Section R9-22-1601. General Eligibility Requirements

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 AHC- CCS 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;

Arizona Health Care Cost Containment System - Administration

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 require- ments 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 hospi- tal 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 eligi- bility for AHCCCS medical coverage by submitting an Administration-approved application to the qualified hos- pital.

2.        Application. To initiate the application process, the quali- fied hospital will accept an application from the appli- cant, 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 42 CFR 435.907.

D.      To establish presumptive eligibility, an applicant must com- plete and submit an AHCCCS-approved presumptive eligibil- ity 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 addi- tion, 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 sta- tus 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 deter- mines an individual’s presumptive eligibility and ends with the earlier of:

1.        In the case of an individual on whose behalf an applica- tion has been submitted to AHCCCS or its  designee under Article 3, the day on which AHCCCS or its desig- nee makes a determination on that application; or

2.        In the case of an individual on whose behalf an applica- tion 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 Administra- tion 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 appli- cant may file an application for Medicaid with the Administration or its designee;

3.        Notify AHCCCS of the presumptive eligibility determi- nation;

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 AHC- CCS 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 pre- sumptive eligibility was made by the qualified hos- pital.

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 eligi- bility, the individual may apply for coverage by submitting an application to the Administration or its designee.

Historical Note

New Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Section repealed by exempt rulemaking at 7 A.A.R. 4593, effec- tive October 1, 2001 (Supp. 01-3). New Section made by exempt rulemaking at 12 A.A.R. 3892, effective October 1, 2006 (Supp. 06-3). Section expired under A.R.S. § 41-

1056(E) at 17 A.A.R. 2384, effective October 31, 2011 (Supp. 11-4). New Section made by final rulemaking at 20 A.A.R. 3436, effective January 1, 2015 (Supp. 14-4).