This chapter governs the determination of eligibility for the Maryland Children's Health Program with an income standard based on the modified adjusted gross income methodology specified in the Affordable Care Act of 2010, effective January 1, 2014. Eligibility for the Maryland Children's Health Program may be established for children younger than 19 years old whose family income is equal to or less than 200 percent of the federal poverty level. In this chapter, the following terms have the meanings indicated. Terms Defined. “Affordable Care Act” means the Patient Protection and Affordable Care Act of 2010 (Pub.L.111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub.L.111-152), as amended by the Three Percent Withholding Repeal and Job Creation Act (Pub.L.112-56). Applicant. “Applicant” means an individual whose written application for the Maryland Children's Health Program has been submitted to the local health department or the local department of social services but has not received final action. “Applicant” includes an individual whose application is submitted through a representative. “Application” means the filing of a written, telephonic, or electronic signed application for health coverage in an Insurance Affordability Program to the Department or its designee. “Application date” means the date on which a written, telephonic, or electronic signed application is received by the Department or its designee. “Authorized Representative” has the meaning stated in COMAR 10.01.04.12. “Child” means an individual younger than 21 years old. “Child recipient” means a child younger than 19 years old who is certified as eligible for the Program. “Children’s Health Insurance Program” means the program for uninsured targeted low-income children established under Title XXI of the Social Security Act. “Department” means the Maryland Department of Health. “Designee” means any entity designated to act on behalf of the Department such as: Baltimore City or a county social services department under the supervision of the Department of Human Services; Baltimore City Health Department and its subgrantees, or a county health department; and The Maryland Health Benefit Exchange. “Determination” means a decision regarding an applicant's eligibility for the Maryland Children's Health Program. “Eligibility worker” means an employee of the local health department, or the local department of social services, responsible for determining the eligibility of applicants and recipients. Emergency Medical Condition. “Emergency medical condition” means a condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. “Emergency medical condition” includes labor and delivery. “Emergency medical condition” does not include services related to an organ transplant procedure. “Family members” means those individuals living with the applicant whose income is counted, or would be counted if there were any, as household income under Regulation .07B of this chapter. “Federal poverty level” means the nonfarm income official poverty level as defined by the Office of Management and Budget and revised annually in accordance with §673(2) of the Omnibus Budget Reconciliation Act of 1981. “Inpatient services” means services received by a recipient while in a medical institution, birthing center, or clinic for which Medical Assistance is provided. “Institution for mental diseases” means an institution which falls within the jurisdiction of Health-General Article, §19-307(a)(1), Annotated Code of Maryland, and is licensed under COMAR 10.07.04. “Insurance Affordability Program” means a program that is one of the following: The Maryland State Medicaid program; The Maryland Children’s Health Insurance Program (CHIP), including the program known as Maryland Children’s Health Program (MCHP) Premium; An optional state basic health program established under §1331 of the Affordable Care Act; A program that makes available to qualified individuals coverage in a qualified health plan through the Maryland Health Benefit Exchange with advance payments of the premium tax credit established under §36B of the Internal Revenue Code; or A program that makes available coverage in a qualified health plan through the Maryland Health Benefit Exchange with cost-sharing reductions established under §1402 of the Affordable Care Act. “Living together” means sharing a common household. “Local health department (LHD)” means the Baltimore City Health Department and its subgrantees, or a county health department. “MAGI” means modified adjusted gross income, as calculated for purposes of determining eligibility for insurance affordability programs under the Affordable Care Act. “MAGI Exempt Coverage Group” means coverage groups such as Aged, Blind, Disabled; Categorically Needy; and Medically Needy as defined under COMAR 10.09.24.02, whose eligibility is not determined by MAGI. “Maryland Children's Health Program (Program)” means the program established in Health-General Article, §15-301 et seq., Annotated Code of Maryland, to provide comprehensive medical care and other health care services to certain children. “Maryland Health Benefit Exchange” means the unit of State government that