reglab/statecodes huggingface dataset:
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-7 - COOPERATION IN OBTAINING MEDICAL SUPPORT FROM THE NON-CUSTODIAL PARENT AND ESTABLISHING PATERNITY

Current through 2024-29, July 17, 2024
Section 7.1:
Who Must Comply
Certain individuals must cooperate in obtaining medical
					 benefits from the non-custodial parent of a dependent child (See Part 3) and in
					 establishing paternity. If the individual can show that good cause for not
					 cooperating exists, no referral will be made.
These individuals are parents or caretaker relatives
					 applying on behalf of themselves and their children unless the assistance unit
					 is being covered under Transitional Medicaid.
This provision does not apply to individuals who are
					 pregnant, individuals covered under Transitional Medicaid, individuals enrolled
					 only in the Medicare Savings Program, Maine Rx, DEL, or HIPO. An individual who
					 does not comply with this requirement is not eligible for Medicaid. It is the
					 parent or other specified relative applying on behalf of the child under age 18
					 who is not eligible, not the child.
Section 7.2:
Child Support
				  Requirements
I. Identify and help
				  locate those parents of a dependent child for whom Medicaid is
				  requested.
II. Cooperation includes
				  responding to requests for information from DSER and appearing as a witness at
				  a judicial or other hearing or proceeding.
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-8 - GOOD CAUSE

Current through 2024-29, July 17, 2024
I.
				  Applicant/Participant Rights
A. Every Medicaid
				  or CHIP applicant or recipient may claim good cause for refusing to cooperate
				  with TPL, medical support, or cooperating with the Department's establishment
				  of medical support from the non-custodial parent. When the individual claims
				  good cause, sanctions are not implemented unless it is finally determined that
				  good cause does not exist.
B.
				  Applicants receive an explanation of cooperation requirements, sanctions, and
				  the right to claim good cause. The Department may attempt to establish
				  paternity and collect medical support in cases where there is no risk to the
				  individual or children.
C. If good
				  cause is not granted, the individual is given the opportunity to withdraw from
				  the benefit or provide additional information to substantiate the claim. If
				  good cause is granted, no referral is made.
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-9 - INDIVIDUALS RESIDING IN PUBLIC INSTITUTIONS

Current through 2024-29, July 17, 2024
I.
				  Medicaid coverage is authorized for inmates of state prisons, Mountain View
				  Correctional Facility, Long Creek Youth Development Center, and local or county
				  jails, if the individual meets financial and non-financial criteria applicable
				  to non-inmates. Medicaid will only pay for any coverable in-patient service
				  provided to the inmate while they are an in-patient in a hospital, nursing
				  home, Intermediate Care Facility for Individuals with Intellectual Disabilities
				  (ICF/IID) or juvenile psychiatric facility.
II. Individuals admitted to a medical
				  institution classified as an IMD (Institution for Mental Disease) for over 30
				  days. Examples of Institutions for Mental Disease are Spring Harbor, Acadia,
				  Riverview Psychiatric Center, and the Dorothea Dix Psychiatric Center. The
				  following applies:
A. If over age 20 and under
				  age 65, these individuals are not Medicaid eligible until they are released,
				  conditionally or unconditionally, or are on convalescent leave from the
				  facility. Individuals may apply prior to discharge.
B. If under age 21 (through age 20) or age 65
				  or over, coverage is available for all Medicaid coverable services.
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-10 - APPLICATION FOR OTHER BENEFITS

Current through 2024-29, July 17, 2024
Individuals must apply for other benefits to which they may
					 be entitled. This includes applying for the benefit and providing the
					 Department with necessary information to determine eligibility.
I. Other benefits include, but are not
				  limited to, Social Security, Railroad Retirement, Veteran's Pension/
				  Compensation, Worker's Compensation, and Unemployment Insurance. This provision
				  does not apply to SSI, State Supplement, TANF cash benefits and other Federal,
				  State, local or private programs which make payments based on need.
II. Individuals who apply for Medicaid and
				  DEL and who are eligible for Medicare Parts A, B and/or D must be enrolled in
				  or apply for these programs and a Medicare Part D Prescription Drug Plan at the
				  next available opportunity to do so.
III. Individuals who are enrolled in Medicaid
				  and DEL and subsequently become eligible for Medicare Parts A, B and/or D must
				  be enrolled in or apply for these programs and a Medicare Part D Prescription
				  Drug Plan at the next available opportunity to do so.
IV. There is good cause for not enrolling in
				  Medicare and/or Medicare Part D Prescription Drug Plan if:
A. The individual is not eligible for
				  Medicaid and DEL to pay any premiums and cost sharing for Medicare Parts A
				  and/or B as described in Part 8.
B.
				  The individual is denied enrollment by Medicare or by a Medicare Prescription
				  Drug Plan due to circumstances beyond their control,
C. The individual has prescription drug
				  coverage which is determined by the insurer to be creditable coverage.
				  Creditable coverage means that the coverage on the average is at least as good
				  as the standard Medicare Prescription drug plan. or
D. Enrollment is not cost effective as
				  determined by the Pharmacy Benefits Manager.
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-11 - APPLICATION PROCESS

