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 10.09.24.10 - Determining Financial Eligibility for Institutionalized Persons
Universal Citation: MD Code Reg 10.09.24.10
Current through Register Vol. 51, No. 19, September 20, 2024
A. Scope.
(1) This section applies to persons who are
institutionalized throughout a calendar month.
(2) Institutional status is presumed to begin
on the first day of the first full calendar month in which the person is
institutionalized and ends on the last day of the last full calendar month
before discharge.
(3) Institutional
status is not interrupted by a transfer from one long-term care facility to
another or by a transfer from a long-term-care facility to a
hospital.
(4) Presumed
institutional status changes on the first day of the month of discharge to the
community.
(5) Eligibility for
noninstitutionalized persons shall be determined separately under Regulation
.09 of this chapter.
B. Basis.
(1) Financial eligibility shall be
determined on the basis of the countable resources and income of members of the
assistance unit.
(2) A person is
categorically needy if his total income before deductions does not exceed 300
percent of the current SSI payment standard and his countable resources are
within the applicable amount in Schedule MA-2A.
(3) A person is medically needy if his total
income before deductions exceeds 300 percent of the SSI payment standard or if
countable resources exceed the applicable amount in Schedule MA-2A.
(4) When calculating an institutionalized
recipient's available income for the cost-of-care in a long-term care facility,
in accordance with Regulations .10 and .10-1 of this chapter, guardianship fees
may not be allowed as an income deduction, whether or not the recipient has a
community spouse.
C. Retroactive Eligibility.
(1) A retroactive
eligibility determination shall be made for services incurred by an
institutionalized person within 3 months before the month of application.
Eligibility will be considered only for the month, or months, in which the
expenses were incurred.
(2) The
period under consideration shall be the month, or months, for which coverage is
requested.
(3) Excess Resources.
When the countable resources are greater than the medically needy resource
standard, retroactive eligibility does not exist.
(4) Determination of Available Income for the
Retroactive Period. The following amounts shall be deducted from the total
income in the following order:
(a) For dates
of service beginning July 1, 2003, a personal needs allowance of:
(i) $50 a month for an institutionalized
person other than a person who meets the requirements of §C(4)(a)(iii) of
this regulation.
(ii) $100 a month
for an institutionalized couple.
(iii) $100 a month for a person who resided
in an ICF/IID or mental hospital, participated in therapeutic work activities,
and received remuneration for participation in these activities. An amount
greater than $100 a month but not to exceed the MNIL may be deducted based on
additional documented work-related need.
(b) For dates of service beginning July 1,
2004, a personal needs allowance of:
(i) $60
a month for an institutionalized person other than a person who meets the
requirements of §C(4)(b)(iii) of this regulation;
(ii) $120 a month for an institutionalized
couple; and
(iii) $100 a month for
a person who resides in an ICF/IID or mental hospital, participates in
therapeutic work activities, and received remuneration for participation in
these activities, and an amount greater than $100 a month but not to exceed the
MNIL which may be deducted from available income based on additional documented
work-related need.
(c)
For dates of service beginning July 1, 2005, a personal needs allowance
adjusted annually by an amount not exceeding 5 percent to reflect the
percentage by which social security benefits are increased by the federal
government to reflect changes in the cost of living.
(d) Spousal or Family Allowance or Both. For
an institutionalized spouse as defined under Regulation .11B(6) of this
chapter, an amount equal to the community spouse monthly income allowance as
defined under Regulation .11B(2) of this chapter and, if applicable, an amount
equal to the family allowance as determined under Regulation .11C(3)(c) of this
chapter. For an institutionalized person without a spouse in the community, the
amount needed to maintain an unmarried child or children younger than 21 years
old living at home at a level which, based on verified need, equals the
applicable medically needy income level.
(e) Residential Maintenance Allowance for a
Single Person.
(i) For a person with no spouse
or unmarried child younger than 21 years old at home, the amount not to exceed
the medically needy income level that was needed to maintain the person's
residence during the retroactive period shall be deducted beginning with the
person's earliest first full month of institutionalization if, based on a
medical review process established by the Department, it is determined that the
person will be able to resume living in his community residence and that the
person intends to do so.