determines initial and continuing eligibility for the MAGI based insurance affordability programs, including, by delegation, certain eligibility in the program. “Maryland Medicaid Managed Care Program” means the Health Choice Program authorized by: Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland; and A waiver issued by the federal government under §1115 of the Social Security Act. “Medical Assistance (Medicaid)” means the program administered by the State under Title XIX of the Social Security Act which provides comprehensive medical and other health-related care for eligible individuals. “Period under consideration” means the specific months which are assessed in order to determine eligibility. Public Institution. “Public institution” includes an: Institution that is the responsibility of a government unit or over which a government unit exercises administrative control; or An establishment that furnishes, in single or multiple facilities, food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor. “Public institution” does not mean a medical institution, a skilled nursing facility, or a publicly operated community residence that serves not more than 16 residents. “Qualified alien” means an individual who: Has been fully admitted for permanent residence in the United States under the Immigration and Nationality Act (INA); Has been granted asylum in the United States as a refugee under §208 of the INA; Has been admitted into the United States as a refugee under §207 of the INA; Has been paroled into the United States under §212(d)(5) of the INA for a period of at least 1 year; Has had deportation withheld under §243(h) of the INA; Has been granted conditional entry into the United States under §203(a)(7) of the INA which was in effect before April 1, 1980; Is a documented or undocumented immigrant who has been battered or subjected to extreme cruelty by the individual's U.S. citizen or lawful permanent resident spouse or parent, or by a member of the spouse's or parent's family residing in the same household as the alien, if: The spouse or parent consented to, or acquiesced in, the battery or cruelty; The immigrant has filed a Violence Against Women Act (VAWA) immigration case or a family-based visa petition with Immigration and Naturalization Service (INS); and In the opinion of the agency providing benefits, there is a substantial connection between the battery or cruelty and the need for the benefits to be provided; Is a victim of a severe form of trafficking who has been subjected to: Sex trafficking if the act is induced by force, fraud, or coercion, or the individual induced to perform the act is younger than 18 years old; or Involuntary servitude; Is a member of a federally recognized Indian tribe, as defined in 25 U.S.C. §450b(e); or Is an American Indian born in Canada to whom §289 of the INA applies. “Recipient” means an individual who is certified as eligible for the Maryland Children's Health Program. “Redetermination” means a determination regarding the continuing eligibility of a recipient. “Spouse” means an individual who has been determined to be the husband or wife of another person under State law and for the purpose of determining eligibility for Social Security benefits. “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 individuals. “Title XXI” means the title of the Social Security Act through which funding is provided, in part, for the Maryland Children's Health Program. Eligibility may be established for the Maryland Children's Health Program for children younger than 19 years old whose household income is equal to or less than 200 percent of the federal poverty level. The Department or its designee shall determine eligibility for children. The Department or its designee shall give oral, written, or electronic information about the Maryland Children’s Health Program such as: Requirements for eligibility; Available services; An individual's rights and responsibilities; Information in plain English, supported by translation services; and Information accessible to disabled individuals requesting an application. An individual requesting health coverage from an Insurance Affordability Program shall be given an opportunity to apply. The Department or its designee shall make the application available to the individual without delay, by telephone, mail, in-person, internet, other available electronic means, and in a manner accessible to disabled individuals requesting an application. A resident temporarily absent from the State but intending to return may apply for health coverage from an Insurance Affordability Program by telephone, mail, in-person, internet, and other available electronic means to the Department or its designee in any jurisdiction. The individual shall: Demonstrate continued residency in the State; and Meet all nonfinancial and financial requirements in order to be determined eligible. Application Filing and Signature Requirements. An individual who wishes to apply for health coverage under an Insurance Affordability Program shall submit a written, telephonic, or electronic application signed under penalty of perjury to the Department or its designee in any