A. Chapter Contents

This chapter contains the following topics:

Topic

1101.00 Enrollment with a Health Plan

1101.01 Health Plan Enrollment Process

1101.02 Newborn Enrollment

1101.03 Guaranteed Enrollment Periods

1101.04 Health Plan Enrollment Changes

1102.00    Fee-for-Service

1103.00    Enrollment with a Program Contractor

1103.01 Program Contractor Enrollment Process

1103.02 DDD Enrollment

1103.03 Native American Enrollment

1103.04 County of Fiscal Responsibility

1103.05 Fiscal County Changes

1104.00    ALTCS Enrollment in a Choice County

1105.00    ALTCS Enrollment Changes

1105.01 Changes That Do Not Require PC Agreement

1105.02 Changes Requiring Program Contractor Agreement

1106.00    ALTCS Enrollment Change Within Maricopa County

1106.01 Annual Enrollment Choice

1106.02 Enrollment Changes Authorized by ALTCS Offices

1106.03 Medical Continuity of Care

1107.00    Disenrollment

B. Introduction

This chapter provides information about:

• Initial enrollment with AHCCCS health plans and ALTCS program contractors;

• Who the AHCCCS health plans and ALTCS program contractors are; and

• How and when a customer may change enrollment.

Based on Arizona's method of service delivery (MS 105.00):

• Most customers who receive AHCCCS Medical Services are enrolled with a health plan; and

• Most customers who receive ALTCS Services are enrolled with a program contractor.

• Customers who are not enrolled with a health plan or program contractor receive AHCCCS services on a fee-for-service basis (MS 1102).

• All babies born to AHCCCS-eligible mothers are deemed eligible for AHCCCS Medical Services and are enrolled with a health plan. MS 405.00 contains additional information about enrollment of newborns.

C. Definitions

The following terms are related to AHCCCS enrollment:

Term

Definition

AHCCCS Health Plan

Health plan means an entity that has a prepaid capitated contract with the AHCCCS Administration pursuant to A.R.S. §36-2904 to provide the AHCCCS Medical Service Package (MS 302.01) to customers either directly or through subcontracts with providers.

Auto-assignment

Auto-assignment means the method used by the AHCCCS Administration to assign customers to the various contractors.

Choice

Choice refers to the customer's right to choose a contractor prior to initial AHCCCS enrollment and the customer's annual opportunity to change contractors.

Contractor

Contractor means either a health plan or a program contractor.

Developmentally Disabled

An individual is considered developmentally disabled when the Division of Developmental Disability (DDD) of the Department of Economic Security determines that the individual has a disability that qualifies the individual for DDD services.  

In general, to be determined developmentally disabled, the individual must:

• Be diagnosed as having autism, cerebral palsy, epilepsy or mental retardation before age 18 and have substantial functional limitations;

• Exhibit a significant delay in one or more areas of development if under age 6; or

• Be under age three and be determined to be at risk of having a developmental disability if supports and services are not provided.

Elderly and Physically Disabled

Elderly and physically disabled refers to ALTCS customers who are not developmentally disabled, but:

• Are age 65 or older; or

• Have been determined medically eligible for ALTCS based on physical disabilities.

Enrollment

Enrollment is the process by which an eligible AHCCCS customer becomes a member of an AHCCCS health plan or an ALTCS program contractor. Enrollment is the process of entering the customer's name on contractor's membership list. Enrollment means the contractor is responsible for providing covered medical services for the customer.

Enrollment in Fee for Service

Enrollment in fee-for-service means the AHCCCS customer is not enrolled with a contractor. The medical providers bill AHCCCS Administration directly for services provided to the customer. Native Americans who choose to receive AHCCCS services through American Indian Health Program (AIHP) are enrolled in AIHP, but the services are paid fee-for-service.