Current through 2024-29, July 17, 2024
I. An application
				  is a signed request for MaineCare coverage made through one of the following
				  methods:
A. a document approved by OFI as an
				  application form;
B. the My Maine
				  Connection website;
C. the
				  Federally Facilitated Marketplace (FFM) (
https://www.healthcare.gov/
);
D. The State Based Marketplace (SBM) (
https://CoverME.gov
); or
E. the telephone or fax machine
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-14 - CLOSINGS AND DENIALS

Current through 2024-29, July 17, 2024
Before MaineCare coverage is ended or denied, it must be
					 determined that the individual is not eligible under any coverage group. This
					 includes:
I. Doing a disability
				  determination when there is information that the individual can potentially
				  meet the disability criteria;
II.
				  Determining medical and financial eligibility for a Waiver, Nursing Home Care,
				  or Katie Beckett coverage groups when there is information that the individual
				  can potentially meet these criteria;
III. Determining continuing coverage when
				  SSI/State Supplement cash benefits end;
IV. Determining eligibility under CHIP and
				  Maine Rx.
When individuals lose eligibility for SSI and/or State
					 Supplement payments and a review for continued MaineCare is needed, existing
					 information in the case record is used to determine continuing eligibility for
					 MaineCare. If there is insufficient information in the case record to determine
					 eligibility or a disability determination is necessary, coverage must be
					 continued until ineligibility is determined. If a review form is necessary, it
					 must be sent to the individual within ten days of the date SSI and/or State
					 Supplement coverage has ended.
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-15 - NOTICES

Current through 2024-29, July 17, 2024
Individuals are notified in writing as soon as eligibility
					 is determined. If some of the individuals applying for MaineCare are eligible
					 and some are not, the notice must specify who is and who is not eligible and
					 the reasons for each individual's ineligibility.
I. Individuals whose eligibility begins after
				  the month of application must be sent a denial notice for the month(s) of
				  ineligibility.
II. All individuals
				  who apply for Medicaid must be notified of their eligibility for retroactive
				  coverage. Such notification must indicate the months of eligibility or
				  ineligibility.
III. When an
				  individual is determined to be ineligible, the notification contains-
A. a statement that the application has been
				  denied,
B. the specific reason(s)
				  for the denial,
C. the manual
				  citations which support the decisions, and
D. an explanation of the individual's right
				  to request a hearing.
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 2 - BASIC ELIGIBILITY CRITERIA › Section 144-332-2-16 - UNFUNDED CHECKS

Current through 2024-29, July 17, 2024
An unfunded or bounced check is considered non-payment of a
					 premium. Upon notice from State Treasury that a check has bounced, the
					 household will be sent a notice of non-payment including the amount now due. If
					 no payment is received within 30 days of the first notice, a second notice is
					 sent. If no payment is received, the penalty will take effect the month
					 following the month in which the second notice is sent, if the client has
					 received 15 days advance notice.
Example
The family is sent a second notice of non-payment on May
					 10. No payment is received within fifteen days. The penalty starts June 1. If
					 the notice was not sent until May 30, the penalty would take effect July
					 1.
The penalty is a period of time that the client cannot get
					 coverage under the option for which there is a non-payment. The duration of the
					 penalty period depends on the coverage option involved.
For Working Disabled, coverage cannot continue after the
					 end of the current or last enrollment period unless the unpaid premiums are
					 paid.
For the Special Benefit Waiver, coverage cannot continue
					 after the end of the current period unless all outstanding premiums are
					 paid.
For Katie Beckett, coverage cannot continue after the end
					 of the current three-month premium period unless all outstanding premiums are
					 paid.
Note
: A family's three-month enrollment period
					 cannot be ended to impose this penalty.
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 3 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3-1 - DEFINITIONS

