Chapter 05. Maryland AIDS Drug Assistance Program: Eligibility
Regulation .01 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Acquired Immunodeficiency Syndrome (AIDS)” means the medical condition caused by the Human Immunodeficiency Virus.
(2)
“Applicant” means an individual who has submitted an application to the Maryland AIDS Drug Assistance Program and whose eligibility status for the Maryland AIDS Drug Assistance Program has not yet been determined.
(3)
“Department” means the Maryland Department of Health.
(4)
“Disenroll” means to end Maryland AIDS Drug Assistance Program benefits.
(5)
“Drug” means an article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease licensed by the U.S. Food and Drug Administration and covered by the Maryland AIDS Drug Assistance Program as specified in COMAR 10.18.06.04.
(6)
“Enrolled in MADAP” means that an applicant has been approved to receive Maryland AIDS Drug Assistance Program benefits.
(7)
“Gross household income” means the income derived from sources provided in Regulation .02E of this chapter.
(8)
“Health care practitioner” means any individual licensed to prescribe U.S. Food and Drug Administration-approved drugs or other products in the state in which they practice.
(9)
“Human Immunodeficiency Virus (HIV)” means the virus that causes AIDS.
(10)
“Maryland AIDS Drug Assistance Program (MADAP)” means the program administered by the Department that provides services specified in COMAR 10.18.06.04 for enrolled recipients.
(11)
“Medical Assistance” has the meaning stated in COMAR 10.09.24.02.
(12)
“Recipient” means an individual who is enrolled in MADAP.
(13)
“Resident” means an individual:
(a)
Who is living in the State voluntarily with the intention of making it that individual’s home and not for a temporary purpose; and
(b)
For whom any temporary absence from the State is coupled with an intent to return so as not to interrupt the continuity of the residence.
(14)
“Verification of eligibility” means the information a recipient provides to the Department to confirm that the recipient is still eligible to receive MADAP benefits according to Regulation .03B(1)(a) of this chapter.
Regulation .02 Eligibility.LinkCopy Citation
A.
Except when an individual is enrolled in Medical Assistance but does not have prescription coverage assistance, an individual who is eligible for Medical Assistance is not eligible for MADAP.
B.
To be eligible for benefits, an individual shall meet the following criteria:
(1)
Residency;
(2)
Medical; and
(3)
Financial.
C.
Residency Criteria. To meet the residency criteria the individual shall be a resident of Maryland.
D.
Medical Criteria. To meet the medical criteria the individual shall be infected with HIV as verified by the Department.
E.
Financial Criteria.
(1)
To meet the financial criteria the individual shall have a projected gross household income less than or equal to 500 percent of the Federal Poverty Level Guidelines as updated annually in the Federal Register by the U.S. Department of Health and Human Services under authority of 42 U.S.C. §9902(2).
(2)
Projected gross household income shall be determined based on what can reasonably be expected to be received during the 12-month period beginning with the month in which the completed application is filed or verification of eligibility is submitted.
(3)
Gross household income includes income derived from:
(a)
Wages and salaries, including tips;
(b)
Net income from self-employment or business;
(c)
Unemployment income;
(d)
Social security payments, including disability payments;
(e)
Alimony;
(f)
Retirement income;
(g)
Pension income;
(h)
Investment income;
(i)
Rental income; and
(j)
Other taxable income, such as prizes, awards, and gambling winnings.
(4)
Gross household income under this chapter does not include income derived from:
(a)
Child support;
(b)
Gifts;
(c)
Supplemental Social Security Income;
(d)
Veterans’ disability payments;
(e)
Workers’ compensation; and
(f)
Proceeds from loans, such as student loans, home equity loans, or bank loans.
Regulation .03 Application and Enrollment.LinkCopy Citation
A.
Application.
(1)
Applicant.
(a)
An applicant shall submit a completed application to the Department on the form designated by the Department that includes:
(i)
Responses to all required fields and applicable questions; and
(ii)
Supporting documentation related to residency, medical, and financial eligibility criteria.
(b)
An applicant may voluntarily withdraw the application at any time without prejudice.
(c)
An applicant may submit a new application at any time.
(2)
The Department shall:
(a)
Approve the application if the:
(i)
Application is complete; and
(ii)
Applicant is determined to be eligible;
(b)
Disapprove the application if the:
(i)
Application is incomplete;
(ii)
Applicant fails to provide sufficient information or documentation to determine eligibility; or
(iii)
Applicant provides the appropriate documentation but is determined ineligible; and
(c)
Provide the applicant with written notice of the final disposition of the application.
B.
Enrollment.
(1)
If the Department requests it, a recipient shall:
(a)
Attest to continuing eligibility:
(b)
Submit a completed verification of eligibility form; and
(c)
Provide supporting documentation.
(2)
A recipient’s MADAP benefits shall be suspended, effective at the end of the month following the month the verification of eligibility is due, if the recipient fails to attest to eligibility for MADAP.
(3)
The Department shall:
(a)
Enroll an applicant who has been determined eligible with the stipulation that eligibility must be verified as requested by the Department;
(b)
Establish enrollment in MADAP beginning on the first day of the month in which the:
(i)
Department approves the application; or
(ii)
Recipient will need to access medications through MADAP;
(c)
Redetermine eligibility if the Department receives information that may affect eligibility; and
(d)
Send any relevant verification of eligibility forms to the recipient at least 45 calendar days before the forms are due to be submitted to the Department.
Regulation .04 Changes in Eligibility and Disenrollment.LinkCopy Citation
A.
A recipient shall notify the Department within 10 business days of a change in:
(1)
Availability of third-party payment for services covered under MADAP;
(2)
Gross household income; or
(3)
Address.
