Chapter 62. Separate Children’s Health Insurance Program (CHIP) and CHIP Health Services Initiative Eligibility
Regulation .01 Purpose and Scope.LinkCopy Citation
A.
This chapter governs the determination of eligibility for the separate Children’s Health Insurance Program (separate CHIP) and the CHIP Health Services Initiative with an income standard based on the modified adjusted gross income methodology specified in the Affordable Care Act of 2010, effective January 1, 2014.
B.
Eligibility for the separate CHIP Program may be established for a targeted low-income child from conception to birth when the birthing parent would qualify for Medicaid but for their immigration status, when the family income is equal to or less than 250 percent of the federal poverty level.
C.
Eligibility for the CHIP Health Services Initiative for the birthing parent of a targeted low-income child may be established beginning on the first day of the month following the end of the pregnancy and ending on the last day of the fourth month after the pregnancy ends if the targeted low-income child applied for the separate CHIP Program on or before the day prior to their birth and was subsequently found eligible for the separate CHIP Program.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“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).
(2)
Applicant.
(a)
“Applicant” means an individual whose written application for the separate CHIP Program has been submitted to the local health department or the local department of social services but has not received final action.
(b)
“Applicant” includes an individual whose application is submitted through a representative.
(3)
“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.
(4)
“Application date” means the date on which a written, telephonic, or electronic signed application is received by the Department or its designee.
(5)
“Authorized representative” has the meaning stated in COMAR 10.01.04.12.
(6)
“Birthing parent” means the individual who gives birth to the targeted low-income child who is enrolled in the separate CHIP Program on the day prior to their birth.
(7)
“CHIP Health Services Initiative” means services offered to improve the health of low-income children pursuant to §2105(a)(1)(D)(ii) of the Social Security Act.
(8)
“Department” means the Maryland Department of Health.
(9)
“Determination” means a decision regarding an applicant’s eligibility for the separate CHIP Program.
(10)
“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 participants.
(11)
“Family members” means those individuals living with the applicant whose income is counted as household income under Regulation .07B of this chapter.
(12)
“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.
(13)
“Inpatient services” means services received by a participant while in a medical institution, birthing center, or clinic for which Medical Assistance is provided.
(14)
“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.
(15)
“Insurance affordability program” means a program that is one of the following:
(a)
Maryland Medicaid;
(b)
The Maryland Children’s Health Insurance Program (CHIP), including the program known as Maryland Children’s Health Program (MCHP) Premium;
(c)
The separate CHIP Program;
(d)
An optional state basic health program established under §1331 of the Affordable Care Act;
(e)
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 26 U.S.C. §36B of the Internal Revenue Code; or
(f)
A program that makes available coverage in a qualified health plan through the Maryland Health Benefit Exchange with cost-sharing reductions established under 42 U.S.C. §1402 of the Affordable Care Act.
(16)
“Living together” means sharing a common household.
(17)
“MAGI” means modified adjusted gross income, as calculated for purposes of determining eligibility for insurance affordability programs under the Affordable Care Act.
(18)
“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.
(19)
“Maryland Medicaid Managed Care Program” has the meaning stated in COMAR 10.09.24.02.
(20)
“Period under consideration” has the meaning stated in COMAR 10.09.24.02.
(21)
“Postpartum period” means the period of time beginning on the first day of the month following the end of the pregnancy and ending on the last day of the fourth month after the pregnancy ends.
(22)
“Public institution” has the meaning stated in COMAR 10.09.24.02.
(23)
“Qualified alien” has the meaning defined in 8 U.S.C. §1641.
(24)
“Participant” means an individual who is certified as eligible for the Maryland Children’s Health Program.
(25)
“Redetermination” has the meaning stated in COMAR 10.09.24.02.
(26)
“Separate CHIP Program” means the program for targeted low-income children established under Title XXI of the Social Security Act.
(27)
“Spouse” has the meaning stated in COMAR 10.09.24.02.
