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".
