Sec. 10.09.89.03. Participant Eligibility

A. For an applicant to be eligible for 1915(i) services, the applicant shall meet all of the criteria in §§B-H of this regulation.

B. The applicant shall be younger than 18 years old at the time of enrollment.

C. The applicant shall reside in a home- and community-based setting that is:

(1) Located in the 1915(i) service area; and

(2) Not any of the following excluded settings:

(a) Therapeutic Group Home (TGH) licensed by the Office of Health Care Quality (OHCQ) under COMAR 10.21.07;

(b) Psychiatric Respite Care facility located on the grounds of an institution for mental disease (IMD) for the purpose of placement;

(c) Residential program for adults with serious mental illness licensed under COMAR 10.63; or

(d) Group residential facility licensed under COMAR 10.63.

D. Consent.

(1) For individuals younger than 16 years old, the family or medical guardian of the participant shall give consent for the individual to participate in the 1915(i);

(2) For individuals 16 years old or older, the individual shall give consent to participate in the 1915(i).

E. The applicant shall:

(1) Have a face-to-face psychiatric evaluation completed or updated within 30 days of submission of the enrollment application to the ASO that:

(a) Assigns a Diagnostic and Statistical Manual (DSM) behavioral health diagnosis or Diagnostic Criteria (DC) 0-5 diagnosis;

(b) Determines the applicant to be amenable to active clinical treatment; and

(c) Is conducted by a provider not associated with the CCO by which the participant may eventually be served; and

(2) Meet the Department’s written medical necessity criteria.

F. The accessibility or intensity of currently available community supports and services are inadequate to meet the applicant’s needs due to the severity of the impairment without the provision of one or more of the services contained in the 1915(i) benefit.

G. The applicant may not be served in a Health Home as defined in COMAR 10.09.33 while enrolled in the 1915(i).

H. Medical Assistance Eligibility.

(1) Categorically Needy. An applicant is eligible for 1915(i) services if the applicant is eligible for Medicaid or Maryland Children’s Health Program (MCHP) in accordance with COMAR 10.09.11 or 10.09.24 and has a family income that does not exceed 150 percent of the Federal Poverty Line (FPL).

(2) Optional Categorically Needy. An applicant is eligible for the 1915(i) benefit as optionally categorically needy in accordance with 1902(a)(10)(A)(ii)(XXII) if the individual is receiving services through an existing 1915(c) HCBS waiver program.

I. The Department may assist applicants in the benefit application process by:

(1) Informing the applicant and family verbally and in writing about services available in the 1915(i);

(2) Assisting the applicant and family to complete the eligibility determination for Medical Assistance for the 1915(i), if necessary; and

(3) Once Medical Assistance eligibility is determined, ensuring that the assessments and documentation required for a medical necessity determination are obtained and provided to the Department.

J. Based on the criteria established in §§A-H of this regulation:

(1) An applicant’s eligibility for services under this regulation shall be established by the Department;

(2) There is no retroactive eligibility; and

(3) Benefit eligibility may not begin before:

(a) Verification of the applicant’s Medical Assistance eligibility for the 1915(i); and

(b) Completion of the independent evaluation by the Department that the applicant meets all criteria established in §§A-H of this regulation.

K. If the applicant is determined to meet the needs-based eligibility criteria as established in §§A-H of this regulation, the Department shall:

(1) Obtain written consent from the family or medical guardian to participate in the 1915(i); and

(2) Ensure that the participant is referred immediately upon enrollment determination to a CCO.

L. The Department shall re-evaluate a participant’s:

(1) Needs-based eligibility for 1915(i) services as specified in §§A-G of this regulation every 12 months, or more frequently due to a significant change in the participant’s condition or needs, in accordance with the Department’s medical necessity criteria; and

(2) Medical Assistance eligibility for 1915(i) services in accordance with the Department’s redetermination policy for all Medical Assistance enrollees.