Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.81 - Increased Community Services (ICS) Program
Section 10.09.81.03 - Participant Eligibility
Universal Citation: MD Code Reg 10.09.81.03
Current through Register Vol. 51, No. 19, September 20, 2024
A. General Requirements.
(1) To be eligible for
participation in the ICS Program, an applicant or participant shall be
determined by the Department to meet the conditions of §§B"E of this
regulation.
(2) A participant's
eligibility for ICS services shall be reevaluated by the Department every 12
months or more frequently if needed due to a significant change in the
participant's condition, needs, or financial status.
(3) The Department shall have 45 days from
the date of a complete application to make an eligibility
determination.
B. Technical Eligibility. To be eligible for the services covered under this chapter, an applicant or participant shall be determined by the Department to meet the technical eligibility criteria for ICS services if the individual:
(1) Had been living in a nursing facility at
the time of application and for at least the last 6 months before the date of
application and meets all eligibility requirements before transitioning into
the community;
(2) Had been
eligible for Medicaid for at least 30 consecutive days immediately before being
enrolled in the ICS Program;
(3) Is
not otherwise eligible for services covered under:
(a) The authority of § 1915(c) of Title
XIX of the Social Security Act; or
(b) The Programs of All-Inclusive Care for
the Elderly under COMAR 10.09.44;
(4) Is at least 18 years old;
(5) Has a plan of service that:
(a) Includes Medical Assistance and ICS
services necessary to safely serve the participant in the community;
and
(b) Is determined by the
Department to cost less than the cost to Medicaid if the individual were to
remain in the institution;
(6) Is offered the choice between ICS and
nursing facility services;
(7)
Chooses, or the individual's authorized representative chooses on the
individual's behalf, to receive ICS services;
(8) Is being discharged from a nursing
facility into ICS services in the community and would be institutionalized in a
nursing facility if not for the ICS services;
(9) Resides in a home, as defined under
Regulation .02B of this chapter; and
(10) Uses at least one ICS service within a
12-month period.
C. Medical Eligibility.
(1) An applicant shall
be determined by the Department's utilization control agent to need nursing
facility services covered under COMAR 10.09.10.
(2) Every 12 months, or more frequently if
determined necessary by the Department due to a significant change in the
participant's condition or needs, AERS shall revaluate the participant to
verify the continued need for nursing facility services.
D. Financial Eligibility. An ICS participant shall:
(1) Without regard to any assets of a
spouse, meet the resource limit for Long-Term Care Medical Assistance set forth
in COMAR 10.09.24.08M;
(2) Receive income, after all available
disregards and exclusions set forth in COMAR
10.09.24.07LL and
10.09.24.07JL,
without regard to any income of a spouse, that exceeds 300 percent of the
current monthly Supplemental Security Income payment rate, known as the Federal
Benefit Rate (FBR);
(3) Pay to the
Department an assessment fee equal to the amount by which income, after all
available disregards and exclusions set forth in COMAR
10.09.24.07LL and
10.09.24.07JL,
exceeds 300 percent of the FBR, as follows:
(a) The initial assessment shall be paid to
the Department not later than 15 days from the date of the assessment invoice
sent by the Department to the participant, unless the exception in §D(4)
of this regulation applies;
(b)
Subsequent assessments shall be paid on or before the last day of the month on
which the assessment invoice is sent to the participant by the Department;
and
(c) If a participant receives a
past due notice, the participant has 15 days from the date of the notice to
remit payment; and
(4)
Be allowed an exception to the initial monthly assessment if discharged from
the nursing facility on a date other than the first of the month, in which case
the participant shall be required to pay the first assessment before the first
day of the first full month of ICS participation.
E. Medical Assistance Eligibility.
(1) An individual is not eligible to receive
ICS services during a penalty period under COMAR
10.09.24.08L -1
or 10.09.24.08L -2
due to disposal of assets or establishment of a trust.
(2) All provisions of COMAR 10.09.24 which
are applicable to aged, blind, or disabled institutionalized persons are
applicable to ICS applicants and participants, with the following exceptions:
(a) COMAR
10.09.24.06B(2)(a)(ii);
(b) COMAR
10.09.24.08G(1);
(c) COMAR
10.09.24.08H;
(d) COMAR
10.09.24.10B(2)"(3);
(e) COMAR
10.09.24.10C;
(f) COMAR
10.09.24.10D(2)(a),
(b), and (h);
(g) COMAR
10.09.24.10D(3)"(6);
(h) COMAR
10.09.24.10D
-1B(1);
(i) COMAR
10.09.24.10D
-1B(4);
(j) COMAR
10.09.24.10D
-1B(7);
(k) COMAR
10.09.24.10D
-1C(3)(a); and
(l) COMAR
10.09.24.15A
-2(2).
F. Cost of Care.
(1) For a participant whose home is an
assisted living facility, the Department shall reduce its monthly payment for
assisted living services by the amount remaining after deducting from the
individual's total nonexcluded monthly income the following amounts in the
following order:
(a) A personal needs
allowance, consisting of the amount established in accordance with COMAR
10.09.24.10D(2)(c)
and the assisted living provider's monthly charge to the participant for room
and board; and
(b) Incurred medical
expenses in accordance with COMAR
10.09.24.10D(2)(f) and
(g).
(2)The Department shall determine the amount
of available income to be paid by a participant towards the cost of assisted
living services.
(3) The
participant shall pay the assisted living services provider directly for the
participant's cost of care and room and board.
G. Participant Cap and Registry for ICS Participation.
(1) The Department shall
establish a cap, approved by the federal Centers for Medicare and Medicaid
Services (CMS), on the number of participants who may receive the services
covered under this chapter at any one time, based on available State and
federal funding.
(2) Eligible
individuals shall be enrolled in the ICS Program on a first-come, first-served
basis until the participant cap is reached.
(3) Once the CMS-approved participant cap is
reached, a registry of applicants shall be established by the Department on a
first-come, first-served basis.
H. Termination of Participation. A participant shall be terminated from participation in the ICS Program if the participant:
(1) No longer meets the
eligibility requirements specified in §§B-E of this
regulation;
(2) Voluntarily
chooses, or the participant's legal representative chooses on the participant's
behalf, to disenroll from the ICS Program;
(3) Moves to another state;
(4) Is an inpatient for 30 consecutive days
or more in a hospital or nursing facility; or
(5) Dies.
I. Re-Entering the ICS Program.
(1) If a participant is terminated from the
ICS Program, the same individual may re-enter the ICS Program, provided:
(a) That the individual meets all of the
requirements §§B-E of this regulation; and
(b) There is available capacity.
(2) If an individual cannot find a
community residence before his or her application expires, the individual may
reapply to the ICS Program as long as the individual continues to meet all
other eligibility requirements.
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