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 144-332-5.5-11 - ADMINISTRATIVE HEARINGS

Current through 2024-29, July 17, 2024
Rules regarding hearings are identified in Part 1, Section
					 7; except as they differ for Cub Care as identified in this section. A hearing
					 may be requested for an adverse action taken during the enrollment period, but
					 benefits will not be continued beyond the enrollment period pending the hearing
					 decision. For coverage to continue beyond the enrollment period, the individual
					 must file a reapplication and be found eligible without a penalty. If for some
					 reason a household's premium is increased during the enrollment period due to
					 adding a child to Cub Care and the increase is appealed, the increased premium
					 will be effective when the child is added to Cub Care coverage pending the
					 hearing decision. The household's increased premium is due in accordance with
					 the policies of this section and any unpaid premium is subject to a penalty of
					 ineligibility.
If a household appeals a penalty period being imposed at
					 the time of reapplication, the penalty will be imposed pending the hearing
					 decision.
If the hearing decision reverses the Department action, any
					 penalty imposed will be lifted and any increased premiums that have been paid
					 will be returned to the household.
SECTION 12: PREMIUMS
Section 12.1 G eneral
Except for Alaska Natives and Native American Indians who
					 are members of a Federally recognized Tribe, individuals who are eligible for
					 Cub Care must pay a premium. Chart 8.5 identifies the amount of the premium
					 that is due basedon household income and the number of children covered under
					 Cub Care.
The premium for the twelve month enrollment period does not
					 change except to reflect the number of children being covered.
Any change in premium is effective the month the child's
					 coverage begins or ends.
Section 12.2 C overage for the Current Enrollment
					 Period
I. Premiums are due on
				  the first day of each month for coverage for that month. When a premium is not
				  paid by the first of the month in which it is due, the Department will give
				  notice of non-payment.
Note:
Notice will also be given at the
					 beginning of the 12th month of the twelve month
					 enrollment period for any premiums that are still unpaid.
II. There is a grace period for non-payment
				  of premiums. For the first through the eleventh months of the twelve month
				  enrollment period, the grace period extends through the last day of the twelve
				  month enrollment period.
The individual will also be notified that coverage will end
					 at the end of the 12th month without further notice
					 if a reapplication is not received.
For example, if the enrollment period is 11/08 through
					 10/09, the individual has until 10/31/09 to pay his/her premiums for month one
					 through eleven.
The grace period for payment of the premium due in the
					 12th month is the 15th of
					 month number thirteen.
For example, if the twelve month enrollment period is
					 11/'08 to 10/09, the individual has until 11/15/09 to pay his/her premium for
					 month twelve.
If the 1st or the
					 15th fall on a weekend or holiday, the premium is
					 then due on the next workday.
Section 12.3 Nonpayment of Premiums
A. Following a current enrollment period,
				  there may be a period of ineligibility because premiums have not been paid or
				  not paid when they are due. Pemiums are due on the first day of every
				  month.
B. At the beginning of the
				  12th month of the enrollment period, notification
				  will be given if any premiums for the enrollment period have not been paid when
				  due. The individual will also be notified of the penalty incurred because of
				  the nonpayment.
The penalty will be lifted immediately if the payment is
					 subsequently received by the Department within the grace period.
C. Premiums can be paid monthly,
				  for more than one month at a time, or they can be paid in advance for the
				  twelve month enrollment period. Payments will be credited to the earliest
				  months of coverage first, during the current enrollment period.
Example:
A monthly premium of $8.00 is due during a twelve month
					 enrollment period from January to December and the first payment for $40.00 is
					 received on June 1st. Months one through five will
					 be credited with a premium paid. The June payment is overdue.
D. There is a month of ineligibility for each
				  month a premium was due, coverage was received, and a premium payment was not
				  made when due.
The maximum period of ineligibility is three months.
The penalty periods start in the first month following the
					 end of the enrollment period in which the premium was due.
Example
If no premiums are paid for the twelve month enrollment
					 period of 1/08 through 12/08, the child is ineligible for Cub Care for the
					 months of 1/09, 2/09, and 3/09.
E. If the twelve month enrollment period is
				  shortened due to a withdrawal from Cub Care, a penalty will be imposed for each
				  month Cub Care coverage was received and a premium was due and was not paid by
				  the end of the enrollment period.
Example
An enrollment period of July through December ends on
					 August 31st due to a withdrawal from the program. If
					 the premiums due for July and August have not been paid by August
					 31st there will be a penalty period of two months,
					 starting on September 1st when the individual is not
					 eligible for Cub Care.
F.
				  Any penalty under Cub Care will run concurrently with Medicaid coverage. For
				  example, if a child is denied coverage under Cub Care due to nonpayment of a
				  premium for July and August, but the child is eligible for Medicaid during
				  those months, Medicaid would be granted. The child is then potentially eligible
				  for Cub Care in September.
If a child under penalty due to nonpayment of a premium
					 reapplies and is found to be otherwise eligible for Cub Care, the penalty
					 period will be imposed for up to the first three months following the end of
					 the enrollment period in which the premium was due. Coverage will be granted
					 for the remaining months.
Example
During a January to June enrollment period, no premiums
					 were paid. A reapplication is filed and the children are financially eligible.
					 July, August, and September are penalty months and eligibility exists for
					 October, November, and December.
G. If a child moves from a household where a
				  penalty has been imposed for nonpayment of a premium to a household where there
				  is no penalty, the child is potentially eligible for Cub Care.
The penalty stays with the adults responsible for the
					 premium payment.
H. Good
				  cause for nonpayment exists and no penalty is imposed if premiums are not paid
				  or not paid when due because of the following reasons:
(1) mail delay;
(2) illness of the child's responsible
				  relative; or
(3) unanticipated
				  emergency beyond the control of the responsible relative.
Section 12.4: Refunds
A refund is due if:
A. a premium has been paid due to Department
				  error,
B. a payment is received
				  after the grace period. This payment, at the option of the family, will be:
(1) refunded to the family;
(2) credited to past due premiums;
				  or
(4)
				  credited to future premiums due.