Current through 2024-29, July 17, 2024
DEPENDENT CHILD
: A dependent child means a
					 child who is under the age of 18 or is age 18 and a full-time student in
					 secondary school (or equivalent vocational or technical training), if before
					 attaining age 19 the child may reasonably be expected to complete such school
					 or training.
FEDERAL POVERTY LEVEL (FPL)
: A measure of
					 income issued annually by the Department of Health and Human Services (HHS)
					 that is used to determine financial eligibility for programs and benefits. The
					 poverty guidelines are updated periodically in the Federal Register by the U.S.
					 Department of Health and Human Services under the authority of
					 42 U.S.C. §
											9902(2).
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 3 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3-2 - ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES

Current through 2024-29, July 17, 2024
To be eligible for MaineCare in a coverage group for which
					 MAGI-based methodology applies, an individual must:
I. Be a covered individual;
II. Have an eligibility group;
III. Meet basic eligibility criteria in this
				  Part and in Parts 2 and 17; and
IV.
				  Meet income criteria.
To get Medicaid coverage under an eligibility group for
					 which MAGI-based methodology applies, an individual must meet the criteria of
					 at least one of the groups listed in Sections 2.1-2.4 of this part. An
					 individual may meet the criteria of more than one group at the same time in
					 which case they should be enrolled with the group which is the easiest way for
					 them to get the best coverage.
Section
				  2.1:
Children
I.
Newborns
A. If the newborn's
				  mother is receiving Medicaid (or is covered as part of the retroactive period)
				  on the date the baby is born, the baby is eligible regardless of the income of
				  the household. The mother must be fully covered by Medicaid on the day of the
				  baby's birth. If the mother meets the deductible amount on the day of the
				  baby's birth and is partially responsible for any medical bills on that date,
				  the newborn is not eligible in this group.
B. Coverage continues for one year. This
				  means that the baby is eligible without regard to changes in income or
				  composition of the household.
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 3 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3-3 - OTHER NON-MAGI ELIGIBILITY GROUPS

Current through 2024-29, July 17, 2024
Other special coverage groups refers to various special
					 groupings created by federal and/or state legislation. Specifically, IV-E
					 Eligible and State Adoption Assistance:
I.
Move-In from Out of State
An individual under the age of 21, who is receiving Title
					 IV-E funds from another state or is covered by a State Adoption Agreement from
					 another state and moves to Maine, is eligible for Medicaid. The income and
					 assets of the child and parents are not considered to determine eligibility for
					 this child.
There must be an assignment of rights to medical support
					 and the Department must be provided with a Social Security number for the
					 child.
There are three groups of children who fall into this
					 category:
A. Children whose medical
				  and financial circumstances qualify them for federal IV-E adoption
				  assistance;
B. Children whose
				  medical and financial circumstances qualify them for federal IV-E foster care
				  assistance; and
C. Children whose
				  medical and financial circumstances qualify them for state adoption assistance.
The foster or adoptive parents in Maine are provided with a
					 written explanation of their status by the state of origin which usually serves
					 as verification of their status.
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 3 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3-4 - TRANSITIONAL MAINECARE

Current through 2024-29, July 17, 2024
Transitional MaineCare (TM) is MaineCare coverage that is
					 available to families who become ineligible for MAGI-based coverage due to
					 increased earnings or hours of employment of the parent or caretaker relative
					 (as defined by Section 2.2 in this Part), or because of receipt of or increase
					 in alimony.
Section 4.1:
General
				  Requirements
Section 4.1.1:
Covered Individuals
TM is available to individuals who were eligible for
					 MAGI-based MaineCare coverage in either the Children Under 18, or the
					 Parent/Caretaker groups (except Expansion Adults with income above 100%
					 FPL).
TM households are determined on an individual basis using
					 MAGI household composition rules. Some individuals may be granted TM while
					 others may continue in MAGI coverage groups.
Membership in a TM household includes those individuals
					 whose needs and income were included in determining eligibility for the MAGI
					 coverage group at the time of closing.
The following individuals may also be added to a TM
					 household:
I. a parent/caretaker
				  relative who returns home whose needs and income would be considered in
				  determining coverage under MAGI, and whose earnings/alimony, either alone or
				  added to other income of the household, result in the loss of MAGI
				  coverage;
II. a child or
				  parent/caretaker relative who moves into the home after TM has
				  started;
III. a child who is born
				  after TM has started; or
IV. a
				  pregnant individual who was included in a MAGI household and loses coverage
				  after the end of the pregnancy, if the individual's spouse and/or dependent
				  children are receiving TM.
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 3.5 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3.5-1 - DEFINITIONS

