Md. Code Regs. 10.09.44.05

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.44.05 - Participant Eligibility

A. An eligible person shall:

(1) Reside in the PACE approved service area upon enrollment;

(2) Be 55 years old or older;

(3) Be able to be maintained in a community-based setting with the assistance of PACE at the time of enrollment without jeopardizing the participant's health or others' health or safety;

(4) Be determined by the Department to need the level of care required under the State Plan for coverage of nursing facility services for longer than 4 months; and

(5) Be willing to abide by the provision that requires participants to receive all health and long-term care services exclusively from the PACE provider and its contracted or referred providers.

B. Medical Assistance Eligibility Services.

(1) Medical Assistance eligibility for services under this chapter is determined under this regulation and applicable sections of COMAR 10.09.24, as cited in §B(2)-(4) of this regulation.

(2) Categorically Needy. An individual is eligible for services under this chapter as categorically needy if the individual is receiving Medical Assistance as:

(a) A recipient of Supplemental Security Income (SSI);

(b) A member of a low income family with children, as described in § 1931 of the Social Security Act; or

(c) Any other type of categorically needy person in accordance with COMAR 10.09.24.03B.

(3) Optionally Categorically Needy.

(a) An individual is eligible for services under this chapter as optionally categorically needy in accordance with 42 CFR § 435.217, if the individual's countable:

(i) Income does not exceed 300 percent of the applicable payment rate for SSI; and

(ii) Resources do not exceed the SSI resource standard for one individual.

(b) For the purpose of determining Medical Assistance eligibility for the optionally categorically needy:

(i) The individual is treated as an assistance unit of one individual; and

(ii) Countable income and resources are determined based on the rules for income and resources set forth in COMAR 10.09.24 as applicable to an aged, blind, or disabled individual who is institutionalized, with the exceptions in §B(3)(g) of this regulation.

(c) An individual is not eligible under §B(3) of this regulation if a disposal of assets or establishment of a trust or annuity results in a penalty under COMAR 10.09.24, until such time as the penalty period expires.

(d) The spousal impoverishment rules in § 1924 of the Social Security Act and COMAR 10.09.24.10B -1 are applicable, except for the differences specified in this regulation.

(e) Medical Assistance eligibility shall be redetermined at least every 12 months.

(f) If the applicant or recipient is not aged, blind, or determined disabled by the Social Security Administration, the Department of Human Resources shall determine whether the applicant or recipient is technically eligible for Medical Assistance as a disabled person, in accordance with COMAR 10.09.24.05E.

(g) All provisions of COMAR 10.09.24 which apply to an aged, blind, or disabled individual who is institutionalized are applicable to applicants and participants under this chapter who are considered optionally categorically needy, with the following exceptions in full or in part:

(i) COMAR 10.09.24.04J(1)-(3);

(ii) COMAR 10.09.24.04K;

(iii) COMAR 10.09.24.06B(2)(a)(ii);

(iv) COMAR 10.09.24.08G(1);

(v) COMAR 10.09.24.08H;

(vi) COMAR 10.09.24.09H;

(vii) COMAR 10.09.24.10H; and

(viii) COMAR 10.09.24.10H -1.

(h) Home Exclusion. The home, as defined in COMAR 10.09.24.08B, is not a countable resource under §B(3) of this regulation if it is occupied by the applicant or participant, the applicant's or participant's spouse, or any one of the following relatives who are medically or financially dependent on the applicant or participant:

(i) Child;

(ii) Parent; or

(iii) Sibling.

(i) Medical Assistance eligibility shall be determined by the Department within 45 days after the Department or its representative receives a signed application according to COMAR 10.09.24.04J(3)-(10).

(4) Post-Eligibility Determination of Available Income for Optionally Categorically Needy.

(a) The countable monthly income considered for the post eligibility determination is calculated in accordance with §B(3) of this regulation and COMAR 10.09.24 for institutionalized aged, blind, or disabled individuals, except that the income disregards specified in COMAR 10.09.24.07LL are not applied.

(b) For individuals eligible under §B(3) of this regulation who reside in a licensed assisted living facility, the Department shall calculate a client contribution towards the cost of services under this chapter, based on the amount remaining after deducting from the individual's countable monthly income the following amounts in the following order:

(i) A personal needs allowance of $60;

(ii) A spousal or family maintenance allowance in accordance with COMAR 10.09.24.10D(2)(b); and

(iii) Incurred medical expenses as specified in COMAR 10.09.24.10D(2)(d) and (e).

(c) For individuals who reside in an assisted living facility whose contribution toward the cost of service is calculated under §B(4)(b) of this regulation, the provider shall collect the participant's available income. The amount collected under this paragraph may not exceed the monthly capitation amount under this chapter for the participant.

(d) For individuals eligible under §B(3) of this regulation who reside in a long-term care facility, the Department shall calculate a client contribution towards the cost of services under this chapter, based on the amount remaining after deducting from the individual's countable monthly income the following amounts in the following order:

(i) A personal needs allowance in accordance with COMAR 10.09.24.10D(2)(a);

(ii) A spousal or family maintenance allowance in accordance with COMAR 10.09.24.10D(2)(b);

(iii) A residential allowance in accordance with COMAR 10.09.24.10D(2)(c); and

(iv) Incurred medical expenses as specified in COMAR 10.09.24.10D(2)(d) and (e).

(e) For individuals who reside in a long-term care facility whose contribution toward the cost of service is calculated under §B(4)(d) of this regulation, the provider shall collect the participant's available income.

C. Enrollment shall be on a voluntary basis, without respect to race, age greater than the lower limit required, creed, sex, color, national origin, marital status, or physical or mental handicap.

D. An individual is not eligible for enrollment in PACE, regardless of whether the individual is otherwise eligible for benefits under the Program, if the individual is:

(1) Living outside the PACE provider's service area;

(2) Not included in the PACE provider's target population specified in the PACE Program Agreement; or

(3) Enrolled in:

(a) A managed care organization contracting with the Department;

(b) A Medicaid home and community-based services waiver under § 1915(c) of the Social Security Act;

(c) Rare and expensive case management (REM) under COMAR 10.09.69; or

(d) A Medicaid capitated program that includes nursing facility or community-based long term care services.

Md. Code Regs. 10.09.44.05

Regulations .05 adopted as an emergency provision effective November 1, 2002 (29:25 Md. R. 1979); adopted permanently effective April 28, 2003 (30:8 Md. R. 540)