Sec. 10.09.27.05. Participant Eligibility

A. Requirements. Model waiver participants shall meets the financial eligibility requirements under §B, C, or D of this regulation and the nonfinancial requirements of §§E and F of this regulation.

B. Categorically needy eligibility recipients of supplemental security income benefits under Title XVI of the Social Security Act are eligible for medical assistance benefits as categorically needy individuals as specified in COMAR 10.09.24.

C. Optional Categorically Needy Eligibility. Individuals who do not qualify for supplemental security income benefits may apply for eligibility under the provision of this section and applicable sections of COMAR 10.09.24, as follows:

(1) COMAR 10.09.24, exclusive of Regulations .06, .08L, .09, and .10, applies for the purpose of determining eligibility as an optional categorically needy individual.

(2) An individual is eligible for medical assistance benefits as an optional categorically needy individual if he complies with the requirements of §C(1) of this regulation, including the requirement that resources not exceed the applicable standard for supplemental security income eligibility, and if the income of the individual before the disregards specified in §C(3) of this regulation does not exceed 300 percent of the supplemental security income benefit amount payable under §1611(b)(i) of the Social Security Act to an individual in his own home who has no income or resources.

(3) Disregards. The following disregards are subtracted from income computed according to COMAR 10.09.24.07, exclusive of Regulation .07L and M, in order to determine the amount of the income of recipients qualifying under this section to be applied toward the cost of services specified in Regulation .04 of this chapter.

(a) The amount of the medically needy income standard for one person established under COMAR 10.09.24.07N;

(b) Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party, including:

(i) Medicare and other health insurance premiums, deductibles, or co-insurance charges, and

(ii) Necessary medical or remedial care recognized under State law but not covered under the Program.

D. Medically Needy Eligibility. Financial eligibility for individuals who do not qualify as categorically needy recipients as specified in §B, or optional categorically needy recipients as specified in §C of this regulation is determined according to provisions of COMAR 10.09.24 relating to determinations of medically needy eligibility.

E. To be eligible to receive services under the model waiver for disabled children a person shall:

(1) Be certified and annually recertified as requiring nursing home care under the Program pursuant to COMAR 10.09.10 or COMAR 10.09.11;

(2) Be approved by the Department or its designee as appropriate for home care based on a comprehensive assessment of the participant's health status as set forth in Regulation .01B(15) of this chapter;

(3) Choose between institutional or home care services under the Program;

(4) Be a recipient:

(a) For whom it can reasonably be expected that the cost of home care services would not exceed the cost of the level of care provided in an institution, and

(b) Whose plan of care meets the requirement of §F of this regulation relating to cost effective coverage of home care services.

F. Eligibility for coverage of home care services for disabled children is limited to individuals for whom the projected total cost that would be incurred by the Program if the coverage and services specified in this chapter were not available is greater, on an annual basis, than the projected total cost that would be incurred by the Program for the services listed in Regulation .04 of this chapter and all other services available under the Program based on the following formula:

A + B + C + D = E + F + G

when:

A = the estimated cost of home care services as specified in Regulation .04 of this chapter;
B = the estimated cost of noninstitutionalized long term care services not listed in Regulation .04 of this chapter but available under the Program;
C = the estimated cost of institutional long term care under the Program;
D = the estimated cost of services available under the Program but not included in elements A, B, or C;
E = the estimated cost of noninstitutional long term care services available under the Program in the absence of the model waiver;
F = the estimated cost of institutional long term care under the Program in the absence of the model waiver; and
G = the estimated cost of services available under the Program in the absence of the model waiver but not included in elements E or F.