MaineCare Eligibility
Section 1: Coverage and Eligibility

Contents

Contents of this page
1.1 MaineCare Coverage Categories in this Guide
1.2 What counts as income for MaineCare?
1.3 Deductions from Income
1.4 Asset Rules
1.5 Pregnant Women
1.6 Katie Beckett for Disabled Children
1.7 Health care services covered by full-benefit MaineCare

Section 1: Coverage and Eligibility

1.1 MaineCare Coverage Categories in this Guide

* Benefit packages are outlined in the MaineCare Member Handbook (click on link for the Member Handbook).

There are other groups of people who can also get MaineCare. See Section 5, Section 6, and Who's Covered and Who's Not for more information.

Section 1: Coverage and Eligibility

1.2 What counts as income for MaineCare?

What counts: (partial list)

• Earned income ( gross wages from an employer)
• For people who are self-employed, the "net profit and loss" line on the Schedule C (or other IRS Form 1040 self employment attachment) is divided by 12, unless other current information is provided
• Seasonal income is counted during the months worked
• Unearned income (like Social Security, unemployment benefits or Workers' Compensation)
• Child Support

What does not count: (partial list)

• Income from other people in the household who are not the parents or guardians of the children living with the family (like grandparents, a boyfriend or girlfriend, adult brothers and sisters, or aunts and uncles). Anyone not legally responsible is not financially responsible and their income does not count. These other household members also do not count in figuring out family size. These individuals may be eligible for MaineCare in a different category and as a separate household.
• Wages of dependent children age 20 and younger do not count, as long as they are full-time students or part-time students not working full-time.
  
• Section 125 payments (cafeteria plans) do not count to the extent used to purchase benefits.

Rules about SSI: A person who gets SSI automatically gets MaineCare. However, the SSI income that person gets is not counted when determining eligibility of other family members. The person who gets SSI is also not included when determining family size.

Rules about income from stepparents
A stepparent may or may not be counted as part of the MaineCare household. DHHS will include the stepparent in the family only if it will help everyone to get MaineCare. DHHS will figure this out in the way that gives most health care to the family.

Section 1: Coverage and Eligibility

1.3 Deductions from Income

Some money can be subtracted from gross income when determining eligibility for MaineCare.

To calculate the monthly countable income:

If someone receives a weekly paycheck, he or she should multiply that amount by 4.3 to determine monthly income. If someone receives a paycheck twice per month (usually on the 1st and 15th), he or she should multiply that amount by 2 to determine monthly income. If someone receives a biweekly paycheck, he or she should multiply that amount by 2.15 to determine monthly income. Remember it is gross income that counts (the full amount of taxable wages).

Note: Current income is used to establish monthly countable income. For example, if the family income changed from last year such as workers who were laid-off or the self-employed whose business income varied, he or she should report the unemployment income or current business income (not from last year’s taxes).

To find out eligibility for free MaineCare for children, 19 and 20-year-olds, parents and pregnant women, first subtract any of these expenses from the applicant’s monthly gross income:

1. The first $90/month of a family member's earned income (from work). If both parents are working, they can each deduct the first $90 of earned income, for a total of $180.
2. Child care expenses actually paid, up to $200/month (for children age 1 and younger) or $175/month per child (for children age two and older).
3. Child support payments paid by a family member to someone outside the household.
4. Up to $50/month for child support received by the household.

Then, if the income that's left is less than the total in Column B, below (Column C for parents and pregnant women), the household meets the income requirement for free coverage.

Children age 18 and younger in families with income ranging from greater than 150% to 200% of the federal poverty level (FPL) may be eligible for CHIP MaineCare (with monthly premium). To find out eligibility for children's CHIP MaineCare (with a monthly premium), take the family's total monthly gross income and subtract:

1. The first $90/month of a family member’s earned income (from work). If both parents are working, they can each deduct the first $90 of earned income, for a total of $180.
2. Up to $50/month for child support received by the household

Then, if the family’s income that's left is between the amounts listed in Column B and Column C, children age 18 and younger will be eligible for CHIP MaineCare. The family will need to pay a monthly CHIP premium for their child's coverage, which ranges from $8 to $64 per month per family.

Monthly Gross Income Eligibility Chart

Remember to deduct all expenses, as described in Section 1.4 above, before comparing adjusted gross monthly income (also called countable income) to the amounts in this table.

The federal government determines the federal poverty level (FPL) each year. The FPL increases a small amount each year, usually around February, to adjust to the rising cost of living.

*CHIP MaineCare for children in households with countable income (gross income minus any deductions) from greater than 150% to 200% FPL must pay a monthly premium that ranges from $8 to $64 per family. The amount of the CHIP premium depends on the family’s income and size. CHIP MaineCare is sometimes referred to as low-cost MaineCare, or premium MaineCare (in the past it was called Cub Care). (A premium is charged for these children because their MaineCare coverage is provided through the State Children’s Health Insurance Program [CHIP], which requires premiums.) DHHS sends a bill and a postage-paid envelope to the family to pay the premium each month, although premium costs can also be paid up to 12 months in advance or at the end of the 12-month eligibility period.

