Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.24 - Medical Assistance Eligibility
Section 10.09.24.02 - Definitions
Universal Citation: MD Code Reg 10.09.24.02
Current through Register Vol. 51, No. 19, September 20, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Aged" means a person who is 65 years old
or older.
(2) "Aid to the
Permanently and Totally Disabled" means a former category of public assistance
mandated under Title XIV of the Social Security Act,
42 U.S.C. § 1351 et seq., and replaced by Title XVI of
the Social Security Act, 42
U.S.C. § 1381 et seq.
(3) "Appeal" means a process by which an
applicant, recipient, or representative obtains review of a decision, action,
or inaction of the Department or the local department of social
services.
(4) "Applicant" means a
person whose written application for Medical Assistance has been submitted to
the local department of social services but has not received final action. This
includes a person, who need not be alive at the time of application, whose
application is submitted through a representative.
(5) "Application" means the filing of a
written and signed application form for Medical Assistance at the local
department of social services or its designee.
(6) "Application date" means the date on
which a written, signed application is received by the local department of
social services.
(7) "Application
form" means the form designated by the Department to be completed, signed, and
submitted to the local department of social services, or a designee, as an
official application for Medical Assistance.
(8) "Assistance unit" means one person, or a
group of persons whose eligibility for Medical Assistance benefits is
determined in conjunction with each other.
(9) "Blindness" means 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 no greater
than 20 degrees.
(10) Caretaker
Relative.
(a) "Caretaker relative" means a
parent or other person related by blood, marriage, or adoption and living with
and caring for an unmarried child younger than 21 years old who is deprived of
parental support due to death, continued absence from the home, incapacitation
of a parent, or unemployment of the principal wage earner parent. A parent
whose absence is occasioned solely by reason of the performance of active duty
in the uniformed service of the United States is not considered absent from the
home. The following relatives and their spouses meet this definition: father,
mother, brother, sister, stepfather, stepmother, stepbrother, stepsister,
uncle, aunt, first cousin, nephew or niece, and persons of preceding
generations as denoted by the prefix of grand, great, and great-great; persons
who legally adopt a child or his parent as well as the natural and other
legally adopted children of these persons; and other relatives of adoptive
parents in accordance with State law. A caretaker relative retains his status
as a caretaker relative when the only child or children in his custody receives
SSI benefits. This is the only instance when a caretaker relative without
children in an assistance unit qualifies as a caretaker relative.
(b) "Continued absence from the home" means
that the parent is out of the home, the nature of the absence either interrupts
or terminates the parent's functioning as a provider of maintenance, physical
care, or guidance for the child, and the known or indefinite duration of the
absence precludes counting on the parent's performance of his function in
planning for the present support or care of the child.
(c) "Incapacitation" means that a parent has
a mental or physical defect, illness, or impairment which eliminates the
parent's ability to support or care for the child and is expected to last for a
period of at least 30 days.
(d)
"Principal wage earner parent" means whichever parent, in a home in which both
parents of a child are living, earned a greater amount of income in the period
specified below:
(i) For initial eligibility,
the 24 months immediately preceding the month in which application is filed on
the basis of the unemployment of a parent;
(ii) For eligibility for each subsequent
month of the certification period, the 24 months immediately preceding the
current month.
(e)
Unemployed Parent.
(i) "Unemployed parent"
means the principal wage earner parent who:
(aa) Has been unemployed for at least 30 days
before the receipt of Medical Assistance; and
(bb) Has not left a job or refused to seek or
accept employment without good cause within 30 days of the date of
application.
(ii) The
condition of unemployment is met when the parent is employed less than 100
hours per month; or is employed 100 hours or more per month, if the parent's
work is intermittent and the excess hours are of a temporary nature, as
evidenced by the fact that the work hours were under the standard for the two
previous months and are expected to be under the standard during the next
month.
(10-1)
"Carrier" means a:
(a) Health
insurer;
(b) Non-profit health
service plan;
(c) Health
maintenance organization;
(d)
Dental plan organization; and
(e)
Any other person included as a third party in Section 1902(a)(25)(A) of the
Social Security Act, as amended by the Federal Deficit Reduction Act of
2005.
(11) "Categorically
needy" means aged, blind, or disabled persons, or families and children, who
are otherwise eligible for Medical Assistance and who meet the financial
eligibility requirements for FIP, SSI, or Optional State Supplement.
