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 10.09.24.15 - Liens, Adjustments, and Recoveries
Universal Citation: MD Code Reg 10.09.24.15
Current through Register Vol. 51, No. 19, September 20, 2024
A. Definitions. In this regulation, the following terms have the meanings indicated:
(1) "Dependent" means a:
(a) Child of the decedent, or the decedent's
descendants;
(b) Sibling, including
half or step, of the decedent; or
(c) Parent of the decedent, or the decedent's
ancestors.
(2)
"Discharge from a long-term care facility and return home" means the release of
a person from that facility for the purpose of returning to the home for
permanent residence.
(3) "Equity
interest in the home" means co-ownership of the home which is not the result of
a transfer of the property for less than the fair market value within 2 years
before institutionalization.
(4)
"Estate" means all real and personal property and other assets included within
an individual's estate, as defined for purposes of State probate law.
(5) "Group health plan" means any plan,
including a self-insured plan, of or contributed to by an employer to provide
health care, directly or otherwise, to the employer's employees, former
employees, or their families.
(6)
"Incorrect payment of benefits" means payment of benefits to which a recipient
is not entitled.
(7) "Lawfully
residing in the home" means residing in the home with the permission of the
owner or, if under guardianship, the owner's legal guardian.
(8) "Real property" means property which is
fixed or immovable, such as land or a building.
(9) "Residing in the home on a continuous
basis" means using the home as the principal place of residence.
(10) "Substantial hardship" means the
Department's estate claim will result in the sale or transfer of the real
property owned by the decedent and that the sale or transfer will result in the
removal from the property of a dependent who:
(a) Resided in the property on the date of
the decedent's death;
(b) Has
resided in the property continuously for a period beginning at least 2 years
before the decedent's death; and
(c) Cannot provide an alternate
residence.
A-1. The Department shall make a claim against income or resources, or both, of a recipient for benefits correctly paid, or to be paid, under the following circumstances:
(1) Under a court order;
(2) In any situation in which a recipient has
a cause of action against any person for medical expenses arising from that
cause of action; or
(3) As a result
of payment by the Department for services for which health care coverage was
available to a recipient.
A-2. Liens.
(1) Incorrect Payments. Following a court
judgment which has determined that benefits were incorrectly paid for a person,
the Department shall impose a lien against the person's property, both personal
and real, before the person's death, on account of Medical Assistance claims
paid or to be paid on the person's behalf.
(2) Correct Payments. Except as provided
under §A-2(3) of this regulation, the Department shall impose a lien
against the real property of a person, before the person's death, on account of
Medical Assistance claims paid or to be paid on that person's behalf under the
following circumstances:
(a) The person owns
real property, is a patient in a long-term care facility, and is required, as a
condition of receiving Medical Assistance services, to spend for costs of
medical care all but a minimal amount of his income required for personal
needs; and
(b) The Department has
determined, after notice and opportunity for a hearing, that there is no
reasonable expectation that the person can be discharged from the long-term
care facility and return home.
(3) Restrictions on Placing a Lien. The
Department may not impose a lien on the home of an institutionalized individual
under §A-2(2) of this regulation if any of the following individuals
lawfully reside in the home. The institutionalized individual's:
(a) Spouse;
(b) Child as defined in Regulation .02B of
this chapter;
(c) Son or daughter
who is blind or disabled as defined in Regulation .05D and E of this chapter;
or
(d) Sibling, who has an equity
interest in the home and who was residing in the home for a period of at least
1 year immediately before the date of the institutionalized person's admission
to a long-term care facility.
(4) Termination of a Lien. Any lien imposed
on a person's real property under §A-2(2) of this regulation will dissolve
if the person is discharged from a long-term care facility and returns to the
home.
(5) Delay in the Imposition
of a Lien.
(a) When the imposition of a lien
against a person's property is delayed because of the person's mental
incompetence, eligibility may be granted pending the appointment of a legal
representative for the person.
