Apply For Ahcccs – Fill Out and Use This PDF

APPLICATION FOR AHCCCS MEDICAL ASSISTANCE AND

MEDICARE SAVINGS PROGRAMS

You can apply online by using Health-e-Arizona Plus at

www.healthearizonaplus.gov

Keep Pages A, B, C, D, E, F, and G for your records

If you are over age 65, blind or disabled, or if you are eligible for Medicare, use this application to apply for AHCCCS Medical Assistance and/or Medicare Savings Programs. Or, you can apply online at www.healthearizonaplus.gov.

How can I qualify for AHCCCS Medical Assistance?

•Your gross monthly income can be no more than $1,133 for an individual or $1,526 for a couple (after a $20 standard deduction and other allowed deductions if you have earned income and/or dependent children).

•You must be a resident of the state of Arizona and a United States citizen or a non-citizen who meets Medicaid requirements.

•You must apply for pension, disability or retirement benefits if potentially available to you.

•If you are under age 65 and not receiving Social Security Disability income, a disability determination will be part of your application process.

How can I qualify for a Medicare Savings Program?

If you are receiving or eligible for Medicare Part A, use this application to apply for help with your Medicare premium(s), copayments and deductibles. There are three Medicare Savings Programs. Each one has a different income limit and different benefits.

•You must apply for pension, disability or retirement benefits if potentially available to you.

*If you are enrolled with a Medicare HMO, your co-pays will also be paid. If you elect additional coverage from a Medicare HMO, you will be responsible for any additional premiums and costs.

What services does AHCCCS Medical Assistance cover?

*AHCCCS prescription coverage is limited for people who have Medicare.

What does AHCCCS Medical Assistance cost? Premiums

Most people do not have to pay a monthly premium for AHCCCS Medical Assistance. Some people with income too high to qualify for AHCCCS Medical Assistance with no monthly premium may be able to get it by paying a monthly premium. If you have to pay a premium, the monthly premium amounts are:

•$10 - $70 for KidsCare

•$10 - $35 per person for employed people with disabilities

American Indians and Alaskan Natives: Per federal law, American Indians enrolled with a federally recognized tribe, children and grandchildren of American Indians enrolled with a federally recognized tribe and certain Alaskan Natives do not have to pay a premium. To get AHCCCS Medical Assistance at no cost, you must give us proof of tribal enrollment.

Co-payments

A co-payment is the amount you pay a health care provider when you receive a medical service. Your co-payment amount will vary depending on which AHCCCS program you are enrolled in and the services you need. For some AHCCCS programs, the provider can deny services if the co- payments are not made. Co-payments for services are:

•$2.30 to $10.00 for prescriptions

•$0 to $30.00 for non-emergency use of an emergency room

•$2.30 to $3.00 for physical, occupational or speech therapy

•$3.40 to $5.00 for outpatient visits for evaluation and management services including doctor’s office visits

Remember to report any changes in income because this may change your co-payment amount.

The following people are never asked to pay co-payments:

•Children under age 19.

•Individuals up through age 20 eligible to receive services from the Children’s Rehabilitative Services (CRS) program.

•People who receive hospice care.

•People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services.

•American Indian members who are active or previous users of the Indian Health Service, tribal health programs operated under Public Law 93-638 or urban Indian health programs.

•People who are acute care members and who are residing in nursing homes or residential facilities

such as an Assisted Living Home and only when the acute care member’s medical condition would otherwise require hospitalization. The exemption from copayments for acute care members is limited to 90 days per contract year.

In addition, co-payments are never charged for the following services for anyone:

•Hospitalizations

•Emergency services

•Family planning services and supplies

•Services paid for on a fee-for-service basis

•Pregnancy-related health care including tobacco cessation treatment for pregnant women

RIGHTS AND RESPONSIBILITIES OF APPLICANTS/RECIPIENTS

You have the RIGHT to:

1.Be treated fairly and equally regardless of race, religion, national origin, sex, age, disability, or political beliefs.