(12) "Child" means an unmarried person
younger than 21 years old.
(13)
"Chronic hospital" means an institution which falls within the jurisdiction of
Health-General Article, §19-307(a)(1), Annotated Code of Maryland, and is
licensed pursuant to COMAR 10.07.01.
(14) "Comprehensive care facility" means a
nursing facility licensed as a comprehensive care facility pursuant to COMAR
10.07.02.
(14-1) "Continuing care
retirement community (CCRC)" means an entity that obtains certificate of
registration issued by the Maryland Department of Aging in accordance with
COMAR 32.02.01 and pursuant to its authority under Article 70B, Annotated Code
of Maryland.
(15) "Corrective
Managed Care Program" means the program administered by the Division of
Utilization and Eligibility Review of the Medical Care Compliance
Administration which limits recipients who have abused or misused Medical
Assistance benefits to access most covered services through a single primary
medical provider and a single pharmacy.
(16) "Department" means the Department of
Health and Mental Hygiene, the single State agency designated to administer the
Medical Assistance Program.
(17)
"Department of Human Resources" means the department of State government which
administers the FIP program.
(18)
"Determination" means a decision regarding an applicant's eligibility for
Medical Assistance.
(19) "Disabled"
means the inability to perform any substantial gainful activity by reason of a
medically determinable physical or mental impairment which can be 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.
(20) "Eligibility technician" means an
employee of the local department of social services responsible for determining
eligibility of applicants and recipients.
(20-1) "Emergency services" means services
provided by a licensed medical practitioner after the onset of a medical
condition manifesting itself by symptoms of sufficient severity that the
absence of immediate medical attention could reasonably be expected by a
prudent layperson, possessing an average knowledge of health and medicine, to
result in:
(a) Placing health in
jeopardy;
(b) Serious impairment to
bodily functions;
(c) Serious
dysfunction of any bodily organ or part; or
(d) Development or continuance of severe
pain.
(20-2) "Entrance
fee" means a sum of money or other consideration, other than a surcharge that:
(a) Is paid by a resident to a CCRC initially
or in deferred payments, pursuant to a written continuing care agreement
between the CCRC and the resident, which governs the use, treatment, and refund
of the entrance fee;
(b) Assures a
resident of continuing care in the CCRC facility for a term of more than 1 year
or for life; and
(c) Is at least
three times the weighted average of the monthly cost of the periodic fees
charged to independent living and assisted living units.
(21) "Extended care facility" means a nursing
facility licensed as an extended care facility pursuant to COMAR
10.07.02.
(21-1) "Family
Investment Program (FIP)" means a category of public assistance mandated under
Title IV-A of the Social Security Act,
42 U.S.C. § 601 et seq.
(21-2) "Guardian of the person" means a
guardian appointed by a court pursuant to Estates and Trusts Article, Title 13,
Subtitle 7, Annotated Code of Maryland, to serve the interests of a minor or
disabled person under that subtitle.
(21-3) "Guardian of the property" means a
guardian appointed by a court pursuant to Estates and Trusts Article, Title 13,
Subtitle 2, Annotated Code of Maryland, to serve the interests of a minor or
disabled person under that subtitle.
(22) "Hospital" means an institution which
falls within the jurisdiction of Health-General Article, §19-307(a)(1),
Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01, or is
licensed according to applicable standards established by the state in which
the hospital is located.
(23)
Income.
(a) "Income" means any property or
service received by a person in cash or in-kind which can be applied directly,
or by sale or conversion, to meet basic needs for food, shelter, and medical
expenses.
(b) "Earned income" means
payment received by a person in cash or in-kind as a result of employment,
including self-employment. Earned income consists of wages, salaries,
commissions, tips, and profit from self-employment.
(c) "In-kind income" means support or
benefits in the form of food or shelter, or both, received by a
person.
(d) "Unearned income" means
all income which does not meet the definition of earned income.
(24) "Family Investment
Administration" means the administrative unit of the Department of Human
Resources and its affiliated local departments responsible for determining an
applicant's or recipient's eligibility for Public Assistance, Medical
Assistance, and Medical Assistance, State-Only.
(25) "Incurred medical expenses" means those
paid or unpaid bills for medical care which are recognized under State law and
are or will be the obligation of the applicant.
