Me. Stat. tit. 22 § 3174-G

Current through 131st (2023-2024) Legislature Chapter 684

Section 3174-G - Medicaid coverage of certain elderly and disabled individuals, children and pregnant women; transitional Medicaid

1.Delivery of services. The department shall provide for the delivery of federally approved Medicaid services to the following persons:

A. A qualified woman during her pregnancy and up to 60 days following delivery when the woman's family income is equal to or below 209% of the nonfarm income official poverty line; [2021, c. 519, §1(AMD).]

A-1. Notwithstanding paragraph A, beginning August 1, 2022 and for as long as coverage is allowable by federal law, a qualified woman during her pregnancy and up to 12 months following delivery when the woman's family income is equal to or below 209% of the nonfarm income official poverty line; [2021, c. 519, §2(AMD).]

A-2. [2021, c. 519, §3(RP).]

A-3. [2021, c. 519, §4(RP).]

B. A person under 21 years of age when the person's family income is equal to or below 300% of the nonfarm income official poverty line. Rules adopted pursuant to this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A;

C. A qualified elderly or disabled person when the person's family income is equal to or below 100% of the nonfarm income official poverty line; [2005, c. 3, Pt. M, §1(RPR); 2005, c. 3, Pt. M, §2(AFF).]

D.[Repealed]

E.[Effective until contingency; See PL 2011, c. 657, Pt. Z, §2] On or before September 30, 2012, the parent or caretaker relative of a child described in paragraph B when the child's family income is equal to or below 200% of the nonfarm income official poverty line, subject to adjustment by the commissioner under this paragraph and, beginning October 1, 2012, the parent or caretaker relative of a child described in paragraph B when the child's family income is equal to or below 133% of the nonfarm income official poverty line, subject to adjustment by the commissioner under this paragraph. Medicaid services provided under this paragraph must be provided within the limits of the program budget. Funds appropriated for services under this paragraph must include an annual inflationary adjustment equivalent to the rate of inflation in the Medicaid program. On a quarterly basis, the commissioner shall determine the fiscal status of program expenditures under this paragraph. If the commissioner determines that expenditures will exceed the funds available to provide Medicaid coverage pursuant to this paragraph, the commissioner must adjust the income eligibility limit for new applicants to the extent necessary to operate the program within the program budget. If, after an adjustment has occurred pursuant to this paragraph, expenditures fall below the program budget, the commissioner must raise the income eligibility limit to the extent necessary to provide services to as many eligible persons as possible within the fiscal constraints of the program budget, as long as on or before September 30, 2012 the income limit does not exceed 200% of the nonfarm income official poverty line and, beginning October 1, 2012, the income limit does not exceed 133% of the nonfarm income official poverty line;

E.[Effective on contingency; See PL 2011, c. 657, Pt. Z, §2] On or before September 30, 2012, the parent or caretaker relative of a child described in paragraph B when the child's family income is equal to or below 200% of the nonfarm income official poverty line, subject to adjustment by the commissioner under this paragraph and, beginning October 1, 2012, the parent or caretaker relative of a child described in paragraph B when the child's family income is equal to or below 100% of the nonfarm income official poverty line. Medicaid services provided under this paragraph must be provided within the limits of the program budget. Funds appropriated for services under this paragraph must include an annual inflationary adjustment equivalent to the rate of inflation in the Medicaid program. On a quarterly basis, the commissioner shall determine the fiscal status of program expenditures under this paragraph. If the commissioner determines that expenditures will exceed the funds available to provide Medicaid coverage pursuant to this paragraph, the commissioner must adjust the income eligibility limit for new applicants to the extent necessary to operate the program within the program budget. If, after an adjustment has occurred pursuant to this paragraph, expenditures fall below the program budget, the commissioner must raise the income eligibility limit to the extent necessary to provide services to as many eligible persons as possible within the fiscal constraints of the program budget, as long as on or before September 30, 2012 the income limit does not exceed 200% of the nonfarm income official poverty line;

F. A person 20 to 64 years of age who is not otherwise covered under paragraphs A to E when the person's family income is below or equal to 125% of the nonfarm income official poverty line, as long as the commissioner adjusts the maximum eligibility level in accordance with the requirements of the paragraph.

(2) If the commissioner reasonably anticipates the cost of the program to exceed the budget of the population described in this paragraph, the commissioner shall lower the maximum eligibility level to the extent necessary to provide coverage to as many persons as possible within the program budget.

(3) The commissioner shall give at least 30 days' notice of the proposed change in maximum eligibility level to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs and the joint standing committee of the Legislature having jurisdiction over health and human services matters; [IB 2017, c. 1, Pt. A, §1(AMD).]

