that infants in families with income over 185% and 
equal to or below 200% 325% of the nonfarm income official poverty line who meet 
the eligibility requirements of the Cub Care program established under section 
3174-T are eligible to participate in the Cub Care program instead of Medicaid. Rules 
adopted pursuant to this paragraph are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A;
Sec. 2.  22 MRSA §3174-G, sub-§1, ¶D, as repealed and replaced by PL 2007, c. 
695, Pt. C, §10, is amended to read:
D.  A child one year of age or older and under 19 years of age when the child's family 
income is equal to or below 200% of the nonfarm income official poverty line, except 
that the department may adopt a rule that provides that children described in this 
paragraph in families with income over 150% and equal to or below 200% 325% of 
the nonfarm income official poverty line who meet the eligibility requirements of the 
Cub Care program established under section 3174-T are eligible to participate in the 
Cub Care program instead of Medicaid. Rules adopted pursuant to this paragraph are 
routine technical rules as defined in Title 5, chapter 375, subchapter 2-A;
Sec. 3.  22 MRSA §3174-T, as amended by PL 2017, c. 284, Pt. SSSSSS, §1, is 
further amended to read:
§3174-T.  Cub Care program 
1.  Program established.  The Cub Care program is established to provide health 
coverage for low-income children who are ineligible for benefits under the Medicaid 
program and who meet the requirements of subsection 2, 2-A or 2-B.  The purpose of the 
Cub Care program is to provide health coverage to as many children as possible within 
the fiscal constraints of the program budget and without forfeiting any federal funding 
that is available to the State for the State Children's Health Insurance Program through the 
federal Balanced Budget Act of 1997, Public Law 105-33, 111 Stat. 251, referred to in 
this section as the Balanced Budget Act of 1997.
2.  Eligibility; enrollment.  Health coverage under the Cub Care program is 
available to children under 19 years of age whose family income is above the eligibility 
level for Medicaid under section 3174-G and below the maximum eligibility level 
established under paragraphs A and B, and who meet the requirements set forth in 
paragraph C and for whom premiums are paid under subsection 5.
A.  The maximum eligibility level, subject to adjustment by the commissioner under 
paragraph B, is 200% 325% of the nonfarm income official poverty line.
B.  If the commissioner has determined the fiscal status of the Cub Care program 
under subsection 8 and has determined that an adjustment in the maximum eligibility 
level is required under this paragraph, the commissioner shall adjust the maximum 
eligibility level in accordance with the requirements of this paragraph.
(1)  The adjustment must accomplish the purposes of the Cub Care program set 
forth in subsection 1.
(2)  If Cub Care program expenditures are reasonably anticipated to exceed the 
program budget, the commissioner shall lower the maximum eligibility level set 
in paragraph A to the extent necessary to bring the program within the program 
budget.
(3)  If Cub Care program expenditures are reasonably anticipated to fall below 
the program budget, the commissioner shall raise the maximum eligibility level 
set in paragraph A to the extent necessary to provide coverage to as many 
children as possible within the fiscal constraints of the program budget.  If Cub 
Care program expenditures are reasonably anticipated to exceed the program 
budget after raising the maximum eligibility level pursuant to this subparagraph, 
the commissioner may lower the maximum eligibility level to the level 
established in paragraph A.
(4)  The commissioner shall give at least 30 days' notice of the proposed change 
in maximum eligibility level to the joint standing committee of the Legislature 
having jurisdiction over appropriations and financial affairs and the joint standing 
committee of the Legislature having jurisdiction over health and human services 
matters.
C.  All children resident in the State are eligible except a child who:
(1)  Is eligible for coverage under the Medicaid program;
(2)  Is covered under a group health insurance plan or under health insurance, as 
defined in Section 2791 of the federal Public Health Service Act, 42 United 
States Code, Section 300gg(c) (Supp. 1997); or
(4)  Is an inmate in a public institution or a patient in an institution for mental 
diseases; or.
