Sec. 10.09.26.12. Medical Assistance Eligibility

A. Definitions. In this regulation, the following terms have the meanings indicated:

(1) "Aged" means a person who is 65 years old or older.

(2) "Blind" means having a condition in which a person is certified by an ophthalmologist as having either central visual acuity of 20/200 or less in the better eye with correcting glasses, or a field defect in which the peripheral field has contracted to such an extent that the widest diameter of the visual field subtends an angular distance of not greater than 20 degrees.

(3) "Child" means an individual who is younger than 21 years old.

(4) "Community spouse" means an individual who:

(a) Lives in the community outside a medical institution;

(b) Is not determined to meet the criteria for participation in the Waiver for Individuals with Developmental Disabilities or any other waiver under §1915(c) of Title XIX of the Social Security Act; and

(c) Is married to an institutionalized spouse.

(5) "Continuous period of institutionalization" means:

(a) At least 30 consecutive days of institutional care in a nursing facility or other medical institution; or

(b) A determination that a spouse meets the criteria for participation in the Waiver for Individuals with Developmental Disabilities or any other waiver under §1915(c) of Title XIX of the Social Security Act.

(6) "Disabled" means the inability to perform any substantial gainful activity by reason of a medically determinable physical or mental impairment which is expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months.

(7) "Institutionalized spouse" means an individual who is married to a community spouse and who:

(a) Is an inpatient in a nursing facility or other medical institution with a length of stay exceeding 30 days; or

(b) Is determined to meet the criteria for participation in the Waiver for Individuals with Developmental Disabilities or any other waiver under §1915(c) of the Social Security Act.

B. Financial eligibility for waiver participants is determined according to this regulation and COMAR 10.09.24, as cited in §§C-F of this regulation.

C. Categorically Needy. An individual is eligible for waiver services as categorically needy if the individual is receiving Medical Assistance as a:

(1) Recipient of Supplemental Security Income (SSI); or

(2) Member of a low income family with children, as described in §1931 of the Social Security Act.

D. Medically Needy. An individual is eligible for waiver services as medically needy if the individual is receiving Medical Assistance as a medically needy person in accordance with COMAR 10.09.24.03D.

E. Optionally Categorically Needy.

(1) An individual is eligible for 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 SSI, and the individual's countable resources do not exceed the SSI resource standard for one person.

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

(3) For the purpose of determining countable income for the optionally categorically needy, income is determined based on the income rules set forth in COMAR 10.09.24 which are applicable to a child or an aged, blind, or disabled individual who is institutionalized, with the exceptions specified at §E(9) of this regulation.

(4) For the purpose of determining countable resources for the optionally categorically needy, resources are determined based on the resource rules set forth in COMAR 10.09.24, which are applicable to a child or an aged, blind, or disabled person who is institutionalized, with the exceptions specified at §E(9) of this regulation.

(5) An individual is not eligible to receive waiver services if a disposal of assets or establishment of a trust or annuity results in a penalty under COMAR 10.09.24, until such time as the penalty period expires.

(6) The spousal impoverishment rules at COMAR 10.09.24.10-1 are applicable, with the differences specified in this regulation.

(7) Medical Assistance eligibility shall be redetermined at least every 12 months.

(8) As part of the determination and redetermination of Medical Assistance eligibility as optionally categorically needy, the Department of Human Services shall determine whether the applicant or recipient is eligible as a disabled person in accordance with COMAR 10.09.24.05E, unless the applicant or recipient is aged, blind, or a child, or has been determined as disabled by the Social Security Administration.

(9) All provisions of COMAR 10.09.24 which are applicable to a child or an aged, blind, or disabled individual who is institutionalized are applicable to waiver applicants and participants who are considered as optionally categorically needy, 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 10.09.24.09;

(g) COMAR 10.09.24.10;

(h) COMAR 10.09.24.10-1; and

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

(10) Home Exclusion. The home, as defined in COMAR 10.09.24.08B, is not considered a countable resource under §E of this regulation if it is occupied by the waiver applicant or participant, the applicant's or participant's spouse, or any one of the following relatives who are medically or financially dependent on the applicant or participant:

(a) Child;

(b) Parent; or

(c) Sibling.

F. Post-Eligibility Determination of Available Income for Optionally Categorically Needy.

(1) The countable monthly income considered for the post-eligibility determination is calculated in accordance with rules at §E of this regulation and at COMAR 10.09.24 for institutionalized aged, blind, or disabled individuals, except that the income disregards specified at COMAR 10.09.24.07L are not applied.

(2) For individuals eligible under §E of this regulation who reside in a residential habitation facility, the Department shall reduce its monthly payment for residential habilitation services by the amount remaining after deducting from the individual's countable monthly income the following amounts in the following order:

(a) A personal needs allowance of $170 and the residential habilitation provider's monthly charge of at most $375 to the participant for room and board, as of the effective date of this amendment, either or both of which may be adjusted based on a schedule issued by the Department;

(b) A spousal maintenance allowance in accordance with COMAR 10.09.24.10D(2)(b); and

(c) Incurred medical expenses as specified at COMAR 10.09.24.10D(2)(d) and (e).

(3) The Department shall determine the amount of available income to be paid by a participant towards the cost of care in a residential habilitation facility, based on the countable income remaining after deducting the amounts specified at §F(2) of this regulation.

(4) The residential habilitation provider shall collect the participant's available income, in an amount which may not exceed the cost of residential habilitation services as determined by the Department for the participant.

(5) The sum of the participant's cost of care contribution and the Department's payment may not exceed the total cost of residential rehabilitation services as determined by the Department for the participant.