Current through 2024-29, July 17, 2024
DEPENDENT CHILD:
A dependent child means a
					 child who is under the age of 18 or is age 18 and a full-time student is
					 secondary school (or equivalent vocational or technical training), if before
					 attaining age 19 the child may reasonably be expected to complete such school
					 or training.
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 3.5 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3.5-2 - ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES

Current through 2024-29, July 17, 2024
To be eligible for MaineCare in the category of a
					 Categorically Needy eligibility group for which MAGI-based methodology applies,
					 an individual must:
A. be a covered
				  individual;
B. have an eligibility
				  group;
C. meet basic eligibility
				  criteria in this Part and in Parts 2 and 17.5; and
D. meet income criteria.
In order to get Medicaid coverage under an eligibility
					 group for which MAGI-based methodology applies, an individual must meet the
					 criteria of at least one of the groups below. An individual may meet the
					 criteria of more than one group at the same time in which case they should be
					 enrolled with the group which is the easiest way for them to get the best
					 coverage.
Section 2.1:
Children
An individual who is under the age of 21.
A. Newborns
(1) If the newborn's mother is receiving
				  Medicaid (or is covered as part of the retroactive period) on the date the baby
				  is born, the baby is eligible regardless of the income of the household. The
				  mother must be fully covered by Medicaid on the day of the baby's birth. In
				  other words, if mother meets the deductible amount on the day of the baby's
				  birth and is partially responsible for any medical bills on that date, the
				  newborn is not eligible in this group.
(2) Coverage continues for one year. This
				  means that the baby is eligible without regard to changes in income or
				  composition of the household.
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 3.5 - ELIGIBILITY GROUPS REQUIREMENTS › Section 144-332-3.5-3 - OTHER NON-MAGI ELIGIBILITY GROUPS

Current through 2024-29, July 17, 2024
Other special coverage groups refers to various special
					 groupings created by federal and/or state legislation. Specifically:
Refugee/Asylees
										IV-E Eligibles and State Adoption
						assistance
Section 3.1:
Refugees/Asylees
Persons who are eligible for services under the Refugee
					 Resettlement Program (RRP) are eligible for Medicaid provided that financial
					 and basic eligibility requirements are met. Eligibility is determined on the
					 basis of need without regard to family composition or the presence of children.
					 Age is not considered. Financial eligibility follows MAGI-Based budgeting in
					 Part 17.5.
A.
Special
				  Eligibility Factors
(1) Each applicant
				  must have a Form I-94, I-151, or I-551 indicating that the individual has been
				  admitted under Section 212(d)(5) of the Immigration and Naturalization Act
				  (INA) or granted asylum under Section 208 of the INA.
(2) Any funds received through the RRP are
				  counted as unearned income and used in determining eligibility.
(3) The following guideline should be used
				  for documentation:
(a) Form I-94 may be
				  accepted as proof of age.
(b) Any
				  documents that the refugees brought with them when they emigrated showing the
				  relationship among family members is acceptable evidence of
				  relationship.
(c) School records
				  and medical records established since arrival in the United States may be used
				  as methods of verification.
(d)
				  Information recorded in the refugee assistance case folder may be used as
				  supporting evidence.
(e) If there
				  are no written records of any kind, the refugee's statement is acceptable
				  unless the statement appears unreasonable.
(4) The income of sponsors and any
				  income-in-kind they provide is not used in determining eligibility.
(5) Children born to refugees in this country
				  are considered United States citizens. They are issued alien registration
				  numbers which are the same as their mother's with the suffix 01, 02, 03, etc.
				  These children are considered a part of the refugee family for eligibility
				  purposes.
(6) Individuals who are
				  dependents of repatriated United States citizens may be eligible during the
				  first ninety days after their arrival in the United States if the individuals
				  qualify as refugees under the RRP.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-1 - DEFINITIONS

