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Manual Overview

The Maryland State Medical Assistance (MA) Manual was developed to assist Case Managers (CMs) with determining eligibility for MA for the State of Maryland. The MA Manual is a supportive guide for Local Departments of Social Services (LDSS), Local Health Departments (LHD), and other governmental and non-governmental entities.

It provides a clear statement for the State of Maryland policies and procedures for eligibility for MA which has been printed to date. The policies and procedures described here are supported by Maryland‟s MA state plan, which has been approved by the Centers for Medicare & Medicaid Services (CMS) and embodied in the Code of Maryland Regulations (COMAR 10.09.24).

The Manual embodies 16 chapters with table of contents and objectives in the beginning of each section, attachments and examples within each section, Frequently asked Questions (FAQs) and Answers at the end of each section, and COMAR located in the back of the entire Manual. All applicable statutes and regulations should be referenced as needed for more detailed information regarding its usages. In order to obtain information regarding a particular topic, one can find it in the following ways:

 Refer to the Table of Contents;

 Refer to the Code of Maryland Regulations (COMAR 10.09.24);  Check the individual section content and objectives;  Reference the Frequently Asked Questions (FAQs) and Answers at the end of each section; or  Check updated manual releases.

Goals for this Manual 1. Provide a clear understanding of the Maryland MA program and your role within the eligibility determination process; and 2. Provide a quick guide to help you find answers to questions you may have about MA eligibility. The online version of this manual can be downloaded in its entirety. It may also be downloaded in sections on the State website at http://dhmh.maryland.gov.

The State of Maryland MA Manual was developed by the Office of Eligibility Services.

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Program Description

Medical Assistance, also called MA or Medicaid, is a joint federal and state program, authorized under Title XIX of the Social Security Act, which provides health care benefits, including long- term care coverage, to low-income individuals who qualify. It is administered by the state and pays most medical bills with both federal and state funds. The Maryland Department of Health and Mental Hygiene (DHMH) provide Medicaid coverage to individuals determined to be categorically needy or medically needy. Medicaid coverage is automatically granted to individuals receiving other public assistance, including Supplemental Security Income (SSI), Temporary Cash Assistance (TCA), and Foster Care. These individuals are said to be “categorically needy eligible.” Low-income families, children, persons younger than 21, caretaker relatives other than parents, pregnant women, and aged, blind, or disabled adults may also qualify for Medicaid. An individual can have private health insurance and still be eligible for Medicaid. Medicaid is payer of last resort. The eligibility rules vary for different groups of persons and the kinds of medical care covered may vary from group to group. If a person needs help paying for his/her own or family member‟s medical bills, he/she should fill an application on-line or at the LDSS to find out about his/her MA eligibility.

Benefits and eligibility requirements are the same across the state. General Program Requirements In order to qualify for this benefit program, you must be a resident of the State of Maryland and meet federal citizenship requirements. Automatic Medical Assistance as a State Option The Personal Responsibility and Work Opportunity Act of 1996 (PRWORA) eliminated the requirement for automatic “categorical” MA eligibility for recipients of TCA. Instead, states were given the option of providing automatic MA Eligibility to recipients of TCA. Maryland has chosen this option. This means that TCA recipients will continue to automatically receive MA, by state option rather than Federal requirement.

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Public Information Provision of Public Information If anyone requests public information about MA policies and procedures, DHMH must provide the information either orally or in writing. Information must be provided about the: MA eligibility requirements, including the income and resource limits, and the policies related to spend-down of over-scale income and reduction of over-scale resources; Available MA services; and The applicant‟s or recipient‟s (A/R‟s) and representative„s rights and responsibilities. DHMH publishes fact sheets and brochures and a website about MA at: http://mmcp.dhmh.maryland.gov. Information about MA eligibility is also available by calling the DHMH Division of Eligibility Services: 410-767-1463 or 1-800-492-5231 ext.1463. HIPAA Privacy

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require the use of standard electronic health transactions by health insurance plans; including private, commercial, Medicaid and Medicare, healthcare clearinghouses and healthcare providers. The primary intent of the law is to allow providers to meet the data needs of every insurer electronically with one billing format using standardized healthcare industry data and code sets. Centers for Medicare & Medicaid Services (formerly known as Health Care Financing Administration) Common Procedure Coding System (HCPCS) are the specified code set for procedures and services. Additional information on HIPAA can be obtained from the Department‟s web site at http://dhmh.maryland.gov/hipaa.

MARYLAND MEDICAL ASSISTANCE PROGRAM ELIGIBILITY MANUAL (COMAR 10.09.24) TABLE OF CONTENTS Manual Overview………………………………………………………………………......................100

Goals for the Manual…………………………………………………………………………………100

Program Description………………………………………………………………………………….101

Public Information…………………………………………………………………............................102

HIPAA Privacy………………………………………………………………………………………..102

Section 200 Definitions………………………………………………... ……………………………..200

Section 300 Coverage Groups………………………………………………………………..............300

Section 400 Application Requirement ………………………………………………………............400

Section 500 Non-Financial Eligibility Requirements ………………………………………............500

Section 600 The Assistance Unit……………………………………………………………..............600

Section 700 Income …………………………………………………………………………..............700

Section 800 Resources ………………………………………………………………………..............800

Section 900 Determining Financial Eligibility for Non- Institutionalized Persons…………….....900

Section 1000 Eligibility for Institutionalized Persons…………………………………….............1000

Section 1100 Certification Periods…………………………………………………………............1100

Section 1200 Post- Eligibility Requirements………………………………………………............1200

Section 1300 Hearings ………………………………………………………………………...........1300

Section 1400 Fraud and Abuse ………………………………………………………………….....1400

Section 1500 Liens, Adjustments, and Recoveries………………………………………………..1500

COMAR……………………….………………………………………………………………….....1600

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200 State of Maryland Medical Assistance Manual Revised July 2012

Section 200 Definitions A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) "Aged" means a person who is 65 years old or older. (2) "Aid to the Permanently and Totally Disabled" means a former category of public assistance mandated under Title XIV of the Social Security Act, 42 U.S.C. §1351 et seq., and replaced by Title XVI of the Social Security Act, 42 U.S.C. §1381 et seq. (3) "Appeal" means a process by which an applicant, recipient, or representative obtains review of a decision, action, or inaction of the Department or the Local Department of Social Services (LDSS). (4) "Applicant" means a person whose signed application for Medical Assistance has been submitted to the Local Department of Social Services but has not received final action. This includes a person, who need not be alive at the time of application, whose application is submitted through a representative. (5) "Application" means the filing of a signed application form for Medical Assistance at the local department of social services or its designee. (6) "Application date" means the date on which a signed application is received by the local department of social services. (7) "Application form" means the form designated by the Local Department of Social Services to be completed, signed, and submitted to the local department of social services, or a designee, as an official application for Medical Assistance. (8) "Assistance unit" means one person, or a group of persons whose eligibility for Medical Assistance benefits is determined in conjunction with each other. (9) "Blindness" means a condition in which a person is certified by an ophthalmologist as having either central visual acuity of 20/200 or less in the better eye with correcting glasses, or a field defect in which the peripheral field has contracted to such an extent that the widest diameter of the visual field subtends an angular distance of no greater than 20 degrees. (10) Caretaker Relative. (a) "Caretaker relative" means a parent or other person related by blood, marriage, or adoption and living with and caring for an unmarried child younger than 21 years old who is deprived of parental support due to death, continued absence from the home, incapacitation of a parent, or unemployment of the principal wage earner parent. A parent whose absence is occasioned solely

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201 State of Maryland Medical Assistance Manual Revised July 2012

by reason of the performance of active duty in the uniformed service of the United States is not considered absent from the home. The following relatives and their spouses meet this definition: father, mother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew or niece, and persons of preceding generations as denoted by the prefix of grand, great, and great-great; persons who legally adopt a child or his parent as well as the natural and other legally adopted children of these persons; and other relatives of adoptive parents in accordance with State law. A caretaker relative retains his status as a caretaker relative when the only child or children in his custody receives SSI benefits. This is the only instance when a caretaker relative without children in an assistance unit qualifies as a caretaker relative. (b) "Continued absence from the home" means that the parent is out of the home, the nature of the absence either interrupts or terminates the parent's functioning as a provider of maintenance, physical care, or guidance for the child, and the known or indefinite duration of the absence precludes counting on the parent's performance of his function in planning for the present support or care of the child. (c) "Incapacitation" means that a parent has a mental or physical defect, illness, or impairment which eliminates the parent's ability to support or care for the child and is expected to last for a period of at least 30 days. (d) "Principal wage earner parent" means whichever parent, in a home in which both parents of a child are living, earned a greater amount of income in the period specified below: (i) For initial eligibility, the 24 months immediately preceding the month in which application is filed on the basis of the unemployment of a parent; (ii) For eligibility for each subsequent month of the certification period, the 24 months immediately preceding the current month. (e) Unemployed Parent. (i) "Unemployed parent" means the principal wage earner parent who: (aa) Has been unemployed for at least 30 days before the receipt of Medical Assistance; and (bb) Has not left a job or refused to seek or accept employment without good cause within 30 days of the date of application. (ii) The condition of unemployment is met when the parent is employed less than 100 hours per month; or is employed 100 hours or more per month, if the parent's work is intermittent and the excess hours are of a temporary nature, as evidenced by the fact that the work hours were under the standard for the two previous months and are expected to be under the standard during the next month. (10-1) "Carrier" means a:

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202 State of Maryland Medical Assistance Manual Revised July 2012

(a) Health insurer; (b) Non-profit health service plan; (c) Health maintenance organization; (d) Dental plan organization; and (e) Any other person included as a third party in Section 1902(a)(25)(A) of the Social Security Act, as amended by the Federal Deficit Reduction Act of 2005. (11) "Categorically needy" means aged, blind, or disabled persons, or families and children, who are otherwise eligible for Medical Assistance and who meet the financial eligibility requirements for FIP, SSI, or Optional State Supplement. (12) "Child" means an unmarried person younger than 21 years old. (13) "Chronic hospital" means an institution which falls within the jurisdiction of Health-General Article, §19-307(a)(1), Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01. (14) "Comprehensive care facility" means a nursing facility licensed as a comprehensive care facility pursuant to COMAR 10.07.02. (14-1) "Continuing care retirement community (CCRC)" means an entity that obtains certificate of registration issued by the Maryland Department of Aging in accordance with COMAR 32.02.01 and pursuant to its authority under Article 70B, Annotated Code of Maryland. (15) "Corrective Managed Care Program" means the program administered by the Division of Utilization and Eligibility Review of the Medical Care Compliance Administration which limits recipients who have abused or misused Medical Assistance benefits to access most covered services through a single primary medical provider and a single pharmacy. (16) "Department" means the Department of Health and Mental Hygiene, the single State agency designated to administer the Medical Assistance Program. (17) "Department of Human Resources" means the department of State government which administers the FIP program. (18) "Determination" means a decision regarding an applicant's eligibility for Medical Assistance. (19) "Disabled" means the inability to perform any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months.

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203 State of Maryland Medical Assistance Manual Revised July 2012

(20) "Eligibility technician" means an employee of the local department of social services responsible for determining eligibility of applicants and recipients. (20-1) "Emergency services" means services provided by a licensed medical practitioner after the onset of a medical condition manifesting itself by symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected by a prudent layperson, possessing an average knowledge of health and medicine, to result in: (a) Placing health in jeopardy; (b) Serious impairment to bodily functions; (c) Serious dysfunction of any bodily organ or part; or (d) Development or continuance of severe pain. (20-2) "Entrance fee" means a sum of money or other consideration, other than a surcharge that: (a) Is paid by a resident to a CCRC initially or in deferred payments, pursuant to a written continuing care agreement between the CCRC and the resident, which governs the use, treatment, and refund of the entrance fee; (b) Assures a resident of continuing care in the CCRC facility for a term of more than 1 year or for life; and (c) Is at least three times the weighted average of the monthly cost of the periodic fees charged to independent living and assisted living units. (21) "Extended care facility" means a nursing facility licensed as an extended care facility pursuant to COMAR 10.07.02. (21-1) "Family Investment Program (FIP)" means a category of public assistance mandated under Title IV-A of the Social Security Act, 42 U.S.C. §601 et seq. (22) "Hospital" means an institution which falls within the jurisdiction of Health-General Article, §19-307(a)(1), Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01, or is licensed according to applicable standards established by the state in which the hospital is located. (23) Income. (a) "Income" means any property or service received by a person in cash or in-kind which can be applied directly, or by sale or conversion, to meet basic needs for food, shelter, and medical expenses.

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204 State of Maryland Medical Assistance Manual Revised July 2012

(b) "Earned income" means payment received by a person in cash or in-kind as a result of employment, including self-employment. Earned income consists of wages, salaries, commissions, tips, and profit from self-employment. (c) "In-kind income" means support or benefits in the form of food or shelter, or both, received by a person. (d) "Unearned income" means all income which does not meet the definition of earned income. (24) "Family Investment Administration" means the administrative unit of the Department of Human Resources and its affiliated local departments responsible for determining an applicant's or recipient's eligibility for Public Assistance, Medical Assistance, and Medical Assistance, State-Only. (25) "Incurred medical expenses" means those paid or unpaid bills for medical care which are recognized under State law and are or will be the obligation of the applicant. (26) "Intermediate care facility" means a nursing facility which meets the standards for certification and participation in Title XIX and has entered into a provider agreement with the Department pursuant to COMAR 10.09.11. (27) "Intermediate care facility-mental retardation" means a nursing facility for the mentally retarded which meets the standards for certification and participation in Title XIX and has entered into a provider agreement with the Department pursuant to COMAR 10.09.11. (28) "Living together" means sharing a common household. (29) "Local department of social services (LDSS)" means the Baltimore City or a county social services department under the supervision of the Department of Human Resources. (30) "Long-term-care facility" means a skilled nursing facility, intermediate care facility, intermediate care facility—mental retardation, chronic hospital, tuberculosis hospital, or mental hospital. (31) "Mandatory State Supplement" means a cash payment a state is required to make under Section 212, P.O. 93-66 to an aged, blind, or disabled person to provide him with the same amount of cash assistance he was receiving under Old Age Assistance, Aid to the Permanently and Totally Disabled, or Public Assistance to the Needy Blind if his SSI payment is less than that amount. (31-1) "Maryland Medicaid Managed Care Program" means the Medicaid reform program established under COMAR 10.09.62—10.09.73, as authorized by Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland. (32) "Medicaid" means Medical Assistance provided under the State Plan approved under Title XIX of the Social Security Act.

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205 State of Maryland Medical Assistance Manual Revised July 2012

(33) "Medical Assistance (MA)" means the program administered by the State under Title XIX which provides comprehensive medical and other health-related care for eligible categorically and medically needy persons. (34) "Medical Care Compliance Administration" means the administrative unit of the Department responsible for ensuring that health care services provided to recipients are appropriate and effectively utilized. (35) "Medical Care Operations Administration" means the administrative unit of the Department responsible for maintaining a file of all eligible persons and paying providers of service. (36) "Health Systems Financing Administration" means the administrative unit of the Department responsible for establishing regulations, policies, and procedures for the Medical Assistance program. (37) "Medical institution" means an institution that: (a) Is organized to provide medical care, including nursing and convalescent care; (b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards; (c) Is authorized under State law to provide medical care; and (d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. (38) "Medically needy" means persons who are otherwise eligible for Medical Assistance, who are not categorically needy, and whose income and resources are within the limits set under the State Plan. (39) "Medicare" means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq. (40) "Mental hospital" means an institution which falls within the jurisdiction of Health-General Article, §19-307(a)(1), Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.04. (41) "Migrant worker" means a person who moves from place to place to harvest or process seasonal crops. (42) "Old Age Assistance" means a former category of public assistance mandated under Title I of the Social Security Act, and replaced by Title XVI of the Social Security Act, 42 U.S.C. §1381 et seq.

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206 State of Maryland Medical Assistance Manual Revised July 2012

(43) "One-time-only" means a time-limited certification. (44) "Optional State Supplement" means a cash payment made by a state to an aged, blind, or disabled person, under §1616 of the Social Security Act. (45) "Period under consideration" means the specified months which are assessed for determination of eligibility. (46) "Public Assistance" means cash assistance payments, including state supplementary payments, made to persons who are eligible for programs administered under Title IV-A or Title XVI of the Social Security Act. (47) "Public Assistance to the Needy Blind" means a former category of public assistance mandated under Title X of the Social Security Act and replaced by Title XVI of the Social Security Act, 42 U.S.C. §1381 et seq. (48) Public Institution. (a) "Public institution" means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. (b) "Institution" means an establishment that furnishes, in single or multiple facilities, food, shelter, and some treatment or services to four or more persons unrelated to the proprietor. (c) "Public institution" does not mean a medical institution, a skilled nursing facility, or a publicly operated community residence that serves no more than 16 residents. (49) Publicly Operated Community Residence that Serves No More Than 16 Residents. (a) "Publicly operated community residence that serves no more than 16 residents" means a facility that is publicly operated, serves no more than 16 residents, and offers services beyond food and shelter. (b) "Publicly operated community residence that serves no more than 16 residents" does not mean: (i) Residential facilities located on or adjacent to any large institution or multipurpose center; (ii) Educational or vocational institutions that primarily provide an approved or accredited program to some or all of their residents; (iii) Medical treatment facilities which provide medical care or remedial service on an inpatient basis; or (iv) Correctional or holding facilities which provide for persons who are prisoners, have been arrested or detained, or are held under court order as material witnesses or juveniles.

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207 State of Maryland Medical Assistance Manual Revised July 2012

(49-1) "Qualified alien" means an alien who: (a) Has been fully admitted for permanent residence under the Immigration and Nationality Act (INA); (b) Has been granted asylum under §208 of the INA; (c) Has been admitted into the United States as a refugee under §207 of the INA; (d) Has been paroled into the United States under §212(d)(5) of the INA for a period of at least 1 year; (e) Has had deportation withheld under §243(h) of the INA; or (f) Has been granted conditional entry under §203(a)(7) of the INA in effect before April 1, 1980. (50) "Recipient" means a person who is certified as eligible for Medical Assistance. (51) "Redetermination" means a determination regarding continuing eligibility of a recipient. (52) "Remedial service" means any service, other than a physician's service, provided within the scope of practice as defined by State law by a person licensed as a practitioner under State law. (53) "Resources" means accumulated personal wealth over which a person has the authority or power to liquidate his interest, including cash savings, savings accounts, certificates of deposit, money market certificates, checking accounts, stocks, bonds, cash value of life insurance, burial plots, prepaid burial plans, real property, personal property, mortgages, and mutual funds. (54) "Retroactive coverage" means the availability of coverage for incurred medical expenses covered under the State Plan for a period not to exceed 3 months before the month of application. (55) "Skilled nursing facility" means a nursing facility which: (a) Is licensed as a comprehensive care facility (SNF/CCF), or as an extended care facility (SNF/ECF), or both; (b) Meets the requirements for certification and participation in Title XIX of the Social Security Act as a skilled nursing facility; and (c) Has entered into a provider agreement with the Department pursuant to COMAR 10.09.10. (56) "Social Security Administration" means the administrative unit in the United States Department of Health and Human Services responsible for administering programs under Titles II, IV-A, IV-D, and XVI of the Social Security Act.

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208 State of Maryland Medical Assistance Manual Revised July 2012

(57) "Spend-down" means a procedure by which an applicant who is ineligible for Medical Assistance due to excess income becomes eligible by deducting incurred medical expenses from excess income. (58) "Spouse" means a person who has been determined to be the husband or wife of another person under State law or for the purposes of determining eligibility for Social Security benefits. (59) "State Plan" means a comprehensive written commitment by a Medicaid agency, submitted under §1902(a) of the Social Security Act, to administer or supervise the administration of a medical assistance program in accordance with federal requirements. (60) "Supplemental Security Income (SSI)" means a federally administered program providing benefits to needy aged, blind, and disabled individuals under Title XVI of the Social Security Act, 42 U.S.C. §1381 et seq. (61) "Third party" means a person, institution, corporation, public or private agency or organization who is or may be liable to pay all or part of the medical cost of injury, disease, or disability of an applicant or recipient. (62) "Title XIX" means the title of the Social Security Act, 42 U.S.C. §1396 et seq., which governs establishment of a medical assistance program for low income persons. (63) "Tuberculosis hospital" means an institution which falls within the jurisdiction of Health- General Article, §19-307(a)(1), Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01.

COMAR 10.09.24.03

300 State of Maryland Medical Assistance Manual Revised July 2012 Section 300 Table of Contents Coverage Groups 300.1 Introduction–Coverage Groups

300.2 Medicaid Categorically Needy (CN) Coverage

300.3 Medicaid Medically Needy (MN) Coverage 300.4 Coverage Group Tracks (a) Family and Children Coverage Groups (FAC) (F-Track) (b) Pregnant Women (c) Maryland Children‟s Health Program (MCHP) (P-Track) MCHP Premium (D-Track) (d) Foster Care & Subsidized Adoptions (E-Track) (e) Refugees (G-Track) (f) X02 Undocumented or Unqualified Immigrants- Emergency Medical Services (g) Aged, Blind, or Disabled (ABD) (S-Track) or Children or Adults in Long Term Care ((T-Track) Attachment A (Local Department of Social Service Contact List) Attachment B (Local Health Department Contact List) (h) Women‟s Breast and Cervical Cancer Health Program (WBCCHP) Attachment A- WBCCHP Coordinators Contact List (i) Qualified Medicare Beneficiaries (QMB) (j) Dually Eligible Persons (k) Specified Low-Income Medicare Beneficiaries (SLMB) Attachment A- 2012 Dual Eligible Standards (l) Disabled Adult Children (DAC) (m) Disabled Widowed Beneficiaries (DWB) (n) Qualified Disabled and Working Individuals (QDWI) Coverage Group (S06) (o) Family Planning Program (p) Children and Temporary Cash Assistance (TCA) adults in Long-Term Care Facilities (LTCF) 300.5 Pickle Amendment

Frequently Asked Questions (FAQs) and Answers

Objectives for Section 300 1. Define frequently used coverage groups; 2. Define Pickle Amendment; 3. How to apply and the eligibility criteria for each group.

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301 State of Maryland Medical Assistance Manual Revised July 2012

300.1 Introduction-Coverage Groups A coverage group is a group of people who meet specific criteria to receive Medical Assistance (also known as Medicaid or MA) or other benefits through Maryland‟s Medical Care Programs. Sometimes the only difference between coverage groups is a single criterion.

For example, children under the age of one are in one group, while those between one and six years of age are in another. Families whose income is within the medically needy income limit are in one group and those with income exceeding the limit (spend-downs) are in another. Consequently, there are many different coverage group codes to describe how recipients qualify for benefits. How many coverage group codes? There are 68 coverage group codes in the Maintenance Management Information System (MMIS-II). Each coverage group is identified by a code; one letter designating the “track,” followed by two numbers (e.g., F01). Some coverage group codes are assigned to recipients by a database program; Client Automated Resource and Eligibility System (CARES), as part of an eligibility determination that is used by Department of Health and Mental Hygiene (DHMH) and Department of Human Resources (DHR). Other codes originate within DHMH in order to identify recipients enrolled in programs that are not included in CARES. Generally, Case Manager (CM) does not need to know all 68 coverage groups but should be familiar with the tracks 300.2 Medicaid Categorically Needy (CN) Coverage Definition: The federally matched Medicaid (Title XIX) and CHIP (Title XXI) programs provide the broadest scope of medical coverage. Persons may be eligible for Categorically Needy (CN) only or may also be eligible for cash benefits under the Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF) programs. CN includes full scope coverage for Pregnant Women (PW), children, the aged, blind, and persons with disabilities.

Coverage Group: The following persons are eligible without having to file a separate application and are

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302 State of Maryland Medical Assistance Manual Revised July 2012

Covered as Categorically: o A person receiving Temporary Cash Assistance (TCA), SSI, Mandatory State Supplement, or Optional State Supplement. o A Pregnant Woman who has been denied TCA solely because she is not in her last trimester of pregnancy. o A family which has been denied TCA solely because the amount of the payment would be less than $10. o A Family terminated from TCA because of increased earnings or hours of employment: a) If a family loses TCA solely because of increased income from employment or increased hours of employment, MA shall be provided to all members of the family for a 4 month period if: 1) The family received TCA in three or more months of the six- month period immediately preceding the month in which it became ineligible for TCA; and 2) At least one, but not necessarily the same member of the family is employed throughout the 4 month period b) The 12 month period begins with the first month of TCA ineligibility.

The following persons shall apply for MA and, if determined eligible, are covered as CN:

o A person who is eligible for TCA, SSI, or Optional State Supplement benefits except for a requirement of those programs that is specifically prohibited under Title XIX. o A person who: In August, 1972, was entitled to Social Security Assistance, Survivors, and Disability

Insurance, and: 1) Was receiving TCA, Social Security, Aid to the Permanently and Totally Disabled, or Public Assistance to the Needy Blind; 2) Was not receiving TCA, Social Security, Aid to the Permanently and Totally Disabled, or Public Assistance to the Needy Blind but would have been eligible if he had applied; or 3) Would have been eligible for TCA, Social Security, Aid to the Permanent and Totally Disabled, or Public Assistance to the Needy Blind if he/she was not in a medical institution or intermediate care facility.

Eligibility Criteria:

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303 State of Maryland Medical Assistance Manual Revised July 2012 Children under age six whose family income is below 133% of the Federal Poverty Level (FPL); Pregnant Woman whose family income is below 250% of the FPL (services are limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care); SSI recipients in most States; Recipients of adoption or foster care assistance under Title IV of the Social Security Act; or Special protected groups (typically individuals who lose their cash assistance due to earnings from work or from increased Social Security benefits, but who may keep Medicaid for a period of time) 300.3 Medicaid Medically Needy (MN) Coverage Medically Needy (MN) is a federal and state funded Medicaid program for persons who are aged, blind, or with a disability; pregnant women; or children with income above CN limits. MN provides slightly less medical coverage than CN, and requires greater financial participation by the customer.

Coverage Groups: The following persons who apply for and meet the requirements of these regulations are covered as MN:

A Pregnant Woman who has been denied TCA solely because her income or resources exceed the cash assistance level; A person younger than 21 years old; A caretaker relative (and spouse); An aged, blind, or disabled person; and A person who was eligible as MN in December, 1973, on the basis of the blindness or disability criteria of aid to the Permanently and Totally Disabled or Public Assistance to the Needy Blind and who continues to meet current requirements except for blindness or disability criteria. Eligibility Criteria: The household‟s income is used to determine if they meet the standards for medically needy. If your assets are no more than the MN limits, but income exceeds the MN standard, you may “spend-down” to qualify for Medicaid coverage during a six-month period. The difference between the amount of your income and the eligibility standard is called excess income. Under the spend-down process, your application will remain in preserve until the end of the six-month period. If during that time you incur medical expenses, the amount of your medical bills can be deducted from your excess income.

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304 State of Maryland Medical Assistance Manual Revised July 2012 If you meet your excess income amount within the six-month period, you may be determined eligible for Medicaid for the remainder of the six-month period.

To qualify for Medicaid as “MN”, your assets (i.e. resources) must be no more than the cap for your household size (e.g. $2,500 for a household of one person). There is no spend-down process for assets. If a person or household is asset over-scale as of the first day of the month, the person or household is ineligible for the entire month. The individual or household will remain ineligible until the assets are reduced to below the MN limit through allowable means (such as daily living expenses or paying down expenses). The individual or household may then reapply for Medicaid. If the assets are transferred or disposed for less than full value within 60 months before applying for Medicaid, there may be a penalty of ineligibility for Long Term Care (LTC) or waiver applicants. 300.4 Coverage Group Tracks A track is a group of related coverage groups. Currently there are 11 tracks. The same eligibility rules are used for all coverage groups in the same track.

The most commonly used tracks are used below:

Families and Children (FAC) (F-Track) Children placed in foster care or subsidized adoptions (E-Track) Low income pregnant women and children in the Maryland Children‟s Health Program (MCHP) (P-track) Uninsured children under the age of 19 whose income is above 200% but below 300% of the Federal Poverty Level. (MCHP Premium) (D-Track) Aged, blind, or disabled individuals (ABD) (S-Track) Refugees (G-Track) Aliens (X02) Undocumented or Unqualified Immigrants LTC cases have their own tracks, ABD individuals (L-track) Children and TCA adults and Family LTC (T-track). FAC LTC spend-down group (T99). Note: This is for a child in LTC, who has monthly income so high that it exceeds the LTC facility‟s cost of care, and places the child in spend-down. While this rarely occurs, the group is needed because it is covered under the State Plan.

Knowing the basic requirements for each track enables the user to quickly understand a recipient‟s enrollment in a particular coverage group.

(a) Family and Children Coverage Groups (FAC) ( F-Track)

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305 State of Maryland Medical Assistance Manual Revised July 2012 FAC are low income families with dependent children or other eligible children under the age of 21 who meet the financial and technical eligibility requirements for the State‟s TCA Program, which replaced Aid to Families with Dependent Children (AFDC) effective October 1, 1996 are automatically eligible for Medicaid. Families consist of parent(s) (biological, step or adoptive) or other caretaker relatives and unmarried children living with them). An eligible pregnant woman also constitutes family, low-income families, or children. Medicaid may also be granted to families or individuals who would qualify for TCA benefits but did not apply, or who lost their TCA eligibility for one of the following reasons: Increased earnings or hours of employment; Loss of earned income disregards; Increased child support collections; Non-compliance with TCA work requirements; or Failing to meet another TCA non-financial requirement.

Where to apply

A customer may apply at their local department of social services (LDSS) (see Attachment A); A customer may apply at local health department (LHD) if they are applying for a child, family and children, or if pregnant or online at; www.Marylandsail.org.

Eligibility Criteria

Household includes a child under 21 years of age; Income that is below the Medically Needy Income Level (MNIL) for your household size; (Household may be eligible if the medical expenses that are owed are very high. This is called a "spend-down"). Able to provide proof of citizenship and identity or provide proof of Legal Permanent Residency.

Voluntary Withdrawal

An individual who has filed an application may voluntarily withdraw that application at any time. In this event, the application will remain the property of the LHD or LDSS. When an application is voluntarily withdrawn, customers may come back within the consideration period to reapply with their original application. This will prevent the CM from doing retro. Application Denial When an application is denied, a new application may be filed the following month.

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306 State of Maryland Medical Assistance Manual Revised July 2012 (b) Pregnant Women, (c) Maryland Children’s Health Program (MCHP) (P-Track) MCHP Premium (D-Track) The Maryland Children‟s Health Program (MCHP) gives full health benefits for children up to age 19 who are enrolled in D04 if their parent or caretaker relative is willing to pay the P- Track and MCHP monthly premium and if their household income is above $250% and at or below 300% of the FPL. In addition it covers Pregnant Women of any age who meets the income guidelines. MCHP enrollees obtain care from a variety of Managed Care Organizations (MCOs) through the Maryland Health Choice Program. The certification period for a child in MCHP is 12 months. Redeterminations for MCHP and MCHP Premium cases will be mailed every 12 months with the exception of Pregnant Women cases. There are no redeterminations for Pregnant Women since pregnancy status is not continuous. MCHP Eligibility Criteria An applicant must meet both technical and financial eligibility criteria for MCHP. Technical factors include permanent Maryland resident or (intent to stay), citizenship and identity or qualifying immigration status. Immigrants whose immigration status does not qualify them for full coverage may be eligible for services received to treat an emergency condition; As a condition for eligibility, the applicant (child or Pregnant Woman) must provide the LDSS or LHD with their Social Security number; Eligibility cannot be denied, delayed or discontinued pending the issuance of the Social Security number; Social Security numbers can be verified through the State Verification and Exchange System (SVES); Financial eligibility: family income is within income standards for the size of the family. Income standards are based on the FPL and change annually. Income of a Care Taker Relative Other than Parent (CTROP) is not counted when determining financial eligibility; To be eligible, children must be under age 19 and have a family income at or below 200% of the FPL for free coverage in MCHP; To be eligible as a Pregnant Woman, the woman of ANY AGE must be pregnant or in the first or second postpartum month and have family income at or below 250% of the FPL; Resource consideration is not considered when determining MCHP eligibility.

Application

A person who wishes to apply for MCHP must submit a signed application form or Eligibility Determination Document (DHR/FIA 9701) to their LHD/LDSS or Apply online at www.marylandsail.org

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307 State of Maryland Medical Assistance Manual Revised July 2012 The applicant may be assisted by the person of their choice including the local department staff. The date of application is the date on which a signed application form is received by the local department (mailed or hand delivered). Regarding processing application time limitations for the LHD, a decision shall be made promptly, but no later than 10 days from the date of application. As for the LDSS, a decision shall be made promptly, but not later than 30 days from the date of application. The certification period for a child in MCHP is 12 months.

Redetermination

Redeterminations for MCHP cases will be mailed every 12 months with the exception of pregnant women cases. There are no redeterminations for pregnant women since pregnancy status is not continuous. Voluntary Withdrawal An individual who has filed an application may voluntarily withdraw that application at any time. In this event, the application will remain the property of the LHD or LDSS. When an application is withdrawn, a new application may be filed the following month and a new period under consideration is established.

Application Denied

When an application is denied, a new application may be filed the following month. (d) Foster Care & Subsidized Adoptions (E-Track) The Title IV-E foster care and subsidized adoption program was created by U.S. Public Law 96- 272 as set forth in Title IV, Part E of the Social Security Act. The purpose of Title IV-E foster care program is to prevent the unnecessary placement of children from low-income families by offering states fiscal incentives for providing preventive services. The purpose of Title IV-E subsidized adoptions program is to ensure that “Special Needs” children who are difficult to place in adoptive homes do not remain in foster care solely for financial reasons. In Maryland, “Special Needs” is defined as any one of the following:

Age six or older after November 1984 or two years old prior to November 1984; A member of a minority race; A member of a sibling group; Physically or mentally handicapped or emotionally disturbed; A child with a high risk of physical or mental disease.

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308 State of Maryland Medical Assistance Manual Revised July 2012 The Centers for Medicare and Medicaid Services (CMS) approved changes in MA eligibility requirements for E-track children in out-of-home placements. Income and resources are no longer a factor of MA eligibility for foster care or subsidized adoption children in the E-track. Therefore, the only reason for a foster care child to be MA eligible in the State-only coverage group of E03 is if the child fails a technical factor of MA eligibility, such as citizenship or Social Security number (SSN). Non-IV-E eligible children in State subsidized adoptions are eligible in the federal category of E02 if they meet MA technical eligibility requirements and have special needs for medical, mental health, or rehabilitative care. E01 is for IV-E or SSI eligible foster care or subsidized adoption children. E02 is for non-IV-E foster care children or special needs subsidized adoption children who are not IV-E or SSI eligible, but meet the MA technical eligibility requirements. The State-only category of E04 is for all other children in State subsidized adoptions.

When the state places a child in foster care or subsidized adoption, it is imperative that the MA certification process is timely so that the child has immediate access to health care coverage. If there are unpaid medical bills for the child, retroactive eligibility should be determined for the three months prior to the date of MA E-track application. Good communication between the OHP service worker, FIA MA case manager, and IV-E specialist (who determines IV-E eligibility) at the LDSS is necessary to ensure prompt and correct MA coverage. This information provides uniform procedures to be followed by all local offices when processing E-track MA applications filed on behalf of a child in Out of Home Placement (OHP) (IV-E or State foster care and subsidized adoptions) when: The child is filing an initial MA-application and is not already active or pending in CARES for MA and/or other eligibility; or The child applicant is already a recipient in an active or pending Assistance Unit (AU), such as TCA, Food Stamps (FS), SSI, MA, or the Maryland MCHP. Eligibility for OHP is established by the DHR regulations found in COMAR 07.02.11. Federal funding of OHP services is governed by Title IV-E of the Social Security Act (SSA).

The E-track is only for foster care children committed by the courts to the custody of the DHR and for children receiving subsidized adoption services from DHR. The MA application for a foster care child must clearly indicate if parental rights have been terminated, because this triggers a child support referral. The procedures in this section are not applicable to children placed in foster care or adoption by private agencies or individuals, who should have their eligibility determined under the appropriate MA or MCHP coverage group other than the E- track. They are not eligible in the E-track. However, the E-track may include children who are dually committed to the custody of DHR and the Department of Juvenile Services (DJS), so long as the child is receiving foster care or subsidized services from DHR.

As long as children in the Kinship Care Subsidized Guardianship Waiver Program remain under the State‟s custody, they stay MA eligible in their E-track coverage group. Once guardianship is granted and the service case is closed, children in the Kinship Care Subsidized Guardianship Waiver Program must have their eligibility determined in the appropriate MA or MCHP coverage group other than the E-track. They are no longer eligible in the E-track. FIA Action

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309 State of Maryland Medical Assistance Manual Revised July 2012 Transmittal 01-02 dated 8/7/2000 addresses how to redetermine eligibility when the guardianship through the Kinship Care Program goes into effect for children previously certified in the E- track. Coverage Groups in the E-track for Children in State Out-of-Home Placements (Foster Care) or in Subsidized Adoptions. Note: The MA CM should not test for income or resources for any of the coverage groups in the E-track as a condition of MA eligibility, but should still test for technical MA eligibility. The MA CM should enter $1 for the foster care or subsidized adoption income and enter any child support, SSI, or SSDI income with a valid value of “ON” (“other non-countable”). The MA CM should narrate for each type of non-countable income that is entered and for any other of the child‟s reported income or resources of the child that are not counted for the E-track eligibility determination, but may be needed for a future application. Following is a description of the basic MA eligibility requirements for each coverage group in the E-track: E01: IV-E or SSI Children in Foster Care or Subsidized Adoption Federally matched MA is automatically provided, without a separate test for MA eligibility, to any child receiving adoption for foster care benefits who is either eligible under Title IV-E of the Social Security Act or SSI-eligible. Since CARES has little programming for E01, a case should only be pended in E01 if the MA CM confirms (through SVES, SDX, or SOLQ) that the child is receiving SSI benefits or if IV-E eligibility is confirmed by the LDSS IV-E specialist, not based on a presumption of SSI or IV-E eligibility. o If it is later found that an E02, E03, or E04 child is IV-E or SSI eligible, the MA CM should “J” Screen an existing E01 assistance unit (AU) or use “Add-A-Program” to establish an AU for the E01 coverage effective as of the 1st day of the month after the MA CM is notified of the IV-E or SSI eligibility. If a previous E01 AU is available, the MA CM could “J” Screen an existing E01 AU, if one was previously available. o OHP children who receive SSI are included in E01, rather than in the S02 Coverage group, even if they are not IV-E eligible. However, since CARES is programmed to deny an E01 application with SSI (“SI”) income, the Child‟s SSI income should be entered on the CARES UINC Screen with a valid value of “ON” for other non-countable income. The MA CM should fully narrate in CARES.

E02: Non-IV-E Foster Care and Special Needs Subsidized Adoption Federally matched MA is provided to foster care children who are not IV-E eligible but who do meet the MA technical eligibility criteria at COMAR 10.09.24.05 (Chapter V of the Medicaid Eligibility Manual), including the MA citizenship requirements. Non-IV-E children also qualify for E02 if they are receiving

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310 State of Maryland Medical Assistance Manual Revised July 2012 subsidized adoption services through the DHR, have special needs for medical, mental health, or rehabilitative care, and meet the MA technical eligibility requirements. Since CARES is programmed to apply the same medically needy financial rules for this group as for F98, the MA CM must assure that CARES does not deny an eligible OHP case for E02 due to failing financial eligibility criteria (see Section II).

E03: State Funded Foster Care The State funds full MA coverage for foster care children who are not federally eligible for E01 or E02. o Since CARES does not trickle properly to E03 from E01 or E02, the MA case manager should use “Add-A-Program” or “J” Screen an existing E03 AU and complete the eligibility process for an E03 AU if a foster care child is ineligible for E01 or E02. The MA CM must assure that a foster care child is in the appropriate coverage group, and is only in E03 if MA technical eligibility criteria are not met (e.g. SSN, citizenship). o If it is later determined that the child is IV-E or SSI eligible, the MA CM should “Add-A-Program” or “J” Screen an existing E01 AU and complete the eligibility process for an E01 AU. o If verifications later confirm that the non-IV-E foster care child meets the MA technical eligibility criteria in COMAR 10.09.24.05 (including citizenship requirements), the MA CM should “Add-A-Program” or “J” Screen an existing E02 AU and complete the eligibility process for an E02 AU.

E04 State Funded Subsidized Adoption

The State funds full MA coverage for children in State subsidized adoptions who are not federally eligible for E01 or E02.

o Since CARES does not trickle properly to E04 from E01 or E02, the MA CM should “Add-A-Program” or “J” Screen an existing E04 AU and complete the eligibility process for a E04 AU if a subsidized adoption child is ineligible for E01 or E02. o If it is later determined that the child is IV-E or SSI eligible, the MA CM should “Add-A-Program” or “J” Screen an existing E01 AU and complete the eligibility process for an E01 AU. o If verifications later confirm that the non-IV E subsidized adoptions child with special medical needs meets the MA technical eligibility criteria in COMAR 10.09.24.05 (including citizenship requirements), the MA CM should “Add- A-Program” or “J” Screen an existing E02 AU and complete the eligibility process for an E02 AU.

CARES Procedures Followed by MA CM for MA Eligibility Determinations in the E- Track

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311 State of Maryland Medical Assistance Manual Revised July 2012 (A) Notification by the Service Worker and IV-E Specialist

A service unit (SU), which shows the type of service for the child, is created for each child concerning foster care, kinship care, or subsidized adoption. This is based on the demographics, service information, and proper enumeration provided by the service worker. Either the existing Client ID is matched or, if there is no existing Client ID, a new one is created for the child.

The service worker promptly advises the FIA MA CM of a child in foster care or subsidized adoption who needs to be certified for E-track OHP MA eligibility. The MA CM is also informed if retroactive eligibility should be determined based on the child‟s living circumstances prior to the OHP application month (e.g., newborn abandoned in hospital, child living with parent(s) or caretaker relative, child in LTC facility for less than a full calendar month). The service worker acts as the child‟s representative for purposes of filing the MA application. The service worker must provide all available information and verifications requested by the MA CM, including related to retroactive eligibility and unpaid medical bills. The IV-E specialist provides information to the MA CM about the child‟s IV- E eligibility. The MA eligibility determination should not be delayed by the IV-E determination. If the child meets technical eligibility for MA and the IV-E specialist has not yet determined IV-E eligibility when the MA application is being processed and finalized, the MA CM should PEND the application under Medical Coverage group E02 and complete the eligibility determination process. If the child is later determined to be IV-E eligible, the MA CM should “Add-A-Program” or “J” Screen an existing E01 AU and complete the eligibility process for an E01 AU as of the 1st of the month after the MA CM is notified by the IV-E specialist.

