10- 144 C.M.R. ch. 332, § 7-5

Current through 2024-51, December 18, 2024

Section 144-332-7-5 - KATIE BECKETT COVERAGE

Katie Beckett is a MaineCare coverage group for children who are ineligible under a Family - Related or any other SSI - Related coverage group and who:

I. are age 18 and under (up to age 19);

II. reside in the community (not in a medical institution);

III. meet the SSI/SSA criteria for disability; and

IV. need in-patient care provided by a hospital, nursing facility, psychiatric hospital, or an ICF-MR. The cost of providing care outside the facility must not exceed the annual cost of institutional care needed by the child as determined by the Office of MaineCare Services.

V. If a child covered under Katie Beckett no longer resides with the parent(s), parental deeming under SSI - Related rules ends (See Section 2.2.3 of this Part). The child may then be eligible as SSI - Related and may not need the Katie Beckett coverage group.

Section 5.1: Income and Assets

If the criteria in I - IV above are met, the income and assets of the child only are considered in determining financial eligibility. Parental income and assets are disregarded. There is no cost of care and there is no penalty for transfer of resources.

I. The child's gross income as defined in SSI - Related coverage must be less than or equal to the Categorical Nursing Care Limit (see Chart 4.1). If income exceeds this amount, the individual is not eligible.

II. The child's countable assets as defined in Part 16 must be less than $2,000.

Section 5.2: Premiums

I. Except for Alaska Natives and Native Americans who are members of Federally-recognized Tribes, the Department must receive monthly premiums as described below, in order for the child to receive Katie Beckett coverage.

A.Amount

1. The amounts of the monthly premiums, based on family income as a percentage of the Federal Poverty Level, are identified in Chart 3.12.

2. The premium amounts in the chart apply to a family, regardless of the number of Katie Beckett children in the family.

3. For purposes of calculating family income as a percentage of Federal Poverty Level to determine monthly premiums, family size is the total of the child or children covered under the Katie Beckett group, his or her siblings and his or her parents who reside in the household. Family income is based on gross monthly non- excluded income of the family. Income excluded by SSI - Related coverage and stepparent income (unless the stepparent is to be counted in the family size) are both excluded.

a. There are no deductions or disregards from income.

b. Current income is projected over a twelve month period.

c. SSI - Related Medicaid rules are used in anticipating income and in the treatment of irregular, fluctuating, contract, seasonal and self-employment income.

d. Premium amounts due can be changed if there is a change in income or health insurance that is expected to last for more than a full calendar month. The change in premium amount is effective the month after the month the change in income or health insurance occurred, as long as the change in income or health insurance is reported within ten days of its occurrence; otherwise, the change in premium is effective the month after the month the change in income or health insurance is reported. Adverse action notice will be given when a premium is increased.

e. There are two premium schedules:

i. a standard premium for children without any other creditable private health insurance coverage. Creditable insurance coverage is defined in 42 U.S.C. § 300gg(c)(1) and includes any health benefits plan, individuals or group, a medical care program of the Indian Health Service or another tribal organization, any government insurance plan for Armed Forces, Peace Corps volunteers or government employees, provided by a carrier for the purposes of providing, paying for or reimbursing expenses for health services. Creditable insurance coverage does not include coverage which is limited in scope such as dental insurance or vision care insurance; and

ii. a discounted premium for children covered by a private health insurance plan.

Note: For families using the Private Health Insurance Program (PHIP) benefit, the standard premium schedule applies.

B.Payment

1. Payment is due to be received by the Department on the first day of the month for which the child receives coverage.

2. Premiums can be paid monthly, for more than one month at a time, or in advance for the twelve month eligibility period. Payments will first be credited to the earliest months of coverage during the current twelve month eligibility period. If retroactive coverage is granted according to Part 2, Section 13.4, then payment will also be due for the retroactive months of coverage. These payments for retroactive coverage will be created first.

For example: A monthly premium of $92.00 is due during the twelve month review period from January to December and the first payment of $92.00 is received on March 1st. Month one (January) will be credited with a premium paid. The February and March payments are overdue.

3. Payment must be paid up to date every three months. If not, advance notice of closing will be sent to end coverage the last day of the 3rd month.

For example: The 1st month of coverage is January. As of March 1st, premiums for January, February, and March are paid. As of June 1st, payments are received by DHHS for April, but no payment is received for May or June. Action is taken to end Medicaid coverage effective June 30th.

4. There is a grace period for nonpayment of premiums. The grace period extends through the last day of every 3rd month.

5. If payment is received the month following the month coverage has ended, a new medical assessment is not needed to determine if the child is in the need of institutional level of care. Reapplications for any following months require a new medical assessment. Aprior decision on meeting the SSA disability criteria can be used if the review date of this decision is in the future.

6. If MaineCare coverage under the Katie Beckett group is closed due to non-payment or non-timely payment of a premium, coverage under Katie Beckett cannot be reinstated for twelve months starting with the month the closing is effective unless all past due premiums are paid in full.

7. Coverage under this group can be reinstated in fewer than 12 months if there is good cause for late or non-payment of premiums because of one of the following reasons:

a. mail delay;

b. illness of the parent; or

c. unanticipated emergency beyond the control of the parent or the responsible individual.

C.Refunds

A refund is due if an agency error occurs. Any adjustment will be limited to twelve months prior to knowledge that an agency error has occurred.

II. If a child under age 18 is getting Medicaid coverage through the SSI cash program and he/she becomes ineligible for an SSI cash payment due to the parents' income or assets, the child may continue to get full Medicaid coverage and a $40.00 payment through the SSI and State Supplement program if the child:

A. is disabled;

B. received SSI benefits while in a medical facility (hospital or nursing home) for at least one month; and

C. meets the inpatient level of care standard for Katie Beckett.

The SSI office will ask the state Department of Health and Human Services to see if the child meets the medical need standard for the Katie Beckett option. The SSI office will let the parents know if the child meets the criteria and can get the $40.00 payment from SSI/State Supplement as well as continued Medicaid coverage. SSI may refer to this option as the "waiver of parental deeming".

10- 144 C.M.R. ch. 332, § 7-5