jurisdiction An applicant is responsible for completing the application but may be assisted in the completion by an individual of the applicant's choice. For the purpose of establishing eligibility of a child applicant who is neither pregnant nor postpartum, a parent or stepparent living with the child shall complete and sign the written, telephonic, or electronic application. If the child does not live with a parent, an authorized representative who is 21 years old or older shall complete and sign the application. The date of application shall be the date on which a written, telephonic, or electronic, signed application is received by the Department or its designee. The application may be mailed or submitted electronically to the Department or its designee. An individual who has filed a written, telephonic, or electronic application may voluntarily withdraw that application but the application remains the property of the Department or its designee and the withdrawal does not affect the periods under consideration specified under §I of this regulation. Period Under Consideration. The Department or its designee shall establish a current period under consideration based on the date of application established under §G of this regulation. For a child, the period under consideration is the 12-month period beginning with the month of application. Processing Applications — Time Limitations. When a written, telephonic or electronic application is filed, a decision shall be made promptly but not later than: 10 days from the date of application when filed at the local health department; or 30 days from the date of application when filed at the Department or its designee, but not the local health department. The time standards specified in §J(1) of this regulation cover the period from the date of application to the date the Department or its designee sends a written or electronic notice of its decision to the applicant. The Department or its designee shall inform the applicant by written or electronic notice of the missing information needed to determine eligibility, and the applicable time limit of 10 or 30 days. When an applicant fails to complete the application or to provide the required information needed to determine eligibility within the 10 or 30 day limit provided under §J(1)of this regulation, the applicant shall be determined ineligible. If an applicant is determined ineligible for the current period under consideration due to a nonfinancial factor, the application shall be disposed of and the application date may not be retained. If the applicant reapplies, a new period under consideration shall be established based on the date the new application is filed. Required Information. All information needed to determine eligibility for the Maryland Children's Health Program shall be reported. When there is evidence of inconsistency with attested information given by the applicant and reported by the state and federal databases, the applicant shall be required to offer an explanation and appropriate verification to reconcile the inconsistency. Social Security Number. As a condition of eligibility, an applicant shall furnish to the Department or its designee a Social Security number for the applicant. If the applicant cannot furnish a Social Security number, the applicant shall apply for a number. Assistance may not be denied, delayed, or discontinued pending the issuance or verification of the number if the applicant complies with this subsection. Eligibility may not be established until the applicant: Furnishes a Social Security number; or Requests the assignment of the number through the Social Security Administration. Failure to provide the required Social Security number shall result in ineligibility for the applicant. If an applicant lacks the resources to meet the requirements of this regulation, the Department or its designee services shall assist the applicant in obtaining the necessary documents, and any costs incurred shall be paid for out of administrative funds. If the application indicates that a Social Security number was issued previously, the Department or its designee shall request validation of the number by the Social Security Administration. Individuals described under COMAR 10.09.24.05D(4)(b) who are applying for limited benefits to treat an emergency medical condition are not subject to the requirements in §A(1)—(4) of this regulation. Third-Party Liability. A recipient shall notify the Department or its designee 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 recipient's medical expenses. A recipient shall cooperate with the Department or its designee in completing a form designated by the Department to report all pertinent information and in collecting available health insurance benefits and other third-party payments. In accident situations, a recipient shall notify the Department or its designee of the: Time, date, and location of the accident; Name and address of the attorney; Names and addresses of all parties and witnesses to the accident; and Police report number if an investigation is made. The Department or its designee shall: Maintain a written or electronic record including