A. Chapter Contents

This chapter contains the following topics:

Topic

401.00    AHCCCS Care

402.00    AHCCCS Freedom to Work

403.00    Arizona Long Term Care System (ALTCS)

404.00    Breast and Cervical Cancer Treatment Program (BCCTP)

405.00    Deemed Newborns

406.00    Families with Children

407.00    Health Insurance for Parents

408.00    Healthcare Group

409.00    KidsCare

410.00    Medical Expense Deduction (MED)

411.00    Medicare Cost Sharing (MCS)

412.00    Pregnant Women

413.00    S.O.B.R.A. Child

414.00    SSDI - Temporary Medical Coverage

415.00    SSI Cash

416.00    Supplemental Security Income Medical Assistance Only (SSI MAO)

417.00    Title IV-E Foster Care and Adoption Subsidy

418.00    Young Adults Transitional Insurance (YATI)

B. Introduction

By reading this chapter for each AHCCCS Health Insurance Program and coverage group you will learn:

• Who determines eligibility;

• Conditions of eligibility;

• Service package;

• Enrollment;

• Customer cost;

• Funding source;

• Legal authorities; and

• PMMIS key codes.

A. General Description

AHCCCS Care is for individuals or couples who are not eligible as a family.

B. Who Determines Eligibility?

The Department of Economic Security, Family Assistance Administration, determines eligibility for AHCCCS Care.

The following link will take you to the DES AIMBIG policy manual:
http://www.azdes.gov/faa/policy/default.html

C. Conditions of Eligibility

The conditions of eligibility for AHCCCS Care are:

• Valid application;

• Cooperation in providing information needed for eligibility determination;

• Resident of Arizona;

• Social Security number;

• U.S. citizen or appropriate non-citizen status;

• Not in a penal institution;

• Apply for potential benefits;

• Assignment of rights to medical benefits and cooperation; and

• Income at or below 100% of the FPL.

D. Service Package

Customers eligible for AHCCCS Care receive AHCCCS Medical Services (MS 302.01). 

If the customer meets all eligibility requirements except U.S. citizenship or appropriate non-citizen status, the customer is eligible to receive emergency services only (MS 302.03).

E. Enrollment

Customers approved for coverage under AHCCCS Care are enrolled in an AHCCCS Health Plan (MS 1101.00).  Use the following tables to determine where to refer customers with questions about enrollment.

BEFORE ENROLLMENT...

IF the customer has questions about...

THEN the customer can...

Choosing a Health Plan

• Call the eligibility office where he/she applied;

• Review the AHCCCS Application for Health Insurance (Page D); or

•  Call the AHCCCS Communications Center

Doctors, other providers, or available services

• Call the Health Plans

AFTER ENROLLMENT...

IF the customer has questions about....

THEN the customer can...

Changing a Health Plan

•  Call the AHCCCS Communications Center

Choosing a doctor

• Call the Health Plan

Other providers, or available services

• Call the Health Plan

The AHCCCS Communications Center telephone numbers:

•  If calling from area codes 602, 623, or 480 dial (602) 417-7100

•  If calling from area codes 520 or 928 dial (800) 334-5283

F. Customer Cost

The customer does not pay a premium for AHCCCS Medical Services. However, the customer may be responsible for co-payments for certain services (MS 1205.00).

G. Funding Source

AHCCCS Care is funded by federal and state funds.

Funding Source

Amount Effective 10/01/01

Type of Funds

Center for Medicare and Medicaid Services (CMS)

77.08%

Title XXI

State of Arizona

22.92%

Combination of State General Fund and Tobacco Settlement Funds.

H. Legal Authorities

The table below shows the legal authorities and the references applied to AHCCCS Care eligibility.

Legal Authority

References

1115 Waiver

Arizona Revised Statute (ARS)

Arizona Administrative Code (AAC)

I. PMMIS Key Codes

Listed below are the PMMIS eligibility key codes and descriptions.

