10.14.05.14

.14 Application Process for Cancer Treatment Grants.

A. An applicant for a cancer treatment grant shall submit a completed application to the CCPC.

B. Cancer treatment grants are open and continuous throughout the year to the extent that funding is available.

C. An applicant seeking a cancer treatment grant to pay for cancer treatment costs shall include in the Department's application packet:

(1) A completed cancer treatment grant application for each individual for whom grant funds are being requested, including the:

(a) Name;

(b) Phone number;

(c) Mailing address;

(d) County; and

(e) Signature of the:

(i) Individual diagnosed with cancer if the individual is an adult; or

(ii) Parent or guardian if the individual diagnosed with cancer is younger than 18 years old;

(2) A letter written by the individualís physician on the physicianís letterhead:

(a) Confirming:

(i) That the individual has been diagnosed with or treated for cancer or the individual has a finding suggestive of cancer and needs to obtain a cancer diagnosis; and

(ii) The dates of diagnosis or treatment; and

(b) Containing the physician's:

(i) Full name;

(ii) Address;

(iii) Specialty; and

(iv) Medical license number;

(3) Proof of current Maryland residency for at least 6 months before the application date for each individual for whom grant funds are being requested in one of the following forms:

(a) Maryland driverís license or State identification card;

(b) Lease or rental agreement;

(c) Property tax bill;

(d) Motor vehicle registration;

(e) Pay check or stub with name and home address;

(f) Utility bill;

(g) Voter registration card; or

(h) W-2 statement issued not more than 12 months ago;

(4) Proof of annual family income for each individual for whom grant funds are being requested, including a copy of at least one of the following:

(a) Most recent:

(i) Income tax return; or

(ii) W-2 form;

(b) Pay stubs for two:

(i) Consecutive pays; or

(ii) Pays in the same month;

(c) Social security entitlement letter; or

(d) Notarized letter from the individual stating that the individual is not working and does not have any income;

(5) Documentation of the eligibility of the individual for grant funds, including:

(a) The family size of the individual for whom the applicant is applying; and

(b) The familyís annual household income;

(6) Certification that the applicant will:

(a) Keep financial records, as described in Regulation .16B of this chapter;

(b) Send demographic and fiscal information on each individual covered to the CCPC at the end of the grant period; and

(c) Act as the authorized representative of the individual.

(7) Attestation that grant funds will not be used to supplant any existing funding for this cancer treatment activity; and

(8) If the applicant currently receives funding for a similar cancer treatment activity, a list of the funding:

(a) Source;

(b) Amount; and

(c) Period for the activity.

D. An applicant seeking a cancer treatment grant to pay for deductibles and patient contribution costs through their health insurance policy under Regulation .08E(2) of this chapter shall include in the Departmentís application packet:

(1) A completed and signed Maryland Cancer Fund — Cancer Treatment Grant application that;

(a) Certifies that the applicant shall pay:

(i) The deductible and patient contribution amount; and

(ii) Costs for services not covered under the individualís health insurance policy for a time period not to exceed 1 year; and

(b) Includes a treatment plan for a total request not to exceed a specified amount, as determined by the Department, per individual per year, including the:

(i) Deductible and patient contribution amount; and

(ii) Costs for services not covered under the individualís health insurance policy.

(2) Documentation of the individualís health insurance policy.

E. An applicant seeking a cancer treatment grant to pay directly for cancer treatment costs under Regulation .08E(3) of this chapter shall include in the Departmentís application packet:

(1) A completed Maryland Cancer Fund — Cancer Treatment Grant application; and

(2) A signed document that certifies that the applicant shall pay directly for cancer treatment costs for the individual for a time period not to exceed 1 year; and certifies that the applicant shall:

(a) Reimburse the provider in an amount not greater than the Medical Assistance rate for the medical procedure or the HSCRC-regulated rate for the medical procedure performed, if the medical procedure is performed in a HSCRC-regulated facility; or

(b) Accept the Medical Assistance rate as payment in full for the cancer treatment procedures performed, if the applicant is a medical provider; and

(3) Includes a treatment plan for a total request not to exceed $20,000 per individual, including:

(a) The planned cancer treatment procedures; and

(b) The Medical Assistance or HSCRC-regulated rate for each procedure.