Md. Code Regs. 10.09.56.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.56.02 - Participant Eligibility

A. Medical Eligibility for the Autism Waiver.

(1) To be medically eligible for the services covered under the chapter, an applicant shall be certified by the licensed psychologist, licensed social worker, licensed clinical professional counselor, certified school psychologist, or approved service coordinator employed or contracted by the local lead agency, the local education agency, the State, or the State's designee to need ICF-IID level of care using the standardized process for determination of eligibility for level of care in an ICF-IID.

(2) Every 12 months, or more frequently if determined necessary by the service coordinator or multidisciplinary team due to a significant change in the participant's condition or needs, a participant's medical need for ICF-IID level of care shall be reevaluated by the licensed psychologist, licensed social worker, licensed clinical professional counselor, certified school psychologist, or approved service coordinator employed or contracted by the local lead agency, the local education agency, the State, or the State's designee, as part of the multidisciplinary team process and using the form for determination of eligibility for level of care in an ICF-IID.

(3) The form certifying ICF-IID level of care shall be signed by the:

(a) Chairman of the multidisciplinary team, who is the official representative of the local school system or local lead agency; and

(b) Team's licensed psychologist, licensed social worker, licensed clinical professional counselor, certified school psychologist, or approved service coordinator employed or contracted by the local lead agency, the local education agency, the State, or the State's designee.

B. Technical Eligibility for the Autism Waiver. An applicant or participant shall be determined by the multidisciplinary team to meet the waiver's technical eligibility-criteria if the individual:

(1) Is between 1 year old and the end of the school year in which the individual turns 21 years old;

(2) Is determined to be developmentally disabled and is diagnosed with autism spectrum disorder, every 3 years or more often as requested by MSDE, by a qualified diagnostician using an evaluation methodology considered sufficient by the multidisciplinary team;

(3) Uses at least one waiver service monthly, not including family consultation, unless otherwise authorized by the State Department of Education;

(4) Has an IFSP or IEP;

(5) If the child has an IEP, receives 15 hours or more per week of special education and related services and requires a more intensive therapeutic program than other students or is currently participating in an approved Home and Hospital Program pursuant to the procedures of COMAR 13A.03.05 and 13A.05.01;

(6) Is identified through the public education or early intervention service system as being potentially qualified for and needing Autism Waiver services;

(7) Can be safely maintained in the community with the assistance of Autism Waiver services;

(8) Chooses, or the parent or parents of a minor child chooses on the child's behalf, to receive Autism Waiver services as an alternative to services in an (ICF-IID), and documents that choice on the consent form for Autism Waiver services; and

(9) Is not enrolled in:

(a) Home Care for Disabled Children under a Model Waiver, in accordance with COMAR 10.09.27;

(b) Community Based Services for Developmentally Disabled Individuals Pursuant to a 1915(c) Waiver, in accordance with COMAR 10.09.26; or

(c) Any other Medicaid waiver program under § 1915(c) of Title XIX of the Social Security Act.

C. Medical Assistance Eligibility.

(1) Categorically Needy. A recipient is eligible for Autism Waiver services if the recipient is eligible for Medicaid in the community according to the categorically needy regulations in COMAR 10.09.24 or 10.09.11.

(2) Optionally Categorically Needy.

(a) An individual is eligible for Autism Waiver services as optionally categorically needy in accordance with 42 CFR § 435.217 if the individual's countable income does not exceed 300 percent of the applicable payment rate for Supplemental Security Income (SSI), and the individual's countable resources do not exceed the SSI resource standard for one.

(b) For the purpose of determining financial eligibility for the optionally categorically needy, the individual is treated as an assistance unit of one.

(c) For the purpose of determining countable income for the optionally categorically needy, income is determined based on the income regulations in COMAR 10.09.24 which are applicable to aged, blind, or disabled individuals who are institutionalized, with the exceptions specified in §C(4) of this regulation.

(d) For the purpose of determining countable resources for the optionally categorically needy, resources are determined based on the resource regulations set forth in COMAR 10.09.24.08B and .10 which are applicable to aged, blind, or disabled persons who are institutionalized, with the exceptions specified in §C(4) of this regulation.

(3) An individual is not eligible to receive Autism Waiver services if a disposal of assets or establishment of a trust results in a penalty under COMAR 10.09.24.08B-1 or .08-2, until the penalty period expires.

(4) All provisions of COMAR 10.09.24 which are applicable to aged, blind, or disabled institutionalized persons are applicable to Autism Waiver applicants and participants, with the following exceptions:

(a) COMAR 10.09.24.04J(1), (2), and (3);

(b) COMAR 10.09.24.04K;

(c) COMAR 10.09.24.06B(2)(a)(ii);

(d) COMAR 10.09.24.08G(1);

(e) COMAR 10.09.24.08H;

(f) COMAR 10.09.24.09H;

(g) COMAR 10.09.24.10H; and

(h) COMAR 10.09.24.10H -1.

(5) Post Eligibility Determination of Available Income. The participant's or parents' income may not be applied toward the costs of the participant's:

(a) Autism Waiver services; or

(b) Room and board in a residential habilitation facility.

D. Autism Waiver Eligibility.

(1) If an applicant is verified by the multidisciplinary team and the State Department of Education:

(a) To meet all of the criteria specified in §§A-C of this regulation, the participant's service coordinator, the representative of the local school system or local lead agency, the representative of the State Department of Education, and the Program shall certify Autism Waiver eligibility and the Program shall establish the effective date for enrollment; or

(b) Not to meet all of the criteria specified in §§A-C of this regulation:

(i) The service coordinator, the representative of the local school system or local lead agency, and the representative of the State Department of Education shall certify the Autism Waiver eligibility determination; and

(ii) The applicant, or the parent or parents of a minor child, shall be informed in writing by the Department for ineligibility, and the right to appeal and request a fair hearing, in accordance with COMAR 10.01.04 and 10.09.24.13H, and 42 CFR Part 431, Subpart E.

(2) Every 12 months, or more often if there is a significant change in the participant's condition or needs:

(a) The multidisciplinary team and the State Department of Education shall verify whether the participant remains eligible for the Autism Waiver by meeting all of the criteria specified in §§A-C of this regulation;

(b) The service coordinator, the representative of the local school system or local lead agency, and the representative of the State Department of Education shall certify the redetermination of Autism Waiver eligibility; and

(c) If the multidisciplinary team and the State Department of Education verify that the participant no longer meets all of the eligibility criteria specified in §§A-C of this regulation, the:

(i) Participant's eligibility shall be terminated, as of the effective date established by the multidisciplinary team and the State Department of Education, and

(ii) Participant, or the parent or parents of a minor child, shall be informed in writing of the determination, the reason or reasons for ineligibility, and the right to appeal and request a fair hearing, in accordance with COMAR 10.01.04 and 10.09.24.13H, and 42 CFR Part 431, Subpart E.

Md. Code Regs. 10.09.56.02

Regulation .02A, B amended as an emergency provision effective October 1, 2004 (32:1 Md. R. 24); amended permanently effective April 25, 2005 (32:8 Md. R. 741)
Regulations .02B as an emergency provision effective July 1, 2002 (29:17 Md. R. 1376); emergency status extended at 30:3 Md. R. 176 and 30:10 Md. R. 667; amended permanently effective April 14, 2003 (30:7 Md. R. 487)
Regulation .02A, B amended effective April 16, 2012 (39:7 Md. R. 492); amended effective 43:7 Md. R. 449, eff.4/11/2016; amended effective 47:10 Md. R. 516, eff. 5/18/2020; amended effective 51:18 Md. R. 809, eff. 9/16/2024.