(5)  Within the 3 months prior to application for coverage under the Cub Care 
program, was insured or otherwise provided coverage under an employer-based 
health plan for which the employer paid 50% or more of the cost for the child's 
coverage, except that this subparagraph does not apply if:
(a)  The cost to the employee of coverage for the family exceeds 10% of the 
family's income;
(b)  The parent lost coverage for the child because of a change in 
employment, termination of coverage under the Consolidated Omnibus 
Budget Reconciliation Act of 1985, COBRA, of the Employee Retirement 
Income Security Act of 1974, as amended, 29 United States Code, Sections 
1161 to 1168 (Supp. 1997) or termination for a reason not in the control of 
the employee; or
(c)  The department has determined that grounds exist for a good-cause 
exception.
D.  Notwithstanding changes in the maximum eligibility level determined under 
paragraph B, the following requirements apply to enrollment and eligibility:
(1)  Children must be enrolled for 12-month enrollment periods. Prior to the end 
of each 12-month enrollment period the department shall redetermine eligibility 
for continuing coverage; and
(2)  Children of higher family income may not be covered unless children of 
lower family income are also covered.  This subparagraph may not be applied to 
disqualify a child during the 12-month enrollment period.  Children of higher 
income may be disqualified at the end of the 12-month enrollment period if the 
commissioner has lowered the maximum eligibility level under paragraph B.
E.  Coverage under the Cub Care program may be purchased for children described in 
subparagraphs (1) and (2) for a period of up to 18 months as provided in this 
paragraph at a premium level that is revenue neutral and that covers the cost of the 
benefit and a contribution toward administrative costs no greater than the maximum 
level allowable under COBRA.  The department shall adopt rules to implement this 
paragraph.  The following children are eligible to enroll under this paragraph:
(1)  A child who is enrolled under paragraph A or B and whose family income at 
the end of the child's 12-month enrollment term exceeds the maximum allowable 
income set in that paragraph; and
(2)  A child who is enrolled in the Medicaid program and whose family income 
exceeds the limits of that program.  The department shall terminate Medicaid 
coverage for a child who enrolls in the Cub Care program under this 
subparagraph.
F.  The department may not apply an asset test to a child or child's family when the 
child is otherwise eligible for the Cub Care program under this section.
2-A.  Persons 19 and 20 years of age.  Health coverage under the Cub Care program 
is available to a person 19 or 20 years of age whose family income is above the eligibility 
level for Medicaid under section 3174-G and below the maximum eligibility level 
established under subsection 2, paragraphs A and B and who meets the requirements set 
forth in subsection 2, paragraph C.  All the requirements of eligibility, program 
administration, benefit delivery and outreach established in this section apply to persons 
and 20 years of age.
2-B.  Noncitizens.  Health coverage under the Cub Care program is available to a 
person under 21 years of age who is not a citizen of the United States and whose family 
income is above the eligibility level for Medicaid under section 3174-G and below the 
maximum eligibility level established under subsection 2, paragraphs A and B and who 
meets the requirements set forth in subsection 2, paragraph C.  All the requirements of 
eligibility, program administration, benefit delivery and outreach established in this 
section apply to a person under 21 years of age who is not a citizen of the United States.
3.  Program administration; benefit design.  With the exception of premium 
payments under subsection 5 and any other requirements imposed under this section, the 
Cub Care program must be integrated with the Medicaid program and administered with 
it in one administrative structure within the department, with the same enrollment and 
eligibility processes, benefit package and outreach and in compliance with the same laws 
and policies as the Medicaid program, except when those laws and policies are 
inconsistent with this section and the Balanced Budget Act of 1997.  The department 
shall adopt and promote a simplified eligibility form and eligibility process.
4.  Benefit delivery.  The Cub Care program must use, but is not limited to, the same 
benefit delivery system as the Medicaid program, providing benefits through the same 
health plans, contracting process and providers.  Copayments and deductibles may not be 
charged for benefits provided under the program.
5.  Premium payments.  Premiums must be paid in accordance with this subsection.
A.  Premiums must be paid at the beginning of each month for coverage for that 
month according to the following scale:
(1)  Families with incomes between 150% and 160% of the federal nonfarm 
income official poverty line pay premiums of 5% of the benefit cost per child, but 
not more than 5% of the cost for 2 children;
(2) Families with incomes between 160% and 170% of the federal nonfarm 
income official poverty line pay premiums of 10% of the benefit cost per child, 
but not more than 10% of the cost for 2 children;
(3)  Families with incomes between 170% and 185% of the federal nonfarm 
income official poverty line must pay premiums of 15% of the benefit cost per 
child, but not more than 15% of the cost for 2 children; and
(4)  Families with incomes between 185% and 200% of the federal nonfarm 
income official poverty line must pay premiums of 20% of the benefit cost per 
child, but not more than 20% of the cost for 2 children.