Free MaineCare for children in households with monthly gross income of 150% FPL or lower; parents; pregnant women; and 19- and 20-year-olds requires no monthly premium.

Income Calculation Example

Q: Dirk has twins, age 1. He works at a utility company making $3057 before any taxes are taken out. He has insurance for himself through his company, but can’t afford to put his kids on the plan. He pays $400 per month to a child care provider to take care of both his children. He also pays $279 per month in child support for another child that lives with his wife (they are separated).

A: Dirk’s income looks high for either category of MaineCare. However, before we write him off, we should check to see if he’s eligible for Free MaineCare:

$3057 (gross income)
$90 (earned income deduction)
$400 (child care costs)
- $279 (child support paid)

$2288 (monthly countable income)

It appears as if Dirk’s children are within the CHIP MaineCare guidelines ($3052) when you deduct the $90 disregard, but his countable income is actually $1 below the Free MaineCare guidelines ($2289), so his twins will qualify for Free MaineCare. He may also qualify to get Free MaineCare to wrap around his coverage if he is within the asset limits.

Section 1: Coverage and Eligibility

1.4 Asset Rules

For children (age 18 and younger) and pregnant women, DHHS will not count assets. But, any income from an asset, such as interest from a bank account, will count as income.

For parents and 19 and 20 year olds, there is a $2,000 asset limit. This means a family cannot have property or other valuable items worth more than $2,000. But, many assets are not counted in the $2,000 limit.

Assets that do NOT count against the $2,000 limit:

• The family's home and surrounding lot
• Basic items used in day-to-day living, such as furniture, tools and equipment
• Two cars or trucks (the second vehicle must be necessary for employment, medical treatment, or essential daily activities, or it must have been modified for operation by a person with a disability or for the transportation of a person with a disability)
• Property used to produce income such as boats, trucks, and machinery
• Money in a savings account, CD, pension plan, or IRA: up to $8,000 for a single person, $12,000 for a family of two or more
• Real estate that is up for sale
• Loans that must be repaid
• The cash value of life insurance the family has purchased
• Up to $10,000 in a Family Development Account (FDA) that can be spent only for education, home repair or purchase, a car or truck needed for work or school, small business start up, health care, or to use for an emergency or other family need approved by DHHS
• Other less common assets listed in DHHS rules

Equity value of owned property: For property that does count against the $2,000 limit (for instance, a plot of land that is owned but not lived on by the MaineCare member/applicant), it is the equity value of the property that counts towards the asset limit. So, a family may own land worth $7,000 but have only $1,000 in equity; in this case, only the $1,000 would count toward the asset limit.

Money or gifts received: A lump sum of money (over the asset limits) which is received while a family is getting MaineCare won't count as an asset if the family spends it, within 30 days, on back bills or on assets that don't count (like a home improvement). Retroactive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) checks won't count as an asset for a longer time period. Contact Maine Equal Justice for more information.

Section 1: Coverage and Eligibility

1.5 Pregnant Women

General eligibility rules for pregnant women:

• Eligible up to 200% of the federal poverty level (Column C)
• Household size is increased by one (or two if expecting twins)
• Marital status, assets, and cooperation with Third Party Liability (TPL) and support enforcement are not factors in determining eligibility
• In the case of unmarried parents who live together, acknowledgment of paternity cannot be made prior to the baby's birth. This means that the father's income and assets are not used in determining eligibility for the pregnant woman and he is not counted as a member of her MaineCare household
• Other people who live with the pregnant woman may also be eligible for MaineCare under separate eligibility guidelines
• Coverage can be retroactive for up to 3 months if the woman was pregnant and financially eligible during that time period
• Once a woman is found eligible for MaineCare because she is pregnant, she will continue to be eligible for 60 days beyond the day her pregnancy ends (and through the last day of the month in which the 60th day falls)
• If a woman is receiving MaineCare when the baby is born, the baby will be eligible for MaineCare for 12 if the mother notifies DHHS of the birth and applies for a Social Security number for the baby.

Who is included in the household when the pregnant woman is a minor?

If the pregnant woman does not live with her parents, regardless of her age, her parents' income will not count.

An 18- to 21-year-old who is pregnant or is a parent is an "independent child." The parents' ("grandparents") income and assets are not considered in budgeting.

In the case of a pregnant minor or minor parent who is age 17 or younger and living with her parents (the "grandparents"), DHHS will first look to see if everyone in the household can be enrolled in MaineCare based on the entire household's income and assets. Even if the grandparents are ineligible for MaineCare, the pregnant minor (or minor parent and her children) may still be eligible. Some of the grandparents' income will be considered available to the pregnant minor, but not all of it. And none of it will be considered available to the grandchildren. Even if the minor is ineligible because of the income of the grandparents, the minor parent's child (the grandchild) is likely to be eligible.

