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10.09.24.00.htm 10.09.24.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 24 Medical Assistance Eligibility Authority: Estates and Trusts Article, §14.5-1002; Health-General Article, §2-104(b) 2-105(b) 15-103, 15-105, 15-121 and 15-401―15-407; Annotated Code of Maryland
10.09.24.01.htm 10.09.24.01. 01 Purpose and Scope.. A. This chapter governs the determination of eligibility for the Maryland Medical Assistance Program.B. Eligibility may be established for the following coverage groups:. 1) The MAGI coverage groups whose income standard is based on the modified adjusted gross income methodology specified in the Affordable Care Act of 2010, effective January 1, 2014; and2) The MAGI Exempt coverage groups whose income standard is based on Title XIX of the Social Security Act.
10.09.24.02.htm 10.09.24.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Aged" means a person who is 65 years old or older.. 2) "Aid to the Permanently and Totally Disabled" means a former category of public assistance mandated under Title XIV of the Social Security Act, 42 U.S.C. §1351 et seq. and replaced by Title XVI of the Social Security Act, 42 U.S.C. §1381 et seq.3) "Appeal" means a process by which an applicant, recipient, or representa
10.09.24.02-1.htm 10.09.24.02-1. 02-1 MAGI Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) “Affordable Care Act” means the Patient Protection and Affordable Care Act of 2010 (Pub.L.111-148) as amended by the Health Care and Education Reconciliation Act of 2010 (Pub.L.111-152) as amended by the Three Percent Withholding Repeal and Job Creation Act (Pub.L.112-56)2) Authorized Representative” has the meaning stated in COMAR 10.01.04.12..
10.09.24.03.htm 10.09.24.03. 03 Coverage Groups.. A. The following individuals, including recipients of Temporary Cash Assistance, may be determined eligible for the MAGI coverage groups:1) Parents and other caretaker relatives whose household income is equal to or less than 133 percent of the federal poverty level;2) Pregnant and postpartum women of any age whose household income is equal to or less than 250 percent of the federal poverty level;3) Childless adults 19 years old or older and youn
10.09.24.03-1.htm 10.09.24.03-1. 03-1 Coverage Group for Women with Breast or Cervical Cancer ― Purpose, Definitions, and Eligibility Criteria.A. Purpose.. 1) The purpose of Regulations .03-1 and .03-2 of this chapter is to exercise the State's option under Title XIX of the Social Security Act to create a new Medical Assistance optional categorically needy coverage group for women who need treatment for breast cancer, cervical cancer, or precancerous conditions, in accordance with the Breast and Cervi
10.09.24.03-2.htm 10.09.24.03-2. 03-2 Coverage Group for Women with Breast or Cervical Cancer ― Eligibility, Determination, and Covered Services Process.A. Screening. A woman is considered to have received screening services if the:. 1) NBCCEDP funded all or part of the woman's screening services; or. 2) NBCCEDP did not fund all or part of the woman's screening services, but the screening services were rendered by a provider or entity funded at least in part by the NBCCEDP and the:a) Screening services wer
10.09.24.03-3.htm 10.09.24.03-3. 03-3 Medicare Savings Program Coverage.. A. Non-Financial and Resource Eligibility for the Medicare Savings Programs. In order to be eligible for the Medicare savings program under §E―H of this regulation, an individual:1) May not be enrolled in Medical Assistance or the Maryland Children's Health Program under this chapter or under COMAR 10.09.11;2) Shall be entitled to hospital insurance benefits under Medicare Part A, or medical insurance benefits under Medicare Part
10.09.24.03-4.htm 10.09.24.03-4. 03-4 Medicare Buy-In Coverage for Medical Assistance Recipients.. A. If a recipient, who is determined federally eligible and enrolled in Medical Assistance or the Maryland Children’s Health Program according to the requirements of this chapter or COMAR 10.09.11, is entitled to hospital insurance benefits under Medicare Part A, or medical insurance benefits under Medicare Part B, or both, with or without payment of premiums, the Medical Assistance program shall
10.09.24.04.htm 10.09.24.04. 04 Application ― General Requirements.. A. The Department or its designee shall determine initial (retroactive and current) and continuing eligibility.B. The Department or its designee shall give oral, written, or electronic information about the Medical Assistance Program such as:1) Requirements for eligibility;. 2) Available services;. 3) An individual's rights and responsibilities;. 4) Information in plain English, supported by translation services; and.
