A. Chapter Contents

This chapter contains the following topics:

Topic

101.00    What is AHCCCS Health Insurance?

102.00    Who Can Qualify for AHCCCS Health Insurance?

103.00    How to Apply for AHCCCS Health Insurance

104.00    Agencies and Organizations Participating in AHCCCS

104.01    The AHCCCS Administration

104.02    The Department of Economic Security

104.03    The Social Security Administration

104.04    Arizona Department of Health Services

104.05    Office of Administrative Hearings

104.06 Native American Organizations: Tribes, Native American Community Health Center (NACHC), and Indian Health Services (IHS)

105.00    Arizona's Method of Service Delivery

106.00    AHCCCS Health Insurance Implementation Milestones

B. Introduction

By reading this overview chapter, you will learn about:

• AHCCCS Health Insurance;

• The five AHCCCS Health Insurance programs;

• Who can qualify for AHCCCS Health Insurance;

• Agencies and organizations participating in AHCCCS Health Programs;

• Arizona's method of service delivery; and

• Implementation milestones that relate to eligibility for AHCCCS Health Insurance.

A. AHCCCS Health Insurance

Arizona Health Care Cost Containment System (AHCCCS) Health Insurance was established by the State of Arizona to provide health care for Arizona residents.

There are five health insurance programs available under the AHCCCS Administration:

• Arizona's Medicaid

• KidsCare

• Health Insurance for Parents

• Medicare Cost Sharing

• Healthcare Group

• Social Security Disability Insurance-Temporary Medical Coverage (SSDI-TMC)

B. What is Medicaid?

The Centers for Medicare and Medicaid Services (CMS) is the federal agency that oversees the Medicaid programs. CMS was formerly called the Health Care Financing Administration (HCFA). Medicaid is a jointly funded, Federal-State health insurance program for certain low-income and needy people. It is also known as Title XIX of the Social Security Act, which provides for federal grants to the states for medical assistance programs. AHCCCS is responsible for submitting a written State Plan, which assures that Arizona's Medicaid program will be administered in conformance with the federal requirements of the Social Security Act and provides a basis for Financial Federal Participation (FFP). The table below lists Arizona's Medicaid coverage groups and a brief description of each coverage group in alphabetical order.

Medicaid Coverage Group

Description

AHCCCS Care (AC)

Available to single, individual, or married couples who do not qualify for traditional Medicaid programs because they are not age 65 or older, blind, or disabled and do not have any dependent children. (MS 401.00.)

AHCCCS Freedom to Work (FTW)

Available to working individuals who have a disability. Individuals may be eligible for Long Term Care Services or AHCCCS Medical Services. (MS 402.00)

Arizona Long Term Care System (ALTCS)

Available to individuals who are elderly, physically or developmentally disabled and have a medical need for long-term care services. (MS 403.00)

Breast and Cervical Cancer Treatment Program (BCCTP)

Available to women under age 65 who are screened and diagnosed as needing medical treatment for breast cancer, cervical cancer or a pre-cancerous cervical lesion by one of the programs in the Arizona National Breast and Cervical Cancer Early Detection Program (AZ-NBCCEDP). (MS 404.00)

Deemed Newborns

Available for up to one year of coverage for children born to mothers receiving Medicaid (Title XIX) medical services as long as the child continuously lives with the mother in the State of Arizona. Eligibility begins on the child's date of birth and ends with the last day of the month in which the child turns age one. (MS 405.00)

Families with Children (AFC)

Available to families that include deprived, dependent children. Coverage under AFC is based on requirements in Section 1931 of the Social Security Act. Therefore, it is sometimes referred to as "1931". (MS 406.00)

Families whose AFC benefits are terminated due to:

• Employment payments, may be eligible for an additional six months after becoming ineligible due to excess income.

• Receipt of or increase in child support payments, may be eligible for an additional four months after becoming ineligible due to excess income.

Medical Expense Deduction (MED)

Available to individuals, couples, or families without children whose income exceeds the Medicaid limits may be eligible after deducting their medical expenses from their income. (MS 410.00)

Pregnant Women

Available to pregnant women beginning with any month of pregnancy through the 60-day postpartum period. (MS 412.00)

Note: Women who lose S.O.B.R.A. eligibility receive Family Planning Services for up to 24 months.