(B) Screening and Pending the MA Case When the MA CM is notified by the service worker of a foster care or subsidized adoption child requiring an OHP MA eligibility determination: Perform an inquiry in CARES to research and determine if the child is a member of another AU as active, pending, closed or denied. Because the service AU has already been opened by the service worker, these cases should already be known to CIS, and a match should be made to the client on the database. Make every effort to screen the child for an existing Client ID to prevent assigning multiple IDs. If more than one ID exists, refer to CARES Bulletin 98-17, Multiple Client IDs, for how to close the duplicate ID. Note: When a child is adopted, there is actually a break with the old AU and Client ID number. The child may get a new Social Security number (SSN), also. Only if a complete break is not intended for the adopted child would the old SSN, AU, and Client ID be linked on CARES with the new identifiers.

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312 State of Maryland Medical Assistance Manual Revised July 2012 Screen the child in the appropriate E-track coverage group, using Option “J” on the AMEN Screen in CARES. o Use E01 only if it is confirmed that the child is IV-E or SSI eligible. o Use E02 for all other foster care or subsidized adoption placements. o CARES does not trickle properly from E01 or E02 to E03 or E04. Therefore, “Add-A-Program” or “J” Screen an existing AU for E03 if a foster care child is not eligible for E01 or E02. For a subsidized adoption child, “Add-A-Program” or “J” Screen an existing AU for E04 if the child is not eligible for E01 or E02. For instance, in option “J” screening for E02, use income type: SF-State subsidized Foster Care and include $1 as the payment amount on the CIRC screen. (C) Interview After properly screening and pending the child in the appropriate E-track MA coverage group, select option “O” to complete the “Interview” process on CARES. The MA CM should never bypass this step. Option “O” is necessary because the CARES system performs a “copy back” function of information between the ongoing month and the processing months. 1. An “interview” is conducted between the service worker and the MA CM through a paper application rather than face-to-face interview. The DHR/FIA CARES 9708 is used as the MA application. The MA CM is responsible for establishing and maintaining the MA case record. The MA CM enters the information into CARES for the E-track MA AU created during the “J” screening process. 2. For the E-track AU, be sure to enter the child‟s appropriate living arrangement code on the DEM1 screen. o If the child is either IV-E or SSI eligible, enter the living arrangement as: “SE” Subsidized Adoption, IV-E. o If the child is neither IV-E nor SSI eligible, enter the living arrangement as: “FC” Foster Care, Non IV-E; or “SA” State Subsidized Adoption, Non IV-E. o Do not use the valid value “AH”, At Home, for children placed in foster care or State subsidized adoption. o Complete all the necessary information to include Parental Status and the correlating Absent Parent screens, when applicable. o Use caution when processing Subsidized Adoption cases, because absent parent information is not necessary.

3. If there is an active AU with the child as a member in another program (e.g., TCA, FS), contact the Worker of Record for the TCA/FS/MA/MCHP case to request that the child be removed from the existing AU as of the end of the current month. The entire AU may need to be closed if there are no remaining TCA eligible children. If the child is removed from the existing AU

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313 State of Maryland Medical Assistance Manual Revised July 2012 historically to the beginning of the month of OHP, the family may have to repay TCA and/or FS assistance received on the child‟s behalf for that month. o If the child is active for MA in the month of OHP as a member of a TCA, MA, MCHP, and/or FS AU, change the living arrangement to “NO” on the child‟s DEM1 screen for the ongoing month. This includes SSI-eligible children. If the child is an active SSI AU (S02), the child‟s S02 AU must be closed then immediately processed under the E01 eligibility, in order to indicate foster care/subsidized adoption eligibility and to take advantage of the special HealthChoice rules and assistance for E-track children. o If the child is a member of a pending TCA, MA and/or MCHP AU in the month of OHP, make the living arrangement change effective the month of placement. o If the child is an active or pending FS-only AU in the month of OHP, change the living arrangement for the ongoing month. o For any of the above instances, two narrations must be completed on CARES. Narrate on the TCA, FS, or MA NARR screen from which the child is being removed, as well as the NARR screen of the E-track MA eligibility case.

If this is an initial MA application for a child who does not have an existing active or pending TCA, MA, MCHP, and/or FS AU, pend the appropriate E- track coverage, narrate, and determine eligibility as of the month of OHP.

4. Determine MA eligibility in the appropriate E-track coverage group, as follows:

Finalize MA eligibility as soon as possible (within the 30-day time Limitations), for either the current month or the ongoing month (see #3 above), even if the child support or IV-E eligibility information is not yet available. The child support information may be added later to the CARES screens when it becomes available. Any income from child support must be coded as “ON” so it will not affect the child‟s MA eligibility. If the child is SSI-eligible or confirmed as IV-E eligible by the IV- E specialist, the MA CM should finalize the case in E01, including closing an SSI-eligible child in S02. If the child is not eligible for IV-E or SSI or the IV-E specialist has not determined IV-E eligibility by the time that the MA CM finalizes the case, the MA CM should determine eligibility in E02. If the child is not eligible for E01 and E02, the MA CM should “Add-A-Program” or “J” Screen an existing AU for the State-only category of: o E03 if the child is receiving foster care assistance; or o E04 if the child is receiving subsidized adoption services.

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314 State of Maryland Medical Assistance Manual Revised July 2012 5. For the E-track AU, enter on CARES the appropriate address. The authorized representative screen is optional, but may also be completed.

For a foster care AU:

o On the ADDR screen, enter the LDSS address as the residential address, as well as the service worker information as dictated by your agency. The service worker will receive the MA card, HealthChoice enrollment materials (if E01 or E02), and all eligibility services.

For a subsidized adoption AU:

o On the ADDR screen, enter the child‟s adoptive home as the residential address. o Optional: On the AUTH REP screen, enter the adoptive parent as Authorized Representative, type “R2”, so that the adoptive parent will receive the MA card, HealthChoice enrollment materials (if E01 or E02), and all eligibility notices.

6. Presently, CARES requires that any child in the E-track have either foster care or State subsidized adoption income. Due to this requirement, enter $1.00 on the UINC screen for such unearned income. o Use income type “FC”, “DA” or “DD” for coverage group E01. o Use income type “SF” for E02 or E03. o Use income type “SS” for E02 or E04. Since income and resources are no longer a factor of MA eligibility for the E- track, enter no other countable income or resources for the child. Enter any child support, SSI, or SSDI income with a valid value of “ON” for other non- countable income, and fully narrate on both the NARR screen and the Remarks screen about the child‟s income and resources, which may be needed for a future application. CARES will deny any E-track AU once SSI (“SI”) income is entered. Therefore, to change the coverage group of an SSI child from S02 to E01, the amount of SSI income must be coded as “ON” (other non-countable income) on the UINC screen. In addition, $1 of foster care income must be entered on the UINC screen to ensure the child‟s technical eligibility on CARES for E01. Code the $1 income as “FC” (IV-E foster care) and process the case. Follow these procedures until you are notified that CARES has been modified. (D) Processing and Finalizing the Eligibility Determination

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315 State of Maryland Medical Assistance Manual Revised July 2012 Select options “P” Process and “Q” Finalize. Note that the eligibility tests for the E-track are different than the tests performed in other MA tracks, to facilitate prompt eligibility determinations. 1. For E01, there are virtually no eligibility tests on CARES for MA eligibility. For that reason, a child must not be screened in this coverage group unless the child is confirmed as SSI or IV-E eligible. A child screened in this coverage group will not fail MA eligibility, but will be certified as federally eligible, if processed correctly with the correct corresponding valid values. Until modifications are made to CARES for E-track coverage groups, trickling should not occur. 2. For E02, CARES applies the same eligibility tests as for the FAC MN category F98, which are no longer applicable for E-track eligibility. This is why countable resources and income should not be entered for E02, except for $1 of foster care or subsidized adoption income. The MA CM must assure that CARES does not deny an E02 AU for financial eligibility reasons. If CARES denies an E02 AU for MA technical eligibility reasons (e.g. SSN, citizenship), the MA CM should “Add A Program” or “J” Screen an existing AU for a State-only E03 AU for a foster care case or E04 AU for a subsidized adoption case. 3. If retroactive MA eligibility (for at most three months period to the month of E-track application) is requested due to the child‟s unpaid medical bills, the MA CM must obtain information from the OHP service worker about the child‟s living arrangements prior to the OHP application month. The coverage group used for determining retroactive eligibility is based on those living arrangements and other factors related to eligibility. 4. It is imperative that a child placed in foster care or subsidized adoption is certified as promptly as possible, and that there is no lapse of coverage when a child is removed from another AU to be opened in an E-track coverage group. a. It is optimal to remove the child from an active AU on one day and then to open eligibility in an E-Track coverage on the following day, since two transactions (close/open) do not read over to MMIS through the interface on the same day. Check MMIS to make sure that the transactions took effect. b. All E-Track applications must be finalized as soon as practicable, with or without complete verifications. o If the IV-E eligibility has not yet been determined by the IV-E specialist, finalize the case in E02. If the child is not eligible for E02 due to MA technical eligibility requirements (e.g. verifications, SSN, citizenship), “Add-A-Program” or “J” Screen an existing AU for the State-only category of E03 for a foster care case or E04 for a subsidized adoption case. o If there are any outstanding verifications, use the valid value of “OT” for “Other” so the E03 or E04 AU will process within the 30-day timeframe. o Create a 745 alert to check on requested or outstanding verifications within a month if the child was not eligible for: o E01 because the IV-E specialist has not yet determined IV-E eligibility; or o E02 due to lack of verifications related to technical MA eligibility (e.g., SSN, citizenship).

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316 State of Maryland Medical Assistance Manual Revised July 2012 c. If verification is later received that will enable certification in the federally matched coverage group, do “Add-A-Program” or “J” Screen an existing AU, close the original AU, and certify the child in either E01 (for SSI or IV-E foster care of subsidized adoptions) or E02 (for non-IV-E federally-eligible foster care or special needs subsidized adoption).

(E) Post Eligibility Activity Once the MA eligibility is certified on CARES, there is an overnight electronic transfer of the MA date from CARES to MMIS at DHMH. There is also an electronic transfer of absent parent data from CARES to the DHR Child Support Enforcement Administration. The service worker provides information about the absent parents for establishment of child support via the Eligibility Determination Document (EDD) from CARES or the CARES 9708 application form, during the processing of the OHP MA eligibility for foster care cases. If the child was not already MA eligible, DHMH issues the MA card and sends it to the service worker/unit for a foster care child or to the adoptive parent. If the child was already MA eligible, the MA CM should process a request for a duplicate MA card, to assure that the service worker or adoptive parent has the child‟s MA card. The request should be entered the day after the E-track MA eligibility is committed to CARES, using the following CARES procedures: From the CARES Main Menu, select option “L- Financial Mgmt Misc.” On “LMEN” selection option “S- MA Card Reissuance” and enter the Client ID. On the “MACR” (MA Card Reissuance) Screen, verify information and select “Y” in

the “Reissue Another Card” field. Press Enter to commit the request. CARES will return to “LMEN” with a message of “Insert Successful”. Update case narrative to reflect duplicate card request.

Children certified in E01 or E02 are eligible for HealthChoice. If the child is already enrolled in HealthChoice, the child remains with the same Managed Care Organization (MCO) and primary care provider (PCP) when the child‟s coverage group changes to the E-track. The child‟s representative should follow HealthChoice procedures to request a different MCO and/or PCP, if necessary. If the child is not currently enrolled in HealthChoice but was enrolled within the past 120 days, the child is auto-assigned to the previous MCO. The representative may request a change of MCO and/or PCP if necessary. If the child is neither currently enrolled in HealthChoice nor enrolled within the past 120 days, the enrollment broker will send the HealthChoice packet to the representative for selection of an MCO. Children eligible in the State-only coverage groups of E03 and E04 are not enrolled in HealthChoice, but receive the full range of MA covered services on a fee-for-service basis. However, because they are not HealthChoice eligible, they may not be enrolled in the Rare and Expensive Case Management (REM) program.

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317 State of Maryland Medical Assistance Manual Revised July 2012 Since CARES does not schedule an annual redetermination for an active E01 AU, the MA CM should set a 745 Alert to review the case at least every 12 months or sooner if the child is turning 21 within a year. Then, the MA CM must verify with the IV-E specialist that the IV-E eligibility continues and verify with the OHP service worker that the OHP service case is still open. NOTE: ALL CASE ACTIVITIES MUST BE FULLY NARRATED IN CARES.

Children Discharged from Out-of-Home Placements- Unscheduled Redetermination Eligibility Policies and CARES Procedures

I. Overview Federal and State regulations provide for the prompt redetermination of MA or Medicaid eligibility when there is a change in an individual‟s circumstances (e.g. living arrangements, income, and resources) that may result in the loss of or change in eligibility. Federal and State guidelines also stipulate that MA eligibility must continue until it has been determined that an individual no longer meets the criteria for continued eligibility. This information in this section sets forth policies and procedures, effective upon receipt, which is to be followed to facilitate the transition when a court rescinds a child‟s commitment to the State‟s custody and the child is discharged from an out-of-home placement (OHP). Each LDSS identifies which MA CM is responsible for implementing these policies and procedures. These procedures ensure that these children will continue to receive health care benefits, without a lapse in MA coverage, until they have been given the opportunity to reestablish continued eligibility under MA community or LTC or the Maryland Children‟s Health Program (MCHP). When a child is discharged from the OHP, the service worker at the LDSS is to give the child‟s parent or representative the child‟s Medical Care Program identification card, so the child may access MA services while the child‟s eligibility is being redetermined. If the child is enrolled in HealthChoice, the service worker is to inform the parent/representative of the child‟s MCO and PCP, and give the parent/ representative the child‟s MCO card. The MCO should then be provided with updated contact information about the child‟s head of household or emergency contact. Note: Scheduled redeterminations are required at least every 12 months for coverage groups E02, E03, and E04. Also, continued IV-E certification must be verified with LDSS‟s IV-E specialist at least every 12 months for coverage group E01. For E02, E03, and E 04, CARES automatically sends a redetermination package before the end of the certification period to the child‟s authorized representative before approving MA eligibility for another 12-month certification period. II. Procedures for MA case managers to initiate an Unscheduled Redetermination When a Child is Discharged from Out-of-Home Placement.

A. Medical Assistance eligibility may not be terminated based on a child‟s discharge from

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318 State of Maryland Medical Assistance Manual Revised July 2012 OHP. The child‟s OHP MA eligibility must continue until it has been determined that no other MA or MCHP eligibility exists. The MA CM at the LDSS must initiate an unscheduled redetermination. To facilitate this process and the child‟s transition from OHP to the community or a LTC facility, at most 90 days of extended MA eligibility will be granted after the child leaves the OHP, allowing time for completion of an unscheduled redetermination. The following applies when the MA CM is notified by the service worker that the child has been discharged from OHP to the community or a LTC facility (e.g. residential treatment center, hospital, nursing care facility, ICF/MR):

o The MA CM must change the redetermination end date to allow the case go to into the CARES automatic redetermination cycle. o Since the child is still in an E-track coverage group as a household of one, CARES will send the DHR/FIA CARES 9709 application, rather than the CARES 9701 or MCHP application. CARES will send the redetermined package with the current worker of record as the contact person and with that MA CM‟s district office (DO) as the completion of the unscheduled redetermination. o Income and resources will not be considered for the 90-day extension of MA eligibility but will be considered for the new period under consideration.

B. The MA CM follows these procedures to initiate the unscheduled redetermination when a child is discharged from out-of-home placement:

1. Leave the child as the head of household (HOH). Do not change information on the “DEM1” screen at this time, such as for living arrangements. Make no changes to the “UINC” screen for income or resources, except to delete the child‟s OHP income following the correct CARES processing steps or to make the changes indicated in #4 below for SSI income. Income and resources will not be considered for the extended period of MA eligibility after the discharge, only for the period under consideration for the unscheduled redetermination. 2. The “ADDR” Screen must be updated to reflect the discharge address indicated by the service worker as the child‟s new address. Delete any authorized representative information on the “AUTH REP” Screen for the OHP case. 3. After waiting at least a day to confirm that the address change has been updated on MMIS, the MA CM should process a request through CARES for a duplicate card to be issued to the discharge address for the child, using the following CARES procedures:

o From the CARES Main Menu, select option “L- Financial Mgmt Misc.” o On “LMEN” selection option “S- MA Card Reissuance” and enter the Client ID.

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319 State of Maryland Medical Assistance Manual Revised July 2012 o On “MACR” (MA Card Reissuance) Screen, verify information and select “Y” in the “Reissue Another Card” field. Press Enter to commit the request. o CARES will return to “LMEN” with a message of “Insert Successful”. o Update the case narrative to reflect the duplicate card request.

4. For E01: A redetermination cannot be initiated on an E01 assistance unit (AU). Therefore, the redetermination end date cannot be shortened/changed on the MAFI screen, and CARES will not send a redetermination packet. The following procedure should be used to redetermine eligibility when a child, who is certified as an E01, is discharged from OHP.

o Check SDX/SVES for whether the child is currently receiving Supplemental Security Income (SSI). o If the child is an SSI recipient, redetermine eligibility from E01 to S02 effective the 1st day of the next month, either through “Add A Program” or by “J” screening the child‟s old SSI S02 AU. o Review the ADDR screen to assure the correct mailing address. Update accordingly. o Change the Living Arrangement code on the DEM1 screen to “AH”. o Delete all unearned income on the UINC screen. o Add the child‟s SSI income back on the UINC screen as “SI”, and also enter any other verified countable income (e.g., child support, SSA, etc.) with the correct coding. o If necessary during processing, waive adverse action to assure that the begin date for S02 eligibility is effective the 1st date of the following month. o In order to avoid dual participation, the MA CM must “507” the pending S02 AU while processing the application month. o Finalize the S02 AU and review the eligibility begin date. o Fully narrate.

If the child does not receive SSI, change the coverage group from E01 to E02 so that an unscheduled redetermination can be initiated. This can be performed through Option L on the AMEN Screen via “Add-a-Program” to the existing E01 AU or by “J” screening a previous E02 AU. o On the KIND Screen, place a “y” in the selection field for MA. o Continue through “Add-A-Program”. On the CIRC Screen under unearned type/amounts, enter “SF” as the valid value for FAC foster care income (OHP Income) and $1 as the amount value. This will cause the proper coverage group to populate on the INCH Screen. o On the INCH Screen, place a “y” in the selection field for E02 Med Coverage Group. Enter the current date as the application date, when the coverage group is changed from E01 to E02. o Proceed through “Add-A-Program” screens to completion.

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320 State of Maryland Medical Assistance Manual Revised July 2012 o On the AMEN Screen, the E02 AU Number will now be populated. Change the Option to “O” for Interview and process the case. o Review the ADDR Screen to assure the correct mailing address. o Remember to enter closure reason code “507” to the E01 AU on the affiliated STAT screen in order to avoid dual participation in the ongoing months. o Change the Living Arrangement Code on the DEM1 Screen to “FC”. o On the UINC Screen, delete the E01 income by placing a “y” in the delete field and pressing PF 24. From the SHEL Screen, press PF7, which will return you to the UINC Screen. On the UINC Screen, enter “SF” and $1 for unearned foster care income. Delete the “FC” or other E01 income from the UINC Screen for the ongoing month. o Continue through the “Interview” process. Upon processing eligibility, confirm and allow closure of the E01 coverage to avoid dual participation in the ongoing month. Waive any adverse action, and override any closure notification. o Back at the AMEN Screen, select “P” to Process Application Months. o Remember to “507” the E02 coverage for the current application month only to avoid dual participation with the E01 coverage already being received. o On the MAFI Screen for the ongoing month during finalization of the E02 AU, shorten the “Redet End Date” to 90 days from the “Redet Begin Date”. Complete CARES processing.

For E02, E03, or E04: The following procedures should be used to redetermine MA eligibility when a child who is certified as an E02, E03, or E04 is discharged from OHP. Using option “R” from “AMEN”, initiate and complete an unscheduled redetermination for the existing E02, E03 or E04 AU. On the “MAFI” screen, adjust the redetermination end date to 90 days from the first day of the month following the month in which the MA CM became aware of the discharge from OHP, to allow inclusion into the CARES automatic redetermination cycle. Since the child remains in the “E” track until the redetermination is completed, the CARES 9708 application will be sent, even if the child is discharged back home.

o If the discharge date is during the first nine months of the child‟s certification period, the redetermination end date must be adjusted to 90 days from the first day of the month following the month in which the MA CM became aware of the discharge from OHP. o If the discharge takes place in the last three months of eligibility, the MA CM must initiate the redetermination in the month following the month in which he or she became aware of the discharge. Complete the redetermination and shorten the “REDET END DATE” to 90 days from the “REDET BEGIN DATE”. Following this procedure will ensure that CARES begins a “new

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321 State of Maryland Medical Assistance Manual Revised July 2012 redetermination cycle” and in doing so, will generate a new redetermination packet to the discharge address. o If the assistance unit (AU) was closed on CARES during the previous month due to failure to complete the redetermination process, the MA CM should “J” Screen the closed AU number from the first day of the month in which eligibility ended. Complete the application process and, in finalization, shorten the “REDET END DATE” to 120 days from the “REDET BEGIN DATE” to allow inclusion into the automatic redetermination cycle. For an E-track child returned to an active F-track household: The MA CM for the household‟s F-track case should be contacted. If there is sufficient information for the MA CM to determine that the child qualifies as a member of the F-track AU, there is no need to initiate an unscheduled redetermination for the child. If eligible, the child‟s E-track AU is closed effective the end of the month that the MA CM became aware of the child‟s discharge from the State‟s custody to the F-track household. The child is added as a member of the F–track AU effective the first day of the following month, so the household may begin to receive any public assistance for the child as soon as possible. 5. If a transfer of the case is necessary due to the child‟s new address and living arrangements, electronically transfer the case through CARES and send a copy of the paper file to the appropriate DO and/or MA CM. Set an Alert to notify any new MA CM that the above action was completed, and forward the case for follow-up. 6. Be sure to narrate on CARES all case action in each E-track case.

III. Procedures for MA CM to Redetermine MA/MCHP Eligibility for Children

Discharged from OHP.

A. If the redetermination application is returned by the child‟s parent or representative, pend the new medical coverage group, applying all applicable rules for AU composition, HOH, etc. A face-to-face interview is not required. In “Interview”, the MA CM updates the ADDR Screen and the DEM1 Living Arrangement. The MA CM determines whether the child is living at home. The MA technical and financial eligibility factors must be met for all household members for whom benefits are requested. Since CARES will send the CARES 9708 form, the application will not collect information about other household members. 1. The MA CM will contact the child‟s parent/representative to clarify who in the household is applying for benefits and for what type(s) of benefits. The MA CM will inquire about the income and resources of any household members who are

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322 State of Maryland Medical Assistance Manual Revised July 2012 applying or who are considered as Non-Members (NM) of the AU. 2. If necessary, the MA CM mails the CARES 9701 application to the parent/representative, specifying and highlighting the sections to complete (including signatures) that are not included on the CARES 9708 (for children considered as a household of one in an OHP, a LTC facility, or a home and community-based services waiver). 3. For the application month of the household‟s new AU, the “FINL RESP” code for the child must be entered as “NM” to avoid dual participation and insure that eligibility is determined correctly for any other AU members. If the MA CM determines that the child is eligible for MCHP in the P-track and there is no associated case (e.g. Food Supplement Program), the MA CM will change the D.O., electronically transfer the active P-track case, and mail a copy of the paper records to the appropriate LHD. If the MA CM determines that the child is eligible in a MA community or LTC category, or if there is an associated case for an MCHP AU (e.g. Food Supplement Program), the AU remains active at the LDSS. If the child moves into a household currently receiving TCA or if the HOH applies and is found eligible for TCA benefits for the child and other household members, the child‟s MA coverage may need to be changed to the “F” track before the end of the 90-day extended certification period. Then, the family may receive TCA and perhaps also FS benefits for the child as soon as possible, and for any other newly enrolled household members. If the child is discharged from OHP to a LTC (including an RTC or transferred to another D.O. and/or MA CM for a MA LTC eligibility determination. If it is determined that MA eligibility no longer exists for the child, the parent/representative must receive timely and adequate written notification, and the opportunity to request a hearing. A foster care child who is in the E03 State-only category because the MA citizenship requirements are not met will not be MA or MCHP eligible when discharged from the State‟s custody.

B. If the redetermination application is not received by the end of the extended certification period, even after reminder notices, CARES will close the child‟s AU due to failure to complete the redetermination. The procedures in section 12 for tardy redeterminations apply if the application for continued eligibility is returned within four months of the redetermination due date, or if a new application is filed within that time frame.

IV. Procedures for the MA CM to Follow When a Child is Aging-Out of Benefits for Out-of-Home Placements.

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323 State of Maryland Medical Assistance Manual Revised July 2012 COMAR 07.02.11 specifies age limitations for services under the Out-of-Home Placement Program of the Department of Human Resources. The same age limitations apply for MA eligibility for children in OHP. Regardless of the circumstances, no one aged 21 or older should remain in the E-track, due to MA eligibility age restrictions for the E-track. The MA CM must consult with the service worker about the child‟s OHP eligibility and manually set a “745” Alert for 90 days prior to when the recipient will “age-out” of eligibility for OHP before the child turns age 21.

On the ALWG screen (Create Worker-Generated Alert), enter all the necessary information to set a “745” alert. In the “Display Date” field, enter the date 90 days prior to the first day of the month in which the client turns 21 years old. In the “Due Date” field, enter the month, day, and year in which the child turns 21 years old. The MA certification period must be adjusted by the MA CM so an unscheduled redetermination is initiated by CARES. Follow the steps outlined in this section for all E-track redeterminations. If the recipient will be at least 21 years old at the end of OHP eligibility, the recipient‟s MA eligibility must be redetermined for the appropriate adult category (e.g. blind or disabled adult, parent or caretaker relative of a minor child). CARES will generate an “age alert” one month before the child turns 21. NOTE: ALL CASE ACTIVITIES MUST BE FULLY NARRATED IN CARES. (e) Refugees (G-Track) Aliens who are classified as refugees, asylees, or victims of severe trafficking may be covered for MA services in the G-Track for at most eight months after either their month of U.S entry as a refugee or their effective month of asylum or victim of severe trafficking status. Who are Refugees, Asylees, or victims of severe trafficking? Refugees are persons granted protective status while abroad. Typically, they have been forced to flee their homeland and are unable to return. Asylees are persons granted protective status after entering the United States as defined by the Immigration and Naturalization Service (INS). Victims of severe trafficking means sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

Protection is granted only to those who have a well founded fear of being persecuted on any of the following ways:

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324 State of Maryland Medical Assistance Manual Revised July 2012

Race Religion Nationality Social group Political opinion

Refugees, granted asylees, and severe forms of trafficking victims are provided services through the Refugee Resettlement Services Program. (Refugee Resettlement Service program is governed by COMAR 07.03.23) Refugee Medical Assistance Eligibility Criteria The first eight months after arrival to the United States Meet financial eligibility Application A person seeking services as a primary resident in the state of Maryland receives services at following locations: The Baltimore Resettlement Center (BRC) Suburban Washington Resettlement Center (SWRC) provides a wide array of resettlement services. (f) X02 Undocumented or Unqualified Immigrants- Emergency Medical Services Federally matched MA coverage for emergency medical services is provided to undocumented or unqualified immigrants who are residents and financially eligible for MA services but do not meet the citizenship or alien eligibility requirements. What are X02 Services for Undocumented or Unqualified Immigrants? Emergency medical services for illegal or ineligible aliens The following are some of the conditions considered Emergency Medical Services (EMS) Labor and delivery Dialysis and related services for aliens with end stage Renal Disease Individual with the diagnosed of AIDS

X02 Eligibility Criteria

Undocumented aliens

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325 State of Maryland Medical Assistance Manual Revised July 2012 Ineligible aliens Eligibility is determined based on a professional review of medical records to evaluate if the services received was an emergency service Qualified aliens who do not meet the five year bar don‟t meet the standard requirements for FAC, PW/MCHP The ineligible or undocumented pregnant alien can now file an application with the LDSS and LHD prior to the birth of a child When a determination of eligibility is completed a manual letter will be sent to recipients informing them of their eligibility Medical emergency other than labor and delivery, the CM must submit a DES 401 application (the summary with admission and discharge dates, Emergency Room (ER) admission and ER documentations showing the medical services that were rendered were an emergency nature)

Submit by mail: Delmarva Foundation for Medical Care, Inc Attn MDMA Acute, 6940 Columbia Gateway Drive Suite 420 Columbia, MD 21046-2788

Or submit via fax with a cover page to 1-888-513-1995, cover page should include: Facility Name, Patient Name and Date of Birth, Admission/Discharge Dates, Undocumented Alien Review (or x02) Questions or concerning, providers should call Delmarva‟s provider services number, which is 1- 866-571-3629.

(g) Aged, Blind, or Disable (ABD) (S-Track) or (T-Track) - Children or Adults in Long Term Care

Medicaid coverage for the ABD provides coverage for people who are Disabled or Blind or 65 or older or fatally ill and meet income and asset requirements. The initial certification period is 12 months six-months if eligible for spend-down. (Certification Period of COMAR 10.09.24.11) ABD MN Non-Spend-down (S98) Federally matched MA is provided to ABD whose income and resources (including those of their spouse living with them) are within the MA community MN income and resource standards. ABD Medically Needy Spend-down (S99)

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326 State of Maryland Medical Assistance Manual Revised July 2012 ABD, whose resources are within the MA community MN resource standard but whose income exceeds the medically needy income standard, qualify for federally matched MA when they spend-down their excess income-i.e., when their incurred medical expenses equal the amount of income that exceeded the income standard. Individuals eligible under MA spend-down may not be enrolled in HealthChoice. Aged A person who is 65 years of age or older Aged is reached the day of the anniversary of birth LDSS can accept the SSA determination of age for persons receiving SSB

Blind

A person shall meet the definition of Blindness, according to COMAR 10.09.02b which states a condition in which a person is certified by an ophthalmologist as having either central vision acuity 20/200 or less in the better eye with correcting glasses, or defect in which the peripheral filed has contracted to such an extent that the diameter of the field visual test subtends an angular distance of no greater than 20 degrees or Missing both eyes.

Disabled

Disability determination must be made by the SSA or the State Review Team (SRT). SRT is a unit within the DHR. DHR/FIA responsible for making a disability determination To be determined disabled, a person must have a disability that is expected to last at least 12 months or may result in death The determination by SSA is binding on the State until it is changed by the SSA

ABD Eligibility Criteria

Recipients of SSI from the SSA are automatically eligible for Medicaid. Individuals who lost SSI eligibility due to an annual cost of living increase in their Social Security income or a change in the federal disability definition are eligible for Medicaid. Individuals qualify as ABD MN, if they are ABD and their household income and assets do not exceed the Medicaid income and asset standards for the MN (e.g., $350 per month in income and $2,500 in assets for a household of one person). The allowed income and assets vary depending upon family size. (Coverage Groups 03 of COMAR 10.09.24.03) Individuals qualify through ABD spend-down, if they are ABD persons whose household assets meet the medically needy standards but whose household income exceeds the Medicaid income limit for the MN. The individual becomes Medicaid-eligible once incurred medical expenses total or exceed that excess amount. (COMAR 10.09.24.03)

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327 State of Maryland Medical Assistance Manual Revised July 2012 Recipients of Public Assistance to Adults (PAA) are automatically eligible for Medicaid. PAA is a state funded program through the DHR, which supports ABD adults living in assisted living facilities, Project HOME adult foster care, or residential rehabilitation facilities of DHMH.

Application Meet the definition of ABD (COMAR 10.09.02b) Meet financial eligibility

Attachment A Local Department of Social Services

County Address Telephone/Fax Number

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328 State of Maryland Medical Assistance Manual Revised July 2012 Baltimore City DSS Talmadge Branch Building (Walk In) 1910 N. Broadway Baltimore MD 21213 PO Box 17466 (Mail Only) Baltimore MD 21203-7466 443-423-6300 443-423-6501 Fax Allegany County DSS 1 Frederick Street Cumberland, MD 21502 301-784-7000 301-784-7222 FAX Anne Arundel County DSS 80 West St 2nd Floor Deck Annapolis, MD 21401 410-269-4500 410-974-8566 FAX Glen Burnie: 410-421-8550 Baltimore County DSS 6401 York Road Towson, MD 21212 410-853-3000 410-853-3955 FAX Catonsville: 410-853-3450 Dundalk: 410-853-3400 Essex: 410-853-3800 Reisterstown: 410-853-3010 Calvert County DSS 200 Duke Street Prince Frederick, MD 20678-0100 443-550-6900 410-286-7429 FAX Caroline County DSS 300 Market Street Denton, MD 21629 410-819-4500 410-819-4501 FAX Carroll County DSS 10 Distillery Drive Westminster, MD 21157 410-386-3300 410-386-3429 FAX Cecil County DSS Elton District Court/ Multi-Service Building 170 E. Main Street Elkton, MD 21921 410-996-0100 410-996-0464 FAX Calls from Rising Sun: 410-658-2145 Charles County DSS 200 Kent Avenue LaPlata, MD 20646 301-392-6400 301-870-3958 FAX Dorchester County DSS P.O. Box 217 (Mail Only) 627 Race Street (Walk In) Cambridge, MD 21613 410-901-4100 410-901-1047 FAX Frederick County DSS Frederick, MD 21705 100 E. All Saints Street (Walk In) Frederick, MD 21701 301-600-4555 301-600-4550 FAX Garrett County DSS 12578 Garrett Highway Oakland, MD 21550-0556 301-533-3000 301-334-5449 FAX Harford County DSS 2 South Bond St Bel Air, MD 21014 410-836-4700 410-836-4945 FAX 410-879-4500 Howard County DSS 7121 Columbia Gateway Dr. Columbia MD, 21046

410-872-8700 410-872-4231 Kent County DSS 350 High Street P.O. Box 670 Chestertown, MD 21620

410-810-7600 410-778-1497 FAX

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329 State of Maryland Medical Assistance Manual Revised July 2012

Montgomery County DHHS 1301 Piccard Drive, 2nd Floor Rockville, Md. 20850 240-777-4600 240-777-4100 FAX Germantown: 240-777-3420 240-777-3477 FAX Silver Spring: 240-777-3100 240-777-3070 FAX Prince George‟s County DSS 425 Brightseat Road Landover, MD 20785

301-909-6000 301-909-6067 FAX Hyattsville: 301-209-5000 301-209-5276 FAX South County: 301-316-7700 301-316-7701 FAX Queen Anne‟s County DSS 125 Comet Drive Centreville, MD 21617

410-758-8000 410-758-8110 FAX St Mary‟s County DSS Joseph D. Carter Building 23110 Leonard Hall Drive P.O. Box 509 (Mail Only) Leonardtown, MD 20650

240-895-7000 240-895-7099 FAX Somerset County DSS P.O. Box 369 (Mail Only) 30397 Mt. Vernon Road Princess Anne, MD 21853

410-677-4200 410-677-4300 FAX Talbot County DSS 301 Bay Street P.O. Box 1479 (Mail Only) Easton, MD 21601

410-770-4848 410-820-7117 FAX Washington County DSS 122 N. Potomac Street P.O. Box 1419 (Mail Only) Hagerstown, MD 21740

240-420-2100 240-420-2299 FAX Wicomico County DSS 201 Baptist Street, Suite 27 Salisbury, MD 21801

410-713-3900 410-713-3910 FAX

Worcester County DSS 299 Commerce Street P.O. Box 39 (Mail Only) Snow Hill, MD 21863

410-677-6800 410-677-6810 FAX

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330 State of Maryland Medical Assistance Manual Revised July 2012 Attachment B- Local Health Department

County/Program Address Telephone/Fax Number Allegany Maryland Children‟s Health Program 12501 Willowbrook Rd. P.O. Box 1745 S.E. Cumberland, MD 21502

(301) 759-5076 (301) 777-2097 FAX Anne Arundel County Department of Health Maryland Children‟s Health Program 1 Harry S. Truman Pkwy. Suite 200 Annapolis, MD 21401

(410) 222-4792 (410) 222-4391 FAX Baltimore County Baltimore County Health Department MCHP Program 8501 LaSalle Rd. Suite 103 Towson, MD 21286 (410) 887-2957 (410) 887-8095 FAX Baltimore City Baltimore Health Care Access MCHP

One Calvert Plaza 201 E. Baltimore Street 9th Floor Baltimore, Md. 21202

(410) 649-0512 (410) 649-0533 FAX Calvert Maryland Children‟s Health Program P.O. Box 980 Prince Frederick, MD 20678

(410) 535-5400 (301) 855-1353 (410) 535-1955 FAX Caroline Caroline County Health Department P.O. Box 10 (Mail Only) 403 S. 7th Street Denton, MD 21629

(410) 479-8004 (410) 479-0244 FAX Carroll County Health Department 290 S. Center Street P.O. Box 845 Westminster, MD 21158

(410) 876-4916 (410) 876-4905 FAX Cecil Maryland Children‟s Health Program 401 Bow Street Elkton, MD 21921-5511

(410) 996-5126 (410) 996-5124 FAX Charles Co. Nursing & Community Health Services P.O. Box 1050 White Plains, MD 20695-1050

(301) 609-6869/6868/6883 (301) 609-6837 (301) 609-6899 FAX Dorchester Dorchester County Health Department 503-B Muir Street Cambridge, MD 21613

(410) 228-3294 (410) 228-8976 FAX Frederick Frederick County Health Department

350 Montevue Lane Frederick, MD 21702

(301) 600-3124 TEL (301) 600-3111 FAX Garrett County Health

1025 Memorial Drive Oakland, MD 21550

(301) 334-7700 (301) 334-7701 FAX Harford Maryland Children‟s Health Program

120 S. Hays St. P.O. Box 797 Bel Air, MD 21014

(443) 643-0343 (443) 643-0344 FAX Howard County Health Department

7180 Columbia Gateway Drive Columbia, MD 21046

(410) 313-7500 (410) 313-5838 FAX

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Kent County Health Department Maryland Children‟s Health Program

125 S. Lynchburg Street Chestertown, MD 21620

(410) 778-7023 (410) 778-7019 FAX Montgomery Service Eligibility Unit

1335 Piccard Drive, Upper Level Rockville, MD 20850

8630 Fenton Street, 10th floor Silver Spring, MD 20910

12900 Middlebrook Road Germantown, MD 20874

(240) 777-3120 (240) 777-1013 FAX

(240) 777-3066 (240) 777-1307 FAX

(240) 777-3591 (240) 777-3563 FAX Prince George‟s Maryland Children‟s Health Program 425 Brightseat Road, Suite 101 Landover, MD 20785 (888) 561-4049 (301) 324-2809 FAX Queen Anne‟s

206 N. Commerce Street Centreville, MD 21617 (410) 758-0720 (443) 262-9357 FAX St. Mary‟s MCHP Eligibility & Outreach

P.O. Box 316 21580 Peabody Street Leonardtown, MD 20650-0316

P.O. Box 316 21580 Peabody Street Leonardtown, MD 20650-0316

Somerset Somerset County Health Department

7920 Crisfield Highway Westover, MD 21871

(443) 523-1700 (410) 651-2572 FAX Talbot County Health Department

100 S. Hanson St. Easton, MD 21601

(410) 819-5670 (410) 819-5691 FAX Washington Maryland Children‟s Health Program

1302 Pennsylvania Avenue Hagerstown, MD 21742

(240) 313-3330 (240) 313-3334 FAX Wicomico Maryland Children‟s Health Program

(Mail Only) 108 E. Main Street (In Person) 300 West Carroll St. Salisbury, MD 21801

(410) 543-6944 (410) 543-6568 FAX Worcester Berlin Health Center

9730 Healthway Drive Berlin, MD 21811

(410) 629-0164 (410) 957-2005 (410) 629-0185 FAX

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332 State of Maryland Medical Assistance Manual Revised July 2012

(h) Women’s Breast and Cervical Cancer Health Program (WBCCHP) I. Introduction The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (the Act) (Public Law 106-354) amends Title XIX of the Social Security Act to give states the option to cover a Medical Assistance (Medicaid) categorically needy coverage group for uninsured women between 40 and 64 years old, who are screened through the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and are diagnosed as in need of treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer. Coverage under this program is subject to the availability of State and federal funds. This Medicaid coverage group is named the Women‟s Breast and Cervical Cancer Health Program (WBCCHP), effective April 1, 2002. Services provided for Women with Breast or Cervical Cancer This program covers women for MA services who have been screened by the Breast and Cervical Cancer Program (BCCP) through the LHD (which has certain income limitations) and diagnosed with breast or cervical cancer. The following requirements must be met: Be a woman between the age of 40 and 64 years old, who is a Maryland resident; Be uninsured, or have insurance that does not cover cancer treatment; Be in need of treatment; and Not be eligible for Medicaid or Medicare.

There are no additional income and assets limitations, as long as the woman is screened through the BCCP program under the DHMH Public Health Services program and meets other eligibility criteria (i.e. residency, citizenship, social security number). (Section 300.1(h) Attachment A, WBCCHP Local Program Coordinators) Application

Women can obtain applications to enroll in the program from the Breast and Cervical Cancer Program coordinator at their LHD, The DHMH, Center for Cancer Surveillance and Control, Applications can also be completed at the offices of participating providers LDHs will forward complete applications to the DHMH case reviewer for eligibility requirements. Eligibility determinations will be the responsibility of the DHMH Women applying for the program must submit confirmation that breast or cancer screening services were received through the BBCCP a physician, certification of biopsy, diagnosis and the need for treatment

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333 State of Maryland Medical Assistance Manual Revised July 2012 Certifications and Redeterminations:

The initial certification period for the WBCCP is 12 months Eligibility will be redetermined by the DHMH reviewer prior to the end of 12 months The redetermination period of eligibility will be the lesser of 12 months or the estimated length of treatment as indicated on the certification of diagnosis form completed by the woman‟s physician or certified registered nurse practitioner.