10.09.24.04-1.htm 10.09.24.04-1. 04-1 Specific Application Requirements for MAGI Exempt Coverage Groups.. A. All of the requirements of Regulation .04 of this chapter shall apply with the exceptions stated in this chapter.B. Application Filing and Signature Requirements.. 1) An individual who wishes to apply for Medical Assistance shall submit a signed application to the Department or its designee in the jurisdiction where his residence is located.2) A deemed newborn is eligible for receiving Medi
10.09.24.05.htm 10.09.24.05. 05 Nonfinancial Eligibility Requirements ― Citizenship.. A. Eligibility. To be eligible for federal coverage of full Medical Assistance benefits, an individual shall be:1) A citizen of the United States, including:. a) An individual who was born in:. i) One of the 50 states;. ii) The District of Columbia;. iii) Puerto Rico;. iv) Guam;. v) The Northern Mariana Islands; or. vi) The Virgin Islands;. b) A child born outside of the United States if:. i) The federal requiremen
10.09.24.05-1.htm 10.09.24.05-1. 05-1 Documentation of Citizenship and Identity.. A. An applicant or recipient shall be required as a condition of eligibility to provide documentary evidence of identity as well as citizenship or nationality, to the Department's satisfaction, based on federal requirements, if the individual is:1) Declared to be a citizen or national of the United States; and. 2) Being determined for:. a) Initial eligibility based on an application filed on or after September 1, 2006; or.
10.09.24.05-2.htm 10.09.24.05-2. 05-2 Nonfinancial Eligibility Requirements ― Emergency Medical Services for Ineligible or Illegal Aliens.A. An alien shall be eligible for federal Medical Assistance coverage of emergency medical services, as specified under §B and C of this regulation, if the alien is determined by the Department to:1) Have received emergency medical services described under §B and C of this regulation that are necessary for treatment of an emergency medical condi2) Meet all other require
10.09.24.05-3.htm 10.09.24.05-3. 05-3 Nonfinancial Eligibility Requirements ― Residency.. A. To be eligible for the Maryland Medical Assistance Program, an applicant or recipient shall be a Maryland resident.B. An individual is a Maryland resident if the individual resides in Maryland with the intent of remaining permanently or for an indefinite period, regardless of whether the individual maintains the residence permanently or at a fixed address.C. Residency in a state begins on the day that an individual:.
10.09.24.05-4.htm 10.09.24.05-4. 05-4 Nonfinancial Criteria for MAGI Exempt Coverage Groups.. A. Blindness.. 1) To be eligible for Medical Assistance as a blind individual, an applicant or a recipient shall be blind as defined at Regulation .02 of this chapter.2) Procedure for Determination of Blindness.. a) If an applicant's or recipient's eligibility for Medical Assistance is determined on the basis of blindness, an ophthalmologist or a licensed optometrist shall examine the individual, unless:
10.09.24.05-5.htm 10.09.24.05-5. 05-5 Nonfinancial Eligibility Requirements ― Institutions.. A. Inmate of a Public Institution.. 1) To be eligible for Medical Assistance, an applicant or recipient may not be incarcerated as an inmate of a public institution.2) Inmate Status.. a) An individual is considered incarcerated as an inmate of a public institution if the individual resides in a public institution involuntarily as a result of being accused or found guilty of a criminal offense, including th
10.09.24.06.htm 10.09.24.06. 06 MAGI Exempt Assistance Unit.. A. Purpose and Scope. This regulation establishes who shall be a member of an assistance unit, who may be excluded from an assistance unit, who will have separate eligibility determinations, and whose income and resources will be considered in determining financial eligibility for MAGI Exempt applicants and recipients of Medical Assistance.A-1. More Than One Assistance Unit Among Individuals Living Together. More than one assistance unit
10.09.24.06-1.htm 10.09.24.06-1. 06-1 MAGI Household Unit.. A. Purpose and Scope.. 1) This regulation establishes who shall be a member of the MAGI household and who will be excluded from the MAGI household.2) The regulation applies to applicants and recipients of coverage groups described under Regulation .03A of this chapter.B. Household Composition.. 1) An individual, plus anyone for whom the individual claims a personal exemption, shall be included in the federal tax filing unit in the taxable yea