Six Month Guarantee

Available to individuals who are enrolled with a health plan for the first time and become ineligible prior to 6 months of enrollment. Customers in the following coverage groups receive continued AHCCCS coverage under the guarantee enrollment period, providing the customer does not voluntarily withdraw, is eligible when enrolled, is not an inmate of a public institution or adopted, and remains an Arizona resident.

• AHCCCS Care (MS 401.00);

• Families with Children (MS 406.00);

• Breast and Cervical Cancer Treatment Program (MS 404.00);

• AHCCCS Freedom to Work (MS 402.00);

• Supplemental Security Income (MS 415.00);

• Supplemental Security Income Medical Assistance Only (MS 416.00);

• S.O.B.R.A. Child (MS 413.00);

• Pregnant Women (MS 412.00);

• Title IV-E Foster Care and Adoption Subsidy (MS 417.00); and

• Young Adult Transitional Insurance (MS 418.00).

Note: The six-month guarantee does not apply to customers receiving Long Term Care services.

S.O.B.R.A. Child

Available to children up to their 19^th birthday. S.O.B.R.A. is named for the Sixth Omnibus Reconciliation Act, which created this coverage group. (MS 413.00)

Supplemental Social Security Income (SSI) Cash

Available to individuals receiving SSI cash benefits from the Social Security Administration (SSA) because they are age 65 or older, blind or disabled. (MS 415.00)

Supplemental Social Security Income Medical Assistance Only (SSI MAO)

Available to certain individuals who may not be eligible for SSI Cash assistance may be determined eligible for SSI MAO. These customers must be age 65 or older, blind, or disabled to receive AHCCCS medical services under the SSI Non-cash coverage group. (MS 416.00)

Title IV-E Foster Care and Adoption Subsidy

Available to customers with an adoption assistance agreement or foster care maintenance payments under the provisions of Title IV-E of the Social Security Act. They are deemed to meet the non-medical conditions of eligibility for ALTCS. (MS 417.00)

Young Adult Transitional Insurance (YATI)

Available to any individual under age 21 who was in DES foster care when turning 18 years old. (MS 418.00)

C. What is KidsCare?

KidsCare is Arizona's version of the State Children's Health Insurance Program (SCHIP) authorized by the addition of Title XXI to the Social Security Act. It is a federal and state program providing health care services to children under age 19. Based on federal laws, a customer who is eligible for Medicaid cannot be approved for Title XXI coverage. If the customer is screened to be potentially eligible for Medicaid, the Department of Economic Security (DES) or another AHCCCS office completes the eligibility determination for Medicaid. KidsCare is a federal block grant program. An eligible child who becomes ineligible for KidsCare is guaranteed a one-time, 12-month period of enrollment unless the child became ineligible due to:

•  Age;

• Moving out of Arizona;

• Other health insurance coverage;

• Non-payment of the required premium; or

• The child becomes an inmate in a public institution. 

(MS 409.00)

D. What is Health Insurance for Parents?

Health Insurance for Parents is for parents of KidsCare and S.O.B.R.A. eligible children. It is authorized by a Health Insurance Flexibility and Accountability Demonstration (HIFA) 1115 Waiver. This program is funded by Title XXI funds. (MS 407.00)

E. What is Medicare Cost Sharing?

Medicare is a Federal Health Insurance Program under Title XVIII of the Social Security Act. The customer pays part of the insurance and the federal government subsidizes the rest. The Medicare Cost Sharing programs help the customer reduce the cost of their Medicare related expenses. The Medicare Cost Sharing Programs include:

• Qualified Medicare Beneficiary (QMB),

• Specified Low Income Medicare Beneficiaries (SLMB),

• Qualified Individual-1 (QI-1), and

• Qualified Working Individuals (QDWI).

Note: Some individuals may be eligible for AHCCCS Medical Services and a Medicare Cost Sharing Program at the same time. (MS 411.00)

F. What is Healthcare Group

Healthcare Group was created by the Arizona legislature, effective January 1, 1988, to provide an affordable health care option for small employers. A self-employed individual or employers with 50 or fewer employees are eligible to participate in Healthcare Group by purchasing health care insurance for their employees dependents through participation AHCCCS health plans. Employers contract directly with the selected health plan and choose the benefit level and cost sharing option that is suitable for their organization. (MS 408.00)

G. What is SSDI-TMC

Social Security Disability Insurance-Temporary Medical Coverage (SSDI-TMC) was created by the Arizona legislature, effective October 1, 2006, to provide health insurance coverage to individuals who are no longer eligible for Medicaid (for example, due to excess income when they began to receive Social Security Disability benefits), but who are not yet eligible for Medicare benefits. The program is 100% state funded. Enrollees will be accepted subject to the availability of funds. An applicant may be placed on a waiting list if funding is insufficient. There are no resource or income limits for the program. However, verification of gross household income is required for the calculation of the monthly premium amount. (MS 414.00)

A. Customers Who Qualify for AHCCCS Health Insurance

The table below presents a variety of customer situations and the appropriate AHCCCS program or coverage group the customer may qualify for, as well as where the customer can apply for AHCCCS Health Insurance.

