Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter II - PROGRAM PARTICIPATION › Section 144-103-II-2.2 - Recipients

Current through 2024-29, July 17, 2024
1. Eligibility Period
Eligibility periods are generally six months.
It is the responsibility of the recipient to report changes
					 in circumstances which affect eligibility, such as, but not limited to, income,
					 assets, and/or household income, to the Department.
Such changes are to be reported within 10 days from
					 occurrence. For income purposes "occurrence" will be considered the date the
					 increased income was received. For all other purposes, "occurrence" will be
					 considered the date the change took place.
All changes reported by the recipient during the six month
					 eligibility period must be reviewed by the Eligibility Specialist to determine
					 the effect of the change on the recipient's eligibility. Within thirty (30)
					 calendar days of receipt of the information, the Department will determine if
					 the recipient remains eligible for the Program.
If the new information results in Program termination, the
					 Eligibility Specialist must determine the individual's eligibility, if any, for
					 any other medical assistance program.
2. Eligibility Recall
The Eligibility Specialist may want to look at specific
					 eligibility factors rather than review the individual' entire situation. In
					 such instances, the Eligibility Specialist may recall the case at any time. The
					 Eligibility Specialist must recall the case when:
- There is reason to believe the individual's circumstances
					 will change.
- The countable assets of the household are within $200 of
					 the appropriate standard. If this occurs, the assets must be reviewed every
					 three months.
- The countable assets of the household are within $100 of
					 the appropriate standard. If this occurs, the assets must be reviewed
					 monthly.
3. Eligibility
				  Reviews
Eligibility will be reviewed at least at the end of each
					 eligibility period. Recipients must complete and submit review forms. If the
					 review form is not received in a Department Regional Office by the end of the
					 month in which the last day of the advance notice period falls it is considered
					 a new application if and when it is received unless there is good cause, in
					 which case it will not be considered a new application.
Good cause for missing the filing deadline may be
					 established by the Eligibility Specialist. Reasons for good cause include but
					 are not limited to:
* mail delay;
* illness or death in the family or of other significant
					 people; or
* circumstances beyond the control of the recipient.
4. Eligibility Criteria
Income
The 2000 section of the Maine Medicaid Eligibility Manual
					 on treatment of AFDC related income, except for income limits, shall be used to
					 determine countable income.
Income of recipients in the "basic" Program must be at or
					 below 100% of the federal poverty guidelines. Income of recipients in the
					 "transition" Program must be greater than 100%, or less than or equal to 150%
					 of the federal poverty guidelines See section 2.2-7 for additional information
					 regarding the "transition" program.
Monthly Income Limits
Family
100% of
150% of
Size
Poverty Level
Poverty
								Level
1
614
920
2
820
1230
3
1027
1540
4
1234
1850
5
1440
2160
6
1647
2470
7
1854
2780
8
2060
3090
Each Added Person
207
310
Assets
The 3000 section of the Maine Medicaid Eligibility Manual
					 on treatment of assets for SSI related, except for the asset limits, shall be
					 used to determine countable assets.
The asset limits for both "basic" and "transition" Programs
					 are as follows:
* Age 20-64 = $2,000 for the first person $3,000 for two
					 people $100 for each additional individual; or
* Age 65+ = $10,000 for each individual or individual
					 living with a spouse.
5.
				  Conditions Of Participation
Covered Individuals
Individuals age twenty (20) and older whose countable
					 income and assets are less than or equal to the Program limits may participate
					 in the Maine Health Program.
Cooperation With Medicaid
As a condition of eligibility, recipients must cooperate
					 with the Department to establish whether they qualify for Medicaid.
					 Noncooperation will result in denial or termination of Program coverage.
When a recipient's medical condition changes so that she
					 may qualify for Medicaid, the recipient is required to cooperate in determining
					 eligibility for Medicaid.
Verification Of Eligibility Information
Verification of information needed to determine eligibility
					 must be requested initially from the recipient. If information is requested
					 from other sources (with the exception of public records), the individual must
					 be informed. If collateral contacts are necessary and the individual does not
					 give consent, termination will occur.
When a decision cannot be made due to inconclusive or
					 conflicting information, the individual will be notified what questions remain
					 and what needs to be resolved. If the Department cannot determine that
					 eligibility exists after contacting the individual or collateral contacts,
					 assistance will be terminated. Termination will be carried out in conformance
					 with the rights of individuals, including an advance notice of adverse action
					 and the right to request a Fair Hearing.
It is the responsibility of the Department to assist the
					 individual in establishing eligibility for medical assistance. It is the
					 responsibility of the individual to satisfy all eligibility requirements. The
					 individual or the individual's representative is responsible for supplying
					 verification of information to all persons in the household whose circumstances
					 affect eligibility. If this information is not provided, eligibility does not
					 exist.
