Apply For Ahcccs PDF Details

The Arizona Health Care Cost Containment System (AHCCCS) is the state's Medicaid program. It provides coverage for low-income individuals and families, as well as for those with disabilities. If you're looking for affordable health care coverage, AHCCCS may be a good option for you. In this post, we'll discuss how to apply for AHCCCS and what benefits are available. We'll also include information on how to renew your AHCCCS coverage.

You'll find details about the type of form you would like to fill out in the table. It will show you the span of time you will require to fill out apply for ahcccs, exactly what parts you will need to fill in, and so forth.

Form NameApply For Ahcccs
Form Length18 pages
Fillable fields0
Avg. time to fill out4 min 30 sec
Other namesapply online for ahcccs, ahcccs application pdf, ahcccs apply online, apply for ahcccs health insurance

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

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

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.


Qualified Medicare

Specified Low-Income



Beneficiary (QMB)

Beneficiary (SLMB)

Individual – 1 (QI-1)

Program 





• You must be a resident of the

state of Arizona.



• You must be a United States citizen or a non-citizen who meets Medicaid





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









Income Limits









(after allowed

$0 - $1,133

$0 - $1,526
















Receiving or eligible for






Medicare Part A

Medicare Part A


Medicare Part A

What is the

• Pays your Medicare Part B

• Pays your Medicare Part B

• Pays your Medicare





Part B Premium




• Pays your Medicare













Part A Premium (if not free)







• Pays your Medicare















• Pays your Medicare














*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.

DE-103 (Rev. 01/2022)

Page A

What services does AHCCCS Medical Assistance cover?

• Prescription medication*

• Medical supplies

• Medically necessary transportation

• Doctor’s office visits

• Chemotherapy

• Medically necessary specialist care

• Hospital services

• Behavioral health care

• Laboratory and X-ray services

• Dialysis

• Immunizations (shots)

• Rehabilitation services

• 90 days of nursing care

• Emergency medical care





*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.


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:


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

DE-103 (Rev. 01/2022)

Page B

How does AHCCCS Medical Assistance work?

If you are approved for AHCCCS Medical Assistance, you will receive your health care from an AHCCCS Complete Care (ACC) plan unless:

You are American Indian and you choose American Indian Health Program as your health plan.

You are approved for one of the Medicare Savings Programs.

AHCCCS can only pay for your emergency services because of your status with United States Citizenship and Immigration Services. If you are approved for emergency services only, you may

receive medical services from any provider (doctor, hospital, etc.) that has an agreement to bill AHCCCS for covered emergency services.

How does a health plan work?

The health plan works with health care providers (doctors, hospitals, pharmacies, etc.) to provide all AHCCCS covered services.

The health plan will send you a member handbook once you are enrolled.

You can call the health plan if you have any questions about your benefits or services or if you

need an accommodation because of a disability or interpreter services. The phone number for your health plan’s member or customer services can be found on your AHCCCS ID Card and in your Member Handbook.

How can I get behavioral health services?

You can go through your primary doctor, or

Call the behavioral health telephone number on your AHCCCS ID Card.

What if I have Medicare or other health insurance?

Be sure to tell your health plan that you have Medicare or any other health insurance.

If your doctor does not contract with your AHCCCS Complete Care (ACC) plan, your doctor must call the ACC plan to coordinate care or you may be responsible for any Medicare or other health insurance co-payments or deductibles.

If you are in an HMO, you should pick a primary doctor who works with both your HMO and your ACC plan.

If you have Medicare, your prescription coverage under AHCCCS is limited. If you have questions about prescriptions, call 1-800-MEDICARE (633-4227), or your AACC plan.

What do primary doctors and specialists do?

Once enrolled, you will get a list of primary doctors in your area from the health plan. You must choose your primary doctor or one will be assigned to you. You have the right to change your primary doctor at any time by calling your health plan’s member or customer services. Your primary doctor will:

Take care of your health care.

Be responsible for authorizing your non-emergency medical services.

Be the first person you go to for non-emergency medical care.

Send you to a specialist when needed.

DE-103 (Rev. 01/2022)

Page C

Who Can Complete an Application?

This application may be completed by you or anyone you choose who knows or can get the information needed to complete the application for you and your family members. The terms “applicant” and “you” on this form refer to the person applying for AHCCCS Medical Assistance and/or Medicare Savings Program benefits. You and your spouse can use the same application form to apply. If you have a conservator or guardian, your conservator or guardian must complete this form for you.

Instructions to the Applicants

Check YES or NO on the application form when asked if you are applying for AHCCCS Medical Assistance or for help to pay Medicare costs. You can check YES to either question or to both.

Answer all questions on pages 1 through 6 for each person applying.

If you need more room, attach additional sheets of paper to provide all requested details.

Read page E for an explanation of your rights and responsibilities and providing a social security number.

Sign the application.

Attach all requested verification when you send your application.

Keep pages A, B, C, D, E, F, and G for your records and mail pages 1 through 6 to the MA-SP Office:

AHCCCS Medical Assistance

Specialty Programs (MA-SP)

801 East Jefferson Street

Phoenix, AZ 85034

FAX: 602-258-4619

If you are applying for AHCCCS Medical Assistance, read page G and choose an AHCCCS Complete Care (ACC) plan.