(28)
“Targeted low-income child” means an individual who qualifies for the Maryland Children’s Health Program from conception to birth when the birthing parent is not eligible for Medicaid as a citizen or qualified alien, when the family income is equal to or less than 250 percent of the federal poverty level.
(29)
“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.
(30)
“Title XXI” means the title of the Social Security Act through which funding is provided, in part, for the separate CHIP Program.
Regulation .03 Coverage Groups.LinkCopy Citation
A.
Eligibility for the separate CHIP Program may be established for a targeted low-income child from conception to birth when the:
(1)
Birthing parent is not a citizen or qualified alien; and
(2)
Family income is equal to or less than 250 percent of the federal poverty level.
B.
Eligibility for the CHIP Health Services Initiative may be established for a birthing parent for postpartum coverage if a targeted low-income child applied for the separate CHIP Program on or before the day prior to their birth and was subsequently found eligible for the separate CHIP Program.
Regulation .04 Application.LinkCopy Citation
A.
The Department or its designee shall determine eligibility for a targeted low-income child and a birthing parent.
B.
The Department or its designee shall give oral, written, or electronic information about the separate CHIP Program and CHIP Health Services Initiative such as:
(1)
Requirements for eligibility;
(2)
Available services;
(3)
An individual’s rights and responsibilities;
(4)
Information in plain English, supported by translation services; and
(5)
Information accessible to disabled individuals requesting an application.
C.
An individual requesting health coverage from an insurance affordability program shall be given an opportunity to apply.
D.
The Department or its designee shall make the application available to the individual without delay by telephone, by mail, in person, or by internet or other available electronic means, and in a manner accessible to disabled individuals requesting an application.
E.
A resident temporarily absent from the State but intending to return may apply for health coverage from an insurance affordability program by telephone, by mail, in person, or by internet or other available electronic means to the Department or its designee in any jurisdiction. The individual shall:
(1)
Demonstrate continued residency in the State; and
(2)
Meet all nonfinancial and financial requirements to be determined eligible.
F.
Application Filing and Signature Requirements.
(1)
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.
(2)
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.
G.
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.
H.
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.
I.
Period Under Consideration.
(1)
The Department or its designee shall establish a current period under consideration based on the date of application established under §G of this regulation.
(2)
For a targeted low-income child, the period under consideration is from conception to birth, and for retroactive eligibility, the 1, 2, or 3 months immediately preceding the month of application for the separate CHIP Program if those months are prior to the birth.
(3)
For the birthing parent, the period under consideration is the postpartum period and contingent on the application of the targeted low-income child on or before the last day of the fourth month after the pregnancy ends.
J.
Processing applications time limitations shall operate in accordance with the requirements of COMAR 10.09.24.04.
K.
Required Information. All information needed to determine eligibility for the separate CHIP Program and CHIP Health Services Initiative shall be reported. When there is evidence of inconsistency between information attested by the applicant and data reported by the State and federal databases, the applicant shall be required to offer an explanation and appropriate verification to reconcile the inconsistency.
Regulation .05 Application — Additional Requirements.LinkCopy Citation
A.
Third-Party Liability.
(1)
A participant 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 participant’s medical expenses.
(2)
A participant 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.
(3)
In accident situations, a participant shall notify the Department or its designee of the:
(a)
Time, date, and location of the accident;
(b)
Name and address of the participant’s attorney;
(c)
Names and addresses of all parties and witnesses to the accident; and
(d)
Police report number if an investigation is made.
B.
The Department or its designee shall:
(1)
Maintain a written or electronic record including documentation of any required elements of eligibility; and
(2)
Restrict disclosure of information concerning a participant to purposes directly connected with the administration of the Medical Assistance Program, including:
(a)
Establishing eligibility;
(b)
Determining the extent of coverage under Medical Assistance;
(c)
Providing services for participants; and
(d)
Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the Medical Assistance Program.
C.
An applicant or participant shall give consent to verify information needed to establish eligibility to the Department or its designee, by submitting a written, telephonic, or electronic application.
Regulation .06 Nonfinancial Eligibility Requirements.LinkCopy Citation
A.