Code

Description

463

467

6-Month Guarantee

585

587

927

Emergency Services

930

A. General Description

AHCCCS Freedom to Work (FTW) is for eligible individuals with disabilities who are working.

There are two FTW coverage groups:

• The Basic Coverage Group, and

• The Medically Improved Group.

B. Who Determines Eligibility?

AHCCCS Freedom to Work Eligibility Specialists in the Phoenix South office determine eligibility for Freedom to Work.

General Conditions of Eligibility

The general conditions of eligibility for AHCCCS Health Insurance for both Freedom to Work coverage groups are listed below:

• Valid application (MS 533.00);

• Age: at least age 16, but under age 65 (MS 502.00);

• Cooperation in providing information needed for eligibility determination; (MS 510.00);

• Resident of Arizona (MS 529.00);

• Not in a penal institution (MS 523.00);

• Social Security number (MS 531.00);

• U.S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00);

• Apply for potential benefits (MS 524.00);

• Assignment of rights to medical benefits and cooperation (MS 504.00);

• Monthly countable income under 250% FPL (MS 613.00); and

• Pay the FTW premium (MS 526.00).

In addition, to qualify for the AHCCCS Medical Services Package the customer must also:

• Have too much income to be eligible for all other acute care coverage groups (MS 520.00);

In addition, to qualify for the ALTCS Services Package the customer must also:

• Have too much income or resources to be eligible for ALTCS;

• Be medically in need of long term care services (MS 1000.00);

• Reside in a setting (living arrangement) where long term care services can be provided. (MS 519.00).

D. Basic Coverage Group -Special Conditions of Eligibility

In addition to meeting the general conditions of eligibility for FTW in MS 406.C, a customer must meet the following special conditions to qualify for AHCCCS Health Insurance under the Freedom to Work Basic Coverage Group:

• Disabled (MS 511.00): Disabled means:

·Receiving Social Security Disability (SSD);

·Determined disabled by the Disability Determination Services Administration (DDSA) in a special process that disregards employment earnings and substantial Gainful Employment (SGA); or

·For ALTCS FTW, be determined medically eligible for ALTCS services by the Pre-Admission Screening (PAS).

• Employed (MS 512.00): For the Basic Coverage Group employed means the customer:

·Is working either part-time or full time;

·Is paid for working; and

·Pays Social Security and Medicare taxes either through withholding from wages or by direct payments to the IRS.

E. Medically Improved Coverage Group- Special Conditions of Eligibility

In addition to meeting the general conditions of eligibility for FTW in MS 402.00.C, a customer must meet the following special conditions to qualify for AHCCCS Health Insurance under the Freedom to Work Medically Improved Coverage Group:

• Become ineligible for AHCCCS Health Insurance under the FTW Basic Coverage Group because his or her medical condition has improved to the point where he or she no longer meets the Disability Determination Services Administration's definition of disabled;

• Be employed (MS 512.00): For the Medically Improved Coverage Group employed means:

·Earning at least the federal minimum wage and working at least 40 hours per month, or

·Having gross monthly earnings at least equal to the amount of the federal minimum wage and working 40 hours per month.

On July 24, 2007, the President signed legislation to increase the federal minimum wage in increments in 2007, 2008 and 2009.

• On July 24, 2007, the minimum wage is $5.85 an hour. ($5.85 times 40 hours equals $234.00)
• On July 24, 2008, the minimum wage is $6.55 per hour. ($6.55 times 40 hours equals $262.00)
• On July 24, 2008, the minimum wage is $7.25 per hour. ($7.25 times 40 hours equals $290.00)

• To determine if the customer's earnings meet this requirement use:

·The gross earnings of a wage earner; or

·Gross receipts less business expenses of a self-employed individual.

• Continue to have a medically determinable severe impairment (MS 530.00).

F. Service Package

Customers eligible for Freedom to Work receive AHCCCS Medical Services (MS 302.01). 

Customers, who meet the ALTCS medical eligibility requirements, in addition to the financial and non-financial eligibility requirements, receive an ALTCS services package (MS 302.02). Customers who receive ALTCS services under the FTW coverage groups may qualify for the ALTCS Transitional Program (MS 1000.00). 