If you have any questions regarding these programs, or need help filling out the application, please call:

If you are calling from area codes (480, 602 or 623) dial (602) 417-5010 and choose option 5.

If calling from area codes (520, 760 or 928) dial toll free 1-800-528-0142.

After we receive your application, we will either contact you for additional information or, if your application is complete, make a decision about whether you qualify. We will send you a notice explaining the decision.

DE-103 (Rev. 01/2022)

Page D


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.


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

contacting other sources.


DE-103 (Rev. 01/2022)

Page E


(Applicable only to AHCCCS Medical Assistance and the Qualified Medicare Beneficiary Program)

I understand that if I am or members of my family are approved for AHCCCS benefits, AHCCCS can collect payment from any other parties who may be responsible for paying for our health care costs. This includes:

Private or employer-sponsored health insurance (not including Medicare)

Persons, such as an absent spouse or parent, who are legally responsible for providing medical support

Private or employer-sponsored disability insurance

Private or employer-sponsored accident insurance

Insurance claims, jury awards, or legal settlements resulting from injuries

I understand that AHCCCS cannot collect more than the costs paid by AHCCCS. I also understand that I must give information about other responsible parties and take any action needed to receive medical support. This includes establishing paternity of my children, unless I can prove good cause not to do so.

DE-103 (Rev. 01/2022)

Page F

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).

Geographic Service Area (GSA)


Available AHCCCS Complete Care (ACC) Health Plans



American Indian Health Program

• Apache

• Navajo

• Care1st Health Plan

• Coconino

• Yavapai

• Health Choice Arizona

• Mohave






• American Indian Health Program

• Maricopa


• Arizona Complete Health - Complete Care Plan (formerly

• Gila



Health Net Access)

• Pinal, excluding ZIP codes

Banner-University Family Care

85542, 85192, and 85550

• Molina Complete Care



• Mercy Care



• Health Choice Arizona



• UnitedHealthcare Community Plan



• American Indian Health Program

• Cochise

• Santa Cruz

• Arizona Complete Health - Complete Care Plan (formerly

• Graham

• Yuma


Health Net Access)

• Greenlee

• ZIP codes 85542,

Banner-University Family Care

• La Paz

85192, and 85550

• UnitedHealthcare Community Plan (Pima County Only)

• Pima





Health Plan Name

Phone Number



American Indian Health Program

Maricopa County:







All other counties:







Arizona Complete Health -



Complete Care Plan (formerly




Health Net Access)




Banner-University Family Care



Care1st Health Plan



Molina Complete Care



Mercy Care



Health Choice Arizona







UnitedHealthcare Community Plan


DE-103 (Rev. 01/2022)

Page G



Are you applying for AHCCCS Health Insurance?





Are you applying for help to pay Medicare costs?



























First Name



Last Name






Social Security Number












Date of Birth







Medicare Claim Number













Are you a U.S. Citizen?



is your immigration status?







❑Yes, a U.S. citizen


❑Lawful Permanent Resident (LPR)

❑Deportation Withheld







❑Indefinite Detainee

❑No, not a U.S. citizen






❑Parolee for at Least One Year

If no, what number is on






❑ Citizen of Republic of the

your immigration card?


❑American Indian Born in Canada

Marshall Islands



Cuban-Haitian Entrant


❑ Citizen of Federated States of


❑ Hmong or Laotian Highlander






❑Victim of Trafficking


❑ Citizen of Republic of Palau



❑Afghan/Iraqi Special Immigrant






❑Battered Alien







❑Conditional Entrant





















Home Address










Zip Code













Mailing Address (if different)








Zip Code











Home Phone Number


Work Phone Number



Message Number














What language do you speak?





Other ________________

What language do you read?





Other ________________

Ethnic Group - Optional (will not affect eligibility) ❑ Hispanic

Non-Hispanic Latino





Race - (Select one or more) (Optional) White

Asian Native American

Black/African American Hawaiian or other Pacific Islander

Alaska Native

Check your current Marital Status:


Effective Date of Current Marital Status:

Never Married

Married Divorced









If married, do you and your spouse live together?

Yes No

If NO, date of separation: __________

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

Accommodations for Printed Letters

Does the customer, authorized representative, or legal guardian have a visual impairment that requires an alternative format for printed letters?

No Yes If yes, who needs the accommodation:

If yes, what kind of alternative format do you need? Please choose one option:

Letters in HEAplus account (note: this person must have an HEAplus account)

Readable PDF sent by secure email

Large print: larger print letters sent by U.S. mail will be provided Arial 24 point font.


Authorized Representative

If you want to allow someone else to represent you or you have a legal guardian, provide the information below.

Representative’s Name: ___________________________________________________________

Is representative your legal guardian?



Representative’s Mailing Address: ___________________________________________________

City: _______________________ State: ____ Zip Code: __________

Representative’s Phone Number: ____________________________________________________

What is the representative’s preferred language to speak?



Other: ____________________________________________________


What is the representative’s preferred language to read?




Other: ____________________________________________________







My representative would like to get information about this application by:







No Email address: _________________________________________________







No Number to text (standard text rates apply): ___________________________


If ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.

DE-103 (Rev. 01/2022)

Page 2

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