(ii)
Institutional status is not interrupted by a transfer from one long-term care
facility to another or by a transfer to a hospital.
(f) Incurred expenses for medical care or
remedial service that have not been paid for by any third party, including a
family member or an insurer, and are not required to be paid for by any third
party, such as an insurer, including:
(i)
Medicare and other health insurance premiums, deductibles or co-insurance
charges;
(ii) In the case of
eligibility determinations before August 1, 2005, necessary medical care or
remedial service recognized under State law but not covered under the State
Plan; and
(iii) In the case of
eligibility determinations on or after August 1, 2005, unless a court of
competent jurisdiction issues a contrary ruling in a final unappealable order,
necessary medical care or remedial service recognized under State law but not
subject to Medical Assistance reimbursement.
(g) Incurred expenses for necessary medical
care or remedial service described under §C(4)(f)(iii) of this regulation
as follows:
(i) For eligibility
determinations on or after August 1, 2005, unless a court of competent
jurisdiction issues a contrary ruling in a final unappealable order, incurred
expenses may not include medical expenses for dates of service more than 3
months before the month of the Medical Assistance application; and
(ii) Incurred expenses shall be limited to
the fees reimbursed by Medical Assistance in effect on the date of service and
shall be for actual charges if no Medical Assistance fee exists.
(h) The maximum deduction for
unpaid nursing facility bills incurred during a penalty period resulting from a
transfer of assets shall be zero.
(5) Subject to the requirements of §C(6)
of this regulation, effective October 1, 2016, the personal needs allowance set
forth in §C(4) of this regulation shall be increased as follows:
(a) For a Medicaid recipient who has been
assigned a guardian of the person, $50 per month;
(b) For a Medicaid recipient who has been
assigned a guardian of the property, $50 per month;
(c) For a Medicaid recipient who has been
assigned a single guardian serving all purposes, $50 per month; and
(d) For a Medicaid recipient who has been
assigned one individual to serve as guardian of the person and one different
individual to serve as guardian of the property, $100 per month.
(6) A guardian shall submit a
monthly bill to the Medicaid recipient or authorized representative in order
for a guardianship fee to be added to the recipient's personal needs allowance
set forth in §C(4) of this regulation.
(7) If the effective date cited in
§C(4)(f)(ii) and (iii), and (g)(i) of this regulation is invalidated by
final unappealable order of a court of competent jurisdiction, the effective
date shall be April 1, 2009.
(8)
When the available income as determined under §C(4) of this regulation is
equal to or less than the person's incurred cost-of-care to the facility and
countable resources are equal to or less than the medically needy resource
standard, retroactive eligibility exists and begins on the first day of the
period under consideration. Certification is established under Regulation .11D
of this chapter.
(9) When the available income as determined under
§C(4) of this regulation is greater than the person's incurred
cost-of-care to the facility and countable resources are equal to or less than
the medically needy resource standard, retroactive eligibility may exist under
§C(10) of this regulation.
(10) Retroactive Spend-Down Eligibility,
(a) In determining retroactive spend-down
eligibility, documented medical expenses incurred more than 3 months before the
month of the Medical Assistance application shall be considered if the incurred
expenses:
(i) Have not been paid for by any
third party, including a family member or an insurer;
(ii) Are not required to be paid for by any
third party, such as an insurer;
(iii) Were not incurred during a penalty
period; and
(iv) Were not forgiven
by the provider.
(b) The
incurred medical expenses shall be considered on a month-by-month basis
beginning with the earliest month in the period under consideration and shall
be deducted from excess available income in the following order:
(i) Medicare and other health insurance
premiums, deductibles, or co-insurance charges;
(ii) Expenses incurred for necessary medical
care or remedial services that are recognized under State law but are not
covered under the State Plan;
(iii)
Expenses incurred for necessary medical care or remedial services that are
covered under the State Plan.
(c) The medical expenses used to establish
retroactive spend-down eligibility may not be:
(i) Reimbursed by the Medical Assistance
Program;
(ii) Used for any
subsequent eligibility determination; or
(iii) Incurred before the period for which
retroactive eligibility is requested.