Current through 2024-29, July 17, 2024
FAMILY SIZE
: Family size means the number of
					 persons counted as members of an individual's household. In the case of
					 determining the family size of a pregnant woman, the pregnant woman is counted
					 as herself plus the number of children she is expected to deliver. In the case
					 of determining the family size of other individuals who have a pregnant woman
					 in their household, the pregnant woman is counted as 1 person.
FEDERAL POVERTY LEVEL (FPL):
A measure of
					 income issued annually by the Department of Health and Human Services (HHS)
					 that is used to determine financial eligibility for programs and benefits. The
					 poverty guidelines are updated periodically in the Federal Register by the U.S.
					 Department of Health and Human Services under the authority of
					 42 U.S.C. §
											9902(2).
HOUSEHOLD INCOME
: Household Income means the
					 sum of the MAGI-based income, of every individual included in the individual's
					 household (subject to the rule described in Section
					 2(C) below), EXCEPT
					 that income in the following circumstances will not be included in household
					 income:
(1) The MAGI-based income of an
				  individual who is included in the household of his or her natural, adopted or
				  step parent, and is not expected to be required to file a tax return under
				  section 6012(a)(1) of
				  the Internal Revenue Code for the taxable year in which eligibility for
				  Medicaid is being determined, whether or not the individual files a tax return;
				  and/or
(2) The MAGI based income of
				  a tax dependent who is an individual other than a spouse or a biological,
				  adopted, or step child who expect to be claimed as a tax dependent by another
				  taxpayer, who is not expected to be required to file a tax return under section
				  6012(a)(1) of
				  the Internal Revenue Code for the taxable year in which eligibility for
				  Medicaid is being determined, whether or not such tax dependent files a tax
				  return.
MAGI-BASED INCOME
: MAGI-Based income is as
					 defined in Part 17, Section
					 2.1.
TAX DEPENDENT
: Tax dependent, pursuant to
					 42 C.F.R. §
											435.4, has the same meaning as the term
					 "dependent" under section
					 152 of the Internal Revenue Code,
					 as an individual for whom another individual claims a deduction for a personal
					 exemption under section
					 151 of the Internal Revenue Code
					 for a taxable year.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-2 - BASIC BUDGETING PRINCIPLES

Current through 2024-29, July 17, 2024
To determine an individual's eligibility for Medicaid, the
					 following calculation applies:
A.
				  Determine the individual's Household.
B. Determine the individual's Household
				  Income.
C. Compare the individual's
				  Household Income to the Income Standard. If the individual's Household Income
				  is over the income standards, subtract an amount equal to 5 percentage points
				  of the Federal poverty level for the applicable family size and reassess by
				  comparing the individual's Household income to the Income Standard.
D. If the individual's household income is at
				  or below the Income Standard, then the individual is eligible for
				  Medicaid.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-3 - HOUSEHOLD

Current through 2024-29, July 17, 2024
A. For purposes of "Household Income",
				  household will be defined as follows:
(1)
Basic rule for taxpayers not claimed as a tax dependent:
If an
				  individual requesting coverage expects to file a tax return for the taxable
				  year in which an eligibility determination or renewal of eligibility is being
				  made, and who does not expect to be claimed as a tax dependent by another
				  taxpayer, the household consists of the taxpayer, the individual's spouse if
				  living with and/or filing jointly, and any person(s) the taxpayer expects to
				  claim as a tax dependent.
(2)
Basic rule for individuals claimed as a tax dependent:
If an
				  individual requesting coverage expects to be claimed as a tax dependent for the
				  taxable year in which an eligibility determination or renewal of eligibility is
				  being made (even if he/she also expects to file a tax return), his/her
				  household will consist of the tax filer who expects to claim the individual as
				  a tax dependent, the tax filer's spouse if living with and/or filing jointly,
				  and any person(s) the tax filer expects to claim as a tax dependent (including
				  the individual) unless the individual meets one of the following exceptions.
(a) The individual expects to be claimed as a
				  tax dependent of someone other than the individual's spouse or biological,
				  adopted or step parent;
(b) The
				  individual is a child under age 19 living with both parents, but expects to be
				  claimed as a tax dependent by only one parent because the parents don't file
				  jointly;
(c) The individual is a
				  child under age 19 who expects to be claimed by a non-custodial
				  parent.
(3)
Rules
				  for individuals who neither file a tax return nor are claimed as a tax
				  dependent OR who meets one of the exception from Section
				  3 A(2) of this Part:
If an
				  individual meets one of the three exceptions listed in Section
				  3 A(2), or if an individual does not
				  expect to be a tax filer for the taxable year in which an eligibility
				  determination or renewal of eligibility is being made and does not expect to be
				  claimed as a tax dependent, his/her household will consist of:
(a) The individual;
(b) The individual's spouse if living with
				  the individual;
(c) The
				  individual's natural, adopted and step children under the age of 19 if living
				  with the individual; and/or
(d) If
				  the individual is under the age of 19, the individual's natural, adopted and
				  step parents and natural, adoptive and step siblings also under age 19 if
				  living with the individual.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-4 - HOUSEHOLD INCOME STANDARD