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334 State of Maryland Medical Assistance Manual Revised July 2012

Attachment A- Women‟s Breast and Cervical Cancer Health Program (WBCCHP)

Program Coordinator(s) Email Address Telephone Number Fax Number Allegany Joanna Schroyer jschroyer@dhmh.state.md.us (301) 759-5083 (301) 777-2053 Anne Arundel Amy Kane hdkane00@aacounty.org (410) 222-4792 (410) 222-4391

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335 State of Maryland Medical Assistance Manual Revised July 2012 Baltimore County Constance Notaro Debbie Wilson cnotaro@baltimorecountymd.gov dawilson@baltimorecountymd.gov (410) 853-3311 (410) 887-3432 (410) 853-3211 (410) 887-3421 Calvert Sharon Owens sowens@cmhlink.org (410) 286-7992 (410) 286-7990 Caroline Leigh Marquess Laura Patrick leigh@dhmh.state.md.us laurap@dhmh.state.md.us (410) 479-8080 (410) 479-2014 Carroll Judy Trickett jtrickett@dhmh.state.md.us (410) 876-4916 (410) 876-4905 Cecil Brenda Sochurek bsochurek@dhmh.state.md.us (410) 996-5168 (410) 996-5169 Charles Dawn Cox dawnc@dhmh.state.md.us (301) 609-6861 /6883,6952, 6837,6861 (301) 609-6899 Dorchester Gale Jackson gjackson@dhmh.state.md.us (410) 228-3223 (410) 228-8976 Frederick Lori Stockman Roseann Russo lstockman@frederickcountymd.gov rrusso@frederickcountymd.gov (301) 600-3124 (301) 600-3372

Garrett

Caroline Evans

cevans@dhmh.state.md.us

(301) 334-7720

(301) 334-7771 Harford Wendy Richard wrichard@dhmh.state.md.us (410) 612-1780 (410) 612-9184 Howard Sarah Muse smuse@howardcountymd.gov (410) 313-5845 (410) 313-5838 Kent Andrea Edwards aedwards@dhmh.state.md.us (410) 778-7035 (410) 778-7019 Montgomery Donna Carter Donna.Carter@montgomerycountymd.gov (240) 777-3120 (240) 777-1013 Prince George‟s Myra Ball Elaine Stillwell mball@co.pg.md.us ejstillwell@co.pg.md.us (301) 883-3525 (301) 883-3561 Queen Anne‟s Cheryl Salaski csalaski@dhmh.state.md.us (443) 262-4509 (443) 262-9351 St. Mary‟s Lori Norton nortonl@smhd.com (301) 475-4275 (301) 475-4350 Somerset Cynthia Abbott Kristin Bradshaw-Dicintio CINDY.Admin.Somerset@dhmh.state.... KRISTINBR.Admin.Somerset@dhmh..... (443) 523-1752 (443) 523-1754 (410) 651-3425 Talbot Caron West caron@dhmh.state.md.us (410) 819-5600 (410) 819-5683 Washington Wendi Beckley wbeckley@dhmh.state.md.us (240) 313-3235 (240) 313-3422 Wicomico Sylvia Kumer sward@dhmh.state.md.us (410) 543-6944 (410) 543-6568 Worcester Twila Fykes twilaf@dhmh.state.md.us (410) 632-1100 (410) 632-0080

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336 State of Maryland Medical Assistance Manual Revised July 2012

(i) Qualified Medicare Beneficiaries (QMB) Baltimore City Linda Wieczynski Linda.Wieczynski@medstar.net (410) 649-0512 (410) 649-0533 University Care Rhonda Silva rsilva@umm.edu (410) 328-4673 (410) 362-5347

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337 State of Maryland Medical Assistance Manual Revised July 2012

Background

Federal legislation requires a state‟s Medicaid Program to pay the Medicare B premiums, co- insurances and deductibles for Medicare beneficiaries whose countable income and/or resources are above the applicable amount in a state‟s medically needy income and resources standards but are at or below the applicable amounts in the QMB income and resource standards, provided the applicant meets all other regular Medical Assistance (MA) eligibility requirements.

A Qualified Medicare beneficiary (QMB) is:

A person entitled to Medicare hospital benefits under Part A. (This includes a person entitled to hospital insurance benefits by reason of enrollment in the premium paying Part A program); A person who is not otherwise eligible for MA due to excess or resources; Countable income does not exceed 100 percent of the poverty income guidelines. The poverty income guidelines are issued annually by the U.S. Department of Health and Human Services Countable resources do not exceed twice the applicable SSI resource limit; A blind or disabled Medicare beneficiary who is a parent may request to be included in an FAC unit with their child/children; if they decide to do so, they can still receive QMB benefits

A QMB must also meet the general non-financial requirements or conditions of eligibility for MA of COMAR 10.09.24 such as filing an application, enumeration, citizenship, identity, residency and assignment of rights.

General Explanation

The QMB Buy-in provision is an extension of the current MA Program which provides for State payment of the Medicare Part B premium, co-insurances and deductibles. Buy-in coverage for a person who is determined to be a QMB, as defined in Section B of this part, is for a person who is otherwise ineligible for MA. (NOTE: Medicare Beneficiaries who are eligible for MA are also eligible for the buy-in coverage concurrent with their MA eligibility. The procedures relating to this group of dually eligible persons are included in Part II.)

The general MA policies and procedures apply to the eligibility determination. There are, however some differences that are addressed in this section. The differences are:

Only the Medicare beneficiary is included in the assistance unit; The income and resource deeming methodology from an ineligible spouse (parent);

COMAR 10.09.24.03

338 State of Maryland Medical Assistance Manual Revised July 2012 Retroactive coverage does not apply; Spend-down does not apply; and A higher income and resource standard.

The effective date of the Buy-in coverage is January 1, 1989. Scheduled redeterminations are required at 12-month intervals. Eligible persons will be issued a gray and white QMB identification card. A QMB eligible person or couple whose resources are within Schedule MA- 2, but whose income exceeds Schedule MA-1 may also qualify for regular MA under spend- down. Refer to section K and L of this part for complete procedures. If a Buy-in recipient meets MA spend-down eligibility, the case status changes from QMB Buy-in only to MA and Buy-in coverage (dual eligibility).

Nothing in this section changes the eligibility determination methodology of a Medicare Beneficiary who is ineligible for the Buy-in.

Applicable Regulations

Since the majority of Medicare beneficiaries are aged (65 years old or older), the ABD rules will generally apply to the eligibility determination. A smaller number of beneficiaries are disabled, some of whom are the parents of minor children who live in the home.

Application

A completed DHR/FIA 9705 application form by mail QMB applications can be used when applying for QMB/SLB (Specified Low income Medicare Beneficiaries)

The procedures in COMAR 10.09.24.04 are applicable. The application form DHR/FIA 9705 is the instrument by which eligibility information is collected. Unless specifically stated otherwise, the filing of an application form represents an application for both MA and the QMB Buy-in only coverage. In the case of a Medicare beneficiary request to apply for the Buy-in only coverage, that request may be honored and the local department is not required to determine MA eligibility for other family members.

Consistent with COMAR 10.09.24.04, which allows an applicant to decide the category in which he/she wants eligibility established, a blind or disabled Medicare beneficiary who is a parent may be included in an FAC unit with his/her children and spouse if he/she is to do so.

QMB Eligibility Criteria

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339 State of Maryland Medical Assistance Manual Revised July 2012

NOTE: For the purpose of this release, the terms “ineligible spouse” and “ineligible child” apply to one who is not receiving or entitled Medicare.

Assistance Unit Requirements

An AU unit may include only a person who is a Medicare beneficiary. In the case of a married couple both of whom are Medicare beneficiaries; both spouses are included in the same unit and their eligibility is tested together as a couple. Otherwise, the unit will include only one person. If only one of the married couple is a Medicare beneficiary, only the Medicare beneficiary is included in the unit. However, the income and resources of the ineligible spouse are considered. (Total countable resources of a couple are combined and measured against the QMB resource standard for two persons). Children are not counted in the resource measurement. Refer to Attachment A, 2012 Dual Eligible Standards. Refer to Section G for income deeming requirements.

Note: Ineligible Spouse applies to one who is not receiving or entitled to Medicare.

Determination of Countable Income

Countable income is evaluated in accordance with COMAR 10.09.24.07. The countable income to be considered is that of the assistance unit member(s) (Medicare beneficiary/ beneficiaries) or, in the case of an ineligible spouse, that of the ineligible spouse as well. The exclusions and disregards apply to the income that is considered available to the Medicare beneficiary, including that of the ineligible spouse. The Social Security cost-of-living adjustments (COLAS), effective January, are to be disregarded in determining income eligibility through April. The first month in which the COLAS are to be applied is May. Countable income, after disregards, is measured against the QMB income standard. If a Medicare beneficiary has an ineligible spouse and ineligible children, the income of the ineligible spouse must be considered in determining the Medicare beneficiary‟s eligibility. The procedures for determining the amount of the ineligible spouse‟s income to be deemed to the Medicare beneficiary spouse are in Section G of this part.

Resource Consideration

The countable resources to be considered are those of the applicant and the spouse of the applicant whether or not the spouse is also eligible. Countable resources are measured against the QMB resource standard for one person if the Medicare beneficiary has no spouse, or against the QMB resource standard for two persons if there is a spouse.

No other family members are included in the measurement. If there are excess resources, the individual or couple is determined ineligible. Deem Income from an Ineligible Spouse to a Medicare Beneficiary

COMAR 10.09.24.03

340 State of Maryland Medical Assistance Manual Revised July 2012 If an ineligible spouse lives in the same household and is the parent of a dependent ineligible child or children living in the home, in order to determine the amount of the ineligible countable income in the following order:

First (using the ABD exclusions and disregards in COMAR 10.09.24.07), determine how much unearned and earned income the ineligible spouse has. The ABD disregards are applied in the following order:

o Apply the $20.00 disregards ABD general disregard to any unearned income; if none, apply it to the earned income. o Next, apply the earned income disregard ($65+.5 or remainder) to the remaining earned income.

Then deduct an allocation for each of the ineligible children living in the household. Exceptions: Do not allocate for ineligible children who are receiving income maintenance payments. These payments are made under:

o The Family Investment Program (TCA); o Title XVI of the Social Security Act (SSI, including State Supplement); o The Refugee Act of 1980 (those payments based on need); o The Disaster Relief Act of 1974; o State or local government assistance programs based on need; and o U.S. Veteran Administration Programs (those payments based on the need).

The allocation for each child is the difference between the applicable SSI payment rate for a couple and that for an individual minus the amount of his/her income. These allocations are first deducted from the ineligible spouse‟s unearned income. If the ineligible spouse does not have enough unearned income to cover the allocations, the balance is deducted from the ineligible spouse‟s earned income. The amount of the allocation automatically increases whenever the SSI payment standard increases. The amount of the allocation to be used to determine the amount of the benefit for a current month is based on the payment rate that applied in the second prior month.

NOTE: The allocation of income applies only to the ineligible children and income of the ineligible spouse. Do not allocate to children the income of the Medicare beneficiary.

Determining the Medicare Beneficiary‟s Eligibility for the Buy-in Coverage.

COMAR 10.09.24.03

341 State of Maryland Medical Assistance Manual Revised July 2012 Compare the amount of the ineligible spouse‟s income which remains after the appropriate allocations, to the difference between the applicable SSI payment rate for a couple and that for an individual. If the amount is not more than the difference between the applicable SSI payments rate for a couple and that for an individual, there is no income to deem from the ineligible spouse to the Medicare beneficiary. In this case, compare only the Medicare beneficiary‟s own countable income to the QMB income standard for one person to determine if the Medicare beneficiary is eligible for the buy-in coverage.

If the amount of the ineligible spouse‟s income that remains after appropriate allocations is more than the difference between the applicable SSI payment standard for a couple and that for an individual, take the following steps:

o Combine the remainder of the ineligible spouse‟s unearned income with the Medicare beneficiary‟s own unearned income and the remainder of the ineligible spouse‟s earned income with the Medicare beneficiary‟s own earned income. o Apply all appropriate income exclusions and disregards of COMAR 10.09.24.07. o Compare the remainder to the QMB income standard for 2 persons. If the remainder is equal to or less then the QMB income standard for 2 persons, the Medicare beneficiary is eligible for the Buy-in coverage. o If the net countable income exceeds the applicable QMB standard, and the resources are within Schedule MA-2; the Medicare Beneficiary is ineligible for the Buy-in. Recalculate the income for regular MA based on Schedule MA-1 and take appropriate action based on the spend-down provisions. Refer to sections K and L. If, under this same circumstance, the resource exceeds Schedule MA-2, the person is totally ineligible for MA.

Income Deeming Examples

Following are examples of how to deem income from an ineligible spouse to an eligible spouse.

Example 1:

Mr. P, a disabled Medicare beneficiary, applies for the Medicare Buy-in coverage. He lives with his wife and 14-year old son, neither of whom is a Medicare beneficiary. Since Mr. P has requested Buy-in-coverage only, his is a one-person ABD assistance unit. Mr. P. and his son receives OASDI ($350 and $100 monthly, respectively) and Mrs. P is employed and earns $550.00 monthly. The family has countable resources of $3,000, therefore, Mr. P is resource eligible. To determine his income eligibility, the income of his wife is taken into account. Take the following steps to determine if any of the wife‟s income is deemed to be available to Mr. P:

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342 State of Maryland Medical Assistance Manual Revised July 2012

Step 1-Determination of Mrs. P‟s Countable Income Apply the $250.00 ABD general and earned income (EI) ($65.00 + ½ of remainder) disregards. Note: the $20.00 general disregard is first applied to unearned income. If there‟s no unearned income, then apply to the E.I.

Mrs. P‟s unearned income $ 0.00 $550.00 Mrs. P‟s earned income $550.00 -20.00 530.00 -65.00 $465. 00÷2=$232.50

Step 2- Determination of Income to be deemed from Ineligible Spouse (Mrs. P)

Income allocation for ineligible child (difference between SSI payment rate for a couple and an individual): a. $553.00-$368.00=$185.00 b. Reduce child‟s allocation amount of his/her own income.

Allocation for child $185.00 Child‟s income -100.00 (Difference between child‟s allocation and $85 Child‟s income)

b. Calculate Mrs. P‟s remaining income after allocation. Mrs. P‟s income $232.00 Child‟s allocation -85.00

Mrs. P‟s remaining income $147.50

Since Mrs. P‟s remaining income ($147.50) is not more than the difference between the applicable SSI payment standard for a couple and that for an individual ($185.00), there is no income to deem from Mrs. P to Mr. P.

Step 3-Calculation of Mr. P‟s Income for Buy-in Eligibility Decision

a. OASDI-Mr. P‟s unearned income $415.00 Apply the $20 ABD general disregard

-20.00 Net countable income $395.00 b. Compare Mr. P‟s net countable income to the QMB income standard for 1 person (425.). $395.00

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343 State of Maryland Medical Assistance Manual Revised July 2012 -425.00

$ -0-

c. Mr. P‟s net income of $395 is within the QMB income standard of $425.0. His resource is within the QMB resource standard of $4000.00. d. Decision: Mr. P is eligible for the Buy-In coverage.

Example II:

Mrs. K a disabled Medicare Beneficiary, applies for the Medicare buy-in coverage. She lives with her husband and two children, ages 8 and 10 years old. Since Mrs. K has requested Buy-In coverage only, hers is a one-person, ABD AU.

Mrs. K and her two children receive OASDI ($325 and $135 monthly, per child, respectively). Mr. K is employed and receives $525 weekly.

The family has countable resources of $3800; therefore, Mrs. K is resource eligible. To determine Mrs. K‟s income eligibility, the income of Mr, K must be taken into account.

Take the following steps to determine if any of Mr. K‟s income is deemed to be available to Mrs. K.

Step 1-Determination of Mr. K‟s Countable Income

Multiply Mr. K‟s weekly E. by 4.3 to arrive at monthly income, and apply the $20.00 ABD general and E.I ($65.00-½ of remainder) disregards. (If paid bi-weekly multiply income by 2.15 to arrive at monthly income.)

Mr. K‟s U.I. $0.00 $525.00 Mr. K‟s E.I.

×4.3

2257.50

-20.00

2237.50 -65.00 $2172.50÷2=$1086.25

Step 2-Determination of Income to be deemed from Ineligible Spouse (Mr. K) (Income allocation for ineligible child-differences between SSI payment rate for couple and an individual):

COMAR 10.09.24.03

344 State of Maryland Medical Assistance Manual Revised July 2012 a. $553-$368=$185.00 b. Reduce child‟s allocation by the amount of his/her income: $185.00×2 $370.00 $100.00 -270.00 $135.00×2 $100.00 (Difference between children‟s allocation and income) c. Calculate Mr. K‟s remaining income after allocation. Mr. K‟s income $1086.25 Children‟s allocation - 100.00 Mr. K‟s remaining income $986.25

Since Mr. K‟s remaining income ($986.25) is more that the difference between the applicable SSI payment standard for a couple and that for an individual ($185.00), the remainder of income must be added to Mrs. K‟s income to determine her eligibility for Buy-In coverage.

Step 3-Calculation of Mrs. K‟s Income for Buy-In Eligibility Decision a. Combine Mr. & Mrs. K‟s unearned income and apply the $20.00 ABD general disregard.

Mr. K‟s unearned income $ 0.00 $325.00 Mrs. K (OASDI) +325.00 -20.00 $325.00 $305.00

b. Combine the remainder of Mr. and Mrs. K‟s E.I. and apply the ABD E.I. ($65.00+1/2 of remainder) disregard.

Mr. K‟s E.I $986.25 Mrs.K‟s E.I + 0.00 $986.25 -65.00 $921.25 ÷2=$460.63

c. Combine and compare Mr. and Mrs. K‟s U.I and E. I to the QMB income standard for 2 people ($575.00).

U.I $305.00 $765.63 E.I +460.63 - 575.00 $765.63 $190.63 d. Mrs. K‟s total income is $190.63 over the QMB income standard for 2 people. e. Decision: Mrs. K is not eligible for Buy-In coverage, due to excess income.

COMAR 10.09.24.03

345 State of Maryland Medical Assistance Manual Revised July 2012 Note: Because resources also exceed applicable amount in Schedule MA-2the case is not preserved for MA spend-down eligibility.

Example III:

Mr. C, a disabled Medicare beneficiary, applies for the Medicare Buy-in coverage. He lives with his wife and their two children, who are not Medicare beneficiaries. Since Mr. C has requested Buy-in coverage only, his is a one-person assistance unit. Mr. C and his two children receive OASDI ($405, and $100 monthly, per child, respectively). Mrs. C earns $430.00 monthly and receives $100.00 monthly unearned income. The family has countable resources of $2, 900; therefore, Mr. C is resource eligible. To determine his income eligibility, the income of his wife is taken into account. Take the following steps to determine if any of Mrs. C‟s income is deemed to be available to Mr. C.

Step 1-Determination of Mrs. C‟s Countable Income

Apply the $20.00 ABD general and E.I. ($65 -1/2 of remainder) disregards

$100.00 $430.00 -20.00 -65.00 $ 80.00 $365.00 ÷2=$182.50

Step 2-Determination of Income to be deemed from Ineligible Spouse (Mrs. C) Income allocation for each ineligible child-difference between SSI payment rate for a couple and an individual):

a. $553-$368=$185.00 b. Reduce each child‟s allocation by the amount of his/her own income: c. Calculate Mrs. C‟s remaining income after allocation. Note: Child allocation is first deducted from unearned income. If there‟s not enough unearned, the remainder is deducted from E.I.

Mrs. C‟s unearned income: $80.00 Children‟s allocation -170.00 Mrs. C‟s remaining income $90.00

Mrs. C‟s earned income $182.50 Allocation carryover -90.00 Mrs. C‟s remaining income $92.50

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346 State of Maryland Medical Assistance Manual Revised July 2012 Since Mrs. C‟s remaining income ( $92.50) is not more than the differences between the applicable SSI payment standard for a couple and that for an individual ($185.00), there is no income to deem from Mrs. C to Mr. C.

Step 3-Calculation of Mr. C‟s Income for Buy-In Eligibility Decision

a. OASDI- Mr. C‟s unearned income $405.00 Apply the $20 ABD general disregard -20.00 Net countable income $385.00

b. Compare Mr. C‟s net countable income to the QMB income standard for 1 person ($425).

$385.00 -425.00 $ -0-

c. Mr. C‟s net income of $385.00 is within the QMB income standard of $425.00. His resources are within the QMB resource standard of $4, 000. d. Decision: Mr. C is eligible for the Buy-in coverage.

Overall Decision: a. Eligible-Notice Requirement: Use DES 202.

b. Ineligible solely due to excess income-Notice Requirements Use DHMH 4213B and DHMH 4200A

c. MA ineligible due to excess resources or non-financial factors-Notice Requirement: Use DES 300.

Income Calculation for Spouses When Both Are Medicare Beneficiaries with No Children

When both spouses are Medicare beneficiaries and they are not the parents of any dependent children living with them, their eligibility for the Buy-in is determined together as a single unit. Follow the standard MA ABD income calculation using the regular MA disregards of COMAR 10.09.24.07L.

If the net countable income and countable resources are equal to or less than QMB income and resource standards for 2 persons, each spouse is eligible for the Buy-in.

COMAR 10.09.24.03

347 State of Maryland Medical Assistance Manual Revised July 2012 The same procedure applies when one of the spouses is not a Medicare beneficiary. The single difference is that the ineligible spouse is not certified for Buy-in. if the ineligible spouse requests assistance; his/her MA eligibility must be tested separately under the existing MA or MASO rules as appropriate. Under this circumstance, the income and resources of the QMB are considered in determining the non-QMB eligible spouse‟s MA eligibility and measured against the MA-I and MA-2 standards for 2 persons.

Certification (Buy-in Only)

Certification for the Buy-on coverage is for a 12-month period and begins the month following the month the person is determined eligible. Certification continues until the person is determined ineligible.

(Retroactive coverage does not apply to a person who is eligible only for the Buy-on.) Do not confuse the month a person becomes eligible with the month the CM.

Completion of the DHMH 2583 (Insurance Reporting Form) is required for eligible Buy-In case. There is a notice requirement for CM to send appropriate notice to client.

Scheduled Redeterminations

Scheduled redeterminations for persons certified for the Buy-in only are conducted once every 12 months. If a recipient is determined ineligible, the local department must take the necessary action to cancel the case in accordance with timely and adequate notice requirements. The cancellation is effective no earlier than the month ineligibility is determined. Notice Requirements: A person may file a new application at any time. The application process explained in this part applies to reapplication.

Unscheduled Redeterminations

Even though QMB cases are certified for 12-month periods and scheduled redeterminations are due once every 12 months, in the event of an unscheduled redetermination, for calculation purposes, it is necessary to split the 12 months into two six-month periods.

Upon notice of a change in circumstances, it is necessary to determine if the recipient continues to be eligible for the remainder of the current certification period. In the case of an increase in income, in order to determine continued eligibility, it is necessary to add the new income to be received and compare the total to be received compare the total to the applicable amount in the QMB income standard. If the total amount, after application of the disregards, is equal to or less than the allowable QMB standard, the recipient remains eligible for the balance of the current period. No notice requirements. No further action needed. 268-8229

If the income exceeds the allowable amount, the recipient is ineligible. The local department must take action to cancel the case in accordance with timely and adequate notice requirements.

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348 State of Maryland Medical Assistance Manual Revised July 2012 Notice Requirement: Use DES 303. The person may file a new application at any time. The application process explained in this release also applies to reapplications.

If the unscheduled redetermination results in ineligibility for any other reason, the local department must take action to cancel the case in accordance with timely with adequate notice requirements. No further action is required. The person may file a new application at any time.

NOTE: A case may be closed no earlier than the month ineligibility was determined.

Improper Program Payment

Follow existing Manual procedures if erroneous payments result from the actions, inactions or delayed actions on the part of either the recipient or the local department.

A QMB Recipient Right to Apply for MA Spend-down

A QMB eligible person or couple whose resources are within the MA requirement, but whose income exceeds schedule MA-1 (income standards) may also qualify for regular MA under spend-down. A recipient in QMB Buy-in only that meets spend-down is considered dual eligible. Excess income for spend-down purposes is based on the amount in excess of the applicable amount in Schedule MA-1. If applicable QMB eligible person is ineligible for MA solely because of excess income, the eligible person may apply for a status change from QMB to MA spend-down by submission of incurred medical expenses not covered by Medicare, others insurance or the QMB Buy-in.

Spend-down Eligibility Procedures

Although Medicare may notify the recipient that these Buy-in services are covered services, the fact of the person‟s Buy-in status is sufficient evidence that these expenses are not obligations of the recipient and, therefore, may not be deducted from excess income.

A Medicare beneficiary is routinely notified of the results of all claims submitted on his/her behalf. The notice is called the Medicare Summary Notice form which is issued by a State‟s Medicare carriers). In Maryland the carrier(s) are as follows:

Novitas Solutions, Inc. Address: PO Box 890385 Camp Hill, PA 17089-0385 Phone: 1-877-235-8073

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349 State of Maryland Medical Assistance Manual Revised July 2012 The notice includes a full explanation of what Medicare was billed for, what was paid, what was not paid and whether the provider accepted the Medicare reimbursement as payment in full. If the provider billed for a higher rate than Medicare pays, and the provider does not accept the Medicare reimbursement as payment in full, the Medicare Summary Notice will include the fact that the beneficiary is responsible for the difference between the amount that Medicare actually paid and the actual charges. However, since the Medicare Beneficiary is enrolled in the Buy-in coverage, local departments will disregard that information for spend-down purposes with the exception that follows, assuming the beneficiary does not have a Medicare supplemental policy such as Blue Shield.

The remaining amount owed for services other than an inpatient hospital bill may be applied to excess income if the provider has billed the MA Program and the Program has refused payment because the Program will not pay for services in excess of what Medicare has paid. In this instance, the additional charges may be applied to excess income for spend-down purposes.

(j) Dually Eligible Persons Medicare beneficiaries who are eligible for MA are also eligible for the Buy-In coverage concurrent with their MA eligibility. This group is referred to as dually eligible. The Medical Care Operations Administration (MCOA) will, on the basis of the reported Medicare coverage, imprint QMB on the Medicare beneficiary MA card. No additional action for the Buy-in coverage is required of the local department for the initial certification. The Buy-in coverage has been, in the past, a regular part of MA coverage for Medicare beneficiaries who qualify for MA. That coverage will continue. The single difference is that under the new law, Federal Financial Participation (FFP) is available to the State for the payment of the Medicare Buy-in premiums, whereas, currently, the total premium is paid from state general funds. As a result of the availability of FFP, MA eligible persons must be certified for the Buy-in Coverage. (k) Specified Low-Income Medicare Beneficiaries (SLMB) In 1993, the Specified Low-Income Medicare Beneficiaries became effective with only one income standard. SLMB is a person: Who is entitled to Medicare hospital benefits under Part A; Who is not otherwise eligible for MA due to excess income or resources; Whose resources do not exceed the QMB resource limit, and; Whose countable income exceeds 100% of Federal Poverty level but does not exceed 120% of the Federal poverty level. SLMB Eligibility Criteria

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350 State of Maryland Medical Assistance Manual Revised July 2012 Must meet technical requirements for Medical assistance, (such as filing an application, enumeration, citizenship, identity, residency, assignment of rights, etc.). The ABD rules apply to SLMBs.

Must meet the other requirements for QMB. When determining resource eligibility for SLMB, CM should use the QMB resource standard. SLMB eligibility is determined only after a person has applied for MA and QMB and has been determined ineligible for both. The income standard is higher. It requires that income not only be at or below 120% of poverty, but that it also be greater than 100% of poverty. Application

SLMB only pays the premium; deductable and co pays are not covered. Call local department of social services and request an application for QMB/SLMB. Fill out the packet the mail-in application. A person may not apply for SLMB only. Return the application to your nearest LDSS. The LDSS/LHD numbers are on the last page of the document for customers to keep for their records.

When customers mail form, they are requesting QMB or SLMB benefits through the Maryland MA Program. Once they are found eligible, each year the LDSS/LHD will mail the customer a case information form (CIF) to be reviewed and returned so the customer eligibility for continued QMB/SLMB benefits can be redetermined.

Certification

SLMB eligibility starts at the beginning of the month of the application. Regarding retro- eligibility, it starts in the earlier retro month and extends for a 12 month period. Scheduled redeterminations are required every 12 months. If you are eligible for SLMB, you will pay only your monthly Medicare Part B medical insurance premium. You will receive a letter in the mail telling you if you are eligible, but you will not receive a card. The MMIS-II is unable to manage this Medicaid information; therefore another system has been developed. SLMB certifications will be made via CARES; however, this data will be maintained on a personal computer file instead of MMIS-II. The following procedures must be used to certify a SLMB Unique Case Number Assignment. SLMB will be assigned a unique M.A. case number by the LDSS CM.

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351 State of Maryland Medical Assistance Manual Revised July 2012 The first two positions will be 96. The second two positions will be the county indicator (e.g. Baltimore city=30. Baltimore county=03). The next four (4) positions will be a special SLMB case number assigned by DHR/LDSS. The last three (3) positions will be the last two digits of the birth year plus a 0 or tie- breaker (e.g. 1950=500). Spend-down When spend-down eligibility ends, the recipient must reapply for MA/QMB if SLMB coverage is desired.

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352 State of Maryland Medical Assistance Manual Revised July 2012

Attachment A-2012 Dual Eligible Standards

2012 Dual Eligible Standards (Based on Percentage of Federal Poverty Level)

Qualified Medicare Beneficiary (QMB):

Monthly Income Limits: (100% FPL + $20)* All States and DC (Except Alaska & Hawaii): $ 951- Individual $1,281 – Couple Alaska: $1,185 – Individual $1,597 – Couple Hawaii: $1,092-Individual $1,471 – Couple

Asset Limits: $6,940-Individual $10,410 – Couple

Specified Low-Income Medicare Beneficiary (SLMB):

Monthly Income Limits: (120% FPL + $20)* All States and DC (Except Alaska & Hawaii): $1,137-Individual $1,533 – Couple Alaska: $1,417-Individual $1,912 – Couple Hawaii: $1,306-Individual $1,761 – Couple

Asset Limits: $6,940-Individual $10,410 – Couple

Qualifying Individual (QI):

Monthly Income Limits: (135% FPL + $20)* All States and DC (Except Alaska & Hawaii): $1,277 – Individual $1,723 – Couple Alaska: $1,592 – Individual $2,149 – Couple Hawaii $1,467 – Individual $1,979 – Couple

Asset Limits: $6,940 – Individual $10,410 – Couple

Qualified Disabled Working Individual (QDWI):

Monthly Income Limits: (200% FPL + $20)* (Includes additional earned income disregards)

All States and DC (Except Alaska & Hawaii): $3,809 – Individual $5,129 – Couple Alaska: $4,742 – Individual $6,392 – Couple Hawaii: $4,372 – Individual $5,889 – Couple Asset Limits: $4,000 – Individual $6,000 – Couple Includes: $20 = Amount of the Monthly SSI Income Disregard $1500= Burial Credit

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353 State of Maryland Medical Assistance Manual Revised July 2012 (l) Disabled Adult Children (DAC) If the Social Security Administration (SSA) considers an individual eligible for Supplemental Security Income (SSI), the individual is eligible for MA as an SSI recipient, even if the individual does not receive SSI cash benefits due to receipt or increase of Social Security benefits. An SSI-eligible person who is at least 18 years old is MA-eligible as a Disabled Adult Child (DAC) if the parent, on whom the individual is dependent, dies or receives Social Security benefits as an elderly or disabled person, and the SSI recipient files a claim for Social Security benefits based on the parent‟s Social Security account. If the individual‟s Social Security cash benefit exceeds the SSI benefit, the individual no longer receives SSI cash payments. The individual must be “deemed” by SSA as SSI-eligible in a no-pay status. This sequence of events makes the individual a DAC. Since the individual is still SSI eligible, he/she remains MA- eligible as such. The DAC does not need to file a MA application in order to obtain and retain MA coverage. The MA does not need to file a MA application in order to obtain and retain MA coverage. The MA eligibility CM must assure that the DAC‟s MA eligibility remains active without a break after the SSI payments end, and SSI eligibility continues in a no-pay status. For an individual to be MA-eligible as a DAC, the individual must be “deemed” by SSA as SSI- eligible in a no-pay status. This occurs when the individual becomes income over scale for SSI cash benefits due to receipt or increase of Social Security Childhood Disability Benefits under the parent‟s Social Security account. Eligibility criteria must be met for Childhood Disability Benefits: The individual is at least 18 years old, unmarried, not the head of a household, and dependent on a parent because the individual is blind or disabled; The individual has blindness or a disability that began before age 22; and The individual‟s parent either died or became eligible for Social Security because the parent is elderly or disabled. The State Data Exchange System (SDX) or State Verification and Exchange System (SVES) should indicate that the SSI recipient is MA-eligible as a DAC when SSI cash payments end or when SSI eligibility is initiated in a no pay status. SDX/SVES should have the following information in order for an individual to be considered a DAC: DAC Eligibility Criteria The individual is at least 18 years old; The individual has “D”(deemed) as the SSI status for Medicaid eligibility; The individual has “NCI” (no payment) as the SSI payment status; The individual‟s SSA claim number differs from the individuals‟ Social Security number, because he/she eligible under the parent‟s SSA claim number; The individual„s SSA claim number ends with a “C” suffix (Beneficiary Identification Code- BIC), followed by a number (e.g. “212-22-1212 C1).

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354 State of Maryland Medical Assistance Manual Revised July 2012 This information is not always transmitted accurately or timely by SSA. Upon discovering that a DAC was denied or terminated for MA eligibility due to an SDX or CM error, the CM must certify the individual as MA-eligible retroactive to the date that MA eligibility was erroneously denied or terminated. Anyone who meets the DAC criteria must be certified as eligible for MA without a lapse in coverage from the time that SSI cash payments ended. Even though a DAC may have income in excess of the MA medically needy income limit (MNIL), the individual is eligible as a DAC. They are not required to complete a MA application form. A financial eligibility determination is not conducted. Eligibility Upon Employment If a DAC becomes employed, the earned income or accumulated resources may make the individual financially ineligible for the deemed status of SSI eligibility. When SSA‟s database indicates that a DAC is no longer SSI-eligible, the individual is no longer categorically eligible for MA as an SSI recipient. The MA eligibility CM must then redetermine the individual‟s eligibility for the most appropriate coverage group. The policies and procedures followed in section 12 and its CARES supplement for “Redeterminations for Former SSI recipients.” Eligibility must be redetermined before MA coverage may be terminated, with a notice of adverse action issued at least 10 days before any closure. Although a DAC may have received SSI benefits as a child, this is not a requirement. An individual is eligible for SSI payments as a child if the individual: Qualifies for SSI based on disability and financial eligibility is either: Under 18 years old, or Under 22 years old and regularly attending school, college, or training that was designed to prepare the individual for a paying job; Is not married; and Is not the head of household CARES Procedures The following procedures are used to certify a DAC as eligible in coverage group S02 on CARES: Delete the SSI income from the UINC screen effective the month that the SSI payments ended. Enter the SSA income effective the month that the Social Security payments began. (These months should be the same.) At the bottom of the UINC screen, enter “SI” in the “Appl type” field, and enter “S” in the “Stat” field, Enter the date the SSI cash payments were terminated.

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355 State of Maryland Medical Assistance Manual Revised July 2012 SSI eligibility has not been closed yet, these changes may be entered as interim changes. If SSI eligibility has already been terminated, the case will need to be rescreened, and these changes entered before finalization. (m) Disabled Widowed Beneficiaries (DWB) A widow or widower who receives SSI based on his or her own disability, but is later found to be eligible for Social Security benefits based on the account of the deceased spouse, is referred to as a disabled widowed beneficiary (DWB). These persons may also be referred to as “Kennelly Widows.” The SSA benefit is generally greater than the SSI benefit, resulting in the DWB‟s loss of SSI eligibility. Even though the DWB no longer receives an SSI payment, he/she is deemed eligible for MA as an SSI recipient. DWB Eligibility Criteria

The person is a former SSI recipient;

The person is not yet 65 years old;

The person is ineligible for Medicare;

The person‟s SSA claim number is the Social Security number of the deceased spouse. Certifications Anyone who meets all of these criteria may be certified. These persons are required to file an application. Resources may not exceed the SSI resource standard of $2000; however, even if income exceeds the MNIL they are still considered CN. CARES Procedures In a non-CARES jurisdiction, certify a SWB as category 06. In a CARES jurisdiction, the DWB is in coverage group S02. Delete the SSI income from the UINC screen effective the month it terminated; enter the SSA income effective the month it began (these should be the same months). On the bottom of the UINC screen enter “SI” in the “Appl type” field, and “S” in the “Stat” field. Enter the date SSI was terminated. If the SSI case has not yet been closed, these changes may be entered as interim changes. If the SSI eligibility has already been terminated, the case will need to be rescreened, matched and the changes entered before finalization. (n) Qualified Disabled and Working Individuals (QDWI) Coverage Group (S06) Non-elderly persons who are entitled to Medicare Part A (Hospital Insurance) by reason of their disability, but who are not eligible to receive a Social Security benefit because they are employed, may be eligible for federally matched MA coverage of their Medicare Part A premiums if their income is at or below 200% of the federal poverty level and their resources do not exceed twice the SSI standard. A card is not issued for QDWI recipients since the benefit does not cover any medical expenses just the Medicare Part A premium.

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356 State of Maryland Medical Assistance Manual Revised July 2012 QDWI Eligibility Criteria The A/R must have been entitled to Medicare Part A while eligible for Social Security disability benefits and have lost eligibility because he/she is working. The individual must continue to be considered disabled by the SSA. The age range for QDWI eligibility is 21-64 years old. The applicant should be tested under ABD regulations. Eligibility as a QDWI is based on the disabled individual losing Social Security benefits due to employment. If the person is married, the income and resources of the spouse are considered, even though the AU only includes the QDWI eligible person. The income considered available to the A/R may not exceed 200% of the FPL for the household size (one or two persons if there is a spouse). The resources considered available to the A/R may not exceed twice the maximum standard for Supplemental Security Income (SSI). Since the current SSI resource standard is $2,000.00, the maximum allowable resources for QDWI eligibility are $4,000.00 for one person and $6,000.00 for a couple. This is the same resource standard used for QMB/SLMB; however, the income limit is different. To be eligible for QDWI, the applicant/recipient may not be active in any other Medicaid coverage group When a person active as a QDWI (S06) applies for more comprehensive Medicaid benefits during the certification period and is determined eligible in another coverage group, the S06 case must be closed in conjunction with opening the new case to avoid dual participation in CARES. The Case Manager must establish a 745 Alert for the end of the new MA certification period, as reminder to review for the S06 eligibility. If the individual loses eligibility for the higher Medicaid coverage group, the Case Manager should follow current redetermination procedures in the MA Manual, Chapter 12, including consideration as a QDWI. Verify that the QDWI status still applies, using SOLQ/SVES) The A/R must meet the technical Medicaid requirements in COMAR 10.09.24.04 and .05. Since these individuals must still be considered disabled by SSA, they will not receive a disability determination by the State Review Team (SRT). Disability status must be verified on SOLQ/SVES. Use this information to complete the CARES DEM2 screen Disability Fields Income and resources are considered according to the requirements in COMAR 10.09.24 for a non-institutionalized aged, blind or disabled person. (NOTE: A person becomes entitled free Medicare Part A when he or she attains age 65 and is considered aged.) The QDWI coverage group does NOT provide for any retroactive coverage prior to the month of application

Application

Individuals must apply for this Medicaid benefit at the LDSS. Eligibility for this program is not granted automatically. It is based on a letter from SSA to the person indicating potential eligibility. The CM must still use SOLQ/SVES to verify the eligibility status. Once the

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357 State of Maryland Medical Assistance Manual Revised July 2012 eligibility determinations are finished and the S06 is finalized, suppress all CARES notices on the MAFI screen for the S98 (unless eligible), S99, and S06 cases and send the appropriate attached manual notice. If pending the S06 case would cause it to exceed the 30 day period for making an eligibility determination, determine the S06 case and take the appropriate action when eligibility is determination, determine the S06 case take the appropriate action when eligibility is determined for the original pending case (e.g. closing the S06 case and opening an S99 case). The CARES 9701 application is used by the LDSS for these applicants. The applicant should be tested for eligibility in both S98 and S06. Pend both at the same time. The applicant should have a letter from SSA indicating the QDWI status, but a copy of this letter is not required. The CM must verify that the individual is potentially QDWI eligible per SSA by having a “Current Pay Status” of N33 or N44 on SVES. The disability coding on SVES must also be reviewed to determine whether the person is still considered disabled by SSA. If these individuals have a „Current Pay Status” code N27 on SVES indicating that they are no longer considered disabled by SSA, they are not eligible as a QDWI. The N27 ineligibility code on SVES is changed by the SSA system to a termination code after one year. Persons may apply for QDWI in the same month as their SSA notification that they are no longer entitled to Medicare Part A. Individuals who do not apply for QDWI within 7 months of the SSA notice will have to wait until next Medicare open enrollment period (January 1- March 31) for the federal government to approve their Buy-In coverage, and then the State‟s payments may not begin until July 1. If the delay in applying, they may also be required by SSA to pay a premium surcharge, unless they are covered by an employee group health plan based on their own or their spouse‟s current employment. The QDWI eligible is personally responsible for any surcharge(s) because the State will not pay a premium surcharge The UINC screen must be properly coded with the A/R‟s SSA claim number and BIC, and completed with the unearned income fields, and Application Type, etc. fields at the bottom of the screen. The termination date for previous benefits must be entered to indicate the termination of a prior period of SSA eligibility. The application must be processed within a 30 day period. If there is a delay reason, place the appropriate delay code on the CARES MISC screen. The CARES notice for approval or denial of the application must be suppressed by the Case Manager, and the appropriate approval or denial notice (see attachments) must be completed and issued manually. Any closing notice to a recipient must also be suppressed on CARES, and a QDWI closing notice (see attachment) completed and issued manually.