Fee-For-Service

Fee-for-service (FFS) means the AHCCCS Administration directly pays providers, including non-contracting providers for the services provided to the customer instead of paying a capitation to a health plan or program contractor. AHCCCS pays the lesser of the billed charges or the AHCCCS capped fee-for-service rates, unless a different fee is specified by contract between the Administration and the provider, or is otherwise required by law.

Geographic Service Area (GSA)

A geographical service area is an area in the State of Arizona designated by the AHCCCS Administration within which a contractor provides, directly or through a subcontract, a covered health care service to a member enrolled with that contractor

PMMIS

PMMIS, the Pre-Paid Medical Management Information System, is a statewide, automated system that processes and reports on the AHCCCS prepaid capitated cost-containment program and fee-for-service programs.

Prior Period Coverage (PPC)

Prior period coverage refers to the period of time from the effective date of ALTCS eligibility to the day before the approval was transmitted to PMMIS. During prior period coverage:

• The capitation amount paid to the program contractor is less than the amount paid for the ongoing capitation;

• The program contractor can pay medical providers who are AHCCCS providers but are not part of their network;

• The program contractor does not pay for home and community based service expenses incurred in the customer's home or in an alternative HCBS living arrangement.

Program Contractor

Program contractor means the Division of Developmental Disabilities (DDD) or any other entity that contracts with the AHCCCS Administration pursuant to A.R.S.§36-2940 or 36-2944 to provide the range of services included in the ALTCS Service Package (MS 302.02) to customers either directly or through subcontracts with providers.

D. Programs and Legal Authorities

Enrollment with a contractor applies to the following programs:

Program

Legal Authorities

ALTCS

AAC R9-28-412 through R9-28-418

AHCCCS Freedom to Work

AAC R9-22-1921

AAC R9-28-1323

SSI-MAO

AAC R9-22-1701 through R9-22-1704

Breast & Cervical Cancer Treatment

AAC R9-22-2001

E. Enrollment Rights

The customer may grieve an adverse action related to enrollment or provision of services that is taken by a health plan, a program contractor or AHCCCS Administration. Grievance information is in MS 1726.00.

F. Rosters

Daily and monthly enrollment files are produced electronically for each contractor. 

Daily enrollment files include:

• New additions (members) for whom the contractor is responsible.

• Persons newly disenrolled or deceased for whom the contractor is no longer responsible;

• Changes to customers' demographic data such as name, address or date of birth; and

• Share of cost (if applicable) and rate code changes.

Availability of the enrollment files to the contractor is considered legal notification of the contractor's responsibility for providing care to enrolled customers. 

Monthly enrollment files, which are produced three days prior to the end of the month for each contractor, identify the total active population for each contractor as of the first of the next month. They are to be used as reconciliation files by the contractors.

A. Health plan responsibilities

A health plan:

• Provides services as a Managed Care Organization (MCO);

• The MCO contracts with primary care physicians (PCP), specialists, dentists, hospitals, and other ancillary providers to form a network of service providers;

• AHCCCS customers are assigned to primary care physicians. The PCP is responsible for the over all health care of the customer assigned to him/her including but not limited to: supervision, coordination, the referral process for medically necessary specialty care, and maintenance of the customer's medical records.

B. Who are the AHCCCS health plans?

AHCCCS contracts with American Indian Health Program (AIHP) to provide services to Native Americans statewide. 

AHCCCS contracts with Comprehensive Medical/Dental Program (CMDP/DES) to provide services to foster care children statewide. 

AHCCCS awards other health plan contracts by Geographic Service Areas (GSAs) as follows

2

Yuma, LaPaz

4

Apache, Coconino, Mohave, Navajo

6

Yavapai

8

Gila, Pinal

10

Pima, Santa Cruz

12

Maricopa

14

Cochise, Graham, Greenlee

C. AHCCCS health plans

AHCCCS has contracts with the following health plans:

D. When does enrollment occur?

Enrollment begins on the date that eligibility begins. 

