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 6 - SUPPLEMENTAL SECURITY INCOME(SSI) - RELATED MEDICAID COVERAGE
Section 144-332-6-5 - COVERED INDIVIDUALS
Current through 2024-38, September 18, 2024
Section 5.1 : Definitions
When determining SSI - Related eligibility, individuals are considered to be eligible individuals, ineligible spouses, eligible couples or an eligible child.
An "eligible individual" is the person who is applying for or receiving Medicaid.
An "ineligible spouse" is the person to whom the individual is married, who is living with the individual, and who is not applying for or is not receiving Medicaid. The spouse can choose to be an ineligible spouse.
An "eligible couple" are married individuals, living together, who both have made application for or are recipients of SSI, the State Supplement or SSI - Related Medicaid. Both individuals must meet all eligibility criteria. It is not possible to treat each spouse as an eligible individual if they are living together. Each spouse is considered an eligible individual effective the month after they cease to live together. For married couples who are residing in the same nursing home room (see Part 14, Section 4.2) or who are applying for waiver services in the community (see Part 13, Sections 4 and 6), special criteria may need to be considered.
An individual whose marriage has been terminated through death, divorce or annulment is considered not married.
An "eligible child" is an individual who has a disability or visual impairment and who is neither married nor the head of a household and
* under age 18; or
* under age 22 (through age 21) and a student regularly attending school or college or training designed to prepare him/her for a paying job. The child/student can have the student earned income exclusion (See Part 17, Section 4.54) and an ineligible child allocation (See Part 7, Section 2.2.1).
Child status ends effective with the month after the month of attainment of age 18 (age 22 if a student) or the month after the month s/he last meets the definition of a child.
Section 5.2 : Eligible Groups
All SSI - Related Medicaid eligible individuals and couples must meet financial guidelines and be a member of one of the following groups:
Individuals or couples who meet the criteria for SSI or the State Supplement and who have not applied or who do not want to apply for either or both cash payments.
Commencing 4/1/77, those individuals or couples formerly entitled to concurrent benefits from SSI and Social Security who would be eligible for SSI if annual cost of living adjustments are not counted (See Appendix C for specifics).
Individuals or couples who are residing in these homes have special income guidelines for State Supplement eligibility. If income exceeds these special guidelines the individual or couple may still be eligible for MaineCare (See Part 12).
Individuals or couples who are residing in these homes have special income limits for MaineCare coverage (See Part 12).
Individuals must be in a facility licensed by the Department of Health and Human Services to provide nursing care services. There are four types of facilities:
Individuals in these types of facilities must meet special eligibility criteria (See Part 14).
There are programs available for individuals who require nursing home care and are living in the community. These programs are called "Home and Community Based Waiver Programs" because they provide special services and follow special eligibility criteria (See Part 13).
The waiver programs are:
If the newborn's mother is receiving Medicaid (or is covered as part of the retroactive period) on the date the baby is born, the baby is eligible for coverage regardless of the newborn's income or assets. The mother must be fully covered by Medicaid on the day of the baby's birth. In other words, if mother meets the deductible amount on the day of the baby's birth and is partially responsible for any medical bills on that date, the newborn is not eligible in this group.
Coverage continues for one year. This means that the baby is eligible without regard to: changes in family income or composition, cooperation with DSER, cooperation with TPL, obtaining a Social Security number or declaring citizenship status.
Individuals under this eligibility option are children with disabilities, age 18 and younger, who are living in the community and would be eligible for Medicaid if they were in need of institutional level of care. There are no special services provided to this group (See Part 7, Section 5 ).
These are individuals who are not eligible for Medicare and who lost their SSI or State Supplement benefits due to receipt of disabled widow(er)'s benefits from Social Security. If the individual meets all other SSI criteria and would be eligible for SSI or State Supplement benefits if the amount of Social Security benefits received as a disabled widow(er) were excluded income, the individual is eligible for categorically needy, SSI - Related Medicaid coverage. The exclusion of income from the Social Security disabled widow(er) continues until the individual is eligible for Medicare or would be ineligible for SSI or State Supplement benefits for a reason other than the income from Social Security disabled widow(er)'s benefits.
A Disabled Adult Child is an individual who lost his/her eligibility for SSI or State Supplement on or after 7/1/87 due to an increase in or initial receipt of Social Security Benefits based on their DAC status. These individuals who maintain their DAC status with Social Security may continue to receive Medicaid coverage. In determining eligibility for Medicaid, the increase in Social Security Benefits that resulted in SSI ineligibility will be disregarded. Other changes in income will be taken into account and will affect eligibility. Countable income must be under the current SSI or State Supplement income limit.
A person receives Social Security Benefits under DAC status if the following conditions are met:
Individuals may lose coverage under this group and later regain it. Continued eligibility is not necessary.
Within this section there are other groups which are included in Federal Law. These are listed in Appendix D for informational purposes.
Individuals under age 18 are Medicaid eligible if the individual:
If the individual is closed from SSI for a reason other than not meeting the changed disability criteria, such as being over income or assets, or failing to cooperate in establishing eligibility, this protected status does not apply and the individual must then meet current Medicaid eligibility criteria.
Once an individual has been receiving Medicaid under this protected status and they fail to meet any of the criteria in I - IV above, the protected status is lost and eligibility is determined using the current Medicaid criteria.
This coverage group includes individuals who meet the SSI standard for disability and who have earnings subject to federal tax withholding but are not eligible for Medicaid under any other coverage group. These individuals may buy into Medicaid by paying a monthly premium if the specific requirements of this coverage group are met. This is an SSI - Related coverage group using SSI - Related rules for treatment of income and assets, however, there are income and asset limits specific to this coverage group.
Section 1619(b) refers to the section in the Social Security Act which authorizes coverage for this group. These are individuals who are considered disabled by SSI but their earned income disqualifies them for an SSI payment. However, due to the use of a higher income guideline by SSI, they continue to be carried by SSI case as an open case and they are Medicaid eligible.