Coverage

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358 State of Maryland Medical Assistance Manual Revised July 2012 The federal government approves the effective date for the State‟s payment of Medicare Part A for QDWI, based on the date of the SSA eligibility letter and when the individual applies for QDWI at the LDSS. The effective (begin) date of S06 eligibility will not necessarily be the 1st day of the month of application. The Centers of Medicare and Medicaid Services (CMS) will advise the DHMH Buy- In Unit of the effective date. The Buy-In Unit will inform the LDSS Case Manager if the effective date on CARES for S06 eligibility needs to be changed through an unscheduled redetermination.

Procedures

Once the CM has determinate that the A/R is eligible for QDWI benefits, the eligibility date should begin the same month as the date of the application. The case should be certified for a year and have a yearly redetermination.

When the CM is notified by the DHMH Buy-In Unit of the premium begin date, the CM must initiate an unscheduled redetermination to reset the effective date for a new 12 month certification period. A new application is not necessary because all eligibility factors remain the same.

o Complete the redetermination, which will reset the certification period forward 12 months. If for some reason the redetermination end date needs to be modified, shorten the redetermination end date as necessary to coincide with the begin date of premium payments. Suppress the CARES notices, and send manual QDWI notices to include the date the State will begin paying the Medicare Part A premium. A person must be under 65 years old to be eligible in this coverage group. The month before the customer turns 65, the CM will receive a CARES Alert (216). CARES will close the S06 AU at the end of the month in which the client turns age 65. As with all other MA coverage groups, the customer must be tested for MA eligibility in accordance with federal guidelines for delinking. o An individual who turns 65 year old during the consideration period must be determined for QDWI eligibility for any months prior to the attainment of 65. When the appropriate eligibility is determined and the notice sent advising the individual of the determination, the CM must also include a statement that they are not eligible once they reach age 65 because they are “potentially” eligible for free Medicare Part A. Also, they should contact SSA if they have not already been notified of this eligibility CMS will notify the DHMH Buy-In Unit when a person reaches 65 years old and the State‟s payment of the Medicare Part A premium is no longer due. The Buy-In Unit will then have the S06 case closed on MMIS effective the last day of the month of entitlement to S06 coverage. The Buy-In Unit will provide the information to the LDSS CM. The CM then must close the case

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359 State of Maryland Medical Assistance Manual Revised July 2012 on CARES (if it has not been closed already), suppress the CARES notice, and send a manual QDWI notice (see attached notice). The QDWI coverage group does not cover the premium for Medicare Part B. The individual may elect to participate in Part B and pay the Part B premium to SSA There are annual redeterminations for coverage group S06 because there is 12 month certification period. CARES should issue the redetermination package on schedule. SVES must be reviewed to determine if the person still meets the criteria for QDWI eligibility. All Medicaid redetermination requirements in COMAR 10.09.24.12 must be met. If eligibility as a QDWI is terminated, the CM must determine if the individual is eligible for any other Medicaid coverage group. Termination of Premium HI (Medicare Part A) and QDWI Eligibility Premium- HI for the working Disabled continue until the earliest of; o The end of the month the following the month the individual is notified by SSA that he or she no longer has a disabling impairment. (This can be verified on SVES as “Current Pay Status” N27.) o The end of the month following the month the individual files a request for termination of Premium HI. o The end of the month the individual becomes re-entitled to premium free HI or turns age 65. o The date of death. The individual must receive a notice of the termination at least 10 days before the effective date, including appeal rights. The CARES notice must be suppressed, and a QDWI termination notice muse be issued manually by the CM (see attached notice).

CARES Screens/Procedures

Follow the general CARES procedures for processing an application for Community MA as ABD. The instructions below are to assist with additional steps or information necessary in relation to the S06 Medicaid Coverage Group. The applicant should be tested for eligibility in both S98 and S06. Pend both at the same time. The eligibility for S98 should be tested first.

If the customer is active (“A” status, not “M” status on the STAT Screen in CARES) in S98 or S99 coverage; finalize the AU for the Active S98 or S99 coverage group and allow the CARES notices eligibility coverage group. Suppress the CARES notice for denial of S06. If the countable income causes the S98 AU to go into a preserved status for spend-down (“M” status), DO NOT FINALIZE the S98 case (using reason code “550”) to prevent it from trickling to preserved “M” status for S99. CARES does

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360 State of Maryland Medical Assistance Manual Revised July 2012 not permit dual participation for the S06 coverage group. Suppress the CARES notice. If the applicant is not eligible for S06, allow CARES to deny the S06 AU, suppress the CARES notice, and send the manual QDWI denial notice. Next, finalize the S98 case to allow tricking to S99, and allow all CARES notices to be sent for the S AU.

Screening (Option J) In screening on the CIRC screen- place a “Y” in the disabled field (this is to insure the selection of the medical coverage group S98). On the INCH screen, select the MA coverage group S98, and add MA coverage group S06. The MA Coverage Type should a “D” for Disabled or a “B” for Blind. (It should not be an “A‟ because aged individuals don not qualify for this program.)

Interview (Option O) During the interview option, the CM will need specific information from a SOLQ/SVES inquiry in order to complete the Disability/Incapacity Fields on the DEM2 screen. In order to be eligible for S06 MA Coverage, the customer must have been receiving SA benefits due to disability and must still be considered by SSA as disabled. Therefore, the Disability/Incapacity Fields must be completed on the DEM2 screen in CARES. If the AU was screened property with a “D” or “B” as the MA Type of the INCH screen, the required fields will be marked with asterisks during the Interview Option on the DEM2 screen.

DEM2 Screen If the S06 case has the MA Type Code of “D” for Disabled or “B” for Blind, the following should be entered on the DEM2 in the correlated fields; o Disab/Incap Field= “O” for Other Disease if disabled or “K” for Visual Impaired if blind o Disability/Incapacity Approval Source= “RS” for SSA Disability Approval o Disability/Incapacity Approval Date (MM/YY)= the date of disability determined by SSA from the SOLA inquiry o Disability/Incapacity Began Date (MM/YY)= the same as the Approval Date o Disability/Incapacity End Date (MM/YY)= since this is indeterminate, enter 99/99 in this field. o Entitle Med A Field= “T” for Terminated (This valid value works correctly in CARES, but is not currently listed as a useable valid value in the Help text. Updating of the Help text has AU will deny for no eligible members and for failing the age requirement.

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361 State of Maryland Medical Assistance Manual Revised July 2012 ERN1 and ERN2 Screens In order for a customer to be eligible for S06 QDWI, the customer must be Employed. Therefore, the CM should have earnings information to key onto ERN1 and ERN2 screens in CARES, following the general procedures.

UINC Screen This screen is not required to process the AU eligibility on CARES. However, a SSA Claim Number with the proper BIC must be entered on the UNIC screen in order to transmit the Medicare number to DHMH. In the claim number Fields: o Enter the Social Security claim number In the BIC Fields: o Enter the BIC associated with the A/R claim number In the Unearned Income field and In the Social field: o Enter “SA” for a Social Security benefit or “RR” for a Railroad benefit In the Amount Field: o Enter $1.00 Complete all other required fields The application Type, State, and Date fields must be completed at the bottom of the screen. In the Appl Type: o Enter “SA” In the State Field: o Enter „T” for termination In the Date field: o Enter the end date of the SSA eligibility

NOTE: The CM should remember that if the eligibility is ever overscale by $1, they will need to view the income and adjust it accordingly by deducting $1 to offset the $1 entered on the UINC screen.

Unscheduled Redeterminations When notification is received that CMS had approved State payment of premium payment for Medicare Part A, an unscheduled redetermination is necessary to reset the effective date for a new 12- month certification period. A new application is not necessary, because all eligibility factors remain the same. Upon notification of the effective premium payment date, the CM is to initiate a redetermination by selecting option “N” (initiate Redet) from the AMEN screen on CARES. Select option “R” and complete all necessary eligibility requirements to maintain eligibility. On the MAFI screen, review the Redet End Date to ensure the proper certification

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362 State of Maryland Medical Assistance Manual Revised July 2012 period. The redetermination end date should be 12 months from the begin payment confirmed by CMS. Confirm eligibility and suppress all notices and send the manual QDWI notice. (see attached.) Notices Suppress ALL CARES notices and send manual notices instead, unless the A/R is approved for S98 eligibility. CARES will automatically generate a closing notice for individuals when they reach age 65. See attached QDWI notices.

COMAR 10.09.24.03

363 State of Maryland Medical Assistance Manual Revised July 2012 Maryland Medical Assistance Program Notice of Eligibility for Medicare Hospital Insurance (Part A) Buy-In Only As a Qualified Disabled Working Individual

Date: ____________________________________________ Customer ID: _____________________________________ District: __________________________________________

Dear ___________________: This is to notify you that based on the application you filed on _____________________, we have determined that you are eligible for State payment of your Medicare Part A Hospital Insurance premiums. After the federal government determines the effective date, you will be informed when the State will begin paying your Medicare Part A premiums. The State will issue payment directly to the U.S. Social Security Administration. The State‟s payments will continue until you are notified that you are no longer eligible. You will not receive a Maryland Medical Care Program card because you are just eligible for coverage of Medicare Part A premiums. You are not eligible for Medical Assistance (Medicaid) to cover medical services. You should continue to pay the monthly premium for Medicare Part A until you are notified of when the State will begin paying the Medicare Part A premiums for you. If you pay for the same month that the State pays, the Social Security Administration will pay you back. If the federal government determines that you must pay a surcharge, besides your regular premium, you are responsible for payment of the surcharge. The State does not pay any surcharges. If you elect to participate in Medicare Part B, you are responsible for paying the Part B premium to the U.S. Social Security Administration. You will be required to re-establish your eligibility for this coverage at least once every 12 months. You will be notified of that requirement in advance of the due date. The necessary instructions and forms will be mailed to you at that time. You must notify this agency of any changes in your situation such as employment, income, savings, property, stocks, bonds, insurance, address, and telephone number. Any of these changes could affect your eligibility. You must report changes within 10 working days of the change to your Case Manager at the telephone number below. If you have any questions about this notice, you should contact your Case Manager.

Sincerely, ________________________ Case Manager

_________________________ Telephone

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364 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Fair Hearings

You have the right to appeal this decision within 90 days from the date of this notice. Your request must be made in writing on a form you may obtain from your Case Manager. Please include the specific reason(s) for your appeal. If you wish, someone at the local department of social services may assist you in completing the form for filing your appeal. Bring the form to your local department of social services office, or you may mail your request for a hearing to the following address: Office of Administrative Hearings Administrative Law Building 11101 Gilroy Road Hunt Valley, Maryland 21031-1301

The hearing will be scheduled at a time and place that are convenient for you. You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may represent yourself, or if you wish you may be represented by legal counsel or by a relative, friend or other person, although it is not required that someone represent you. You may bring any witnesses you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you so desire.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1-800-999-8904.

COMAR 10.09.24.03

365 State of Maryland Medical Assistance Manual Revised July 2012 Maryland Medical Assistance Program Notice of Eligibility for Medicare Hospital Insurance (Part A) Buy-In Only As a Qualified Disabled Working Individual

Date: ___________________________________________ Customer ID: _____________________________________ District: _________________________________________ ________________________________ ________________________________ ________________________________

Dear__________________________:

This is to notify you that based on the application you filed on ____________________, we have determined that you are eligible for State payment of your Medicare Part A Hospital Insurance premiums. The federal government has determined that the effective date for the State to start making your premium payments is ______________________.

If you have paid for any months of Medicare Part A premiums that the State will now pay, the U.S. Social Security Administration will pay you back for those months. If the federal government determines that you must pay a surcharge, besides the regular premium, you are responsible for payment of any surcharge. The State does not pay any surcharges. If you elect to participate in Medicare Part B, you are responsible for paying the premium to the Social Security Administration. Contact the Department of Health and Mental Hygiene‟s Buy-In Unit at 1-800-638-3403 if you have any questions about your Medicare Buy-In.

Contact your Case Manager at the telephone number below, if you have any questions about this notice or your eligibility.

Sincerely,

_______________________________

Case Manager

_______________________________

Telephone

COMAR 10.09.24.03

366 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Fair Hearings

You have the right to appeal this decision within 90 days from the date of this notice. Your request must be made in writing on a form you may obtain from your Case Manager. Please include the specific reason(s) for your appeal. If you wish, someone at the local department of social services may assist you in completing the form for filing your appeal. Bring the form to your local department of social services office, or you may mail your request for a hearing to the following address: Office of Administrative Hearings Administrative Law Building 11101 Gilroy Road Hunt Valley, Maryland 21031-1301

The hearing will be scheduled at a time and place that are convenient for you. You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may represent yourself, or if you wish you may be represented by legal counsel or by a relative, friend or other person, although it is not required that someone represent you. You may bring any witnesses you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you so desire.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1-800-999-8904.

COMAR 10.09.24.03

367 State of Maryland Medical Assistance Manual Revised July 2012 Maryland Medical Assistance Program Notice of Eligibility for Medicare Hospital Insurance (Part A) Buy-In Only As a Qualified Disabled Working Individual

Date: _________________________________________________ Customer ID: ___________________________________________ District:________________________________________________ _______________________________________________________ _______________________________________________________ __________________________________ __________________________________ __________________________________

Dear ___________________:

Based on the application you filed on __________________, you are not eligible for Medical Assistance coverage of health care services or for State payment of your Medicare Part A Hospital Insurance premium. You are not eligible for the following reason(s):  1.You did not provide the information necessary to complete your eligibility determination. The information required is: ____________________________________________________________________________________ ______________________________________________________________________________________________ If you send in this information before __________________________, you will not have to file another application form. This agency will re-activate your original application and determine your eligibility.  2. Your income exceeds the maximum allowable amount of:

Income Standards

Medical Assistance Qualified Disabled Working Individual $__________________ $____________________ The type and amount of income counted is listed below: ______________________________ $____________________ ______________________________ $____________________ ______________________________ $____________________ The amount of income deducted is: ______________________________ $ ____________________ ______________________________ $ ____________________ ______________________________

$_____________________

The total amount of your countable income is: $_____________________  3. Your assets exceed the maximum allowable amount of:

Asset Standards

Medical Assistance Qualified Disabled Working Individual

$________________ $____________________ The assets counted are listed below: _______________________________________

$_______________________ _______________________________________

$_______________________ _______________________________________

$_______________________ _______________________________________

$_______________________

The total amount of your countable assets is: $_____________________

COMAR 10.09.24.03

368 State of Maryland Medical Assistance Manual Revised July 2012 You should reapply when your income and/or assets no longer exceed the maximum allowable amount.  4. You do not meet the following eligibility requirements:________________________________________________________________________ ____________________________________________________________________________________________________________________________ This decision is based on COMAR 10.09.24 and/or the Social Security Act [1902(a)(10)(E)(ii),1905(p)(3)(A)(I)]. If you do not agree with this decision, you have the right to request a Fair Hearing within ninety (90) days of the date of this notice. If you have any questions about this notice, you may contact your Case Manager at the telephone number below.

Sincerely,

___________________________

Case Manager

___________________________ Telephone

COMAR 10.09.24.03

369 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Fair Hearings

You have the right to appeal this decision within 90 days from the date of this notice. Your request must be made in writing on a form you may obtain from your Case Manager. Please include the specific reason(s) for your appeal. If you wish, someone at the local department of social services may assist you in completing the form for filing your appeal. Bring the form to your local department of social services office, or you may mail your request for a hearing to the following address: Office of Administrative Hearings Administrative Law Building 11101 Gilroy Road Hunt Valley, Maryland 21031-1301

The hearing will be scheduled at a time and place that are convenient for you. You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may represent yourself, or if you wish you may be represented by legal counsel or by a relative, friend or other person, although it is not required that someone represent you. You may bring any witnesses you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you so desire.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1-800-999-8904.

COMAR 10.09.24.03

370 State of Maryland Medical Assistance Manual Revised July 2012 Maryland Medical Assistance Program Notice of Eligibility for Medicare Hospital Insurance (Part A) Buy-In Only As a Qualified Disabled Working Individual

Date: ___________________________________________ Customer ID: _____________________________________ District: _________________________________________ ________________________________ ________________________________ ________________________________

Dear__________________________: It has been determined that you are no longer eligible as of _________________________________________ for the State‟s payment of your Medicare Part A Hospital Insurance premium. This determination is based on the following reasons:  1. You no longer meet the following eligibility requirements: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________  2. You failed to complete the redetermination process. Your eligibility will be considered and may be re-established without a gap in coverage if you file the redetermination package or a new application with your Case Manager by ______________________.  3. You failed to provide the requested information needed to determine your continued eligibility. The information required is: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

If you send this information to your Case Manager before ________________________, you will not have to file another redetermination application. This agency will re-activate your original redetermination application and determine your continued eligibility for State payment of the Medicare Part A premium.

 4. You or your authorized representative declined to continue to participate in the Medicare Part A Hospital Insurance Buy-In Program as a Qualified Disabled Working Individual.  5. Other reason(s) ______________________________________________________________________________________ This decision is based on COMAR10.09.24 and/or the Social Security Act [1902(a)(10)(E)(ii), 1905(p)(3)(A)(I)]. If you do not agree with this decision, you have the right to request a Fair Hearing within ninety (90) days of the date of this notice. If you have any questions about this notice, you may contact your Case Manager at the telephone number below.

Sincerely,

________________________ Case Manager

________________________ Telephone

COMAR 10.09.24.03

371 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Fair Hearings You have the right to appeal this decision within 90 days from the date of this notice. Your request must be made in writing on a form you may obtain from your Case Manager. Please include the specific reason(s) for your appeal. If you wish, someone at the local department of social services may assist you in completing the form for filing your appeal. Bring the form to your local department of social services office, or you may mail your request for a hearing to the following address: Office of Administrative Hearings Administrative Law Building 11101 Gilroy Road Hunt Valley, Maryland 21031-1301 The hearing will be scheduled at a time and place that are convenient for you. You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may represent yourself, or if you wish you may be represented by legal counsel or by a relative, friend or other person, although it is not required that someone represent you. You may bring any witnesses you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you so desire.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1-800-999-8904. (o) Family Planning Program Effective January 1, 2012, The DHMH has expanded the current MA Family Planning Program (FP). Medicaid will cover family planning services for low income women under the age of 51 in addition to the current postpartum women. What is Family Planning (FP) Program? Provides family planning benefits for certain low income eligible women. Applicant must be under 51 years of age, a Maryland resident, and a U.S. citizen or a qualified alien who meets all requirements for benefits. The FP is a fee- for service program and recipients will not be enrolled in a MCO‟s. FP Eligibility Criteria: A U.S. citizen or qualified alien A Maryland resident Female, under 51 years of age who; o Is not pregnant o Has not had a permanent sterilization An applicant must also have household income that does not exceed 200% of the Federal Poverty Level. Women who already have MA are not eligible for this program

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372 State of Maryland Medical Assistance Manual Revised July 2012

Family Planning Benefit Coverage

Visit to the doctor or clinic Pelvic exams, pap smears, and screenings for Sexually Transmitted Infection (STI‟s) and HIV( Human immunodeficiency virus ) as part of annual visit Consultation about birth control methods Prescriptions and devices for birth control Permanent sterilization (must be over 21)

NOTE: Eligibility Determination, The FP eligibility staff at DHMH will determine eligibility and notify applicants of the eligibility decision by mail.

(p) Children and Temporary Cash Assistance (TCA) adults in Long-Term Care Facilities (LTCF)

The T- Track for Family LTC is used for MA eligibility determinations for children and certain adults admitted to a LTCF. The T-track is different from the L-Track, which is for ABD in LTC. The T-Track is for children and adults whose MA LTC eligibility is determined using the eligibility policy for: FAC under COMAR 10.09.24- Medical assistance Eligibility; or Children under COMAR 10.09.11-Maryland Children‟s Health Program (MCHP), but not including MCHP coverage under Title XXI of the Social Security Act (coverage groups P13 and P14 and the D-Track.

When a child (under 21 years old) is admitted to a LTCF, MA LTC eligibility is determined for the T-Track. If the child is currently MA community eligible (E, F, G, H, or S track) or MCHP eligible (P-Track), an unscheduled redetermination is necessary. If the child is not an active MA or MCHP recipient, an initial MA LTC eligibility determination is conducted. The L-Track is only used for a child who is a recipient of Supplemental Security Income (SSI) or whose LTC eligibility is determined using ABD rules. All SSI recipients, adults or children, who have no other source of income, have their LTC eligibility determined for coverage group L01, so they are not subject to annual redeterminations (see Policy Alert 10-08).

When a child, parent, or caretaker relative, who is active in MA community coverage group F01 due to receipt of TCA, is admitted to a LTCF, MA LTC eligibility may be determined for the T- Track coverage group T01. Then, the recipient does have to be determined as aged, blind, or disabled in the L-Track in order to be covered by MA for LTC services.

COMAR 10.09.24.03

373 State of Maryland Medical Assistance Manual Revised July 2012 Note: The information below provide local offices uniform policies and procedures to be followed when determining LTC eligibility in the T-Track for a child or a TCA adult.

Eligibility Policy-Coverage Groups in the T-Track for Children or TCA Adults in Long- Term Care Following is a description of the basic eligibility for policy for the T-track. For all individuals being determined for T-track eligibility:

Eligibility is determined by LTC MA CM at the LDSS‟s. However, a Financial Agent or a MA CM at the Division of Eligibility Waiver Services (DEWS) determines MA LTC eligibility for seriously mentally ill or emotionally disturbed children who are admitted to an Institution for Mental Disease (IMD), Regional Institute for Children and Adolescents (RICA), or Residential Treatment Center (RTC). The applicant/recipient (A/R) is considered a household of one person, since the child is an out-of-home placement. Children who are active in coverage groups S02 for SSI recipients, or who are revealed by clearances using SVES/SDX/SQLQ to be receiving SSI, should have their LTC eligibility determined in coverage group L01 if they have no income besides SSI, the same as adult SSI recipients admitted to LTCFs. The DHR/FIA CARES 9708 is used as the MA application form for a children A/R. If the A/R is considered an adult, the DHR/FIA CARS 9709 is used. As with the L-track, The T-track requires a DHMH 257 before MA LTC eligibility may be determined. The State‟s Utilization Control Agent must certify that the child needs the level of care provided by the LTCG. A child is considered institutationalized as of the 1st day of the first full calendar month in the LTCF. However, an adult is considered institutionalized as of the 30th consecutive day in hospital or by transfer to a different LTCF. i.e. A child who is 10 years old and active coverage group P08 enters a LTCF on 7/15. The child is an acute hospital 8/2-8/8, then returns to the LTCF and is there as of the end of August. Eligibility is determined for T05. P08 eligibility ends as of 7/31. T05 eligibility and the LTC span begin as of 8/1. When a MA or MCHP recipient is admitted to the LTCF, the community-based eligibility continues and the services in the LTCF are paid until the recipient is considered to be institutionalized. Then, a MA LTC eligibility determination is necessary in order of MA to cover the LTC services. If the recipient is enrolled in the HealthChoice when admitted to the LTCF, the MCO or the Mental Hygiene Administration for recipient admitted to a (Residential Treatment Center or other psychiatric facility) covers the authorized care in the LTCF while the recipient is considered a community MA or MCHP recipient.

COMAR 10.09.24.03

374 State of Maryland Medical Assistance Manual Revised July 2012 If a MA or MCHP community recipient is admitted to a LTCF for a less than 30- day stay follow procedures in the MA Eligibility Manual. If a MA or MCHP community recipient is covered by Medicare for skilled or chronic care in a LTCF, follow the policies and procedures in the MA Eligibility Manual. The MA LTC post-eligibility policies and procedures related to spousal impoverishment and calculation of the available income towards the cost of care are applied to recipients determined eligible in the T-track. These policies and procedures are specified in Chapter 10 of the MA Eligibility Manual and in COMAR 10.09.24.10 and 10-1. For recipients eligible in the T-track, MA pays the portion of the facility‟s cost of care that exceeds the recipient‟s available income, and also covers all the MA services for which the recipient qualifies.

Family Long-Term-Care T-Track

T01 TCA Adult or Child in Long-Term-Care When a child or adult who receives TCA under TANF Section 1931 (F01 coverage group) is placed in a LTCF, MA will pay the cost of care in the facility and cover other MA services for which the recipient is eligible. The TCA financial and non-financial eligibility requirements are specified in COMAR 07.03.03 and the TCA manual, established by the DHR.

T02 FAC Long-Term-Care-Medically Needy

MA is provided for an unmarried child under 21 years old in a LTCF, if the child‟s resource do not exceed the medically needy resource standard ( no more than $2, 500 in countable resources, after subtracting exclusions) and if the child‟s countable net income ( after subtracting exclusions and disregards) is insufficient to pay the LTCF‟s cost of care. These are the same LTC medically needy income and resource standards used for coverage group L98- ABD persons in LTC. However, the T02 coverage groups uses the FAC rules in COMAR 10.09.24.07 and .08 and Chapters 7 and 8 of the MA Eligibility Manual for the income and resource exclusions and the income disregards.

T03 Child Under 1 Year Old in Long Term Care

MA is provided for a child under 1 year old who resides in a LTCF. The financial and non- financial eligibility rules for P06 are used, as specified in COMAR 10.09.11 and the MCHP Eligibility Manual. The child‟s income must be at or below 185% of the federal poverty level (FPL). There is no resources test.

COMAR 10.09.24.03

375 State of Maryland Medical Assistance Manual Revised July 2012 T04 Child from 1 Year Old Up to 6 Years Old in Long -Term-Care

MA is provided for a child who is at least one year old but less than six years old who resides in a LTCF. The financial and non-financial eligibility rules for P07 are used, as specified in COMAR 10.09.11 and the MCHP Eligibility Manual. The child‟s income must be at or below 133% of the FPL. There is no resource test.

T05 Child Under 19 Years Old in Long-Term-Care

MA is provided for a child under 19 years old who resides in a LTCF. The financial and non- financial eligibility rules for P08 are used, as specified in COMAR 10.09.11 and the MCHP Eligibility Manual. The child‟s income must be at below 100% of the FPL. There is no resource test.

T99 FAC Long- Term- Care- Medically Needy Spend-down

Unmarried children under 21 years old in a LTCF who resources do not exceed the MN resource standards ($2,500), but whose available income exceeds the cost of care in the facility, are eligible for MA if the child‟s total medical expenses are greater than the amount by which the child‟s income exceeds the cost of care. These cases trickle from T02, due to being resource- eligible but income over-scale. Like T 0, the T99 coverage group uses the FAC rules for consideration of income and resources. T99 is similar to L99, which trickles from L98 for the same reasons. MA will not pay for the cost of care in the LTCF because the recipient‟s available income covers the cost. However, MA will cover other medical services for which the recipient is eligible.

II. CARES Procedures Followed by Medical Assistance Case Managers for MA Eligibility Determinations in the T-Track

The MA CM should screen an applicant in the coverage group for which the applicant is most likely to qualify and which best fits the applicant‟s circumstances. For example: If the recipient is 18-20 years old, the recipient should be screened in T02 which goes up

to 21 years old rather than in T05 which goes up to 19 years old. If the applicant has countable resources exceeding the medically needy resource standard of $2,500 for T02, the applicant should be screened in T03-T-05, depending on the applicant‟s age. Resources are not considered for T03-T05. If an A/R is determined ineligible for one T-Track coverage group and either CARES does not trickle or trickles incorrectly, the MA CM should Add-A-Program to screen the A/R in other coverage groups for which the A/R may qualify in the T or L track. The

COMAR 10.09.24.03

376 State of Maryland Medical Assistance Manual Revised July 2012 CAREs denial/closure notice should be suppressed by the MA CM, unless it is determined that the A/R is not eligible for any other LTC coverage group.

AU Screen in T01

A T01 assistance unit (AU) consists of a child or adult who at admission to a LTCF is actively receiving TCA benefits and so is MA community-eligible in F01. MA will pay the facility‟s cost of care while the child or adult remains eligible for TCA. When the CM adds a program to the existing F01 AU, CARES will not display T01 coverage group on the “INCH” screen. Therefore, the CM must call it up. In order to process correctly a T01 Au: o The Living Arrangement for this recipient must be coded as “TL” (Temporary LTC Admissions) on the customer‟s “DEM1” screen for both the F01 and T01 Aus. o All members of the recipient‟s F01 AU must be coded on the “STAT” screen as a Nonmember (NM) for the recipient‟s T01 Au. o The recipient must be changed on the “STAT” screen to a NM of the F01 Au, which should trigger unscheduled redeterminations for the F01 AU.

As long as the family remains eligible for TCA (and so is MA eligible as F01), the LTC recipient should remain eligible in T01, unless the recipient ages out of TCA. Then, the recipient‟s LTC eligibility should be redetermined for the most appropriate coverage group.

AU Screened in T02

This MA coverage group is for an unmarried child under age 21 residing in a LTCF, whose countable resources do not exceed the medically needy standard for a household of one person ($2,500) and whose countable net income is insufficient to pay the LTC cost of care.

If the child‟s resources are within standard and the income is within standard (less than the LTC cost-of-care), the case is eligible for T02 and certified for 12 months, as long as the child‟s age is under 21.

If the child is ineligible for T02 because the child‟s resources are within standard but the income is in excess of the standard (LTC cost-of-care), the case trickles to T99 (spend- down) in a preserved “M” status. As with other MA coverage groups, CARES also evaluates the income. For only the T-track, CARES actually changes the MA coverage group from T02 to T99, indicates that the Au is in spend-down, and gives the Au status Reason Code of “401” to deny for over-scale resources. Therefore, the CM should add

COMAR 10.09.24.03

377 State of Maryland Medical Assistance Manual Revised July 2012 the reason of “301” for over-scale income to the denial/closure notice that CARES generates for T02. CARES denies/closes MA eligibility for a case trickling to T99, and does not allow the CM to update the medical expense screens to authorize a spend-down.

If the child is ineligible for T02 because the child‟s resources are over-scale and the income is in excess of the standard (LTC cost of care), CARES denies/closes due over- scaling resources (not also due to over-scale income). Therefore, the case manager should add the reason of “301” for over-scale income to the denial/closure notice that CARES generates.

If the child is ineligible for T02 because the child‟s resources are over-scale but the income is within standard for T02, CARES may trickle the T02 Au to T03-T05 depending on the child‟s age. If not, the MA CM should Add-A-Program to determine eligibility for T03-T05.

AU Screened in T03

For a child under age 1: If the income is within 185% FPL, the T03 Au is eligible and certified for 12 months. If the child is ineligible for T03 because the child‟s income is over 185% FPL, but the child‟s income does not exceed the cost-of-care and the child‟s resources are within the T02 standard, the CM should Add-A-Program to determine the child‟s eligibility for T02. If the child is ineligible for T03 because the child‟s income is over 185% FPL, the child‟s income is greater than the cost-of-care and the child‟s resources are within the T02 standard, CARES will apply the T02 cost-of-care rules and the AU will go into spend-down (T99). Since CARES gives the AU Status Reason Code as only “401” to deny for over-scale resources, the CM should add the reason of “301” for over-scale income to the notice that CARES generates. CARES denies/closes the eligibility and does not allow the worker to update the medical expense screens to authorize spend- down. If the child is ineligible for T03 because the child‟s resources are also over-scale for the T02 standard, CARES denies/closes due to over-scale resources (Code 401). In the denial notice that CARE generates, the CM should also add the reason of “301” for over-scale income.

AU Screened in T05

For a child who is under age 19 but at least six years old: If the income is within 100% FPL, the T05 is eligible and certified for 12 months.

COMAR 10.09.24.03

378 State of Maryland Medical Assistance Manual Revised July 2012 If the child is ineligible for T05 because the child‟s income is over 100% FPL, but the child‟s income does not exceed the cost-of-care and the child‟s resources are within the T02 standard, the CM should Add-A-Program to determine the child‟s eligibility for T02. If the child is ineligible for T05 because the child‟s income is over 100% FPL, but the child‟s income is greater than the cost-of-care and the child‟s resources are within the T02 standard CARES will apply the T02 cost-of-care rules and the AU will go into spend-down (T99). If the child is ineligible for T05 because the child‟s income is over 100% FPL, but the child‟s income is greater than the cost-of-care and the child‟s resources are also over- scale for the T02 standard. CARES denies/closes due to over-scale resource (Code 401). In the denial notice that CARES generates, the CM should also add the reason of “301” for over-scale income.

III. Post-Eligibility Activity

T01 Who Loses TCA Eligibility When T01 recipient ages out of TCA eligibility, the recipient‟s LTC eligibility must be redetermined. If the recipient is unmarried and 21 years old, the Eligibility should be redetermined for T02. Otherwise, the recipient‟s LTC eligibility should be redetermined under the ABD rules for L98. If the F01 AU of a T01 child reports a change in countable resources to exceed the TCA categorically needy limit, both AU‟s will close down (closure reason “401”). CARES will not trickle. Before closing the T01 AU, the CM should Add -A- Program to redetermine eligibility in the T03-T05 coverage group, as appropriate based on the child‟s age. The T03-T05 coverage groups do not have a resource test. If the T01 recipient is an adult whose F01 AU loses TCA eligibility due to over-scale resources, the recipient should be given the opportunity to reduce resources in order to retain MA LTC eligibility in the L98 coverage group. If the resources are not promptly reduced, the T01 case should be closed with proper notice. If the F01 AU of a T01 recipient loses TCA eligibility due to over-scale income or another reason, CARES closes both the F01 and T01 AU‟s. Before closing the T01- T05 coverage group, as appropriate. Also, the T01 recipient should be removed as a non- member of the F-track AU, so the active T-track recipient will not case dual participation for the F-track AU.

T02 Who Becomes Resource- Ineligible

COMAR 10.09.24.03

379 State of Maryland Medical Assistance Manual Revised July 2012 If the child‟s resources become over-scale for T02 but the income remains within standard for T03-T05 depending on the child‟s age, CARES will trickle the AU to appropriate T-track coverage group with respect to the child‟s age. If the trickling does not occur properly, the MA CM should Add-A-Program to determine eligibility in the most appropriate coverage group.

T03-T05 Who Become Income- Ineligible

If the resources become over-scale for T02 but the income remains within standard for T03-T05 (based on the child‟s age) but does not exceed the LRCF‟s cost-of-care, the case manager should Add-A-Program to determine the child‟s eligibility for T02.

Child who Age Out of Coverage Group or No Longer Qualifies Due to Marriage

For a child in T03-T05, the CM should set an alert to trigger an unscheduled redetermination at least 90 days before the child reaches the age limit for the coverage group. The T03 should be tested for T04, the T04 should be tested for T05, and the T05 should be tested for T02. If the child being tested for T04 or T05 has resources that are within the T02 standard and the income is over the standard for T04 or T05, and the T05 (based on the child‟s age) but does not exceed the LTCF‟s cost-of-care, the CM should Add-A-Program to determine the child‟s eligibility for T02. If the child who is aging out of T05 is married, the CM must redetermine eligibility under the ABD rules of L98. When a child in T02 becomes 20 years old, the CM should set an alert to trigger an unscheduled redetermination at least 90 days before the child reaches 21 years old. The recipient‟s LTC eligibility should redetermined under the ABD rules for L98. When a child in T02 gets married, the CM must redetermine eligibility under the ABD rules of L98.

Unscheduled Redetermination When Recipient is Discharged for LTCF

When a T-track recipient is discharged from a LTCF an unscheduled redetermination is required. MA eligibility may not be terminated until it is determined that the recipient is not eligible for community MA or MCHP. The redetermination procedures for a child discharged from a LTCF are similar to the specific procedures discussed in Chapter 10, Redeterminations Procedures for Children Under the Age of 21 Being Discharged from IMDs, RICAs, or RTCs. For Adults discharged to the community, the policies and procedures are addressed on pages 1000-55 and 1000-56 of the MA Eligibility Manual.

COMAR 10.09.24.03

380 State of Maryland Medical Assistance Manual Revised July 2012 The LDSS must promptly trigger a redetermination of the recipient‟s eligibility for whatever coverage group fits the recipient‟s new circumstances.

o If the recipient returns to an active TCA household, the LDSS determines if the recipient should be added to the existing TCA AU, and so would become MA eligible in the F01 coverage group. o If the recipient‟s community household is not eligible for TCA or the F-Track, a child‟s eligibility may be determined in the P-Track and an adult‟s eligibility maybe determined in the S-Track. o If a child is discharged into State-sponsored foster care or subsidized adoption, eligibility is determined in the E-Track. o If the recipient is discharged into a home and community-based services waiver, eligibility is determined by the DEWS in the H-Track.

NOTE: ALL CASES ACTIVITIES MUST BE FULLY NARRATED IN CARES.

300.5 Pickle Amendment

The Pickle Amendment created a separate category of Medicaid eligibility. Under the Pickle Amendment, an individual who received both SSA and SSI benefits but became ineligible for SSI due to cost-of-living adjustments (COLA) in the SSA benefit will remain eligible for Medicaid if the individual would continue to be eligible for SSI benefits if the COLA increases in the SSA benefits were disregarded. The Pickle Amendment requires that an individual is to be deemed an SSI recipient

Pickle Amendment Eligibility Criteria:

Terminated from SSI at any time since April 1977 (regardless of reason for termination). Currently receiving SSA as an ABD. Concurrently received both SSI and SSA at time of termination, The SDX document, SSI termination and SSA award letters, or a combination of these may verify the concurrent receipt of SSA and SSI. Currently meets all non- financial requirements for SSI and; Would currently be eligible for a SSI payment if the amount of the COLAS received since termination were deducted from the gross income

New Applications:

COMAR 10.09.24.03

381 State of Maryland Medical Assistance Manual Revised July 2012 ABD applications for MA, including those preserved spend-down status. Must be considered for eligibility under the Pickle Amendment. CM determine if an aged, blind, or disabled receipt of SSA and meets the criteria of concurrent receipt of SSA and SSI. The applicants are designated as Potentially Pickle Eligible (PPE) and the recipients is Pickle Eligible, they will be certified under the Pickle Amendment For persons who apply under the Pickle Amendment only, but are found ineligible, MN procedures are applied only if it can be determined at the time of application that the person is eligible as medically needy. If it cannot be determined at the time of application, MN procedures are not applied. Pickle Eligibility is denied and the applicant is to be advised to reply time as medically needy. The case would be deemed as “PPE”

Developing the COLA Deduction:

In order to compute the COLA deduction, the CM must ascertain the date of SSI termination. (sources, SDX, case material or documents submitted by the applicant/recipient) The gross amount of the SSA, either at the time SSI was terminated or currently ( see Attachment A, Calculating worksheet for Pickle Amendment)

Pickle Amendment Certifications and Redeterminations:

Person determined eligible under the Pickle Amendment will have a twelve month certification period Certification begins the month of application All active MA cases labeled PPE must be reviewed annually at the time (Annual Review) of the Cost of Living Adjustment (COLA) to determine if the change in the SSI Income and Resource standards will affect their eligibility under the Pickle Amendment. For determination of SSI termination, certification begins the month following SSI termination For cases determined eligible during the Annual Review, certification begins the month the COLA is received PPE cases found eligible at scheduled or unscheduled redeterminations are certified at scheduled or unscheduled redeterminations are certified beginning the month Pickle Eligibility is established Pickle Amendment Instructions for Use of Notices DHMH 3803 Notice of Medical Assistance Eligibility for Former Supplemental Security Income Recipients

COMAR 10.09.24.03

382 State of Maryland Medical Assistance Manual Revised July 2012 This letter is used to notify all persons who are found eligible under the Pickle Amendment. Check the appropriate space in the heading of the letter, “Application” or “Redetermination”, and the corresponding space in the body of the letter. Complete the body with appropriate dates

DHMH 4214 Notice of Ineligibility for Medical Assistance (Pickle Amendment Applicant)

This letter is used to notify those persons who apply for Medical Assistance under the Pickle Amendment only and are found ineligible. These are persons who are not current Medical Assistance recipients and who file an application in response to the individual or public notice of potential eligibility.

DHMH 4215 Notice of Ineligibility under the Pickle Amendment (Current Recipients)

This letter is used to notify current Medical Assistance recipients that they have been considered for Pickle eligibility but have been found ineligible under this provision. These are current recipients who have had a Pickle determination made as a result of the onetime review or annual review. This letter does not affect the person‟s current eligibility as medically needy.

DHMH 4226 Notice of Termination of Medical Assistance (Pickle Amendment)

This letter is used to notify persons who were previously eligible under the Pickle Amendment that their eligibility has been redetermined and they are no longer eligible. Excess income and/or resource amounts are based on the medically needy standards that have been applied after the person was determined no longer eligible under the Pickle Amendment. If Pickle eligibility was lost due to a cessation of disability or blindness the person would be considered under MASO regulations and income is to be considered for a 3 month period. Persons who lose Pickle eligibility for other reasons will have income considered for 6 months under the ABD regulation. Circle the appropriate period

COMAR 10.09.24.03

383 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 1159F

Worksheet- Pickle Eligibility

A person is eligible under the Pickle Amendment if all factors are met.

If the response to any statement is “No”, do not continue worksheet; the person is determined ineligible under the Pickle Amendment.

Yes

No I. Terminated from SSI after April, 1977

Received both SSI and SSB prior to termination

Currently receives Social Security Benefits

II. Aged, Blind or Disabled

Citizenship, residency, etc.

III. Resources of $________________ less than or equal to SSI standard of _________________

IV. Income Calculation: Gross Monthly Income $_________ COLA Deduction - _____ Net Monthly Income $_________ less than SSI standard

$_________

COMAR 10.09.24.03

384 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 1159G

Worksheet- COLA Deduction

(Pickle Amendment)

Method A

Locate appropriate line based on SSI termination date.

Enter the amount of Social Security Benefit at time of SSI termination in Column 1.

Multiply by COLA factor, Column II, enter Product in Column III.

Enter the amount from Column III on the next line, Column I.

Continue until current benefit is reached.

I

II

III

SSI Terminated

Before:

Previous Benefit COLA Factor

Increased Benefit

July, 1977

______________ x 1.059

= __________________

July, 1978

______________ x 1.065

= __________________

July, 1979

______________ x 1.099

= __________________

July, 1980

______________ x 1.143

= __________________

July, 1981

______________ x 1.112

= __________________

July, 1982

______________ x 1.074

= __________________

Jan., 1984

______________ x 1.035

= __________________

Jan., 1985

______________ x 1.035

= __________________

________

______________x ___________ = __________________

________

______________x ___________ = __________________

________

______________x ___________ = __________________

Current SSB

$ _____________

Benefit at SSI Termination

$___________

COLA Deduction

$______________

COMAR 10.09.24.03

385 State of Maryland Medical Assistance Manual Revised July 2012 Method B

Enter current Social Security Benefit on Line I, Column I.

