Md. Code Regs. 10.09.81.03

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

Section 10.09.81.03 - Participant Eligibility

A. General Requirements.

(1) To be eligible for participation in the ICS Program, an applicant or participant shall be determined by the Department to meet the conditions of §§B"E of this regulation.

(2) A participant's eligibility for ICS services shall be reevaluated by the Department every 12 months or more frequently if needed due to a significant change in the participant's condition, needs, or financial status.

(3) The Department shall have 45 days from the date of a complete application to make an eligibility determination.

B. Technical Eligibility. To be eligible for the services covered under this chapter, an applicant or participant shall be determined by the Department to meet the technical eligibility criteria for ICS services if the individual:

(1) Had been living in a nursing facility at the time of application and for at least the last 6 months before the date of application and meets all eligibility requirements before transitioning into the community;

(2) Had been eligible for Medicaid for at least 30 consecutive days immediately before being enrolled in the ICS Program;

(3) Is not otherwise eligible for services covered under:

(a) The authority of § 1915(c) of Title XIX of the Social Security Act; or

(b) The Programs of All-Inclusive Care for the Elderly under COMAR 10.09.44;

(4) Is at least 18 years old;

(5) Has a plan of service that:

(a) Includes Medical Assistance and ICS services necessary to safely serve the participant in the community; and

(b) Is determined by the Department to cost less than the cost to Medicaid if the individual were to remain in the institution;

(6) Is offered the choice between ICS and nursing facility services;

(7) Chooses, or the individual's authorized representative chooses on the individual's behalf, to receive ICS services;

(8) Is being discharged from a nursing facility into ICS services in the community and would be institutionalized in a nursing facility if not for the ICS services;

(9) Resides in a home, as defined under Regulation .02B of this chapter; and

(10) Uses at least one ICS service within a 12-month period.

C. Medical Eligibility.

(1) An applicant shall be determined by the Department's utilization control agent to need nursing facility services covered under COMAR 10.09.10.

(2) Every 12 months, or more frequently if determined necessary by the Department due to a significant change in the participant's condition or needs, AERS shall revaluate the participant to verify the continued need for nursing facility services.

D. Financial Eligibility. An ICS participant shall:

(1) Without regard to any assets of a spouse, meet the resource limit for Long-Term Care Medical Assistance set forth in COMAR 10.09.24.08M;

(2) Receive income, after all available disregards and exclusions set forth in COMAR 10.09.24.07LL and 10.09.24.07JL, without regard to any income of a spouse, that exceeds 300 percent of the current monthly Supplemental Security Income payment rate, known as the Federal Benefit Rate (FBR);

(3) Pay to the Department an assessment fee equal to the amount by which income, after all available disregards and exclusions set forth in COMAR 10.09.24.07LL and 10.09.24.07JL, exceeds 300 percent of the FBR, as follows:

(a) The initial assessment shall be paid to the Department not later than 15 days from the date of the assessment invoice sent by the Department to the participant, unless the exception in §D(4) of this regulation applies;

(b) Subsequent assessments shall be paid on or before the last day of the month on which the assessment invoice is sent to the participant by the Department; and

(c) If a participant receives a past due notice, the participant has 15 days from the date of the notice to remit payment; and

(4) Be allowed an exception to the initial monthly assessment if discharged from the nursing facility on a date other than the first of the month, in which case the participant shall be required to pay the first assessment before the first day of the first full month of ICS participation.

E. Medical Assistance Eligibility.

(1) An individual is not eligible to receive ICS services during a penalty period under COMAR 10.09.24.08L -1 or 10.09.24.08L -2 due to disposal of assets or establishment of a trust.

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

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

(b) COMAR 10.09.24.08G(1);

(c) COMAR 10.09.24.08H;

(d) COMAR 10.09.24.10B(2)"(3);

(e) COMAR 10.09.24.10C;

(f) COMAR 10.09.24.10D(2)(a), (b), and (h);

(g) COMAR 10.09.24.10D(3)"(6);

(h) COMAR 10.09.24.10D -1B(1);

(i) COMAR 10.09.24.10D -1B(4);

(j) COMAR 10.09.24.10D -1B(7);

(k) COMAR 10.09.24.10D -1C(3)(a); and

(l) COMAR 10.09.24.15A -2(2).

F. Cost of Care.

(1) For a participant whose home is an assisted living facility, the Department shall reduce its monthly payment for assisted living services by the amount remaining after deducting from the individual's total nonexcluded monthly income the following amounts in the following order:

(a) A personal needs allowance, consisting of the amount established in accordance with COMAR 10.09.24.10D(2)(c) and the assisted living provider's monthly charge to the participant for room and board; and

(b) Incurred medical expenses in accordance with COMAR 10.09.24.10D(2)(f) and (g).

(2)The Department shall determine the amount of available income to be paid by a participant towards the cost of assisted living services.

(3) The participant shall pay the assisted living services provider directly for the participant's cost of care and room and board.

G. Participant Cap and Registry for ICS Participation.

(1) The Department shall establish a cap, approved by the federal Centers for Medicare and Medicaid Services (CMS), on the number of participants who may receive the services covered under this chapter at any one time, based on available State and federal funding.

(2) Eligible individuals shall be enrolled in the ICS Program on a first-come, first-served basis until the participant cap is reached.

(3) Once the CMS-approved participant cap is reached, a registry of applicants shall be established by the Department on a first-come, first-served basis.

H. Termination of Participation. A participant shall be terminated from participation in the ICS Program if the participant:

(1) No longer meets the eligibility requirements specified in §§B-E of this regulation;

(2) Voluntarily chooses, or the participant's legal representative chooses on the participant's behalf, to disenroll from the ICS Program;

(3) Moves to another state;

(4) Is an inpatient for 30 consecutive days or more in a hospital or nursing facility; or

(5) Dies.

I. Re-Entering the ICS Program.

(1) If a participant is terminated from the ICS Program, the same individual may re-enter the ICS Program, provided:

(a) That the individual meets all of the requirements §§B-E of this regulation; and

(b) There is available capacity.

(2) If an individual cannot find a community residence before his or her application expires, the individual may reapply to the ICS Program as long as the individual continues to meet all other eligibility requirements.

Md. Code Regs. 10.09.81.03