<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.09.89.03" title_num="10" subtitle_num="09" chapter_num="89" heading="Participant Eligibility.">
  <paragraph num="A.">
    <text>For an applicant to be eligible for 1915(i) services, the applicant shall meet all of the criteria in §§B—H of this regulation.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The applicant shall be younger than 18 years old at the time of enrollment.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The applicant shall reside in a home- and community-based setting that is:</text>
    <paragraph num="(1)">
      <text>Located in the 1915(i) service area; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Not any of the following excluded settings:</text>
      <paragraph num="(a)">
        <text>Therapeutic Group Home (TGH) licensed by the Behavioral Health Administration (BHA) under COMAR 10.21.07;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Psychiatric Respite Care facility located on the grounds of an institution for mental disease (IMD) for the purpose of placement;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Residential program for adults with serious mental illness licensed under COMAR 10.63; or</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Group residential facility licensed under COMAR 10.63.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Consent.</text>
    <paragraph num="(1)">
      <text>For individuals younger than 16 years old, the family or medical guardian of the participant shall give consent for the individual to participate in the 1915(i);</text>
    </paragraph>
    <paragraph num="(2)">
      <text>For individuals 16 years old or older, the individual shall give consent to participate in the 1915(i).</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>The applicant shall:</text>
    <paragraph num="(1)">
      <text>Have a face-to-face psychosocial assessment completed or updated within 30 days of submission of the enrollment to the ASO that:</text>
      <paragraph num="(a)">
        <text>Assigns a Diagnostic and Statistical Manual (DSM) behavioral health diagnosis or Diagnostic Criteria (DC) 0-5 diagnosis;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Determines the applicant to be amenable to active clinical treatment; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Is conducted by a provider not associated with the CCO by which the participant may eventually be served; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Meet the Department’s written medical necessity criteria.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The accessibility or intensity of currently available community supports and services are inadequate to meet the applicant’s needs due to the severity of the impairment without the provision of one or more of the services contained in the 1915(i) benefit.</text>
  </paragraph>
  <paragraph num="G.">
    <text>The applicant may not be served in a Health Home as defined in COMAR 10.09.33 while enrolled in the 1915(i).</text>
  </paragraph>
  <paragraph num="H.">
    <text>Medical Assistance Eligibility.</text>
    <paragraph num="(1)">
      <text>Categorically Needy. An applicant is eligible for 1915(i) services if the applicant is eligible for Medicaid or Maryland Children’s Health Program (MCHP) in accordance with COMAR 10.09.11 or 10.09.24 and has a family income that does not exceed 300 percent of the Federal Poverty Line (FPL).</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Optional Categorically Needy. An applicant is eligible for the 1915(i) benefit as optionally categorically needy in accordance with §1902(a)(10)(A)(ii)(XXII) if the individual is receiving services through an existing 1915(c) HCBS waiver program.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>The Department may assist applicants in the benefit application process by:</text>
    <paragraph num="(1)">
      <text>Informing the applicant and family verbally and in writing about services available in the 1915(i);</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Assisting the applicant and family to complete the eligibility determination for Medical Assistance for the 1915(i), if necessary; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Once Medical Assistance eligibility is determined, ensuring that the assessments and documentation required for a medical necessity determination are obtained and provided to the Department.</text>
    </paragraph>
  </paragraph>
  <paragraph num="J.">
    <text>Based on the criteria established in §§A—H of this regulation:</text>
    <paragraph num="(1)">
      <text>An applicant’s eligibility for services under this regulation shall be established by the Department;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>There is no retroactive eligibility; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Benefit eligibility may not begin before:</text>
      <paragraph num="(a)">
        <text>Verification of the applicant’s Medical Assistance eligibility for the 1915(i); and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Completion of the independent evaluation by the Department that the applicant meets all criteria established in §§A—H of this regulation.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="K.">
    <text>If the applicant is determined to meet the needs-based eligibility criteria as established in §§A—H of this regulation, the Department shall:</text>
    <paragraph num="(1)">
      <text>Obtain written consent from the family or medical guardian to participate in the 1915(i); and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Ensure that the participant is referred immediately upon enrollment determination to a CCO.</text>
    </paragraph>
  </paragraph>
  <paragraph num="L.">
    <text>The Department shall re-evaluate a participant’s:</text>
    <paragraph num="(1)">
      <text>Needs-based eligibility for 1915(i) services as specified in §§A—G of this regulation every 12 months, or more frequently due to a significant change in the participant’s condition or needs, in accordance with the Department’s medical necessity criteria; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Medical Assistance eligibility for 1915(i) services in accordance with the Department’s redetermination policy for all Medical Assistance enrollees.</text>
    </paragraph>
  </paragraph>
</regulation>