documentation of any required elements of eligibility; and Restrict disclosure of information concerning a recipient to purposes directly connected with the administration of the Medical Assistance Program, including: Establishing eligibility; Determining the extent of coverage under Medical Assistance; Providing services for recipients; and Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the Medical Assistance Program. An applicant or recipient shall give consent to verify information needed to establish eligibility to the Department or its designee, by submitting a written, telephonic or electronic application. Citizenship. In order to be eligible for full benefits under the Maryland Children's Health Program, an individual shall meet the federal requirements for Medical Assistance eligibility as a citizen or qualified alien, as specified at COMAR 10.09.24.05. Residency. In order to be eligible for benefits under this chapter, an individual shall be a resident of Maryland, in accordance with the requirements at COMAR 10.09.24.05-3. Age. In order to be eligible for benefits under this chapter, a child shall be younger than 19 years old. Inmate of a Public Institution. In order to receive benefits under this chapter, an individual may not be an inmate of a public institution, as specified at COMAR 10.09.24.05-5B. Institution for Mental Diseases. In order to be eligible for benefits under this chapter, an individual between 21 and 64 years old or a child applying under Title XXI of the Social Security Act may not be a patient in an institution for mental diseases, unless such individuals are eligible in accordance with COMAR 10.09.24.05-5C. No Private Health Insurance. In order to be eligible for benefits under Title XXI of the Social Security Act, an individual whose income is equal to 133 percent but less than 200 percent of the Federal Poverty Level, may not be covered by an employer-sponsored health benefit plan. An alien who fails to meet the requirements under §A of this regulation, but meets all other nonfinancial and financial factors of eligibility under this chapter, may be determined eligible for coverage under COMAR 10.09.24.05-2. Documentation of Citizenship and Identity. An applicant may not be determined eligible for Maryland Children’s Health Program until the requirements of this regulation are met. An applicant or recipient shall be required as a condition of eligibility to provide documentary evidence of identity as well as citizenship or nationality, to the Department's satisfaction, based on federal requirements, if the individual is: Declared to be a citizen or national of the United States; and Being determined for: Initial eligibility based on an application filed on or after September 1, 2006; or Continuing eligibility based on a redetermination with an end date on or after September 30, 2006. An applicant may be determined eligible for Maryland Children’s Health Program for a period of 90 days to provide requested documents. When an applicant fails to provide documentation of citizenship within the 90 day period, the applicant shall be determined ineligible. If an applicant or recipient fails to meet the requirements of §H of this regulation within the time standards specified in Regulation .04J(1) of this chapter, and the time standards are not extended, the Department shall: Deny eligibility for an applicant; or Terminate eligibility for a recipient, in accordance with the requirements for timely notice in COMAR 10.01.04. The requirements at §H of this regulation shall be met for all Medical Assistance coverage groups except for: Supplemental Security Income beneficiaries; Newborns who are deemed eligible, for a period of 1 year, for Medical Assistance based on the mother's Medical Assistance eligibility for the newborn's date of birth; Newborns deemed eligible who are born to an otherwise eligible non-qualified alien woman meeting the requirements of under COMAR 10.09.24.05-2 who has filed an application and has been determined eligible for Medical Assistance for the newborn's date of birth; Individuals who are entitled to Medicare benefits or enrolled in any part of Medicare; Individuals receiving SSDI disability insurance benefits under §223 of the Social Security Act, or monthly benefits under §202 of the Social Security Act, based on the individual's disability; Children who are receiving foster care or adoption assistance under Title IV-B or Title IV-E of the Social Security Act; and Other categories of individuals who are considered by the federal government to have previously presented satisfactory documentary evidence of identity as well as citizenship or nationality. Continuing eligibility for a recipient may not be approved at redetermination until the requirements of §H of this regulation are met. If there is documentation in an applicant's or recipient's written or electronic record or a federal or state's database that demonstrates that the individual meets the requirements of §H of this regulation, the individual shall be considered to meet the requirements of §H of this regulation, unless the: Department has cause to question the documentation previously