36-2907.10. Transplants; extended eligibility

A. If during a redetermination process for eligibility pursuant to this article a person who is enrolled and who is eligible pursuant to this article for a medically necessary and appropriate transplant pursuant to section 36-2907, subsection A, paragraph 10 is determined ineligible for coverage pursuant to section 36-2901.04 due to excess income or ineligible for coverage pursuant to section 36-2901, paragraph 6, subdivision (a), item (i), (ii) or (iii) and that person has not yet received the transplant, the person may extend the person's eligibility based on the total spend down requirement for the household divided by the number of persons in the household.

B. In order to extend eligibility the person shall enter into a contractual agreement with a hospital to pay the amount of excess income determined pursuant to this section. The hospital shall only be reimbursed by the administration at the contracted rate of the transplantation surgery, including up to one hundred days of posttransplantation care. The administration shall deduct the amount of excess income that the person agrees to pay the hospital before payment is made to the hospital for transplant services authorized by this section. The amount of excess income shall not be changed once the extended period of eligibility begins. The administration is not responsible to pay any of the spend down amount if the person does not pay the hospital. The contracting hospital shall submit a copy of the person's contractual agreement with the hospital to the administration.

C. The administration shall authorize extended eligibility services only for transplant candidates.

D. Extended eligibility pursuant to this section is for one twelve-month continuous period of time and is funded only pursuant to section 36-2907.12.

E. This section does not prohibit a person from applying for eligibility pursuant to any other applicable law.

F. If the administration and a hospital that performed a transplant surgery on a person who is eligible pursuant to this section do not have a contracted rate, the administration shall not reimburse the hospital more than the contracted rate established by the administration.

G. A person who has extended eligibility pursuant to section 36-2907.11 is not eligible for services pursuant to this section.

H. The extended eligibility of a person who is determined to be no longer medically eligible for a transplant terminates at the end of the month in which it is determined the person is not medically eligible for the transplant unless the person is otherwise eligible for services pursuant to section 36-2901, paragraph 6, subdivision (a).