10.09.24.07.htm 10.09.24.07. 07 Consideration of Income.. A. This regulation contains the rules for considering earned and unearned income of:. 1) Members of the MAGI household unit and those individuals whose income is considered pursuant to Regulation .06-1 of this chapter in determining financial eligibility of individuals for retroactive and current eligibility for the period under consideration; or2) Members of the MAGI exempt assistance unit and those individuals whose income and resources are c
10.09.24.08.htm 10.09.24.08. 08 Consideration of Resources for MAGI Exempt Coverage Groups.. A. This regulation contains the rules for considering resources of members of the MAGI exempt assistance unit and those individuals whose income and resources are considered pursuant to Regulation .06 of this chapter in determining financial eligibility of an assistance unit for retroactive and current eligibility for the period under consideration.B. Definitions.. 1) "Account" means cash savings or any other form
10.09.24.08-1.htm 10.09.24.08-1. 08-1 Disposal of Assets for Less Than Fair Market Value.. A. Definitions. In this regulation, the following terms have the meanings indicated:. 1) "Assets" means all income and resources of an individual and of an individual's spouse, including any income or resources which the individual or the individual's spouse is entitled to but does not receive because of action by:a) The individual;. b) The individual's spouse;. c) A person, including a court or administrative body:.
10.09.24.08-2.htm 10.09.24.08-2. 08-2 Treatment of Trust Amounts.. A. For the purpose of this regulation, "trust" has the meaning defined under Regulation .08-1A of this chapter.B. Treatment of Trusts Established after August 10, 1993.. 1) In determining eligibility for Medical Assistance for any period under consideration beginning on or after October 1, 1993, in the case of trusts established after August 10, 1993, an individual shall be considered to have established a trust if assets of the individual a
10.09.24.08-3.htm 10.09.24.08-3. 08-3 Resource Consideration of Entrance Fees for Continuing Care Retirement Communities.. A. Treatment of Entrance Fees before January 1, 2006. For Medical Assistance applications or requests for spousal resource assessments filed before January 1, 2006, the entrance fee shall be considered in accordance with the policies for exclusion of home property in this chapter.B. Treatment of Entrance Fees On or After January 1, 2006.. 1) For Medical Assistance applications or requests
10.09.24.08-4.htm 10.09.24.08-4. 08-4 Resource Consideration of Long-Term Care Partnership Policies.. A. This regulation establishes the rules for applicants and recipients who:. 1) Own a long-term care (LTC) partnership policy; and. 2) Meet all factors of Medicaid eligibility in accordance with MAGI Exempt coverage groups described in this chapter.B. Definitions.. 1) In this regulation, the following terms have the meanings indicated.. 2) Defined Terms.. a) “Benefit payment amount” means the dollar value
10.09.24.09.htm 10.09.24.09. 09 Determining Financial Eligibility for Noninstitutionalized Individuals.. A. Basis.. 1) Financial eligibility is determined on the basis of the countable net income and resources of members of the MAGI exempt assistance unit and those individuals whose income and resource are considered pursuant to Regulations .06, .07, and .08 of this chapter for the period under consideration. For current eligibility under spend-down, a review to identify changes in the unit's financial and nonf
10.09.24.10.htm 10.09.24.10. 10 Determining Financial Eligibility for Institutionalized Persons.. A. Scope.. 1) This section applies to persons who are institutionalized throughout a calendar month.. 2) Institutional status is presumed to begin on the first day of the first full calendar month in which the person is institutionalized and ends on the last day of the last full calendar month before discharge.3) Institutional status is not interrupted by a transfer from one long-term care facility to another
10.09.24.10-1.htm 10.09.24.10-1. 10-1 Treatment of Income and Resources of Certain Institutionalized Spouses.. A. Basis.. 1) Except as this regulation specifically provides, the provisions of this regulation may not affect:a) The determination of what constitutes income or resources;. b) The methodology and standards for determining and evaluating income and resources;. c) The criteria and standards for determining financial and nonfinancial eligibility for Medical Assd) Any other provision of this chapter..