G. A person otherwise eligible who is a noncitizen legally admitted to the United States to the extent that coverage is allowable by federal law if the person is:

(1) A woman during her pregnancy and up to 60 days following delivery; or

(2) A child under 21 years of age; [2021, c. 519, §5(AMD).]

G-1. Notwithstanding paragraph G, beginning August 1, 2022, a person otherwise eligible who is a noncitizen legally admitted to the United States for as long as and to the extent that coverage is allowable by federal law if the person is:

(1) A woman during her pregnancy and up to 12 months following delivery; or

(2) A child under 21 years of age; and [2021, c. 519, §6(AMD).]

G-2. [2021, c. 519, §7(RP).]

G-3. [2021, c. 519, §8(RP).]

H. No later than 180 days after the effective date of this paragraph, a person under 65 years of age who is not otherwise eligible for assistance under this chapter and who qualifies for medical assistance pursuant to 42 United States Code, Section 1396a(a)(10)(A)(i) (VIII) when the person's income is at or below 133% plus 5% of the nonfarm income official poverty line for the applicable family size. The department shall provide such a person, at a minimum, the same scope of medical assistance as is provided to a person described in paragraph E.

Cost sharing, including copayments, for coverage established under this paragraph may not exceed the maximum allowable amounts authorized under section 3173-C, subsection 7.

No later than 90 days after the effective date of this paragraph, the department shall submit a state plan amendment to the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services ensuring MaineCare eligibility for people under 65 years of age who qualify for medical assistance pursuant to 42 United States Code, Section 1396a(a)(10)(A)(i) (VIII).

The department shall adopt rules, including emergency rules pursuant to Title 5, section 8054 if necessary, to implement this paragraph in a timely manner to ensure that the persons described in this paragraph are enrolled for and eligible to receive services no later than 180 days after the effective date of this paragraph. Rules adopted pursuant to this paragraph are routine technical rules as defined by Title 5, chapter 375, subchapter 2-A. [IB 2017, c. 1, Pt. A, §3(NEW).]

For the purposes of this subsection, the "nonfarm income official poverty line" is that applicable to a family of the size involved, as defined by the federal Department of Health and Human Services and updated annually in the Federal Register under authority of 42 United States Code, Section 9902(2). For purposes of this subsection, "program budget" means the amounts available from both federal and state sources to provide federally approved Medicaid services.

[2021, c. 519, §§1-8(AMD); 2021, c. 635, Pt. CCC, §§1, 2(AMD).]

1-A.Elderly prescription drug program.

[2001, c. 650, §1(RP).]

1-B.Funding. State funds necessary to implement subsection 1-C must include General Fund appropriations and Other Special Revenue allocations from the Fund for a Healthy Maine to the elderly low-cost drug program operated pursuant to section 254-D, including rebates received in that program from pharmaceutical manufacturers, that are no longer needed in that program as a result of the Medicaid waiver obtained pursuant to subsection 1-C.

[2005, c. 401, Pt. C, §5(AMD).]

1-C.Prescription drug waiver program. Except as provided in paragraph G, the department shall apply to the federal Centers for Medicare and Medicaid Services for a waiver or amend a pending or current waiver under the Medicaid program authorizing the department to use federal matching dollars to enhance the prescription drug benefits available to persons who qualify for the elderly low-cost drug program established under section 254-D. The program created pursuant to the waiver is the prescription drug waiver program, referred to in this subsection as the "program."

A. As funds permit, the department has the authority to establish income eligibility levels for the program up to and including 200% of the federal nonfarm income official poverty level, except that for individuals in households that spend at least 40% of income on unreimbursed direct medical expenses for prescription medications, the income eligibility level is increased by 25%. [2001, c. 650, §3(NEW).]

B. To the extent reasonably achievable under the federal waiver process, the program must include the full range of prescription drugs provided under the Medicaid program on the effective date of this subsection and must limit copayments and cost sharing for participants. If cost sharing above the nominal cost sharing for the Medicaid program is determined to be necessary, the department may use a sliding scale to minimize the financial burden on lower-income participants. [2001, c. 650, §3(NEW).]

C. Coverage under the program may not be less beneficial to persons who meet the qualifications of former section 254 than the coverage available under that section on September 30, 2001. [2005, c. 401, Pt. C, §6(AMD).]

D. In determining enrollee benefits under the program, to the extent possible, the department shall give equitable treatment to coverage of prescription medications for cancer, Alzheimer's disease and behavioral health. [2001, c. 650, §3(NEW).]

E. The department is authorized to provide funding for the program by using funds appropriated or allocated to provide prescription drugs under sections 254-D and 258. [2005, c. 401, Pt. C, §6(AMD).]

F. The department is authorized to amend the waiver or adjust program requirements as necessary to take advantage of enhanced federal matching funds that may become available. [2001, c. 650, §3(NEW).]

