Title: Section 43-2.5 - Eligibility for coverage

Effective Date

06/02/2010

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 or the applicant's physician or the physician's designee. The applicant's physician or the physician's designee will be required to submit information regarding an applicant's medical condition on a State-approved form.

(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 435% 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) Liquid resources shall be reviewed to determine their availability in determining eligibility for the program. In order to be eligible, an applicant's liquid resources must be less than $25,000. Liquid resources are cash or those assets which can be readily converted to cash such as bank accounts, lump sum payments, i.e., stocks, bonds and mutual fund shares.

(d) 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 of HIV or AIDS.

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

(f) 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 applicants available household income, if the applicants 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, and (3) an employer contribution of 50% or more of the total cost of the health insurance premium, if the applicant is employed full time and eligible for employer sponsored health insurance.
 

Volume

VOLUME A-1 (Title 10)

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