B.  When a premium is not paid at the beginning of a month, the department shall 
give notice of nonpayment at that time and again at the beginning of the 6th month of 
the 6-month enrollment period if the premium is still unpaid, and the department shall 
provide an opportunity for a hearing and a grace period in which the premium may be 
paid and no penalty will apply for the late payment.  If a premium is not paid by the 
end of the grace period, coverage must be terminated unless the department has 
determined that waiver of premium is appropriate under paragraph D.  The grace 
period is determined according to this paragraph.
(1) If nonpayment is for the first, 2nd, 3rd, 4th or 5th month of the 6-month 
enrollment period, the grace period is equal to the remainder of the 6-month 
enrollment period.
(2)  If nonpayment is for the 6th month of the 6-month enrollment period, the 
grace period is equal to 6 weeks.
C.  A child whose coverage under the Cub Care program has been terminated for 
nonpayment of premium and who has received coverage for a month or longer 
without premium payment may not reenroll until after a waiting period that equals the 
number of months of coverage under the Cub Care program without premium 
payment, not to exceed 3 months.
D.  The department shall adopt rules allowing waiver of premiums for good cause.
6.  Incentives.  In the contracting process for the Cub Care program and the Medicaid 
program, the department shall create incentives to reward health plans that contract with 
school-based clinics, community health centers and other community-based programs.
7.  Administrative costs.  The department shall budget 2% of the costs of the Cub 
Care program for outreach activities.  After the first 6 months of the program and to the 
extent that the program budget allows, the department may expend up to 3% of the 
program budget on activities to increase access to health care.  Administrative costs must 
include the cost of  staff with experience in health policy administration equal to one full-
time equivalent position.  In addition, the department shall apply for additional federal 
funds available for Medicaid outreach activities.  The goal of outreach activities under 
this subsection is to enroll 100% of children eligible for the Cub Care program or the 
MaineCare program.  The department shall contract with one or more organizations with 
experience in providing health care information and services to the public on a statewide 
basis for the outreach activities pursuant to this subsection.
8.  Quarterly determination of fiscal status; reports.  On a quarterly basis, the 
commissioner shall determine the fiscal status of the Cub Care program, determine 
whether an adjustment in maximum eligibility level is required under subsection 2, 
paragraph B and report to the joint standing committee of the Legislature having 
jurisdiction over appropriations and financial affairs and the joint standing committee of 
the Legislature having jurisdiction over health and human services matters on the 
following matters:
A.  Enrollment approvals, denials, terminations, reenrollments, levels and projections.  
With regard to denials, the department shall gather data from a statistically significant 
sample and provide information on the income levels of children who are denied 
eligibility due to family income level;
B.  Cub Care program expenditures, expenditure projections and fiscal status;
C.  Proposals for increasing or decreasing enrollment consistent with subsection 2, 
paragraph B;
D.  Proposals for enhancing the Cub Care program;
E.  Any information the department has from the Cub Care program or from the 
Bureau of Insurance or the Department of Labor on employer health coverage and 
insurance coverage for low-income children;
F.  The use of and experience with the purchase option under subsection 2, paragraph 
D E; and
G.  Cub Care program administrative costs.
9.  Provisions applicable to federally recognized Indian tribes.  After consultation 
with federally recognized Indian nations, tribes or bands of Indians in the State, the 
commissioner shall adopt rules regarding eligibility and participation of children who are 
members of a nation, tribe or band, consistent with Title 30, section 6211, in order to best 
achieve the goal of providing access to health care for all qualifying children within 
program requirements, while using all available federal funds.
10.  Rulemaking.  The department shall adopt rules in accordance with Title 5, 
chapter 375 as required to implement this section.  Rules adopted pursuant to this 
subsection are routine technical rules as defined by Title 5, chapter 375, subchapter II-A 
2-A.