G. If, upon thorough analysis, the department determines that a waiver under this subsection is not feasible or would not significantly benefit participants in the elderly low-cost drug program, the department may decide not to pursue the waiver. Within 30 days of a decision not to proceed with a waiver and before taking action on that decision, the department shall report to the joint standing committee of the Legislature having jurisdiction over health and human services matters and shall provide a detailed analysis of the reasons for reaching that decision. [2001, c. 650, §3(NEW).]

[2005, c. 401, Pt. C, §6(AMD).]

1-D.Enrollment fee. The department may assess an annual enrollment fee of $25 for participation in the MaineCare program for a family including a parent or caretaker relative of a child described in subsection 1, paragraph B when the family's income exceeds 150% of the nonfarm income official poverty line.

2.Resource test. The department may not apply a resource test to those children and pregnant women who are made eligible under this section, unless these persons also receive Temporary Assistance for Needy Families or United States Supplemental Security Income benefits.

[1989, c. 502, Pt. A, §72(NEW); 1997, c. 530, Pt. A, §34(AMD).]

3. Benefits authorized. The scope of medical assistance to be provided within this section must be that authorized by the Federal Sixth Omnibus Budget Reconciliation Act, Public Law 99-509.

[2019, c. 485, §2(AMD).]

4.Transitional Medicaid. The department shall administer a program of transitional Medicaid to families receiving benefits under Section 1931 of the federal Social Security Act in accordance with 42 United States Code, Section 1396r-6 and this subsection. The amount, duration and scope of services provided under this subsection must be the same as that provided to a parent or caretaker relative of a child described in subsection 1, paragraph B .

A. The department shall provide transitional Medicaid for a 12-month extension period in accordance with 42 United States Code, Section 1396r-6, Subsection (a), Paragraph (5) to families whose eligibility for Medicaid assistance terminated due to an increase in earned income, an increase in hours of employment or a loss of a time-limited earnings disregard.

B. The department shall provide transitional Medicaid for 4 months to families whose eligibility for Medicaid assistance terminated due to an increase in the amount of child support received by the family.

22 M.R.S. § 3174-G

Amended by 2024, c. 597,§ 10, eff. 8/9/2024.

Amended by 2024, c. 597,§ 9, eff. 8/9/2024.

Amended by 2024, c. 597,§ 8, eff. 8/9/2024.

Amended by 2024, c. 597,§ 7, eff. 8/9/2024.

Amended by 2024, c. 597,§ 6, eff. 8/9/2024.

Amended by 2024, c. 597,§ 5, eff. 8/9/2024.

Amended by 2022, c. 635,§ CCC-2, eff. 4/20/2022.

Amended by 2022, c. 635,§ CCC-1, eff. 4/20/2022.

Amended by 2022, c. 519,§ 8, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 7, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 6, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 5, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 4, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 3, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 2, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2022, c. 519,§ 1, eff. 8/8/2022, app. retroactively to 1/1/2022.

Amended by 2021SP1, c. 461,§ 7, eff. 10/18/2021.

Amended by 2021SP1, c. 461,§ 6, eff. 10/18/2021.

Amended by 2021SP1, c. 461,§ 5, eff. 10/18/2021.

Amended by 2021SP1, c. 461,§ 4, eff. 10/18/2021.

Amended by 2021SP1, c. 461,§ 3, eff. 10/18/2021.

Amended by 2021SP1, c. 461,§ 2, eff. 10/18/2021.

Amended by 2021SP1, c. 461,§ 1, eff. 10/18/2021.

Amended by 2019, c. 485,§ 2, eff. 9/19/2019.

Amended by 2012, c. 477,§ Z-1, eff. 2/23/2012.

Amended by 2011, c. 380,§§ KK-2, KK-3, eff. 6/20/2011.

1989, c. 502, §A72 (NEW) . 1997, c. 530, §A34 (AMD) . 1997, c. 643, §RR4 (AMD) . 1997, c. 777, §A1 (AMD) . 1999, c. 401, §§KKK2,3 (AMD) . 1999, c. 401, §KKK10 (AFF) . 1999, c. 531, §F2 (AFF) . 1999, c. 731, §§KK1,OO1 (AMD) . 1999, c. 790, §A25 (AMD) . 2001, c. 450, §§A1,2 (AMD) . 2001, c. 650, §§1-3 (AMD) . 2003, c. 469, §A11 (AFF) . 2003, c. 469, §A5 (AMD) . 2003, c. 673, §§Y1,2 (AMD) . 2003, c. 673, §Y3 (AFF) . 2005, c. 3, §M1 (AMD) . 2005, c. 3, §M2 (AFF) . 2005, c. 401, §§C5,6 (AMD) . 2007, c. 539, Pt. NNN, §1 (AMD) . 2007, c. 695, Pt. C, §§9, 10 (AMD) .