EXAMPLE: The SSI MAO Office receives Ms V's application for AHCCCS Medical Services on May 17^th. On June 3^rd an Eligibility Specialist approves her application effective May 1^st. Ms. V is enrolled with the heath plan she selected effective May 1^st. Prior period coverage begins on May 1^st and ends on June 2^nd. Full capitation begins June 3^rd.

E. What happens after enrollment?

Within 10 days of enrollment, the health plan provides the customer with:

• Printed information about the health plan's services and service locations that has been approved for distribution by the AHCCCS Administration.

• The name, address, and telephone number of the member's primary care provider and information on how the member may change primary care providers, if dissatisfied with the primary care provider assigned.

The customer receives an ID card in the mail.

A. Can the customer choose a health plan?

Usually the customer can choose a health plan during the application process. 

• Encourage the customer to choose a health plan before the application is approved.

• The customer must enroll with a health plan that serves the county in which he or she resides. Each Arizona county is served by multiple health plans. 

• Native American customers may choose American Indian Health Program (AIHP) as their health plan. AIHP is an option in all counties. 

• The Application for AHCCCS Health Insurance (AH-001) provides a list of the health plans available in each county and instructions for choosing a health plan. The customer is instructed to indicate a health plan choice on the application.

• The agency responsible for the eligibility determination (AHCCCS, the Social Security Administration, or the Department of Economic Security) offers the customer information concerning AHCCCS health plans.  

EXCEPTION: If the customer was enrolled with an AHCCCS health plan within the 90 days prior to the current approval date, the customer is automatically re-enrolled with the same health plan by the Prepaid Medical Management Information System (PMMIS).

B. Health plan selection

Follow these enrollment procedures when the applicant:

• Has never been enrolled with an AHCCCS health plan; or

• Has been dis-enrolled from an AHCCCS health plan for more than 90 days:

Step

Action

1

Inform the applicant of the opportunity to choose the health plan and the options available in the county. The Application for AHCCCS Health Insurance (AH-001) enrollment choice explains the customer's opportunity to choose a health plan.

Native Americans also have the option of enrolling with American Indian Health Program (AIHP).

2

Obtain an enrollment choice from the applicant. If a health plan choice was not specified on the application form, call the applicant to obtain enrollment choice.

Do not make a recommendation on health plan choices. Instruct the applicant to call the health plan if additional information is requested regarding service providers.

3

Enter the health plan choice in ACE on the Enrollment Choice tab.

4

Document the pre-enrollment action on the comments screen for the Enrollment Choice tab.

C. Auto-assignment to a health plan

A Native American living on-reservation who does not make a choice is enrolled with AIHP. 

Other customers who do not choose a health plan are automatically enrolled in a health plan by PMMIS based on their geographic service area and zip code at the time of approval. ACE allows approval of the case with a blank choice field. A letter (created by PMMIS) is subsequently sent to the customer indicating the health plan assignment.

D. AIHP enrollment

A customer enrolled with Indian Health Service (AIHP) may choose to receive services through AIHP or a Tribal Facility or outside the AIHP network. 

When a medically necessary service is not available through AIHP or a Tribal Facility, AIHP may refer the customer to an AHCCCS fee-for-service provider. All referrals made must be for medically necessary services, which are initiated and approved by AIHP or the Tribal Facility.  

AIHP is responsible for paying for all services the customer receives from AIHP or a Tribal Facility provider, but the fee-for-service providers bill the AHCCCS Administration. 

A. AHCCCS eligibility

A baby born to a mother who is eligible for AHCCCS and enrolled in a health plan is enrolled with a health plan or AIHP, based on the mother's enrollment. 

The newborn is auto-assigned to a health plan when the mother:

• Is not enrolled with a health plan;

• Is enrolled with CMDP; or

• Receives AHCCCS services on a fee-for-service basis..

B. Enrollment choice

AHCCCS Administration notifies the mother of the newborn of her right to choose a different health plan for her baby.

C. Guaranteed enrollment period

Most babies born to AHCCCS eligible mothers are eligible for a guaranteed enrollment period.