B.
If a change reported in §A of this regulation results in a recipient no longer qualifying for MADAP, the Department shall:
(1)
Determine the recipient ineligible for MADAP; and
(2)
Disenroll the recipient.
C.
The notice of intended action, which notifies the recipient of the disenrollment, shall:
(1)
Be mailed to the recipient at least 15 business days before the effective date of disenrollment;
(2)
Include an explanation of the action;
(3)
Cite the regulation supporting the action; and
(4)
Explain the right of the recipient to request reconsideration or an appeal of the decision.
D.
If the recipient is determined to be ineligible before the next verification of eligibility is due to be submitted to the Department because of a change in eligibility, the disenrollment shall be the earlier of:
(1)
The date on which the recipient’s next verification of eligibility is due to be submitted to the Department; or
(2)
The first day of the month that is at least 15 calendar days after the date of the notice of ineligibility for MADAP benefits.
E.
If the recipient’s Medical Assistance coverage is pending or active, the recipient shall be disenrolled, as determined by the Department.
Regulation .05 Reconsideration and Appeal.LinkCopy Citation
A.
An applicant or recipient who has been notified by the Department of ineligibility for or disenrollment from MADAP benefits may request reconsideration of the decision by submitting additional supporting documentation or information to the Department within 30 business days of notification.
B.
If an applicant or recipient submits a timely request for reconsideration, the Department shall:
(1)
Review all additional supporting documentation, within 5 business days of the Department’s receipt of the request for reconsideration; and
(2)
Issue a final decision in writing to the applicant or recipient.
C.
If an applicant or recipient is dissatisfied with the final decision of the Department, the applicant or recipient may appeal the reconsideration by requesting in writing for a hearing with the Department.
D.
The Office of Administrative Hearings shall:
(1)
Conduct a hearing according to the procedures set forth in COMAR 28.02.01;
(2)
Hold a hearing to review the decision within 45 days of the postmarked date on the letter requesting a hearing; and
(3)
Issue a decision in writing to the applicant or recipient.
Regulation .06 Recovery of Payments.LinkCopy Citation
If MADAP benefits have been incorrectly paid or another payer has been identified, the Department shall seek recovery of the amount of those payments.
Regulation .07 Fraud.LinkCopy Citation
The Department shall pursue cases of suspected misrepresentation or fraud pursuant to Criminal Law Article, §8-503, Annotated Code of Maryland, or any other applicable statutory provision.
Regulation .08 Confidentiality.LinkCopy Citation
Unless otherwise authorized by law, the Department:
A.
Shall keep all applicant and recipient personal information confidential;
B.
May not disclose personal information kept on an applicant or recipient without written consent of the:
(1)
Applicant;
(2)
Recipient;
(3)
Applicant’s parent or legal guardian; or
(4)
Recipient’s parent or legal guardian;
C.
Shall comply with the laws and regulations concerning the privacy and security of protected health information under:
(1)
Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and
(2)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. §§1320d et seq., as amended, the HITECH Act, 42 U.S.C. §§17932, et seq., as amended, and 45 CFR Parts 160 and 164, as amended, and their implementing regulations; and
D.
Shall ensure that all interactive video technology-assisted communication comply with HIPAA patient privacy and security regulations.
Regulation .09 Availability of Funding and Program Termination.LinkCopy Citation
A.
If sufficient monies are not available to fund MADAP, the Department shall take the action necessary to eliminate a deficit which may include MADAP termination.
B.
If MADAP is terminated the Department shall provide benefits for each current recipient until the earlier of:
(1)
The date on which the next verification of eligibility is due to be submitted to the Department; or
(2)
Six months from the date MADAP is terminated.
Chapter annotations
Authority: Health General Article, §§2-104(b) and(i), 2-105(a) and (b), and 18-102(a), Annotated Code of Maryland
History: Effective date:
History: Regulations .01—.15 adopted as an emergency provision effective November 27, 2002 (29:25 Md. R. 1979); adopted permanently effective February 17, 2003 (30:3 Md. R. 180)
History: Regulation .01B amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .02 amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .03B, C amended as an emergency provision effective August 11, 2004 (31:18 Md. R. 1348); amended permanently effective October 11, 2004 (31:20 Md. R. 1485)
History: Regulation .03C amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .05 amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .05A amended as an emergency provision effective August 11, 2004 (31:18 Md. R. 1348); amended permanently effective October 11, 2004 (31:20 Md. R. 1485)
History: Regulation .05E amended as an emergency provision effective November 14, 2003 (30:24 Md. R. 1737); amended permanently effective February 16, 2004 (31:3 Md. R. 207)
History: Regulation .06C amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .07 repealed as an emergency provision effective January 1, 2014 (41:4 Md. R. 298); repealed permanently effective May 26, 2014 (41:10 Md. R. 561)
History: Regulation .08A amended as an emergency provision effective January 1, 2014 (41:4 Md. R. 298); amended permanently effective May 26, 2014 (41:10 Md. R. 561)
History: Regulation .08B amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .09C adopted effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .11 amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .15A amended effective March 16, 2015 (42:5 Md. R. 486)
History: Chapter revised effective March 28, 2016 (43:6 Md. R. 408)
History: Regulation .01B amended effective May 20, 2019 (46:10 Md. R. 488); October 14, 2024 (51:20 Md. R. 899)
History: Regulation .02D amended effective October 14, 2024 (51:20 Md. R. 899)
History: Regulation .02D, E amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .03 amended effective October 14, 2024 (51:20 Md. R. 899)
History: Regulation .03B amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .04A, D amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .09B amended effective May 20, 2019 (46:10 Md. R. 488)