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 6 - SUPPLEMENTAL SECURITY INCOME(SSI) - RELATED MEDICAID COVERAGE › Section 144-332-6-5 - COVERED INDIVIDUALS

Current through 2024-29, July 17, 2024
Section 5.1
:
				  Definitions
When determining SSI - Related eligibility, individuals are
					 considered to be eligible individuals, ineligible spouses, eligible couples or
					 an eligible child.
An "eligible individual" is the person who is applying for
					 or receiving Medicaid.
An "ineligible spouse" is the person to whom the individual
					 is married, who is living with the individual, and who is not applying for or
					 is not receiving Medicaid. The spouse can choose to be an ineligible
					 spouse.
An "eligible couple" are married individuals, living
					 together, who both have made application for or are recipients of SSI, the
					 State Supplement or SSI - Related Medicaid. Both individuals must meet all
					 eligibility criteria. It is not possible to treat each spouse as an eligible
					 individual if they are living together. Each spouse is considered an eligible
					 individual effective the month after they cease to live together. For married
					 couples who are residing in the same nursing home room (see Part 14, Section
					 4.2 ) or who are applying for waiver services in the community (see Part 13,
					 Sections 4 and 6 ), special criteria may need to be considered.
An individual whose marriage has been terminated through
					 death, divorce or annulment is considered not married.
An "eligible child" is an individual who has a disability
					 or visual impairment and who is neither married nor the head of a household
					 and
* under age 18; or
* under age 22 (through age 21) and a student regularly
					 attending school or college or training designed to prepare him/her for a
					 paying job. The child/student can have the student earned income exclusion (See
					 Part 17, Section 4.54 ) and an ineligible child allocation (See Part 7, Section
					 2.2.1 ).
Child status ends effective with the month after the month
					 of attainment of age 18 (age 22 if a student) or the month after the month s/he
					 last meets the definition of a child.
Section 5.2
: Eligible Groups
All SSI - Related Medicaid eligible individuals and couples
					 must meet financial guidelines and be a member of one of the following
					 groups:
Section 5.2.1
:
				  Individuals or Couples Meeting SSI/State Supplement Criteria
Individuals or couples who meet the criteria for SSI or the
					 State Supplement and who have not applied or who do not want to apply for
					 either or both cash payments.
Section
				  5.2.2
: Individuals or Couples Eligible Under the Pickle
				  Amendment or Lynch VS. Rank
Commencing 4/1/77, those individuals or couples formerly
					 entitled to concurrent benefits from SSI and Social Security who would be
					 eligible for SSI if annual cost of living adjustments are not counted (See
					 Appendix C for specifics).
Section
				  5.2.3
: Individuals or Couples Residing in Adult Foster
				  Homes (Private or State Assisted) or Flat Rate Boarding Homes
Individuals or couples who are residing in these homes have
					 special income guidelines for State Supplement eligibility. If income exceeds
					 these special guidelines the individual or couple may still be eligible for
					 MaineCare (See Part 12).
Section
				  5.2.4
: Individuals or Couples Residing in Cost
				  Reimbursement Boarding Homes, and Residential Care Facilities
Individuals or couples who are residing in these homes have
					 special income limits for MaineCare coverage (See Part 12).
Section 5.2.5
: Individuals in Nursing
				  Care Facilities
Individuals must be in a facility licensed by the
					 Department of Health and Human Services to provide nursing care services. There
					 are four types of facilities:
I.
				  General Hospitals (Awaiting Placement)
II. Skilled Nursing Care Facilities
				  (SNF)
III. Intermediate Nursing
				  Care Facilities (ICF)
IV. Nursing
				  care sections of the following institutions for the care of the mentally
				  disabled:
A. Riverview Psychiatric Center
				  (RPC)
B. Dorothea Dix Psychiatric
				  Center (DDPC)
Individuals in these types of facilities must meet special
					 eligibility criteria (See Part 14).
Section 5.2.6
: Individuals Receiving
				  Nursing Care in Community Settings
There are programs available for individuals who require
					 nursing home care and are living in the community. These programs are called
					 "Home and Community Based Waiver Programs" because they provide special
					 services and follow special eligibility criteria (See Part 13).
The waiver programs are:
I. Home and Community Benefits for the
				  Elderly and for Adults with Disabilities Waiver
II. Support Services for Members with
				  Intellectual Disability or Autistic Disorders
III. Home and Community Benefits for Members
				  with Intellectual Disabilities or Autistic Disorder Waiver
IV. Home and Community Based Waiver Benefit
				  for Children with Intellectual Disabilities and/or Pervasive Developmental
				  Disorders (ID and/or PDD)
V. Home
				  and Community Based Waiver Benefit for Adults with Other Related Conditions
				  Aged 21 and Over
VI. Home and
				  Community Based Waiver Benefit for Adults with Brain Injury
Section 5.2.7
: Newborns
				  Born to Mothers on Medicaid
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 for coverage regardless of the newborn's income or assets. 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.
