COMAR 10.09.61.03. Participant Eligibility

A. Medical Eligibility.

(1) To be eligible for the services covered under COMAR 10.09.07 , a waiver applicant or participant shall be certified by the Department or its designee as needing nursing facility services, pursuant to COMAR 10.09.10 .

(2) The initial assessment for enrollment to the Program shall be conducted by AERS and submitted to the Department or its designee for certification.

(3) For the purpose of enrollment, the assessment of the applicant’s need for nursing facility services is valid for 1 year.

(4) The Department or its designee shall annually certify as medically eligible only those financially eligible participants who require nursing facility services as defined under COMAR 10.09.10 .

(5) The annual continued stay assessment shall be conducted by the medical day care provider's nursing staff or, at the discretion of the Department, by the Department's designee, with an assessment instrument approved by the Department and submitted to the Department or its designee for certification.

B. Technical Eligibility. An individual shall be determined by the Department or its designee to be eligible for waiver services if the individual:

(1) Is 16 years old or older;

(2) Is not enrolled simultaneously in both the Medical Day Care Services Waiver, and:

(a) Another Medicaid home and community-based services waiver under §1915(c) of the Social Security Act;

(b) Programs of All-Inclusive Care for the Elderly (PACE); or

(c) A Medicaid capitated program that includes nursing facility or community-based long term care services;

(3) Has a service plan that:

(a) Recommends medical day care services at least one time per week based on a medical order;

(b) Is based on an initial or continued stay assessment approved by the Department or its designee;

(c) Is developed and signed by:

(i) The participant or authorized representative; and

(ii) Appropriate members of the multidisciplinary team;

(d) Is revised as necessary due to a significant change in the participant’s condition or service needs;

at least one time per week based on a medical order;

(b) Is based on an initial or continued stay assessment approved by the Department or its designee;

(c) Is developed and signed by:

(i) The participant or authorized representative; and

(ii) Appropriate members of the multidisciplinary team;

(d) Is revised as necessary due to a significant change in the participant’s condition or service needs;

(e) Is reviewed at least annually by the participant or authorized representative and the multidisciplinary team to:

(i) Determine the appropriateness and adequacy of the services; and

(ii) Ensure that the services furnished are consistent with the nature and severity of the participant's condition and with the plan of care;

(4) Is determined by the Department or its designee as appropriate for home and community-based care;

(5) Is informed of feasible alternatives to nursing facility services that are available under the waiver;

(6) Is offered the choice between waiver and nursing facility services; and

(7) Chooses, or the individual's authorized representative chooses on the individual's behalf, to receive waiver services.