Sec. 10.20.01.03. Recipient Eligibility and Certification for Program Participation

A. To be eligible for enrollment in the Program an applicant shall:

(1) Be a resident of Maryland and one of the following:

(a) A citizen of the United States,

(b) A qualified alien, as specified in §C of this regulation, who is eligible in accordance with the requirements related to the 5-year bar specified at §D of this regulation; or

(c) An alien who is:

(i) Eligible for and receiving Supplemental Security Income (SSI);

(ii) A member of a federally recognized Indian tribe, as defined in 25 U.S.C. §450b(e); or

(iii) An American Indian born in Canada to whom §289 of the Immigration and Nationality Act (INA) applies.

(2) Be certified by a physician as having end stage renal disease;

(3) Meet one of the following requirements:

(a) Have begun a regular course of maintenance renal dialysis in a certified facility or have received a renal transplant, or both; or

(b) Have begun a course of maintenance renal dialysis in an out-of-State facility when the Program has preauthorized the treatment based on the facility's proximity to the applicant's residence or to assure continuity of care, or both; and

(4) Submit an application in accordance with Regulation .02 of this chapter.

B. An individual detained by a federal, state, or local penal or correctional system as a result of a charge, indictment, or conviction of a criminal offense is not eligible for Program enrollment.

C. Qualified Aliens. According to §431 of the Personal Responsibility and Work Opportunity and Reconciliation Act of 1996 (PRWORA), qualified aliens admitted to the United States shall include:

(1) The following types of aliens, who may be subject to the 5-year bar specified at §D of this regulation, depending on their most recent date of entry and their date of qualified alien status:

(a) Aliens who were lawfully admitted to the United States for permanent residence or who since admission were granted lawful permanent resident status in accordance with the INA;

(b) Aliens granted parole for at least 1 year under §212(d)(5) of the INA; and

(c) A documented or undocumented immigrant who was battered or subjected to extreme cruelty by the individual’s United States citizen or lawful permanent resident spouse or parent, or by a member of the spouse’s or parent’s family residing in the same household as the immigrant, if:

(i) The spouse or parent consented to, or acquiesced in, the battery or cruelty;

(ii) The abusive act or acts occurred in the United States;

(iii) The individual responsible for the battery or cruelty no longer lives in the same household as the victim;

(iv) A Violence Against Women Act immigration case or a family-based visa petition has been filed; and

(v) There is a substantial connection between the battery or cruelty and the need for Medical Assistance benefits; and

(2) The following types of aliens, who are not subject to the 5-year bar specified in §D of this regulation:

(a) Alien children and pregnant women who are lawfully residing in the United States, including legal permanent residents who have resided in the United States for less than 5 years as described under §214 of the Children’s Health Insurance Program Authorization Act of 2009 (CHIPRA);

(b) Aliens who were lawfully admitted to the United States for permanent residence as Amerasian immigrants under §584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988;

(c) Refugees admitted under §207 of the INA;

(d) Aliens granted asylum under §208 of the INA;

(e) Aliens whose deportation is being withheld under:

(i) §243(h) of the INA as in effect prior to April 1, 1997; or

(ii) §241(b)(3) of the INA, as amended;

(f) Cuban or Haitian entrants, as defined at §501(e) of the Refugee Education Assistance Act of 1980;

(g) Aliens granted conditional entry under §203(a)(7) of the INA in effect before April 1, 1980;

(h) Children receiving federal payments for foster care or adoption assistance under Part B or E of Title IV of the Social Security Act, if the child’s foster or adoptive parent is considered a citizen or qualified alien; and

(i) Victims of a severe form of trafficking, in accordance with §107(b)(1) of the Trafficking Victims Protection Act of 2000, who have been subjected to:

(i) Sex trafficking if the act is induced by force, fraud, or coercion, or the individual who was induced to perform the act was younger than 18 years old on the date that the visa application was filed; or

(ii) Involuntary servitude.

D. Five-Year Bar to Program Benefits for Qualified Aliens.

(1) Qualified aliens in the categories specified in §C(1) of this regulation who entered the United States on or after August 22, 1996, were not eligible for Program benefits for 5 years from the date that the qualified alien:

(a) Entered the United States with the status of a qualified alien; or

(b) Obtained the status of a qualified alien, if the individual did not enter the United States as a qualified alien.

(2) The 5-year bar specified in §D(1) of this regulation shall also be applied to qualified aliens who entered the United States before August 22, 1996, but did not remain continuously present in the United States from the last date of entry before August 22, 1996 until the date of qualified alien status.

(3) An alien is not considered to be continuously present in the United States as specified in §D(2) of this regulation if, before the date of qualified alien status, the alien had:

(a) A single absence from the United States of more than 30 days; or

(b) Absences from the United States totaling more than 90 days.

(4) The 5-year bar to eligibility for Program benefits, specified in §D(1) of this regulation, does not apply to:

(a) Qualified aliens in the categories specified at:

(i) §C(1) of this regulation, who are not subject to the 5-year bar in accordance with §D(1) or (2) of this regulation; or

(ii) §C(2) of this regulation;

(b) A qualified alien who is:

(i) An honorably discharged veteran of the armed forces of the United States;

(ii) On active duty in the armed forces of the United States; or

(iii) The lawfully admitted spouse, including a surviving spouse who has not remarried, or lawfully admitted unmarried dependent child of an honorably discharged veteran or individual on active duty in the armed forces of the United States; and

(c) Lawful permanent residents who:

(i) Entered the United States under another exempt category specified at §D(4)(a)-(b) of this regulation; and

(ii) Converted to lawful permanent resident status.