Coverage continues for one year. This means that the baby
					 is eligible without regard to: changes in family income or composition,
					 cooperation with DSER, cooperation with TPL, obtaining a Social Security number
					 or declaring citizenship status.
Section
				  5.2.8
: Children Eligible Under "Katie Beckett"
Individuals under this eligibility option are children with
					 disabilities, age 18 and younger, who are living in the community and would be
					 eligible for Medicaid if they were in need of institutional level of care.
					 There are no special services provided to this group (See Part 7, Section 5
					 ).
Section 5.2.9
:
				  Certain Individuals Receiving Social Security Disabled Widow(er)'s Benefits who
				  are not Receiving Medicare
These are individuals who are not eligible for Medicare and
					 who lost their SSI or State Supplement benefits due to receipt of disabled
					 widow(er)'s benefits from Social Security. If the individual meets all other
					 SSI criteria and would be eligible for SSI or State Supplement benefits if the
					 amount of Social Security benefits received as a disabled widow(er) were
					 excluded income, the individual is eligible for categorically needy, SSI -
					 Related Medicaid coverage. The exclusion of income from the Social Security
					 disabled widow(er) continues until the individual is eligible for Medicare or
					 would be ineligible for SSI or State Supplement benefits for a reason other
					 than the income from Social Security disabled widow(er)'s benefits.
Section 5.2.10
: Disabled
				  Adult Children (DAC)
A Disabled Adult Child is an individual who lost his/her
					 eligibility for SSI or State Supplement on or after 7/1/87 due to an increase
					 in or initial receipt of Social Security Benefits based on their DAC status.
					 These individuals who maintain their DAC status with Social Security may
					 continue to receive Medicaid coverage. In determining eligibility for Medicaid,
					 the increase in Social Security Benefits that resulted in SSI ineligibility
					 will be disregarded. Other changes in income will be taken into account and
					 will affect eligibility. Countable income must be under the current SSI or
					 State Supplement income limit.
A person receives Social Security Benefits under DAC status
					 if the following conditions are met:
I. s/he is the child (or eligible grandchild)
				  of a retired, deceased or disabled worker;
II. the individual is at least 18 years of
				  age; and
III. Home and Community
				  Benefits for Members with Intellectual Disabilities or Autistic Disorder Waiver
Individuals may lose coverage under this group and later
					 regain it. Continued eligibility is not necessary.
Section 5.2.11
: Other Covered
				  Groups
Within this section there are other groups which are
					 included in Federal Law. These are listed in Appendix D for informational
					 purposes.
Section 5.2.12
: Individuals under Age 18 Who are Closed From SSI Due to August, 1996
				  Change in Disability Criteria
Individuals under age 18 are Medicaid eligible if the
					 individual:
I. was in current pay
				  status with SSI in August, 1996;
II. is closed due to not meeting the child
				  disability standards that became effective on 8/23/96;
III. continues to meet the SSI child
				  disability criteria in effect prior to 8/23/96; and,
IV. continues to meet federal SSI income and
				  resource standards.
If the individual is closed from SSI for a reason other
					 than not meeting the changed disability criteria, such as being over income or
					 assets, or failing to cooperate in establishing eligibility, this protected
					 status does not apply and the individual must then meet current Medicaid
					 eligibility criteria.
Once an individual has been receiving Medicaid under this
					 protected status and they fail to meet any of the criteria in I - IV above, the
					 protected status is lost and eligibility is determined using the current
					 Medicaid criteria.
Section
				  5.2.13
: Working Disabled
This coverage group includes individuals who meet the SSI
					 standard for disability and who have earnings subject to federal tax
					 withholding but are not eligible for Medicaid under any other coverage group.
					 These individuals may buy into Medicaid by paying a monthly premium if the
					 specific requirements of this coverage group are met. This is an SSI - Related
					 coverage group using SSI - Related rules for treatment of income and assets,
					 however, there are income and asset limits specific to this coverage
					 group.
Section 5.2.14
: Section 1619(b)
Section 1619(b) refers to the section in the
Social
					 Security Act
which authorizes coverage for this group. These are
					 individuals who are considered disabled by SSI but their earned income
					 disqualifies them for an SSI payment. However, due to the use of a higher
					 income guideline by SSI, they continue to be carried by SSI case as an open
					 case and they are Medicaid eligible.