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REFERENCE TITLE: AHCCCS; enrollment verification; presumptive eligibility |
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State of Arizona House of Representatives Fifty-seventh Legislature First Regular Session 2025
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HB 2449 |
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Introduced by Representatives Carbone: Gillette, Livingston, Nguyen, Willoughby, Wilmeth; Senators Carroll, Gowan, Shamp
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An Act
amending title 36, chapter 29, article 1, Arizona Revised Statutes, by adding sections 36-2903.17 and 36-2903.18; relating to the Arizona health care cost containment system.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 36, chapter 29, article 1, Arizona Revised Statutes, is amended by adding sections 36-2903.17 and 36-2903.18, to read:
36-2903.17. Data matching agreements; review of member eligibility information; waiver requests
A. The administration shall enter into a data matching agreement with the department of gaming and the Arizona state lottery commission to identify members who have lottery or gambling winnings of $3,000 or more. the administration shall review this information On at least a monthly basis. If a member fails to disclose winnings of $3,000 or more and is identified through the database match, the administration shall consider the member's failure to disclose the information a violation of the system's terms of eligibility.
B. On at least a monthly basis, the administration shall receive and review death record information from the department of health services concerning members and shall adjust system eligibility accordingly.
C. On at least a quarterly basis, the administration shall receive and review information from the department of economic security and the industrial commission of ARizona concerning members that indicates a change in circumstances that may affect eligibility, including changes to unemployment benefits, employment status or wages.
D. On at least a monthly basis, the administration shall review information concerning members that indicates a change in circumstances that may affect eligibility, including potential changes in residency as identified by out-of-state electronic benefit transfer card transactions.
E. On at least a quarterly basis, the administration shall receive and review information from the department of revenue concerning members that indicates a change in circumstances that may affect eligibility for the system, including potential changes in income, wages or residency as identified by tax records.
F. Unless required by federal law, the administration may not accept self-attestation of income, residency, age, household composition, caretaker or relative status or receipt of other health insurance coverage without independent verification before enrollment. The administration may not request authority to waive or decline to periodically check any available income-related data sources to verify eligibility.
G. The administration may not accept eligibility determinations for the system from an exchange established pursuant to 42 United States code section 18041(c). The administration may accept assessments from an exchange established pursuant to 42 United States code section 18041(c) but shall independently verify eligibility and make eligibility determinations.
H. If the administration receives information concerning a member that indicates a change in the member's circumstances that may affect eligibility, the administration shall review the member's eligibility.
I. The administration may execute a memorandum of understanding with any other department of this state for information required to be shared pursuant to this section. The administration may contract with one or more independent vendors to provide ADDITIONAL data or information that may indicate a change in circumstances and affect an individual's eligibility.
J. On or before April 1, 2026, the administration shall submit to the centers for medicare and medicaid services any waiver requests necessary to implement this section.
36-2903.18. Presumptive eligibility; limits; standards; notification; training
A. The administration shall request approval from the centers for medicare and medicaid services for a section 1115 waiver to allow the administration to eliminate mandatory hospital presumptive eligibility and restrict presumptive eligibility determinations to children and pregnant women eligibility groups. If approval for the section 1115 waiver is denied, the administration shall resubmit a subsequent request for approval within twelve months after each denial.
B. Unless required by federal law, the administration may not designate itself as a qualified health entity for the purpose of making presumptive eligibility determinations or for any purpose not expressly authorized by state law.
C. When making presumptive eligibility determinations, a qualified hospital shall do all of the following:
1. Notify the administration of each presumptive eligibility determination within five working days after the date the determination is made.
2. Assist individuals who are determined presumptively eligible under the system with completing and submitting a full application for system eligibility.
3. Notify each applicant in writing and on all relevant forms with plain language and large print that if the applicant does not file a full application for system eligibility with the administration before the last day of the following month, presumptive eligibility coverage will end on the last day of the following month.
4. Notify each applicant that if the applicant files a full application for system eligibility with the administration before the last day of the following month, presumptive eligibility coverage will continue until an eligibility determination is made on the application that was filed.
D. The administration shall apply the following standards to establish and ensure that accurate presumptive eligibility determinations are made by each qualified hospital:
1. Whether the qualified hospital submitted to the administration the presumptive eligibility card within five working days after the determination date.
2. Whether a full application for system eligibility was received by the administration before the expiration of the presumptive eligibility period.
3. If a full application was received by the administration, whether the individual was found to be eligible under the system.
E. If the administration determines that a qualified hospital fails to meet any of the standards established under subsection D of this section for any presumptive eligibility determination that the qualified hospital made, the administration shall notify the qualified hospital in writing within five days after the determination. The notice shall include:
1. For the first violation, both of the following:
(a) A description of the standard that was not met and an explanation of why it was not met.
(b) Confirmation that a second finding will require that all applicable hospital staff participate in mandatory training by the administration on hospital presumptive eligibility rules.
2. For the second violation, all of the following:
(a) A description of the standard that was not met and an explanation of why it was not met.
(b) Confirmation that all applicable hospital staff will be required to participate in a mandatory training by the administration on hospital presumptive eligibility rules, including the date, time and location of the training as determined by the administration.
(c) A description of available appellate procedures by which a qualified hospital may dispute the finding and remove the finding from the qualified hospital's record by providing clear and convincing evidence that the standard was met.
(d) Confirmation that if the qualified hospital subsequently fails to meet any of the standards for presumptive eligibility for any determination, the qualified hospital will no longer be qualified to make presumptive eligibility determinations under the system.
3. For the third violation, all of the following:
(a) A description of the standard that was not met and an explanation of why it was not met.
(b) A description of available appellate procedures by which a qualified hospital may dispute the finding and remove the finding from the hospital's record by providing clear and convincing evidence that the standard was met.
(c) Confirmation that, effective immediately, the hospital is no longer qualified to make presumptive eligibility determinations under the system.
Sec. 2. Effective date
This act is effective from and after December 31, 2025.