Chapter 41. Employed Individuals with Disabilities

Except as provided in §A(2) of this regulation, terms used in this chapter that are not defined in §C of this regulation have the meanings stated for the same terms in COMAR 10.09.24.02.

If a term's definition in COMAR 10.09.24.02 references a “local department of social services” in the context of a determination of eligibility, the words “local department of social services” in the COMAR 10.09.24.02 definition shall be replaced, for purposes of the term's meaning in this chapter, with “the Department” .

“Applicant” means an individual:

“Application” means the filing with the Department of a written and signed application form for the Employed Individuals with Disabilities (EID) coverage group to establish eligibility for Medical Assistance benefits.

“Application date” means the date a written and signed application form for determination or redetermination of eligibility for the EID coverage group is received by the Department.

“Assistance unit” means an applicant or recipient and, when living together, the applicant's or recipient's spouse, whose eligibility for Medical Assistance benefits is determined in conjunction with each other.

“Certification period” means a period of time of up to 12 months, beginning on the first day of the month in which the Department receives the application, for which the EID applicant’s or recipient’s eligibility to receive Medical Assistance benefits is certified.

“Chronic hospital” has the meaning stated in COMAR 10.09.06.01B.

“Continuing eligibility” means a recipient's EID eligibility for a subsequent certification period after the current certification period, based on the Department's redetermination of eligibility with respect to an individual who is enrolled in the EID coverage group on the application date.

“Days” has the meaning stated in Article I, §36, Annotated Code of Maryland.

“Department” means the Maryland Department of Health, as defined in COMAR 10.09.36.01, or its authorized agents acting on behalf of the Department.

“Determination” means a decision by the Department regarding an applicant's or recipient's eligibility for the EID coverage group.

“Disability” means an individual's medically determinable impairment that is the basis of a determination that the individual is disabled, according to the standards set forth in §1614(a)(3) of the Social Security Act, except substantial gainful activity is not considered in determining disability.

“Disabled” means having a disability.

“Disregard” means a fixed monetary amount or documented expense that is deducted from countable gross income to determine countable net income.

“Employed” means being engaged in employment:

“Employed Individuals with Disabilities (EID)” means the Medical Assistance coverage group for employed individuals with disabilities, which is:

“Employer-sponsored insurance (ESI)” means group health insurance coverage provided wholly or partly at the expense of an applicant's, recipient's, or spouse's employer.

“Employment” means working for payment either for an employer or on a self-employed basis.

“Excludable” means the types of income and resources that are specified in this chapter as not countable in the determination of eligibility for the EID coverage group.

“Family unit size” means the number of individuals included in an assistance unit, which is used to determine the applicable income or resource standard.

“Grace period” means a period of time not longer than 6 months during which an unemployed EID recipient pays premiums and remains eligible to receive EID benefits despite failing to meet the requirement that EID recipients be employed.

“Hardship” means financial adversity or misfortune significant enough that it reasonably can be expected to compromise an applicant's or recipient's ability to obtain and provide basic food, shelter, and clothing for the applicant or recipient, another member of the assistance unit, or any dependents of the applicant or recipient.

“Health insurance” has the same meaning as “health insurance coverage”, as stated in COMAR 10.09.43.02B.

“Initial eligibility” means the EID eligibility of an individual who is not enrolled in the EID coverage group on the application date.

“Long-term care facility services” means services delivered to patients admitted to a nursing facility, chronic hospital, or a rehabilitation hospital.

“Medical criteria for disability” means the criteria applied by the Social Security Administration (SSA) to determine disability under Title XVI of the Social Security Act, except for the disability criteria that consider an individual's earnings as evidence of an ability to perform substantial gainful activity.

“Medically necessary” means that the service or benefit is:

“Notice of eligibility” means the written notice issued by the Department informing an applicant or recipient of:

“Nursing facility” has the meaning stated in COMAR 10.09.10.01B.

“Period under consideration” means a period of 6 months, beginning on the first day of the month of the application date, for which an assistance unit's income is assessed for a determination of eligibility under this chapter.

“Premium” means the monthly amount an applicant or recipient is required to pay, absent a successful claim of hardship pursuant to Regulation .07C of this chapter, as a condition of eligibility for the EID coverage group and Medical Assistance benefits.

“Provider” has the same meaning as “health care provider”, as stated in Health-General Article, §19-132, Annotated Code of Maryland.

“Recipient” means an individual who has been determined eligible for the EID coverage group.

“Redetermination” means a determination by the Department, at least every 12 months, regarding the continuing eligibility of a recipient, in accordance with the requirements of this chapter.