(d) Retroactive spend-down eligibility is
established on the day the incurred medical expenses considered under
§C(10)(b) of this regulation equal or exceed the excess available income.
Certification is established under Regulation .11D of this chapter.
(e) Retroactive spend-down eligibility is not
established when the incurred medical expenses are less than the excess
available income.
D. Current Eligibility.
(1) Excess Resources. When the countable
resources are greater than the medically needy resource level, eligibility does
not exist.
(2) Determination of
Available Income. The following amounts shall be deducted from total income in
the following order:
(a) For dates of service
beginning July 1, 2003, a personal needs allowance of:
(i) $50 a month for an institutionalized
person other than a person who meets the requirements of §D(2)(a)(iii) of
this regulation.
(ii) $100 a month
for an institutionalized couple.
(iii) $100 a month for a person who resides
in an ICF/IID or mental hospital, participates in therapeutic work activities,
and receives remuneration for participating in these activities. An amount
greater than $100 a month but not to exceed the MNIL may be deducted based on
additional documented work-related need.
(b) For dates of service beginning July 1,
2004, a personal needs allowance of:
(i) $60
a month for an institutionalized person other than a person who meets the
requirements of §D(2)(b)(iii) of this regulation;
(ii) $120 a month for an institutionalized
couple; and
(iii) $100 a month for
a person who resides in an ICF/IID or mental hospital, participates in
therapeutic work activities, and received remuneration for participation in
these activities, and an amount greater than $100 a month but not to exceed the
MNIL which may be deducted from available income based on additional documented
work-related need.
(c)
For dates of service beginning July 1, 2005, a personal needs allowance
adjusted annually by an amount not exceeding 5 percent to reflect the
percentage by which social security benefits are increased by the federal
government to reflect changes in the cost of living.
(d) Spousal or Family Allowance or Both. For
an institutionalized spouse as defined under Regulation .11B(6) of this
chapter, an amount equal to the community spouse monthly income allowance as
defined under Regulation .11B(2) of this chapter and, if applicable, an amount
equal to the family allowance as determined under Regulation .11C(3)(c) of this
chapter. For an institutionalized person without a spouse in the community, the
amount needed to maintain an unmarried child or children younger than 21 years
old living at home at a level which, based on verified need, equals the
applicable medically needy income level.
(e) Residential Maintenance Allowance for a
Single Person.
(i) For a person with no spouse
or unmarried child younger than 21 years old at home, an amount not to exceed
the medically needy income level needed to maintain the person's residence
during institutionalization shall be deducted for a period of up to 6 months
beginning with the person's first full month of current institutionalization
if, based on a medical review process established by the Department, it is
determined that the person will be able to resume living in his community
residence during this period and that person intends to do so.
(ii) The maximum 6-month period is not
interrupted by a transfer from one long-term care facility to another or by
admission to a hospital.
(f) The following incurred medical expenses
that are not subject to payment by a third party:
(i) Medicare and other health insurance
premiums, deductibles or co-insurance charges;
(ii) For eligibility determinations before
August 1, 2005, necessary medical care or remedial service recognized under
State law but not covered under the State Plan; and
(iii) For eligibility determinations on or
after August 1, 2005, unless a court of competent jurisdiction issues a
contrary ruling in a final unappealable order, necessary medical care or
remedial service recognized under State law but not subject to Medical
Assistance reimbursement.
(g) Incurred expenses for necessary medical
care or remedial service described under §D(2)(f)(iii) of this regulation
as follows:
(i) For eligibility determinations
on or after August 1, 2005, unless a court of competent jurisdiction issues a
contrary ruling in a final unappealable order, incurred expenses may not
include medical expenses for dates of service more than 3 months before the
month of the Medical Assistance application; and
(ii) Incurred expenses shall be limited to
the fees reimbursed by Medical Assistance in effect on the date of service and
shall be for actual charges if no Medical Assistance fee exists.
(h) The maximum deduction for
unpaid nursing facility bills incurred during a penalty period resulting from a
transfer of assets shall be zero.