E. Certification Period.

(1) The Program shall establish the certification period during which an individual is eligible to receive Program benefits.

(2) The certification period shall be retroactive to the first day of maintenance renal dialysis or renal transplantation if a completed application is received by the Program within 30 days after the first day of maintenance renal dialysis, or within 30 days after renal transplantation, whichever treatment occurs first.

(3) If a completed application is received by the Program more than 30 days after the first day of maintenance renal dialysis, or more than 30 days after the date of renal transplantation, whichever treatment occurs first, the certification period shall begin on the first day of the month in which the completed application is received by the Program.

(4) The Program shall certify a recipient for a 12-month period.

(5) The Program shall promptly redetermine eligibility when it receives information concerning a recipient's circumstances that may affect continuing eligibility.

F. A recipient shall comply with the following requirements to continue Program enrollment throughout a certification period:

(1) Unless a recipient can document continuing insurance coverage that is equal to or greater than Medicare benefits, apply for enrollment in Part A, Part B, and Part D of Medicare within 60 days of notification to do so by the Program, if not already a Medicare beneficiary;

(2) Apply for enrollment in Part A, Part B, and Part D of Medicare within 60 days following termination of insurance coverage that is equal to or greater than Medicare benefits;

(3) Maintain enrollment in Part A, Part B, and Part D of Medicare if eligible;

(4) Apply for enrollment in Medical Assistance within 60 days of notification to do so by the Program;

(5) Maintain enrollment in Medical Assistance if eligible;

(6) Continue to meet the requirements of §§A and I of this regulation;

(7) Reimburse the Department any monies received from any insurance company or other third party for payment of ESRD treatment costs previously reimbursed by the Program; and

(8) Pay the Program participation fee, if applicable, in accordance with Regulation .04 of this chapter.

G. A recipient is considered to have failed to meet the requirement of §F(4) of this regulation if:

(1) The recipient fails to provide information required for certification or recertification of Medical Assistance eligibility; or

(2) Medical Assistance disenrolls the recipient because of recipient fraud, recipient abuse, or recipient failure to comply with reporting requirements.

H. Reapplication for Continuation of Certification.

(1) The Program shall notify the recipient in writing 60 days before an annual certification period expires.

(2) A recipient shall complete a written application for continuation of certification for Program benefits.

(3) A recipient shall be disenrolled from the Program upon expiration of a certification period unless the Program receives a completed application for continuation of certification 30 days before expiration of a certification period.

I. The recipient shall notify the Program within 30 working days of:

(1) A payment received from any source that is related to treatment of the recipient's ESRD;

(2) The recipient's regaining renal function;

(3) A change in address; or

(4) A change in State residence, citizenship, or alien status.

J. Termination Before Expiration of Certification Period.

(1) The Program shall terminate a recipient’s enrollment in the Program before expiration of the current certification period if the recipient:

(a) Fails to provide the notice required by §I of this regulation;

(b) Voluntarily disenrolls;

(c) No longer meets the medical requirements for participation;

(d) No longer meets the residence, citizenship, or alien status requirements of §A(1) of this regulation;

(e) Fails to pay the Program participation fee described in Regulation .04 of this chapter;

(f) Fails to apply for and maintain enrollment in Medicare, if eligible;

(g) Fails to apply for and maintain enrollment in the Medical Assistance Program if required by the Program;

(h) Fails to pay the Department any monies received from any source for payment of ESRD treatment costs previously reimbursed by the Program;

(i) Has not received a kidney transplant but no longer requires a regular course of maintenance dialysis, 12 months after the date on which the course of dialysis is terminated;

(j) Is incarcerated by a federal, state, or local penal or correctional system;

(k) Has used the Program identification number to fraudulently obtain goods or services, or permits another individual to use the Program identification number to fraudulently obtain goods or services;

(l) Fails to pay the quarterly amount within the required time frame and the Program has not paid for any services provided for the recipient within the quarter; or

(m) Has died.

(2) Pursuant to §J(1)(l) of this regulation, termination is considered voluntary withdrawal and becomes effective retroactive to the first day of the quarter billed.

K. Continuing Certification and Termination Notices.

(1) The Program shall inform a recipient, or the recipient's representative, of the recipient's rights and obligations regarding continuing certification and termination of Program enrollment.

(2) The Program shall give the recipient or the recipient’s representative written notification of the following:

(a) That a certification period is due to expire and reapplication is required as set forth in §H of this regulation;

(b) The effective date of termination of Program enrollment when:

(i) The recipient no longer meets the residence, citizenship, or alien status requirements;

(ii) The recipient is incarcerated; or

(iii) The recipient has died; and

(c) The Program’s intent to terminate the recipient’s enrollment for reasons other than those set forth in §K(2)(a) and (b) of this regulation.

(3) A notice that the certification period is about to expire or of the Program's intent to terminate the recipient's enrollment due to the recipient's failure to apply for recertification or to pay the assessed quarterly premium shall:

(a) Be mailed at least 30 calendar days before the date on which the action is to be effective;

(b) Include a statement of the proposed actions, the reasons for the action, and the regulatory citation supporting the action; and

(c) Include an explanation of the right to request a hearing.

L. If the Program determines that the recipient has used the Program identification number to fraudulently obtain goods or services, or has permitted another individual to use the Program identification number to fraudulently obtain goods or services, and certification is terminated pursuant to §J(1)(k) of this regulation, the recipient is not eligible to reapply for Program certification.