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 5.5 - CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - CUB CARE › Section 144-332-5.5-8 - CHANGES

Current through 2024-29, July 17, 2024
A. The child remains eligible for Cub Care
				  throughout the twelve month period without regard to changes in household
				  income. However, coverage can be ended if the child no longer meets any of the
				  other eligibility requirements identified under "basic eligibility
				  requirements."
B. The child must be
				  moved to Medicaid coverage if s/he withdraws from Cub Care and the child
				  becomes Medicaid eligible due to a change in circumstances and the change is
				  expected to last for a full calendar month. The change to Medicaid will be 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.
If the family withdraws from Cub Care, this will end the
					 twelve month enrollment period. If coverage continues under Cub Care or
					 Medicaid, this starts twelve months of continuous Medicaid coverage.
C. A child can be added to Cub
				  Care when some members of the household are already covered by Cub Care.
For example:
If a child moves into a household, the child can be
						added to Cub Care;
											If a child becomes ineligible for Medicaid, the child
						can be added to Cub Care.
When a child is added, the premium will be based on the
					 household income already established for the current enrollment period.
Household income will not be recalculated even if the child
					 being added has income of their own.
The child can be added effective the month the change
					 occurred as long as the change is reported within ten days of its occurrence;
					 otherwise, the child is added effective the month the change is
					 reported.
A premium is due for each month a child is open for Cub
					 Care coverage unless exempted from payment.
D. When a child is covered by Medicaid and
				  becomes ineligible, coverage will be reviewed for Cub Care. A ten day notice
				  will be given when a child moves from Medicaid to Cub Care coverage.
SECTION 9: ELIGIBILITY PERIODS
A. Coverage under Cub Care is determined for
				  a twelve month enrollment period for all members of a household, beginning with
				  the month of application or, if ineligible for that month, coverage starts in
				  the following month. There is only one enrollment period for a household.
B. Eligibility is determined for a
				  twelve month period by projecting household income over that twelve month
				  period, including the month of application. The child remains eligible for the
				  twelve month period without regard to changes in household income.
In some instances, the individual is not eligible for
					 coverage during the month of application but is eligible for the following
					 month. In this situation, the twelve month eligibility period begins with the
					 month following the month of application.
C. Premiums are set at the beginning of the
				  twelve month enrollment period and do not change regardless of household
				  income. Any household income changes must be reported when the child reapplies
				  for coverage.
Changes affecting eligibility must be reported within ten
					 days of their occurrence. Examples of such changes include: an eligible child
					 no longer resides in the household, or s/he is covered by health insurance.
					 "Occurrence" is the date the change takes place.
The individual may withdraw from Cub Care and end his/her
					 twelve month enrollment period if s/he becomes Medicaid eligible (See Section 7
					 of this Part).
D.
				  Reapplications
The individual must reapply and be found eligible in order
					 for coverage to continue beyond a twelve month enrollment period.
The individual will be sent a reapplication before the
					 twelve month enrollment period ends. In order for coverage to continue for the
					 next twelve months, premiums that have been due must be paid, the child must be
					 otherwise eligible, and there are no penalties in effect.
If, by the 15th of the
					 12th enrollment month, a completed reapplication and
					 all needed documentation is received by OFI, coverage can continue
					 uninterrupted as long as there is financial eligibility and premiums that were
					 due have been paid.
E. A
				  child who has been covered by Cub Care and whose household income exceeds 208%
				  of the Federal Poverty Level (See Chart 6.5) at the end of the twelve month
				  enrollment period will be provided notice for possible extended coverage
				  through the Health Insurance Purchase Option (HIPO). Refer to Chapter 335
				  Health Insurance Purchase Option (HIPO) in this manual. (10-144 CMR Chapter
				  335)
SECTION 10: NOTICES
A. Eligibility or Ineligibility
Individuals will be notified in writing as soon as
					 eligibility is determined. If some of the individuals applying for medical
					 coverage are eligible and some are not, the notice must specify who is or is
					 not eligible and the reasons for each individual's ineligibility.
Individuals whose eligibility begins after the month of
					 application must be sent a denial notice for the months of
					 ineligibility.
When an individual is determined to be ineligible, the
					 notification will contain:
(1) a
				  statement that the application has been denied;
(2) the specific reason(s) for the
				  denial;
(3) the manual citations
				  which support the decisions; and
(4) an explanation of the individual's right
				  to request a hearing;
B.
				  Adverse Action
In situations when the intended action is to discontinue
					 eligibility or to reduce services, timely and adequate notice must be given to
					 the recipient. However, coverage will not be continued beyond the enrollment
					 period pending a hearing decision. Also, as long as a child is open for Cub
					 Care coverage, a premium will be due and unpaid premiums will incur a
					 penalty.
"Timely" means that the notice must be mailed fifteen days
					 before the intended change would be effective (ten days for notice plus five
					 days for mail).
"Adequate" means a written notice which includes a
					 statement of:
(1) the action the
				  Department intends to take;
(2) the
				  reasons for the intended action;
(3) the regulations supporting such action;
				  and
(4) an explanation of the
				  rights to request a hearing.
C. Denials
If a child is not eligible for Medicaid but eligible for
					 coverage under Cub Care, s/he needs to be informed of his/her eligibility for
					 Cub Care, and that Medicaid has been denied.
If an application is denied for MAGI- Related Medicaid and
					 Cub Care, notification will be given that other coverage may be available if
					 the household has large medical bills or a child has a disabling
					 condition.
D. Closings
If coverage under Cub Care is ended for a reason other
					 than the enrollment period has ended, the individual will be given adequate and
					 timely notice. When the child is granted coverage for the twelve month period,
					 s/he will be informed that coverage will automatically end at the end of the
					 twelve month period.