Section 3174-T - Children's Health Insurance Program1. Program established. The Children's Health Insurance Program is established to provide health coverage for low-income children who are ineligible for benefits under the Medicaid program and who meet the requirements of subsection 2 . The purpose of the Children's Health Insurance Program is to provide health coverage to as many children as possible within the fiscal constraints of the program budget and without forfeiting any federal funding that is available to the State for the State Children's Health Insurance Program through the federal Balanced Budget Act of 1997, Public Law 105-33, 111 Stat. 251, referred to in this section as the Balanced Budget Act of 1997.2. Eligibility; enrollment. Health coverage under the Children's Health Insurance Program is available to children under 19 years of age who meet the requirements set forth in paragraph C. A. The department may adopt rules regarding federal funding of the program within federal guidelines up to the maximum eligibility levels described under section 3174-G.B. If the commissioner has determined the fiscal status of the Children's Health Insurance Program under subsection 8 and has determined that an adjustment in the maximum eligibility level is required under this paragraph, the commissioner shall adjust the maximum eligibility level in accordance with the requirements of this paragraph. (1) The adjustment must accomplish the purposes of the Children's Health Insurance Program set forth in subsection 1.(3) If Children's Health Insurance Program expenditures are reasonably anticipated to fall below the program budget, the commissioner shall raise the maximum eligibility level set in paragraph A to the extent necessary to provide coverage to as many children as possible within the fiscal constraints of the program budget. If Children's Health Insurance Program expenditures are reasonably anticipated to exceed the program budget after raising the maximum eligibility level pursuant to this subparagraph, the commissioner may lower the maximum eligibility level .(4) 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.C. All children resident in the State are eligible except a child who: (1) Is eligible for coverage under the Medicaid program;(2) Is covered under a group health insurance plan or under health insurance, as defined in Section 2791 of the federal Public Health Service Act, 42 United States Code, Section 300gg(c) (Supp. 1997); or(4) Is a resident in a public institution or a patient in an institution for mental diseases.(5) Within the 3 months prior to application for coverage under the Children's Health Insurance Program, was insured or otherwise provided coverage under an employer-based health plan for which the employer paid 50% or more of the cost for the child's coverage, except that this subparagraph does not apply if: (a) The cost to the employee of coverage for the family exceeds 10% of the family's income;(b) The parent lost coverage for the child because of a change in employment, termination of coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985, COBRA, of the Employee Retirement Income Security Act of 1974, as amended, 29 United States Code, Sections 1161 to 1168 (Supp. 1997) or termination for a reason not in the control of the employee; or(c) The department has determined that grounds exist for a good-cause exception.D. Notwithstanding changes in the maximum eligibility level determined under paragraph B, the following requirements apply to enrollment and eligibility: (1) Children must be enrolled for 12-month enrollment periods. Prior to the end of each 12-month enrollment period the department shall redetermine eligibility for continuing coverage; and(2) Children of higher family income may not be covered unless children of lower family income are also covered. This subparagraph may not be applied to disqualify a child during the 12-month enrollment period. Children of higher family income may be disqualified at the end of the 12-month enrollment period if the commissioner has lowered the maximum eligibility level under paragraph B.E. Coverage under the Health Insurance Purchase Option of the Children's Health Insurance Program may be purchased for children under 19 years of age described in subparagraphs (1) and (2) for a period of up to 18 months as provided in this paragraph at a premium level that is revenue neutral and that covers the cost of the benefit and a contribution toward administrative costs no greater than the maximum level allowable under the Consolidated Omnibus Budget Reconciliation Act of 1985, COBRA, of the Employee Retirement Income Security Act of 1974, as amended, 29 United States Code, Sections 1161 to 1168 (Supp. 1997). The department shall adopt rules to implement this paragraph. The following children are eligible to enroll under this paragraph: (1) A child who is enrolled under paragraph A or B and whose family income at the end of the child's 12-month enrollment term exceeds the maximum allowable income set in that paragraph; and(2) A child who is enrolled in the Medicaid program and whose family income exceeds the limits of that program. The department shall terminate Medicaid coverage for a child who enrolls in the Children's Health Insurance Program under this subparagraph.F. The department may not apply an asset test to a child or child's family when the child is otherwise eligible for the Children's Health Insurance Program under this section. 3. Program administration; benefit design. With the exception of any requirements imposed under this section, the Children's Health Insurance Program must be integrated with the Medicaid program and administered with it in one administrative structure within the department, with the same enrollment and eligibility processes, benefit package and outreach and in compliance with the same laws and policies as the Medicaid program, except when those laws and policies are inconsistent with this section and the Balanced Budget Act of 1997. The department shall adopt and promote a simplified eligibility form and eligibility process.4. Benefit delivery. The Children's Health Insurance Program must use, but is not limited to, the same benefit delivery system as the Medicaid program, providing benefits through the same health plans, contracting process and providers. Copayments and deductibles may not be charged for benefits provided under the program.5.