“Rehabilitation hospital” has the same meaning as “special rehabilitation hospital”, as stated in COMAR 10.07.01.02C.

“Social Security Disability Insurance (SSDI)” means a federally administered program that provides benefits to individuals with disabilities who have paid sufficient Social Security taxes to be eligible for disability insurance payments under Title II of the Social Security Act, 42 U.S.C §423 et seq.

“Substantial gainful activity” has the meaning stated in 20 CFR §416.910, which the Social Security Administration applies in determining disability under Title XVI of the Social Security Act.

Is 16 years old or older, but younger than 65 years old;

Is employed, except when an unemployment grace period described under Regulation .07 of this chapter applies, and verifies employment and compliance with all applicable requirements relating to FICA, income tax reporting, withholding, and payment requirements, including, if self-employed, payment of estimated taxes, by submitting documentation such as:

Except for the consideration of substantial gainful activity, meets the definition of disability in §1614(a)(3) of the Social Security Act, as determined by:

As specified in COMAR 10.09.24:

Is not a current recipient of:

The Department shall periodically review a recipient's impairments to determine continuing disability status, consistent with §C(2) of this regulation.

Frequency of Continuing Disability Reviews. The Department may schedule the periodic disability reviews required by §C(1) of this regulation at a frequency that is consistent with the time frames set forth in federal law and regulations as specified in 20 CFR §416.989, as amended, and 20 CFR §416.990, as amended, which are incorporated by reference.

Applicant or recipient; and

Applicant's or recipient's spouse when living in the same household, whether or not the spouse is eligible for the same benefits under this chapter.

Except as provided in §B(2) or C of this regulation, the Department shall determine, in accordance with the policies and procedures for aged, blind, or disabled coverage groups specified at COMAR 10.09.24, the countable net income of an EID applicant or participant for purposes of determining the applicable premium amount under Regulation .07 of this chapter.

To determine the countable net income of an EID assistance unit, the Department shall subtract from the assistance unit's total gross income:

As a condition of eligibility for Medical Assistance benefits under this chapter, unless good cause for not doing so is shown, applicants and recipients, shall take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits to which they are entitled, including, but not limited to:

Income Standards. Effective January 1, 2024, no income standard applies to applicants or participant under this chapter.

Except as provided in this section, whether an applicant meets the resource standards for eligibility for the EID coverage group shall be determined according to the policies and procedures for aged, blind, or disabled coverage groups specified in COMAR 10.09.24.

To determine the total countable resources of an applicant, the Department shall apply the general resource exclusions and specific resource exclusions for aged, blind, or disabled coverage groups specified in COMAR 10.09.24 to the total gross resources of the applicant.

From the total countable resources of the applicant determined pursuant to §C(1) and (2) of this regulation, the Department shall subtract the aggregate current cash value of the applicant’s or participant’s ownership interest in any of the following types of accounts:

For an applicant or participant to be eligible for Medical Assistance benefits under this chapter, the countable resources attributed to the applicant’s or participant’s assistance unit pursuant to §§C and D of this regulation may not exceed $10,000 for an individual.

Account Provisions.

Independence Account Registration.

To any individual requesting information, the Department shall provide oral or written information about:

The Department shall issue an EID application form to any individual upon request.

An applicant or recipient may apply for a determination or a redetermination of eligibility for the EID coverage group by submitting to the Department:

Consent Forms. An applicant or recipient, or, if necessary and consistent with the signature requirements specified in COMAR 10.09.24, a representative or other individual acting on behalf of the applicant or recipient, shall sign consent forms as needed to authorize the Department's verification of information needed to establish eligibility through sources such as employers, banks, and public or private agencies.

Social Security Number.

An applicant or recipient shall provide to the Department information and verifications needed for the determination of all elements of nonfinancial, income, and resource eligibility, including but not limited to information relating to health insurance coverage or potential third-party payments.

Additional Information Requirements. An applicant or recipient shall, at the Department's request:

An individual temporarily absent from the State who intends to return to the State:

An applicant or recipient shall cooperate and assist with the Department's eligibility determination or redetermination process under this chapter, including but not limited to the requirements of §A of this regulation.

Maintain a case record for the applicant or recipient, including documentation of all required elements of eligibility;

Conduct a wage-screening inquiry to determine wages, benefits, and claimant history for each assistance unit member;

Verify all factors of eligibility under this chapter for each assistance unit member applying for the EID coverage group; and

Restrict disclosures of information concerning applicants and recipients to purposes directly connected with the administration of the EID coverage group of the Medical Assistance program.