(26) "Intermediate care facility" means a
nursing facility which meets the standards for certification and participation
in Title XIX and has entered into a provider agreement with the Department
pursuant to COMAR 10.09.11.
(27)
"Intermediate care facility for individuals with intellectual disabilities or
persons with related conditions (ICF/IID)" means a nursing facility for the
intellectually disabled which meets the standards for certification and
participation in Title XIX and has entered into a provider agreement with the
Department pursuant to COMAR 10.09.11.
(28) "Living together" means sharing a common
household.
(29) "Local department
of social services (LDSS)" means the Baltimore City or a county social services
department under the supervision of the Department of Human
Resources.
(30) "Long-term-care
facility" means a skilled nursing facility, intermediate care facility,
intermediate care facility for individuals with intellectual disabilities or
persons with related conditions (ICF/IID), chronic hospital, tuberculosis
hospital, or mental hospital.
(31)
"Mandatory State Supplement" means a cash payment a state is required to make
under Section 212, P.O. 93-66 to an aged, blind, or disabled person to provide
him with the same amount of cash assistance he was receiving under Old Age
Assistance, Aid to the Permanently and Totally Disabled, or Public Assistance
to the Needy Blind if his SSI payment is less than that amount.
(31-1) "Maryland Medicaid Managed Care
Program" means the Medicaid reform program established under COMAR
10.09.62-10.09.73, as authorized by Health-General Article, Title 15, Subtitle
1, Annotated Code of Maryland.
(32)
"Medicaid" means Medical Assistance provided under the State Plan approved
under Title XIX of the Social Security Act.
(33) "Medical Assistance (MA)" means the
program administered by the State under Title XIX which provides comprehensive
medical and other health-related care for eligible categorically and medically
needy persons.
(34) "Medical Care
Compliance Administration" means the administrative unit of the Department
responsible for ensuring that health care services provided to recipients are
appropriate and effectively utilized.
(35) "Medical Care Operations Administration"
means the administrative unit of the Department responsible for maintaining a
file of all eligible persons and paying providers of service.
(36) "Health Systems Financing
Administration" means the administrative unit of the Department responsible for
establishing regulations, policies, and procedures for the Medical Assistance
program.
(37) "Medical institution"
means an institution that:
(a) Is organized
to provide medical care, including nursing and convalescent care;
(b) Has the necessary professional personnel,
equipment, and facilities to manage the medical, nursing, and other health
needs of patients on a continuing basis in accordance with accepted
standards;
(c) Is authorized under
State law to provide medical care; and
(d) Is staffed by professional personnel who
are responsible to the institution for professional medical and nursing
services.
(38) "Medically
needy" means persons who are otherwise eligible for Medical Assistance, who are
not categorically needy, and whose income and resources are within the limits
set under the State Plan.
(39)
"Medicare" means the medical insurance program administered by the federal
government under Title XVIII of the Social Security Act,
42 U.S.C. § 1395 et seq.
(40) "Mental hospital" means an institution
which falls within the jurisdiction of Health-General Article,
§19-307(a)(1), Annotated Code of Maryland, and is licensed pursuant to
COMAR 10.07.04.
(41) "Migrant
worker" means a person who moves from place to place to harvest or process
seasonal crops.
(42) "Old Age
Assistance" means a former category of public assistance mandated under Title I
of the Social Security Act, and replaced by Title XVI of the Social Security
Act, 42 U.S.C. § 1381 et seq.
(43) "One-time-only" means a time-limited
certification.
(44) "Optional State
Supplement" means a cash payment made by a state to an aged, blind, or disabled
person, under § 1616 of the Social Security Act.
(45) "Period under consideration" means the
specified months which are assessed for determination of eligibility.
(45-1) "Postpartum period" means:
(a) The period of time beginning on the date
a pregnancy ends and ending on the last day of the month in which the 60-day
period ends; or
(b) Effective for 5
years beginning April 1, 2022, the period of time beginning on the date a
pregnancy ends and ending on the last day of the 12th month following the end
of pregnancy.
(46)
"Public Assistance" means cash assistance payments, including state
supplementary payments, made to persons who are eligible for programs
administered under Title IV-A or Title XVI of the Social Security
Act.
(47) "Public Assistance to the
Needy Blind" means a former category of public assistance mandated under Title
X of the Social Security Act and replaced by Title XVI of the Social Security
Act, 42 U.S.C. § 1381 et seq.
(48) Public Institution.