Divide by COLA factor, Column II, enter result in Column III.

Enter the amount from Column III on the next line, Column I.

Continue until benefit at the time of SSI termination is reached.

I

II

III

SSI Terminated

Most Before:

Current Benefit COLA Factor Previous Benefit

___________

______________ + _________ = _____________

___________

______________ + _________ = _____________

___________

______________ + _________ = _____________

Jan., 1985

______________ + 1.035 = _____________

Jan. 1984

______________ + 1.035 = _____________

July, 1982

______________ + 1.074 = _____________

July, 1981

______________ + 1.112 = _____________

July, 1980

______________ + 1.143 = _____________

July, 1979

______________ + 1.099 = _____________

July, 1978

______________ + 1.065 = _____________

July, 1977

______________ + 1.059 = _____________

Current SSB

$ ___________________

Benefit at SSI Termination

-

______

COLA Deduction

$ ___________________

COMAR 10.09.24.03

386 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 3802

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF MEDICAL ASSISTANCE ELIGIBILITY FOR FORMER SUPPLEMENTAL SECURITY INCOME RECIPIENTS

(Pickle Amendment)

Application

Redetermination

Date of Notice:_____________

Case Numbers: _____________

Dear __________________:

This is to notify you that:

Based on your application for Medical Assistance filed on _____________ you have been determined eligible effective _________________. Within a short time, you will receive a red and white plastic card. You must show your Medical Assistance card and any other health insurance membership cards for all health care services you have received or will receive.

Based on a review of your Medical Assistance eligibility you have been determined eligible effective _________________.

You will continue to receive your Medical Assistance cards until you are notified that you are no longer eligible. You will be required to reestablish your eligibility at least once every 12 months. You will be notified of this requirement at least 45 days before the expiration of your current eligibility period. The necessary instructions and forms will be made available to you at that time.

Except for Social Security benefit cost-of-living increases you receive, you must notify this agency of any changes in your circumstances or your family‟s circumstances such as employment, income, savings, property, stocks, bonds, marital status, living arrangement, address and telephone number. Any of these changes could affect your eligibility. You must report any changes in your situation within 10 working days of this change.

You have the right to request a hearing if you disagree with any decisions relating to your period of eligibility or the services provided. The procedures for requesting a hearing are in the back of this letter.

Sincerely,

_________________________________

Case Manager

__________________________________

DEPARTMENT OF SOCIAL SERVICES

__________________________________

TELEPHONE NUMBER

COMAR 10.09.24.03

387 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Hearings

If you are dissatisfied with any decision relating to your eligibility period or service coverage, you have the right to appeal that decision to the Department of Health and Mental Hygiene. You may obtain the necessary forms from the local department and if you wish, someone there will assist you in filing an appeal.

Your appeal must be filed within 90 days from the notice date on the other side of this letter. The hearing will be scheduled by the Department of Health and Mental Hygiene, at a place and time that is convenient for you. You will be expected to be present; or if for some reason you cannot be present, you must notify the Department of the identity of the person who will attend in your place. You may represent yourself or, if you wish, you may be represented by legal counsel or by a relative, friend, or other person, although it is not required that someone else represent you. You may bring any witnesses you desire to help you establish pertinent facts and explain your circumstances. A reasonable number of persons of the general public may be admitted to the hearing if you desire this. At least six (6) days before the hearing, the local department will send you a letter containing pertinent information, including the specific reason for your wanting to appeal.

COMAR 10.09.24.03

388 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4214

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY FOR MEDICAL ASSISTANCE (Pickle Amendment- Applicant)

Date of Notice: ________________ Case Number: _________________

Dear _____________________:

On __________________ you applied for Medical Assistance under the Pickle Amendment. This requires that you meet certain criteria and that your income and resources be compared to SSI standards. This is to notify you that you have been determined ineligible for the reason(s) checked below:

You are not currently receiving Social Security benefits due to age, blindness or disability.

You were not terminated from SSI since April 1977.

You did not receive both Social Security and SSI at the time of SSI termination.

You do not meet the non-financial requirements for SSI. (Specify) __________________________________________________________.

You failed to appear at the Local Department for the required interview.

You did not provide the information/verifications required to determine your eligibility.

Your total countable resources of $_____________ exceed the applicable SSI resource standard by $ __________________.

Your income exceeds the applicable SSI payment standard by $ ________ monthly. Your Social Security cost-of-living increases have been deducted in arriving at this amount.

Other (Specify) _______________________________________________

This decision is based on COMAR 10.09.24.03B (3). If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You also have the right to reapply and request that your eligibility be tested under the medically needy provisions.

Sincerely,

______________________________

Case Manager

______________________________

Department of Social Services

______________________________

Telephone Number

COMAR 10.09.24.03

389 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Hearing

If you believe the decision of the Local Department of Social Services is incorrect, you have the right to appeal that decision to the Department of Health and Mental Hygiene. You may obtain the necessary forms from the local department and if you wish, someone there will assist you in filing an appeal. Your appeal must be filed within 90 days from the date on the other side of this letter.

The hearing will be scheduled by the Department of Health and Mental Hygiene at a place and time that is convenient to you. You will be expected to be present or, if for some reason you cannot be present, you must notify the Department of the identity of the person who will attend in your place. Your may represent yourself, or, if you wish, you may be represented by legal counsel, a relative, friend, or other person, although it is not required that someone else represent you. You may bring any witness you desire to help you establish facts pertinent to your circumstances. At least six (6) days before the hearing, the local department will send you a letter containing pertinent information, including the specific action or inaction that you are appealing.

The Hearings Officer will decide whether the action of the local department was correct in its interpretation of the law and regulations. This decision will be sent to you as soon as possible, but not later than 90 days after the receipt of your request for a hearing, unless there is a delay because you request that the hearing be postponed.

COMAR 10.09.24.03

390 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4215

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY UNDER THE PICKLE AMENDMENT (Current Recipients)

Date of Notice: ___________ Case Number: ____________

Dear ______________________:

This is to advise you that your Medical Assistance case has been reviewed to determine if you are eligible under the Pickle Amendment. That amendment requires that you meet certain criteria and that your income and resources be compared to the appropriate SSI standards. This is to notify you that you have been determined ineligible under that amendment for the reason(s) checked below:

You are not currently receiving Social Security benefits due to age, blindness or disability.

You were not terminated from SSI since April 1977.

You did not receive both Social Security and SSI at the time of SSI termination.

You do not meet the non-financial requirements for SSI. (Specify) ___________________________________________________.

You did not provide the information/verifications required to determine your eligibility.

Your total countable resources of $_____________ exceed the applicable SSI resource standard by $ __________________.

Your income exceeds the applicable SSI payment standard by $ ________ monthly. Your Social Security cost-of-living increases have been deducted in arriving at this amount.

Other (Specify) _______________________________________________

This decision is based on COMAR 10.09.24.03B (3). Since you are a current recipient of Medical Assistance as a result of an earlier application, your eligibility will continue for the dates shown on your card unless you are notified otherwise.

You are still responsible for reporting changes in your situation which may affect your current eligibility.

If you believe this decision is incorrect, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You continue to have the right to reapply when your current eligibility expires.

Sincerely,

____________________________

Case Manager

____________________________

Department of Social Services

____________________________

Telephone Number

COMAR 10.09.24.03

391 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Hearing

If you believe the decision of the Local Department of Social Services is incorrect, you have the right to appeal that decision to the Department of Health and Mental Hygiene. You may obtain the necessary forms from the local department and if you wish, someone there will assist you in filing an appeal. Your appeal must be filed within 90 days from the date on the other side of this letter.

The hearing will be scheduled by the Department of Health and Mental Hygiene at a place and time that is convenient to you. You will be expected to be present or, if for some reason you cannot be present, you must notify the Department of the identity of the person who will attend in your place. You may represent yourself or, if you wish, you may be represented by legal counsel, a relative, friend, or other person, although it is not required that someone else represent you. You may bring any witness you desire to help you establish the facts pertinent to your circumstances. At least six (6) days before the hearing, the local department will send you a letter containing pertinent information, including the specific action or inaction that you are appealing.

The Hearings Officer will decide whether the action of the local department was correct in its interpretation of the law and regulations. This decision will be sent to you as soon as possible, but no later than 90 days after the recipe of your request for a hearing, unless there is a delay because you request that the hearing be postponed.

COMAR 10.09.24.03

392 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4226

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF TERMINATION OF MEDICAL ASSISTANCE (Former Pickle Amendment Recipient)

Date of Notice: __________________

Case Number: _____________________

Dear ______________________:

This is to notify you that based on a recent review of your eligibility for Medical Assistance; we have determined that you are no longer eligible effective _______________ for the reason(s) checked below: A. Financial:

Your countable income has increased from $ _____________ to ____________. This results in excess income of $ ____________ monthly or $ _____________ for a (circle one) 3 month 6 month period based on the applicable medically needy income level. This decision is based on COMAR 10.09.24.09C. You may become eligible again in the future if you receive medical expenses which equal or exceed the excess amount; however, you must reapply so that an accurate determination can be made.

Your resources exceed the applicable medically needy resource level by $ _______________. This decision is based on COMAR 10.09.24.09C(3). The excess amount must be used to pay for medical or necessary living expenses.

B. Non-Financial: You did not submit a completed and signed application for a redetermination of your eligibility. You failed to appear at the Local Department for the required interview. You did not provide the information/verifications required to determine continued eligibility. Other- Specify: ______________________________________________________. This decision is based on COMAR 10.09.24. ______________________________. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You also have the right to reapply at any time.

Sincerely,

________________________

Case Manager

________________________

Department of Social Services

________________________

Telephone Number

COMAR 10.09.24.03

393 State of Maryland Medical Assistance Manual Revised July 2012 Summary of Procedures for Hearing

If you are dissatisfied with the decision of the Local Department of Social Services, you have the right to appeal that decision to the Department of Health and Mental Hygiene. You may obtain the necessary forms from the local department and if you wish, someone there will assist you in filing an appeal.

Your appeal must be filed within 90 days from the notice date on the other side of this letter. If you request a hearing within 10 days of the date of the cancellation, your Medical Assistance benefits will continue until a decision is issued on your case. However, if you receive extended benefits pending a decision on your appeal and the hearing officer decides that the decision of the Local Department of Social Services was correct, you will be required to pay back the amount the Department paid for medical services you received during the appeal process. This will not be required if it is determined that your request for a hearing resulted from a bona fide belief that the decision of the Local Department of Social Services was in error.

The appeal hearing will be scheduled by the Department of Health and Mental Hygiene at a place and time that is convenient for you. You will be expected to be present, or, if for some reason you cannot be present, you must notify the Department of the identity of the person who will attend in your place. You may represent yourself, or, if you wish, you may be represented by legal counsel or by a relative, friend, or other person, although it is not required that someone else represent you. You may bring any witness you desire to help you establish pertinent facts and explain your circumstances. A reasonable number of persons of the general public may be admitted to the hearing if you desire this. At least six (6) days before the hearing, the local department will send you a letter containing pertinent information, including the specific reason for your wanting to appeal. The Hearing Officer will decide whether or not the action of the local department was correct in its interpretation of the law and regulations. This decision will be sent to you as soon as possible, but not later than 90 days after the receipt of your request for a hearing, unless there is a delay because you request that the hearing be postponed.

COMAR 10.09.24.03

394 State of Maryland Medical Assistance Manual Revised July 2012 MARYLAND MEDICAL ASSISTANCE PROGRAM

IMPORTANT NOTICE ABOUT YOUR MEDICAID ELIGIBILITY

IF YOU ONCE RECEIVED SSI BENEFITS YOU SHOULD READ THIS IMPORTANT NOTICE ABOUT YOUR ELIGIBILITY FOR MEDICAID BENEFITS. (If you never received SSI or if you now receive SSI or TCA or if you live in a Long-Term-Care facility, this notice will not apply to you.)

A federal law called the Pickle Amendment applies to people who meet three tests:

1. They now receive Social Security benefits (a green check); and

2. They used to receive SSI benefits (a gold check) but don‟t receive them now; and

3. They received both a Social Security and an SSI check in the same month, in at least one month since April, 1977.

IF YOU MEET ALL THREE OF THESE TESTS, YOU MAY BE ELIGIBLE TO RECEIVE THE SAME MEDICAID BENEFITS YOU RECEIVED WHEN YOU WERE GETTING SSI. To find out if you are eligible, you (or someone on your behalf) should contact your local Department of Social Services. For more information, call the Department of Social Services in your area. Phone numbers and addresses are listed on the back of this notice.

PLEASE NOTE THAT TO APPLY FOR MEDICAID UNDER THE PICKLE AMENDMENT, YOU OR YOUR REPRESENTATIVE MUST GO TO YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. TAKE THIS NOTICE WITH YOU WHEN YOU GO.

COMAR 10.09.24.03

395 State of Maryland Medical Assistance Manual Revised July 2012 MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF POTENTIAL RETROACTIVE ELIGIBILITY UNDER THE PICKLE AMENDMENT

Date: _______________________

Case Number: ________________

Dear ___________________________:

A review of your Medical Assistance case indicates that you may be eligible for retroactive coverage beginning November 1, 1984. This means that you may be eligible for payment or reimbursement for medical expenses incurred before you applied under the Pickle Amendment. In order to be eligible for this retroactive coverage you must:

- Have incurred medical expenses coverable under the Program during the period November 1, 1984 through _____________________;

- Complete the enclosed application and return it to the local Department of Social Services;

- Appear for a face-to-face interview; and

- Meet all eligibility requirements during the retroactive period.

If you did incur medical expenses during the period specified above, and you wish to apply for coverage or reimbursement of these expenses, complete the enclosed application and return it within 30 days of the date of this notice. A decision not to apply for retroactive coverage will not affect your current eligibility. You will remain eligible for Medical Assistance until you are notified otherwise.

Sincerely,

___________________________

Case Manager

___________________________

Department of Social Services

___________________________

Telephone Number

COMAR 10.09.24.03

396 State of Maryland Medical Assistance Manual Revised July 2012

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF RETROACTIVE ELIGIBILITY UNDER THE PICKLE AMENDMENT

Date:

Case Number:

Dear:

: This is to notify you that based on your application for retroactive Medical Assistance filed on

you have been determined eligible effective

through

. Within a short time, you will receive a red and white plastic card. You must show your Medical Assistance card and any other health insurance membership cards for all unpaid health care services you received during this period. If you have already paid for medical care received during this period. If you have already paid for medical care received during this period please see the enclosed notice for instructions on how to receive reimbursement for their expenses. This decision is based on COMAR 10.09.24.03B (3). Since you are a current recipient of Medical Assistance as a result of an earlier application, your eligibility will continue for the dates shown on your current card unless you are notified otherwise. You are still responsible for reporting changes in your situation which may affect your current eligibility. You have the right to request a hearing if you disagree with any decisions relating to your period of eligibility or the services provided. The procedures for requesting a hearing are on the back of this letter.

Sincerely.

Case Manager

Department of Social Services

Telephone Number

COMAR 10.09.24.03

397 State of Maryland Medical Assistance Manual Revised July 2012

Summary of Procedures for Hearings

If you are dissatisfied with any decision relating to your eligibility period or service coverage, you have the right to appeal that decision to the Department of Health and Mental Hygiene. You may obtain the necessary forms from the local department and, if you wish, someone there will assist you in filing an appeal.

Your appeal must be filed within 90 days from the notice date on the other of side this letter. The hearing will be scheduled by the Department of Health and Mental Hygiene at a place and at a time this convenient for you. You will be expected to be present at the hearing. If, for some reason, you cannot be present, you must notify the Department of the identity of the person who will attend in your place. You may represent yourself or, if you wish, you may be represented by legal counsel or by a relative, friend, or other person. It is not required thought that someone else represents you. You may bring any witnesses you desire to help you establish pertinent facts and explain your circumstances. A reasonable number of persons of the general public maybe admitted to the hearing if you desire. At least six (6) days before the hearing, the local department will send you a letter containing pertinent information, including the specific reason for wanting to appeal.

COMAR 10.09.24.03

398 State of Maryland Medical Assistance Manual Revised July 2012

MARYLAND MEDICAL ASSISTANCE PROGRAM Letter of Instructions on Reimbursement/Payment For Medical Expenses under the Pickle Amendment

Date of Letter:

Case Number:

Dear:

The attached letter indicates that you have been found eligible for Medicaid for the period / through /

/ . If during this period you made payment for medical services, you may be reimbursed if you provide written materials showing the type of service received, by whom it was provided, the amount charged and the amount you paid. This information should be obtained from the provider of the services, e.g., your physician, hospital, pharmacy, and should be sent to:

Division of Eligibility Services Medical Assistance Policy 201 West Preston Street Baltimore, Maryland 21201

If during this period for which you were eligible for Medicaid, you received services for which you did not make payment, please advise the provider of services that he should submit a claim to Medicaid in the usual fashion.

All claims and supporting materials must be received no later than 45 days from the date of this letter. Payment will be made only for services covered under the Medicaid State Plan in effect at the time the services were provided and only in the amount allowable under the State Plan.

If you have questions on how to seek reimbursement for yourself or payment for the provider of services, please call 410-767- 1463. Please indicate that you calling concerning reimbursement for medical services under the Pickle Amendment.

Sincerely,

Case Manager

Department of Social Services

Telephone Number

COMAR 10.09.24.03

399 State of Maryland Medical Assistance Manual Revised July 2012

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY FOR RETROACTIVE COVERAGE UNDER THE PICKLE AMENDMENT

Date:

Case Number:

Dear

:

This is to notify you that based on your application for retroactive Medical Assistance filed on

You have been determined ineligible for the retroactive period

through

.

You have been determined ineligible for that period for the reason(s) checked below:

You were not receiving Social Security benefits due to age, blindness or disability during that period

You did not meet the non-financial requirements for SSI during that period.

(Specify)

.

You did not provide the information/verifications required to determine your eligibility for that period.

Your total countable resources of $

exceeded the applicable SSI resources

standard by $

.

Your income exceeded the applicable standard by $

monthly.

Other (Specify)

.

This decision is based on COMAR 10.09.24.03B (3). Since you are a current recipient of Medical Assistance as a result of an earlier application, your eligibility will continue for the dates shown on you current card unless you are notified otherwise.

You are still responsible for reporting changes in your situation which may affect your current eligibility.

If you believe this decision is incorrect, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You continue to have the right to reapply when your current eligibility expires. Sincerely,

Case Manager

Department of Social Services

Telephone Number

COMAR 10.09.24.03

400 State of Maryland Medical Assistance Manual Revised July 2012

Summary of Procedures for Hearings

If you are dissatisfied with any decision relating to your eligibility period or service coverage, you have the right to appeal that decision to the Department of Health and Mental Hygiene. You may obtain the necessary forms from the local department and, if you wish, someone there will assist you in filing an appeal.

Your appeal must be filed within 90 days from the notice date on the other of side this letter. The hearing will be scheduled by the Department of Health and Mental Hygiene at a place and at a time this convenient for you. You will be expected to be present at the hearing. If, for some reason, you cannot be present, you must notify the Department of the identity of the person who will attend in your place. You may represent yourself or, if you wish, you may be represented by legal counsel or by a relative, friend, or other person. It is not required thought that someone else represents you. You may bring any witnesses you desire to help you establish pertinent facts and explain your circumstances. A reasonable number of persons of the general public maybe admitted to the hearing if you desire. At least six (6) days before the hearing, the local department will send you a letter containing pertinent information, including the specific reason for wanting to appeal.

COMAR 10.09.24.03

401 State of Maryland Medical Assistance Manual Revised July 2012

Worksheet - Pickle Eligibility

A person is eligible under the Pickle Amendment if all factors are met.

If the response to any statement is “No”, do not continue worksheet; the person is determined ineligible under the Pickle Amendment.

Yes

No

I. Terminated from SSI after April, 1977

Received both SSI and SSB prior to termination

Currently receives Social Security Benefits

II. Aged, Blind or Disabled

Citizenship, residency, etc.

III. Resources of $

less than or equal to SSI standard of $

IV. Income Calculation:

Gross Monthly Income $

COLA Deduction ˉ

Net Monthly Income $

less than

SSI standard $

COMAR 10.09.24.03

402 State of Maryland Medical Assistance Manual Revised July 2012

Worksheet- COLA Deduction

(Pickle Amendment)

Method A

Locate appropriate line based on SSI termination date.

Enter the amount of Social Security Benefit at the time of SSI termination in Column I.

Multiply by COLA factor, Column II, enter Product in Column III.

Enter the amount form Column III on the next line, Column I.

Continue until current benefit is reached.

SSI Terminated

I.

II.

III. Before: Previous Benefit COLA Factor Increased Benefit

July, 1977

× 1.059 =

July, 1978

× 1.065 =

July, 1979

× 1.099 =

July, 1980

× 1.143 =

July, 1981

× 1.112 =

July, 1982

× 1.074 =

Jan., 1984

× 1.035 =

Jan., 1985

× 1.035 =

×

=

×

=

×

=

Current SSB

$

Benefit of SSI Termination

-

COLA Deduction

$

COMAR 10.09.24.03

403 State of Maryland Medical Assistance Manual Revised July 2012

DHMH 1159G

Method B

Enter current Social Security Benefit on Line I, Column 1. Divide by COLA factor, Column II, enter result in Column III. Enter the amount from Column III on the next line, Column I. Continue until benefit at the time of SSI termination is reached.

I.

II.

III.

SSI Terminated Most

COLA Factor Previous Benefit

Before:

+

=

+

=

+

=

Jan., 1985

+

1.035 =

Jan., 1984

+

1.035 =

July, 1982

+

1.074 =

July, 1981

+

1.112 =

July, 1980

+

1.143 =

July, 1979

+

1.099 =

July, 1978

+

1.065 =

July, 1977

+

1.059 =

Current SSB

$

Benefit at SSI Termination

-

COLA Deduction

$

COMAR 10.09.24.03

404 State of Maryland Medical Assistance Manual Revised July 2012

Pickle Amendment Instructions for Use of Notices

1. DHMH 3802 Notice of Medical Assistance Eligibility for Former Supplemental Security Income Recipients

This letter is used to notify all persons who found eligible under the Pickle Amendment. Check the appropriate space in the heading of the letter, “Application” or “Redetermination”, and the corresponding space in the body of the letter, “Application” or Redetermination”, and the corresponding space in the body of the letter. Complete the body with appropriate dates.

For new applicants (non-recipients) check the first black in the heading and the body of the letter. For recipients found eligible as a result of the one-time review, annual review, scheduled or unscheduled redetermination, check the second black in the heading and the body of the letter.

2. DHMH 4214 Notice of Ineligibility for Medical Assistance (Pickle Amendment Applicant)

This letter is used to notify those persons who apply for medical assistance under the Pickle Amendment only and are found ineligible. These are persons who are not current Medical Assistance recipients and who file an application in response to the individual or public notice of potential eligibility.

3. DHMH 4215 Notice of Ineligibility Under the Pickle Amendment (Current Recipients)

This letter is used to notify current Medical Assistance recipients that they have been considered for Pickle eligibility but have been found ineligible under this provision. These are current recipients who have had a Pickle determination made as a result of the one-time review or annual review. This letter does not affect the person‟s current eligibility as medically needy.

4. DHMH Notice of Termination of Medical Assistance (Pickle Amendment)

This letter is used to notify persons who were previously eligible under the Pickle Amendment that their eligibility has been redetermined and they are no longer eligible. Excess income and/or resource amount are based on the medically needy standards that have been applied after the person was determined no longer eligible under the Pickle Amendment. If Pickle eligibility was lost due to a cessation of disability or blindness the person would be considered under MASO regulations and income is to be considered for a 3 month period. Persons who lose Pickle eligibility for other reasons will have income considered for 6 months under the ABD regulations. Circle the appropriate period.

COMAR 10.09.24.03

405 State of Maryland Medical Assistance Manual Revised July 2012

A Quick and Easy Method of Screening for Medicaid Eligibility under the Pickle Amendment Screening for Medicaid eligibility under the Pickle Amendment is quick and simple. The screening process will eliminate the great majority of those who are not eligible without the necessity of performing any mathematical calculations. For those who survive the initial screening and for whom mathematical calculations are required, the table below provides a simple formula for performing the necessary calculations.

The Screening Process is as Follows:

Step 1: Does the applicant receive Social Security benefits? If the answer is no, then the person cannot be Pickle eligible. If the answer is yes, go on to the next step.

Step 2: After April 1977, did the applicant receive SSI? If the answer is no, the person cannot be Pickle eligible. If the answer is “yes”, go on to step 3.

Step 3: CM should ask applicant, “When was the last month you received SSI?” Once month is provided CM should then verify State Verification and Exchange System (SVES) for ending date.

Step 4: Look up the month in which the person last received SSI in the following table. Find the percentage that applies to that month. Multiply the present amount of the applicants (and/or spouse‟s) Social Security benefits by the applicable percentage.

Example Mrs. Irma Gherkin received both Social Security and SSI checks in 1976-78. However, her SSI was terminated in March 1978 because she started receiving a private pension that, added to her Social Security benefits, raised her income to an amount above the 1978 SSI income limits. There have been gradual increases in her income since 1978. She now receives a Social Security benefit of $1,229 per month, which happens to be the average monthly benefit for retired workers. Her private pension is $275 a month, giving her a total of $1,504 monthly. In 2012, the income limit for SSI (taking into account a $20 general income disregard) is $718 for an individual. Thus, Mrs. Gherkin‟s income is over twice the SSI income limit, which her state has adopted as the Medicaid limit for persons who are aged, blind or disabled. You screen Mrs. Gherkin for Pickle eligibility as outlined above. Determining that the last month in which she received both Social Security and SSI was March 1978, you look up that time period in the

Following table and find the corresponding reduction factor (.273).

Multiply Mrs. Gherkin‟s current Social Security benefit of $1,229 by that factor, to determine her current countable “Pickle” income.

$1229 multiplied by .273 = $335 (“Pickled” Social Security income, rounded downward) $335 countable Social Security income + $275 private pension = $610 total countable “Pickle” income.

Since $610 is less than the current SSI income limit (including the standard $20 disregard) of $718,

Mrs.Gherkin is eligible for Medicaid, even though she is ineligible for SSI.

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Attachment A Reduction Factors for Calculating Medicaid Eligibility under the Pickle Amendment During 2012

If SSI was terminated during this period: Multiply 2012 Social Security income by

If SS was terminated during this period: Multiply 2012 Social Security income by:

If SSI was terminated during this period: Multiply 2012 Social Security income by: May- June 1977 .257

Jan.1988-Dec.1988 .508

Jan.1999-Dec. 1999 .717 July 1977- June 1978 .273

Jan.1989-Dec.1989 .528

Jan.2000-Dec.2000 .735 July 1978- June 1979 .290

Jan.1990-Dec.1990 .553

Jan. 2001-Dec.2001 .760 July 1979- June 1980 .319

Jan.1991-Dec.1991 .583

Jan.2002-Dec. 2002 .780 July 1980- June 1981 .365

Jan.1992-Dec.1992 .604

Jan.2003-Dec.2003 .791 July 1981- June 1982 .405

Jan.1993-Dec.1993 .622

Jan.2004-Dec.2004 .808 July 1982- Dec 1983 .435

Jan.1994-Dec.1994 .638

Jan.2005-Dec.2005 .829 July 1984- Dec 1984 .451

Jan.1995-Dec.1995 .656

Jan.2006-Dec.2006 .863 July 1985- Dec 1985 .466

Jan.1996-Dec.1996 .673

Jan.2007-Dec.2007 .892 July 1986- Dec 1986 .481

Jan.1997-Dec.1997 .693

Jan.2008-Dec.2008 .912 July 1987- Dec 1987 .487

Jan.1998-Dec.1998 .707

Jan.2009-Dec.20011 .965

i. Due to Social Security‟s rounding rules, the adjustment factors in the table produce an approximate, rather than exact, figure. Because a discrepancy of one cent may mean the difference between Medicaid eligibility as a Pickle case and no meaningful access to health care, advocates should obtain exact information from the Social Security Administration if the figure produced by the screening method results in a determination that the client is over the eligibility limit by a small amount (i.e., $20 or less).

ii. Due to the recession, the cost of living did not increase for two years after 2008. Therefore, there was no Social Security COLA in 2010 or 2011. The cost of living increased by 3.6% in 2011, causing SSI income limits to increase by that amount in January 2012. Because of this history, the Pickle reduction factor is the same for individuals who lost SSI in 2009-2011.

Attachment B

Social Security Cost of Living Adjustments

Date of Increase Increase COLA Factor Jan., 1985 3.5% 1.035 Jan., 1986 3.1% 1.031 Jan., 1987 1.3% 1.013 Jan., 1988 4.2% 1.042 Jan., 1989 4.0% 1.040 Jan., 1990 4.7% 1.047 Jan., 1991 5.4% 1.054 Jan., 1992 3.7% 1.037 Jan., 1993 3.0% 1.030 Jan., 1994 2.6% 1.026 Jan., 1995 2.8% 1.028 Jan., 1996 2.6% 1.026 Jan., 1997 2.9% 1.029 Jan., 1998 2.1% 1.021 Jan., 1999 1.3% 1/013 Jan., 2000 2.4% 1.024 Jan., 2001 3.5% 1.035 Jan., 2002 2.6% 1.026 Jan., 2003 1.4% 1.014 Jan., 2004 2.1% 1.021 Jan., 2005 2.7% 1.027 Jan., 2006 4.1% 1.041 Jan., 2007 3.3% 1.033 Jan., 2008 2.3% 1.023 Jan., 2009 5.8% 1.058 Jan., 2011 3.6% 1.036

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Attachment C

SSI Resource Standards Effective Individual Couple 1/1/1974 $1,500.00 $2,250.00 1/1/1985 $1,600.00 $1,450.00 1/1/1986 $1,700.00 $2,550.00 1/1/1987 $1,800.00 $2,700.00 1/1/1988 $1,900.00 $2,850.00 1/1/1989- 1/1/2012 $2,000.00 $3,000.00

Note: The SSI Resource Standard limits have not changed since 1989.

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Section 300 Frequently Asked Questions and Answers Coverage Groups

1. What is a coverage group? A coverage group is a group of persons who must satisfy a common set of requirements for determining eligibility for Medical Assistance 2. What is a “Track” and what are some of the most common ones? A track is a group of related coverage groups. Currently there are 11 tracks. The same eligibility rules are used for all coverage groups in the same track. Children placed in foster care or subsidized adoptions (E-Track) Low income pregnant women and children in the Maryland Children‟s Health Program (MCHP) (P-Track) Uninsured children under the age of 19 whose income is above 200% but below 300% of the Federal Poverty Level. (D-Track) Aged, blind, or disabled individuals (ABD) (S-Track) Refugees (G-Track) Family and Children (FAC) –F-Track Aliens (X02) Long term care (LTC) cases have their own tracks, o ABD individuals (L-Track) o Children and Temporary Cash Assistance (TCA) adults and Family Long Term Care (T-Track)

3. What is the Pickle Amendment?

Under the Pickle Amendment the program establishes Medical Assistance eligibility for certain former SSI recipients who currently receive Social Security benefits. These are the persons who would still be eligible for SSU payments if their income were reduced by the total amount of all Social Security Cost of Living Adjustments (COLAS) received since their SSI was terminated. The person would be deemed as a SSI recipient. 4. Can an ineligible or illegal pregnant woman apply for Labor and deliver only service prior to birth? Yes, the ineligible or illegal pregnant immigrant can now file an application with the (LDSS) and LHD prior to the birth of a child. 5. Is it possible to be dually eligible for Medicare and MA services? Yes, a recipient in QMB Buy-in only program, that meets spend-down is considered dual eligible.

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Section 400 Table of Contents Application Requirements 400.1 Introduction-MA Application Process (Form) (a) Provision of Public Information (b) Representative (c) Application Date

400.2 Persons Eligible without filing a separate application (a) Recipients of Public Cash Assistance (b) Child Born on or after 10/1/1984 to a MA-Enrolled Mother (1) Certification Procedure for the Newborn Effective 6/1/1985 (2) Certification Procedure for the Newborn of Temporary Cash Assistance (TCA)

Recipient 400.3 Person Required Filing an Application

400.4 General Requirements for Establishing Eligibility (a) Signature Requirements for Establishing Eligibility (1) Family and Children (FAC) Unit Signature Requirements (2) Aged, Blind, or Disabled (ABD) Unit Signature Requirements

400.5 Voluntary Withdrawal

400.6 Eligibility Determination Process (a) Face to Face Interview ( no longer required) (1) Telephone Interviewing Tips (2) Interviewing Responsibilities of the CM Attachment A- Request for Information to Verify Eligibility (b) 401Waiver of Face to Face with the Representative (c) Exploring Alternative Avenues of Eligibility (d) Screening Applications for MA Extension (F02 and F03) (e) Verification Requirement

(1) Due Date for Verification

(2) Required Verification (3) Declaration of Information if Confirmed Impediment to Timely Verifications (f) Reapplication (Reactivation following Rejection of an Application (g) Extension of Time Standards (1) Explanation (2) Explanation of Justification Requirements for Extension of Time (h) Retroactive Eligibility (i) Retroactive and Current Periods

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400.7 Special Verification Requirements for Persons in or Planning to Enter an LTC (a) Period under Consideration (1) Summary of Requirement (2) Disposition of Application (b) When Verification is not Required

400.8 Requirements to Apply for Benefits (a) Social Security Number (b) Required Case Activity

400.9 Public Assistance for Adults (PAA)- MA Retroactive Coverage Procedures (a) General

400.10 Category Selection

400.11 Third Party Liability

400.12 Wage-Screening Inquiry

400.13 Case Record Management

400.14 Request to Add New Family Members (a) Disclosure of Information

400.15 Filing an Application for Medicare Part A

400.16 Applications Procedures Specific to Institutionalized Persons (a) Person/s who can complete the application (b) Person/s able to be a representative (c) Face to Face Interview (d) Application Signature Requirements (e) Assistance Unit Requirements (f) Period under Consideration (g) Verification Requirements Specific to Long Term Care (LTC) Eligibility

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400.17 Steps Taken to Complete Form (a) Demographic Information (b) Income (c) Resources (d) Life Insurance (e) Real Property

400.18 Verification for Deductions from Available Income for the Cost of Care (a) Health Insurance (b) Residential Maintenance Allowance (c) Spousal Maintenance Allowance

400.19 Good Faith C, Concept

400.20 Post Eligibility (a) For Eligible Person (b) For Ineligible Person Attachment A- Notice of Ineligibility Due to Excess Income Frequently Asked Questions (FAQs) and Answers

Objectives for Section 400

1. Explain the Application Process in detail; 2. Provide requirement for establishing eligibility; 3. Clear explanation for the application procedures for institutionalized persons.

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400.1 Introduction -Application Process (Form)

An individual interested in applying for Medical Assistance (MA), or a representative may contact the Local Department of Social Service (LDSS) or Local Health Department (LHD) or go online at www.marylandsail.org to complete the appropriate application form, based on the type of coverage requested. The MA application form is the instrument which information pertinent to the determination of eligibility is gathered from the Applicant/Representative (A/R) or the A/R’s representative. DHMH designates which forms may be used as MA applications and which forms establish the application date. Screening forms, such as the DHR/FIA Cares 9711 Request for Assistance, are not approved by DHMH as MA application forms.

A person requesting to file an MA application must be given an opportunity to apply without delay. The application must be made available to the person upon request.

The individual must complete the application and mail, fax or hand delivers it to their LDSS or LHD where they live. Addresses of the LDSS or LHD are located in Appendix A and Appendix B.

Applicants can also send your applications electronically through the Service Access & Information Link (SAIL) system at www.marylandsail.org.

An individual who temporarily leaves the state but intends to return may apply by mail.

In the case of a deceased person who did not apply before he/she died, a representative may complete, sign, and file an application on his or her behalf. Example: Died 7/2/2007 has bills for April, retro would be for April/May/June (retro would only be for the requesting month). Certification would end the date of death 7/2/2007.

If an individual need help applying for benefits, have questions, or do not speak English and need free translation services, please call 1-800-456-8900 or 1-800-332-6347. Si necesita ayuda para Llenar el formulario favor de llamar al 1-800-456-8900 o 1-800-332- 6347. The individual must be made aware of the significance of the date of application and its effect on retroactive eligibility, and be provided a list of basic information required.

(a) Provisions of Public Information

If anyone request public information about their MA eligibility or the process, the Case Manager (CM) must provide the following information orally or in writing:

Available MA services MA requirements Income Policies/Spend down explanation Case manager never make a determination over the phone or without gathering all of the information.

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(b) Representative

A representative may assist the A/R in the application and redetermination process and in other matters related to the A/R’s MA eligibility. Only one designated representative at a time may be recognized as authorized to act on the A/R’s behalf. Designation of a representative is indicated in writing on the MA application form or a letter submitted to the Department or its designee.

An A/R who is at least 18 years old and mentally competent to provide information required by the Department is not required to have a representative, but may choose to designate a representative to provide assistance or act on the A/R’s behalf in matters related to MA eligibility. A pregnant woman of any age is not required to have a representative and may sign the application and attend the interview on her own behalf, even if she is younger than 18 years old. A child younger than 18 years old (unmarried and not pregnant), or an individual who is not mentally competent to provide required information. Must have a representative designated writing to act on the individuals’ behalf in matters related to MA eligibility. A representative may be one of the following individual who is at least 18 years old:

o An individual who is related to the A/R by birth or marriage; o The A/R’s legally recognized guardian or representative with power-of- attorney; o The caregiver with whom an A/R younger than 18 years old lives, if the child does not live with the child’s parent or other caregiver relative; o An individual designated by the A/R if the A/R is at least 18 years old; o A provider’s representative/hospital/institution o The A/R’s legal counsel o A governmental representative who is not involved with determining the A/R’s MA eligibility (e.g. social services social worker) o Anyone that can provide the required information o The representative must be 21 years of age to sign the application for someone under 21.

(c) Application Date

A written, signed application received by the LDSS/LHD (either by mail, fax, or in person) must be registered with an application date upon receipt. The LDSS/LHD must date stamp the application on the day it is received, even if the application is filed in a Maryland jurisdiction where the applicant does not live, as long as the applicant lives in another Maryland jurisdiction. There can be no delay in registering the application for any reason.

The application date is the date that the LDSS/LHD or other designated entity receives a MA application with appropriate signature on a form approved by DHMH. Mail in or faxed applications and signatures are accepted. Applicants may also apply online at www.marylandsail.org.

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Following the initial eligibility determination, communication between the LDSS/LHD and the recipient or representative is usually by mail or telephone. Faxes and emails are not used to request or provide information. Redeterminations are conducted through a mail-in process. A redetermination package, including an application form and a notice with the due date, is mailed to the recipient or representative, who completes and returns the package with any required verifications to the LDSS/LHD in mail.

400.2 Persons Eligible for MA without Filing a Separate Application

(a) Recipients of Public Cash Assistance

Recipients determined eligible for the following types of public cash assistance (Even if they are in a no-pay status) are eligible for MA without filing a separate MA application. Supplemental Security Income (SSI) coverage groups L01 and S02 Temporary Cash Assistance (TCA) coverage groups F01-F03 Public Assistance to Adults (PAA) coverage groups S01 Foster Care or subsidized adoption under Title IV-E of the Social Security Act (Coverage group E01); and (Refugee Cash Assistance (RCA) coverage groups G01 and G02

(b) Child Born to a MA-Enrolled Mother

Newborn (NB) are presumptively eligible for MA for a period up to 15 months if the mother is enrolled as a Maryland MA recipient on the date of the newborn’s birth. The NB’s MA coverage is tied to the mother’s MA enrollment for the date of birth. Therefore, an application and determination of the newborn’s eligibility are not required in order to add the newborn to the mother’s currently eligible Assistance Unit (AU). Coverage of the newborn under this policy applies irrespective of any ineligibility factor that may pertain to the newborn, except that the newborn must be a Maryland resident.

If the mother is determined eligible for MA or the Maryland Children’s Health Program (MCHP) for a certification period including the newborn’s birth, the child is certified in coverage group P03, unless the mother was eligible in coverage group P11. Then, the newborn is certified in coverage group P12. The presumptive eligibility for the newborn applies even if:

The mother is determined eligible for the date of birth after the fact; or The mother is eligible in the X-track for ineligible or illegal aliens.

The newborn continues to be presumptively eligible in coverage group P03 or P12 for one year from the month of birth, unless the newborn moves from Maryland, dies, or becomes eligible in a different MA coverage group (e.g., T-track for long term care or E-Track for foster care or subsidized adoption). Therefore, the newborn retains eligibility in P03 or P12 even if the mother loses MA eligibility or the baby moves out of the mother’s household during the baby’s 15- month certification period. After 15 months of MA, a Redetermination must be conducted.

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Requirement: Baby must reside in Maryland

If the newborn is added to a TCA AU (coverage groups F01-F03), the newborn’s eligibility may be affected by a change in circumstances of any family member; including the newborn, which makes the TCA AU ineligible. Then, each AU member, including the newborn, must have their MA eligibility determined for the most appropriate coverage group. The newborn’s automatic eligibility in the TCA AU is also lost if the newborn ceases living with the mother. Upon expiration of the newborn’s presumptive eligibility period, a redetermination must be conducted to determine the child’s continued eligibility, applying regular policies and procedures. Timely redeterminations are required to assure that coverage is not continued inappropriately. Eligibility factors pertaining to the newborn which could not be considered during the 15-month presumptive eligibility period must be considered at this time. A MA ineligible child must be considered for possible coverage under MCHP.