(b)
The effective date of the lien shall be the date eligibility was
granted.
A-3. Adjustments and Recoveries.
(1) The Department
shall seek recovery of Medical Assistance benefits correctly paid:
(a) From the estate of any individual who was
55 years old or older when the individual received Medical Assistance benefits;
and
(b) From the estate or upon
sale of the property on which a lien was imposed and which was owned by an
individual described under §A-2(2) of this regulation.
(2) The Department shall seek
recovery under §A-3(1) of this regulation of Medical Assistance benefits
correctly paid only:
(a) After the death of
the person's surviving spouse;
(b)
When the individual has no surviving child as defined in Regulation .02B of
this chapter;
(c) When the person
has no surviving son or daughter who is blind or disabled as defined in
Regulation .05D and E of this chapter; and
(d) In the case of liens imposed on a
person's home under §A-2(2) of this regulation, when there is no:
(i) Sibling of the person lawfully residing
in the home, who has resided there for a period of at least 1 year immediately
before the date of the person's admission to a long-term care facility and who
has lawfully resided there on a continuous basis since that time, or
(ii) Son or daughter of the person lawfully
residing in the home, who has resided there for a period of at least 2 years
immediately before the date of the person's admission to a long-term care
facility, who has lawfully resided there on a continuous basis since that time,
and who can establish to the Department's satisfaction that he or she provided
the care that permitted the person to reside in the home rather than in the
facility.
(3)
The Department may not seek recovery from the estate of a deceased individual
under §A-3(1) and (2) of this regulation if, in the Department's judgment,
substantial hardship exists.
(4)
The Department may not seek recovery from the estate of a deceased individual
for Medical Assistance payments of Medicare premiums, copayments, or
deductibles.
(5) The Department may
not seek recovery from the estate of a deceased individual to the extent of the
value of LTC partnership policy benefits furnished to the individual up to the
time of death. B.-F. (text unchanged)
B. The Department shall accept reimbursement when voluntarily offered by a current or former recipient or someone acting on his behalf.
C. Repealed.
D. Extended Benefits Pending a Hearing Decision.
(1) The local department of social
services shall refer to the Medical Care Compliance Administration for
reimbursement consideration all cases in which:
(a) A recipient received extended benefits
pending a hearing and decision by the hearing officer; and
(b) The hearing officer affirmed the decision
of the local decision of the local department of social services.
(2) The Medical Care Compliance
Administration shall institute procedures to recover the cost of any
expenditures made on behalf of a recipient in cases identified in §D(1) of
this regulation. This provision may not apply to a person who requested a
hearing and extended benefits resulting from a bona fide belief that the local
department of social services has taken an adverse action
erroneously.
E. The local department of social services shall refer to the Medical Care Compliance Administration for investigation and other appropriate action all cases in which a recipient has received coverage erroneously as a result of the action or inaction of the recipient, representative, or person acting responsibly for the recipient.
F. The Department shall investigate and take appropriate action in all cases in which eligibility has been incorrectly established as a result of the action or inaction of a recipient, representative, or person acting responsibly for the recipient.
G. Assignment of Benefits, Release of Information, and Requirement of Cooperation by Recipient in Recovery Procedures.
(1) A recipient of
Medical Assistance is deemed to have created an authorization for the release
to the Department of all data, records, and information by insurance companies,
nonprofit health service plans, providers of medical care, employers, unions,
governmental agencies, and any other agencies, organizations, or individuals
necessary for the Department's pursuit of third-party reimbursement. The
authorization extends to all information relevant to third-party reimbursement
or third-party health care coverage.
(2) The local department of social services
shall take reasonable measures to identify and report to the Department on a
form designated by the Department all possible third-party benefits available
to persons determined eligible for Medical Assistance.
(3) The Department shall collect available
benefits from third parties determined liable to pay for services received
under Medical Assistance.
