Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.03 - BENEFIT ELIGIBILITY

Current through 2024-29, July 17, 2024
Any person whose family income is less than or equal to
					 350% of the federal poverty level is eligible for the Maine Rx Plus Benefit.
					 This is referred to as "financial eligibility." Applicants will remain eligible
					 for one year beginning on the date determined eligible and must reapply
					 annually.
In addition, any person who incurs unreimbursed expenses
					 for prescription drugs equaling 5% or more of family income, or who incurs
					 unreimbursed expenses for all medical care equaling 15% or more of family
					 income, is eligible for the remainder of the eligibility period. This is
					 referred to as "spend down eligibility."
The Department will use the following processes to
					 determine eligibility:
A.
				  Determination of Financial Eligibility
The Office of Integrated Access and Support (OIAS) will
					 determine family income as set forth at 10-144 C.M.R. Chapter 332, MaineCare
					 Eligibility Manual. If the family income as determined by BFI is equal to or
					 less than 350% of the federal poverty level, the applicant is financially
					 eligible for Maine Rx Plus Benefits.
B. Determination of Spend Down Eligibility
If applicants do not meet financial eligibility as
					 determined by OIAS, they may request that the Department consider eligible
					 expenses incurred by the household during the six months prior to application.
					 This six-month period is the medical spend down eligibility period. The
					 Department will use income information prorated for this time period to
					 determine the percentage of expenses incurred during the medical spend down
					 eligibility period. If the applicant's unreimbursed expenses for prescription
					 drugs are equal to 5% or more of family income, or unreimbursed expenses for
					 medical care are equal to 15% or more of family income, the applicant is
					 eligible for Maine Rx Plus on the basis of the spend down.
To be considered for spend down eligibility applicants must
					 submit receipts or bills for unreimbursed prescription drug expenses and/or
					 medical expenses to the Maine Rx Plus Spend Down, Department of Health and
					 Human Services, 11 State House Station, Augusta Maine, 04333-0011. Applicants
					 may submit a signed statement of incurredexpenses for those expenses for which
					 a receipt has been lost. If found eligible due to medical spend down,
					 applicants will remain eligible for one year from the date application is
					 made.
All documented, unreimbursed medical and prescription drug
					 expenses incurred by the applicant or family member shall be considered in the
					 spend down determination, except the following:
1. Any costs incurred and paid prior to the
				  medical spend down period; or
2.
				  Any medical costs paid by any third party, including an insurance carrier or a
				  state or federal government benefits program; or
3. Medical costs paid by others for which the
				  individual has no obligation to repay.
The Department will notify applicants within 30 days of
					 receipt of documented prescription and medical expenses whether or not they are
					 eligible for Maine Rx Plus.