Disability Determined by Social Security Administration. With respect to an application submitted by an individual determined to be disabled as provided in Regulation .03B(3)(b) of this chapter, unless the time standard is extended pursuant to §D of this regulation, the Department shall, not later than 30 days from the application date:

No Disability Determination by Social Security Administration. Unless the time standard is extended pursuant to §D of this regulation with respect to an applicant who has had no determination of disability or continuing disability completed by the Social Security Administration within the time frame prescribed by Regulation .03C(2) of this chapter, the Department shall complete the requirements specified in §A(1)(a) or (b) of this regulation not later than 90 days from the application date.

Time Standard for Redeterminations. Before the beginning of a new certification period, the Department shall:

Unless the time standard is extended pursuant to §D of this regulation, the applicant or recipient shall, within the time standards specified in §B(2)—(4) of this regulation, provide to the Department:

If the Department's request for information or verification is part of the application packet, an applicant or recipient shall provide the signed and completed application and supporting information and materials specified in Regulation .05A(3) of this chapter to the Department early enough for the Department to meet the 30-day time standard specified in §A of this regulation for completion, subject to any premium payment required by Regulation .07 of this chapter, of an eligibility determination or redetermination.

If the Department's request is made after the application date, an applicant or recipient shall provide the requested information and verifications to the Department within 10 days of the date of the Department's notice pursuant to §A(1)(b) of this regulation.

For redeterminations, the recipient shall provide to the Department, by the last day of the current certification period, all materials and information required by §B(1)—(3) of this regulation.

Unless a claim of hardship is raised pursuant to Regulation .07C of this chapter, an applicant or recipient shall submit, within the time allowed by §B of this regulation, the premium required by Regulation .07A of this chapter.

If a claim of hardship raised pursuant to Regulation .07C of this chapter is denied by the Department, the applicant or recipient to whom Regulation .07C(3) of this chapter applies shall pay the premium required by Regulation .07A of this chapter within 10 days of the date of the Department’s notice pursuant to Regulation .07C(2) of this chapter.

The Department shall extend the time standards specified in §B of this regulation if:

If the circumstances described in §D(1) of this regulation are present:

The applicant or recipient fails to meet the timeliness requirements of §B of this regulation without the circumstances set forth in §D(1) of this regulation being present; or

The time standard for the applicant's or recipient's submission of information and verifications set forth in §B of this regulation initially was extended pursuant to §D(1) of this regulation, but the requirements of §D(1) of this regulation are no longer met.

To deny eligibility except as provided in §E of this regulation; or

As a waiting period for EID enrollment of eligible individuals.

An individual who has filed an application for the EID coverage group with the Department may voluntarily withdraw the application at any time.

An individual who has withdrawn an application for the EID coverage group may not reactivate the application except as provided in COMAR 10.09.24.

If an applicant or recipient withdraws a pending application, the application form shall remain the property of the Department.

Unless an exception under §A(2) of this regulation applies or a timely claim of hardship is raised pursuant to §C of this regulation, an applicant or recipient shall, as a condition of eligibility for the EID coverage group, pay the premium specified in §A(3) of this regulation.

Limitation of Premium Requirement.

An applicant or participant whose assistance unit has income:

Request for Payment. With respect to an applicant or recipient determined eligible subject to the requirements of §A(3) of this regulation, the Department shall issue a request for payment of the applicable premium, indicating that the applicant or recipient shall pay the amount specified within 30 days of the date the Department mailed the request for payment.

An applicant or recipient to whom §A(3) of this regulation applies shall, within 30 days of the Departments request for payment pursuant to Regulation §A(4) of this regulation:

Upon request by the recipient, the Department shall approve an unemployment grace period, not to exceed 6 months within a 12-month period, provided the recipient:

If an applicant who is required to pay a premium under §A(3) of this regulation, and is the subject of a request for payment issued by the Department pursuant to §A(4) of this regulation, does not pay the premium or submit a hardship claim within 30 days of the Department's notice, the Department shall:

If recipient who is required to pay a premium under §A(3) of this regulation, and is the subject of a request for payment issued by the Department pursuant to §A(4) of this regulation, does not pay the premium or submit a hardship claim within 30 days of the Department's notice, the Department shall:

An applicant or recipient whose eligibility is denied or terminated due to failure to pay the premium as specified in §A(4) of this regulation may not be reenrolled in the EID coverage group until the applicant or recipient pays all monies due to the Department in full.