A. Introduction

The first time some customers are approved for certain AHCCCS Health Insurance programs, they may qualify for a guaranteed minimum period of AHCCCS eligibility. 

The groups of customers who may qualify for a guaranteed enrollment period are:

• Medicaid customers who receive the AHCCCS Medical Services Package;

• Customers who are approved for KidsCare; and

• Newborns.

The guarantee period is calculated at the time the discontinuance is received by PMMIS. Eligibility for the guaranteed enrollment period is based on the reason the customer became ineligible for the AHCCCS program.

There is no guaranteed enrollment period for customers who receive ALTCS or a Medicare Cost Sharing Program.

B. Medicaid guaranteed enrollment period

The first time a Medicaid customer is approved for AHCCCS Medical Services, the customer is guaranteed six months of AHCCCS eligibility unless the customer:

• Moves out of state;

• Is incarcerated;

• Is adopted; or

• Was ineligible at the time of initial enrollment.

This one-time, six-month guarantee applies to a customer who is approved for the following programs:

• AHCCCS Care (MS 401.00)

• AHCCCS Freedom to Work (MS 402.00)

• Breast & Cervical Cancer Treatment Program (MS 404.00)

• Families with Children (MS 406.00)

• Medical Expense Deduction (MED) (MS 410.00)

• Pregnant Women (MS 412.00)

• S.O.B.R.A. Child (MS 413.00)

• SSI Cash (MS 415.00)

• Supplemental Security Income Medical Assistance Only (SSI MAO) (MS 416.00)

• Title IV-E (MS 417.00)

• Young Adult Transitional Insurance (YATI) (MS 418.00)

C. KidsCare Guaranteed Enrollment Period

The first time a customer is approved for KidsCare, the customer is guaranteed twelve months of AHCCCS eligibility unless the customer:

• Reaches age 19;

• Moves out of state;

• Is incarcerated;

• Is enrolled in a Medicaid category;

• Obtains private or group health coverage;

• Is adopted;

• Is a patient in an institution for mental disease;

• Has whereabouts unknown;

• Does not pay the monthly premium;

• Fails to cooperate; or

• Was ineligible at the time of the initial enrollment.

D. Newborn Guaranteed Enrollment Period

Newborns are guaranteed a 6 or 12 month enrollment period based on the eligibility category of the mother, unless the baby:

• Does not reside with the mother; or

• Does not remain an Arizona resident.

E. AHCCCS FTW

The six-month guarantee applies to a customer who is approved AHCCCS Medical Services under the Basic Coverage Group of AHCCCS Freedom to Work, unless the customer:

•Fails to pay the FTW premiums;

•Moves out-of-state;

•Dies;

•Voluntarily withdraws from the AHCCCS program;

•Is an inmate of a public institution;

•Was factually ineligible when initially enrolled with the health plan; or

•Is adopted.

The customer is billed for premium payments throughout the six-month guarantee period. 

The six-month guarantee does not apply to eligibility for ALTCS services under AHCCCS Freedom to Work.

A. Correcting errors

If you erroneously enroll a customer with the wrong health plan, call the Technical Services Center at (602) 417-4200 to report the correct information.

B. Customer requests

Except for customer requests to correct an agency error, direct all customer requests for a health plan change to the Communications Center:

• Direct telephone requests to (602) 417-7100 or 1-800-962-6690. 

• Direct written requests to MD 3400.

C. Annual enrollment choice

Customers may change enrollment once a year during their anniversary month. 

• The enrollment anniversary month is the month in which the customer was first enrolled with an AHCCCS health plan. 

• If more than one person in a household receives AHCCCS Medical Services, the household's anniversary month is the month in which enrollment occurred for the customer that has been an AHCCCS recipient for the longest time. All customers in the household who want to change health plans may do so at the same time. 

EXCEPTION: Native American customers may change between Indian Health Services (AIHP) and an AHCCCS health plan at any time.