2.To apply for AHCCCS Medical Benefits and to be given a notice that tells you if you are eligible or not.

3.Review AHCCCS manuals that show the rules and regulations of the AHCCCS program if you want to know the reason why your application is denied.

4.Have all information you give regarding your eligibility kept private according to state and federal law.

5.A fair hearing if you disagree with an adverse action taken by the AHCCCS Administration. Adverse action means your application for AHCCCS services was denied, your AHCCCS benefits were ended or your AHCCCS services were reduced. You may also request a hearing if a decision is not made on your application within 45 days and the delay is due to AHCCCS. Your hearing will be conducted by an Administrative Law Judge and a decision will be issued by the AHCCCS Director. You have the right to review your case record before the hearing. You have the right to represent yourself or to have someone else represent you. If you wish to ask for a hearing, your request must be in writing and mailed or delivered to the Office of Administrative Legal Services, 801 East Jefferson, MD 6200, Phoenix, Arizona 85034 or faxed to 602-253-9115.

You have the RESPONSIBILITY to:

1.Provide AHCCCS with the needed information to correctly determine your eligibility and authorize AHCCCS to investigate and contact any sources necessary to confirm the accuracy of the information which pertains to eligibility.

2.Take necessary steps to obtain any annuities, pensions, retirement and disability benefits to which you may be entitled, including, but not limited to Social Security benefits, Railroad Retirement, Veteran’s benefits and unemployment compensation.

3.To report payments going in or out of your trust, if you have one.

If you are eligible you MUST:

1.Notify the AHCCCS/ALTCS office as soon as possible but no later than within 10 days by phone, letter or in person, whenever there are any changes in your income, address, marital status, Medicare coverage, household composition, or other circumstances which could affect your eligibility.

2.Cooperate with Arizona or Federal personnel in the completion of a quality control review of your eligibility.

PROVIDING SOCIAL SECURITY NUMBERS and IMMIGRATION STATUS

You must provide or apply for a Social Security number (SSN) for every applicant. Immigrants who are not legally able to obtain a SSN are not required to provide one. This is required under the Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369. Providing a Social Security number for someone who is not applying is optional. We will not use your SSN as your AHCCCS identification number. Your SSN will be used to check the identity of those receiving assistance, to prevent double payments, to determine benefits available under other programs, to verify state residency or other conditions of eligibility, and to make mass annual changes more easily. Your SSN will be used in computer matching available through the State Income and Eligibility Verification System (IEVS) to obtain wage, income and other information from: (a) the IRS, (b) the Social Security Administration, (c) Arizona Department of Economic Security, and (d) other states administering TANF, Medicaid, Unemployment Insurance, Food Stamps, Programs under Title I, X, XIV, XVI of the SSA and other state wage information collection agencies. AHCCCS will use the information available from this computer matching to verify income and whether you have Medicare. When the information you give is questionable, AHCCCS will verify the information by

How to choose a health plan

You need to choose an AHCCCS Complete Care (ACC) health plan that serves your county.

•All ACC plans provide the same covered medical services.

•Before choosing an ACC plan, check with your doctor, pharmacy or hospital to see if they work with the ACC plan that you want. If you want more information about the doctors, specialists or hospitals that work with an ACC plan that serves your county, call the number listed below for the ACC plan or visit the ACC plan’s website.

•American Indian members may choose from American Indian Health Program or an ACC plan.

•If you do not choose an ACC plan, one will be assigned to you.

•If you have been enrolled in an ACC plan within the past 90 days, you may be enrolled with your previous ACC plan.

•If you need help selecting an ACC plan you may speak to a Beneficiary Support Specialist by calling (602) 417-7100 from area codes (480), (602), and (623) or 1-(800)-334-5283 from area codes (520) and (928).

AHCCCS APPLICATION FORM

Did anyone you are applying for receive medical services in the last three months and need help with these expenses?  Yes  No If so, who? _____________________________________________

What months?_______________________ _______________________ _____________________

Is the person needing help with medical expenses pregnant or had a pregnancy end in the last 5 months?  Yes  No