Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.24 - Medical Assistance Eligibility › Section 10.09.24.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
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.
(4) "Applicant" means a
				  person whose written 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
				  written and 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 written, signed application is received by the local department of
				  social services.
(7) "Application
				  form" means the form designated by the Department 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 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:
(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.
(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.
(21-2) "Guardian of the person" means a
				  guardian appointed by a court pursuant to Estates and Trusts Article, Title 13,
				  Subtitle 7, Annotated Code of Maryland, to serve the interests of a minor or
				  disabled person under that subtitle.
(21-3) "Guardian of the property" means a
				  guardian appointed by a court pursuant to Estates and Trusts Article, Title 13,
				  Subtitle 2, Annotated Code of Maryland, to serve the interests of a minor or
				  disabled person under that subtitle.
(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.
(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 for individuals with intellectual disabilities or
				  persons with related conditions (ICF/IID)" means a nursing facility for the
				  intellectually disabled 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 for individuals with intellectual disabilities or
				  persons with related conditions (ICF/IID), 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.
(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.
(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.
(45-1) "Postpartum period" means:
(a) The period of time beginning on the date
				  a pregnancy ends and ending on the last day of the month in which the 60-day
				  period ends; or
(b) Effective for 5
				  years beginning April 1, 2022, the period of time beginning on the date a
				  pregnancy ends and ending on the last day of the 12th month following the end
				  of pregnancy.
(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.
(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.
(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.