36-2907.11. Retaining transplant status

A. If during a redetermination process for eligibility pursuant to this article a person who is eligible for a medically necessary and appropriate transplant as determined by the administration 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 enter into a contract with a hospital to pay the amount of excess income. For purposes of this section, the administration shall compute excess income based on the total spend down requirement for the household divided by the number of persons in the household. The administration shall recompute excess income pursuant to this section at the time the transplant becomes available.

B. If the hospital enters into the contractual agreement with the person, the hospital shall allow the person to retain the person's transplant candidacy status as long as the person is medically eligible but the person is not eligible for services pursuant to this article unless that person is determined eligible pursuant to subsection D of this section.

C. A person who has extended eligibility pursuant to section 36-2907.10 is not eligible for services pursuant to this section.

D. Once a transplant is scheduled or performed the person shall reapply for eligibility pursuant to section 36-2901, paragraph 6, subdivision (a) and, if a spend down of excess income is necessary in order to be eligible for services pursuant to this article, the administration shall compute this income pursuant to the process specified in subsection A of this section. If the transplant is performed within thirty days before the date of the eligibility determination, the administration shall pay the hospital on a retroactive basis at the contracted rate for costs of the transplant surgery, including up to one hundred days of posttransplantation care. The administration shall deduct the amount of excess income that the person has agreed to pay the hospital before payment is made to the hospital for transplant services pursuant to this section. The amount of excess income shall not be recomputed after the date the person becomes eligible pursuant to this section. The administration is not responsible for paying any 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.

E. Eligibility pursuant to this section shall be funded only pursuant to section 36-2907.12.

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

G. If the administration and a hospital that performed a transplant surgery on a person 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.