Sec. 10.09.46.03. Participant Eligibility

A. Medical Eligibility for the Waiver.

(1) To be medically eligible for the services covered under this chapter, an applicant shall be certified by the Program's utilization control agent to need nursing facility level of care or special hospital level of care.

(2) Every 12 months, or more frequently if determined necessary by the BHA or Program due to a significant change in the participant's condition or need, a participant's medical need for nursing facility level of care or special hospital level of care shall be reevaluated by the Program's utilization control agent.

B. Technical Eligibility for the Waiver. An applicant or participant shall be determined by the BHA, using the form for determination of eligibility for BI waiver services, to meet the waiver's technical eligibility criteria if the individual:

(1) Is 22 years old or older but younger than 65 years old at the time of initial admission to the waiver;

(2) Is diagnosed with brain injury as defined in Regulation .01B(4) of this chapter by a qualified physician;

(3) Was 18 years old or older when the brain injury was sustained;

(4) Is receiving:

(a) Care in a State psychiatric hospital that is determined to be inappropriate because the individual does not need that level of care;

(b) Brain injury community placement funded by the BHA with all-State funds;

(c) Care in a nursing facility owned and operated by the State or an out-of-State rehabilitation institution funded by the Program; or

(d) Care in a Maryland licensed special hospital for chronic disease accredited by CARF in brain injury inpatient rehabilitation;

(5) Is not enrolled in another waiver program under §1915(c) of Title XIX of the Social Security Act;

(6) Is clinically appropriate to be served in the waiver program and the waiver plan of care can serve the individual safely in the community;

(7) Chooses directly, or a legal representative chooses on the individual's behalf, to receive waiver services as an alternative to services in a nursing facility or special hospital, and documents that choice on the consent form for BI waiver services included in the approved waiver proposal;

(8) Costs the Program no more in the community than what the individual would have cost the Program in the alternative institutional placement at the nursing facility level of care or special hospital level of care, as demonstrated on the waiver plan of care and by the Program's paid claims; and

(9) Uses at least one waiver service in a 12 month period.

C. Financial Eligibility for Medicaid. Waiver participants shall qualify for one of the categories of assistance set forth in Regulation .02 of this chapter.

D. During a 12-month waiver year, as defined in the approved waiver proposal, eligible individuals shall be enrolled in the waiver up to the maximum number of unduplicated participants established for that waiver year in the approved waiver proposal.

E. Overall Waiver Eligibility.

(1) Using the form for determination of eligibility for BI waiver services, if an applicant is determined by the BHA:

(a) To meet all of the criteria specified in §§A-C of this regulation, the BHA or its authorized representatives shall sign and date the form to certify waiver eligibility and establish the effective date for waiver enrollment; or

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

(i) The BHA or its authorized representatives shall sign and date the form to certify waiver ineligibility determination and specify in writing the reason or reasons for the determination; and

(ii) The applicant or legal representative shall be informed of the determination and the right to appeal and request a fair hearing, in accordance with COMAR 10.01.04 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 BHA and the Program's utilization control agent shall reevaluate whether the participant remains eligible for the waiver by meeting all of the criteria specified in §§A-C of this regulation;

(b) The BHA or its authorized representatives shall sign and date the form for determination of eligibility for BI waiver services to certify the redetermination of waiver eligibility; and

(c) If the BHA determines 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 BHA; and

(ii) The participant or legal representative shall be informed of the determination and the right to appeal and request a fair hearing, in accordance with COMAR 10.01.04 and 42 CFR Part 431, Subpart E.

F. Cause for Termination of a Participant's Waiver Enrollment.

(1) A participant shall be disenrolled from the waiver, as of the date established by the Department, if the participant:

(a) No longer meets all of the criteria for waiver eligibility specified in §§A-C of this regulation;

(b) Voluntarily chooses, or the participant's legal representative chooses on the participant's behalf, to disenroll from the waiver;

(c) Is an inpatient for more than 30 days in a State psychiatric hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID);

(d) Moves to another state; or

(e) Dies.

(2) Reentering the Waiver. If a participant is discharged from the waiver, the same individual may reenter the waiver during the same waiver year, if the individual meets all eligibility requirements of the waiver.

(3) The participant or legal representative shall be informed of the determination and the right to appeal and request a fair hearing, in accordance with COMAR 10.01.04 and 42 CFR Part 431, Subpart E.