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 10.09.24.12 - Post-Eligibility Requirements
Universal Citation: MD Code Reg 10.09.24.12
Current through Register Vol. 51, No. 19, September 20, 2024
A. Notice of Eligibility Determination. The local department of social services shall inform an applicant of his legal rights and obligations and give the applicant written notification of the following:
(1)
For eligible persons:
(a) A finding of
eligibility, the beginning and ending dates for coverage; and
(b) The right to request a hearing.
(2) For ineligible persons:
(a) A finding of ineligibility, the reason
for the finding, and the regulation supporting the finding; and
(b) The right to request a hearing.
B. Recipient Responsibility.
(1) A recipient or his
representative shall notify the local department of social services within 10
working days of changes affecting the eligibility of a member of the assistance
unit.
(2) A recipient or his
representative shall limit use of the Medical Assistance card to the person
whose name appears on the card.
(3)
Third-Party Liability.
(a) A recipient or his
representative shall notify the local department of social services within 10
working days when medical treatment has been provided as a result of any
accident or other occurrence in which a third party might be liable.
(b) Recipients shall cooperate with the local
department of social services in completing a form designated by the Department
to report all pertinent information that would assist the Medical Care
Compliance Administration in seeking reimbursement.
(c) In accident situations, recipients shall
notify the local department of social services of the time, date, and location
of the accident, the name and address of the attorney, the names and addresses
of all parties and witnesses to the accident, and the police report number if
an investigation is made.
(4) When written notice of cancellation is
received, a recipient shall discontinue use of the Medical Assistance card on
the first day of ineligibility and return it to the Medical Care Operations
Administration.
(5) Failure to
comply with the provisions of §B(1), (2), and (3) of this regulation may
result in the termination of assistance.
(6) Failure to comply with the provisions of
§B(1)-(4) of this regulation may result in legal action, referral to the
Medical Care Compliance Administration for reimbursement, fraud investigation,
or both, for illegal use of the Medical Assistance card.
(7) Recipients shall cooperate with the
State's Quality Control review process, including provision and verification of
all information pertinent to eligibility determination. Failure to cooperate
shall result in the following actions:
(a)
The Quality Control Division shall notify the local department of social
services of a recipient's failure to cooperate;
(b) The local department of social services
shall immediately attempt to secure the recipient's cooperation;
(c) If the recipient still refuses to
cooperate, his coverage shall be terminated in accordance with this provision,
subject to the regulation governing timely and adequate notice.
C. Redeterminations.
(1) Redetermination for Former SSI
Recipients.
(a) The local department of
social services shall promptly redetermine eligibility when notice has been
received from the Social Security Administration that a person's SSI benefits
have been terminated.
(b) When
notice of SSI termination is received, the local department of social services
shall notify the person that redetermination is required to establish
continuing eligibility and shall make the application available to
him.
(c) When the written, signed
application is received by the local department of social services, a new
period under consideration will be set. The new period will be related to the
date the application is received but may not include any months in which the
person was entitled to coverage under the current certification
period.
(d) The local department of
social services shall notify the person or his representative of the required
information and verifications needed to determine eligibility and the time
standards in acting in the redetermination process.
(e) The local department of social services
shall require the recipient or his representative to appear in person unless
the local department of social services has determined that face-to-face
contact is not necessary to make an accurate eligibility
determination.
(f) All
non-financial and financial factors for continuing eligibility shall be
met.
(g) The following applies when
the person is determined ineligible for Medical Assistance:
(i) When the SSI termination is received by
the tenth day of the month, the local department of social services shall
cancel certification effective the end of the month, unless the recipient
requests a hearing in accordance with Regulation .13 of this chapter.
(ii) When the SSI termination notice is
received after the tenth day of the month, the local department of social
services shall cancel certification effective the end of the following month
unless the recipient requests a hearing in accordance with Regulation .13 of
this chapter.
(h) Notice
of Eligibility Decisions.
(i) Eligible
Persons. Persons who are determined eligible for a new period under
consideration shall be sent notice in accordance with §A(1) of this
regulation.
(ii) Ineligible
Persons. Persons determined ineligible shall be sent notice in accordance with
§A(2) of this regulation.
(i) When ineligibility is due to excess
income only, the person will be provided with an explanation of the spend-down
provision. Spend-down eligibility may be established at any time during the new
period under consideration.
(2) Unscheduled Redetermination.
(a) The local department of social services
shall promptly make unscheduled redetermination when:
(i) The person's circumstances suggest future
changes which may affect eligibility before the due date of a scheduled
redetermination;
(ii) Relevant
facts or changes in circumstances are reported by the recipient or someone on
his behalf; or
(iii) Relevant facts
or changes are brought to the attention of the local department of social
services from other responsible sources.
(b) The local department of social services
shall notify the recipient that redetermination is required to establish
continuing eligibility. Notification will be sent in a timely manner so that a
decision of eligibility will be made within 30 days from the date of
change.
(c) The local department of
social services shall notify the recipient of the required information and
verifications needed to determine eligibility and the time standards in acting
in the redetermination process.
(d)
The local department of social services shall require the recipient or his
representative to appear in person unless the local department of social
services has determined that a face-to-face contact is not necessary to make an
accurate eligibility determination.
(e) All non-financial and financial factors
for continuing eligibility shall be met.
(f) Eligibility Decisions.
(i) Eligibility Continued for the Remainder
of the Certification Period. Recipients who are determined eligible for the
remainder of the certification period will be sent notice in accordance with
§A(1) of this regulation.
(ii)
Recipients Determined Ineligible for the Remainder of the Certification Period.
Recipients determined ineligible for the remainder of the certification period
because of a change in circumstances or failure to establish eligibility
following a change in circumstances, shall be sent notice in accordance with
§A(2) of this regulation.
(g) A person may reapply at any time after
the cancellation of current eligibility and a new period under consideration
will be established.
(3)
Scheduled Redetermination.
(a) The local
department of social services shall make scheduled redeterminations at least
once every 6 months for noninstitutionalized persons certified under Regulation
.11B(3) of this chapter and at least once every 12 months for institutionalized
persons certified under Regulation .11D(3) of this chapter.
(b) The local department of social services
shall notify the recipient that redetermination is required to establish
continuing eligibility. The notice and application will be sent at least 45
days before expiration of the current certification period.
(c) When the written, signed application is
received by the local department of social services, a new period under
consideration will be set. The new period will be related to the date the
application is received but may not include any months in which the person was
entitled to coverage under the current certification period.
(d) A recipient shall be treated the same as
an applicant at the time of scheduled redetermination.
(e) All nonfinancial and financial factors of
eligibility shall be met.
(f) The
local department of social services shall make timely decisions in accordance
with the provisions of Regulation .04I of this chapter.
(g) Eligibility Decisions.
(i) Eligibility Established. Applicants who
are determined eligible for a new period under consideration shall be sent
notice in accordance with §A(1) of this regulation.
(ii) Ineligibility Established. Applicants
determined ineligible for the new period under consideration shall be sent
notice in accordance with §A(2) of this regulation.
(h) When ineligibility is due to excess
income only, the applicant will be provided with an explanation of the
spend-down provision. Spend-down eligibility may be established at any time
during the new period under consideration.
D. Subsequent Application. A person may reapply when eligibility is not met during the periods established in §C(1) and (3) of this regulation.
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