Current through Register Vol. 30, No. 38, September 20, 2024
A. Notwithstanding Article 3, a qualified
hospital may determine Hospital Presumptive Eligibility (HPE), on the basis of
pre-liminary information, that an individual is eligible for AHCCCS medical
coverage during the presumptive eligibility period described in this section,
if the individual is a United States citizen or eligible qualified alien, and
the individual is:
1. Pregnant with gross
household income that does not exceed 156% of the FPL;
2. An adult who meets the requirements of
R9-22-1427(E);
3. A caretaker
relative as defined in
R9-22-1401(B)
with gross household income that does not exceed 106% of the FPL;
4. Under age 19 with gross household income
that does not exceed the limit set in R9-22-1427(D) for the child's
age;
5. A woman screened for breast
or cervical cancer by an Arizona program of the National Breast and Cervical
Cancer Early Detection Program who meets the requirements of
R9-22-2003(A);
or
6. A former foster care child
who meets the requirements of
R9-22-1432.
B. Definitions. In addition to
definitions contained in
R9-22-101
and A.R.S. §
36-2901,
the words and phrases in this Article have the following meanings unless the
context explicitly requires another meaning:
"Qualified hospital" means a hospital that has signed an
agreement with the Administration to process HPE applications and has not been
disqualified.
C.
Application Process:
1. Right to apply. A
person may apply for presumptive eligibility for AHCCCS medical coverage by
submitting an Administration-approved application to the qualified
hospital.
2. Application. To
initiate the application process, the qualified hospital will accept an
application from the applicant, an adult who is in the applicant's household,
as defined in
42 CFR
435.603(f), or family, as
defined in section 36B(d)(1) of the Internal Revenue Service (IRS) Code, an
authorized representative, or if the applicant is a minor or incapacitated,
someone acting responsibly for the applicant by submitting a written or online
application under
42CFR
435.907.
D. To establish presumptive eligibility, an
applicant must complete and submit an AHCCCS-approved presumptive eligibility
application signed under penalty of perjury to a qualified hospital. The
applicant must attest to the name(s), relation-ship(s), and income of all
persons in the household. In addition, the applicant must provide and attest to
the following information regarding each household member on whose behalf
AHCCCS medical coverage is sought:
1. The
individual's date of birth;
2.
Whether the individual is pregnant;
3. Whether the individual has been determined
eligible for Breast and Cervical Cancer Treatment Program, described under
Article 20;
4. Whether the
individual is a former foster child, described under
R9-22-1432;
5. The U.S. citizenship status or eligible
qualified alien status under A.R.S.
36-2903.03
of the individual; and
6. The
individual's permanent and mailing addresses;
7. The individual's Arizona residency status;
and
8. Whether the individual has
Medicare coverage.
E.
Presumptive eligibility begins on the date the hospital determines an
individual's presumptive eligibility and ends with the earlier of:
1. In the case of an individual on whose
behalf an application has been submitted to AHCCCS or its designee under
Article 3, the day on which AHCCCS or its designee makes a determination on
that application; or
2. In the case
of an individual on whose behalf an application has not been submitted to
AHCCCS or its designee under Article 3, on the last day of the following month
in which the determination of presumptive eligibility was made by the qualified
hospital.
F. An
individual may not be determined presumptively eligible more often than once
every two years.
G. Coverage and
reimbursement of services.
1. The
Administration shall provide coverage of medically necessary services described
under Article 2 to persons determined eligible for HPE on a fee-for-service
basis.
2. Providers shall submit
claims for services provided to persons determined eligible for HPE to the
Administration as described under Article 7.
H. A member may withdraw from HPE coverage by
notifying the Administration or its designee.
I. Upon determining an individual
presumptively eligible, the qualified hospital shall:
1. Notify the applicant at the time a
determination regarding presumptive eligibility is made, in writing and orally
if appropriate, of the determination for each individual on whose behalf
presumptive eligibility was requested and the effective date of the presumptive
eligibility;
2. Provide the
applicant with a regular AHCCCS-approved application form and inform the
applicant that the applicant may file an application for Medicaid with the
Administration or its designee;
3.
Notify AHCCCS of the presumptive eligibility determination;
4. Notify the applicant at the time the
determination is made that presumptive eligibility ends with the earlier of:
a. In the case of an individual on whose
behalf an application has been submitted to AHCCCS or its designee under
Article 3, the day on which AHCCCS or its designee makes a determination on
that application; or
b. In the case
of an individual on whose behalf an application has not been submitted to
AHCCCS or its designee under Article 3, on the last day of the following month
in which the determination of presumptive eligibility was made by the qualified
hospital.
J.
A determination by a qualified hospital that an individual is not presumptively
eligible is not appealable under Chapter 34. If a qualified hospital denies an
individual presumptive eligibility, the individual may apply for coverage by
submitting an application to the Administration or its designee.