A customer who is eligible for AHCCCS Freedom to Work may also be approved for QMB or SLMB, but cannot be eligible for QI-1.

G. Enrollment

Customers approved for coverage under AHCCCS Freedom to Work are enrolled in an AHCCCS Health Plan (MS 1101.00) or Program Contractor for ALTCS (MS 1103.00). Use the following tables to determine where to refer customers with questions about enrollment.

BEFORE ENROLLMENT...

IF the customer has questions about...

THEN the customer can...

Choosing a Health Plan

• Call the eligibility office where he/she applied;

• Review the AHCCCS Application for Health Insurance (Page D); or

•  Call the AHCCCS Communications Center

Doctors, other providers, or available services

• Call the Health Plans

AFTER ENROLLMENT...

IF the customer has questions about....

THEN the customer can...

Changing a Health Plan

•  Call the AHCCCS Communications Center

Choosing a doctor

• Call the Health Plan

Other providers, or available services

• Call the Health Plan

The AHCCCS Communications Center telephone numbers:

•  If calling from area codes 602, 623, or 480 dial (602) 417-7100

•  If calling from area codes 520 or 928 dial (800) 334-5283

H. Customer Cost

Customers who qualify for AHCCCS Medical Services or ALTCS Services under a FTW coverage group may have to pay a premium (MS 1206.00) or Share of Cost (MS 1201.00, 1202.00 and 1203.00.D). Those who pay a premium may also be responsible for certain co-payments (MS 1205.00).

J. Funding source

AHCCCS Freedom to Work is funded by federal and state funds.

Funding Source

Amount Effective 10/01/01

Type of Funds

Center for Medicare and Medicaid Services (CMS)

67.25%

State of Arizona

32.75%

Combination of State General Fund and Tobacco Settlement Funds.

K. Legal Authorities

The table below shows the legal authorities and the references that apply to FTW eligibility.

Legal Authority

References

United States Code

Arizona Revised Statute (ARS)

Arizona Administrative Code (AAC)

L. PMMIS Key Codes

Listed below are the PMMIS eligibility key codes and a description of each.

Code

Description

393

403

482

492

725

735

A. General Description

Arizona Long Term Care System (ALTCS) is a Medicaid program under AHCCCS. ALTCS provides long term care services to financially and medically eligible Arizonans who are elderly, physically disabled or developmentally disabled and have a medical need for long term care services.

B. Who Determines Eligibility?

The Arizona Health Care Cost Containment System Administration (AHCCCSA) determines eligibility for ALTCS.

C. Conditions of Eligibility

The conditions of eligibility for ALTCS are listed in the following chart:

 IF the customer ...

THEN the conditions of eligibility are...

Is receiving or deemed to be receiving SSI Cash (MS 532.00), or is receiving Title IV-E Foster Care (MS 515.00) or Adoption Subsidy (MS 501.00)

• Valid application (MS 533.00);

• Interview, if required (MS 518.00);

• Resident of Arizona (MS 529.00);

• Not in a penal institution (MS 523.00);

• Reside in an appropriate ALTCS living arrangement (MS 519.00)

• Assignment of rights to medical benefits and cooperation (MS 504.00);

• Does not have a trust which causes the resources or income to exceed the limit (MS 800.00); and

• Medical need for LTC (MS 1000.00).

Is not receiving or deemed to be receiving SSI Cash, or is not receiving Title IV-E Foster Care or Adoption Subsidy

• Valid application (MS 533.00);

• Interview, if required (MS 518.00);

• Categorical element (age 65 years or older (MS 503.00), blind (MS 505.00), or disabled (MS 511.00));

• Cooperation in providing information needed for eligibility determination (MS 510.00);

• Resident of Arizona (MS 529.00);

• Social Security number (MS 531.00);

• U. S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00);

• Not in a penal institution (MS 523.00);

• Reside in an appropriate ALTCS living arrangement (MS 519.00)

• Apply for potential benefits (MS 524.00);

• Assignment of rights to medical benefits and cooperation (MS 504.00);

•  Resources (MS 700.00):

· $2000 for individual

· $3,000 for couple

(If the applicant has a spouse living in the community, between $18,552 and $92,760 of the couple's resources may be disregarded);

• Resource Assessment (Community Spouse only ) (MS 709.00);

•  Income (MS 600.00):

· 300% of FBR (MS 616.00.B)

· 100% of FBR (MS 615.00.B); and

• Medical Need for LTC (MS 1000.00).