(a) "Public institution" means an institution
that is the responsibility of a governmental unit or over which a governmental
unit exercises administrative control.
(b) "Institution" means an establishment that
furnishes, in single or multiple facilities, food, shelter, and some treatment
or services to four or more persons unrelated to the proprietor.
(c) "Public institution" does not mean a
medical institution, a skilled nursing facility, or a publicly operated
community residence that serves no more than 16 residents.
(49) Publicly Operated Community Residence
that Serves No More Than 16 Residents.
(a)
"Publicly operated community residence that serves no more than 16 residents"
means a facility that is publicly operated, serves no more than 16 residents,
and offers services beyond food and shelter.
(b) "Publicly operated community residence
that serves no more than 16 residents" does not mean:
(i) Residential facilities located on or
adjacent to any large institution or multipurpose center;
(ii) Educational or vocational institutions
that primarily provide an approved or accredited program to some or all of
their residents;
(iii) Medical
treatment facilities which provide medical care or remedial service on an
inpatient basis; or
(iv)
Correctional or holding facilities which provide for persons who are prisoners,
have been arrested or detained, or are held under court order as material
witnesses or juveniles.
(49-1) "Qualified alien" means an alien who:
(a) Has been fully admitted for permanent
residence under the Immigration and Nationality Act (INA);
(b) Has been granted asylum under § 208
of the INA;
(c) Has been admitted
into the United States as a refugee under § 207 of the INA;
(d) Has been paroled into the United States
under § 212(d)(5) of the INA for a period of at least 1 year;
(e) Has had deportation withheld under §
243(h) of the INA; or
(f) Has been
granted conditional entry under § 203(a)(7) of the INA in effect before
April 1, 1980.
(50)
"Recipient" means a person who is certified as eligible for Medical
Assistance.
(51) "Redetermination"
means a determination regarding continuing eligibility of a
recipient.
(52) "Remedial service"
means any service, other than a physician's service, provided within the scope
of practice as defined by State law by a person licensed as a practitioner
under State law.
(53) "Resources"
means accumulated personal wealth over which a person has the authority or
power to liquidate his interest, including cash savings, savings accounts,
certificates of deposit, money market certificates, checking accounts, stocks,
bonds, cash value of life insurance, burial plots, prepaid burial plans, real
property, personal property, mortgages, and mutual funds.
(54) "Retroactive coverage" means the
availability of coverage for incurred medical expenses covered under the State
Plan for a period not to exceed 3 months before the month of
application.
(55) "Skilled nursing
facility" means a nursing facility which:
(a)
Is licensed as a comprehensive care facility (SNF/CCF), or as an extended care
facility (SNF/ECF), or both;
(b)
Meets the requirements for certification and participation in Title XIX of the
Social Security Act as a skilled nursing facility; and
(c) Has entered into a provider agreement
with the Department pursuant to COMAR 10.09.10.
(56) "Social Security Administration" means
the administrative unit in the United States Department of Health and Human
Services responsible for administering programs under Titles II, IV-A, IV-D,
and XVI of the Social Security Act.
(57) "Spend-down" means a procedure by which
an applicant who is ineligible for Medical Assistance due to excess income
becomes eligible by deducting incurred medical expenses from excess
income.
(58) "Spouse" means a
person who has been determined to be the husband or wife of another person
under State law or for the purposes of determining eligibility for Social
Security benefits.
(59) "State
Plan" means a comprehensive written commitment by a Medicaid agency, submitted
under § 1902(a) of the Social Security Act, to administer or supervise the
administration of a medical assistance program in accordance with federal
requirements.
(60) "Supplemental
Security Income (SSI)" means a federally administered program providing
benefits to needy aged, blind, and disabled individuals under Title XVI of the
Social Security Act, 42
U.S.C. § 1381 et seq.
(61) "Third party" means a person,
institution, corporation, public or private agency or organization who is or
may be liable to pay all or part of the medical cost of injury, disease, or
disability of an applicant or recipient.
(62) "Title XIX" means the title of the
Social Security Act, 42
U.S.C. § 1396 et seq., which governs
establishment of a medical assistance program for low income persons.
(63) "Tuberculosis hospital" means an
institution which falls within the jurisdiction of Health-General Article,
§19-307(a)(1), Annotated Code of Maryland, and is licensed pursuant to
COMAR 10.07.01.
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