Current through 2024-38, September 18, 2024
When eligibility within either a parent/caretaker relative
or child under age 21 eligibility group for which MAGI-based methodology
applies ceases because of hours of, or income from, employment of the
parent/caretaker relative or because of receipt of alimony, Transitional
Medicaid may be available.
Section 4.1: Definitions
Family - a family consists of individuals
whose needs and income were included in determining eligibility in a coverage
group for which MAGI-based methodology applies at the time this coverage ended.
It also includes those individuals whose needs and income would be taken into
consideration in determining eligibility for a coverage group for which
MAGI-based methodology applies if the family were applying in the current
month.
Included in the definition is:
a parent/caretaker relative who returns home, who is
included in an eligibility group for which MAGI-based methodology applies and
whose earnings, either alone or added to other income of the household, result
in the family losing coverage under an eligibility group for which MAGI-based
methodology applies;
a child or parent/caretaker relative who moves into
the home after TM has started; or
a child who is born after TM has started.
Section 4.2: Eligibility for Transitional Medicaid:
Individuals Who Become Ineligible for Coverage under MAGI-Based Coverage Due to
Increased Earnings
Section 4.2.1: Computation of Transition
Period
Individuals who lose eligibility in a coverage group for
which MAGI-based methodology applies due to the earnings of a parent/caretaker
relative may remain eligible for Medicaid for up to a year. The scope of
services will be the same as those provided to those eligible under an
eligibility group for which MAGI-based methodology applies.
These individuals may receive up to twelve additional
months of medical coverage known as Transitional Medicaid (TM). The twelve
months are divided into two separate eligibility periods, each consisting of
six months. There are different requirements for each extension. Individuals
receiving TM must continue to assign their rights to payment for medical care
from any third party. The custodial parent is not required to cooperate in
obtaining medical support or payments from the non-custodial parent (See Part
2, Sections 6 and 7).
The twelve month count starts with the first month of
ineligibility, which may not necessarily be the effective month of the loss of
coverage under an eligibility group for which MAGI-based methodology
applies.
Example:
A family reports an increase in the parent's earnings on
April 5th. The parent is now ineligible in April.
The first month for TM is April, the first month of ineligibility, and not May,
which would be the effective month for the closing under an eligibility group
for which MAGI-based methodology applies.
Section 4.2.1.1: Initial Six Month Extension (Months
One - Six):
A.
Conditions of Eligibility
At least one member must have been eligible for and
receiving coverage under an eligibility group for which MAGI-based methodology
applies in one of the prior three months immediately preceding ineligibility.
Retroactive coverage under an eligibility group for which MAGI-based
methodology applies will be counted for this purpose even if there is only one
month of retroactive coverage and no current eligibility under an eligibility
group for which MAGI-based methodology applies.
For example, the family applies in July. Eligibility exists
only for June. The family gets coverage under an eligibility group for which
MAGI-based methodology applies for June and TM starting in July.
Exception
(1) An individual is not eligible for the
initial six month extension of Transitional Medicaid if the individual is a
member of a family which has received Medicaid, if the State makes a finding
that, at any time during the last 6 months in which the family was receiving
such aid, before otherwise being provided extended eligibility under this
section, the individual was ineligible for Medicaid because of fraud.
(2) The closing of coverage in an eligibility
group for which MAGI-based methodology applies must be due to the earnings of a
specified relative as defined by Section 2 above.
Examples
(a) Mother and one child are covered under an
eligibility group for which MAGI-based methodology applies. Father or
stepfather returns to the home. When eligibility is determined including the
father or stepfather and his earnings, the mother and father or stepfather is
over income for eligibility in a coverage group for which MAGI-based
methodology applies. The mother and father or stepfather are eligible for
TM.
(b) Mother, father and two
children are covered under an eligibility group for which MAGI-based
methodology applies. Mother and father have earnings. One child leaves the home
or turns age 18 resulting the family being over income for an eligibility group
for which MAGI-based methodology applies. Mother, father, and child under age
18 are eligible for TM.
(c) Mother
and two children are covered under an eligibility group for which MAGI-based
methodology applies. The 17 year old (not attending school) has countable
earnings, which result in the mother being over income under an eligibility
group for which MAGI-based methodology applies. The mother is not eligible for
TM because it is not the earnings of the parent/caretaker relative that
resulted in ineligibility for a coverage group for which MAGI-based methodology
applies.