Individuals qualifying for coverage under this section are not required to provide a Social Security number or meet satisfactory immigration status.
B.
Residency. To be eligible for benefits under this chapter, an individual shall be a resident of Maryland, in accordance with the requirements of COMAR 10.09.24.05-3.
C.
Age. To be eligible for benefits under this chapter, a birthing parent shall apply for coverage before the last day of the fourth month after the pregnancy ends, regardless of the birthing parent’s age.
D.
Inmate of a Public Institution. To receive benefits under this chapter, a targeted low-income child or birthing parent may not be an inmate of a public institution, as specified in COMAR 10.09.24.05-5B.
E.
Institution for Mental Diseases. To be eligible for benefits under this chapter, a targeted low-income child or birthing parent 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.
F.
No Private Health Insurance. In order to be eligible for benefits under Title XXI of the Social Security Act, a targeted low-income child or birthing parent whose income is equal to 133 percent but less than 250 percent of the Federal Poverty Level may not be covered by an employer-sponsored health benefit plan.
G.
Required Information.
(1)
An applicant shall report to the Department all information needed to determine eligibility for the separate CHIP Program and CHIP Health Services Initiative.
(2)
When there is evidence of inconsistency between information attested by the applicant and data reported by the State and federal databases, the applicant shall be required to offer an explanation and appropriate verification to reconcile the inconsistency.
Regulation .07 Consideration of Household Income.LinkCopy Citation
A.
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.
B.
Determining Countable Household Income.
(1)
In determining an applicant’s financial eligibility for the separate CHIP Program, the applicant’s current household income is considered.
(2)
For the targeted low-income child applicant, household income shall consist of the income of the child applicant and the following family members when living with the child applicant:
(a)
The child applicant’s parents; and
(b)
At the option of the child applicant’s parents, any of the child applicant’s siblings.
C.
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.
D.
Treatment of Income.
(1)
Countable gross income for the separate CHIP Program shall be the household income calculated according to MAGI.
(2)
MAGI income limits shall be:
(a)
Converted from traditional income limits to account for elimination of income disregards; and
(b)
Increased by 5 percentage points of the federal poverty level for the following circumstances:
(i)
When an individual’s income exceeds the Medicaid income standard; and
(ii)
The income standard is the highest income standard under which the individual can be determined eligible.
(3)
Household Composition. For purposes of determining the income standard applicable to an applicant or participant, the following rules apply:
(a)
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;
(b)
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:
(i)
Spouse; and
(ii)
Natural, adopted, or step children;
(c)
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:
(i)
Natural, adopted, or step parents; and
(ii)
Natural, adopted, or step siblings;
(d)
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; and
(e)
For a child applicant, the household size shall consist of the child and the following individuals:
(i)
Natural, adopted, or step parents; and
(ii)
Natural, adopted, or step siblings.
(4)
No resources or assets test may be applied to an applicant or participant who is subject to a MAGI-based income test.
Regulation .08 Determining Financial Eligibility.LinkCopy Citation
An applicant is financially eligible for the separate CHIP Program or the CHIP Health Services Initiative if, for the period under consideration, the applicant’s countable household income as determined under Regulation .07 of this chapter does not exceed 250 percent of the federal poverty level for a family size equal to the size of the family of the applicant.
Regulation .09 Certification Periods.LinkCopy Citation
A.
For a targeted low-income child, certification for the separate CHIP Program begins:
(1)
On the first day of the month of application, no earlier than conception, and continues until the last day of the month in which the pregnancy ends; or
(2)
For retroactive coverage, if medical expenses were incurred during the earlier months:
(a)
3 months before the month of application but no earlier than conception; and
(b)
Continues until the last day of the month in which the pregnancy ends.
B.
For the birthing parent of a targeted low-income child, certification for the CHIP Health Services Initiative begins:
(1)
On the first day of the month following the end of the pregnancy, and continues until the last day of the fourth month after the pregnancy ends;
(2)
For retroactive coverage, if medical expenses were incurred during the earlier months:
(a)
3 months before the month of application, if those months are not prior to the last day of the month in which the pregnancy ends; and
(b)
Continues until the last day of the month in which the pregnancy ends.