(4) A
person who receives medical services that were or will be paid for by the
Program is deemed to have made assignment to the Department of:
(a) His own rights to any medical care
support available under an order of a court or an administrative agency, and
any third-party payments for medical care; and
(b) The rights of any other individual
eligible under the plan, for whom he can legally make an assignment.
(5) Assignment of rights to
benefits does not include assignment of rights to Medicare benefits.
(6) An applicant or recipient of Medical
Assistance shall cooperate in:
(a)
Establishing paternity for a child born out of wedlock for whom he can legally
assign rights; and
(b) Obtaining
medical care support and payments for himself and any other individual for whom
he can legally assign rights.
(7) Waiver.
(a) The Department shall waive the
requirements in §G(6) of this regulation if the Department, through the
local department of social services, determines that the individual has good
cause for refusing to cooperate.
(b) With respect to establishing support
paternity of a child born out of wedlock or obtaining medical care and payments
for a child for whom the individual can legally assign rights, the Department,
through the local department of social services, shall find that cooperation is
against the best interests of the child if it is reasonably anticipated that
cooperation will result in:
(i) Physical harm
to the child for whom support is to be sought;
(ii) Emotional harm to the child for whom
support is to be sought;
(iii)
Physical harm to the parent or caretaker relative with whom the child is living
which reduces the person's capacity to care for the child adequately;
or
(iv) Emotional harm to the
parent or caretaker relative with whom the child is living, of such nature or
degree that it reduces the person's capacity to care for the child
adequately.
(c) If at
least one of the following circumstances exists, and the Department, through
the local department of social services, believes that because of the existence
of that circumstance, in the particular case, proceeding to establish paternity
or secure support would be detrimental to the child for whom support would be
sought, the Department, through the local department of social services, shall
find that cooperation is against the best interests of the child:
(i) The child for whom support is sought was
conceived as a result of incest or forcible rape;
(ii) Legal proceedings for the adoption of
the child are pending before a court of competent jurisdiction; or
(iii) The applicant or recipient is currently
being assisted by a public or licensed private social agency to resolve the
issue of whether to keep the child or relinquish him for adoption, and the
discussions have not gone on for more than 3 months.
(d) If the Department of Human Resources has
made a finding that good cause for refusal to cooperate does or does not exist,
the Department shall adopt that finding as its own for this purpose.
(e) With respect to obtaining medical care
support and payments for an individual in any case not covered by §G(7)(b)
or (c) of this regulation, the Department, through the local department of
social services, shall find that cooperation is against the best interests of
the individual or other person to whom Medical Assistance is being furnished,
if it is reasonably anticipated that cooperation will result in reprisal
against, and cause physical or emotional harm to, the individual or other
person.
(8) The
Department, through the local department of social services shall:
(a) Deny or terminate eligibility for any
applicant or recipient who refuses to cooperate as required under §G(6) of
this regulation unless cooperation has been waived;
(b) Provide Medical Assistance to any
individual who:
(i) Cannot legally assign his
own rights, and
(ii) Would
otherwise be legally eligible for Medical Assistance but for the refusal by a
person legally able to assign his rights or to cooperate as required by this
regulation.
(9) The assignment created by this regulation
shall be effective as long as the recipient is eligible for Medical Assistance
and remains effective for all services paid by the Program during this period
of eligibility, and for those services which were erroneously provided to
ineligible persons and paid for by the Program.
H. An applicant for, or recipient of, Medical Assistance shall enroll, unless unable to do so on the applicant's own behalf, in a group health plan when the enrollment is determined by the Department to be cost-effective.
I. Premiums may not be paid for employer group health insurance plans under the following circumstances:
(1) The insurance plan is that
of an absent parent;
(2) The
premium is used to meet a spend-down obligation; or
(3) The insurance plan is designed to provide
coverage only for a temporary period of time, less than 6 months, unless the
household's anticipated medical expenditures are enough to make the policy
cost-effective.
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