[Repealed only if the Department of Health and Human Services receives approval from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services to remove premium and waiting period requirements for health coverage for low-income children under the Cub Care program] Premium payments. Premiums must be paid in accordance with this subsection. A. Premiums must be paid at the beginning of each month for coverage for that month according to the following scale: (1) Families with incomes between 150% and 160% of the federal nonfarm income official poverty line pay premiums of 5% of the benefit cost per child, but not more than 5% of the cost for 2 children;(2) Families with incomes between 160% and 170% of the federal nonfarm income official poverty line pay premiums of 10% of the benefit cost per child, but not more than 10% of the cost for 2 children;(3) Families with incomes between 170% and 185% of the federal nonfarm income official poverty line must pay premiums of 15% of the benefit cost per child, but not more than 15% of the cost for 2 children; and(4) Families with incomes between 185% and 200% of the federal nonfarm income official poverty line must pay premiums of 20% of the benefit cost per child, but not more than 20% of the cost for 2 children.B. When a premium is not paid at the beginning of a month, the department shall give notice of nonpayment at that time and again at the beginning of the 6th month of the 6-month enrollment period if the premium is still unpaid, and the department shall provide an opportunity for a hearing and a grace period in which the premium may be paid and no penalty will apply for the late payment. If a premium is not paid by the end of the grace period, coverage must be terminated unless the department has determined that waiver of premium is appropriate under paragraph D. The grace period is determined according to this paragraph.(1) If nonpayment is for the first, 2nd, 3rd, 4th or 5th month of the 6-month enrollment period, the grace period is equal to the remainder of the 6-month enrollment period.(2) If nonpayment is for the 6th month of the 6-month enrollment period, the grace period is equal to 6 weeks.C. A child whose coverage under the Children's Health Insurance Program has been terminated for nonpayment of premium and who has received coverage for a month or longer without premium payment may not reenroll until after a waiting period that equals the number of months of coverage under the Children's Health Insurance Program without premium payment, not to exceed 3 months.D. The department shall adopt rules allowing waiver of premiums for good cause.6. Incentives. In the contracting process for the Children's Health Insurance Program and the Medicaid program, the department shall create incentives to reward health plans that contract with school-based clinics, community health centers and other community-based programs.7. Administrative costs. The department shall budget 2% of the costs of the Children's Health Insurance Program for outreach activities. After the first 6 months of the program and to the extent that the program budget allows, the department may expend up to 3% of the program budget on activities to increase access to health care. In addition, the department shall apply for additional federal funds available for Medicaid outreach activities. The goal of outreach activities under this subsection is to enroll 100% of children eligible for the Children's Health Insurance Program or the MaineCare program.8. Quarterly determination of fiscal status; reports. On a quarterly basis, the commissioner shall determine the fiscal status of the Children's Health Insurance Program, determine whether an adjustment in maximum eligibility level is required under subsection 2, paragraph B and report 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 on the following matters: A. Enrollment approvals, denials, terminations, reenrollments, levels and projections. With regard to denials, the department shall gather data from a statistically significant sample and provide information on the income levels of children who are denied eligibility due to family income level;B. Children's Health Insurance Program expenditures, expenditure projections and fiscal status;C. Proposals for increasing or decreasing enrollment consistent with subsection 2, paragraph B;D. Proposals for enhancing the Children's Health Insurance Program;E. Any information the department has from the Children's Health Insurance Program or from the Department of Professional and Financial Regulation, Bureau of Insurance or the Department of Labor on employer health coverage and insurance coverage for low-income children;F. The use of and experience with the Health Insurance Purchase Option under subsection 2, paragraph E; andG. Children's Health Insurance Program administrative costs.9. Provisions applicable to federally recognized Indian tribes. After consultation with federally recognized Indian nations, tribes or bands of Indians in the State, the commissioner shall adopt rules regarding eligibility and participation of children who are members of a nation, tribe or band, consistent with Title 30, section6211, in order to best achieve the goal of providing access to health care for all qualifying children within program requirements, while using all available federal funds.10. Rulemaking. The department shall adopt rules in accordance with Title 5, chapter 375 as required to implement this section. Rules adopted pursuant to this subsection are routine technical rules as defined by Title 5, chapter 375, subchapter 2-A.11. Children's Health Insurance Program drug rebate agreement. Effective October 1, 1999, the department shall enter into a drug rebate agreement with each manufacturer of prescription drugs that results in a rebate equal to that which would be achieved under the federal Social Security Act, Section 1927.12.[Repealed only if the Department of Health and Human Services receives approval from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services to remove premium and waiting period requirements for health coverage for low-income children under the Cub Care program] Premium rate review; adjustment. Effective July 1, 2004, the department shall periodically evaluate the amount of premiums charged under this section to ensure that the premiums charged reflect the most current benefit cost per child. The commissioner shall adjust the premiums by rule. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.Amended by 2024, c. 597,§ 11, eff. 8/9/2024.Amended by 2023SP1, c. 405,§ A-62, eff. 7/10/2023.Amended by 2022, c. 635,§ CCC-7, eff. only if the Department of Health and Human Services receives approval from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services to remove premium and waiting period requirements for health coverage for low-income children under the Cub Care program .Amended by 2022, c. 635,§ CCC-3, eff. 4/20/2022.Amended by 2017, c. 284,§ SSSSSS-1, eff. 7/4/2017.RR 1997, c. 2, § 46 (RAL) . 1999, c. 401, §§QQ1,2 (AMD) . 1999, c. 401, §QQ5 (AFF) . 1999, c. 522, § 1 (AMD) . 1999, c. 731, §§PP1,2 (AMD) . 1999, c. 790, §A61 (AFF) . 2001, c. 450, §A3 (AMD) . 2003, c. 20, §K10 (AFF) . 2003, c. 673, §§TTT1,2 (AMD) . 2003, c. 673, §§TTT3,5 (AFF) . 2005, c. 683, §A34 (AMD) .Updated by Revisor to correct stigmatizing language.