Section 43-2.5 - Eligibility for coverage

43-2.5 Eligibility for coverage.

(a) An applicant must be confirmed as medically eligible to participate in the program. The Department of Health will confirm medical eligibility based upon information received from the applicant and the applicant's clinical practitioner or their designee. The applicant's clinical practitioner or their designee will be required to submit information regarding an applicant's medical condition on a State-approved form consistent with their scope of practice.

(b) Financial eligibility will be based upon the available household income.

(1) In order to be eligible, an applicant's available household income must be equal to or less than 500% of the amount under the annual United States Department of Health and Human Services poverty guidelines for the applicant's family size. Federal poverty guidelines are published annually by the Department of Health and Human Services in the Federal Register.

(2) Applicants must provide income information for a reasonable period prior to application. Applicants who are self-employed must provide business records for the three months prior to application indicating type of business, gross income and net income.

(c) Full and proper use shall be made of existing public and private medical and health services and facilities for obtaining therapeutic drugs, medical services, and related supplies and equipment for the treatment or prevention of HIV or AIDS.

(d) An applicant or recipient of assistance may be required as a condition of eligibility or continued eligibility to assign any rights they may have for coverage benefits under any health insurance policy or group health plan to the department.

(e) In order to be eligible for ADAP Plus Insurance Continuation, an applicant must have:

(1) a health insurance policy that is determined to be cost effective by the department, based on the cost of premiums, limitations of coverage (i.e., deductible, caps, co-payments) and estimates of the monetary value of projected utilization and reimbursement under the insurance policy; and

(2) a premium cost that is more than 4% of the applicant's available household income, if the applicant's available household income is greater than 200% of the amount under the annual United States Department of Health and Human Services poverty guidelines for the applicant's family size. 

 

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 201(1)(o), 201(1)(p) and 2776(1)(e)