Regulation .14 Application Process for Cancer Treatment Grants.
Regulation .14 Application Process for Cancer Treatment Grants.LinkCopy Citation
A.
An applicant for a cancer treatment grant shall submit a completed application to the CCPC.
B.
Cancer treatment grants are open and continuous throughout the year to the extent that funding is available.
C.
An applicant seeking a cancer treatment grant to pay for cancer treatment costs shall include in the Department's application packet:
(1)
A completed cancer treatment grant application for each individual for whom grant funds are being requested, including the:
(a)
Name;
(b)
Phone number;
(c)
Mailing address;
(d)
County; and
(e)
Signature of the:
(i)
Individual diagnosed with cancer if the individual is an adult; or
(ii)
Parent or guardian if the individual diagnosed with cancer is younger than 18 years old;
(2)
A letter written by the individual’s physician on the physician’s letterhead:
(a)
Confirming:
(i)
That the individual has been diagnosed with or treated for cancer or the individual has a finding suggestive of cancer and needs to obtain a cancer diagnosis; and
(ii)
The dates of diagnosis or treatment; and
(b)
Containing the physician's:
(i)
Full name;
(ii)
Address;
(iii)
Specialty; and
(iv)
Medical license number;
(3)
Proof of current Maryland residency for at least 6 months before the application date for each individual for whom grant funds are being requested in one of the following forms:
(a)
Maryland driver’s license or State identification card;
(b)
Lease or rental agreement;
(c)
Property tax bill;
(d)
Motor vehicle registration;
(e)
Pay check or stub with name and home address;
(f)
Utility bill;
(g)
Voter registration card; or
(h)
W-2 statement issued not more than 12 months ago;
(4)
Proof of annual family income for each individual for whom grant funds are being requested, including a copy of at least one of the following:
(a)
Most recent:
(i)
Income tax return; or
(ii)
W-2 form;
(b)
Pay stubs for two:
(i)
Consecutive pays; or
(ii)
Pays in the same month;
(c)
Social security entitlement letter; or
(d)
Notarized letter from the individual stating that the individual is not working and does not have any income;
(5)
Documentation of the eligibility of the individual for grant funds, including:
(a)
The family size of the individual for whom the applicant is applying; and
(b)
The family’s annual household income;
(6)
Certification that the applicant will:
(a)
Keep financial records, as described in Regulation .16B of this chapter;
(b)
Send demographic and fiscal information on each individual covered to the CCPC at the end of the grant period; and
(c)
Act as the authorized representative of the individual.
(7)
Attestation that grant funds will not be used to supplant any existing funding for this cancer treatment activity; and
(8)
If the applicant currently receives funding for a similar cancer treatment activity, a list of the funding:
(a)
Source;
(b)
Amount; and
(c)
Period for the activity.
D.
An applicant seeking a cancer treatment grant to pay for deductibles and patient contribution costs through their health insurance policy under Regulation .08E(2) of this chapter shall include in the Department’s application packet:
(1)
A completed and signed Maryland Cancer Fund — Cancer Treatment Grant application that;
(a)
Certifies that the applicant shall pay:
(i)
The deductible and patient contribution amount; and
(ii)
Costs for services not covered under the individual’s health insurance policy for a time period not to exceed 1 year; and
(b)
Includes a treatment plan for a total request not to exceed a specified amount, as determined by the Department, per individual per year, including the:
(i)
Deductible and patient contribution amount; and
(ii)
Costs for services not covered under the individual’s health insurance policy.
(2)
Documentation of the individual’s health insurance policy.
E.
An applicant seeking a cancer treatment grant to pay directly for cancer treatment costs under Regulation .08E(3) of this chapter shall include in the Department’s application packet:
(1)
A completed Maryland Cancer Fund — Cancer Treatment Grant application; and
(2)
A signed document that certifies that the applicant shall pay directly for cancer treatment costs for the individual for a time period not to exceed 1 year; and certifies that the applicant shall:
(a)
Reimburse the provider in an amount not greater than the Medical Assistance rate for the medical procedure or the HSCRC-regulated rate for the medical procedure performed, if the medical procedure is performed in a HSCRC-regulated facility; or
(b)
Accept the Medical Assistance rate as payment in full for the cancer treatment procedures performed, if the applicant is a medical provider; and
(3)
Includes a treatment plan for a total request not to exceed $20,000 per individual, including:
(a)
The planned cancer treatment procedures; and
(b)
The Medical Assistance or HSCRC-regulated rate for each procedure.