Is under age 19 or is pregnant; and has resources, which exceed the ALTCS limit

• Valid application (533.00);

• Interview, if required (MS 518.00);

• Categorical element (child (MS 507.00) or pregnant (MS 525.00));

• Cooperate in providing information needed for eligibility determination (MS 510.00);

• Resident of Arizona (MS 529.00);

• Social Security Number (MS 531.00);

• U. S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00);

• Not in a penal institution (MS 523.00);

• Reside in an appropriate ALTCS living arrangement (MS 519.00);

• Apply for potential benefits (MS 524.00);

• Assignment of rights to medical benefits and cooperation (MS 504.00);

• Income: the S.O.B.R.A. child level (MS 615.00.I) or S.O.B.R.A. pregnant women level (MS 615.00.J); and

• Medical Need for LTC (MS 1000.00).

D. Service Package

The type of service package a customer who is eligible for ALTCS receives depends on the customer's living arrangement and/or if the customer has refused HCBS or made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services.

IF the customer ...

THEN the service package is the...

Is residing in a living arrangement in which Long Term Care services can be received (MS 519.00)

Full ALTCS service package (MS 302.02.A.)

Is residing in a living arrangement in which Long Term Care services can not be received (MS 519.03)

Limited ALTCS service package

Refuses the home and community based services offered by the case manager

Has made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services (MS 900.00).

E. Customer Cost

Some ALTCS customers have to pay a share of the cost of their ALTCS health insurance (MS 1201.00). 

F. Enrollment

Customers approved for coverage under ALTCS are enrolled with an ALTCS Program Contractor (MS 1103.00). 

G. Funding Source

ALTCS is funded by federal, state and county monies. 

Funding Source

Amount Effective 10/01/01

Type of Funds

Center for Medicare and Medicaid Services (CMS)

67.25%

State of Arizona

22.75%

State General Fund

County

10%

County Funds

H. Legal Authorities

The table below shows the legal authorities and the references applied to ALTCS eligibility.

Legal Authority

References

United States Code (USC)

Code of Federal Regulations (CFR)

Arizona Revised Statute (ARS)

Arizona Administrative Code (AAC)

I. PMMIS Key Codes

Listed below are the PMMIS eligibility key codes and a description of each.

Code

Description

040

050

060

085

090

100

120

130

140

A. General Description

The Breast & Cervical Cancer Treatment Program (BCCTP) is for women who need treatment for breast cancer, cervical cancer, or a pre-cancerous cervical lesion.

B. Who Determines Eligibility?

The AHCCCS BCCTP Unit, located in the SSI MAO office, determines eligibility for BCCTP.

C. General Conditions of Eligibility

To be eligible for AHCCCS Medical Services (MS 302.01) through the Breast and Cervical Cancer Treatment Program (BCCTP), a woman must meet the following eligibility requirements:

• Valid application (MS 533.00);

• Cooperation in providing information needed for eligibility determination (MS 510.00);

• Screened and diagnosed as needing treatment for breast cancer, cervical cancer or a pre-cancerous cervical lesion by one of the programs in the AZ-NBCCEDP (MS 506.00);

• Under age 65 (MS 502.00);

• Resident of Arizona (MS 529.00);

• Social Security number (MS 531.00);

• U.S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00);

• Not in a penal institution (MS 523.00);

• No creditable insurance or insurance that does not cover treatment of breast and/or cervical cancer (MS 517.00); and

• Ineligible for AHCCCS under all other Title XI