IF the customer is. . .

He/she may qualify for. . .

By applying at. . .

Age 65 or older, blind, or disabled, and in need of long term care services

ALTCS

An ALTCS Office

Age 65 or older, blind, or disabled

AHCCCS Medical Services

The SSI MAO Office

Medicare Cost Sharing

The SSI MAO Office

An employed person with a disability

AHCCCS Freedom to Work

The SSI MAO Office or an ALTCS office

A child

S.O.B.R.A.

A DES Office

AHCCCS for Families

KidsCare

The KidsCare Office

A family with dependent children

AHCCCS for Families

A DES Office

Pregnant

S.O.B.R.A.

A DES Office

An adult with children

AHCCCS Health Insurance for Children

• The KidsCare Office; or

• A DES Office

An adult without children

AHCCCS Care

A DES Office

A person or family with excessive medical expenses

Medical Expense Deduction (MED)

A DES Office

A women age 18-64 diagnosed with breast or cervical cancer through the National Breast and Cervical Cancer Early Detection Program

Breast and Cervical Cancer Treatment Program

Arizona Department of Health Services (ADHS), Well Woman Health Check Program

Self-employed or a small business employer

Healthcare Group

www.healthcaregroupaz.com 

Call (602) 417-6717 or (800) 545-0676 outside metro Phoenix or visit the website

A. Who Can Apply

Anyone can apply for AHCCCS Health Insurance.

How a customer applies for AHCCCS Health Insurance depends on the type of services the customer needs.

The Application for AHCCCS Health Insurance (AH-001) is available for printing from the AHCCCS website http://www.azahcccs.gov/Publications/Forms/Member/UniversalApp/ApplicationforAHCCCSHealthInsurance.pdf. Other applications are available upon request at any AHCCCS or DES eligibility office.

To locate the closest AHCCCS office go to: http://www.azahcccs.gov/Services/locations.asp

To locate the DES office that serves your community, go to: http://www.de.state.az.us/faa/contact.asp

Long term care services

• Age 65 or older; or

• Blind; or

• Disabled

• Call or go to the nearest ALTCS office; or

• Send a Request for Application for AHCCCS Long Term Care Services(DE-101) to the nearest ALTCS office.

Medical services

• Age 65 or older; or

• Blind; or

• Disabled

Send an Application for AHCCCS Health Insurance (AH-001) to the AHCCCS SSI-MAO Office.

Pregnant

Apply at the nearest Department of Economic Security office.

Applying for children

Send an Application for AHCCCS Health Insurance (AH-001) to KidsCare or DES.

Applying for children and parents

• Send an Application for AHCCCS Health Insurance (AH-001) to KidsCare; or

• Apply at the nearest Department of Economic Security Office.

Applying for adults without children

Apply at the nearest Department of Economic Security office.

Help with Medicare costs

Send an Application for AHCCCS Health Insurance (AH-001) to the AHCCCS SSI-MAO Office or to the nearest ALTCS office.

A. Introduction

There are several agencies in the state of Arizona who work with the AHCCCS Administration to provide services and assistance in the eligibility process to AHCCCS customers who are applying for AHCCCS Health Insurance. The other agencies responsible for working with the AHCCCS Administration include:

• The Department of Economic Security (DES);

• The Social Security Administration (SSA);

• The Arizona Department of Health Services (ADHS);

• The Office of Administrative Hearings (OAH); and

• Native American Organizations.

A. Responsibilities

The AHCCCS Administration (AHCCCSA) supervises the planning, implementation, and continued operation of the Arizona Health Care Cost Containment System (AHCCCS).