(3) Subject to the requirements of §D(4)
of this regulation, effective October 1, 2016, the personal needs allowance is
increased as follows:
(a) For a Medicaid
recipient who has been assigned a guardian of the person, $50 per
month;
(b) For a Medicaid recipient
who has been assigned a guardian of the property, $50 per month;
(c) For a Medicaid recipient who has been
assigned a single guardian serving all purposes, $50 per month;
(d) For a Medicaid recipient who has been
assigned one individual to serve as guardian of the person and one different
individual to serve as guardian of the property, $100 per month.
(4) A guardian shall submit a
monthly bill to the Medicaid recipient or authorized representative in order
for a guardianship fee to be added to the recipient's personal needs allowance
set forth in §D(2) of this regulation.
(5) If the effective date cited in
§D(2)(f)(ii) and (iii) and (g)(i) of this regulation is invalidated by
final unappealable order of a court of competent jurisdiction, the effective
date shall be April 1, 2009.
(6)
If, after application of the disregards in §D(2) of this regulation, the
person's income equals or is less than the projected cost-of-care, eligibility
exists and may begin on the first day of the period under consideration. The
amount remaining after application of the disregards in §D(2) of this
regulation is available income to be applied to the person's cost-of-care.
Certification is established under Regulation .11D of this chapter.
(7)
If, after application of the disregards in §D(2) of this regulation, the
person's income exceeds the projected cost-of-care, eligibility may be
established under §D(8) of this regulation.
(8) Spend-down Eligibility.
(a) In determining spend-down eligibility,
documented medical expenses incurred during the time periods and meeting the
conditions specified in this section shall be considered.
(b) Medical expenses incurred before the
month of application shall be considered if the expenses:
(i) Were not considered in any retroactive
certification;
(ii) Were not used
to establish spend-down eligibility for a prior certification;
(iii) Have not been paid for by any third
party, including a family member or an insurer, and are not required to be paid
for by any third party, such as an insurer;
(iv) Were not incurred during a penalty
period;
(v) Remain the obligation
of any person whose income and resources are considered in determining
eligibility; and
(vi) Have not been
forgiven by the provider of the services, as evidenced by account statements
dating up to 3 months before the month of application.
(c) Medical expenses incurred at any time
during or after the month of application and before the end of the period under
consideration shall be considered if they:
(i) Were not paid for by any third party,
including a family member or an insurer;
(ii) Are not required to be paid for by any
third party, such as an insurer;
(iii) Were not incurred during a penalty
period; and
(iv) Have not been
forgiven by the provider.
(d) Each medical bill verifying expenses
shall include a statement of the service and the date the service was rendered.
For purchases of medicines and medical supplies or equipment, the statement
from the provider shall include the item purchased and the date and cost of the
purchase.
(e) Medical expenses
incurred during the time periods specified in §D(8)(b) and (c) of this
regulation shall be deducted from the excess available income beginning with
the earliest time period and in the following order:
(i) Medicare and other health insurance
premiums, deductibles, or co-insurance charges;
(ii) Expenses incurred for necessary medical
care or remedial services that are recognized under State law but are not
covered under the State Plan;
(iii)
Expenses incurred for necessary medical care or remedial services that are
covered under the State Plan.
(f) Spend-down eligibility is established for
the remainder of the period under consideration on the day the incurred medical
expenses, considered under §D(8)(e) of this regulation, including
projected private cost-of-care obligations, equal or exceed the amount of
excess available income. Certification is established under Regulation .11D of
this chapter.
(g) The medical
expenses used to establish spend-down eligibility may not be:
(i) Reimbursed by the Medical Assistance
Program; or
(ii) Used for any
subsequent eligibility determination.
(h) Eligibility exists on the day that
incurred medical expenses equal or exceed the amount of excess available
income.
(i) When spend-down
eligibility is not established during the application process, the applicant
shall be notified of his ineligibility and advised of the spend-down provision.
The application date shall be preserved for possible spend-down eligibility at
any time during the established period under consideration.
(j) Eligibility exists on the day during the
preserved spend-down period that incurred medical expenses equal or exceed the
amount of excess available income. Certification is established under
Regulation .11D of this chapter.
(k) When the incurred medical expenses do not
equal the amount of excess available income during the period under
consideration, eligibility does not exist. A new application date and period
under consideration will be established when the applicant reapplies after the
expiration of the established period under consideration.
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