(1) Certification Procedure for the Newborn

Certification of a NB on MA master file is initiated by the DHMH office of Eligibility Services (OES). This procedure expedites certifications of newborns and must be followed by both hospital and LDSS/LHD. The procedure is as follows:

OES is notified by hospital via the DHMH form 1184(Hospital report of NB), that a child has been born to a mother who is a MA or MCHP recipient. OES certifies NB on MA Eligibility Verification System (EVS) master file using the mother’s case number to establish a temporary case number until the CARES interface assigns a permanent case number for the child. Therefore, the child will not have a CARES IRN at this point. OES sends a completed 1184 to LDSS/LHD, as appropriate, for eligibility processing Upon receipt of an 1184, the LDSS/LHD case manager must make determinations on their own: a. Was the mother eligible for the date of the NB birth b. If eligible, add the NB to the mother’s AU# (add program/add person- more members). c. Review the 1184 for any errors or inconsistencies (name, address, eligibility, dates, category codes, etc) and take necessary corrective action as needed d. If there is a discrepancy between the CARES and MMIS as to whether the mother was MA/MCHP eligible for the date of the child’s birth, the LDSS/LHD case manager reviews the case record to determine the correct eligibility status and then takes the appropriate action. e. If mother’s eligibility ends, the baby (PO3) will received MA for 15 months. f. Note: No application is needed to add the NB g. If the mother gives up legal custody of the NB and the child does not go home with the mother, the NB does NOT automatically qualify for the MA/MCHP. The caretaker for the child would have to apply for the child

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h. The newborn’s eligibility should terminate, however, if the child moves out-of-state. Then, terminate eligibility in accordance with timely and adequate notice requirements i. If an LDSS or LHD is informed of a newborn’s birth but the hospital or clinic failed to initiate the DHMH 1184 process, the LDSS/LHD must take action on its own to determine if the infant is automatically eligible for MA. The LDSS/LHD must determine if the mother was eligible for the date of the newborn’s birth and if that eligibility currently exists. If the mother continues to be eligible, the LDSS/LHD case manager adds the newborn to the mother’s unit.

(2) Certification Procedure for the Newborn of a Temporary Cash Assistance recipient

The TCA policy in regard to adding a newborn to the TCA grant is outlined in the TCA manual. The client will be given a copy of the DHMH form1184 by the hospital. The DHMH form 1184 can be used for birth verification so that the newborn may, if otherwise eligible, be added to the TCA assistance unit. If a child is born to a TCA applicant in the month of application and the mother is found eligible in that month, certifications of the newborn’s MA and certifications for the mother and other eligible members of the TCA unit begins the first day of the month in which they were found eligible for TCA. If the child was born prior to the month of the applicant/mother’s eligibility for TCA and there are outstanding medical bills, refer to the policies for Non-Public Assistance for Adults (NPAA) MA or MCHP for determination of retroactive eligibility.

400.3 Person Required to File an Application

All persons requesting MA (or for whom MA is requested) who are not SSI or TCA recipients are required to file an written, signed, application with the LDSS/LHD in order for an eligibility determination to be made.

CM must provide the following information to customer:

Application date Retroactive months (retro) List of information needed and why Due date for information Customer must report any changes that come about within 10 business days

400.4. General Requirements for Establishing Eligibility

A signed application which is not completed to full specifications is still acceptable for the purpose of registering the application date. However, an application which has no signature does not constitute a valid application even if it is otherwise complete. Such an application must be immediately returned to the person with an explanation of the reason for the return and will not be registered with an application date until it is signed and returned to the LDSS/LHD. Listed below are application requirements for an application to be completed:

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(a)Signature Requirements for Establishing Eligibility

No signature, application can NOT be completed-return to the customer. Signed but not complete can be pended An applicant is required to sign the application under penalty of perjury Applicants include both spouses (relaxed to one signature) Applicant include both parents of children if both parents are in the home (this has been relaxed and only one signature is necessary) The Care Taker Relative other than Parent (CTROP) and spouse of the CTROP if the spouse of the CTROP wants to be included for the program and resources and income would be counted Spouse to spouse Parent to child

(1)Family and Children (FAC) Unit Signature Requirements

Both parents must sign if they are both in the home. This has been relaxed so that only one signature is necessary. Married couples with children-both to sign (Flexible signature so only one signature is necessary) 18 years old or older not living with parent-or CTROP emancipated minor child may sign the application for both filing and eligibility purposes. In this instance the LDSS must make efforts to contact the parents and verify child’s living arrangement and insurance coverage. Child living with CTROP-CTROP to sign An authorized representative who is 21 years old or older must sign the application for an unmarried child younger than 18 years old that is not living with a parent or CTROP. They can be one of the following:

a. A person with court order b. Legal guardianship or custody of the applicant c. The adult with whom the child lives d. A person chosen and authorized by the applicant to represent him when no one else is available.

(2) Aged, Blind, or Disabled (ABD) Unit Signature Requirements

A blind or disabled child who is 18 years old or older and competent may sign for his/her own application. An ABD applicant, if competent and able to do so must sign his/her own application

For the purpose of establishing only the date of application, the applicant or a person acting on behalf of the applicant may sign the application form. If the applicant is not competent or is unable to sign, the application must be accompanied by an affidavit from a physician that verifies that the applicant is not

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competent or is physically unable to sign the form. If the application is accompanied by such an affidavit than an authorized representative can sign If a child is blind or disabled and because of age or incompetence is not abele or permitted to sing, the parent with whom the child lives must sign for the child The representative must sign for a blind or disabled child who does not lie with his/her parents and is unable to sign because of age or incompetence

400.5 Voluntary Withdrawal

A person who has filed an application may voluntarily withdraw that application. The application form however remains the property of LDSS/LHD. The withdrawal of an application does not alter a penalty period associated with the disposal of a resource.

Note: If customer applies again and includes the month of the prior w/d, the original application is reactivated and sets the period under consideration (eliminates applying for retro).6 months to consider income and verifications. Customer will be eligible for a year.

When an applicant formally withdraws an application, they cannot subsequently be forced to apply for Medical Assistance for a prior month for which they do not want coverage. Therefore, any applicant who formally withdraws an application and subsequently applies for a later period only should have their period under consideration set by the latter, not withdrawn application. If a subsequent application includes the month of the prior withdrawn application, the original application is reactivated and sets the period under consideration.

400.6 Eligibility Determination Process

Once an application has been filed with the LDSS/LHD and the date of an application has been established, the process of determining eligibility, with its time limitations, begins.

The LDSS/LHD CM must make a prompt decision on each application that is filed. The decision must be made no later than 30 days from the date of the application or, if the case involves a determination of disability, no later than 60 days from the date of application. Refer to section entitled: Extension of Time Standards” for exceptions to this rule. The 30 and 60-day time limits refer to the date the notice of decision is actually mailed to the applicant.

A decision of eligibility or ineligibility is based on MA policy and procedures. Persons who apply as ABD are SSI-related and the eligibility requirements are basically those of the SSI program. People who apply as FAC are TCA related and the eligibility requirements are basically those of the TCA program a single assistance unit may not be a combination of the two.

The eligibility determination process involves a number of steps and procedures:

Interviewing the A/R by phone or ( in person) Obtaining appropriate signatures on application Establishing the period under consideration; and Obtaining necessary documentation and verification

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(a) Face to Face Interview ( no longer required) 1. The face-to-face interview is no longer mandatory, but may be required at the discretion of the CM or at the request of the A/R. 2. When it is determined that a face-to-face interview is required, the LDSS/LHD CM or at the request of the A/R. 3. When it is determined that a face-to-face interview is required, the LDSS/LHD CM shall arrange for the interview 4. The primary purpose of the interview should, shift from filling out the application to reviewing the filed application, interviewing for its accuracy and completeness, and making the necessary adjustments.

The CM should prepare for the interview in advance of the scheduled time. It is reasonable to assume that some filed applications will not be accurate or complete. The expectation is that those who are able to complete the application themselves should do so in a setting that is independent of the interview. Local departments must decide on a case-for-case basis whether to require a person to finish an incomplete application from before the interview or whether to assist the person in completing the application form during the interview.

(1) Telephone Interviewing Tips

An interview, whether face-to-face or by telephone, is structured communication for the purpose of gathering necessary customer information to assist in determining eligibility. Its success depends on the skill of the interviewer and the rapport that develops between the interviewer and the customer.

a) Plan the telephone interview. It requires preparation. 1. Get organized 2. Decide the objective of the call a. What is it you need to know? b. Why are you calling the customer? 3. Familiarize yourself with relevant past and current information 4. Write down all information needed 5. Gather complete and accurate information

b) During the interview 1. Confirm your understanding of the circumstances a. Ask questions until you are clear on all issues, b. Request the customer repeat them back to you 2. Use a good closing statement to prevent unnecessary and time-consuming phone calls to and from customers. a. Examples: “Is there anything else you need to tell me before we hang up? “Do you have any questions for me?

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“Do you know what information you need to send/bring in? “Do you understand all that we talked about?”

CM must report on the number of telephone interviews completed, it is important that CM code and document to capture when the interview is completed by phone

(2) Interviewing Responsibilities of the CM

The CM has both the authority and responsibility to ask questions beyond those stated on the application form when appropriate for an accurate determination of eligibility. The questions should better enable the CM to:

Analyze the information provided Collect additional information ( letter will be mailed describing additional information to bring) (Appendix A) Reconcile inconsistencies Discuss potential entitlement to benefits not being received and to refer for an application of benefits Inform the A/R of his/her responsibility for the accuracy and completeness of the information provided Explain the various assistance unit choices and exclusion options to the A/R and engage him/her in the decision-making process Make the necessary adjustments on the application form based on the A/R’s selection options; Obtain all required signatures on the application; Establish separate cases as needed based on the choices of the A/R and the provisions of Regulation .06; and Perform whatever other tasks are needed.

It is important that:

1. The CM’s time be used in the most efficient manner: 2. Persons who are capable, take responsibility for the completion and signing of original application is reactivated and sets the period under consideration and their Application; and 3. Appropriate assistance is provided to persons who are not capable of taking responsibility for completing their own application. The CM may, however, apply reasonable and practical measures to encourage applicants to speed up the application process for their own benefit and that of the LDSS CM assisting those applicants who need help in establishing their eligibility and who have no responsible person to act on their behalf. Local departments will need to: Provide applicants with a clear explanation of the information needed to establish eligibility, why it is needed, and how it will be used;

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Set time limits for applicants to provide the required information. The due date should be reasonably related to the types and amount of information to be collected and the source(s) of the information; and Provide applicants with a written list of the required information and the types of acceptable verifications. The last part of the interview should be devoted to a discussion of The general use of the MA card; The rights and responsibilities of applicants; Fraud and abuse, and the consequences of committing either or both; The requirements to report changes in family circumstances, including changes in household makeup; The spend-down provision; The redetermination process: and Other subjects as needed on a case-by-case basis, including a clear explanation and a written statement of additional required information.

The above items need to be discussed in all cases except those whose technical (non-financial) ineligibility is determined prior to or during the interview. Every effort should be made to avoid the necessity of more than one face-to-face interview. Good planning and effective interviewing can result in considerable time saving and improved case management.

The A/R may be assisted by a person or persons of his choice in the application process and may be accompanied by this person or persons to the interview.

When it is determined, the interview may be conducted with an authorized rep or a person responsible, when it cannot be conducted with the applicant because of unusual circumstances such as severely incapacity disabilities, which preclude the applicant’s appearing at the local department. All institutionalized persons are presumed to meet this criterion.

The waiver also generally applies to chronically, ill, housebound, immobile persons who may not be aged and who are largely dependent upon others to perform their required day-to-day activities for an indefinite period of time. Many persons who are unable to meet the face-to-face interview requirement are able to provide information about them. In these situations, the representative who completes and signs the application for the person and appears for the face-to-face interview should make every effort to enlist the person’s aid.

In the case of an unmarried person younger than 18 years old who is not living with a parent or a Caretaker Relative Other than Parent (CTROP), the face-to-face interview may be conducted with one or more of the following persons, 18 years or older:

a) The parent or other knowledgeable relative of the child; b) The non-related person with whom the child is living; or c) Another designated responsible person who is knowledgeable about the child’s circumstances.

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If the interview cannot be conducted with any of these persons, then another designated responsible person who is knowledgeable about the child’s circumstances is acceptable. In either case, the parents, if living in the state, should be contacted by CM to verify the child’s physical separation from the parents, the child’s income and resources, and whether or not the parents have the child covered under any health insurance plan. Whoever acts on behalf of the child must provide all information that is pertinent to an accurate determination of eligibility.

For a child in the custody of a public or private agency, a representative of the agency may complete and sign the application. The representative must insofar as possible, include the parents, foster parents, or other knowledgeable persons in the collection of information. Many of these children have income, resources, and health insurance coverage, all of which are pertinent to the eligibility determination process and are usually not known unless there is contact with those who are knowledgeable about their situation.

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Attachment A-Request for Information to Verify Eligibility

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(b) 401 Waiver of Face to Face Interview with the Representative

The LDSS/LHD may waive the requirement for a face-to-face interview with a representative of a public or private agency who files on application for Medical Assistance (DHMH 115B (7/83)) on behalf of a child under 21 committed to the agency.

Public and private agencies including the department of Juvenile services (DJS), Social Service Administration (SSA), Mental Retardation/Developmental Disabilities Administration, Associated Catholic Charities, and Family and Children’s Society.

It may waive the requirement if, in gathering information required for the child’s placement, the representative has had recent face-to-face contact with his parent or guardian or, in the absence of one of these, some other responsible person who is knowledgeable about the child’s circumstances. Face-to-face contact between a representative and a parent or a guardian may be deemed to satisfy the face-to-face interview requirement. Provided the LDSS meets the additional requirements which follow.

The LDSS/LHD must contact the person who completed the application and determine:

1. If the information contained in the MA application was gathered from recent contact with the parents or other responsible persons; and 2. The dates and type(s) of contact (e.g., face-to-face, letter, or telephone).

In the context of this requirement, “recent” means the month of the application or the month prior to the month of application.

The LDSS/LHD must also discuss with the representative the responsibility to report all changes, proper use of the card, etc.

If, based on this contact, the LDSS/LHD is not satisfied that the information necessary to determine eligibility has been recently gathered and is complete and accurate, waiver of the face- to-face interview may not be allowed. (For persons residing in or entering a long-term care facility, see section entitled “Application Procedures Specific to Institutionalized Persons”).

(c) Exploring Alternative Avenues of Eligibility

The MA program has numerous eligibility coverage groups. For eligibility determinations, local departments must have systems and processes in place that explore all reasonable avenues of eligibility. At application, these systems must ensure that eligibility is tested beyond the first designated coverage group. At redetermination, these systems and processes must first consider whether the individual continues to be eligible under the current coverage group and, in the case of a negative finding, explore eligibility under other possible coverage groups. The extent to which, and the manner in which, other possible coverage groups must be explored will depend on the circumstances of the case and the information available to the local department.

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In the event that an applicant fails to qualify in the first coverage group in which they are tested, the local department must test the applicant in other possible coverage groups for which they may qualify. This may include testing eligibility beyond a CARES-generated sprout, as from F99 to the P-track. In order to conduct this additional test, the local department must gather enough information from the applicant to establish which coverage groups may be possibilities. Possible questions for the applicant include, but are not limited to:

Does the ABD applicant have a related minor child in his/her care? Does the FAC applicant (adult or child) have a disabling condition or visual impairment? Is the FAC applicant a Medicare recipient?

Information gathered from questions such as these will enable the local department to test the applicant in alternative coverage groups for which the applicant may qualify. Where there is more than one potential coverage group and the applicant chooses one over another in the Informed Choice discussion, this should be noted in the case narrative.

The declaratory statement (medical coverage statement), ordinarily completed in MCHP applications, should also be completed for TCA and FAC applications. Eligibility in the F- track would not be precluded if it is missing. However, eligibility in coverage group P14 would be precluded if the case trickles to that group and the declaratory statement is missing.

(d) Screening Applications for Medical Assistance Extensions (F02 and F03)

Previously, TCA cases reached the Earnings Extension (F02) and Child Support Extension (F03) only through the “trickle” process. Now CM may initiate F02 and F03 cases through screening process. Screening for the MA extensions is appropriate when the TCA case was closed without the earnings or child support information which would have automatically allowed the case to trickle. A new field (MA EXT) on the MISC screen will be used to initiate the extension. If valid value “D” is used the MA EXT field, the case will not trickle through the F- Track.

For most people, the application should be processed within 45 calendar days of the date you apply. If an applicant is pregnant, their application should be processed within 10 work days, if the case manager has all of their required information. If an applicant is referred to Disability Determination Services for a disability determination, their application will be processed within 90 calendar days, or as soon as possible after your disability determination is complete if the disability determination takes more than 90 days.

(e) Verification Requirements

When an application is received, the local department of social service conducts system clearance (e.g. Client Automatic Resources and Eligibility System (CARES), State Verification Exchange System (SVES), State on-line Query (SOQL) and Maryland Automated Benefits System (MABS) to determine whether the applicant has current Medical Assistance coverage group, to investigate what benefits or income the applicant or spouse is receiving, and to obtain or verify other information related to the application. Information provided by the A/R may be

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contradictory or different than information obtained from the clearances. If the LDSS/LHD CM has any reason to question the information represented by the A/R on the application or at the interview, or if the information presented in contradictory, incomplete, vague, or incomprehensible, the case manager should request additional information or verification from A/R.

a. Verifications by the A/R of the following information is always required in addition to the declaratory information provided by the A/R on the Medical Assistance application form: Income: Verification of income is no longer mandatory for the F-Track coverage groups Income must be verified for all other coverage groups Resources: All resources will be verified for all coverage groups. Resources will not be verified for the F-Track group, except for F98 and F99. Private health insurance or other third party medical coverage (request a copy of the front and back of the insurance card) Additional information as needed Age/Identity/Citizenship Note: F05 and MCHP are declaratory for income and most verification. Citizenship and Identity are still needed

b. The CM should only ask the A/R for verification of other information if: The CM requires additional information in order to determine technical or financial eligibility (e.g. the information provided by the A/R is incomplete or unclear or there is a discrepancy) The CM has no other source to obtain the needed information or to verify certain information on the application; and The information or verification may have an immediate bearing on the case or may impact eligibility.

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(1)Due Date for Verifications

The LDSS/LHD CM must inform the A/R in writing of the required information and verifications to determine eligibility and the due date. The A/R, in turn must provide all required information and verifications early enough for the LDSS/LHD CM to meet the 10-30 or 60 day-day limit. If an applicant does not provide the required information to enable the LDSS/LHD CM to determine eligibility within the applicable time frame, the applicant may be determined ineligible. However, an extension of time frame standards is required of the LDSS under certain circumstances. For Instructions or when to apply these standards refer to the section entitle “Extension of Time Standards.”

(2)Required Verifications

The various factors affecting eligibility that may require verification are listed, along with the method of verification, in Appendix A of this section 400. While some factors can be verified in a number of ways, others (such as income and resources) require verification from a specific source. The following factors call for special comment.

As general rule, written verification should be signed and dated. The document should also include the name, address, and telephone number of the person providing the verification. LDSSs are authorized by the A/R’s signature on a Consent of Release of Information form to contact a signatory and verify the validity of a statement.

SDX/SVES/SOLQ Verifications- The following information is verified by the LDSS through the State Data Exchange (SDX), State of Verification Exchange System (SVES), or State on-Line Query (SOLQ). Hard-copy verification from the A/R is only necessary if there is any discrepancy.

Date of birth Social Security number Supplemental Security Income (SSI) benefits Social Security benefits Railroad Retirement benefits Medicare entitlement and enrollment Medicare number Citizenship and Identity (Please refer to chapter 500 verification of citizenship and identity for listings of acceptable verification)

SAVE Verification of Alien Status- If the applicant indicates that he/she is not a U.S. Citizen but is a legal entrant, the LDSS/LHD uses the Systematic Alien Verifications for Entitlements (SAVE) system in order to verify the alien status, most recent date of U.S. entry, and date of qualified alien status. If no discrepancy is found, hard-copy verifications by the A/R are not required. Verifications of Alien status either SAVE or from the A/R are not required for an alien applying for only emergency medical services.

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Residence may be verified by a rent book, rent receipt, gas/electric or telephone bill, statement from the landlord, etc. Whatever is used, it is essential that the verifications source indicate that the applicant lives at a specific address. The address must be complete and the case manager must determine if the address is in Maryland. For the homeless person, the case manager must establish that the person has no permanent address in the Maryland or in any other state. Decisions as to whether or not such persons are Maryland residents must be evaluated on a case by case basis.

Age-A birth certificate is only of the acceptable methods for establishing date of birth. There are a number of other methods such as insurance policies or baptismal, confirmation, marriage, Social Security, employment, school, or military service records. However, when an age limit is reached within the calendar year, the A/R must also provide proof of the actual month of birth.

Note: The Department of Juvenile Justice Services (DJS) representative for a child who is an applicant for medical Assistance is not required to provide verifications of the child’s age. It may be presumed that the child is less than 21 years of age based on the child’s commitment to the DJS.

Earned income for person-other that the self-employed must be verified by pay stubs or a complete written, signed, and dated statement from the employer showing weekly, biweekly, etc. gross earnings and expenses and or a copy of the most recent valid tax return. Life Insurance- When the applicant has life insurance with cash value; a statement must be obtained from the insurance company on company letterhead that verifies all necessary information-current cash surrender value, policy number, policy owner. For the applicant’s initial eligibility determination, however, the case manager may use the current cash value from an amortization table in the life insurance policy, if the policy has a table reflecting the estimated current value. Then, verification of the actual current cash value by the insurance company is required no later than the first redetermination of eligibility.

If mail to the insurance company is undeliverable and there is no way to contact the company, the Maryland Insurance Commission should be contacted to help locate the company or its successor. If the company cannot be found, any information available on the cash value of the life insurance may be used. If no information can be obtained on the cash value, the life insurance is excluded as a resource. If the A/A makes a good faith effort to obtain information on the cash value, the eligibility determination is not delayed or denied due to the inability to determine the current cash value of life insurance.

Representative- Since the Medical Assistance program does not require a representative to be legally authorized by a court in order to act on the applicant’s behalf, it is not necessary to obtain verification of guardianship or Power of Attorney. Signatures on the Medical Assistance application are sufficient to authorize a representative acting on the applicant’s behalf.

(3)Declaration of Information if Confirmed Impediment to Timely Verifications

At times, an application for Medical Assistance is filed and verifications of a specific factor of eligibility cannot be promptly production for reasons beyond the applicant’s control. When neither

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the applicant nor the representative can obtain a specific required verification within 45 days after the date of application, the CM should determine whether an eligibility decision is possible based on the information and verifications provided to date and a written declaration by the applicant or representative of the facts related to the factor of eligibility that has not yet been verified. Au eligibility decision using this declaration for factor of eligibility means that information provided by the applicant or representative may be considerate as having temporarily met verification requirement if the MA case manager determines that the applicant/representative has satisfactorily demonstrated and documented in writing that all of the following conditions exists:

The applicant/representative made a “good faith effort” to obtain the required verification in a timely manner; The required verification cannot be obtained within 45 days for reasons beyond control of the applicant/representative, and there is no other way to verify the specific factor of eligibility;

The A/R has provided information that he/she believes to be accurate; There is no other existing information that leads to MA case manager to believe that the statement of the A/R is inaccurate or incomplete; and The applicant/representative agrees to produce the required verification no later than the next scheduled redetermination

When all of these conditions are met, the worker may base the eligibility determination on the applicant/representative’s written declaration of the facts related to the factor of eligibility.

Example 1:

An application is filed on 1/1/2004 on behalf of Ms. Smith. Ms. Smith daughter, Claudia, is representing her mother in the application process. Ms. Smith is in a nursing home due to a stroke, which has left her unable to communicate. Prior to her stroke, Ms. Smith handled her own affairs and did not appoint a durable P.O.A. Ms. Smith has two bank accounts. Claudia’s name is on one account. Therefore, she is unable to obtain verification of the balance from the bank. The second account was with Shady Saving and Loan that merged 6 months ago with another financial institution, RCG Bank and Trust. Claudia has a 10-month old statement from Shady Savings and Loan showing a $600.00 balance, but has no account number or documentation from the new institution. She has contacted the new institution, but they refuse to releases any information to someone without a P.O.A. or guardianship. On 1/25/04, Claudia presents the following documents to the MA CM:

A copy of her letter to RCG Bank and Trust, requesting the 1/1/04 balance from Shady account #12345 A letter from RCG Bank and Trust, stating that records cannot be researched based on this information, and that the account information may only be released to the account holder P.O.A. or guardian. A letter from an attorney agreeing to represent Claudia in a guardianship case, but advising that this process will take 3 to 6 months to complete. The Shady Savings and Loan bank statement from February 2003 showing a $602 balance.

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A letter signed by Claudia, explaining her unsuccessful efforts to obtain a current statement, stating that she believes that RCG and Trust account does not exceed $650, and agreeing to submit to verifications of the 1/1/2004 account balance an current balance as soon a she gains guardianship and obtains the from Shady saving and Loan. In this case, the CM considers the $650 as a countable resource, which together with the other assets totals $1, 657. All other factors of eligibility are met. The ease narrated with regard to the outstanding verification, and Ms. Smith eligibility is approved. No later than the first annual redetermination, the MA case manager must obtain verification from Claudia of the account balance for the month of applications, as well as current month. If not received by the first annual redetermination, the case will be closed for failure to submit the required verifications.

Example 2:

Mr. Cheetum is confined to a nursing home and is represented by his (Power of Attorney) P.O.A., Mr. J. Jones, Esq. Mr. Jones provides bank balances as of the month of application, but states his client’s assets prior to the last month are unknown, and that his client is in no condition to assist in the verification process. Since Mr. Jones was retained as P.O.A. prior to his client’s incapacitation, it is reasonable to assume that Mr. Cheetum discussed his financial affairs with his attorney at that time. It is incumbent upon Mr. Jones to review records and request information to establish Mr. Cheetum’s assets over the look-back period (60 months). Although this process may take longer than the timeliness standard, a decision of eligibility cannot be made because Mr. Jones states he cannot provide a written statement concerning his belief as to the value and disposition of his client’s asset during and look-back period. Mr. Jones may request an extension of time limits. If he does not, the application may be denied for failure to submit verifications, and will be reactivated if Mr. Jones provides the verifications before the end of the period under consideration.

Note: Maryland is not changing its eligibility policy to permit presumptive eligibility or declaratory applications. All factors of MA eligibility must still be verified either by the A/R or by the MA case manager. However, the verifications requirement must be reasonable. Allowance must be given for unusual situations when the A/R is making a “good faith effort” but, due to a confirmed impediment outside his/her control, is unable to obtain the required verification within 45 days.

It is not acceptable for an application to remain pending indefinitely without an eligibility decision. The application should be denied if the A/R does not provide the required verifications by the due date, even if all of the conditions specified above are met, and the MA case manager either does not have enough information to determine eligibility, or the information that the MA case manager has received is questionable or contradictory. If the MA CM has enough information to be able to clearly ascertain the facts of the case, eligibility should be determined, even if specific verifications cannot be obtained until later. Eligibility is not guaranteed. If a verification subsequently shows that the recipient is ineligible, the MA case manager should promptly conduct an unscheduled redetermination for this change is information Existing policy relating to the extension of time limits may also be applied. However, such extensions should be utilized routinely and repeatedly to delay eligibility determinations beyond 45 days from the date of application.

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When the MA case manager permits declaration of the specific factor of eligibility, the MA case manager should set a “745” alert to follow up at the first redetermination or at the time that the verification is expected to be available. If the A/R has not provided the verifications, the MA case manager should call or write with a reminder of the verifications requirements. If the verification is not received by the first redetermination, MA eligibility should be terminated due to failure to provide verifications

(f)Reapplication(Reactivation Following Rejection of an Application )

Some applications disposed of may be reactivated, however is a case was denied due to excess resources it cannot be. An applicant may not be determined ineligible due to administrative delays. Administrative delays include delays on the part of the State Review Team (SRT) to determine disability within the time frame as well s delays for any reason on the part of an LDSS.

When an applicant is determined ineligible due to a technical factor (citizenship, residence) or excess resources, the application is disposed of and that action is final since the applicant will remain ineligible for any month in which technical or resources ineligibility existed. ( The reactivation period does not apply)

If the applicant reapplies, believing that the factor of ineligibility has overcome, a new application is required and a new period under considering established based on the new application date. The incurred medical expenses from a retroactive period during which technical ineligibility or excess resources existed may be applied to excess income, if any, for the current period.

Retroactive eligibility may concurred by requested with current eligibility upon reapplication, however, the retroactive period may not include any month(s) in which the applicant did not overcome the factor of prior technical or resource ineligibility.

Example:

Application is filed on 4/15/2011. An earlier application was filed on 1/15/2011 and rejected due to excess resources. The period under consideration has not expired but the applicant’s resources were not reduced to an eligibility level until 4/15/2011; therefore, the earliest period that the applicant can become resource eligible is 5/2011. In this instance the period under consideration is 5/2011- 10/2007. Since the applicant can never establish eligibility for the period prior to 5/2011, unpaid medical expenses incurred during that period which will not be covered by a third party may be applied to excess income for the new period.

(g) Extension of Time Standards The 30 to 60 day time standard must be extended to allow applicant sufficient time to provide the required information when: o The examining physician delays or fails to provide disability determination within the 60 day period

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o The applicant is actively attempting to establish his/her eligibility but has been unable to provide the required information through no fault of their own o There is an administrative or other emergency beyond the control of the LDSS

If any one of the above condition exist, the period of time allowed to complete the application must be extended.

The CM shall document the reason for the delay in the applicant records The extension of time will continue as long as the requirements are met. The CM shall deny medical assistance when these requirements are not met

(1) Explanation

In order for an applicant to meet eligibility requirements, he/she must be told what information must be provided and the due date. This requirement presumes that the applicant has disclosed all information pertinent to his/her eligibility before or during the face-to-face interview. If an applicant fails to disclose pertinent information before or during the face-to-face interview and the failure cause local department delay in requesting verifications, the extension of time does not apply; however, if the applicant is determined ineligible and reapplies before the period expires, the case must be evaluated under the reactivation procedures.

If all pertinent information is reported to the local department no later that the date of the face-to-face interview, the local department is obligated to provide the applicant a written list of all the verifications( financial and non-financial) that are needed to determine eligibility. If the local department fails to do so, the local department must take that fact into account deciding whether or not the applicant can be expected to complete the requirements within the 30 or 60-day time frame.

The time standards are binding on both applicant and local department. It is necessary that local departments make decisions and send a written notice to applicants at the appropriate time, whether the standard time frames or an extension of time applies.

(2) Explanation of Justification Requirements for Extension of Time

The reactivation process may not be substituted for the extension of time standards when it is appropriate to extend the time standards. It is appropriate to extend the time standards when an applicant has been unable to provide the required information through no fault of his/her own and the applicant provides written documentation of that fact, or the local department is able to verify in some way that the applicant did not delay the request for information. Most required information is obtainable within a period of 7 working days or less. Some examples of the kinds of information, that may not be readily available to an applicant through no fault of his/her own are:

The exact cash value of a life insurance policy when that information is not available in the local office of the insurance company; An independent appraisal of real property, A physician’s report for disability determinations; or

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Income information from a former employer

As documentation of efforts to obtain the required information, the applicant is expected to request a written, signed, and dated statement from the source of the requested information on letterhead stationary when the request for the information is made. Local departments may need to use some other type of evidence satisfactorily documents that the delay is not the fault of the applicants.

In the case of information needed on life insurance, the applicant should request assistance from the insurance agent who can likely obtain the information quicker through computer printout or other automated files.

If the time frame associated with the extension is not met, another extension may be granted if the applicant presents updated written proof that he/she has made follow-up requests for the information. The process may continue so long as the applicant presents current proof of his/her efforts to obtain the required information. Although the primary responsibility for providing information rests with the applicant, assistance by a local department is not precluded. If, however, a local department assumes full responsibility for obtaining the required information, the local department is obligated to retain that application in pending status. An applicant can only be held accountable for those activities that have been assigned to him/her.

(h)Retroactive Eligibility

Retroactive eligibility may be considered for those months in the retroactive period in which the person has incurred medical expenses. The period under consideration is 1, 2 or 3 months immediately preceding the month of application Review each retro month separately Example: Application date Jan 1, 2012 Retro months= October 2011, November 2011, December 2011 Retro can be considered for all three months or just one or two months All technical and financial factors must be assessed for the months in which there are incurred medical bills for which the person is applying for assistance If the applicant requests MA for the retro and the current, separate eligibility determinations are required. The information may be collected on the same application NOTE: An applicant can be found ineligible for one period and not the other, eligible for both or ineligible for both.

(i) Retroactive and Current Periods

If the applicant request MA for the retroactive as well as the current period, separate eligibility determinations are required, though the information may be collected on single application form. An applicant may be found ineligible for one period and not for the other, eligible for both, or ineligible for both.

Examples:

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1. A retroactive eligibility determination for an interrupted period within the retroactive period of an retroactive eligibility determination combined with a current eligibility determination equals two applications and /or eligibility determinations. 2. A retroactive eligibility determination for the first and third month of the retroactive period equals two applications and or/or eligibility determinations. (First and third months are interrupted periods). If accompanied by a current eligibility determination a third application and/or eligibility determination is required. 3. A retroactive eligibility determination for a continuous, uninterrupted period of one to three months equals one application and/or eligibility determination. If accompanied by a current eligibility determination, a second application and/or eligibility determination is required.

As a general rule, the number of applications and/or eligibility determination may be determined by the number of separate applications that are required. Separate calculation and decision sheets and separate form AMF-Is needed for each determination. Each determination is counted as an application.

400.7 Special Verification Requirements for Persons in or Planning to Enter an Long Term Care Facility

When an application is filed for a person who is already in or planning to enter an LTC facility for a general hospital, all necessary information and verifications should be requested. If all required information/verification is not submitted that fact needs to be included in the notice of ineligibility along with any other reason for ineligibility. For example, an applicant presents a book showing excess resources and the application shows that the person has other countable resources which would increase the amount of the excess, but the applicant fails to provide verifications of the exact value of the other resources. In this circumstance, the notice of ineligibility should include the fact that the applicant is ineligible based on the excess resources associated with the bank account. The notice should also include a statement that the applicant has additional resources (specify type) the values of which are unverified but which may increase the amount of the excess. This same principle applies regardless of the specific reason for ineligibility. This should be done only after the applicant has been given sufficient opportunity to provide all required information but fails to do so. Because of the significant impact of excess resources and eligibility, it is important that eligibility determinations be made within the 30-day time frame, or earlier if possible so that applicants can take appropriate action to reduce the resources consistent with Program policy, and limit the period of ineligibility.

(a) Period Under Consideration

For an institutionalized person, the period under consideration must be adjusted when the person applies pending admission to a LTC facility or in the month of admission to a LTC facility. For details refer to procedures for institutionalized persons in chapter 1000.

(1) Summary of Requirements

1. A completed and signed application form is required when a person requests current or retroactive

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coverage or both. 2. Verification-When an applicant files a completed application form for MA coverage, verification of all elements of current or retroactive eligibility or both are required.

a. Current eligibility- When an applicant meets the requirement to complete all application form and requests coverage for the current period, verification of all elements of eligibility is required for the current period.

b. Retroactive Eligibility- When applicant meets the requirement to complete the application form and requests coverage for the retroactive period only, but does not provide verification of elements for the current period, he/she may be determined ineligible for the retroactive period only if he/she fails to provide verification of elements are pertinent to the determination of eligibility for the retroactive period.

(2) Disposition of Application

An applicant must provide all required information/verification early enough to allow for a decision by the LDSS within the 30 or 60 day time frame. The applicant is determined ineligible when he/she fails to provide all required information/verification within the time frame. If the applicant complete the application form and verifies all elements of eligibility for the retroactive period but does not verify all elements for the current period, certify for the retroactive period., if current ineligibility exists because of failure to verify, ODO the application for that period. If the person reapplies, follow the applicable procedures in Section F “Reapplication following a decision of ineligibility.”

An applicant may voluntarily withdraw his/her application for MA.

Period under consideration ( reactivation) expires

A request and application filed for MA after the expiration of the original period under consideration will be considered New Application. Nor part of the expired current period under consideration may be converted to a retroactive period since the person has already applied for those months as part of the current period. However, the incurred unpaid expenses from the expired period may, with the written consent of the applicant, be applied to excess income, if any for the new current period. The DHMH form 4284, “Authorized to Apply Incurred Medical Expenses from an Expired Period to the Current Period”, is signed and dated by the applicant and CM. This authorization is required in situations of ineligibility for reasons other than technical ineligibility or excess resources. Incurred expenses from a retroactive period of ineligibility for technical reasons or excess resources may be applied to excess income for a current period, if any without written authorization.

Example:

Application is filed on 9/15/2011. An earlier application was filed on 1/15/2011 and rejected due to insufficient income information. The initial period under consideration is 1/2011 through 6/2011 and has expired. Therefore, the new application, 9/15/2011, establishes both the date of application and current period under consideration ( 9/2011-2/2012).

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Since the original period has expired, the unpaid medical expenses income during that period which will not be covered by a third party may with the applicant’s written authorization per above, be applied to excess income for the new period.

(b)When verification is not Required

A determination of ineligibility may be made on the basis of unverified facts submitted by the applicant/representative if such facts clearly indicate ineligibility. There are, however, some exceptions to this policy. The following procedures apply to persons who are not in, or planning to enter on Long Term Care (LTC) facility or a general hospital:

1. When the only factor of ineligibility for an applicant is excess income, verification of income is necessary to establish the exact spend-down liability. If the required information is not submitted, a decision of ineligibility must be rendered based on failure to provide the required information. 2. When a recipient reports increased income, verification of the increase is needed if the person wants eligibility to continue for the remainder of the period under consideration. If continued eligibility is not requested, the case may be closed based on the person’s statement of income. (Closed cases may not be preserved for spend-down. Preserved status applies only to application). If the required information is not submitted, a decision of ineligibility must be rendered based on failure to provide the required information. 3. When a determination of ineligibility for an applicant is due to excess resources, every effort should be made to have the applicant provide verification of the exact resource amount. If an applicant fails to provide at required information and or/verifications related to excess resources, it is appropriate to reject the application. However, if the exact amount of the excess is not known, that fact plus any other reasons for ineligibility should be noted in the letter. Refer to Policy Alert 08-1 for a detailed discussion of the treatment of the excess resources of an A/R who is in or entering on LTC facility or an acute hospital.

400.8 Requirements to apply for benefits

Applicants and recipients are required to apply for all income benefits to which may be entitled. Eligibility may not be established until they furnish proof that they have met this requirement. This applies to both members of the assistance unit and the non-assistance unit members whose income and resources are considered.

LDSS/LHD staff must have a general knowledge of various benefit requirements, be able to identify applicant and recipient circumstances which may indicate entitlement to certain benefits, and refer applicants and recipients accordingly. Refer to Chapter .07 for description of types of benefits and how to apply.

Applicants and recipients determined by the LDSS to be unable to perform the required activity because of the applicant’s or recipient’s physical or mental condition and far whom there is no other person to perform the activity are not themselves required to apply for income benefits. Under this circumstance, the LDSS/LHD must obtain from the agency determining entitlement to income benefits, a statement of the requirements for application for income be3enift and work cooperatively

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with the agency and the applicant to meet those requirements. The requirement to apply for all income benefits to which there may be entitlement does not extend to requiring application for SSI or Public Assistance. The LDSS/LHD should advise an applicant of the existence of the SSI and Public Assistance Programs and where to apply, but cannot impose a requirement to apply or take any adverse action based on the applicant’s failure to apply.

The requirement to apply for income benefits does not apply contributions to a pension system to which a person belonged for at least 5 years, but not longer belongs for reasons other than retirement or disability. Persons are not required to withdraw such finds as condition of eligibility. Refer to CR 559. However, if a person chooses to withdraw funds in a lump sum, the funds will be considered an income benefit for the period under consideration beginning with the month the month it is received. Once a person verifies that application for potential benefits has been made, a determination of initial eligibility may not is delayed pending the results of the application filed for those benefits. Each case involving pending application for income benefits should be flagged for the anticipated date of decision on entitlement. If that date cannot be readily established, the case should be flagged for contact within three months to determine if an anticipated date of decision has been established. At the time of redetermination or reapplication, eligibility shall be determined on the basis of the applicant’s or recipient’s documented reasonable and continuous efforts to establish entitlement to income benefits. When an applicant or recipient cannot provide documentation from the source that this requirement has been met, eligibility is to be terminated. When the requirement has been met but no decision has been made, the LDSS must maintain follow-up activities until documentation of the final decision is received.

(a) Social Security Number

As a condition of eligibility, applicants and recipients must provide the LDSS with a Social Security Card (or cards if more than one number has been issued) for each member of the assistance unit and any person whose income and resources are considered in determining the financial eligibility of the assistance unit. If the applicant or recipient cannot furnish a Social Security Card for each of these persons, he/she must apply for a card.

Application for the card and verification of that fact are requirements must be met before eligibility can be granted.

The Maryland Department of Juvenile Service (DJS) representative for a child is an applicant for Medical Assistance may act as a representative for that child in filing for a Social Security Card if the DJS representative shows the local department a copy of the court documents committing to the child to the DJS. Once a card has been applied for (and that fact verified), Medical assistance may not be denied, delayed or discontinued pending the issuance or verification of the number. Failure to apply for a card, however or (failure to provide the required verification) will result in the ineligibility for the person whose Social security number has both been applied for.

If an applicant or recipient is physically or mentally incapable of acting for him or lacks the resources to meet the above requirements, the LDSS/LHD must assist him in obtaining the necessary

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documents and ay costs incurred by the LDSS/LHD will be paid of administrative funds.

If the application indicates that a Social Security card was issued previously, the LDSS must request validation of the number by the Social Security Administration.

(b) Required Case Activity

It is unlikely that, upon receipt of a request for MA, the local department will search the files and determine if there is already an application on file for an unexpired period. The chances are that a new application form will be issued routinely. At the point the face-to-face interview is scheduled following receipt at the written and signed new application, the CM will need to have at hand all previous applications and determine which one, if any, is appropriate for use as the reactivated application for the unexpired period.

The reactivated application is the one to be retained in the case folder. If the other applications include information that is not a part of the reactivated application, the new information should be identified and transferred to the reactivated application. The applicant should initial and date each new entry. Once this is done, the other applications are not to be invalidated and discarded.

The case summary sheet should reflect a recording of all contacts and activities and the dates for some beginning with the filing date of the reactivated application and ending on the dates for some beginning with the filing date of the reactivated application and ending on the expiration date.

