Md. Code Regs. 10.09.41.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.41.02 - Definitions

A. Applicability of COMAR 10.09.24.02D efinitions.

(1) Except as provided in §A(2) of this regulation, terms used in this chapter that are not defined in §C of this regulation have the meanings stated for the same terms in COMAR 10.09.24.02.

(2) If a term's definition in COMAR 10.09.24.02 references a "local department of social services" in the context of a determination of eligibility, the words "local department of social services" in the COMAR 10.09.24.02 definition shall be replaced, for purposes of the term's meaning in this chapter, with "the Department".

B. In this chapter, the following terms have the meanings indicated.

C. Terms Defined.

(1) "Applicant" means an individual:

(a) Who is not a recipient;

(b) Who has submitted to the Department an application for the Employed Individuals with Disabilities coverage group; and

(c) Whose application has not received final action.

(2) "Application" means the filing with the Department of a written and signed application form for the Employed Individuals with Disabilities (EID) coverage group to establish eligibility for Medical Assistance benefits.

(3) "Application date" means the date a written and signed application form for determination or redetermination of eligibility for the EID coverage group is received by the Department.

(4) "Assistance unit" means an applicant or recipient and, when living together, the applicant's or recipient's spouse, whose eligibility for Medical Assistance benefits is determined in conjunction with each other.

(5) "Certification period" means a period of time of up to 12 months, beginning on the first day of the month in which the Department receives the application, for which the EID applicant's or recipient's eligibility to receive Medical Assistance benefits is certified.

(6) "Chronic hospital" has the meaning stated in COMAR 10.09.06.01B.

(7) "Continuing eligibility" means a recipient's EID eligibility for a subsequent certification period after the current certification period, based on the Department's redetermination of eligibility with respect to an individual who is enrolled in the EID coverage group on the application date.

(8) "Days" has the meaning stated in Article I, § 36, Annotated Code of Maryland.

(9) "Department" means the Department of Health and Mental Hygiene, as defined in COMAR 10.09.36.01, or its authorized agents acting on behalf of the Department.

(10) "Determination" means a decision by the Department regarding an applicant's or recipient's eligibility for the EID coverage group.

(11) "Disability" means an individual's medically determinable impairment that is the basis of a determination that the individual is disabled, according to the standards set forth in § 1614(a)(3) of the Social Security Act, except substantial gainful activity is not considered in determining disability.

(12) "Disabled" means having a disability.

(13) "Disregard" means a fixed monetary amount or documented expense that is deducted from countable gross income to determine countable net income.

(14) "Employed" means being engaged in employment:

(a) That is verifiable;

(b) That yields earnings during the period under consideration; and

(c) The earnings from which are subjected to reporting, withholding, and payment as required by law, including but not limited to individual income tax, payroll tax, estimated income tax, and withholding or payments required by the Federal Insurance Contribution Act.

(15) "Employed Individuals with Disabilities (EID)" means the Medical Assistance coverage group for employed individuals with disabilities, which is:

(a) Operated under the regulations of this chapter;

(b) Funded jointly by the State and the federal governments; and

(c) Administered by the Department.

(16) "Employer-sponsored insurance (ESI)" means group health insurance coverage provided wholly or partly at the expense of an applicant's, recipient's, or spouse's employer.

(17) "Employment" means working for payment either for an employer or on a self-employed basis.

(18) "Excludable" means the types of income and resources that are specified in this chapter as not countable in the determination of eligibility for the EID coverage group.

(19) "Family unit size" means the number of individuals included in an assistance unit, which is used to determine the applicable income or resource standard.

(20) Grace period means a period of time not longer than 6 months during which an unemployed EID recipient pays premiums and remains eligible to receive EID benefits despite failing to meet the requirement that EID recipients be employed.

(21) "Hardship" means financial adversity or misfortune significant enough that it reasonably can be expected to compromise an applicant's or recipient's ability to obtain and provide basic food, shelter, and clothing for the applicant or recipient, another member of the assistance unit, or any dependents of the applicant or recipient.

(22) "Health insurance" has the same meaning as "health insurance coverage", as stated in COMAR 10.09.43.02B.

(23) "Initial eligibility" means the EID eligibility of an individual who is not enrolled in the EID coverage group on the application date.

(24) "Long-term care facility services" means services delivered to patients admitted to a nursing facility, chronic hospital, or a rehabilitation hospital.

(25) "Medical criteria for disability" means the criteria applied by the Social Security Administration (SSA) to determine disability under Title XVI of the Social Security Act, except for the disability criteria that consider an individual's earnings as evidence of an ability to perform substantial gainful activity.

(26) "Medically necessary" means that the service or benefit is:

(a) Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

(b) Consistent with current accepted standards of good medical practice;

(c) The most cost-efficient service that can be provided without sacrificing effectiveness or access to care; and

(d) Not primarily for the convenience of the consumer, family, or provider.

(27) "Notice of eligibility" means the written notice issued by the Department informing an applicant or recipient of:

(a) The Department's finding of eligibility or ineligibility; and

(b) The legal rights and obligations of the applicant or recipient associated with the Department's determination.

(28) "Nursing facility" has the meaning stated in COMAR 10.09.10.01B.

(29) "Period under consideration" means a period of 6 months, beginning on the first day of the month of the application date, for which an assistance unit's income is assessed for a determination of eligibility under this chapter.

(30) "Premium" means the monthly amount an applicant or recipient is required to pay, absent a successful claim of hardship pursuant to Regulation .07C of this chapter, as a condition of eligibility for the EID coverage group and Medical Assistance benefits.

(31) "Provider" has the same meaning as "health care provider", as stated in Health-General Article, §19-132, Annotated Code of Maryland.

(32) "Recipient" means an individual who has been determined eligible for the EID coverage group.

(33) "Redetermination" means a determination by the Department, at least every 12 months, regarding the continuing eligibility of a recipient, in accordance with the requirements of this chapter.

(34) "Rehabilitation hospital" has the same meaning as "special rehabilitation hospital", as stated in COMAR 10.07.01.02C.

(35) "Social Security Disability Insurance (SSDI)" means a federally administered program that provides benefits to individuals with disabilities who have paid sufficient Social Security taxes to be eligible for disability insurance payments under Title II of the Social Security Act, 42 U.S.C § 423 et seq.

(36) "Substantial gainful activity" has the meaning stated in 20 CFR § 416.910, which the Social Security Administration applies in determining disability under Title XVI of the Social Security Act.

Md. Code Regs. 10.09.41.02

Regulations .02 adopted as an emergency provision effective April 1, 2006 (33:9 Md. R. 795); adopted permanently effective July 3, 2006 (33:13 Md. R. 1063)
Regulation .02C amended as an emergency provision effective October 1, 2008 (35:22 Md. R. 1955); amended permanently effective February 9, 2009 (36:3 Md. R. 208)
Regulation .02C amended effective May 27, 2013 (40:10 Md. R. 917)
Regulation .02 amended effective 42:3 Md. R. 316, eff.2/16/2015