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<regulation prefix="Regulation" num=".03" citation="COMAR 10.09.81.03" title_num="10" subtitle_num="09" chapter_num="81" heading="Participant Eligibility.">
  <paragraph num="A.">
    <text>General Requirements.</text>
    <paragraph num="(1)">
      <text>To be eligible for participation in the ICS Program, an applicant or participant shall be determined by the Department to meet the conditions of §§B — E of this regulation.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A participant's eligibility for ICS services shall be reevaluated by the Department every 12 months or more frequently if needed due to a significant change in the participant's condition, needs, or financial status.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The Department shall have 45 days from the date of a complete application to make an eligibility determination.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Technical Eligibility. To be eligible for the services covered under this chapter, an applicant or participant shall be determined by the Department to meet the technical eligibility criteria for ICS services if the individual:</text>
    <paragraph num="(1)">
      <text>Had been living in a nursing facility at the time of application and for at least the last 6 months before the date of application and meets all eligibility requirements before transitioning into the community;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Had been eligible for Medicaid for at least 30 consecutive days immediately before being enrolled in the ICS Program;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Is not otherwise eligible for services covered under:</text>
      <paragraph num="(a)">
        <text>The authority of §1915(c) of Title XIX of the Social Security Act; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The Programs of All-Inclusive Care for the Elderly under COMAR 10.09.44;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Is at least 18 years old;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Has a plan of service that:</text>
      <paragraph num="(a)">
        <text>Includes Medical Assistance and ICS services necessary to safely serve the participant in the community; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Is determined by the Department to cost less than the cost to Medicaid if the individual were to remain in the institution;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Is offered the choice between ICS and nursing facility services;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Chooses, or the individual’s authorized representative chooses on the individual’s behalf, to receive ICS services;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Is being discharged from a nursing facility into ICS services in the community and would be institutionalized in a nursing facility if not for the ICS services;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Resides in a home, as defined under Regulation .02B of this chapter; and</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Uses at least one ICS service within a 12-month period.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Medical Eligibility.</text>
    <paragraph num="(1)">
      <text>An applicant shall be determined by the Department’s utilization control agent to need nursing facility services covered under COMAR 10.09.10.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Every 12 months, or more frequently if determined necessary by the Department due to a significant change in the participant's condition or needs, AERS shall revaluate the participant to verify the continued need for nursing facility services.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Financial Eligibility. An ICS participant shall:</text>
    <paragraph num="(1)">
      <text>Without regard to any assets of a spouse, meet the resource limit for Long-Term Care Medical Assistance set forth in COMAR 10.09.24.08M;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Receive income, after all available disregards and exclusions set forth in COMAR 10.09.24.07L and 10.09.24.07J, without regard to any income of a spouse, that exceeds 300 percent of the current monthly Supplemental Security Income payment rate, known as the Federal Benefit Rate (FBR);</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Pay to the Department an assessment fee equal to the amount by which income, after all available disregards and exclusions set forth in COMAR 10.09.24.07L and 10.09.24.07J, exceeds 300 percent of the FBR, as follows:</text>
      <paragraph num="(a)">
        <text>The initial assessment shall be paid to the Department not later than 15 days from the date of the assessment invoice sent by the Department to the participant, unless the exception in §D(4) of this regulation applies;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Subsequent assessments shall be paid on or before the last day of the month on which the assessment invoice is sent to the participant by the Department; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>If a participant receives a past due notice, the participant has 15 days from the date of the notice to remit payment; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Be allowed an exception to the initial monthly assessment if discharged from the nursing facility on a date other than the first of the month, in which case the participant shall be required to pay the first assessment before the first day of the first full month of ICS participation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Medical Assistance Eligibility.</text>
    <paragraph num="(1)">
      <text>An individual is not eligible to receive ICS services during a penalty period under COMAR 10.09.24.08-1 or 10.09.24.08-2 due to disposal of assets or establishment of a trust.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>All provisions of COMAR 10.09.24 which are applicable to aged, blind, or disabled institutionalized persons are applicable to ICS applicants and participants, with the following exceptions:</text>
      <paragraph num="(a)">
        <text>COMAR 10.09.24.06B(2)(a)(ii);</text>
      </paragraph>
      <paragraph num="(b)">
        <text>COMAR 10.09.24.08G(1);</text>
      </paragraph>
      <paragraph num="(c)">
        <text>COMAR 10.09.24.08H;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>COMAR 10.09.24.10B(2) — (3);</text>
      </paragraph>
      <paragraph num="(e)">
        <text>COMAR 10.09.24.10C;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>COMAR 10.09.24.10D(2)(a), (b), and (h);</text>
      </paragraph>
      <paragraph num="(g)">
        <text>COMAR 10.09.24.10D(3) — (6);</text>
      </paragraph>
      <paragraph num="(h)">
        <text>COMAR 10.09.24.10-1B(1);</text>
      </paragraph>
      <paragraph num="(i)">
        <text>COMAR 10.09.24.10-1B(4);</text>
      </paragraph>
      <paragraph num="(j)">
        <text>COMAR 10.09.24.10-1B(7);</text>
      </paragraph>
      <paragraph num="(k)">
        <text>COMAR 10.09.24.10-1C(3)(a); and</text>
      </paragraph>
      <paragraph num="(l)">
        <text>COMAR 10.09.24.15A-2(2).</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>Cost of Care.</text>
    <paragraph num="(1)">
      <text>For a participant whose home is an assisted living facility, the Department shall reduce its monthly payment for assisted living services by the amount remaining after deducting from the individual's total nonexcluded monthly income the following amounts in the following order:</text>
      <paragraph num="(a)">
        <text>A personal needs allowance, consisting of the amount established in accordance with COMAR 10.09.24.10D(2)(c) and the assisted living provider's monthly charge to the participant for room and board; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Incurred medical expenses in accordance with COMAR 10.09.24.10D(2)(f) and (g).</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The Department shall determine the amount of available income to be paid by a participant towards the cost of assisted living services.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The participant shall pay the assisted living services provider directly for the participant’s cost of care and room and board.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Participant Cap and Registry for ICS Participation.</text>
    <paragraph num="(1)">
      <text>The Department shall establish a cap, approved by the federal Centers for Medicare and Medicaid Services (CMS), on the number of participants who may receive the services covered under this chapter at any one time, based on available State and federal funding.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Eligible individuals shall be enrolled in the ICS Program on a first-come, first-served basis until the participant cap is reached.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Once the CMS-approved participant cap is reached, a registry of applicants shall be established by the Department on a first-come, first-served basis.</text>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>Termination of Participation. A participant shall be terminated from participation in the ICS Program if the participant:</text>
    <paragraph num="(1)">
      <text>No longer meets the eligibility requirements specified in §§B — E of this regulation;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Voluntarily chooses, or the participant's legal representative chooses on the participant's behalf, to disenroll from the ICS Program;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Moves to another state;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Is an inpatient for 30 consecutive days or more in a hospital or nursing facility; or</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Dies.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>Re-Entering the ICS Program.</text>
    <paragraph num="(1)">
      <text>If a participant is terminated from the ICS Program, the same individual may re-enter the ICS Program, provided:</text>
      <paragraph num="(a)">
        <text>That the individual meets all of the requirements §§B — E of this regulation; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>There is available capacity.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>If an individual cannot find a community residence before his or her application expires, the individual may reapply to the ICS Program as long as the individual continues to meet all other eligibility requirements.</text>
    </paragraph>
  </paragraph>
</regulation>