The responsibilities of the AHCCCSA include:

• Oversight of the AHCCCS health care system;

• Administering some health insurance programs;

• Monitoring and coordinating other agencies, which are responsible for determining eligibility for some AHCCCS health insurance programs;

• Contracting with health plan networks and providers;

• Monitoring the quality of care provided by participating health care providers; and

• Maintaining the state's database of eligible members.

B. Mission

Reaching across Arizona to provide comprehensive, quality health care for those in need. 

C. Vision

Shaping tomorrow's managed health care. . .from today's experience, quality, and innovation.

D. AHCCCS Code of Conduct

• We treat all people with courtesy and respect.

• Our decisions are not made in isolation from each other, or from our business partners.

• We listen, we learn.

• We tell the truth, we are accurate and we are consistent with what we communicate internally and externally.

• We consider all questions valuable.

• We expect each employee to continuously examine our business processes, and to suggest improvements.

• We expect each other to think outside the box, color outside the lines and make an occasional mess.

• We are ethical in all our dealings.

E. AHCCCS Core Values

The AHCCCS core values are:

 Value

Description

Passion

Good health is a fundamental need of everyone. This belief drives us, inspires and energizes our work.

Community

Health care is fundamentally local. We consult and work with, are culturally sensitive to and respond to the unique needs of each community we serve.

Quality

Quality begins as a personal commitment to continual and rigorous improvement, self-examination, and change based on proper data and quality improvement practices.

Respect

Each person with whom we interact deserves our respect. We value ideas for change, and we learn from others.

Accountability

We are personally responsible for our actions and understand the trust our government has placed on us. We plan and forecast as accurately as possible. Solid performance standards measure the integrity of our work. We tell the truth and keep our promises.

Innovation

We embrace change, but accept that not all innovation works as planned. We learn from experience.

Teamwork

Our mission requires good communication among interdependent areas inside and outside the agency. Internally, we team up within and across divisions. Externally, we partner with different customers as appropriate.

Leadership

We lead primarily in two ways: by setting the standards by which other programs can be judged, and by developing and nurturing our own future leaders.

F. Division of Member Services

The largest division within the AHCCCSA is the Division of Member Services (DMS). DMS assists eligible individuals in obtaining health care through eligibility and enrollment processes.

DMS includes:

• Assistant Director's Staff;

• Field Operations Administration (FOA);

• Program Support Administration (PSA);

• Office of Automation;

• Communication and Customer Service Administration;

• Technical Operations and PMMIS Enhancement ; and

• Quality Compliance Administration (QCA).

G. Assistant Director's Staff

The table below describes the sections of the Assistant Director's staff and their functions.

• Oversees, directs and coordinates with DES for Title XIX eligibility policy and Title XXI related issues;
• Coordinates with Social Security for Title XIX SSI-related eligibility issues; and
• Coordinates and prepares areas of law development for the Division of Member Services.

• Oversees the development of the DMS budget and monitors expenditures;
• Coordinates the acquisition and maintenance of facilities; and
• Provides administrative support to special projects.

• Oversees employee relations issues providing direction, guidance and recommendations to division managers and supervisors;
• Identifies administrative (personnel, payroll and employee development0 policies and training needs for the division including developing and delivering training to managers/supervisors and staff;
• Conducts internal and/or grievance investigations, prepares response/recommendations and propose resolutions to Assistant Director;
• Oversees and/or process all personnel actions for the division (new hires, promotions, resignations, terminations, etc);
• Monitors division full-time employee count, develops and implements recruitment and retention strategies; and
• Coordinates HRIS and Hiring Gateway activities for the division.

H. Field Operations Administration (FOA)

The Field Operations Administration (FOA) has ALTCS staff located in 16 field offices statewide and SSI-MAO and KidsCare staff located in Phoenix.

The ALTCS staff determines eligibility for:

• ALTCS;
• Medicare Cost Sharing Programs;
• SSI Non-cash individuals who are ineligible for ALTCS;
• AHCCCS Freedom to Work; and
• Social Security Disability Insurance-Temporary Medical Coverage (SSDI-TMC).

The KidsCare staff determines eligibility for KidsCare.

The SSI-MAO staff determines eligibility for:

• SSI-MAO, including:
• SSI-MAO Specialty Groups
;
• Pickle;
• Disabled Children (DC);
• Disabled Adult Children (DAC); and
• Disabled Widow Widower (DWW).
• Exparte Reviews of Eligibility for Customers who Lose SSI Cash; and
• Federal Emergency Services (FES) under SSI non-cash.
• Medicare Cost Sharing Programs;
• Breast & Cervical Cancer Treatment Program; and
• QI-1 Reapplications.