D. Annual enrollment choice process

The DMS Member Services Administration completes the annual enrollment choice process. This is a description of the annual enrollment choice process:

Stage

Description

Information Mailing

Enrollment choice information is mailed to each customer two months prior to his or her anniversary date.

Enrollment Choice Month

The first month after the material is mailed is the enrollment choice month.

• A customer who wishes to change to a different health plan must notify AHCCCS either by mail, by calling the Automated Voice Response Phone System (IVR), or by calling the AHCCCS Communications Center during this month.

• A customer who does not wish to change enrollment does not have to do anything to remain enrolled with the current health plan.

Transitional Month

The second month is the transitional month. During this time AHCCCS notifies both the current health plan and the new health plan of the enrollment change. This allows the health plans adequate time to transfer records and welcome new members.

Change Month

The enrollment change is effective the first day of the third month.

EXAMPLE: On May 1^st: enrollment choice information is mailed to Ms. K giving her opportunity to change health plans effective July 1st. During May Ms. K calls the Communication Center and requests an enrollment change. During June the current health plan transfers her records to the new health plan. On July 1^st she is enrolled with the new health plan.

E. Other enrollment changes

A customer's enrollment may be changed outside the annual enrollment period when:

• The customer moves to a GSA that is not served by the customer's current health plan MS 1101.00.C);

• The change is the result of a grievance procedure: or

• AHCCCS administration approves the change.

A. AHCCCS Medical Services

AHCCCS Medical Services are provided on a fee-for-service basis when the customer:

• Is eligible for Emergency Services;

• Enrolls with American Indian Health Program (AIHP); or

• Has less than 30 days of prospective eligibility.

B. ALTCS

ALTCS services are paid on a fee-for service basis when:

• The customer is eligible for ALTCS services only during the prior period. For example, when the customer dies before ALTCS is approved but is eligible for ALTCS services in the prior period, ALTCS services are paid on a fee-for-service basis.

• The customer is enrolled with a tribal contractor. The tribal contractor receives a capitation payment from AHCCCS to provide case management services to the customer, but medical services are paid on a fee-for-service basis; or

• There is no tribal or EPD program contractor serving the customer's geographical service area.

• The Assistant Director of the Division of Member Services approves (on a case by case basis) fee-for-service payment for long term care services during the prior period for a customer who:

o    Was enrolled with an AHCCCS health plan when ALTCS was approved; and

o    The AHCCCS health plan's responsibility for paying for nursing facility services for a 90-day period per contract year ended prior to the date the ALTCS approval was processed.

A. Program
contractor
responsibilities

The program contractor:

• Provides services through a managed care plan, also known as a Health Maintenance Organization (HMO). 

• Contracts with nursing facilities, HCBS facilities, hospitals, doctors, pharmacies, and other providers to form a network of service providers. 

• Assigns the case manager who, in conjunction with the customer's primary care physician, develops a service plan for the customer. The case manager is responsible for developing the long term care services plan provided through ALTCS.

B. Who are the ALTCS program contractors?

There are three types of organizations that are program contractors:

• The Department of Economic Security (DES/DDD) (MS 1103.02);

• Native American contractors (MS 1103.03); and

• Program contractors for the Elderly and/or Physically Disabled (EPD) that are determined by the customer's county of fiscal responsibility (MS 1103.04). 

AHCCCS currently has contracts with eight program contractors to provide ALTCS services to Elderly and/or physically Disabled (EPD) customers, who are not enrolled with a tribal contractor. The contracts specify which county or counties each program contractor serves.