(d) A family of four is
covered under an eligibility group for which MAGI-based methodology applies.
Mother has earnings and father, who was employed, starts to get unemployment
benefits putting the mother and father over the income limits for an
eligibility group for which MAGI-based methodology applies. The mother and
father are not eligible for TM since it was the change in Unemployment
Insurance Benefits (UIB) that resulted in being over the income limits for an
eligibility group for which MAGI-based methodology applies.
It is not a condition of eligibility that the specified
parent/caretaker relative remain employed during the first six months of the
initial extension or that included individuals cooperate in establishing
paternity or in obtaining medical support and payments. Individuals in the
household must comply with rules on assigning rights to medical support
(through Third Party Liability (TPL), see Part 2, Section 6).
There is no income test for the initial six month
extension.
Failure to file the income and child care report required
in the fourth month does not affect the coverage provided in the initial
extension.
The coverage group must include a child, who resides in the
household. This child must be under the age of eighteen or between the ages of
18 and 19 and a student regularly attending a secondary school on a full-time
basis (or in the equivalent level of vocational or technical training at the
high school level) and reasonably expected to complete the program prior to his
or her 19th birthday.
B.
Covered Individuals
(1) All family members who were included
members of a MAGI-Based household at the time of closing and/or whose needs and
income were taken into account in determining coverage under MAGI-Based (for
example a parent returned to the home).
(2) Anyone who moves into the home after TM
has started as long as that person would have been covered under MAGI-Based
coverage if the family were applying in the current month.
For example:
a newborn
a non-custodial parent returns
a child moves into the home
a stepparent moves into the home.
C.
Client Reporting
Responsibilities
(1) Each family must
report when a child no longer resides within its household or when there are
any other changes in the family composition.
(2) Each family must file its report of gross
earnings by the 21st of the fourth month. The report will contain verified
information for months one, two, and three of the initial extension.
If necessary, and upon request, a finding of good cause for
failure to file an income report on time or failure to file a completed report
may be determined by the eligibility specialist. Some reasons for good cause
include but are not limited to:
(a)
mail delay;
(b) reported change of
address too late in preceding month for data processing changes for
mailings;
(c) the 21st falls on a
weekend or holiday, in this instance the due date becomes the next working
day;
(d) planned absences
previously reported;
(e) death or
illness of a family member or responsible relative;
(f) circumstances beyond the control of the
responsible relative.
All other changes must be reported within the time frames
outlined in Part 2, Section 12.2, unless otherwise specified.
D.
Agency Notice
Requirements
(1) At the time of the
closing under MAGI-Based rules, a determination must be made for the
individual's eligibility for initial Transitional Medicaid extension and a
notice must be sent informing the individual of the following:
(a) the individual's eligibility for the
extension and a medical card which lists all eligible members; and
(b) the requirement to report the family's
gross monthly earnings by the 21st of the fourth month within the initial
extension as a condition of eligibility for the additional extension (months
seven - twelve); and
(c) the
availability of a second six month extension; and
(d) the conditions under which the initial
extension may be terminated.
(2) In the third month of the initial
extension, a notice (which is due in the 4th month) will be sent informing the
individual of the following:
(a) the
requirement to report the family's gross earnings for each of the three prior
months;
(b) the optional
availability of a second six month extension (months seven - twelve);
(c) a description of when a premium is
required, how it is calculated, and when payments are due; and
(d) a description of the scope of services
provided within the second six months.
(3) In the sixth month of the initial
extension, a notice (which is due in the 7th month) is required informing the
individual of the following:
(a) the
individual's option to continue into the second six month extension; the
requirement for the family to file a report in the seventh month of its gross
earnings and child care for the fourth, fifth, and sixth months of the
extension;
(b) the amount of any
premium, if any, due for the seventh, eighth, and ninth months of the
extension;
(c) a description of the
scope of services provided in the second extension; and
(d) a description of reinstatement for any
remaining months of this extension.
E.
Termination of Initial TM (Months
one - six)
(1) TM will be terminated
with adequate notice when a child no longer resides within the
household.
(2) A determination of
whether the individual is potentially eligible for any other MaineCare
categories must be made prior to terminating extended coverage.