Residence
Recipients must be a resident of Maine.
Eligibility cannot be terminated because:
- an individual has not resided in the State for a
					 specified period of time;
- the individual did not establish residence before
					 entering a medical institution; or
- an individual is temporarily or involuntarily absent from
					 the State, provided the individual intends to return once the purpose for the
					 absence has been accomplished, unless another state has determined the
					 individual has no intent to return to retain residency in Maine.
Social Security Numbers
As a condition of eligibility, an individual is required
					 to:
- furnish the Department with a Social Security number. If
					 the individual has a Social Security number but is unable to provide it, the
					 Department will contact the Social Security Administration in order to obtain
					 the number. Program coverage will not be withheld or terminated while
					 verification of the individual's Social Security number is being obtained from
					 the Social Security Administration; or
- apply to the Social Security Administration for a Social
					 Security number if the individual does not have a Social Security number. The
					 recipient must provide the Department with verification that the application
					 for a Social Security number has been made. Program coverage will not be
					 withheld or terminated for lack of a Social Security number as long as the
					 individual provides verification of application for a Social Security number
					 for those requesting assistance.
No individual can receive Program benefits until the
					 requirements in (1) or (2) above have been met. The Eligibility Specialist
					 should explain that the application for a Social Security number requires the
					 individual to provide a valid birth certificate or other proof of age and
					 verification of identity. The Department must assist the individual in
					 obtaining verification information necessary to apply for a Social Security
					 number. This includes obtaining documents to prove date of birth, citizenship
					 or identity. The Department cannot pay any costs incurred by the individual in
					 obtaining this information.
Individuals must be informed that their Social Security
					 number will be utilized in the administration of the Program and will be used
					 for verification of information such as wages, unemployment benefits and bank
					 accounts.
Citizenship
An individual must be a citizen of the United States or a
					 lawfully admitted alien. An individual who is not a citizen of the United
					 States must be an alien lawfully admitted for permanent residence or otherwise
					 permanently residing in the United States under the color of law (including any
					 alien who is lawfully present in the United States as the result of the
					 application of the provisions of Section 203(a) (7), (207) (c), 208 and 212 (d)
					 (s) of the Immigration and Nationality Act). An individual who has resided in
					 the United States continuously from any date before January 1, 1972, is
					 considered a legally admitted alien.
Each individual who is not a citizen must provide either
					 (1) documents from the Immigration and Naturalization Service or (2) other
					 documents which prove the person is a lawfully admitted alien. Alien status is
					 subject to verification by the Immigration and Naturalization Services.
As a condition of eligibility, recipients must declare
					 their citizenship or alien status, in writing on Department forms.
6. Determining Eligibility
Determine Household Size And Financial
					 Responsibility
The financial responsibility of relatives is limited to
					 spouse for spouse (living together) and parents for minor children living with
					 them. All members who reside in the household and among whom a legal
					 responsibility for support exists will be included in the household when
					 determining eligibility.
Examples: Mr. Jones, age 35 Mrs. Jones, age 33 Daughter
					 Jones' age 14 Son Jones, age 10
Household size is a family of four (4) in determining the
					 eligibility for the adults. For adults, countable income is compared to 100% of
					 federal poverty level for a size of four (4).
Since financial responsibility does not exist from children
					 to parents, those children with income which affects eligibility may be removed
					 from the household unit. Such children are considered to be self-sufficient and
					 no allocation of the parent's income may be made.
Countable Income And Assets
The individual's countable income and assets shall be
					 compared to the income and asset limits.
7. "Transition" Program
Only recipients who have participated in the "basic"
					 Program are eligible to participate in the "transition" Program. Recipients
					 whose household income exceeds the basic Program's income eligibility standards
					 by no more than 50% may participate in the "transition" Program provided the
					 recipients pay a premium to the Department. See Chapter V, Premiums.
"Transition" coverage is available for up to twelve (12)
					 months.
The "transition" period begins the first month the change
					 from the Basic" Program can be effective with twelve (12) day notice when a
					 change in circumstance(s) is reported timely. Recipients must agree to
					 participate in the "transition" Program in the first month in which they are
					 eligible for coverage or lose the opportunity to participate in the
					 "transition" Program. Recipients who become ineligible for the "transition",
					 Program for reasons other than non-payment of fees (e.g. move out of State or
					 income increases more than 50%) are not eligible for reinstatement in the
					 "transition" Program.
"Transition" recipients whose household income decreases
					 are eligible for "basic" Program coverage again. If, subsequently, they become
					 eligible for the "transition" Program because of an increase in household
					 income, they are eligible to receive "transition" coverage
					 again.