400.9 Public Assistance for Adults (PAA)-MA Retroactive coverage procedures

(a) General

To be eligible for retroactive Medical Assistance coverage, a person must apply for MA and be determined eligible. This requirement includes a Public Assistance to Adults (PAA) applicant who has medical bills incurred within 3 months before the month of the PA application. In order for PAA applicants to avail themselves of this benefit, a question concerning past medical bills has been included in the PAA application (DHR/FIA CARES 9701 and MCHP application) on page 1 under the question

What type of assistance do you need now? (Check all that you need) □ Cash Assistance □ Child Care Services □ Food Stamps □ Medical Assistance - Do you have any unpaid medical bills from the past 3 months? □ Yes □ No

The CM must check to make sure that the question is answered. If the question is not answered, then the case manager must make a phone call to the applicant to:

1. Discuss past medical bills with the client and inquire as to whether he/she had medical care during the retroactive months which has not been paid for and for which there is no health insurance coverage. 2. If after discussion, the answer is “No”, no further action is taken regarding retroactive coverage. However if the answer is “Yes”,

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The case manager will:

Verify the client’s indication of incurred medical expenses for the retro months by requesting to see the actual bills. The CM will proceed with the retroactive eligibility determination using current procedures. The CM must make the application date the date of the retro period month

400.10 Category Selection

A person may select any federal category for which technical eligibility may be established. This means that any person who qualifies as both FAC and ABD has a choice as to which of the two categories he/she wishes to apply for assistance in.

400.11 Third Party Liability

All applicants and recipients are require to :

1.Notify the LDSS/LHD within 10 working days when medical treatment has been provided as a result of a motor vehicle accident or other occurrence in which a third party might be liable for the applicants or recipients medical expenses. 2. Cooperate with the LDSS/LHD in completing the form designated by the Department to report all pertinent information and in collecting available health insurance and other third party payments and 3. In accident situations, notify the LDSS/LHD of the time, date, and location of the accident, the name and address of the attorney, the names and address of all parties and witness to the accident, and the police report number if an investigation is made.

In addition to the above requirements, it is necessary that the LDSS/LHD question applicants at the time of applicant and recipients at the time of redetermination as to whether or not they have received treatment as a result of an accident. If they have, the LDSS/LHD must complete the appropriate reporting form and forward it to the following address regardless of how the fact became known:

Division of Recoveries and Financial Services 201 West Preston Street Baltimore MD 21201-2301

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400.12 Wage Screening Inquiry

The LDSS/LHD is required to conduct a wage-screening inquiry to determine wages, benefits, and claimant history for each of the following: Effective 7/1/2008 verification of income for FAC coverage is no longer mandatory however; income must be verified for all other coverage groups. An applicant shall sign consent forms as needed authorizing. The department or its designee is to verify other sources such as employer, banks, and public or private agencies. This information is needed to establish eligibility. All ABD person younger than 70 years unless the person:

a. Resides in an LTC facility; b. Is chronically ill and non-ambulatory

400.13 Case Record Management

The LDSS/LHD must maintain a case record, including documentation of all requirement elements or eligibility, name of the applicant (and spouse, if any). The case record must be maintained while it is an active Medical Assistance case and for an additional period of 2 years after the case close then it may be destroyed. If a case is being reconsidered or reapplication is made within a 2- year period, the prior case record must be reviewed before eligibility is determined in order to compare the past and present information, so that differences may be identified and reconciled.

400.14 Request to Add New Family Members

If after completion of an eligibility determination MA is requested for additional family members, a written, signed application is also required for these persons. Refer to section entitled “Child Born on or After 10/1/84” To a mother eligible for and receiving MA’, instructions on automatic eligibility of the newborn of a currently eligible mother. Their eligibility for assistance will be determined in accordance with the provisions of Regulations.06.

(a) Disclosure of information

The LDSS/LHD must restrict disclosure of information concerning applicants and recipients to purpose directly connected with the administration of the Program. These activities include: Determining eligibility Determining the extent of coverage under Program Providing Services for Recipients; and Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the Program.

The release of information to any agency or administration which is any way responsible for an aspect of the administration of the Program does not constitute a violation of the Privacy Act. A recipient’s Medical Assistance number and certification dates may be given to an inquiring health care provider in those instances when, in the judgment of the LDSS/LHD, it is unreasonable to expect the recipient to provide the information.

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400.15 Filing an Application for Medicare Part A

An applicant who is 65 years old or older, or blind or disabled, is not eligible until he/she furnishes proof that he/she has applied for or is receiving Medicare, Part “A”. Once the application is filed and that fact is verified, determination of eligibility may not be delayed pending the results of the application. Periodic reviews of eligibility are necessary for those blind or disabled persons initially determined ineligible for Medicare because of the required waiting period.

An applicant must present proof from the Social Security Administration that an application has been filed. Although the applicant is required to apply for Medicare, Part “A” there is no requirement to purchase this benefit. Persons who have not earned sufficient quarters of coverage under Social Security are not eligible for free Part A coverage. Nevertheless, the applicant must apply for, but may reject this coverage if payment of a premium is required.

The above requirement also applies to a recipient who attains age 65 or becomes blind or disabled if he/she is not already covered as a disabled person. The LDSS/LHD will need to monitor birthdates at each redetermination and refer a potentially eligible person to the Social Security Administration for application.

400.16 Application Procedures Specific to Institutionalized Persons

The general application requirement and procedures of this chapter to both non-institutionalized and institutionalized persons at the time of application and redetermination. However, because of the physical and mental impairments of many institutionalized persons, it is sometimes necessary to qualify the general requirements. The following qualifications are worthy of note.

(a) Person/s who can complete the application

As with non-institutionalized persons, there is no specific rule as to who may or may not complete the application. However, since there is usually no face-to-face interview with institutionalized persons, it becomes important that the application form be completed by the person who is the most knowledgeable about the applicant’s situation, and that same person, except in rare situations, must be the person with whom the face-to-face interview is conducted. The rare exception might be the situation in which the most knowledgeable person lives in another state and cannot visit this state at each redetermination. However, there must be same contact with the person who completes the application and provides the information.

(b) Person/s able to be representative

The representative should be the individual who normally handles the affairs of the institutionalized person. In most instances, that individual will be relative or legal guardian. However, if neither of these individuals exist, then a friend, hospital social worker, nursing home administrator, or other interested party may act on behalf of the person is considered the representative. This means that the same person who completes and signs the application and who appears for the face-to-face interview is also the person who has the responsibility of doing whatever is necessary to establish the person’s eligibility. This includes, but is not limited to making home visits or other contacts necessary to

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obtain required facts. “Unknown” as an answer to specific questions relating to income and resources is not acceptable.

A representative is also responsible for the accuracy and completeness of the application, for reporting changes to the LDSS/LHD and for establishing continuing eligibility. This responsibility continues until such time as a new representative is designated and the LDSS/LHD receives written notification of the change. The CM advises the representative of these responsibilities during the interview. An employee of an LTC facility, hospital or other agency or organization may not routinely assume the role of a representative by merely filling out the application and mailing it to the LDSS/LHD.

While the representatives are the primary source of information about the person, the LDSS/LHD must not routinely accept information presented by representatives whose source of information is at best questionable. The CM need to check out other possible sources of information and give guidance to the representative as to methods and sources that may be used to collect the required information. While it may be presumed that the institutionalized person cannot meet the face-to-face interview requirement, no such presumption should be made about the person’s ability to participate in other aspects of the application process.

( c) Face to Face Interview

Effective 12/1/2008, LTC CM should no longer require LTC applicant recipient, or their representative to participate in a face to face interview. Face to face interview should only take place by the case manager on a case by case basis or requested by an applicant recipient. If after review of the application, the case manager is unclear about an issue or need additional information, case manager are encouraged to conduct a telephone interview before requiring a face to face interview. Only if this is not possible, should a CM require a face to face interview.

(d) Application Signature Requirements

For the purpose of completing the application form and filing it for registration of the application date, the representative may sign and date it. However, since institutionalized persons are generally not seen by the CM, the institutionalized person, if competent, must sign the application before the LDSS determines eligibility. If the applicant did not sign the application before it is submitted to the LDSS, and the applicant is competent to sign, the LDSS/LHD must return the application to the institutionalized person for signature.

If the institutionalized person is incapable of singing the application but has a competent spouse with whom the person lived prior to institutionalization, the spouse must sign the application.

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(e) Assistance Unit Requirements

When an application is filed prior to institutionalization and there are other family members in home, the assistance unit will be structured in accordance with Chapter .06. When an application is filed for an institutionalized couple who share the same room in the LTC facility, separate case records and numbers as well as separate eligibility determinations are required.

(f) Period Under Consideration

Verification Requirements Specific to Long-Term Care (LTC) Eligibility

The DHR/ FIA 1052-LTC-Request for Information to Verify Eligibility form is sent by the CM to the A/R, specifying information or verifications need to determine LTC eligibility and giving the due date for receipt of the information. The following types of verifications are addressed on the form:

Application-The DHR/FIA CARES 9709 is used as the application form for Medical Assistance LTC eligibility Representative-The DES 2000-LTC-Physician’s statement of Incapacitation is no longer required to be completed and signed by the applicant’s physician, in order for a representative to sign the application and participate in the application process on the applicant’s behalf. Also, the DES 2004- Representative’s Statement is no longer required to be completed and signed by the applicant and the representative, in order to authorize a representative to act on the applicant’s behalf. Since the Medical Assistance program does not require a representative to be legally authorized by a court in order to act on the applicant’s behalf, it is not necessary to obtain verification of guardianship or powers of Attorney. Signatures on the CARES 9709 application are sufficient to authorize a representative acting on the applicant’s behalf. Consent to Release Information The DHR/FIA 704 form is used for applicants to consent to the release of information. For LTC applicants, the DES 2002 form is also signed by the A/R to authorize the long-term care facility (LTCF) to release information to the LDSS related to the LTC application. The DES 2005 form is signed by the A/R to authorize the LDSS to release information about the application to a designate LTCF. Medical Level of Care- In order for the LDSS to determine LTC eligibility, the applicant must be certified by DHMH’s utilization control unit (UCA):

Delmarva Foundation 9240 Centerville Road Easton, Maryland 21601 Fax #888-513-2202

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400.17 Steps Taken to Complete Form

The LTCF or client representative completes Part A of the DHMH 3871B for the Client and it is submitted to the attending physician. The attending physician completes Part B-E of the DHMH 3871 B-E of the DHMH 3871B and it is returned to the facility. The LTCF completes the top portion of the 257 and sends the 257 and 3871B to the UCA The UCA completes the bottom portion of the 257 and Part F of the DHMH 3871B The UCA sends a copy of the 257 and the DHMH 3871B to the LTCF, and the completed original 257 to the LDSS DHMH 257-Long Term Care Patient Activity Report DHMH 3871B-Medical Eligibility Review Form

(a) Demographic Information

The LDSS/LHD verifies an applicant’s Social Security Number and benefits and any Medicare number and enrollment by checking SDZX/SVES/SOLQ. It is only necessary to request verifications from the A/R (e.g. copy of social security card or Medicare card) if there is a discrepancy or the LDSS cannot otherwise obtain the required information. The A/R’s declaration on the application that the applicant is a US citizen is accepted without verification, and only needs to be verified by the A/R if there is a discrepancy. If the A/R reports that the applicant is a legal alien, the LDSS verifies the applicant’s alien status through Systematize Alien Verification Systems (SAVE), and only requests verification if there is a discrepancy or need for additional information. It is necessary for the A/R to provide verification of the applicant’s marital status such as a copy of the marriage certificate or divorce decree. Maryland does not recognize common law marriage. A couple which is considered married under state law has a spouse to spouse financial responsibility until they have received a divorce decree or until one spouse dies.

(b) Income

SSI, Social Security, and Railroad retirement benefits are verified by the LDSS through SDX/SVES/SOLQ. MABS is available as an additional verification of the amount of each type of countable income received by the applicant. Earnings must be verified for the past month or 4 weeks. The CM may request additional verifications if necessary to determine the A/R’s gross countable income. See the section “Verification/Documentation” in the Appendix of this Manual for examples of acceptable income verifications.

(c) Resources

If the spousal share has not already been calculated, resources of both the applicant and spouse must be verified for computation of the spousal share as of the beginning of the applicant’s first continuous period of institutionalization. For determination of current LTC eligibility, the A/R is required to provide verification for the value of each type of countable resource owned by the applicant and /or spouse as of the 1st day of the month of application. Typically, the value of liquid assets (e.g. bank

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accounts) must be verified for the past 3 months. For non-liquid assets, the current, accessible valued must verified. The CM “Verification/Documentation” in the Appendix of the Manual for examples of acceptable resource verifications.

The CM should require the A/R to provide resource verifications for selected months in the look-back period before the month of application if the A/R reports a disposal or if the CM has reason to suspect a disposal, and the disposal would result in a current penalty period. The CM decides how many months and aw what intervals to check for disposal of resource in the past 36 months (60 months for a trust). The CM should require no more moths of verifications than necessary to determine eligibility. To verify bank accounts or other investment accounts that closed during the look-back period, it may be sufficient to obtain only the final statement from the financial institution.

Effective Immediately: Individuals applying for MA-LTC no longer request 60 months of bank statements and financial statements for themselves and their community spouse in order to evaluate the look back period.

When it can be verified that the LTC applicant was a recipient of a needs-based public benefit at any time during the 5 year period before the month of application, verification of the value or resources during the look-back period is not required. Resources still need to be verified as of the month of application. However, when a disposal of resources is reported by the A/R or suspected by the LDSS, all pertinent verifications must be provided by the A/R Needs-based public benefits include but are not limited to:

Supplemental Security Income (SSI) Cash public assistance (TCA, TEMHA, PAA) Community Medical Assistance Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) I or II Maryland Pharmacy Assistance Program (MPAP) Food Stamps Energy Assistance Section 8 or other subsidized housing from the U.S. Department of Housing and urban Development(HUD)

(d) Life Insurance

When the applicant has life insurance with a crash value, a statement must be obtained from the insurance company on company letterhead paper that verifies all necessary information-current cash surrender value, policy number, policy owner. For the applicant’s initial eligibility determination, however, The CM may use the current cash value from an amortization table in the life insurance policy, if the policy has a table reflecting the estimated current value. Then, verification of the actual cash value by the insurance company is required no later than the fist redetermination of eligibility.

If mail to the insurance company is undeliverable and there is no way to contact the company, the Maryland Insurance commission should be contacted to help located the company or its successor. If

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the company cannot be found any information available on the cash valued of the life insurance may be used. If no information can be obtained on the cash value, the life insurance is excluded as a resource. If the A/R makes a good faith effort to obtain information on the cash value, the eligibility determination is not delayed or denied due to the inability to determine the current cash value of life insurance.

(e) Real Property

Excludability of Home Property There are three situations in which a home property of an institutionalized person may be excluded when determine the persons countable resource: The institutionalized person or his/ her representative expresses the intent to return his/her home and resume living there. The intent is obtained in writing on the DHMH form 4255- Home exclusion statement of intent The spouse of the institutionalized person is resuming in the home. The home is excluded as a countable resource when determining MA eligibility, regardless of the institutionalized person’s intent to return. However, the house must be evaluated under the lien provisions if applicant is determined eligible for MA. A dependent relative of an institutionalized person is residing in the home.

400.18 Verification for deductions from available income for the cost of care

(a) Health Insurance

In order for the CM to deduct only the institutionalized person’s health insurance premiums from the available income towards the cost of care, the CM needs either a recent premium bill or a canceled check for a premium payment, as well s a copy of the front and back of the health insurance card. If the CM has reason to believe that the premium being paid is for someone other than the institutionalized person, the CM contact the insurance company to verify the policy’s insured member(s).

(b) Residential Maintenance allowance

It is not required shelter expenses or obtains a copy of the mortgage, lease or rental agreement. However, the DHMH 4245 Physician’s Report and the DHMH 4255 Home exclusions-Statement of Internet are required in order to deduct a residential maintenance allowance, if the institutionalized person intends to return to the home property.

(c) Spousal Maintenance Allowance

If the community spouse does not report shelter expenses on the DES 2003 form, the basic maintenance and shelter allowance is deducted for the spouse. The community spouse’s income must still be reported.

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400.19 Good Faith C, Concept

The concept of “good faith” ha a very specific meaning with regard to MA policy pertaining to the application process. This concept is applied when determining what verification standards are to be applied in a specific case. It is one step in a sequential decision making process.

Most factors of eligibility must be verified by hard copy documentation, electronic, verification or verbal communications between CM and an authoritative source. CM is trained to determine when it is appropriate to use these means of verifications for different factors of eligibility. For MA LTC cases, most factors or eligibility must be verified by written documentation from authoritative sources (e.g. bank statements) or electronically (e.g. Social Security Benefits). CM must request appropriate verifications from the applicant or the applicants authorized representative in writing, and in a time frame that will enable the CM to complete the eligibility determination within the required 30 days.

At times, verifications cannot be submitted within the required time frame. In that circumstance, an applicant or representative may request an extension of time limits. If an extension is requested and granted by the case manager at the end of that period, (generally 45 days from the date of application) the information still cannot be provided by the A/R, a CM may decide to process the application based on a declaration made by the applicant/representative about the eligibility factor in question. A declaration means that the A/R makes a written statement confirming the information to the best of their knowledge, even though written or electronic documentation cannot be obtained. This declaration may be substituted for written or electronic verification for a limited period of time, i.e. until the next redetermination is due. The declaration does not mean that the factor of eligibility is not being considered or is in any way waived. An application could either be denied or granted based on a declaration (e.g. excess resources.

The five (5) conditions below must be met in order for a case manager to decide to determine eligibility based on the declaration rather that a verification. The first of these is “good faith”. The A/R made a “good faith effort” to obtain the required verification in a timely manner. In this context” good faith” means that the A/R has taken the reasonable steps to try to obtain the documentation, but has been unable to do so. If the case manager determines that this element of good faith has been met, the next four (4) factors must be considered:

The reason for failure to obtain information is beyond the control of the A/R He/she believes to be accurate The CM has no other contradictory information or other reasons to doubt the statements The A/ R agrees to provide the written verification as soon as received but no later than the reason for failure to obtain information is beyond the control of the A/R The A/R made a “good faith effort” to obtain the required verification in a timely manner The required verification cannot be obtained within 45 days for reasons beyond the control of the A/R, and there is no other way to verify the specific factor of eligibility The A/R has provided information that he/she believes to be accurate; There is no other existing information that leads the MA CM to believe that the statement of the A/R is inaccurate or incomplete: and The A/R agrees to produce the required verifications no later than the next scheduled

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redetermination

Note: CM will set up a 745 alert to follow up on needed information

“ Good Faith” does not apply to: A provider rendering service in the belief that the individual is or will be eligible The provider’s efforts to assist the applicant/representative in obtaining verification, The providers’ administrative and/or legal efforts to insist that the applicant/representative provide the verification

Although all of these may be appropriate responses by a provider, they do not affect the verification requirements. Only the actions and the statements of the applicant/representatives are evaluated in deciding if a factor of eligibility can be considered based on declaration rather than verification.

400.20 Post eligibility

LDSS/LHD shall inform an applicant of his rights and responsibilities LDSS/LHD must give the applicant written notification of the following:

(a) For eligible persons

A finding of eligibility (the begin & end dates of the coverage)

(b) For ineligible persons

LDSS/LHD must provide in writing the reason for ineligibility and the regulation supporting the finding LDSS/LHD must also advise of the right to request a fair hearing

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Attachment A-Notice of Ineligibility

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY DUE TO EXCESS INCOME Date:____________________

Re: _______________________________ CID# ____________________

Name

Dear _______________________________, This is to notify you that based on the application filed on , the above named person has been determined ineligible for Medical Assistance due to excess income. The income for the period to has been calculated as follows:

Source of Income Monthly Amount for Period Social Security _____________ $_____________ Veterans Benefits _____________ _______________ Pension _____________ _______________ Other _____________ _______________ Total Income $____________ Deductions Personal Needs Allowance _____________ $____________ Spousal/Dependent Allowance _____________ _____________ Residential Allowance _____________ _____________ Cost of Long Term Care _____________ _____________ Other Medical Expenses _____________ _____________ Total Deductions -$____________ Total Available Income $____________ Cost of Care -$____________ Excess Income For Period _____________

If medical expenses are incurred that will not be covered by health insurance or other sources and these expenses equal or exceed the amount of excess income, eligibility for Medical Assistance may be established under the spend-down provision. Enclosed is a sheet that tells you how to keep records of medical expenses. If incurred medical expenses equal the amount of excess income within the time period specified above, you should immediately report this to the Department of Social Services. This decision is based on COMAR 10.09.___.________. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You have the right to reapply. Sincerely, ________________________ _______________________ Case Manager Telephone Number ___________________________________ Department of Social Service

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Section 400 Frequently Asked Questions and Answers Application Requirements

1. Can an application be reactivated if the case was denied due to excess resources?

No, an application can’t be reactivated if the case was denied due to excess resources.

2. A client can appeal an adverse decision of Medical Assistance anytime and have benefits continued pending the Appeal?

No, the client has to appeal an adverse decision of MA within 10 days

3. Where can an individual interested in applying for Medical Assistance (MA), get an application?

There Local Department of Social Services (LDSS), Local Health Department (LHD) or apply online at www.marylandsail.org

4. What is a representative?

A representative may assist the A/R in the application and redetermination process and in other matters related to the A/R’s MA eligibility. Only one designated representative at a time may be recognized as authorized to act on the A/R’s behalf.

5. How many months is a newborn presumptively eligible for MA if the mother is enrolled as a Maryland MA recipient on the date of the newborn’s birth? Newborn are presumptively eligible for MA for a period up to 15 months if the mother is enrolled as a Maryland MA recipient on the date of the newborn’s birth.

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Section 500 Table of Contents Non-Financial Eligibility Requirements

500.1 Introduction-Non- Financial Eligibility

500.2 Citizenship (a) Child Born Overseas to a Citizen Parent (s)

500.3 Qualified Aliens (a) Aliens Subject to the 5 -Year Bar

(b) Aliens Not Subject to the 5- Year Bar

(c) Continuously Present

500.4 Verification of Citizenship and Identity (a) Policies and Procedures for Documenting Citizenship and Identity (b) Documentation Requirements (c) Proof of Citizenship and Identity (d) Affidavits for Documenting Citizenship

Attachment A- DES-AFF-1 Affidavit of Citizenship for Applicant/Recipient

Only Attachment B- DES-AFF-2 Affidavit of Citizenship Attachment C- Affidavit of identity for a Child Younger than 16 years Old (e) Proof of Identity Attachment A- Proof of Identity (f) Collective Naturalization (h) Documentation that an Applicant is a Qualified Alien

500.5 Non- Qualified Aliens

(a) Ineligible Aliens

(b) Undocumented Aliens 500.6 Emergency Medical Service or Medical Assistance for State- Only qualified Aliens (a)X- Track- Coverage State Only Emergency Medical Service (X02) (b)Emergency Medical Services for Undocumented or Ineligible Aliens X02 (c) Explanation of Emergency Medical Services (d) General Eligibility Requirements for Coverage Group X02 (1)Medical Eligibility Requirements for Coverage Group X02 (e) Documentation of Services (1) Documentation of Labor and Delivery Services (2) Documentation of Disability (3) Medical Eligibility Review Process (f ) Certification of Eligibility of X02 Attachment A- DES 401 Emergency Services to Ineligible Aliens

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Attachment B- Notice of Eligibility Attachment C- Notice Ineligibility (Non-Financial Reasons) Attachment D- Notice Ineligibility (Financial Reasons)

500.7 Residency (a) Residency Criteria for Non- Institutionalized Persons (b) Residency Criteria for Institutionalized Person (c) An Alien Visa, Student Visa or other Immigration Documents

500.8 Aged, Blind, and Disability Determination (a)Aged (b)Blind (c)Disability Determination 500.9 Caretaker Relative 500.10 Institution (a) Inmate of a Public Institution

(1) Case Processing Procedures

(2) Medicaid Application for Prison Inmates Prior to Release (b) Institution for Mental Disease (c) Conditional Release or Convalescent Leave from an Institution for Mental

Disease

(d) Residence of an Institutionalized Person

(1) Placement by a State in an Out of State Institution

(2) Former Maryland Residents Residing in an Out of State Facilities Attachment A- Department of Juvenile Justice Facilities

Frequently Asked Questions (FAQ’s) and Answers Objectives for Section 500 1. Define Non- Financial Eligibility Requirements; 2. Indentify Medicaid eligibility for citizens and non citizens; 3. Indentify Medicaid eligibility for inmate of public institution and mental health

institution for persons.

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500.1 Introduction- Non- Financial Eligibility

500.2 Citizenship To be eligible for federal coverage of full Medical Assistance benefits and individual must be one of the followings; A citizen of the United States by birth or naturalization Born in one of the 50 states, the District of Columbia, Puerto Rico, Guam, the Northern

Mariana Islands, or the Virgin Island Born in American Samoa or Swain’s Island and is considered a United States national; or A child younger than 18 years old who was born outside the United States and its

outlying possessions and who automatically acquires United States citizenship upon the

child’s legal entry into the United States for permanent residence if the child is living in

the legal and physical custody of a parent or parents. A qualified alien who has been continuously present in the United State since the most

recent date of entry into the United States, which was before August 22, 1996 regardless

of the date of the date of qualified alien status. A qualified alien who either most recently entered the United States on or after August

22, 1996 or has not been continuously present in the United States since the most recent

date of entry before August 22, 1996, and who: 1. Meets the federally required 5- year bar to public benefits; or 2. Is in an immigration category that is not subject to the 5 year bar.

An alien who is a honorably discharged veteran of the armed forces of the United States, including veterans of the following armed forces:

1.Individuals who served in the Philippine Commonwealth Army during World War II or as Philippine scouts following World War II; and 2. Hmong and other Highland Lao veterans who fought under United States command during the Vietnam War and who were lawfully admitted to the United States for permanent residence.

On active duty in the armed forces for the United States; The spouse, including a surviving spouse who has not remarried, or an unmarried dependent child (younger than 21 years old) of an honorably discharged veteran or alien on active duty in the armed forces of the United States. A recipient of Supplemental Security Income (SSI) benefits A member of a federally-recognized Indian tribe, as defined in 25 U.S.C 450b(e);

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An American Indian born in Canada to whom 289 of the Immigration and Nationality Act (INA) applies.

(a) Child Born Overseas to a Citizen Parent (s) The Child Citizenship Act 2000 (Public Law 106-395) became effective February 7, 2001. This law permits foreign-born children, including adopted children, of U.S. citizens to acquire U.S. citizenship automatically without applying when they enter the U.S. legally for permanent residence, if certain requirements are met. Children who met the Act’s requirements as of the Act’s effective date automatically acquired U.S. citizenship on February 27, 2001. The applies to the following children:

Biological or legitimated children Certain children born out of wedlock to a mother who naturalizes Orphans with a full and final adoption abroad or adoption finalized in the U.S. and Adopted children meeting the two year custody requirement.

As of February 21, 2001 a child born overseas must meet the following requirements in the order to acquire U.S. citizenship automatically; Have at least one natural or adoptive parent who is; A U.S. citizen by birth or naturalization; and Has been physically present in the U.S. or its outlying possessions for a period or periods

totaling at least 5 years , at two of which are after the age of 14 (or one of the child’s

U.S. citizen grandparents meets this physical presence requirement) Younger than 18 years old and Live in the U.S. in the legal and physical custody of the U.S. citizen parent, pursuant to a lawful admission for permanent residence. If the child is adopted, the adoption must be full and final.

500.3 Qualified Aliens An alien is an individual who was not born in the U.S. and is not considered a U.S. citizen by birth or naturalization. The Personal Responsibility and Work Opportunity and Reconciliation Act of 1996 (PRWORA) was signed into law on August 22, 1996. This Act significantly changed aliens’ eligibility for MA and other federal needs- based benefits. The Act restricts the eligibility of certain legal aliens for the federal MA program. Undocumented (illegal) aliens have never been eligible for full MA benefits in a federal category just for coverage of emergency medical services (coverage group X02).

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Task 2: Allow overnight processing in CARES before proceeding onto Step 2. Step 2: Verify SSN CMs who have access to SOLQ must verify the SSN with SOLQ (Verify Title II SSA income and Title XVI SSI income with the SSN verification) If SOLQ verified the SSN, print the verification response for the record. If SOLQ was not able to verify the SSN, you will receive one of the codes shown in the July 2001 SVES/SOLQ MANUAL Section 2, pages II-11 and

II-12 (FIPNet). The SSN must be verified prior to requesting citizenship verification and

moving to Step 3.

CMs who do not have access to SOLQ must verify the SSN with SVES (Verify Title II SSA income and Title XVI SSI income with the SSN verification) Task 1: Use the SVES PF1 request and complete all the appropriate fields to verify the SSN. This request will need to process overnight. Task 2: Once the 24 hour SVES SSN verification has taken place, use PF2 to verify the SSN response. Task 3: If SVES verified the SSN, print all verification response screens for the case record. If SVES was not able to verify the SSN, you will receive one of the codes shown in the July 2001 SVES/SOLQ MANUAL Section 2, pages II-11 and II-12 (FIPNet). Obtain SSN verification from client; once obtained, verify the SSN through SVES. Task 4: The SSN must be verified prior to requesting citizenship verification. As soon as SVES verifies the SSN and the record is printed, use PF4 to delete the PF2 request. Proceed to Step 3. Note: If not deleted, the PF2 request creates a viewing screen but locks the SSN information which will cause Step 4 citizenship verification processing to take 10 days.

Step 3: Determine Eligibility As soon as a new MA or MCHP applicant is determined eligible, the CM must allow the applicant a reasonable opportunity (45 days) to produce documentary evidence of citizenship. During this

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period, the applicant must be enrolled in coverage if they have met all eligibility requirements except citizenship. ACE applicants are to be processed within the required 2 day period, which eliminates the need to verify citizenship prior to receiving coverage. ACE applicants fall within the “reasonable opportunity” clause and can provide documentary evidence of citizenship after they have been assigned coverage. Step 4: Request Citizenship Verification SVES must be used to request citizenship verification (SOLQ cannot be used): Task 1: Use the SVES PF1 request to access the screen for citizenship verification. Task 2: Complete all the appropriate fields to verify citizenship. Enter the new code: Z for the Category of Assistance Task 3: This request will need to process overnight. Task 4: Once the 24 hour SVES citizenship verification has taken place, use SVES PF2 to verify the citizenship response. Task 5: Print the verification response for the applicant’s record. Important Reminder: Step 4 citizenship request will not provide Title II (SSA) and Title XVI (SSI) income information. Step 5: SVES Citizenship Verification Responses and Procedures The CM will receive a response (within 24 hours of the request) displaying one of the following response codes: 1. Citizenship verified Task 1: Send verification copy to the repository at DHMH. Task 2: On the DEM2 screen in CARES, enter “CP” valid value in the citizenship verification field. 2. Citizenship not verified Task 1: Obtain the required documentation to verify citizenship (see AT 08-05). Allow the applicant a reasonable period of time (45 days) to produce the documentation. The case worker must grant active eligibility status during this period and up to 80 days as long as the applicant has met all other eligibility requirements and is pursuing the acquisition of documentation to meet citizenship requirements. Task 2: If documentation is provided within this period, continue providing an active eligibility status through the certification period.

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If the applicant has not produced documentation by the 80th day, close the case for failure to meet citizenship requirements. This closure is not subject to reactivation. Important Reminder: The Adverse Action period provides an additional 10 days for the case to remain on the system. 3. Death with citizenship verified Task 1: Process the case including retroactive period as required Task 2: Verify death of applicant before entering the date of death to close coverage. 4. Death without citizenship verified Task 1: Obtain the required documentation to verify citizenship (see AT 08-05). Task 2: If citizenship verification is received, process the case including retroactive period as required. Task 3: Verify death of applicant before entering the date of death to close coverage. Task 4: If citizenship cannot be verified, process the case as denied for failure to provide information and enter the date of death to close case.

One of the following 1st level documents to documents may be used to verify both citizenship and identity: U.S passport issued by the U.S. Department of State. It is not necessary for the U.S. passport to be currently valid as long as the expired passport was originally issued without limitation. If a passport was issued with a limitation, it may be used as proof of identity but not as proof of citizenship. Certificate of Naturalization (N-550 or N-5700 issued by the Department of Homeland Security for naturalization. Certificate of Citizenship (N-560 or N61) issued by the Department of Homeland Security to individuals who derive citizenship through a parent.

NOTE: If the individual was born outside the U.S. and was not a U.S citizen at birth, one of these documents is required. One of the following 2nd level documents may be used to document citizenship if none of the 1st level documents are available within the time limit for determining eligibility: U.S. Birth Certificate: issued by a state, Commonwealth, Territory, or local

jurisdiction.

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1. The U.S. public birth record must show birth in one of the 50 states, the District of Columbia, American Samoa, Swain’s Island, Puerto Rico (if born on or after January 13, 1941), U.S. Virgin Islands (if born on or after January 17, 1917), Northern Mariana Islands (if born after November 4, 1986), or Guam (if born on or after April 10, 1899). 2. A data match by DHMH with Vital Records birth records in Maryland or another state. In order to be used as 2nd level verification of citizenship, the birth certificate must have been issued before the person was 5 years old 3. Do not accept a souvenir birth certificate issued by the hospital. 4. If the document shows the individual was born in Puerto Rico, the U.S. Virgin Islands, Northern Mariana Islands, or Guam before the date given above, the individual may be a collectively naturalized citizen (see the requirements below for verification of collective Naturalization).

Official military record of service: The document must show a U.S. place of birth (e.g., form DD-214). Evidence of civil service employment by the U.S. government: The document must show employment by the U.S. government before June 1, 1976. Final adoption decree for a child born in the U.S.: The adoption decree must show

the child’s name and a U.S. place of birth. If the adoption is not yet finalized and

the state where the child was born will not release a birth certificate before the

adoption is final, a written certification from a state approved adoption agency

that shows the child’s name and U.S. place of birth is acceptable if it state that the

source of information is an original birth certificate. Certification of Report of Birth Abroad (DS-1350) o Department of State to U.S. citizens who were born outside the U.S. and acquired U.S. citizenship at birth. If the birth was recorded on a FS-240, a certified copy of the DS- 1350 is not issued by the Department of Sate in Washington, D.C. The DS-1350 is not issued outside the U.S. The DS-1350 contains the same information as the current version of the FS-240. Consular Report of Birth Abroad of a Citizen of the United States of America (FS240) o Issued by a U.S. Department of State consular office. A FS-240 can only be prepared at an American consular office overseas while the child is younger than 18 years old. Children born outside the U.S. to U.S. military personnel usually have this form. Certification of Birth Abroad (FS-545) o Issued by U.S. Department of State consulates before November 1, 1990 along with the prior version of the FS-240. In 1990, U.S. consulates ceased to issue the FS-545. Treat FS-545 the same as the DS-1350. U.S. Citizen Identification Card (I-197 or the prior I-179) o Formerly issued by the Immigration and Naturalization Service (INS). The I-179 was issued during 1960 -1973 and the I-197 during 1973- April 7, 1983 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although no longer issued, either form that was previously issued is still valid.

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American Indian Card (I-872): issued by the U.S. Department of Homeland

Security to identify a U.S. citizen member of the Texas Ban of Kickapoo’s living near

the U.S./ Mexican border. A classification code of “KIC” and a statement on the

back denote U.S. citizenship. Northern Mariana Card (1-873) o Issued by the INS to a collectively naturalized citizen of the U.S. who was born in the Northern Mariana Islands before November 4, 1986. Although no longer issued, a form that was previously issued is still valid.

One the following 3rd level documents may be used to document citizenship if none of the 1st or 2nd level documents are available within the time limit for determining eligibility: Extract of a hospital records on hospital letterhead that shows a U.S. place of birth: o The hospital record must have been established at the time of the person’s birth and created at least 5 years before the initial application date for MA.

Example: A redetermination is being conducted for October 2006 for an individual who initially applied for MA in October 2003. The hospital record must have been created before October 1998 and must have been established at the time of the individual’s birth (in order to verify the individual’s birth in the U.S.). For a child younger than 16 years old, the document must have been created either

near the time of birth or at least 5 years before the initial application date for MA or

MCHP. Do not accept a souvenir “birth certificate” issued by the hospital. Life, health, or other insurance record showing a U.S. place of birth: The record must have been created at least 5 years before the initial application date for MA or MCHP.

One of the following 4th level documents may be used to document citizenship if none of the 1st, 2nd, or 3rd level documents are available within the time limit for determining eligibility. Documentation with this low level of reliability should only be used in the rarest of circumstances. Federal or state census record for 1900-1950 showing U.S. citizenship or a U.S. place of

birth; the census record must also show the individual’s age. To secure this information,

the individual or state must complete a form BC-600, Application for Search of census

Records for Proof of Age. Add in the remarks portion: “U.S. Citizenship data requested.”

Also add that the purpose is for Medical Assistance eligibility. A fee is charged for this

form. Medical record (clinic, doctor, or hospital) that shows a U.S. place of birth: 1. The record must have been established at the time of the person’s birth and created at least 5 years before the initial application date for MA or MCHP.

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2. For a child younger than 16 years old, the document must have been created either near the time of birth or at least 5 years before the initial application date for MA or MCHP. 3. An immunization is not acceptable

One of the following records showing a U.S. place of birth, if created at least 5 years before the initial application date for MA or MCHP: 1. An amended U.S. birth certificate (public birth record) that was amended more than 5 years after the person’s birth. 2. A U.S. State Vital Statistics official notification of birth registration. 3. Signed statement by a physician or midwife who attended the birth. 4. Institutional admission papers (e.g., nursing facility). 5. Seneca Indian tribal census record. 6. Bureau of Indian Affairs tribal census records of the Navajo Indians.

(d) Affidavits for Documenting Citizenship If none of the previously discussed documents are available within the time limit for determining eligibility, written affidavits may be used to document citizenship. Affidavits should only be used in rare circumstances. The affidavits must be signed under penalty of perjury. The signer must be able to provide proof of his/her own citizenship and identity. There must be a least two written and signed affidavits by citizens who have personal knowledge of the event(s) (e.g., birth, naturalization) establishing the applicant/recipient’s (A/R’s) claim of citizenship. One of the affidavits must be signed by someone who is not related to the A/R. If the individual signing the affidavit has information explaining why documentary evidence establishing the A/R’s claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well. A third affidavit must be signed by the A/R, another knowledgeable individual (representative, parent, or guardian), or explain why the required documentary evidence does not exist or cannot be readily obtained.

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Attachment A-Affidavit of Citizenship (A/R) Only

State of Maryland Department of Health and Mental Hygiene AFFIDAVIT OF CITIZENSHIP To Be Completed By Applicant/Recipient Only This Document Is Not Valid Unless Fully Completed.

1. � I am a U.S. citizen.

2. � I am 18 years old or older.

3. I am a U. S. Citizen because: � I was born in the U.S. or a U.S. territory. Date and place:__________________________ � I was naturalized as a U.S. citizen. Date and place:_______________________________ � I was born overseas to a U.S. citizen parent(s). Date, place, and parent(s) name: _____________________________________________ � Other: __________________________________________________________________

4. I am unable to produce documents to prove citizenship because: __________________________________________________________________________ __________________________________________________________________________

I affirm and declare under penalty of perjury that the facts I state in this Affidavit are true, correct, and complete to the best of my ability, belief, and knowledge.

Signature

Printed Name

Date Signed DES/AF2 (7/1/

Applicant/Recipient Name: ____________________________Date of Birth: __________

Address: ______________________________________________________________________

Head of Household (if the individual is younger than 21 years old):

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Attachment B-Affidavit of Citizenship

State of Maryland

Department of Health and Mental Hygiene

AFFIDAVIT OF CITIZENSHIP

This Document Is Not Valid Unless Fully Completed.

1. My name is _________________________, and I live at _________________________ _______________________________________________________________________. � I am a U.S. citizen. � I am 18 years old or older.

2. Are you a relative of the individual named above? �

�

3. How long have you known this individual? __________________________ How do you know this individual? _________________________________________

4. How do you know the facts you present in this Affidavit? _______________________________________________________________________

5. I have personal knowledge of how the applicant/recipient became a U.S. citizen. The facts known to me are that he/she was: �

�

� ____________________________________________________________________ �

6. The individual is unable to produce documents to prove citizenship because:

______________________________________________________________________ ______________________________________________________________________

I affirm and declare under penalty of perjury that the facts I state in this Affidavit are true, correct, and complete to the best of my ability, belief, and knowledge.

Signature

Printed Name

Date Signed DES/AF2 (7/1/06)

Applicant/Recipient Name: _____________________________Date of Birth: _________

Address:___________________________________________________________________________ ________________

Head of Household (if the individual is younger than 21 years old): ______________________

_

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Attachment C- Affidavit of Identity (Child Younger than 16 years Old)

State of Maryland Department of Health and Mental Hygiene AFFIDAVIT OF IDENTITY For a Child Younger Than 16 years Old This Document Is Not Valid Unless Fully Completed.

1. My name is ___________________________________, and I live at ___________________

_____________________________________________________________________________. 2. I am the child's: �Parent �Legal guardian �Other

3. I am unable to produce the required documents to prove the child's identity (U.S. passport, Certificate of Naturalization (N-550 or N-570), Certificate of Citizenship (N-560 or N-561), school photo ID card, school record with date and place of birth, nursery or day care record with date and place of birth, learner driver's license, or military dependent's ID card) because: ___________________________________________________________________ ___________________________________________________________________________

I affirm and declare under penalty of perjury that the facts I state in this Affidavit are true, correct, and complete to the best of my ability, belief, and knowledge.