(3) In situations when the intended agency
action is to terminate coverage, adequate and timely notice must be given to
the recipient as described in Part 2, Section 15.
Section 4.2.2: Second Six Month Extension (Months
seven - twelve)
A.
Conditions of Eligibility(1) An
individual must have received TM for all six of the months within the initial
extension to be offered the second extension.
(2) An individual must have filed a timely
report of income in the fourth month as required.
(3) The parent/caretaker relative must remain
employed in each month of the second six months. Individuals are only required
to report a period of being unemployed at the time of filing an income report
form. Good cause reasons will be considered for lack of employment and
established by the Eligibility Specialist. Some reasons for good cause for lack
of employment include but are not limited to:
(a) dismissal/termination by the
employer;
(b) illness of employed
individual;
(c) care of other ill
family members who are residing within the household;
(d) loss of transportation;
(e) harassment;
(f) risk to health and safety;
(g) loss of child care if there is not any
other adequate replacement; or
(h)
other reasons which indicate the action was not deliberate or
willful.
(4) Countable
income is defined in Part 4. A family's countable income must be less than 185%
of the Federal Poverty Level (See Chart 6.5) to be eligible. The countable
income is tested for 185% upon receipt of the required income reports.
(5) Premiums will be charged for
families whose countable income is greater than 150% of the Federal Poverty
Level (See Chart 6.5) but less than 185%. The premium will be three per cent
(3%) of the family's net income (see IV. E below).
(6) Included individuals do not have to
cooperate in establishing paternity or in obtaining medical support and
payments. Included individuals must comply with the rules on assigning rights
to medical support (through Third Party Liability (TPL)).
B.
Covered Individuals
(1) All family members who were members of a
household under MAGI-Based coverage at the time of closing and/or whose needs
and income were taken into account in determining MAGI-Based coverage (for
example a parent returned to the home).
(2) Anyone who moves into the home after TM
has started as long as that person would have been covered under MAGI-Based
coverage if the family were applying in the current month.
For example:
a newborn
a non-custodial parent returns
a child moves into the home
a stepparent moves into the home.
C.
Budget Computations
(1) The only income used to determine if an
individual remains eligible for TM is gross earnings of financially responsible
adults, living within the household, and the gross earnings of any caretaker
relative and their spouse or stepparent who is getting coverage.
(2) The actual cost for child care is an
income deduction. Only that amount of child care costs necessary for the
employment of the specified relative, will be allowed as a deduction as long as
the family is liable for this expense.
(3) Countable income for use in TM is defined
as gross earnings minus allowable child care deductions in meeting the 185% FPL
test. Unearned income is not counted in the 185% FPL test.
(4) The family's countable income is
determined from the two required reports for gross earnings and child care
expenses. These reports are required in the fourth and seventh months during
the extension.
A review is due in the 12th month in order to determine
continuing eligibility for Medical coverage.
Countable income is determined as follows:
a Determine the family's total gross earnings
for the required three month period.
b Deduct from gross wages the allowable child
care costs necessary for the specified relative's employment.
c Divide by three to obtain the average
monthly income.
d Compare the
average monthly income to 185% of the Federal Poverty Level (See Chart 6) for
the family size. If the income is equal to or less than the limit, the family
remains eligible. If the income is greater than the limit, benefits are
terminated with adequate notice.
(5) Premiums are required for families whose
countable income is equal to or greater than 150% but less than 185% of the
Federal Poverty Level (See Chart 6) for that family size.
Monthly premiums will equal 3% of the family's net income
(rounded down to the nearest dollar) and are to be paid by the 21st of the
month following the month for which coverage is being granted.
Example
June coverage requires premium payment no later than July
21st. Net income for the purpose of establishing a premium is defined as gross
earnings of financially responsible adults and caretaker relatives and their
spouse/ stepparents who are being covered minus allowable tax and child care
limited to only those amounts required by law. Allowable child care deductions
are defined earlier in IV.B, above.
For a premium to be considered timely, it must be paid by
the 21st of the month in which it is due. The Eligibility Specialist may
consider a recipient's good cause reason for failure to pay a premium on time
can be looked at for late payments that are received no later than the last day
of the month in which the payment is due. Good cause is established by the
Eligibility Specialist. Some reasons for good cause include but are not limited
to:
(a) mail delay;
(b) planned absences previously reported;
(a) death or illness of a family member or
responsible relative;
(c) other
unanticipated emergencies; or
(d)
circumstances beyond the control of the responsible relative.
