Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 332 - MAINECARE ELIGIBILITY MANUAL › Part 7 - SSI - RELATED MEDICAID BUDGETING › Section 144-332-7-6 - BUDGETING FOR WORKING DISABLED

Current through 2024-29, July 17, 2024
There is a two step test of income that must be met.
I. Countable unearned income must be equal to
				  or less than 100% of the Federal Poverty Level.
II. Countable unearned and earned income
				  subject to federal tax withholding must be less than 250% of the FPL.
Section 6.1
:
				  Earnings
The individual must have earnings subject of federal tax
					 withholding but there is no minimum work requirement and no SGA earnings
					 test.
Section 6.2
:
				  Disability
The individual must meet the SSI criteria for disability.
					 This criteria is met if there is currently in effect a decision by the Social
					 Security Administration that this disability criteria is met.
Section 6.3
: Changes
If the individual becomes eligible for Medicaid without a
					 premium because of a change in income and that change is expected to last for a
					 full calendar month, the individual will be moved to Medicaid coverage without
					 a premium. This change is made effective the month the change occurred as long
					 as this change is reported within ten days of its occurrence; otherwise, it is
					 effective the month the change is reported. "Occurrence" is the date the change
					 takes place.
The individual will be given a refund for any prepaid
					 months in which s/he is subsequently moved to coverage without a
					 premium.
Section 6.4
: Premiums
I.
Due
				  Date/Amount of Premium
A premium payment is due for each month the individual is
					 open for Medicaid under this coverage group unless s/he is exempt from a
					 premium as identified below.
If a couple is eligible under this coverage group, there is
					 one premium for the couple based on the couple's countable income.
Premiums are due on the first day of each month of
					 coverage.
The premium amount is based on countable monthly income
					 projected for the twelve month eligibility period and does not change. A
					 premium is effective the month an individual is added for coverage under this
					 coverage group. Any decrease in premium is effective the month the individual's
					 coverage under this group ends.
If countable monthly income is over 150% and equal to or
					 less than 200% of the FPL, the monthly premium is $10.00. If countable monthly
					 income is over 200% and less than 250% of FPL the monthly premium is
					 $20.00.
II.
Exemptions from Premium Payment
An individual is exempt from a premium:
A. if countable income is less than or equal
				  to 150% of the Federal Poverty Level;
B. if s/he is responsible for paying for
				  their Medicare Part B premium; or
C. if there is good cause for premiums not
				  paid or not paid when due because of one of the following reasons:
1. mail delay;
2. illness of the individual or their
				  responsible relative; or 3. an anticipated emergency beyond the control of the
				  individual or their responsible relative.
D. For periods of retroactive coverage or
				  temporary coverage.
III.
Payment of Premiums
A. Premiums
				  can be paid monthly, for more than one month at a time, or they can be paid in
				  advance for the twelve month eligibility period. Payments will be credited to
				  the earliest months of coverage first, during the current 12 month eligibility
				  period.
Example
A monthly premium of $10.00 is due during a twelve month
					 eligibility period from January to December and the first payment of $50 is
					 received on June 1st. Months one through five will be credited with a premium
					 paid. The June payment is overdue.
B. When a premium is not paid by the first of
				  the month in which it is due the Department will give notice of
				  nonpayment.
C. There is a grace
				  period for nonpayment of premiums. The grace period extends through the last
				  day of the twelve month eligibility period.
Example
If the eligibility period is January through December, the
					 individual has until December 31st to pay his or her premiums for the period
					 January to December. If the last day of the month falls on a weekend or holiday
					 the premium is then due on the next workday.
D. When eligibility under this coverage group
				  ends prior to the end of the twelve month eligibility period, the grace period
				  for premium payment extends to the last day of the month in which coverage
				  under the Working Disabled group ends.
Example
An individual granted 10/07 has a review date of 9/08 but
					 his coverage is changed to Medicaid without a premium for 12/07. The grace
					 period for payment of premiums for October and November is November
					 30th.
E. When eligibility
				  under this coverage group is continued pending a hearing and a premium is due,
				  the grace period is the last day of the month for which coverage is provided.
Example
The premium for the month of July is due July 1st. The
					 grace period extends to July 31st.
IV.
Non Payment of Premiums
A. At the beginning of month twelve of the
				  eligibility period, notification will be given if any premiums for the
				  eligibility period have not been paid when due. The individual will be notified
				  of the penalty to be imposed because of the nonpayment.
B. At the twelve month review a determination
				  will be made as to whether there are any overdue premiums. If so, coverage
				  under the Working Disabled group will end unless there is "good cause" for
				  nonpayment. Coverage as Working Disabled cannot begin again until any unpaid
				  premiums are paid.
V.
Administrative Hearings
A.
				  Coverage as Working Disabled continues pending a hearing decision if a hearing
				  is timely requested even if the individual is not paying premiums that are due.
				  If the individual was responsible for paying a premium prior to the proposed
				  negative action, this premium will continue to be due.
B. If the individual is upheld at the hearing
				  and they have overpaid any premiums s/he will be issued a refund.