Signature

Printed Name

Date Signed

DES/AF3(7/1/06)

Child’s Name: _________________________________________________ Child's Date of Birth: __________ Child's Age: _______ Child's Place of Birth: ____________________________________________ Child's Current Address:

_________________________________________________________

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(e) Proof of Identity One of the following 2nd level documents must be used to document identify if none of the 1st level documents for documenting citizenship and identity are available within the time limit for determining eligibility: Driver’s license or an identification card for a non- driver: issued by the Motor Vehicles Administration for a U.S. state or Territory (not Canada or another country). This is acceptable if it has a photograph or other identifying information for the A/R A(e.g., name, date of birth, race, sex, height, weight, eye color) School identification card with photograph Federal, state, or local government identification card, if it has a photograph or other identifying information for the A/R (e.g., name, date of birth, sex, race, height, weight, or eye color). U.S. military ID card or draft record. U.S. Coast Guard Merchant Mariner card. A cross match with data systems of other federal or state governmental, public assistance, law enforcement, or correction agencies, if the agency establishes and certifies individual’s true identity (e.g., TCA, Food Stamps, Child Support, Child Protective Services, Corrections, Juvenile Services, Motor Vehicle Administration, SVES/SDX/SOLQ for former SSI recipients) Certificate of Degree of Indian Blood, or other U.S. American Indian or Alaska Native Tribal document with a photograph or other personal identifying information relating to the individual. U.S. passport issued with a limitation: It may be used to verify identity, but not to verify citizenship. For children younger than 16 years old, one of the following documents: 1. School record (DHR/FIA 604 form). 2. Nursery or day care record (including pre-school health form) or 3. Written affidavit signed under penalty of perjury by the child’s parent or guardian, stating the date and place of the child’s birth: An affidavit may only be used to document a child’s identity if affidavits were not used to document the child’s citizenship and if none of the other acceptable documents are available to document identity within the time limit for determining eligibility.

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Attachment A- Proof of Citizenship and Identity Proof of Citizenship Proof of Identity U.S. Birth Certificate

Data match of Vital Statistics records by DHMH to document birth record Systematic Alien Verification for Entitlements (SAVE)-for naturalized citizens only

For child under 16: a record created near the date of birth, or 5 years before initial MA/MCHP application, and showing U.S. place of birth on hospital letterhead or other medical record.

Record showing U.S. place of birth, if created at least 5 years before initial MA/MCHP application: record on hospital letterhead or other medical record created near the date of birth, institutional admission papers, signed statement by physician or midwife who attended the birth, Vital Statistics notice of birth registration, insurance record

Final adoption decree for child born in U.S.

Certificate of citizen born abroad (DS-1350, FS-240,FS-545)

Early school record that shows a U.S. place of birth, the date of admission to the school, date of birth (or age at the time the record was made), and the name(s) and place(s) of birth of the applicant’s parent(s)

Religious record - recorded in the U.S. within three months of birth showing US birth, and either the date of the birth or the individual’s age at the time the record was made. The record must be an official record recorded with the religious organization, not the family bible

U.S. military service record showing U.S. place of birth

Evidence of U.S. civil service employment before 6/1/76

Federal or state census record for 1900-1950 showing U.S. citizenship or U.S. place of birth

ID card for naturalized citizen (I-179 or I-197)

Affidavits (can also be used for naturalized citizens) Three written and signed affidavits. Two completed by citizens who have personal knowledge of the person's citizenship, one of whom is not a relative. Both signers must be US citizens. Another affidavit completed by the person, representative, or someone else knowledgeable to explain why the proof isn't available

Photo driver's license or Motor Vehicle Administration (MVA) ID card

Data match with other benefit programs(current or past TCA, Food Stamps, DAP, SSI eligibility) to document identity

Photo school ID card

Photo ID issued by a federal, state, or local government

U.S. military ID card, discharge document, or draft record

Native American Tribal Document

US Coast Guard Merchant Mariner card

For children under 16: Clinic, doctor, hospital, or school record (e.g., DHR/FIA604 or 604-A form), nursery or day care record including pre-school health forms and Form 1131. School records may include report cards but these records must be verified with the issuing school.

Three or more corroborating documents to prove identity such as marriage licenses, divorce decrees, high school and college diplomas, property deeds/titles, and employer ID cards. This process can be used if they are unable to produce a single, more reliable document such as a driver’s license. (These may only be used if the individual did not use affidavits to verify citizenship.)

Note: Recently expired identity documents are usable as long as there is no reason to believe the document does not match the individual.

Affidavits can be used for the following:

For Children under 16 written affidavit signed by parent or guardian- but only if an affidavit was not used as proof of citizenship.

Disabled individuals (Adult/Child) in long term care or rehabilitative residential care facilities; signed by Facility Director or Administrator.

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(f) Collective Naturalization The following requirements are used to document U.S. citizenship for collectively naturalized individuals who were born in Puerto Rico or the U.S. Virgin Islands: Puerto Rico Puerto Rico Law 191 invalidated all Puerto Rican birth certificates issued prior to July 1, 2010. On June 28, the Government of Puerto Rico extended the validity of current Puerto Rico birth certificates through September 30, 2010. All birth certificates will remain valid through September 30, 2010. After this date, every birth certificate must have been reissued by the Puerto Rico Health Department Vital Statistics Record Office. Because individuals are required to provide documentation of citizenship and identity as a condition of eligibility (see AT 08-05), beginning October 1, 2010, Puerto Rican applicants (unless their citizenship can be verified on SVES per AT 10-27 Revised) will need a reissued birth certificate, with a date of issuance on or after October 1, 2010, in order to provide proof of citizenship. As U.S. citizens, applicants born in Puerto Rico are allowed a “reasonable opportunity” period (as defined in AT 10-27 Revised) to produce a birth certificate document.

Evidence of birth in Puerto on or after April 11, 1899 and the individual’s statement that he/she was residing in the U.S., a U.S. possession, or Puerto Rico on January 13, 1941 or Evidence that that individual was a Puerto Rican citizen and the individual’s statement that he/she was residing in Puerto Rico on March 1, 1917 and that he/she did not take an oath of allegiance to Spain.

U.S. Virgin Islands Evidence of birth in the U.S. Virgin Islands and the individual’s statement that he/she was residing in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927. The individual’s statement that he/she was residing in the U.S. Virgin Islands as a Danish citizen on January 17, 1917 and was residing in the U.S., a U.S. possession, or the U.S. Virgin Islands on February 25, 1927 and that he/she did not make a declaration to maintain Danish citizenship. Evidence of birth in the U.S. Virgin Islands, and the individual’s statement that he/she was residing in the U.S., a U.S. possession or Territory, or the Canal Zone on June 28, 1932.

(g)Procedures for Verification of Alien or Immigration Status The primary way to verify alien/immigration status for a legal alien is by the Systematic Alien Verification for Entitlement (SAVE) system of the Department of Homeland Security (see the DHR/FIA Action Transmittal 04-34, issued in April 2004). Inquiry to SAVE may not made by

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an alien name, social security number, and etc, only the identification number on an alien’s immigration document may be used for SAVE inquiry. Therefore, SAVE cannot be used if the CM does not have a valid “INS” number for the alien (e.g., the individual is now a naturalized citizen, is an undocumented alien, or gave the CM an invalid INS number or someone else’s number for the alien (e.g., the individual is now a naturalized citizen, is an undocumented alien, or gave the CM an invalid INS number or someone else’s number) NOTE: Refer to the following transmittals issued by the Department of Human Resources about how to verify immigration status for certain categories of aliens or immigrants: Action Transmittal 05-16: Eligibility for Family Members of Victims of Severe Trafficking in Persons (Derivative T visas) CARES Bulletin 05-16: Legal Immigrants in F-Track Medical Assistance FIA Information Memo 05-47: Mexico’s Matricula Consular Identification Card CARES Bulletin 04-07: 5 Year Bar for Federal Benefits for Qualified Aliens Action Transmittal 03-34: Restoration of Food Stamps to Immigrants Who Have Lived in the United States for Five or More Years FIA Information Memo 99-51: Guidance for Verification of Immigration Status

Form numbers and the types of immigration documentation change over time. For

the most current information about immigration documents issued by the federal

government consult federal web sites, such as http://uscis.gov/

(h)Documentation That an Applicant is a Qualified Alien If qualified alien status cannot be verified through the SAVE system or if additional information is needed to resolve a discrepancy, the following documentation may be used: Lawful Permanent Resident: INS From 1-551 (green card) or for recent arrivals a temporary 1-551 stamp in a foreign passport or on form 1-94. 1.If a lawful permanent resident presents an old INS form (1-151, AR-3 or AR-3a) as evidence of status, contact the Department of Homeland Security to verify the alien’s status by filing a G-845 and attaching a copy of the old form. Also, refer the applicant/beneficiary to the Department of Homeland Security to apply for a replacement card. Refugees- INS Form 1-94 endorsed to show entry as a refugee under 207 of the INA and date of entry to the United States; or INS Form 1-688B, 1-766 annotated “274a 12(a)(3),” or From 1571. Asylees: INS form 1-94 annotated with stamp showing grant of asylum under 208 of the INA; a grant letter from the Asylum Office of the Department of Homeland Security; Form 1-688B or 1-766 annotated 274a 129(a)(5),” or an order of an Immigration Judge granting asylum. If the applicant/beneficiary presents a court order, contact the Department of Homeland Security to verify that the order was not overturned on appeal

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by filing a G-845 with the local Department of Homeland Security district office attaching a copy of the document. Alien who has had Deportation Withheld: under 243(h) of the INA-Order of an immigration Judge showing deportation withheld under 243(h) and date of the grant; or Form 1-688 or 1-766 annotated “274a. 129(a) (10).” If applicant/beneficiary presets a court order, contact INS to verify that the order was not overturned on appeal by filing a G-845 with the local INS district office, attaching a copy of the document. Alien Granted Parole for at least 1 year by the INS: INS Form 1-94 endorsed to show grant of parole under 212(d)(5) of the INA and a date showing granting of parole for at least 1 year. Alien Granted Conditional Entry: Under the immigration law in effect before April 1, 1980-INS Form I-94 with stamp showing admission under 203(a)(7), refugee conditional entry; or Forms I-688B or I-766 annotated “274a 12(a)(3).”

Evidence of Honorable Discharge or active duty status includes the following documents: Discharge: An original of the veteran’s discharge papers issued by the branch of service

in which the applicant was a member. Active Duty Military: An original of the applicant’s current orders posting the applicant to a military, air or naval base. A self-declaration under penalty may be accepted pending receipt of acceptable documentation.

500.5 Non- Qualified Aliens Non-qualified alien are either undocumented or ineligible legal aliens who do not qualify for federal coverage of full MA benefits because they do not meet the citizenship requirement for Medical Assistance (MA) or the Maryland Children’s Health Program (MCHP). Pregnant women who are ineligible qualified aliens may be eligible for most benefits in the State-only coverage category of X02. Undocumented or otherwise ineligible legal aliens may be eligible for coverage of only emergency medical services in the federal coverage category of x02 if they received treatment for an emergency medical condition and meet all other MA or MCHP technical and financial eligibility requirements for full benefits under COMAR 10.09.24 or COMAR 10.09.11 including verified Maryland residency. (a) Ineligible Aliens Ineligible aliens include qualified alien (as defined in the Chapter) who are ineligible for full federal MA or MCHP coverage because they entered the U.S. on or after August 22, 1996 and have not yet met the 5- year bar to coverage. Ineligible aliens also include legal aliens or immigrants who do not meet the definition of a qualified alien, such as aliens lawfully admitted to the U.S. for a temporary or specified time period, not as a permanent legal resident. These temporary visitors include the following:

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Foreign government representatives on official business and their families and

servants Visitors for business or pleasure, including exchange visitor Aliens in travel status while traveling directly through the U.S. Crewmen on shore leave Treaty traders and investors and their families Foreign students International organization representatives and personnel and their families and serverants Temporary workers including agricultural contact workers Members of foreign press, radio, film or information media and their families

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(b)Undocumented Aliens An undocumented (illegal) alien is an alien not lawfully residing in the U.S. for either a permanent or temporary purpose. This group includes persons who entered the U.S. illegally, regardless of the means by which the alien arrived (e.g., border crossing by boat, train, car, bus, and airplane or by foot). Undocumented aliens also include aliens who were legally admitted for a limited period of time and did not leave the U.S. when the approved period expired. 500. 6 Emergency Medical Service or Medical X02 (a)X-Track- Coverage State Only Emergency Medical Service (X02) Certain aliens who are not eligible of MA or MCHP benefits in a full federal category of XO2 Applicants who meet the citizenship/alien requirements for full federal coverage should not be determined eligible in the X- track, such as:

1. Naturalized citizens. 2. Qualified aliens who entered the United States on or after August 22, 1996 and have lived continuously in the U.S. for at least 5 years as a qualified alien. 3. Qualified aliens with an immigration status that is not subject to the 5 year bar, such as asylees, refugees, and victims of trafficking. 4. Qualified aliens who most recently entered the U.S. for a continuous stay before August 22, 1996, even if they entered as an undocumented or ineligible Aliens

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 prohibits eligibility of certain legal aliens for federal benefit programs until the individual lives in the U.S. for at least 5 years as a qualified legal alien if the individual entered the U.S. on or after August 22, 1996. (b) Emergency Medical Services for Undocumented or Ineligible Aliens X02 A non qualified alien may be eligible for federal coverage of treatment for an emergency medical condition only. An undocumented or ineligible alien may qualify for X02 if the individual fails to meet the citizenship/alien requirements but otherwise qualifies for a community coverage group with full federal benefits under COMAR 10.09.24 (MA) or COMAR 10.09.11 (MCHP) except for coverage groups P13 or P14. The individual must meet all of the financial and technical requirements for MA or MCHP eligibility except the technical requirements related to citizenship/alien status and Social Security Number (SSN). NOTE: The CM may not require that an alien applying for emergency medical services only coverage group X02 declare or provide verification of immigration status. Also, the applicant may not be required either to provide SSN or apply for an SSN. However, if information already exists in the record about the applicant’s immigration status and/or SSN, the CM must use that information when determining eligibility. The CM may not require that information be provided

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about the immigration status or SSN of someone who is not applying for public benefits, such as the applicant’s spouse or parents.

(c)Explanation of Emergency Medical Services A non qualified alien may only be eligible for coverage group X02 if the alien needs care and services for the treatment of an emergency medical condition. An emergency medical condition (including labor and delivery) is defined as a medical condition which occurs after a sudden onset and manifests itself by acute symptoms of sufficient severity (including severe pain) from the absence of immediate medical attention can reasonably be expected by a prudent layperson possessing an average knowledge of health and medicine to result in: Placing the patient’s health in serious jeopardy, Serious impairment to bodily function or Serious dysfunction of any bodily organ or part.

Maryland Medicaid regards emergency medical services as those services rendered in a hospital from the moment the individual presents with an emergency medical condition to the time the person’s condition is stabilized. Emergency medical services may also include:

Labor and delivery Dialysis and related services for end stage renal disease (ESRD) Services for Acquired Immune- Deficiency Syndrome (AIDS) and Cancer treatments that are considered by the Department of Health and Mental Hygiene as an emergency medical services.

The emergency medical services covered for undocumented or ineligible aliens under coverage group X02 do not include: Routine pre-natal or post –partum care Any medical services used to treat and/or evaluate a condition if the services do not meet the definition of emergency medical services Medical support, medical equipment, or prescribed drugs which are required beyond the point at which an emergency medical condition is stabilized and Any services related to an organ transplant or other transplant procedure.

(d)General Eligibility Requirements for Coverage Group X02 Except for citizenship/alien status requirements and enumeration (SSN), all MA technical eligibility requirements including residency must be met for X02 coverage.

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All financial eligibility requirements must be met for the community based

coverage group for which eligibility would be determined if the applicant met the federal

citizenship/alien requirements for Families and Children(FAC) in the F track, Aged, Blind or Disabled (ABD) in the S-track or Maryland Children’s Health

Program (MCHP) in the P-track 9 (except for P13 and P14).

1. Spend- down of any excess income is required before X02 eligibility may be established if the applicable coverage group is Medically Needy FAC (F99) or ABD (S99). 2. Resources are not considered if eligibility is determined under MCHP rules for a child under 19 years old or a pregnant woman.

The eligibility requirements include assistance unit requirements, including the consideration of income and resources of financially responsible members who are not requesting coverage (i.e., the applicant’s spouse or the parents of an unmarried minor child applicant). An applicant between the ages of 21 and 64 who is not pregnant and is not the parent or other caretaker relative of an unmarried minor child living in the household (i.e., is not technically eligible under FAC or MCHP rules) must be determined blind or disabled by the Social Security Administration or the Maryland Department of Human Resources’ State Review Team (SRT) in order to meet the technical eligibility rules for an ABD coverage category. If a non- elderly adult is not blind or disabled, the applicant is technically ineligible for X02 coverage, even if the applicant received emergency medical service. Non- qualified aliens applying for coverage of emergency medical services are not required to:

1. Sign a written declaration or otherwise provide documentation of immigration status. 2. Provide or apply for a Social Security Number (SSN) or 3. Provide immigration documents or an SSN for non- applicants in the household, such as the applicant’s spouse or parents.

Only a person with incurred expenses for emergency medical services received by the person may be certified in the X02 coverage group. The certification period for X02 is only for the month(s) that the Utilization Control Agent (UCA) approves the applicant’s medical eligibility for emergency medical services, or the month of the applicant’s labor and delivery.

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(1)Medical Eligibility Requirements for Coverage Group X02 For an alien to be eligible in X02, the service received must be consistent with the “Explanation of Emergency Medical Services”. The UCA determines whether the service meets the X02 coverage requirements by reviewing a medical report of the treatment received. The medical report must be in sufficient detail for the UCA to determine both the diagnosis and whether the treatment was of an emergency nature. The documentation of the emergency nature of the medical services must include: Diagnosis (or diagnoses), Description of treatment, Dates of treatment and MMIS Screen 1 or the CARES or MMIS inquiry screen showing the results of a search for whether the applicant has a previous history on CARES or MMIS.

Following is a list of acceptable medical documentation: When the patient have been discharged 1. Discharge summary with admission and discharge dates. When the patient has not been discharged: 1. Course of medical treatment, including admission date and tentative discharge date.

The following materials are unacceptable for medical documentation: Bills Nurses notes State Review Team (SRT) materials, including DHR 402B Case record materials, including immigration documents.

(e) Documentation of Services (1)Documentation of Labor and Delivery Services The medical eligibility review process by DHMH does not apply to labor and delivery services. The applicant/representative must provide the LDSS or LHD with a copy of the Discharge Summary or other written documentation from the hospital (but not nurses notes or a bill) that includes the mother’s name, the child’s name, the admission and discharge dates, the date of delivery, and confirmation of live birth. This documentation is not required to be signed by the physician or another hospital representative. (2) Documentation of Disability Coverage as X02 is only available to persons who would be eligible in a federal coverage category (MA, FAC, ABD or MCHP) but not for the qualified aliens status. The applicant is only eligible if the emergency medical condition requirement is met as well

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as all other requirements in a federal MA or MCHP category, except citizenship and SSN. Therefore, if the alien is applying as ABD and is not aged (65 or older),) a disability determination by SRT is necessary in addition to the emergency medical review. Then local department should promptly submit the paperwork to UCA for review of the emergency medical condition.

The local department should include a copy of the SRT decision with the request sent to UCA for a medical review. (3) Medical Eligibility Review Process All services, except labor and delivery, must be reviewed and approved by a medical professional within the Delmarva Foundation before payment is made. Medical Assistance does not compensate for service that are not directly related to the injury or illness that caused the emergency. The approval authorizes payment for only those services necessary for treatment and stabilization of the emergency medical condition, not the full range of services covered under the Medical Assistance State Plan The medical report for determining medical emergency must be sent to: Delmarva Foundation Attn: MDMA Acute 6940 Columbia Gateway Dr., Suite 420 Columbia, Md. 21046-2788 Fax 1-888-513-1995

The DES 401 should accompany each report. If the applicant requires an SRT disability determination, the SRT decision must also be included. The UCA will evaluate the medical report to determine if the services received were for the treatment of an emergency medical condition. The local department will be notified of whether the services received meet that requirement. NOTE: The medical eligibility review process does not apply to labor and delivery services. The LDSS or LHD will determine whether the woman meets the medical eligibility requirements based on the documentation of labor and delivery services discussed above. (f)Certification of Eligibility of X02 If all eligibility requirements are met, certify on a one time only basis the alien who has the incurred expense for the approved emergency service (including labor and delivery). If eligibility is being determined by a hospital outstation worker, the LDSS supervisor must review the case and approve eligibility before the worker finalizes the X02 eligibility.

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Attachment A- DES 401 EMS Undocumented or Unqualified Aliens

EMERGENCY SERVICES TO UNDOCUMENTED OR UNQUALIFIED ALIENS

Date: _____________ To: Delmarva Foundation Attn: MDMA Acute 6940 Columbia Gateway Drive, Suite 420 Columbia, MD 21046-2788 1-888-513-1995 (fax number)

From: Local Department Name: _______________________

_ Local Department Address:

Telephone #: ___________________________________

_ SUBJECT: Determination of Emergency Services- Aliens Customer Name:

Customer Date of Birth:

Head of Household Name (if not the customer:

Case Number:

Date of MA Application:

Facility Name:

The above named applicant has submitted a Medical Assistance application for coverage of emergency services received from

to

.

(date) (date)

Federal category for which the applicant is eligible, but for his/her alien status:

FAC MCHP Aged Disabled/Blind

A copy of the following must be attached:

Discharged summary with admission and discharge dates

ER admission

Documentation showing the emergency nature of the medical services

I have checked and agree that the technical and financial information for the applicant has been reviewed and meets the MA requirements except for citizenship

Case Manager Signature: ____________________________________________

(Please sign your name)

Note: no bills or other extraneous information should be submitted

DES 401 (updated 11/11)

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Attachment B- Notice of Eligibility

Maryland Medical Assistance Program

Maryland Children’s Health Program

NOTICE OF ELIGIBILITY

State Funded or Emergency Medical Services for Ineligble or Illegal Aliens

Applicant’s Name:

Date of Notice:

Applicant Address:

Local Department:

Client ID:

Dear

:

This is to notify you that based on the application you filed on

, Eligibility is approved for: � Coverage of full Medical Assistance benefits � Coverage of full Maryland Children’s Health Program benefits The following person or persons are covered:

You will receive a Medical Care Program card for each approved person. When it is time for eligibility to be redetermined, the Program will send you a packet to complete and return by a specified due date.

� Eligibility is approved for coverage of emergency medical services only for the following person:

. Eligibility is limited to services received Between

and

.

When this period ends, you must file a new application in order to be considered for further assistance. Full benefits under Medical Assistance (COMAR 10.09.24) or Maryland Children’s Health Program (COMAR 10.09.11) are not approved because the Program’s citizenship or qualified alien requirements are not met at this time. You will not receive a Medical Care Program card. You must show this notice and any other health insurance membership card to the providers(s) of all emergency medical services received, so they may bill Medical Assistance.

If you have any questions about this notice, call your Case Manager at the number below. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this notice.

Sincerely,

Case Manager

Telephone Number

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Summary of Procedure for Fair Hearings

You have the right to appeal this decision within 90 days from the date of this notice. If you think the decision if wrong you may:

Calling you Case Manager; Calling the State’s help line at 1-800-332-6347; Visiting your local department office; or Mailing or giving a written request for a hearing to you local department office.

The hearing will be schedule at a time and place that are convenient for you You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may bring any witnesses or documents you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you desire.

Prior to the hearing, you may review the documents and records that the Department will use at time of the hearing and you can ask for the names of the witnesses the Department intends to call.

During the time before the hearing, if you have new or additional information you wish the Department to know about, you may request a reconsideration of your case by calling your case manger or eligibility technician.

Under some circumstances, the Department may pay for transportation and other costs if they are necessary for the proper conduct of the hearing.

All these procedures and a fuller explanation of the fair hearing process can be found in the state regulations, COMAR 10.01.04 and in federal regulations 42 C.F.R 431. 200.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1800-999-8904 or the Maryland Disability Law Center at 1800-233-7201.

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Attachment C- Notice of Ineligibility

Notice Ineligibility (Non-Financial Reasons) Maryland Medical Assistance Program Maryland Children’s Health Program NOTICE OF INELIGIBILITY

SERVICES FOR INELIGIBLE OR ILLEGAL ALIENS Applicant’s Name:

Date of Notice:

Applicant’s Address:

Local Department:

Client ID:

Dear

:

This is to notify you that based on the application you filed on

, you have determined ineligible for full Medical Assistance or Maryland Children’s Health Program benefits or for coverage or emergency medical services for the reason (s) checked below:

� You are not a resident of the State of Maryland � The Medicaid Utilization Control Agent determined that you are not disabled. � The Department of Human Resources State Review Team determined that you are not disabled. � You failed to appear at the local department for the required interview. � You did not provide the following required information or verifications: Specify:

� Other

This decision is based on COMAR 10.09. . You may reapply at any time. If you do not agree with the decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this notice.

Sincerely,

Case Manager

Telephone Number

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Summary of Procedure for Fair Hearings You have the right to appeal this decision within 90 days from the date of this notice. If you think the decision if wrong you may:

Calling you CM; Calling the State’s help line at 1-800-332-6347; Visiting your local department office; or Mailing or giving a written request for a hearing to you local department office.

The hearing will be schedule at a time and place that are convenient for you. You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may bring any witnesses or documents you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you desire.

Prior to the hearing, you may review the documents and records that the Department will use at time of the hearing and you can ask for the names of the witnesses the Department intends to call.

During the time before the hearing, if you have new or additional information you wish the Department to know about, you may request a reconsideration of your case by calling your case manger or eligibility technician.

Under some circumstances, the Department may pay for transportation and other costs if they are necessary for the proper conduct of the hearing.

All these procedures and a fuller explanation of the fair hearing process can befound in the state regulations, COMAR 10.01.04 and in federal regulations 42 C.F.R 431. 200.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1800-999-8904 or the Maryland Disability Law Center at 1800-233-7201.

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Attachment D- Notice of Ineligibility Notice Ineligibility (Financial Reasons) Maryland Medical Assistance Program Maryland Children’s Health Program NOTICE OF INELIGIBILITY

SERVICES FOR INELIGIBLE OR ILLEGAL ALIENS

Financial Reasons

Applicant’s Name:

Date of Notice:

Applicant’s Address:

Local Department:

Client ID:

Dear

: This is to notify you that based on the application you filed on

, you have been determined ineligible for full Medical Assistance or Maryland Children’s Health Program benefits or coverage of emergency medical services for the reason (s) checked below:

� Your income is more than the amount allowed. The income considered for the period is:

SOURCE

AMOUNT

DEDUCTIONS Your total income is $

. The amount of deduction is $

. Your net amount of income is $

. The most net income allowed for person(s) is $

. Therefore, you have $

more than is allowed.

This decision is based on Medical Assistance policy at COMAR 10.09. 24.08 and 10.09. 24.09. You may reapply at any time. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting are on the back of this notice.

Sincerely,

Case Manager

Telephone Number

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Summary of Procedure for Fair Hearings You have the right to appeal this decision within 90 days from the date of this notice. If you think the decision if wrong you may:

Calling you Case Manager; Calling the State’s help line at 1-800-332-6347; Visiting your local department office; or Mailing or giving a written request for a hearing to you local department office.

The hearing will be schedule at a time and place that are convenient for you You will be expected to be present. If for any reason you cannot be present, you must notify the Office of Administrative Hearing to reschedule the hearing or to identify the person who will attend in your place. You may bring any witnesses or documents you desire to help you establish pertinent facts and to explain your circumstances. A reasonable number of persons from the general public may be admitted to the hearing if you desire.

Prior to the hearing, you may review the documents and records that the Department will use at time of the hearing and you can ask for the names of the witnesses the Department intends to call.

During the time before the hearing, if you have new or additional information you wish the Department to know about, you may request a reconsideration of your case by calling your case manger or eligibility technician.

Under some circumstances, the Department may pay for transportation and other costs if they are necessary for the proper conduct of the hearing.

All these procedures and a fuller explanation of the fair hearing process can be found in the state regulations, COMAR 10.01.04 and in federal regulations 42 C.F.R 431. 200.

You may obtain free legal aid and help through various resources, such as the Legal Aid Bureau at 1800-999-8904 or the Maryland Disability Law Center at 1800-233-7201.

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500.7 Residency In order to be eligible for the MA assistant program, a person must be a resident of Maryland. The applicant’s statement of his residential address on the signed application will be accepted as verification of State residency. No other verification of residency is necessary unless the local department has reason to question the truth of the statement. Reason to question the stated address exists when the applicant furnishes inconsistent address information or when the applicant’s address information varies from community knowledge or other information in the possession of the local department. In these instances, proof of the residential address must be provided by the applicant to meet the technical eligibility requirement of Maryland residency. A minimum duration of in- state residence is not required. Residency established on any day in the month of application for the MA program constitutes residency for the full month. A person who was a Maryland resident for only part of the period under consideration is ineligible on the basis of residency for any month in which the person was not a resident. A person is not a resident of Maryland if the person entered Maryland for a specific, time- limited purpose and does not intend to remain here permanently or indefinitely. A person who comes to Maryland temporarily seeking only a non institutional medical care (e.g., acute hospital services, labor and delivery services) is not a resident of Maryland. A visitor to the State is not a resident. A student from another state may or may not be a resident of Maryland. Among the factors to consider with regard to a student is the student’s registration with the school as an in state or out –of-state student or the state that is on record for the student’s voter registration, student aid, or driver’s license. A person may not be eligible for MA in two states at the same time. This does mean that a case may not be open in two states at the same time. When a person moves from one state to another, the person is no longer eligible in the former state, the case should be closed immediately. Adequate and timely written notice must be given before a case can be closed. The eligibility CM may not wait for the former state to process a case closure before granting MA eligibility to an otherwise eligible person. The fact that a case is still open in another state is not sufficient reason to deny or delay eligibility for an otherwise eligible case. When granting eligibility in such a case, the eligibility should still make every effort to verify that the former state is aware of the change of residency. The case should be flagged for a reasonable interval to insure that the closing is eventually verified. The CM may assist the other state by sharing case information which may expedite the eligibility determination process. NOTE: Residency is retained until abandoned. Temporary absence from the State, with intention to return to the State, does not interrupt continuity of residency. The situation of a person who routinely lives part of each year in another state must be evaluated to determine which state is the permanent residence. A person is a Maryland resident if throughout an annual absence from Maryland the person declares their intention to remain a resident of Maryland and has not been certified for MA in another state. The anticipated dates of

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absence from Maryland should be ascertained and the case flagged for the anticipated date of return if it falls within the certification period. Routine absence from the state does not include periods of absence for medical treatment preauthorized under the Maryland MA program or unanticipated medical care. Such absences would not adversely affect Maryland residency. NOTE: Notwithstanding any other provisions of this section, the state of residence for a recipient of a state supplementary SSI payment is the state making the supplementary payment. A person receiving state – supplemented SSI from another state may move to Maryland with the intention of making his permanent home here. This person is not automatically eligible for MA in Maryland until his change of state residence had been verified and appropriate changes in his payment amount have been verified and appropriate changes in his payment amount have been made by the Social Security Administration (SSA). SDX provides the appropriate verification. NOTE: A person may become ineligible for SSI if he has income exceeding the basic SSI limit and was eligible in his former state of residence only because of the higher state supplement limit.

(a) Residency Criteria for Non-Institutionalized Persons A non- institutional person younger than 21 years old: Residence shall be established for the parent(s) or other caretaker relative with whom a non institutionalized person younger than 21 years old lives. Residence shall be established for non institutionalized person younger than 21 years old when its is determined that the child is not living with a parent or other caretaker relative and these persons are no longer responsible for the day to day care and supervision of child.

A non institutionalized person 21 years old or older is a resident of the state in which the applicant: Is living voluntarily with the intention of making his/her home or Is living at the time of application, if the applicant is not receiving assistance from another state and entered with a job commitment or seeking employment (whether or not currently employed). The applicant who declares that they entered Maryland seeking employment meets the residency requirement. Proof of employment is not necessary. However, the CM should advise the applicant who has been unsuccessful in finding employment of the services available through the local Employment Security office and any other public employment agency operating in the area. The temporary purpose restriction shall be waived for members of an assistance unit with a migrant worker, if the migrant worker otherwise qualifies.

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Notwithstanding any other provisions of this regulation, the state of residence for a person placed in another state is the state making the placement.

(b) Residency Criteria for Institutionalized Person(s) For the purpose of this section, a person is considered incapable of indicating intent if: The applicant IQ is 49 or less or has a mental age of 7 or less based on tests acceptable to the DHMH Developmental Disabilities Administration The applicant is judged legally incompetent Medical documentation or other documentation acceptable to the State, supports a finding that he is incapable of indicating intent.

Most persons residing in Maryland institutions are considered Maryland residents. However, some of those people should not be considered Maryland residents (such as, a person placed by another state in Maryland facility or a person under 21 years of age whose parents do not live in Maryland). For all other institutionalized persons, the ability to indicate intent with regard to state residency governs the determination of the state of residence. A person who had been judged legally incompetent or has been determined to be incompetent according to the procedures set forth above may not make a blinding statement of intent on his own behalf. The date on which the person is considered to have become incapable of indicating intent will be the date established by the court as the first day of incompetency, the date of the adjudication if not prior day of onset is specified by the court, or the date established by the certifying physician. The incompetency status will continue until rescinded by the court or revised by the certifying physician. The person for whom current (within 6 months of the date of application) IQ or mental age determination exists will be determined incapable of indicating intent if those findings indicate and IQ of 49 or less or mental age 7 or less. The IQ or mental age determination must have been made by a testing agency approved to administer IQ or mental age tests by the state of Maryland. Approved agencies include federal, state, and local governments; local boards of education; and licensed psychiatrists, psychologists, psychiatric, psychological, and associations. The effective date of the inability to indicate intent will be the date established by the testing agency as the earliest date to which the findings are applicable, or the date of the testing if no prior date of applicability is specified by the testing agency. The IQ or mental age determination will remain applicable until modified by a more recent IQ or mental age determination made by an approved testing agency. An applicant is not required to prove IQ or mental age. Any other institutionalized person will be assessed on the basis on the applicant statement of their ability to indicate intent, if the applicant is representing their in the application process. A person is a resident of Maryland if the applicant resides in an institution in Maryland,

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except as provided elsewhere in this section. Notwithstanding any other provisions of his section, the state of residence for a person placed in an institution located in another state is the state making the placement. A resident of a long term care facility in Maryland can intend to remain in that facility for an indefinite period and can be considered a Maryland resident while still having an intention to return to his home out of state at the end of his institutional stay. The out-of- state home may be excludable as home property. A person younger than 21 years old is a resident of the state which: o The applicant parents (or legal guardian if one has been appointed) reside; or o The parent applying for Medical Assistance on the applicant behalf resides (if the parents reside in separate states and there is no appointed legal guardian).

An institutionalized person who is 21 years old or older and became incapable of

indicating intent when the applicant was younger than 21 years old, is a resident of the

state in which: o The applicant or legal guardian (if one has been appointed) reside; or o The parent applying for Medical Assistance on the applicant’s behalf resides (if the parents reside in separate states and there is no appointed legal guardian).

Any other person who is 21 years old or older is a resident of the state in which the applicant is living with the intention to remain permanently or for an indefinite period.

(c) Visitor Visas, State Residency, and Emergency Medical Services State residency is a requirement of eligibility for all coverage of emergency medical services in coverage group X02. A person who entered the State of Maryland for a temporary purpose cannot be considered a resident of Maryland unless the person subsequently decides to remain permanently or for an indefinite period and can verify this intent. An alien with a visitor’s visa or other time-limited approval for U.S. entry may be considered a Maryland resident if the person entered the state:

With a job commitment or seeking employment including a migrant worker or On a temporary basis but remained in Maryland and established it as the State where he/she lives.

An alien’s student visa or other immigration documents may indicate a specific period of time that the person was approved to remain in the U.S. by the Department of Homeland Security. If CM knows that an applicant has a visitor’s visa or other time-limited visa, this is cause for questioning the individual’s residency. Applicants may be asked about their intent to remain in Maryland and how they intend to stay in Maryland. If there is any question about whether the

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applicant is a resident, the CM is required to ask the applicant for written verification of residency. Appendix Verification/ Documentation When an individual with a temporary visa indicates the intent to remain in Maryland permanently or indefinitely, regardless of the expiration date on the visa, the CM must consider various factors when determining whether the residency requirement have been met. The CM must ask the applicant about present and past living arrangements and other pertinent questions in order to verify residency such as:

1. When did you come to Maryland? Why did you come? For how long do you plan to stay in Maryland? 2. Are these living arrangements permanent or temporary? If temporary, what are you

future plan? 3. Are you working in Maryland or someplace else? How are you supporting yourself? What are your sources of income?

500. 8 Aged, Blind, and Disability Determination (a) Age In order to be eligible as an aged person, a person shall be at least 65 years old.

For determining a person’s age July 1 shall be used as an arbitrary birth date if the year, but not the month, of birth is known. An age is reached on the day of the anniversary of birth. The regulations applying to aged, blind, or disabled person may not be applied to a non- blind or non-disabled person for any month prior to the first month that the person may be considered aged as determined by this standard. The local department of social services shall accept the Social Security Administrations’ determination of age 65 for a person receiving a Social Security benefit based on age 65.

(b) Blind In order to be eligible as a blind person, a person shall meet the definition of blindness under Regulation .02 of COMAR 10.09.24.

Procedure for Determination of Blindness: The person shall be examined by an ophthalmologist or a licensed optometrist unless both of the person’s eyes are missing.

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The ophthalmologist or licensed optometrist shall submit a report of the examination to the LDSS or LHD.

The report shall be reviewed by an ophthalmologist, contracted by the Department or its designee, who determines on behalf of the local department of social services or other designated entity determining Medical Assistance (MA) eligibility:

o Whether the person meets the definition of blindness and o The need and frequency of re- examination for periodic redetermination of blindness.

When processing applications involving determination of blindness, it is important for the CM to keep in mind the period under consideration. If the applicant is requesting assistance for the retroactive period under consideration and indicates the existence of the impairment during that period, the required medical and social information must be collected for the retroactive period. The medical form specifying blindness must be completed and used to report information to the SRT and the State’s reviewing ophthalmologist. This form may be supplemented by any additional medical statements or reports submitted by the examining practitioner. Payment may be made to the customer’s ophthalmologist or optometrist, through issuance of a vendor payment, for completion of the medical form at the time of the customer’s MA application and at a scheduled review. Re- examinations for periodic redeterminations’ of blindness will be conducted according to the Procedure for Determination of Blindness. The LDSS or other entity determining MA eligibility shall accept the Social Security Administration’s determination of blindness for a person receiving a Social Security benefit based on blindness. (c) Disability Determination To be eligible for Medical Assistance as disabled in an Aged, Blind or Disabled (ABD) coverage group an applicant shall meet the definition of “disabled.” “Disabled’ is defined as the inability to engage in any substantial gainful activity due to any medically determinable physical or mental impairment which is expected to result in death, or which has lasted or is expected to last for a continuous period of not less than 12 months. Applicants must also meet all other technical and financial requirements. That includes the requirement that the applicants apply for and take all other necessary steps to obtain and accept all income benefits to which he or she may be entitled. Therefore, all applicants must be referred to the Social Security Administration (SSA) to apply for income benefits. Acceptable proof that an applicant has made an SSA application(s) will be discussed later in this Section.

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(1) Procedure for Determination of Disability Applicant with pending SSA Determination The State Review Team (SRT) of the Department of Human Resources determines disability of MA applicants who are requesting eligibility in an ABD coverage group if SSA has not already determined the applicant is currently disabled. The case manage manager must determine if the applicant meets or does not meet Substantial Gainful Activity by calculating the applicants countable earnings and compare earnings to MA- Schedule for SGA guidelines. If the individual doesn’t meet SGA, they have met then initial criteria for being determined “Disabled, the case is then referred to the State Review Team with an SRT Referral Packet.

The Referral Packet consists of:

DHR/FIA 707 State Review Disability or Blindness Determination Transmittal Form Verification of SSA status: o Verification from SSA; OR o Original printout of the appropriate SDX, SVES, and/or SOLQ screen. Original DHR/FIA 827 Authorization to Disclose Information Form; Original DHR/FIA 3368 Disability Report form is completed only when: o The applicant is applying for MA under the X02 category; or o The applicant and/or spouse applying are receiving any type of income Verification of any earned income, if the applicant is employed; OES 06 SGA Worksheet when required, including the Impairment-Related Work Expenses descriptions. The applicant is expected to complete the top portion of the SGA Worksheet; Any original medical documentation that the applicant provides to the LDSS; and DHR/FIA 700 Customer Declaration of Disability Form

(3)Applicant with current SSA Determination (Disabled or not Disabled) If SSA has determined the applicant is currently disabled, the LDSS or other entity determining MA eligibility does not need to submit the disability determination package to SRT for an applicant requesting eligibility in an ABD category. A SSA determination is binding on the State. If SSA changes their decision, their new decision is also binding on the State. The LDSS must use the State Data Exchange (SDX), State Verification Eligibility System (SVES), or State Online Query (SOLQ) to determine the applicant’s Social Security benefits status before sending a disability referral to the SRT as specified below. If the above referenced systems indicate a different status than the applicant states to the LDSS, then verification from SSA is required. A receipt from SSA will serve as proof that the applicant

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applied for SSA benefits. A letter from SSA that contains the SSA determination will serve as proof of SSA’s determination. If SSA has previously denied disability and the applicant alleges new information or produces new evidence affecting the previous denial, the LDSS or other entity determining eligibility shall refer the applicant to SSA to file a new application or for reconsideration of the applicant’s case. The LDSS shall accept the application but the original SSA determination of “not disabled” is binding unless SSA changes their determination after reconsidering the case. Retroactive Consideration If the applicant indicates the existence of one or more impairments during the three months prior to application (retroactive period), the LDSS shall request the retroactive period on the DHR/FIA 707 form submitted to SRT. SRT Procedures The SRT shall review the information provided by the LDSS and other evidence to make a disability determination. The SRT will make every effort to obtain additional information when necessary.

Notification to Applicant of “Not Disabled” Determinations (736 and 739 Forms) If the SRT determines the applicant is not disabled, the SRT will send the LDSS two (2) copies of the DHR/FIA 736 (Medical, Vocational and Educational Assessment). The LDSS uses the DHR/FIA 739 (Disability Determination Notice of Action) as a cover letter to send one copy of the DHR/FIA 736 to the applicant or an authorized representative. The other copy remains in the case record. 500.9 Caretaker Relative In order to be eligible for a MA Families and Children (FAC) coverage group as a caretaker relative an individual must meet the definition of “caretaker relative” as being the parent or other adult who is: Related to a child by blood, marriage, or adoption and Living with and caring for the child

For this purpose, a child is defined as an unmarried person less 21years old. The required verification of an applicant or recipient’s status as a caretaker relative (is addressed under Chapter 6 of this Manual).