Current through 2024-29, July 17, 2024
The Income Standard for the following groups is as
					 follows:
A. parents or caretaker
				  relatives as defined in Part 3, Section
				  2.2: equal to or less than 100% of
				  the Federal Poverty Level.
B.
				  children age 19 and 20 as defined in Part 3, Section
				  2.1 (IV): equal to or less than
				  156% of the Federal Poverty Level.
C. pregnant individuals as defined in Part 3,
				  Section 2.3: equal to
				  or less than 209% of the Federal Poverty Level.
D. effective March 1, 2023 children under age
				  1 as defined in Part 3, Section
				  2.1 (II): equal to or less than
				  208% of the Federal Poverty Level. Uninsured children under age 1, with income
				  between 191% and 208% of the Federal Poverty Level, may be covered under Cub
				  Care (See Part 5)
E. effective
				  March 1, 2023 children age 1 up to and including age 18 (under age 19) as
				  defined in Part 3, Section
				  2.1 (III): equal to or less than
				  208% of the Federal Poverty Level. Uninsured children age 1 and up to age 19,
				  with income between 157% and 208% of the Federal Poverty Level, may be covered
				  under Cub Care (See Part 5)
F.
				  Expansion Adults as defined in Part 3, Section
				  2.4: equal to or less than 133% of
				  the Federal Poverty Level, except for Expansion Parents and Caretaker Relatives
				  eligible under Part 3, Section
				  2.4, whose income must be between
				  100% and 133% of the Federal Poverty Level.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-5 - BUDGET PERIOD

Current through 2024-29, July 17, 2024
Financial eligibility for Medicaid must be based on current
					 monthly household income and family size.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-6 - NO ASSET LIMIT

Current through 2024-29, July 17, 2024
There is no asset limit for any individuals in any of the
					 eligibility groups for which MAGI-based methodology applies.
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 4 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4-7 - GAP-FILLING

Current through 2024-29, July 17, 2024
If an individual is found ineligible through the
					 application of this Part, but his/her household income is below 100% FPL when
					 determined in accordance with
					 26 C.F.R. §
											1.36B-1(e), eligibility will
					 be determined in accordance with the latter.
Under this circumstance, the individual will be asked by
					 OFI to provide documentation to explain the difference between the two
					 determinations. If the documentation provided adequately substantiates the
					 reason for the difference, Medicaid financial eligibility for the individual
					 will be determined in accordance with
					 26 C.F.R. §
											1.36B-1(e).
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-1 - DEFINITIONS

Current through 2024-29, July 17, 2024
FAMILY SIZE
: Family size means the number of
					 persons counted as members of an individual's household. In the case of
					 determining the family size of a pregnant woman, the pregnant woman is counted
					 as herself plus the number of children she is expected to deliver. In the case
					 of determining the family size of other individuals who have a pregnant woman
					 in their household, the pregnant woman is counted as 1 person.
HOUSEHOLD INCOME
: Household Income means the
					 sum of the MAGI-based income, of every individual included in the individual's
					 household, minus an amount equivalent to 5 percentage points of the Federal
					 poverty level for the applicable family size, EXCEPT that income in the
					 following circumstances will not be included in household income: (1) The
					 MAGI-based income of an individual who is included in the household of his or
					 her natural, adopted or step parent, and is not expected to be required to file
					 a tax return under section 6012(a)(1) of the Internal Revenue Code for the
					 taxable year in which eligibility for Medicaid is being determined, whether or
					 not the individual files a tax return; and/or (2) The MAGI based income of a
					 tax dependent who is an individual other than a spouse or a biological,
					 adopted, or step child who expect to be claimed as a tax dependent by another
					 taxpayer, who is not expected to be required to file a tax return under section
					 6012(a)(1) of the Internal Revenue Code for the taxable year in which
					 eligibility for Medicaid is being determined, whether or not such tax dependent
					 files a tax return.
MAGI-BASED INCOME
: MAGI-Based income is as
					 defined in Part 17.5.
TAX DEPENDENT
: Tax dependent, pursuant to
					 42 CFR
					 435.4, has the same meaning as the term
					 "dependent" under section 152 of the Internal Revenue Code, as an individual
					 for whom another individual claims a deduction for a personal exemption under
					 section 151 of the Internal Revenue Code for a taxable year.
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-2 - BASIC BUDGETING PRINCIPLES

