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<regulation prefix="Regulation" num=".05" citation="COMAR 10.09.44.05" title_num="10" subtitle_num="09" chapter_num="44" heading="PACE Participant Eligibility.">
  <paragraph num="A.">
    <text>An eligible person shall:</text>
    <paragraph num="(1)">
      <text>Reside in the PACE approved service area upon enrollment;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Be 55 years old or older;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Be able to be maintained in a community-based setting with the assistance of PACE at the time of enrollment without jeopardizing the PACE participant's health or others' health or safety;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Be determined by the Department to need the level of care required under the State Plan for coverage of nursing facility services for longer than 4 months; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Be willing to abide by the provision that requires PACE participants to receive all health and long-term care services exclusively from the PACE provider and its contracted or referred providers.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Medical Assistance Eligibility Services.</text>
    <paragraph num="(1)">
      <text>Medical Assistance eligibility for services under this chapter is determined under this regulation and applicable sections of COMAR 10.09.24, as cited in §B(2)—(4) of this regulation.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Categorically Needy. An individual is eligible for services under this chapter as categorically needy if the individual is receiving Medical Assistance as:</text>
      <paragraph num="(a)">
        <text>A recipient of Supplemental Security Income (SSI);</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A member of a low income family with children, as described in §1931 of the Social Security Act; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Any other type of categorically needy person in accordance with COMAR 10.09.24.03.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Optionally Categorically Needy.</text>
      <paragraph num="(a)">
        <text>An individual is eligible for services under this chapter as optionally categorically needy in accordance with 42 CFR §435.217, if the individual's countable:</text>
        <paragraph num="(i)">
          <text>Income does not exceed 300 percent of the applicable payment rate for SSI; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Resources do not exceed the SSI resource standard for one individual.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>For the purpose of determining Medical Assistance eligibility for the optionally categorically needy:</text>
        <paragraph num="(i)">
          <text>The individual is treated as an assistance unit of one individual; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Countable income and resources are determined based on the rules for income and resources set forth in COMAR 10.09.24 as applicable to an aged, blind, or disabled individual who is institutionalized, with the exceptions in §B(3)(g) of this regulation.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>An individual is not eligible under §B(3) of this regulation if a disposal of assets or establishment of a trust or annuity results in a penalty under COMAR 10.09.24, until such time as the penalty period expires.</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The spousal impoverishment rules in §1924 of the Social Security Act and COMAR 10.09.24.10-1 are applicable, except for the differences specified in this regulation.</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Medical Assistance eligibility shall be redetermined at least every 12 months.</text>
      </paragraph>
      <paragraph num="(f)">
        <text>If the applicant or participant is not aged, blind, or determined disabled by the Social Security Administration, the Department of Human Services shall determine whether the applicant or participant is technically eligible for Medical Assistance as a disabled person, in accordance with COMAR 10.09.24.05-4B.</text>
      </paragraph>
      <paragraph num="(g)">
        <text>All provisions of COMAR 10.09.24 which apply to an aged, blind, or disabled individual who is institutionalized are applicable to applicants and PACE participants under this chapter who are considered optionally categorically needy, with the following exceptions in full or in part:</text>
        <paragraph num="(i)">
          <text>COMAR 10.09.24.04-1D and E;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>COMAR 10.09.24.04-1F;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>COMAR 10.09.24.06B(2)(a)(ii);</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>COMAR 10.09.24.08F(1);</text>
        </paragraph>
        <paragraph num="(v)">
          <text>COMAR 10.09.24.08G;</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>COMAR 10.09.24.09;</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>COMAR 10.09.24.10; and</text>
        </paragraph>
        <paragraph num="(viii)">
          <text>COMAR 10.09.24.10-1.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(h)">
        <text>Home Exclusion. The home, as defined in COMAR 10.09.24.08F(1), is not a countable resource under §B(3) of this regulation if it is occupied by the applicant or PACE participant, the applicant's or PACE participant's spouse, or any one of the following relatives who are medically or financially dependent on the applicant or PACE participant:</text>
        <paragraph num="(i)">
          <text>Child;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Parent; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Sibling.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(i)">
        <text>Medical Assistance eligibility shall be determined by the Department within 45 days after the Department or its representative receives a signed application according to COMAR 10.09.24.04-1D.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Post-Eligibility Determination of Available Income for Optionally Categorically Needy.</text>
      <paragraph num="(a)">
        <text>The countable monthly income considered for the post eligibility determination is calculated in accordance with §B(3) of this regulation and COMAR 10.09.24 for institutionalized aged, blind, or disabled individuals, except that the income disregards specified in COMAR 10.09.24.07L are not applied.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>For individuals eligible under §B(3) of this regulation who reside in a licensed assisted living facility, the Department shall calculate a client contribution towards the cost of services under this chapter, based on the amount remaining after deducting from the individual's countable monthly income the following amounts in the following order:</text>
        <paragraph num="(i)">
          <text>A personal needs allowance of $60;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>A spousal or family maintenance allowance in accordance with COMAR 10.09.24.10D(2)(d); and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Incurred medical expenses as specified in COMAR 10.09.24.10D(2)(f) and (g).</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>For individuals who reside in an assisted living facility whose contribution toward the cost of service is calculated under §B(4)(b) of this regulation, the provider shall collect the PACE participant's available income. The amount collected under this paragraph may not exceed the monthly capitation amount under this chapter for the PACE participant.</text>
      </paragraph>
      <paragraph num="(d)">
        <text>For individuals eligible under §B(3) of this regulation who reside in a long-term care facility, the Department shall calculate a client contribution towards the cost of services under this chapter, based on the amount remaining after deducting from the individual's countable monthly income the following amounts in the following order:</text>
        <paragraph num="(i)">
          <text>A personal needs allowance in accordance with COMAR 10.09.24.10D(2)(c);</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>A spousal or family maintenance allowance in accordance with COMAR 10.09.24.10D(2)(d);</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>A residential allowance in accordance with COMAR 10.09.24.10D(2)(e); and</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Incurred medical expenses as specified in COMAR 10.09.24.10D(2)(f) and (g).</text>
        </paragraph>
      </paragraph>
      <paragraph num="(e)">
        <text>For individuals who reside in a long-term care facility whose contribution toward the cost of service is calculated under §B(4)(d) of this regulation, the provider shall collect the PACE participant's available income.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Enrollment shall be on a voluntary basis, without respect to race, age greater than the lower limit required, creed, sex, color, national origin, marital status, or physical or mental handicap.</text>
  </paragraph>
  <paragraph num="D.">
    <text>An individual is not eligible for enrollment in PACE, regardless of whether the individual is otherwise eligible for benefits under the Program, if the individual is:</text>
    <paragraph num="(1)">
      <text>Living outside the PACE provider's service area;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Not included in the PACE provider's target population specified in the PACE Program Agreement; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Enrolled in:</text>
      <paragraph num="(a)">
        <text>A managed care organization contracting with the Department;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A Medicaid home and community-based services waiver under §1915(c) of the Social Security Act;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Rare and expensive case management (REM) under COMAR 10.09.69; or</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A Medicaid capitated program that includes nursing facility or community-based long term care services.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>