10.14.02.03

.03 Patient Eligibility.

A. To be eligible to have a covered service reimbursed under the Program, an applicant shall:

(1) Be a resident;

(2) Be screened for breast cancer or cervical cancer, or both, by a:

(a) Hospital;

(b) Local health department; or

(c) Health care provider;

(3) Be found to have an eligible medical condition as described in §B of this regulation;

(4) Meet the health insurance criteria specified in §C of this regulation;

(5) Meet the financial eligibility criteria of an annual gross income that is not more than 250 percent of the federal poverty guidelines, as amended, which are incorporated by reference and updated periodically in the Federal Register by the U.S. Department of Health and Human Services; and

(6) Receive a medical service only from participating health care providers for breast cancer diagnosis, breast cancer treatment, cervical cancer diagnosis, or cervical cancer or precancer treatment, or any combination of these services.

B. A medical condition which may render an applicant medically eligible includes the following:

(1) A mammogram, or breast ultrasound, or other diagnostic breast imaging requiring further diagnosis;

(2) A clinical breast examination requiring further diagnosis;

(3) A Pap test, or human papilloma virus test, or other approved cervical cancer screening test requiring further diagnosis;

(4) A breast biopsy which indicates the need for further diagnosis or treatment; or

(5) A cervical biopsy which indicates the need for further diagnosis or treatment.

C. Health insurance statuses which may render an applicant eligible include the following:

(1) The applicant is not currently covered by health insurance, including Medical Assistance;

(2) The applicant is covered by Medicare which:

(a) Does not provide reimbursement for the covered medical procedure or service;

(b) Has a deductible for the year that has not been met; or

(c) Has a patient contribution amount for the reimbursed medical procedure or service that the applicant is required to pay; or

(3) The applicant has health insurance other than Medical Assistance or Medicare which:

(a) Does not provide reimbursement for the covered medical procedure or service;

(b) Requires that a deductible be paid by the applicant for the covered medical procedure or service;

(c) Reimburses at a rate lower than the Medical Assistance approved rate in the State; or

(d) Has a patient contribution amount for the reimbursed medical procedure or service that the applicant is required to pay;

(4) The applicant is enrolled in one of the following Medical Assistance programs:

(a) Family Planning;

(b) Primary Adult Care (PAC);

(c) Specified Low Income Medicare Beneficiary (SLMB); or

(d) Qualified Medicare Beneficiary (QMB).

D. An applicant is not eligible if:

(1) The applicant is enrolled in a Medical Assistance program other than those listed in §C(4) of this regulation;

(2) During diagnosis or treatment of breast or cervical cancer, the applicant becomes enrolled in a Medical Assistance program other than those cited in §C(4) of this regulation; or

(3) Any of the criteria established in §§A—D of this regulation are not met.

E. An applicant is responsible for the following:

(1) Furnishing factual information regarding the applicantís eligibility, including but not limited to verifying documents regarding financial eligibility and the applicability of health insurance;

(2) Completing, which may include the applicant providing the applicant's social security number, and signing the application form, provided that the Program informs the applicant that:

(a) The applicant's disclosure of the applicant's social security number on the application is voluntary;

(b) The Program's request for the applicant's social security number is authorized by federal law under the Social Security Act (42 U.S.C. 405(c), as amended); and

(c) The applicant's social security number will be used only for the Program's administrative purposes; and

(3) Completing and submitting a Medical Assistance application when notified by the Program that the applicant is considered potentially eligible.

F. Social Security Number Collection.

(1) An applicant is not required to have or disclose a social security number to be eligible for Program benefits.

(2) An applicant's disclosure of the applicant's social security number on the application form is voluntary.

(3) The Program's request for the applicant's social security number is authorized by federal law under the Social Security Act at 42 U.S.C. §405(c)(2)(C)(i) and (vi), as amended.

(4) The Program may only use the social security number provided by an applicant to establish the identity of the applicant for administrative purposes.

(5) The Program may request a copy of an applicant's social security card for administrative purposes.

G. An eligible patient is responsible for the following:

(1) Keeping the Program, local health department, hospital, or health care provider who determines the patientís eligibility for the Program informed of any change in health insurance status;

(2) Selecting and using only a participating health care provider; and

(3) Signing the release of patient information form for the Program developed and approved by the Department.