Regulation .10 Covered Services.LinkCopy Citation
A.
A targeted low-income child certified for the separate CHIP Program is entitled to all health benefits through the Maryland Medicaid Managed Care Program.
B.
A birthing parent certified for the CHIP Health Services Initiative is entitled to all health benefits through the Maryland Medicaid Managed Care Program.
Regulation .11 Post-Eligibility Requirements.LinkCopy Citation
A.
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:
(1)
For eligible individuals:
(a)
The basis and effective date for eligibility;
(b)
Instructions for reporting changes that may affect the participants’ eligibility; and
(c)
The right to request a hearing; or
(2)
For ineligible individuals:
(a)
A finding of ineligibility, the reason for the finding, and the regulation supporting the finding;
(b)
Information regarding application for MAGI Exempt coverage groups; and
(c)
The right to request a hearing.
B.
Participant Responsibility.
(1)
After an individual has been determined to be eligible for the separate CHIP Program and is enrolled in the separate CHIP Program, the participant or the participant’s representative shall:
(a)
Within 10 days of the occurrence, notify the Department if there is a change in the participant’s, the participant’s parent’s, or the participant’s guardian’s:
(i)
Income;
(ii)
Employment;
(iii)
Address; or
(iv)
Health insurance coverage status;
(b)
Limit use of the Medical Assistance card to the individual whose name appears on the card; and
(c)
When written or electronic notice of cancellation is received, discontinue use of the Medical Assistance card on the first day of ineligibility and return the card to the Department.
(2)
Failure to comply with §B(1) of this regulation may result in:
(a)
The termination of assistance; or
(b)
Referral to the Department for fraud investigation, or for criminal or civil prosecution.
(3)
A participant shall cooperate with the Department’s quality control and audit review process, including verification of all information pertinent to the determination of eligibility.
(4)
If the participant refuses to cooperate, the participant’s coverage shall be terminated subject to timely and adequate notice under COMAR 10.01.04.03.
C.
Unscheduled Redetermination.
(1)
The Department or its designee shall:
(a)
Promptly make an unscheduled redetermination of a child participant’s eligibility when changes in circumstances or relevant facts are:
(i)
Reported by someone on the participant’s behalf; or
(ii)
Brought to the attention of the Department or its designee from other responsible sources;
(b)
Notify the participant that redetermination is required to establish continuing eligibility; and
(c)
Notify the participant of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.
(2)
Eligibility Decisions. Participants who are determined:
(a)
Eligible for the remainder of the certification period shall be sent notice in accordance with §A(1) of this regulation; or
(b)
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.
(3)
A participant whose eligibility has been canceled may reapply at any time after the cancellation of eligibility and a new period under consideration shall be established.
D.
Scheduled Redetermination. Except for children eligible as newborns of eligible individuals the Department or its designee shall make a scheduled redetermination of a child participant’s eligibility at least every 12 months.
Regulation .12 Hearings.LinkCopy Citation
The requirements relating to hearings under COMAR 10.01.04 apply to this chapter.
Regulation .13 Fraud and Abuse.LinkCopy Citation
The requirements relating to fraud and abuse under COMAR 10.09.24.14 apply to this chapter.
Regulation .14 Adjustments and Recoveries.LinkCopy Citation
The requirements relating to adjustments and recoveries under COMAR 10.09.24.15, except for COMAR 10.09.24.15A(1) and (2), apply to this chapter.
Regulation .15 Interpretive Regulation.LinkCopy Citation
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 participants without regard to the availability of federal financial participation.
Chapter annotations
Authority: Estates and Trusts Article, §14.5-1002; Health-General Article, §§2-104(b), 2-105(b), 15-103, 15-105, 15-121, and 15-401—15-407;
Annotated Code of Maryland
Annotated Code of Maryland
History: Effective date: November 13, 2023 (50:22 Md. R. 974)