10.09.24.10-2.htm 10.09.24.10-2. 10-2 Substantial Home Equity and Exclusion of Long-Term Care Coverage.. A. Subject to §E of this regulation, an institutionalized individual is not covered by Medical Assistance for long-term care services in a nursing facility, medical institution with a level of care equivalent to a nursing facility, or home and community-based services waiver if:1) The individual’s equity interest in the individual’s home property, reduced by any bona fide, legally binding, documented
10.09.24.11.htm 10.09.24.11. 11 Certification Periods.. A. This regulation specifies the time periods for certifying eligible members of an assistance unit. Certification periods for retroactive and current coverage will be based on consideration periods established in accordance with the provisions of Regulations .09 and .10 of this chapter.B. Certification of Eligible Noninstitutionalized Persons.. 1) The following eligible noninstitutionalized persons shall be certified for a one-time-only period
10.09.24.12.htm 10.09.24.12. 12 Post-Eligibility Requirements.. A. Notice of Eligibility Determination. The Department or its designee shall inform an applicant of the applicant's legal rights and obligations and give the applicant written or electronic notification of the following:1) For eligible individuals in MAGI coverage groups:. a) The basis and effective date for eligibility;. b) Instructions for reporting changes that may affect the recipients eligibility; and. c) The right to request a hearing..
10.09.24.13.htm 10.09.24.13. 13 Hearings.. The procedures for the Department or its designee granting a hearing to an applicant or a recipient and the status of benefits pending a hearing are set forth in COMAR 10.01.04.
10.09.24.14.htm 10.09.24.14. 14 Fraud.. A. "Medicaid fraud" means:. 1) Knowingly and willfully making or causing to be made any false statement or representation of a material fact in any application for any benefit or payment under a State plan established by Title XIX of the Social Security Act of 1939;2) Knowingly and willfully making or causing to be made any false statement or representation of a material fact for use in determining rights to those benefits or payments;
10.09.24.14-1.htm 10.09.24.14-1. 14-1 Recipient Abuse.. A. Forms of Abuse. Recipient abuse exists when:. 1) A recipient utilizes an inappropriate type of provider for care;. 2) A recipient utilizes an appropriate type of provider at an inappropriate frequency for care;. 3) A recipient utilizes an appropriate provider in an inappropriate manner; or. 4) A recipient utilizes a Medical Assistance card in an inappropriate manner.. B. Examples. The following are examples of circumstances that may be recipient abuse:.
10.09.24.15.htm 10.09.24.15. 15 Liens, Adjustments, and Recoveries.. A. Definitions. In this regulation, the following terms have the meanings indicated:. 1) "Dependent" means a:. a) Child of the decedent, or the decedent's descendants;. b) Sibling, including half or step, of the decedent; or. c) Parent of the decedent, or the decedent's ancestors.. 2) "Discharge from a long-term care facility and return home" means the release of a person from that facility for the purpose of returning to the hom
10.09.24.16.htm 10.09.24.16. 16 Interpretive Regulation.. Except if the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
10.09.24.17.htm 10.09.24.17. 17 Information from and Liability of Health Insurance Carriers.. A. A carrier shall:. 1) Provide, at the request of the Department, information about individuals who are eligible for benefits under the Program or are Program recipients so that the Department may determine:a) Whether an individual, the spouse of an individual, or the dependent of an individual is receiving health care coverage from a carrier; andb) The nature of that coverage;. 2) Provide the informatio
10.09.24.9999.htm 10.09.24.9999. Administrative History Effective date: May 1, 1983 (10:6 Md. R. 558). Regulations .01, .02, and .06 amended as an emergency provision effective December 1, 1992 (19:25 Md. R. 2198) amended permanently effective June 1, 1993 (20:10 Md. R. 852)Regulation .02B amended effective May 1, 1986 (13:8 Md. R. 898) August 8, 1988 (15:16 Md. R. 1914) May 1, 1989 (16:8 Md. R. 910) December 1, 1992 (19:23 Md. R. 2041) March 24, 1997 (24:6 Md. R. 485) June 2, 1997 (24:11 Md. R. 793)
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