10A N.C. Admin. Code 45A.0202

Current through Register Vol. 39, No. 9, November 1, 2024

Section 45A .0202 - DETERMINATION OF FINANCIAL ELIGIBILITY

(a) A patient must meet the financial eligibility requirements of this Subchapter to be eligible for benefits provided by the payment programs. Financial eligibility shall be determined by the NC Division of Public Health Purchase of Medical Care Services Unit through application of income scales that reflect federal poverty levels. The income scales can be found at http://www.ncdhhs.gov/control/pomcs/pomcs.htm. The definition of annual net family income in Rule .0203 of this Section and the definitions of family in Rule .0204 of this Section shall be used in applying the income scales, except as provided in Paragraph (c) of this Rule.

(b) A person is financially eligible for services under the Sickle Cell Program if the annual net family income is at or below the federal poverty level in effect on July 1, the beginning of each fiscal year.

(c) A person is financially eligible for the HIV Medications Program if the gross family income is at or below 300 percent of the federal poverty level in effect on July 1, the beginning of each fiscal year, with the following exceptions:

(1) If a waiting list develops, priority for enrollment into the HIV Medications Program shall be given to those whose net family income is at or below 125 percent of the federal poverty level, and second priority to those individuals with income above 125 percent and at or below 250 percent of federal poverty guidelines; and

(2) If the HIV Medications Program's financial eligibility level is changed, all clients enrolled in the HIV Medications Program during the most recent year or at the time the eligibility level is changed shall be eligible to continue to be enrolled in and served by the HIV Medications Program even if the clients' financial status exceeds the newly-established eligibility level. The eligibility of these clients shall remain in force until:

(A) they no longer qualify for the HIV Medications Program other than for financial reasons;

(B) they no longer require the services of the HIV Medications Program;

(C) their income increases such that they have an income that exceeds the level under which they originally qualified for and enrolled into the HIV Medications Program; or

(D) they fail to comply with the rules of the HIV Medications Program.

(3) If an individual is determined to be financially eligible, pursuant to Rule .0203 of this Section, if the application for financial eligibility was received by the Department in the fourth quarter of the fiscal year, the individual shall remain financially eligible for benefits until the end of the next fiscal year unless there is a change in the individual's family size pursuant to Rule .0204 of this Section or family financial resources or expenses during that period pursuant to Rule .0203 of this Section.

The HIV Medications Program shall provide notice of changes to the financial eligibility or other eligibility requirements to interested parties within North Carolina's HIV community (e.g., persons living with HIV disease, their families and caregivers, advocates and service providers, relevant local and state agencies) via electronic or print mechanisms.

(d) A person is financially eligible for the Cancer Program if gross family income is at or below 115 percent of the federal poverty level in effect on July 1 of each year.

(e) The financial eligibility requirements of this Subchapter do not apply to:

(1) School Health Fund financial eligibility determinations performed by a local health department which has chosen to use the financial eligibility standards of the Department of Public Instruction's free lunch program;

(2) Prenatal outpatient services sponsored through Perinatal Program high risk maternity clinic reimbursement funds, 10A NCAC 43C .0300; and

(3) Diagnostic assessments for infants up to 12 months of age with sickle cell syndrome.

(f) Except as provided in Paragraphs (c) and (g) of this Rule, once an individual is determined financially eligible for payment program benefits, benefits pursuant to Rule .0203 of this Section, the individual remains financially eligible for a period of one year after the date of application for financial eligibility unless there is a change in the individual's family size pursuant to Rule .0204 of this Section or there is a change in his family's financial resources or expenses during that period. If there is a change, financial eligibility for payment program benefits must be redetermined. Financial eligibility must be redetermined by the NC Division of Public Health Purchase of Medical Care Services Unit at least once a year.

(g) If the most current financial eligibility form on file with the Department shows that the patient was financially eligible on the date an Authorization Request for payment for drugs was received, the Authorization Request shall be approved so long as the Authorization Request is received prior to the expiration of financial eligibility and the authorized service does not extend more than 30 days after the expiration of financial eligibility.

10A N.C. Admin. Code 45A .0202

Authority G.S. 130A-4.2; 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205;
Eff. July 1, 1981;
Amended Eff. July 1, 1986; April 1, 1984; July 1, 1983; October 1, 1982;
Transferred and Recodified from 10 NCAC 04C .0202 Eff. April 4, 1990;
Temporary Amendment Eff. August 9, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;
Amended Eff. January 1, 1996; July 1, 1995; April 1, 1995; October 1, 1994;
Temporary Amendment Eff. July 1, 1997; April 1, 1997; March 1, 1997;
Amended Eff. August 1, 1998;
Temporary Amendment Eff. November 1, 2006;
Amended Eff. October 1, 2007;
Temporary Amendment Eff. October 1, 2008;
Amended Eff. January 1, 2014; August 1, 2009;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 13, 2015.

Authority G.S. 130A-4.2; 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205; Eff. July 1, 1981;
Amended Eff. July 1, 1986; April 1, 1984; July 1, 1983; October 1, 1982;
Transferred and Recodified from 10 NCAC 04C .0202 Eff. April 4, 1990;
Temporary Amendment Eff. August 9, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;
Amended Eff. January 1, 1996; July 1, 1995; April 1, 1995; October 1, 1994;
Temporary Amendment Eff. July 1, 1997; April 1, 1997; March 1, 1997;
Amended Eff. August 1, 1998;
Temporary Amendment Eff. November 1, 2006;
Amended Eff. October 1, 2007;
Temporary Amendment Eff. October 1, 2008;
Amended Eff. January 1, 2014; August 1, 2009.