MaineCare Eligibility
Section 4: Other Important Information

Contents

Contents of this page
4.1 What if the applicant already has private health insurance?
4.2 Two groups of children not eligible for CHIP MaineCare (children who pay a monthly premium)
4.3 What happens if CHIP premiums aren't paid?
4.4 How to appeal a DHHS decision

Section 4: Other Important Information

4.1 What if the applicant already has private health insurance?

Everyone except CHIP children (who pay a monthly premium) who is eligible for MaineCare can also have private insurance:

• If the family meets the income and asset guidelines for free MaineCare, they may enroll in MaineCare even if they are covered under another health insurance policy (including Medicare). MaineCare will pay for any services covered by MaineCare that are not covered by the private policy or by Medicare.
• If the family has been paying for private insurance coverage, they may choose to drop that coverage for any family members who meet MaineCare guidelines.

For CHIP children (who pay a monthly premium):

• If the household's income is more than the amount in Column B (i.e. more than 150% FPL), the child may not be able to get MaineCare if he or she is already covered by employer-based health insurance. This does not apply if the employer offers coverage for the child, but the family hasn't taken it.
• If health insurance provided by an employer or other health insurance as defined by the Health Insurance Portability and Administrative Act (HIPAA) is dropped, the family may have to wait 3 months for MaineCare coverage for their child, unless they meet one of the exceptions listed below. Most families do meet one of the exceptions.

Exceptions to the 3-month rule for CHIP children (who pay a monthly premium):

• The family (employee) paid 50% or more of the cost of the child's coverage.
• The person who dropped the child's coverage did not live with the family (such as a non-custodial parent).
• The child lost coverage because of a family member's change in jobs or loss of a job for a reason that was not the family member's (employee's) fault.
• The coverage was not through an employer-based plan. For example, it was an individual policy the family bought on their own.
• The family paid over 10% of all family income for family coverage (including the child).
• The child's policy was very limited. For example, it just covered dental care or one disease, such as cancer.
• DHHS decides the family had other good cause for dropping the insurance.

Example: Susan applies for MaineCare for her child in October. She dropped the coverage she had through work in September because she paid the entire cost and couldn't afford it. Susan's child will be eligible for MaineCare if she meets the income guidelines.

Example: Jane dropped her child's coverage under her employer's plan in September. But her employer had been paying more than 50% of the cost of the child's coverage. Additionally, their total health insurance costs were not more than 10% of family income. Jane's child will have to wait until January (3 months) for MaineCare.

Two Important Notes:

1. Parents should not drop other insurance coverage until they find out if their children will be eligible for CHIP MaineCare.
2. If a parent does not live with his or her child and has been ordered by a court or by DHHS to provide health insurance, they may not drop that coverage. If the non-custodial parent does drop coverage, he or she will have to repay any medical bills that MaineCare pays.

Section 4: Other Important Information

4.2 Two groups of children not eligible for CHIP MaineCare (children who pay a premium)

Two groups of children will not be eligible for CHIP MaineCare (remember that children with CHIP MaineCare have a family income that ranges from greater than 150% FLP to 200% FLP - between the amounts listed in Column B and Column C). These two groups are:

• Children who have access to coverage under their parent/guardian's state employee health insurance plan, even if they are not enrolled in the plan. If the state employee is a parent who does not live with the children, then this will not be a problem.
• Children who live in a public institution or an institution for mental illness.

Children in families with lower income may be eligible for free MaineCare. Even if you think one of these rules applies, encourage the family to apply!

Section 4: Other Important Information

4.3 What happens if CHIP premiums aren't paid?

If the family can't afford to pay the MaineCare premium for children, remember:

Premium payments for months 1 through 11 can be made at the end of the child's 12 months of MaineCare eligibility. If payments have been missed at the end of the 12 months and the family has good reason, they can reapply as usual and explain their circumstances. If the family doesn't have a good reason, DHHS may make them wait up to 3 months to sign up their child in MaineCare again. If the family has lost income and can't pay the premium, they should tell DHHS. If their income is below Column B (i.e. below 150% FPL), their child will be covered by free MaineCare, and therefore won't need to pay a CHIP premium for their child's coverage.

Section 4: Other Important Information

4.4 How to appeal a DHHS decision

If a member has a problem or complaint, encourage them to call DHHS and talk it over with their MaineCare Eligibility Specialist. If that does not work, the next step is to talk with the supervisor of that Eligibility Specialist. Many issues can be worked out this way. In some cases, the member may request that you contact DHHS on their behalf. You will need the member’s written permission before the Eligibility Specialist can talk to you.

If the member is not satisfied with DHHS's answer, he or she has the right to appeal any DHHS decision. This includes decisions about eligibility for MaineCare and whether certain medical bills are covered.

If a member decides to appeal a MaineCare eligibility decision, it must be done within 30 calendar days of the date of the DHHS written decision. To appeal, he or she calls the regional DHHS office and asks for a fair hearing. It's good to send a dated follow-up letter asking for a fair hearing. If the 30-day limit for an appeal is missed, the applicant can reapply.

If the member gets free MaineCare and they want to appeal DHHS's decision that their coverage will end, the coverage can continue up to the time of the fair hearing, but only if they call and request a fair hearing within 12 calendar days of the date on the DHHS decision. If they miss the 12-day deadline, they can still appeal within the 30-day deadline. But, the coverage will not continue up to the hearing. If the family wins the hearing, DHHS will pay the back bills up to the hearing.

If the member gets CHIP MaineCare (children who pay a monthly premium) and he or she appeals a DHHS decision to end MaineCare, coverage will not continue up until the fair hearing. Everything else about the fair hearing process is the same.

To appeal other DHHS decisions:

The member can also appeal non-eligibility decisions made by DHHS, such as if DHHS refuses to pay a bill. The member has up to 60 calendar days from the date of the DHHS non-eligibility decision to appeal. To request this type of appeal hearing, call MaineCare Members Services.

To get legal help:

For legal advice or help, call the Consumers for Affordable Health Care HelpLine at 1-800-965-7476 (TDD/TTY is the same number). HelpLine staff will make a referral to free legal services, if necessary.

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