accepted; or Federal government requires additional documentation. The applicant shall report the income of any family member, except for the income of a member that does not file a federal tax return and is not claimed as a federal tax dependent. Determining Countable Household Income. In determining an applicant's financial eligibility for the Maryland Children's Health Program, the applicant's current household income is considered. For the child applicant who is neither pregnant nor postpartum, household income shall consist of the income of the child applicant and the following family members when living with the child applicant: The child applicant's parents; and At the option of the child applicant's parents, any of the child applicant's siblings. For the married child applicant who is neither pregnant nor postpartum, household income shall consist of the income of the married child applicant and the married child applicant's spouse. When an individual has regular income the amount to be considered is that which is available or can reasonably be expected to be available for a projected period of 12 months, including the month of application. Treatment of Income. Countable gross income for the Maryland Children’s Health Program shall be the household income calculated according to MAGI. MAGI income limits shall be: Converted from traditional income limits to account for elimination of income disregards. Increased by 5 percentage points of the federal poverty level for the following circumstances: When an individual’s income exceeds the Medicaid income standard; and The income standard is the highest income standard under which the individual can be determined eligible. Household Composition. For purposes of determining the income standard applicable to an applicant or recipient, the following rules apply. An individual plus anyone for whom the individual claims personal exemption shall be included in the federal tax filing unit in the taxable year in which an initial determination or renewal of eligibility is being made. For an individual who does not file a federal tax return and is not claimed as a federal tax dependent in the taxable year in which an initial determination or renewal of eligibility is being made, the household size shall consist of the individual and the following individuals: Spouse; and Natural, adopted or step children. In the taxable year in which an initial determination or renewal of eligibility is being made, the household size of a child applicant shall consist of the child and the following individuals: Natural, adopted, or step parents; and Natural, adopted, or step siblings. In the case of a married couple living together, each spouse shall be included in the household of the other spouse, regardless of whether they expect to file a joint federal tax return in the taxable year in which an initial determination or renewal of eligibility is being made. No resources or assets test may be applied to an applicant or recipient who is subject to a MAGI-based income test. An applicant is financially eligible for the Maryland Children's Health Program if, for the period under consideration, the applicant's countable household income as determined under Regulation .07 of this chapter does not exceed 200 percent of the federal poverty level for a family size equal to the size of the family for child applicants younger than 19 years old. For a newborn, certification begins on the day the child is born to an eligible woman and ends on the last day of the month of the child's 1st birthday. For an eligible child, certification begins on the first day of the month of application, or up to 3 months before the month of application, if medical expenses were incurred during the earlier months, and continues until the day the child is determined ineligible. A child who, on the day the child becomes 19 years old, is receiving acute inpatient services under this chapter and who, but for attaining that age, would remain eligible for Medical Assistance benefits, shall continue to receive benefits until the end of the stay for which acute inpatient services are furnished. Individuals may be certified for a period of continuous eligibility as described in COMAR 10.09.24.12. A child certified for the Program is entitled to all health benefits through the Maryland Medicaid Managed Care Program. In the case of an alien who is eligible for benefits under COMAR 10.09.24.05D(4)(b), covered services are limited to those that are necessary for the treatment of an emergency medical condition, as defined under Regulation .02B of this chapter. Notice of Eligibility Determination. The Department or its designee shall inform an applicant of the applicant's legal rights and obligations and give the applicant written or electronic notification of the following: For eligible individuals: The basis and effective date for eligibility; Instructions for reporting changes that may affect the recipients eligibility; and The right to request a hearing; For ineligible individuals: A finding of ineligibility, the reason for the finding, and the regulation supporting the finding; Information regarding application for MAGI Exempt