11.  Cub Care drug rebate program.  Effective October 1, 1999, the department 
shall enter into a drug rebate agreement with each manufacturer of prescription drugs that 
results in a rebate equal to that which would be achieved under the federal Social Security 
Act, Section 1927. 
12.  Premium rate review; adjustment.  Effective July 1, 2004, the department shall 
periodically evaluate the amount of premiums charged under this section to ensure that 
the premiums charged reflect the most current benefit cost per child.  The commissioner 
shall adjust the premiums by rule.  Rules adopted pursuant to this subsection are routine 
technical rules as defined in Title 5, chapter 375, subchapter 2-A.
Sec. 4.  Federal Medicaid waivers or state plan amendments; funding.  
The Department of Health and Human Services shall establish coverage under the Maine 
Revised Statutes, Title 22, section 3174-T, subsections 2-A and 2-B as of the effective 
date of this Act using state funds.  The department may seek to acquire matching federal 
funds under the Medicaid program by submitting any waivers or state plan amendments 
to the United States Department of Health and Human Services, Centers for Medicare and 
Medicaid Services determined necessary.
Sec. 5.  Contracts required.  The Department of Health and Human Services 
shall contract for outreach activities, as required in the Maine Revised Statutes, Title 22, 
section 3174-T, subsection 7, beginning no later than January 1, 2020.  The department 
shall apply for federal grant funds available for use for outreach activities, including those 
established under the federal Helping Ensure Access for Little Ones, Toddlers, and 
Hopeful Youth by Keeping Insurance Delivery Stable Act, Public Law 115-120, and any 
subsequent amended versions, and the federal Advancing Chronic Care, Extenders and 
Social Services (ACCESS) Act, Public Law 115-123, and any subsequent amended 
versions.  These funds must be used to supplement the 2% funding and may not supplant 
that funding. 
Sec. 6.  Express lane eligibility; state plan amendment; report.  The 
Department of Health and Human Services shall, no later than January 1, 2020, submit a 
state plan amendment to the United States Department of Health and Human Services, 
Centers for Medicare and Medicaid Services to implement the use of the express lane 
eligibility option available under the federal Children's Health Insurance Program 
Reauthorization Act of 2009, Public Law 111-3, and any subsequent amended versions, 
and to implement the option no later than 6 months after receiving approval for the state 
plan amendment.  The department shall implement a model of express lane eligibility that 
determines eligibility for children under the MaineCare program and the Cub Care 
program, including the state-funded Cub Care program serving persons 19 and 20 years 
of age and noncitizens under 21 years of age established under the Maine Revised 
Statutes, Title 22, section 3174-T, subsections 2-A and 2-B.  The department shall report 
its progress on submitting the state plan amendment and implementing the express lane 
eligibility option to the joint standing committee of the Legislature having jurisdiction 
over health and human services matters no later than January 1, 2021.
SUMMARY
This bill makes the following changes to the Cub Care program.
1.  It changes the maximum eligibility level for family income from 200% of the 
federal poverty level to 325% of the federal poverty level.
2.  It removes the 3-month waiting period for enrollment in the Cub Care program 
following the loss of health insurance or coverage under an employer-based plan.
3.  It establishes that eligibility is not subject to an asset test.
4.  It provides coverage to persons 19 and 20 years of age and to noncitizens under 21 
years of age.  The Department of Health and Human Services is required to use state 
funds to fund the program but may apply for waivers or state plan amendments to the 
United States Department of Health and Human Services, Centers for Medicare and 
Medicaid Services to receive federal matching funds.
5.  It repeals the provisions regarding premium payments for the Cub Care program.
6.  It requires the department to contract for outreach activities rather than providing 
them directly.  The department must have a contract or contracts in place no later than 
January 1, 2020.  The department is also required to seek federal grant funds for 
additional outreach activities under the federal Helping Ensure Access for Little Ones, 
Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act, Public Law 
115-120 and the federal Advancing Chronic Care, Extenders and Social Services 
(ACCESS) Act, Public Law 115-123.
7.  It requires the department to submit a state plan amendment to the United States 
Department of Health and Human Services, Centers for Medicare and Medicaid Services 
to implement the use of the express lane eligibility option no later than January 1, 2020 
and to implement it no later than 6 months after receiving approval.