If the applicant or recipient suffers financial adversity or misfortune so severe that payment of the premium would compromise the applicant's or recipient's ability to obtain and provide basic food, shelter, and clothing for members of the assistance unit or other legal dependents of the applicant or recipient, the applicant or recipient may submit a claim of hardship, specifying the underlying circumstances, to the Department.

The Department shall evaluate the claim of hardship and notify the applicant or recipient of its decision within 30 days of the Department's receipt of the written claim of hardship.

If the Department determines that the applicant or recipient's claim of hardship is without merit, the applicant or recipient shall pay the applicable premium within 10 days after the date the Department's notice is issued pursuant to §C(2) of this regulation.

Notice of Initial Eligibility. If the Department determines that an applicant is eligible, subject to the requirements of Regulation .07A of this chapter, for the EID coverage group, the Department shall issue to the applicant written notice that includes:

Notice of Continuing Eligibility. If the Department determines that a recipient qualifies for continuing eligibility for the EID coverage group, the Department shall issue to the recipient a written notice that includes:

Applicant—Denial Notice. If the Department determines that an applicant is not eligible for the EID coverage group, the Department shall issue to the applicant a written denial notice that includes:

Recipient—Notice of Termination. If the Department finds that a recipient is no longer eligible for the EID coverage group, the Department shall issue to the recipient a written notice of termination that includes:

If the Department finds one or more of the reasons for denial or termination listed in §D(2) of this regulation with respect to an applicant or recipient, the Department shall determine that:

Grounds for denial or termination from the EID coverage group shall include that an applicant or recipient:

A recipient's certification period for initial eligibility shall begin on the first day of the month in which the Department receives the application.

For a recipient approved by the Department for continuing eligibility, the next certification period shall begin on the first day of the month immediately following the month in which the previous certification period ends.

Unless the recipient is terminated before the end of the certification period due to a change in circumstances or other reason for ineligibility, a recipient’s certification period ends, except as provided in §§D(2)(f) and E(4) of this regulation, on the last day of the current 12-month eligibility period.

A recipient's certification period may be extended if the Department requires additional time to complete its redetermination of the recipient's eligibility.

Inform the applicant or recipient of the applicant's or recipient's legal rights and obligations; and

Provide to the applicant or recipient written notice of the findings, rights, and obligations as specified in COMAR 10.09.24.12A(2) and (4) and Regulation .08B or C of this chapter.

A recipient or the recipient's representative shall:

A recipient's failure to comply with the provisions of §B(1) of this regulation may result in the adverse consequences specified in COMAR 10.09.24, including:

Is considered, as specified in COMAR 10.09.24, to have created an authorization for the release of data, records, and information necessary for the Department's pursuit of third-party reimbursement;

Shall assign benefits to the Department and cooperate in the Department's recovery procedures as required in COMAR 10.09.24; and

Shall assist and cooperate with the Department's efforts to collect available health insurance benefits and other third party payments as specified in this regulation and Regulation .12 of this chapter.

Furnished by a provider who, with respect to the services rendered, is approved by the Department to participate in the Medical Assistance Program;

Covered under the State Plan;

Not covered under ESI or any other health insurance coverage besides Medical Assistance; and

Not the subject of any third party liability.

Enrollment in the Maryland Medicaid Managed Care Program (HealthChoice) in accordance with COMAR 10.09.62—10.09.75;

Enrollment in Rare and Expensive Case Management (REM), in accordance with COMAR 10.09.69;

Enrollment in the Program of All-Inclusive Care for the Elderly (PACE) under COMAR 10.09.44; or

Long-term care facility services exceeding 30 consecutive days.

The Department shall refer for reimbursement consideration all cases in which:

The Department:

If a recipient has ESI or other coverage, or if any other individual is obligated, either legally or contractually, to pay for, or to reimburse the recipient for, services covered by this chapter, a provider of covered services shall seek payment from that source before submitting a claim to the Medical Assistance Program.

If an insurance carrier rejects the provider's claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Medical Assistance Program, which shall be accompanied by a copy of the insurance carrier's notice or remittance advice.

If payment is made by both the Medical Assistance Program and the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Medical Assistance Program or the insurance or other source, whichever is less.

A provider shall reimburse the Department for any overpayment.

Completing a form designated by the Department to report all pertinent information to assist the Department in seeking reimbursement for services provided;

Notifying the Department within 10 days if medical treatment has been provided as a result of any accident or other occurrence in which a third party may be liable for health care services provided to the recipient; and

Providing to the Department, as set forth in §J(2) of this regulation, the information required under such circumstances pursuant to COMAR 10.09.24.12 and Regulation .09B(1)(d) of this chapter.