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 were within the scope of a grant, subgrant, or contract under the State's NBCCEDP; or

(b) NBCCEDP grantee elected to include such screening services by that provider as screening services pursuant to the NBCCEDP.

B. Assistance Unit. An applicant or enrollee shall be considered as an assistance unit of one person, including only the applicant or enrollee.

C. Application Process. The requirements of Regulation .04 of this chapter shall apply, except for the following differences for the women's breast and cervical cancer coverage group:

(1) For the initial eligibility application, an individual shall apply through the Maryland Breast and Cervical Cancer Screening Program in the local jurisdiction;

(2) The applicant's or enrollee's written application for an initial determination or a redetermination shall be on the form designated by the Department for the women's breast and cervical cancer coverage group;

(3) The Department shall:

(a) Determine initial eligibility, retroactive or current, based on:

(i) A signed application received from the applicant;

(ii) A form signed by a health professional, certifying that the enrollee needs treatment and, for a redetermination, specifying the anticipated length of treatment;

(iii) Confirmation from the Maryland Breast and Cervical Cancer Screening Program that the applicant received screening services in accordance with §A of this regulation;

(iv) Confirmation from the Maryland Breast and Cervical Cancer Screening Program or the Breast and Cervical Cancer Diagnosis and Treatment Program that the applicant had a biopsy which resulted in a diagnosis of breast cancer, cervical cancer, or a precancerous condition; and

(v) Additional information obtained by the Department to verify the applicant's eligibility in accordance with Regulation .03-1C of this chapter;

(b) Redetermine an enrollee's eligibility at least every 12 months, before the end of the certification period, based on the following:

(i) An application completed by the enrollee, verifying continuing eligibility under Regulations .03-1 and .03-2 of this chapter; and

(ii) A certification form completed by a health professional, verifying that the enrollee needs treatment and specifying the expected length of treatment;

(c) Verify, before determining or redetermining eligibility, that the applicant or enrollee is not:

(i) Currently covered by Medical Assistance and does not have an application under consideration in a coverage group which covers all State Plan services without requiring spend down or payment of a premium; or

(ii) Eligible for a mandatory Medical Assistance categorically needy coverage group;

(d) Determine or redetermine eligibility within 45 days after receipt of a signed application;

(e) Refer the applicant or recipient to the local department of social services or local health department for an eligibility determination or redetermination if the individual may be eligible for a mandatory Medical Assistance categorically needy coverage group; and

(f) Notify the applicant or enrollee of the eligibility decision and the rights for appeal and fair hearing, in accordance with Regulation .13 of this chapter; and

(4) Based on the application date, the Department shall establish a period under consideration, which shall be:

(a) For retroactive eligibility for an initial application, not more than 3 months immediately preceding the month of application, if as of this earlier date the applicant would have met the requirements at Regulation .03-1C of this chapter;

(b) For current eligibility for an initial application, a 12-month period beginning with the month of application; or

(c) For current eligibility for a redetermination, the lesser of:

(i) A 12-month period; or

(ii) The number of months that the individual needs treatment.

D. Certification Period.

(1) An enrollee's certification period shall begin:

(a) For retroactive eligibility with the initial determination, the first day of the month which is up to 3 months preceding the month of the application date if, as of this earlier date, the applicant would have met the requirements of Regulation .03-1C of this chapter, including having been screened for and diagnosed with breast cancer, cervical cancer, or a precancerous condition;

(b) For current eligibility with the initial determination, the first day of the month of the application date; or

(c) For a redetermination, the first day of the month immediately following the month in which the previous certification period ended.

(2) The effective date for retroactive or current coverage under Regulations .03-1 and .03-2 of this chapter shall be April 1, 2002 or later.

(3) An enrollee's eligibility under Regulations .03-1 and .03-2 of this chapter shall end as of the:

(a) End of a certification period for a:

(i) 12-month period; or

(ii) A period less than 12 months, based on how long the enrollee needs treatment; or

(b) Date when the enrollee is no longer eligible under Regulations .03-1 and .03-2 of this chapter due to:

(i) Death;

(ii) Establishment of residency in another state;

(iii) Becoming 65 years old;

(iv) Becoming an institutionalized person; or

(v) No longer being uninsured, such as becoming eligible for another Medical Assistance coverage group which covers all State Plan services without requiring spend down or payment of a premium.

E. Redetermination.

(1) Scheduled Redeterminations.

(a) The Department shall issue a redetermination package to an enrollee at least 60 days before the end of the certification period.

(b) Based on the information presented, the Department shall determine whether the enrollee:

(i) Qualifies for continuing eligibility under the women's breast and cervical cancer coverage group with a new 12-month certification period, because the enrollee needs treatment for at least 12 more months;

(ii) Qualifies for continuing eligibility under the women's breast and cervical cancer coverage group with a new certification period of less than 12 months, based on the length of time that the enrollee needs treatment;

(iii) Does not qualify for continuing eligibility under the women's breast and cervical cancer coverage group because the required information was not received by the Department by the specified deadline, but shall be considered for continuing eligibility under the women's breast and cervical cancer coverage group if the necessary information is received by the Department within 6 months of the date of termination;

(iv) Does not qualify for continuing eligibility under the women's breast and cervical cancer coverage group and does not appear to qualify for a mandatory Medical Assistance categorically needy coverage group; or

(v) Does not qualify for continuing eligibility under the women's breast and cervical cancer coverage group because the enrollee may qualify for a mandatory Medical Assistance categorically needy coverage group, and shall be referred for an eligibility determination at the local department of social services.

(2) Unscheduled Redeterminations.

(a) An enrollee shall inform the Department within 10 days of a change in circumstances, which may impact the enrollee's eligibility under Regulations .03-1 and .03-2 of this chapter.

(b) If the Department receives notice of a change in circumstances which may impact the enrollee's eligibility under Regulations .03-1 and .03-2 of this chapter, the Department shall follow the procedures in §E(1)(b) of this regulation for redeterminations.

(3) If the Department determines as part of a scheduled or unscheduled redetermination that an enrollee does not qualify for continuing eligibility under the women's breast and cervical cancer coverage group, the Department shall determine whether the individual qualifies for any other coverage groups under this chapter or COMAR 10.09.11.

F. Covered Services. Enrollees shall be entitled to full coverage for all services covered under the State Plan, not limited to cancer treatment services, except for enrollment in:

(1) The HealthChoice Maryland Medicaid Managed Care Program, in accordance with COMAR 10.67.01—.06;

(2) Rare and Expensive Case Management (REM), in accordance with COMAR 10.09.69;

(3) A home and community-based services waiver under §1915(c) of Title XIX of the Social Security Act;

(4) Medicare buy-in for Medical Assistance payment of Medicare premiums, copayments, and deductibles for Medicare eligible persons;

(5) Program of All-Inclusive Care for the Elderly; or

(6) Coverage for services in a long-term care facility exceeding 30 consecutive days.