ALTCS EPD Program Contractor

Counties Served

Bridgeway Health Solutions
1501 W. Fountainhead Corporate Park, Suite 201
Tempe, AZ 85282

866-475-3129

Cochise Health Systems
1415 Melody Lane, Bldg A
P.O. Box 4249
Bisbee, AZ 85603-4249

(520) 432-9600

Toll free 1-800-285-7485

Cochise, Graham & Greenlee

Evercare Select
AZ060-N120
3141 North 3^rd Avenue
Phoenix, AZ 85013

(602) 331-5100

Toll free 1-800-293-0039

Apache, Coconino, Maricopa, Mohave, Navajo

Mercy Care Plan
2800 North Central Ave., Suite 400
Phoenix, AZ 85004

(602) 263-3000

Toll free 1-800-624-3879

Maricopa

Pima Long Term Care
Pima Health System
5055 East Broadway, Suite A-200
Tucson, AZ 85711

(520) 512-5500

Toll free 1-800-423-3801

Pima & Santa Cruz

Pinal/Gila County Long Term Care
P.O. Box 2140
971 North Pinal Parkway
Florence, AZ 85232-2140

(520) 866-6775

Toll free 1-800-831-4213

Gila & Pinal

SCAN Long Term Care
1313 E. Osborn Road, Suite 150
Phoenix, AZ 85014

Toll Free 1-888-540-7226

Yavapai County Long Term Care
Department of Medical Assistance
6717 Second Street, Suite D
Prescott Valley, AZ 86314

(928) 771-3560

Toll free 1-800-850-1020

Yavapai

C. When does ALTCS enrollment occur?

The effective date of ALTCS enrollment is determined by the customer's AHCCCS status on the date of approval.

If the customer is

Then ALTCS enrollment and capitation is

Enrolled with an AHCCCS health plan at the time of approval

Prospective beginning on the date ALTCS approval is posted in PMMIS. The customer is disenrolled from the AHCCCS health plan the day before.

EXCEPTION: If the effective date of ALTCS eligibility is before the date the customer was enrolled with a health plan, the prior period begins on the first day of the ALTCS application (or the first eligible month) and ends on the day before the health plan enrollment began.

EXAMPLE: Mrs. Y applied for ALTCS on March 25^th. In April she was approved for SSI-MAO and was enrolled with a health plan effective April 1^st. On May 7^th her ALTCS application was approved effective March 1^st. Mrs. Y is enrolled with a program contractor on May 7^th and that program contractor is also responsible for prior period coverage from March 1^st through March 31^st. Her health plan enrollment is for the period April 1^st to May 7th.

Not enrolled with an AHCCCS health plan

Retroactive to the effective date of eligibility (prior period coverage).

EXAMPLE: Mr. D applied for ALTCS on January 17^th. On March 3^rd his application was approved effective January 1^st. The prior period begins on January 1^st and ends on March 2nd.

H. What happens after enrollment?

After enrollment occurs:

• The program contractor gives the customer written information about their organization. 

• The customer chooses the doctor he or she prefers as a primary care physician (PCP) from the program contractor's list of participating physicians. If the customer does not choose a PCP, one is assigned. The primary care physician coordinates care and acts as a gatekeeper. If the customer's current doctor is a member of the program contractor's network, the customer does not need to change doctors.

• A case manager assigned by the program contractor contacts the customer and the customer's representative soon after enrollment to establish a service plan that best meets the customer's needs. Input from the customer and the customer's family is encouraged.

• The customer receives an ID card in the mail that includes the name and phone number of the program contractor. The customer presents this ID card whenever medical services are requested or provided (e.g., doctors offices, hospitals, labs and pharmacies).

A. Can the customer choose a program contractor

Only elderly or physically disabled (EPD) customers whose county of fiscal responsibility (MS 1103.04) is Maricopa County may choose their program contractor. (Other fiscal counties do not have multiple program contractors.) 

The Eligibility Specialist determines enrollment for all other ALTCS customers according to the following policies:

• EPD Native Americans with on-reservation status are enrolled with the tribe or Native American Community Health (NACH) if the tribe is not a program contractor.

• All other EPD customers are enrolled with the program contractor that serves their county of fiscal responsibility.

• All developmentally disabled ALTCS customers are enrolled with the Division of Developmental Disabilities (MS 1103.02).