Presumptive Eligibility:

If a qualified MaineCare provider (including a Federally Qualified Health Center [FQHC] or a Family Planning office, such as Planned Parenthood, that chooses to provide presumptive eligibility) determines that the pregnant woman's income meets the MaineCare guidelines, she can receive prenatal care beginning the day she comes for services. This is called "presumptive eligibility."

Once the MaineCare provider has made a presumptive determination, the coverage will last through the last day of the month following the month in which the determination is made. In order to avoid a break in coverage, women should be encouraged to apply for on-going MaineCare coverage through the Department of Health and Human Services (DHHS) during this presumptive eligibility period.

Section 1: Coverage and Eligibility

1.6 Katie Beckett for Disabled Children

What is Katie Beckett?

The parents’ income and assets do NOT count when applying for Katie Beckett. Only the income and assets of the child are looked at. In most cases, this means there are no assets or income to look at.

Who can get Katie Beckett?

The parents’ income and assets do NOT count when applying for Katie Beckett. Only the income and assets of the child are looked at. In most cases, this means there is no income or assets to look at.

A child may get Katie Beckett if they:

• Are 18 years old or younger;
• Are NOT eligible for MaineCare in another category;
• Do NOT live in a medical institution; and,
• Meet the Social Security definition for disability.

You do NOT have to get a Social Security disability decision in order to apply for Katie Beckett. MaineCare’s medical review team can look at the child’s medical history to see if they meet the definition. It is hard to tell if a child will meet the disability definition until they go through the application process. If your child cannot do everyday things that children their own age can do, it may be worth applying.

What if my child has private insurance?

A child can get Katie Beckett MaineCare even if they already have private insurance. Some families choose to keep both, and other families choose to have one or the other. In some cases MaineCare will pay the premium for private insurance if the child is eligible for Katie Beckett.

Will I have to pay for Katie Beckett?

Starting on April 1, 2008 there will be low cost premiums for Katie Beckett coverage. Your monthly premium will depend on your household income and if you have private insurance with the Katie Beckett, or just have Katie Beckett.

The parents’ income is not looked at for eligibility. But, the parents' income IS looked at when figuring out the monthly premium. Katie Becket premiums are based on your household income AND if you have private insurance as well as Katie Beckett. Premiums are lower for people who have private insurance along with the Katie Beckett coverage. This is because the state pays less for people who also have private insurance paying for certain services.

Section 1: Coverage and Eligibility

1.7 Health care services covered by full-benefit MaineCare

Health care services covered by full-benefit MaineCare include:

Doctors’ Visits:

• Well-child check-ups
• Sick care
• Specialist care, including surgery
• Prenatal care

Dental Services: Full coverage for children (with limits for adults)

Hospital Care: In-patient, outpatient, and emergency room

Long-Term Care: Coverage for care in a nursing home, or other residential care. Services may also be provided in the home.

Services

• Shots to prevent illness (immunizations)
• Prescription drugs
• ental health services
• Substance abuse services
• Lab tests and x-rays
• Medical equipment and supplies
• Ambulance services
• Chiropractic care
• Family planning
• School-based health centers
• Interpreters
• Transportation to medical and counseling appointments (see a list of transportation agencies)
• Eye exams and eye glasses (with limits for adults)
• Hearing tests (with limits for adults) and hearing aids (for children age 20 and younger)

Therapies

• Speech therapy
• Physical therapy
• Occupational therapy

Early and Periodic Screening, Diagnosis and Treatment

Federal Medicaid law requires States to cover Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children and adolescents under age 21. EPSDT covers four separate screening services—medical, vision, hearing and dental—and includes immunizations, laboratory tests (including lead blood tests), and health education. Each type of screen must be furnished at pre-set, periodic intervals (periodic screens) and when a problem is suspected (interperiodic screens).

The treatment component of EPSDT must include any necessary health care, diagnostic services, treatment, and other measures, described in section 1396d(a) of the Medicaid Act, to “correct or ameliorate” physical and mental illnesses and conditions, whether or not such services are covered for adults in the state’s Medicaid program. EPSDT also includes outreach and informing to notify children and their families of EPSDT and the importance of preventative care, and to offer appointment scheduling and transportation assistance, if needed.

If a service that a child under age 21 needs is for some reason not available under MaineCare, or if the child requires more services than MaineCare may cover, then the child’s provider can file with the Office of MaineCare Services, a request for Prior Authorization for what is called “Optional Treatment- EPSDT Services.”

And More…

This is just a partial list of services covered by full-benefit MaineCare. It is important to note that all children with MaineCare receive the same full-benefit coverage, whether their coverage is through the CHIP program (the children whose families pay a monthly premium) or through straight Medicaid, which includes the Katie Beckett benefit. For more information, call MaineCare Member Services at 1-800-977-6740 (if you are deaf or hard of hearing and have a TTY machine, call 1-800-977-6741).

Important note about copayments: Except for small copayments, doctors and other health care providers cannot charge members in addition to the payments they get from MaineCare. There are no copayments for services provided to children. If a MaineCare member cannot afford to pay a copayment, the provider must still provide the service. The provider may bill the member, but may not deny services in the future due to non-payment of copayments.

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