The AHCCCS Central Screening Unit (CSU) in the FOA receives the Application for AHCCCS Health Insurance from other eligibility offices, providers, and the public. The CSU also retrieves applications from the Health-E-Arizona website. The CSU screens the application and routes the application to the correct eligibility office for an eligibility decision.

I. Program Support Administration (PSA)

The table below describes the sections of the Program Support Administration (PSA) and their function.

Central Office, Program Support Administration and Training

• Develops policy for ALTCS, Medicare Cost Sharing, SSI MAO, KidsCare, and Health Insurance for Parents programs;

• Clarifies policy issues and responds to questions from the AEA and ACEA staff, other AHCCCS divisions, and the public; and

• Produces and maintains eligibility manuals and forms.

• Provides clerical, financial, and medical eligibility training to the AEA and the ACEA staff.

Hearing Coordination

The Eligibility Hearing Coordinator in PSA coordinates and assists the eligibility offices with the hearing process. See MS 1700 for the Hearing Coordinator's responsibilities.

J. Office of Automation

The Office of Automation:

• Provides technical assistance through the Technical Service Center to the AHCCCS Field Operations for all automated systems used in the process of determining eligibility. These systems include:
• KidsCare Eligibility Determination System (KEDS)
• Client Assessment and Tracking System (CATS)
• AHCCCS Customer Eligibility (ACE)
• Completes systems testing;
• Develops and maintains system manuals for the AHCCCS Field Operations staff;
• Participates in new system development; and
• Creates and maintains tables in the ACE, KEDS, and CATS systems.

K. Communication and Customer Service Administration

The Communication and Customer Service Administration:

• Verifies member eligibility status for providers; and
• Oversees enrollment changes.

L. Technical Operations and PMMIS Enhancement

The table below describes the sections of the Technical Operations and PMMIS Enhancement Administration.

Section

Function

Member File Integrity System (MFIS)

• Monitors the AHCCCS recipient database (PMMIS);

• Resolves eligibility and enrollment problems related to data transmission from other agencies; and

• Oversees the Medicare buy-in process.

Technical Operations Production Staff (TOPS)

• Monitors the system on a daily basis;

• Monitors other systems that interface with PMMIS; and

• Reviews reports from the recipient subsystem and health plans.

M. Quality Compliance Administration

The Quality Compliance Administration conducts a process required by Federal / State government to provide an accurate measurement of the accuracy of applications approved and denied for AHCCCS Medical Benefits and ALTCS Programs.  

By reviewing a sample of eligibility determinations, the QCA review process establishes if medical assistance determinations meet the requirements of Federal regulations and waivers, state statutes, the state plan and intergovernmental agreements. Based on the elements of factual eligibility, QCA tracks error and deficiency trends and helps develop a corrective action plan.

The table below describes the sections of the Quality Compliance Administration and their function.

Section

Function

ALTCS

Reviews determinations for long-term care and related SSI-MAO non-cash.

DES

Reviews determinations for all Title XIX programs administered by DES-FAA.

Management Evaluation (ME)

Performs management evaluation reviews of DES eligibility sites to determine whether local office practices and operations contribute to error-free and timely determinations.

Pre-Determination Quality Compliance (PDQC)

Provides investigative services for applications of hospitalized individuals in Maricopa and Pima counties prior to DES determination. Investigations target error prone elements and inconsistent or questionable information.

Multi-Programs (MP)

Reviews determinations for AHCCCS Freedom to Work, Breast and Cervical Cancer Treatment and SSI-MAO non-cash. Assists in the KidsCare Quality Assurance (QA) process.

N. Other AHCCCS Divisions

The table below lists the other divisions within the AHCCCSA and describes their function.

 Division

Function

Office of Strategic Planning & Projects

• Develops the agency's strategic plan and roadmap;

• Conducts agency needs assessment;

• Prioritizes projects;

• Identifies collaborative opportunities; and

• Serves as a liaison with other agencies and stakeholders to further agency objectives.

Office of Intergovernmental Relations

• Functions as the primary liaison with the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicaid and KidsCare programs;

• Responsible for the State Plan, 1115 and HIFA Waivers;

• Coordinates the agency's administrative rules and intergovernmental agreements;

• Monitors and analyzes Federal and State legislation;

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