Current through 2024-29, July 17, 2024
To determine an individual's eligibility for Medicaid, the
					 following calculation applies:
A.
				  Determine the individual's Household.
B. Determine the individual's Household
				  Income.
C. Compare the individual's
				  Household Income to the Income Standard.
D. If the individual's Household Income is at
				  or below the Income Standard, then the individual is eligible for
				  Medicaid.
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-3 - HOUSEHOLD

Current through 2024-29, July 17, 2024
A. For purposes of "Household Income",
				  household will be defined as follows;
(1)
Basic rule for taxpayers not claimed as a tax dependent:
If an
				  individual requesting coverage expects to file a tax return for the taxable
				  year in which an eligibility determination or renewal of eligibility is being
				  made, and who does not expect to be claimed as a tax dependent by another
				  taxpayer, the household consists of the taxpayer, the individual's spouse if
				  living with and/or filing jointly, and any person(s) the taxpayer expects to
				  claim as a tax dependent.
(2)
Basic rule for individuals claimed as a tax dependent:
If an
				  individual requesting coverage expects to be claimed as a tax dependent for the
				  taxable year in which an eligibility determination or renewal of eligibility is
				  being made (even if he/she also expects to file a tax return), his/her
				  household will consist of the tax filer who expects to claim the individual as
				  a tax dependent, the tax filer's spouse if living with and/or filing jointly,
				  and any person(s) the tax filer expects to claim as a tax dependent (including
				  the individual) unless the individual meets one of the following exceptions.
(a) The individual expects to be claimed as a
				  tax dependent of someone other than the individual's spouse or biological,
				  adopted or step parent;
(b) The
				  individual is a child under age 19 living with both parents, but expects to be
				  claimed as a tax dependent by only one parent because the parents don't file
				  jointly;
(c) The individual is a
				  child under age 19 who expects to be claimed by a non-custodial
				  parent.
(3)
Rules
				  for individuals who neither file a tax return nor are claimed as a tax
				  dependent OR who meets one of the exception from Section 3.1 I-B of this
				  Part:
If an individual meets one of the three exceptions listed in
				  Section 3.1-II-B, or if an individual does not expect to be a tax filer for the
				  taxable year in which an eligibility determination or renewal of eligibility is
				  being made and does not expect to be claimed as a tax dependent, his/her
				  household will consist of:
(a) The
				  individual;
(b) The individual's
				  spouse if living with the individual;
(c) The individual's natural, adopted and
				  step children under the age of 19 if living with the individual;
				  and/or
(d) If the individual is
				  under the age of 19, the individual's natural, adopted and step parents and
				  natural, adoptive and step siblings also under age 19 if living with the
				  individual.
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-4 - INCOME STANDARD

Current through 2024-29, July 17, 2024
The Income Standard for the following groups is as
					 follows:
A. parents or caretaker
				  relatives as defined in Part 3.5: equal to or less than 100% of the Federal
				  Poverty Level (See Chart 6.5).
B.
				  children age 19 and 20 as defined in Part 3.5: equal to or less than 156% of
				  the Federal Poverty Level (See Chart 6.5).
C. pregnant women as defined in Part 3.5:
				  equal to or less than 209% of the Federal Poverty Level (See Chart
				  6.5).
D. children under age 1 as
				  defined in Part 3.5: equal to or less than 191% of the Federal Poverty Level
				  (See Chart 6.5).
E. children age 1
				  up to and including age 18 (under age 19) as defined in Part 3.5: equal to or
				  less than 157% of the Federal Poverty Level (See Chart 6.5).
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-5 - BUDGET PERIOD

Current through 2024-29, July 17, 2024
Financial eligibility for Medicaid must be based on current
					 monthly household income and family size.
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-6 - NO ASSET LIMIT

Current through 2024-29, July 17, 2024
There is no asset limit for any individuals in any of the
					 eligibility groups for which MAGI-based methodology applies.
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 4.5 - BUDGETING FOR ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES › Section 144-332-4.5-7 - GAP-FILLING

