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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

6 Approval Date: 3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

MaineCare, both Title XIX and Title XXI funded coverage, is administered by the Maine Department of Health and Human Services. Within the Department, the Bureau of Medical Services is responsible for establishing policy regarding benefits, quality assurance, and claims payment. The Bureau of Family Independence is responsible for determining eligibility.

Children covered under MaineCare with Title XXI funding are provided with the same rights and benefits available to children enrolled with Title XIX funding. All administrative processes are designed by the Department of Health and Human Services to be seamless. As such, all enrollment and eligibility processes, benefit package/benefit delivery policies, and outreach activities are the same for Title XIX and Title XXI, with the only discernable difference being premium billing for those Title XXI children at 151% through 200% FPL.

There are 3 delivery systems.

(1) The MaineCare primary care case management initiative is operational in all 16 counties. With few exceptions, the majority of MaineCare children covered under Title XXI funding access services through primary care case management.

(2) The MaineCare DirigoChoice initiative is operational in all 16 counties. MaineCare members may voluntarily enroll in DirigoChoice if they work for a DirigoChoice eligible business that offers the DirigoChoice plan to its employees and they meet the requirements of an eligible employee. MaineCare members who are dependents of DirigoChoice members may also enroll in DirigoChoice. DirigoChoice meets the conditions necessary to contract as a managed care entity as described in CFR 457.955.

(3) MaineCare members not participating in primary care case management or the DirigoChoice initiative can access services through the fee for service system.

In addition, pursuant to Section 2105(a)(1)(D), the Department will offer “health services initiatives” directed at children and adolescents age 18 or younger. The health services initiatives will be activities sponsored by the Department’s Bureau of Health and do not overlap with MaineCare school based health services.