coverage groups; and The right to request a hearing. Recipient Responsibility. After an individual has been determined to be eligible for MCHP and is enrolled in MCHP: The Department shall periodically redetermine the recipient's eligibility for MCHP as specified under §D; and The recipient or the recipient's representative shall, within 10 days of the occurrence, notify the Department if there is a change in the recipient's, the recipient's parent's, or the recipient's guardian's: Income; Employment; Address; or Health insurance coverage status. A recipient or the recipient's representative shall limit use of the Medical Assistance card to the individual whose name appears on the card. When written or electronic notice of cancellation is received, a recipient shall discontinue use of the Medical Assistance card on the first day of ineligibility and return the card to the Department. Failure to comply with the provisions of §B(1)—(3) of this regulation may result in: The termination of assistance; or Referral to the Department for fraud investigation, or for criminal or civil prosecution. A recipient shall cooperate with the Department’s quality control and audit review process, including verification of all information pertinent to the determination of eligibility. If the recipient refuses to cooperate, the recipient's coverage shall be terminated subject to the regulation governing timely and adequate notice under COMAR 10.01.04. Unscheduled Redetermination. The Department or its designee shall: Promptly make an unscheduled redetermination of a child recipient's eligibility when changes in circumstances or relevant facts are: Reported by someone on the recipient's behalf, or Brought to the attention of the Department or its designee from other responsible sources; Notify the recipient that redetermination is required to establish continuing eligibility; and Notify the recipient of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process. Eligibility Decisions. Recipients who are determined: Eligible for the remainder of the certification period shall be sent notice in accordance with §A(1) of this regulation; or Ineligible because of a change in circumstances or failure to establish eligibility following a change in circumstance shall be sent notice in accordance with §A(2) of this regulation. A recipient whose eligibility has been canceled may reapply at any time after the cancellation of eligibility and a new period under consideration shall be established. Scheduled Redetermination. Except for children eligible as newborns of eligible women, the Department or its designee shall make a scheduled redetermination of a child recipient's eligibility at least every 12 months. The requirements relating to hearings under COMAR 10.01.04 apply to this chapter. The requirements relating to fraud and abuse under COMAR 10.09.24.14 apply to this chapter. The requirements relating to adjustments and recoveries under COMAR 10.09.24.15, with the exception of COMAR 10.09.24.15A(1) and (2), apply to this chapter. State regulations shall be interpreted in conformity with applicable federal statutes and regulations, except if the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation. Health-General Article, §§2-104(b), 15-101(f), 15-103, 15-105, and 15-301 et seq., Annotated Code of Maryland, Ch. 202, Acts of 2003 Effective date: Regulations .01—.17 adopted as an emergency provision effective July 1, 1998 (25:15 Md. R. 1182); adopted permanently effective November 30, 1998 (25:24 Md. R. 1773) Regulations .02—.07 and .09—.13 amended as an emergency provision effective July 1, 2001 (28:14 Md. R. 1319); amended permanently October 29, 2001 (28:21 Md. R. 1856) Regulation .01B amended effective November 10, 2003 (30:22 Md. R. 1580) Regulations .01B amended as an emergency provision effective July 1, 2004 (31:16 Md. R. 1251); amended permanently effective September 27, 2004 (31:19 Md. R. 1432) Regulation .02B amended effective November 10, 2003 (30:22 Md. R. 1580) Regulation .03B amended effective November 10, 2003 (30:22 Md. R. 1580) Regulations .03B amended as an emergency provision effective July 1, 2004 (31:16 Md. R. 1251); amended permanently effective September 27, 2004 (31:19 Md. R. 1432) Regulation .04I amended effective June 21, 2004 (31:12 Md. R. 911) Regulation .06 amended effective October 8, 2007 (34:20 Md. R. 1737) Regulation .06A amended effective November 10, 2003 (30:22 Md. R. 1580) Regulation .06C amended effective June 21, 2004 (31:12 Md. R. 911) Regulation .06I amended effective April 19, 2010 (37:8 Md. R. 614) Regulation .07C amended effective April 19, 2010 (37:8 Md. R. 615) Regulation .08A, B amended effective April 19, 2010 (37:8 Md. R. 615) Regulation .09A amended effective June 21, 2004 (31:12 Md. R. 911); April 19, 2010 (37:8 Md. R. 615) Regulation .10A amended effective November 10, 2003 (30:22 Md. R. 1580) Regulations .10A amended as an emergency provision effective July 1, 2004 (31:16 Md. R. 1251); amended permanently effective September 27, 2004 (31:19 Md. R. 1432) Chapter revised effective January 6, 2014 (40:26 Md. R. 2162) Regulation .11D adopted effective April 13, 2026 (53:7 Md. R. 328)