Current through 2024-29, July 17, 2024
If an individual is found ineligible through the
					 application of this Part, but his/her household income is below 100% FPL when
					 determined in accordance with
					 26 CFR
					 1.36B-1(e), eligibility may
					 be determined in accordance with the latter.
Medicaid financial eligibility for an individual may be
					 determined in accordance with 26CFR1.36 B- 1(e) if the individual's household
					 income determined in accordance with this Part results in financial
					 ineligibility for Medicaid but is below 100% FPL when determined in accordance
					 with
					 26 CFR
					 1.36B-1(e). Under this
					 circumstance, the individual will be asked by OFI to provide documentation to
					 explain the difference between the two determinations. If the documentation
					 provided adequately substantiates the reason for the difference, Medicaid
					 financial eligibility for the individual will be determined in accordance with
					 26 CFR
					 1.36B-1(e),
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 - CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - CUB CARE › Section 144-332-5-1 - DEFINITIONS

Current through 2024-29, July 17, 2024
STATE-BASED MARKETPLACE:
The state-based
					 marketplace (SBM) is a website established and operated by Maine's offical
					 marketplace to facilitate the purchase of health insurance in accordance with
					 the
Patient Protection and Affordable Care Act
(CoverME.gov).
MYMAINECONNECTION:
MyMaineConnection (
www.mymaineconnection.gov
) is a website
					 administered by the Office for Family Independence in which residents of the
					 State of Maine can apply online for medical coverage.
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 - CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - CUB CARE › Section 144-332-5-2 - SCOPE

Current through 2024-29, July 17, 2024
The Children's Health Insurance Program (CHIP), known as
					 CubCare in Maine, is authorized under Title XXI of the
Social Security
					 Act
. It provides health coverage as an expansion of Medicaid to
					 uninsured children who are under the age of 19 who meet certain other
					 requirements as identified in this section.
Maine also implements a separate CHIP for pregnant
					 individuals for the health of the fetus. See Part 2, Section
					 2.3 (III) for eligibility
					 requirements.
The Department has the right to collect from other
					 available insurance or from settlement(s) for accidents or injuries whenever
					 the Medical ID was used.
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 - CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - CUB CARE › Section 144-332-5-3 - BASIC ELIGIBILITY REQUIREMENTS

Current through 2024-29, July 17, 2024
To be eligible for Cub Care, individuals must meet the
					 basic eligibility requirements for Medicaid coverage as identified in Part 2.
					 There is no requirement to refer the non-custodial parent without health
					 insurance to the Division of Support Enforcement and Recovery (DSER).
A.
Children Excluded from
				  Coverage
1. A child who is eligible
				  for coverage under a Medicaid program. This includes Transitional Medicaid
				  (TM).
2. A child age 19 and
				  over.
3. A child who is covered
				  under health insurance as defined by the
Health Insurance Portability
				  and Administrative Act
(HIPAA). This includes most insurance plans
				  except for those covering one particular service or illness only, such as
				  insurance for dental care or cancer. This exclusion applies regardless of
				  whether the coverage is provided through an adult who resides with the child or
				  through an adult living in another household.
4. A child who is covered under a group
				  health insurance plan through an employer.
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 - CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - CUB CARE › Section 144-332-5-4 - APPLICATION PROCESS

Current through 2024-29, July 17, 2024
A. An application
				  is the request for medical coverage made by signing and dating an approved
				  application form. The individual or anyone acting on the individual's behalf
				  may sign the application form. The applicant may choose to have another person
				  help them complete the form.
The date of application is the date the signed application
					 form is received in or by any OFI regional office, My Maine Connection, or the
					 State Based Marketplace. My Maine Connection or the State Based Marketplace
					 will forward the application to OFI. Applications must be processed within 45
					 days of their receipt by the Department. If the applicant is not sent a notice
					 of the eligibility decision within 45 days, temporary coverage will be
					 authorized. (See Part 2 §
											12.3.)
All signed applications will be acknowledged in writing. A
					 written eligibility decision will be sent to the applicant.
An application is valid for authorizing coverage starting
					 the month the application is received.
B. When an individual applies for medical
				  coverage, this is considered to be an application for Medicaid and Cub
				  Care.
C. Verification of
				  information needed to determine eligibility must be requested initially from
				  the individual. If information is requested from other sources (with the
				  exception of public records) the individual must be informed. If the individual
				  does not give consent for other sources to provide the Department with the
				  requested information, denial or termination must occur. (See Part 2 §
										12.1.)
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 denied or terminated.
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 - CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - CUB CARE › Section 144-332-5-5 - ASSETS

Current through 2024-29, July 17, 2024
There is no asset criteria for eligibility under Cub
					 Care.