(6) Premium Base Period
The premium charged, if applicable, for months seven,
eight, and nine is based on the report filed in the fourth month of the initial
extension. This report contains income from months one, two, and three of the
initial extension.
The premium charged, if applicable, for months ten, eleven,
and twelve is based on the report filed in the seventh month of the extension.
This report contains income from months four, five, and six of the initial
extension.
When coverage of the parent/caretaker relative ends due to
non-payment, TM is possible for any remaining months of the extension. Prior to
reinstatement any overdue premiums must be paid.
Example
A parent receives coverage for June but fails to pay the
required premium due no later than July 21st, therefore, coverage is closed
August 31st. (June is the 7th month of the extension). In October the parent
wants reinstatement for October (11th month). Since the parent already received
coverage for June, July and August the premiums for these three months are
required before current coverage can be granted for October. Upon payment for
June, July and August coverage, the parent can be reinstated beginning with
October coverage. The October premium is due no later than November 21st. Since
coverage was not provided in September, no premiums are due for that
month.
Note: When a parent has been closed for TM and
there is an unpaid premium due, the Eligibility Specialist will refer the case
to Third Party Liability (TPL) for possible collection.
D.
Client Reporting
Responsibilities(1) There are two
reports required during the TM extension. They are due by the 21st of the
fourth and seventh months of the extension. Client must provide verification of
income. Additional verification will only be needed if there is a change. In
month twelve a review will occur to determine continuing eligibility for
Medical coverage.
(2) Each family
must report in the same month when a child no longer resides within its
household or when there are any other changes in the family
composition.
(3) Each family must
report if the specified relative is no longer employed. Families are only
required to report this information at the time of filing an income report
form.
All other changes must be reported within the time frames
outlined in Part 2, Section 12.2.
E.
Agency Notice Requirements
A review is due in the 12th month. It is used to determine
continuing eligibility for MaineCare coverage when TM ends.
F.
Termination of Benefits for the
Second Six Month Extension
TM will be closed with adequate notice when:
(1) a child no longer resides within the
household. The coverage group must include a child, who resides in the
household. This child must be under the age of eighteen or between the ages of
18 and 19, and a student regularly attending a secondary school on a full-time
basis (or in the equivalent level of vocational or technical training at the
high school level) and reasonably expected to complete the program prior to his
or her 19th birthday.
(2) a required income report is not
filed.
(3) the parent/caretaker
relative is no longer employed. Note: good cause reasons will be considered for
lack of employment and established by the Eligibility Specialist. Some reasons
for good cause for lack of employment include but are not limited to:
(a) dismissal/termination by the
employer;
(b) illness of employed
individual;
(c) care of other ill
family members who are residing within the household;
(d) loss of transportation;
(e) harassment;
(f) risk to health and safety;
(g) loss of child care if there is not any
other adequate replacement; or
(h)
other reasons which indicate the action was not deliberate or
willful.
(4) when income
increases above 185% of the FPL (See Chart 6).
(5) a required premium is not paid timely nor
good cause granted.
A determination of whether the individual is potentially
eligible for any other MaineCare categories must be made prior to the
termination of Transitional Medicaid.
In situations when the intended Agency action is to
terminate coverage, adequate and timely notice must be given to the recipient
as described in Part 2, Section 15.
Section 4.3: Eligibility for Transitional Medicaid:
Individuals Who Become Ineligible for MAGI-Based Coverage Due to Increased
Alimony
Transitional Medicaid coverage for persons with increased
alimony is limited to 4 months; it continues irrespective of other changes in
household income or composition.
Coverage under a MAGI-based eligibility group must have
been closed solely because of an increase in the amount of alimony being
received by an individual in the household.
The individual must have been eligible under a MAGI-based
eligibility group for three of the six months prior to the month he/she is
determined ineligible.
At the end of the four month period, the individual's
coverage is to be reviewed for potential future coverage. If eligibility does
not exist, coverage is to be ended following advance notice procedures.
The four month count for extended Medicaid begins with the
first month of ineligibility even though the closing under MAGI-based
methodology is later.
Example
A client reports in May that her alimony has increased and
now the countable income exceeds program standards. The four month extension
begins in May, even though the case cannot be closed for May.
