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 Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354).

(2) Applications submitted under Regulations .03-1 and .03-2 of this chapter shall no longer be accepted after December 31, 2013.

(3) An individual who has submitted an application in accordance with §A(1) of this regulation and who has been determined eligible will receive benefits under Regulations .03-1 and .03-2 of this chapter after December 31, 2013.

B. Definitions. In Regulations .03-1 and .03-2 of this chapter, the following terms have the meanings indicated:

(1) "Applicant" means an individual whose application for the Medical Assistance eligibility under the women's breast and cervical cancer coverage group has been submitted to the Department or its authorized representative, but has not received final action.

(2) "Application date" means the date on which a written, signed application for Medical Assistance eligibility under the women's breast and cervical cancer coverage group is received by the Department or its authorized representative.

(3) "Breast and Cervical Cancer Diagnosis and Treatment Program" means the State-funded program of cancer diagnosis and treatment services, which is:

(a) Governed by COMAR 10.14.02; and

(b) Administered by the Department's Center for Cancer Surveillance and Control.

(4) "Cancer treatment services" means active medical treatment for breast cancer, cervical cancer, or a precancerous condition, not including palliative care.

(5) "Categorically needy coverage group" means a category of Medical Assistance eligibility defined at Regulation .03A of this chapter.

(6) "Creditable health insurance coverage" means having one or more of the following types of coverage:

(a) A group health plan;

(b) Health insurance coverage with medical care benefits provided directly or through insurance, reimbursement, or otherwise and including items and services paid for as medical care, under any:

(i) Hospital or medical service policy or certificate;

(ii) Hospital or medical service plan contract; or

(iii) Health maintenance organization contract offered by a health insurance issuer;

(c) Medicare Part A or Part B;

(d) Medical Assistance;

(e) Armed forces insurance; or

(f) A state health risk pool.

(7) "Enrollee" means a woman who is determined eligible and is receiving Medical Assistance benefits under Regulations .03-1 and .03-2 of this chapter.

(8) "Health professional" means a licensed physician or certified registered nurse practitioner.

(9) "Institutionalized person" has the meaning specified at Regulation .08B of this chapter.

(10) "Mandatory Medical Assistance categorically needy coverage group" means a Medical Assistance categorically needy coverage group which the federal government requires a state to cover under the State Plan, in accordance with the Code of Federal Regulations.

(11) "Maryland Breast and Cervical Cancer Screening Program" means the National Breast and Cervical Cancer Early Detection Program in Maryland which:

(a) Is funded by the State or federal government;

(b) Is administered by the Department's Center for Cancer Surveillance and Control through the local jurisdictions; and

(c) Has income and other eligibility requirements.

(12) "National Breast and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the Centers for Disease Control (CDC), established under Title XV of the Public Health Service Act.

(13) "Needs treatment" means that, according to a written certification by a health professional, the individual needs cancer treatment services, such as chemotherapy, radiation, or surgery.

(14) "Precancerous condition" means for:

(a) Cervical cancer, a condition diagnosed as cervical intra-epithelial neoplasia I, II, or III; or

(b) Breast cancer, a condition diagnosed as atypical ductal hyperplasia or lobular carcinoma in-situ.

(15) "Screening services" means services provided by the Maryland Breast and Cervical Cancer Screening Program to screen for breast or cervical cancer, including clinical breast examinations, mammograms, pelvic examinations, Papanicolaou (Pap) tests, and diagnostic services such as breast ultrasound or colposcopically directed biopsy, to ensure that all women with abnormal screening results receive timely and adequate diagnostic and treatment services.

(16) "Uninsured" means:

(a) Not otherwise having creditable health insurance coverage for cancer treatment services; or

(b) Having creditable health insurance coverage, but the cancer treatment services ordered by a health professional are not covered due to one of the following reasons:

(i) The services are not included among the benefits covered by the individual's health insurance plan;

(ii) A period of exclusion has been applied to the individual's health insurance coverage, such as for a preexisting condition; or

(iii) The individual has exhausted the health insurance plan's covered benefits.

(17) "Women's breast and cervical cancer coverage group" means the Medical Assistance optional categorically needy coverage group covered under Regulations .03-1 and .03-2 of this chapter.

C. Eligibility.

(1) The Department shall determine that an applicant or enrollee is eligible for Medical Assistance coverage under Regulations .03-1 and .03-2 of this chapter if the individual:

(a) Is a woman;

(b) Is 40—64 years old;

(c) Is uninsured, with the Department not requiring a waiting period of prior uninsurance;

(d) Received screening services, in accordance with Regulation .03-2A of this chapter;

(e) Had a biopsy through the:

(i) Maryland Breast and Cervical Cancer Screening Program which resulted in a diagnosis of cervical cancer or a precancerous condition; or

(ii) Breast and Cervical Cancer Diagnosis and Treatment Program which resulted in a diagnosis of breast cancer or a precancerous condition;

(f) Needs treatment;

(g) Is not an institutionalized person;

(h) Meets the nonfinancial eligibility requirements for Medical Assistance, as specified in Regulation .05 of this chapter; and

(i) Is not eligible for a mandatory Medical Assistance categorically needy coverage group.

(2) The requirements in this chapter related to financial eligibility, income, and resources:

(a) Shall apply for assessing eligibility for a mandatory Medical Assistance categorically needy coverage group; and

(b) May not apply for determining eligibility for the WBCCHP under Regulations .03-1 and 03-2 of this chapter.