Chapter 91. Hospital Presumptive Eligibility
Regulation .01 Purpose and Scope.LinkCopy Citation
This chapter establishes requirements for the determination of presumptive eligibility by qualified hospitals effective October 1, 2014.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Applicant” means an individual who has applied for presumptive eligibility at a participating hospital.
(2)
“Application” means the presumptive eligibility application.
(3)
“Authorized representative” has the same meaning as set forth in COMAR 10.01.04.01.
(4)
“Department” means the Maryland Department of Health which is the single State agency designated to administer the Maryland Medical Assistance Program pursuant to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.
(5)
“Determination” means a decision regarding an applicant’s presumptive eligibility.
(6)
“Federal poverty level” means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. §9902(2).
(7)
“Former foster care” means an individual who:
(a)
Is younger than 26 years old;
(b)
Is not eligible and enrolled for coverage under a mandatory Medical Assistance group other than childless adult; and
(c)
Was formerly in a Maryland out-of-home placement, including categorical Medical Assistance:
(i)
On attaining age 18 and leaving out-of-home placement; or
(ii)
On attaining age 19—21 during extended out-of-home placement under COMAR 07.02.11.04B.
(8)
“Hospital” means an institution which:
(a)
Falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and
(b)
Is licensed pursuant to COMAR 10.07.01 or other applicable standards established by the state in which the service is provided.
(9)
“Income” means property or a service received by an individual in cash or in-kind, which can be applied directly, or by sale or conversion, to meet basic needs for food, shelter, and medical expenses.
(10)
“Incarcerated inmate in a public institution” has the meaning stated in COMAR 10.09.24.05-5B.
(11)
“Medical Assistance” means the program administered by the State under Title XIX of the Social Security Act, which provides comprehensive medical and other health-related care for eligible individuals.
(12)
“Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42, §U.S.C. 1395 et seq.
(13)
“Presumptive eligibility” means temporary eligibility for Medical Assistance as determined by participating hospitals in accordance with these regulations.
Regulation .03 Requirements.LinkCopy Citation
A.
A hospital eligible to make presumptive eligibility decisions shall:
(1)
Participate as a Maryland Medical Assistance Program provider in good standing; and
(2)
Sign an agreement prepared by the Department.
B.
The agreement required under §A of this regulation shall require that the hospital:
(1)
Comply with Departmental policies and procedures supplied by the Department at the time of application and training;
(2)
Meet accuracy and timeliness standards established by the Department;
(3)
Submit a list to the Department of hospital employees who will attend presumptive eligibility training developed by the Department;
(4)
Prohibit employees who have not attended required trainings and passed a post-training test to make presumptive eligibility decisions; and
(5)
Report all requested information on a form designated by the Department.
C.
Before assisting an applicant in filing a presumptive eligibility application, the hospital employee shall:
(1)
Check the Department’s eligibility verification system to make sure the individual is not actively enrolled in the Maryland Medical Assistance Program;
(2)
Provide information concerning the full Medical Assistance application process to the individual applying for presumptive eligibility and assist or refer the applicant to an individual who can assist the applicant in completing a full Medical Assistance application;
(3)
Determine that the applicant has not:
(a)
Had a prior presumptive eligibility period within the last 12 months for the individual other than pregnant women; or
(b)
Had a prior presumptive eligibility period during the current pregnancy for a pregnant woman.
D.
The hospital employee shall fill out the presumptive eligibility application based on information supplied by the applicant.
E.
The hospital employee shall make a presumptive eligibility decision and sign the presumptive eligibility application based on the following information obtained pursuant to COMAR 10.09.91.05:
(1)
Residency;
(2)
Citizenship;
(3)
Family size and composition; and
(4)
Gross family income.
F.
The hospital employee shall inform the individual in writing of the hospital’s presumptive eligibility decision which includes an explanation of the presumptive eligibility period.
G.
The hospital shall submit the presumptive eligibility application to the Department on the date of application completion to allow the individual to have temporary Medical Assistance coverage.
H.
The hospital shall:
(1)
Keep all written and signed presumptive eligibility applications on file for 6 years; and
(2)
Make the file available to the Department upon request.
Regulation .04 Hospital or Hospital Staff Disqualifications.LinkCopy Citation
A.
A hospital qualified to make presumptive eligibility decisions shall:
(1)
Make presumptive eligibility determinations in accordance with established Departmental policies and procedures; and
(2)
Disqualify individual hospital employees who do not follow established Departmental regulations, policies and procedures.
B.
Upon a finding that a qualified hospital has failed to meet the requirements of §A of this regulation, the Department shall provide the hospital with additional training or take other reasonable corrective action measures to address the noncompliance.
C.
If the remedial measures taken pursuant to §B of this regulation fail to provide a satisfactory resolution, the Department shall disqualify the hospital from making presumptive eligibility determinations.
Regulation .05 Criteria.LinkCopy Citation
A.
An individual, the individual’s guardian, or a representative of the individual with personal knowledge shall apply for presumptive eligibility through a participating hospital.
B.
An individual, the individual’s guardian, or a representative of the individual with personal knowledge who applies for presumptive eligibility shall attest to:
(1)
The citizenship requirements in COMAR 10.09.24.05;
(2)
The residency requirements in COMAR 10.09.24.05-3;
(3)
The individual’s pregnancy status;
(4)
The individual’s family size; and
(5)
The individual’s household’s gross monthly income.
Regulation .06 Populations Eligible.LinkCopy Citation
Presumptive eligibility may be established for the following eligibility groups:
A.
Parents and other caretaker relatives whose household income is equal to or less than 133 percent of the federal poverty level;
B.
Pregnant women whose income is equal to or less than 250 percent of the federal poverty level;
C.
Adults without dependent children who are older than 19 years old and younger than 65 years old, whose household income is equal to or less than 133 percent of the federal poverty level;
D.
Children who are younger than 19 years old who are under 300 percent of the federal poverty level; or
E.
Former foster care individuals who are younger than 26 years old.
Regulation .07 Limitations.LinkCopy Citation
An individual may not apply for presumptive eligibility in Maryland if the individual:
A.
Is currently enrolled in the Maryland Medical Assistance Program or Medicare;
B.
Is an incarcerated inmate in a public institution as defined in COMAR 10.09.24.05-5B;
C.
Had a prior presumptive eligibility period during the last 12 months with the exception of pregnant women;
D.
Does not meet the residency requirements stated in COMAR 10.09.24.05-3; or
E.
Does not meet the citizenship requirements stated in COMAR 10.09.24.05.
Regulation .08 Certification Period.LinkCopy Citation
A.
Presumptive eligibility begins on the day the hospital determines that the individual is presumptively eligible.
B.
Presumptive eligibility ends on the earlier of:
(1)
The day in which the individual is determined eligible for Medical Assistance; or
(2)
The last day of the month following the month in which the hospital determined presumptive eligibility, if:
(a)
An individual is found ineligible for Medical Assistance; or
(b)
An individual failed to apply for Medical Assistance.
C.
A non-pregnant individual may be determined presumptively eligible once per a 12-month period.
D.
A pregnant individual may be determined presumptively eligible once per pregnancy.
Regulation .09 Presumptive Eligibility Appeal Rights.LinkCopy Citation
An individual or an organization does not have appeal rights for presumptive eligibility determinations.
Chapter annotations
Authority: Health-General Article, §§2-104(b), 2-105(b), and 15-103, Annotated Code of Maryland
History: Effective date: December 22, 2014 (41:25 Md. R. 1485)