A. Chapter Contents

This chapter contains the following topics:

Topic

501.00    Adoption Subsidy (IV-E)

502.00    Age

503.00    Aged

504.00    Assignment of Rights to Medical Benefits and Cooperation

504.01 Assignment of Rights to Medical Benefits

504.02 Cooperation in Identifying TPL Sources

504.03 Cooperation with CSEA

504.04 Good Cause for Non-Cooperation With CSEA

505.00    Blind

506.00    Cancer (Breast or Cervical) Diagnosis

507.00    Child

508.00    Citizen of the United States

508.01 Definition

508.02 Proof

508.03 Documentation, Related Forms/Notices and System Instructions

509.00    Community Spouse

509.01 Legal Marriage

510.00    Cooperation in Providing Information

511.00    Disabled

512.00    Employed

513.00    Entitled to Title II DAC Payments

514.00    Entitled to Title II DWW Payments

515.00    Foster Care (IV-E)

516.00    Institution for Mental Disease (IMD)

517.00    Insurance Coverage (No Creditable Coverage)

518.00    Interview

519.00    Living Arrangement

519.01 Customer's Home

519.02 Assisted Living Facilities

519.03 ALTCS Acute Care

519.04 Facilities that Become Registered with AHCCCS After the Customer Applies

519.05 Hospitals

520.00    Medicaid (Ineligible For)

521.00    Medicare

522.00    Non-Citizen Status

522.01 Definitions

522.02 Proof

522.03 Additional Information for Lawful Permanent Residents, Parolees, and Battered Aliens

522.04 Verifying the Validity of the USCIS Document Through SAVE

523.00    Not in a Penal Institution

523.01 Arizona Department of Corrections Referrals for Inmate Inpatient Hospitalization

524.00    Potential Benefits

524.01 Selection Payment Frequency Options

524.02 Requesting Maximum Benefit

524.03 Referral for Veterans Benefits

525.00    Pregnant

526.00    Premium Payment

526.01 Premium Payment for Freedom to Work

526.02 Premium Payment for SSDI - Temporary Medical Coverage

527.00    Prior Receipt of SSI Cash

528.00    Receiving Social Security Title II

529.00    Resident of Arizona

529.01 Temporary Absence

529.02 Out of State Placements

530.00    Severe Impairment

531.00    Social Security Number

532.00    SSI Recipient

533.00    Valid Application

B. Introduction

By reading this chapter, for each condition of eligibility you will learn:

• The requirement;

• The programs and corresponding legal authority;

• Definition;

• Required proof;

• Documentation;

• Related forms/notices; and

• System instructions.

A. Requirement

A person who is receiving Title IV-E Adoption Subsidy is deemed to meet the non-financial and financial eligibility requirements for ALTCS except for the medical (MS 1000.00), trust (MS 800.00), and transfer (MS 900.00) requirements.

B. Programs and Legal Authorities

This requirement applies to the following program.

Program

Legal Authorities

ALTCS

42 USC 1396a

42 CFR 435.115

ARS 36-2934

AAC R9-28-401

C. Definition

An adoption subsidy is a payment by a state using federal funding under Title IV-E of the Social Security Act. Eligibility is based on the need of the child prior to the adoption. Although payments are made to the parents, the adoption assistance is counted income to the child (MS 607.01).

D. Proof

Check PMMIS for Title IV-E Adoption Subsidy status. If customer is a current Title IV-E Adoption Subsidy recipient, PMMIS screens RP145 and RP285 will show a current eligibility key code of 260. 

Other proof includes, but is not limited to:

• Copies of check stubs, if Title IV-E funding is specified;

• A letter from the agency providing the income; or

• Collateral contact with the agency providing the income.

Note: If the customer provides proof of Title IV-E Adoption Subsidy payments but PMMIS screens RP145 and RP285 do not show current eligibility key code of 260, contact the Central Office, Program Support Administration for assistance.

E. Documentation

• Place a copy of proof documents or a copy of PMMIS screen RP145 showing eligibility key code of 260 in case record; and

• Document that the customer is a recipient of Title IV-E Adoption Subsidy payments on the Comments window from the Eligibility tab.

F. Related Forms/ Notices

The following forms or notices apply to this requirement:

Form/Notice

Purpose

Part II SSI Cash or Title IV-E Recipient Information Form (DE104)

To provide an SSI cash recipient or Title IV-E Foster Care or Adoption Subsidy recipient with the means of applying for ALTCS.

Title IV-E/ALTCS Redetermination Form (DE-104R)

To request and gather share of cost, demographic, transfer of resources or trust information to renew eligibility for Title IV-E recipients.

Part II SSI-Cash or Title IV-E Recipient Information Supplement (DE-104 Sup)

To capture necessary information required to determine available resources for a person receiving SSI cash or Title IV-E Foster Care or Adoption Subsidy benefits who owns a trust or trust account(s).

G.  System Instructions

Enter Title IV0E adoption subsidy information in ACE under the Identification menu in the Personal Data window on the Eligibility tab.

A. Requirement

The customer must meet an age requirement to qualify for some AHCCCS programs:

Age

Program

Under age 65

Breast & Cervical Cancer Treatment Program

At least age 16, but under age 65

AHCCCS Freedom to Work

Age 50 through 64

Disabled Widow Widower (DWW)

Under age 18

Disabled Child (DC)

Age 18 or older

Disabled Adult Child (DAC)

B. Programs and Legal Authorities

This requirement applies to the following programs:

Program

Legal Authorities

Breast & Cervical Cancer Treatment Program (BCCTP)

42 USC 1396a(a)(10)(A)(ii)(XVIII)

42 USC 1396a as amended by P.L. 106-354

ARS 36-3901.05

AAC R9-22-2003

Freedom to Work (FTW)

42 USC 1396a(a)(10)(A)(ii)(XV)

42 USC 1396a(a)(10)(A)(ii)(XVI)

ARS 36-2929

ARS 36-2950

Disabled Widow Widower (DWW)

42 USC 1383c(d)

AAC R9-22-1505

Disabled Child (DC)

42 U.S.C. 1396a(a)(10)(A)(i)(II)

AAC R9-22-1505

Disabled Adult Child (DAC)

42 USC 1383c(c)

AAC R9-22-1505

C. Definition

An individual attains a given age on the first moment of the day preceding the anniversary of his or her birth. 

A customer meets an age requirement for the full month in which the lower or upper age limit is attained.  

EXAMPLES:

• Ms. A's birthday is May 23. She attained age 16 on May 22^nd and meets the age requirement for AHCCCS Freedom to Work for the entire month of May.

• Ms. B's 50^th birthday is September 1. She attains age 50 on August 31^st and meets the age requirement for a DWW beginning with the month of August.

• Ms. C's 65^th birthday is November 10^th. She meets the age requirement for BCCTP, FTW or DWW for the entire month of November.

D. Proof for BCCTP

Accept the woman's declaration of age on the application unless there is conflicting evidence. 

Conflicting evidence includes, but is not limited to:

• A WTPY response that shows the name and date of birth do not match;

• An INS document that shows a different date of birth; or

• PMMIS record that shows a different date of birth.

When conflicting evidence exists, use the documents in MS 502.00.E to verify the customer's age.

E. Proof for FTW and DWW, DC and DAC

Use any of the following documents which contain the customer's name and date of birth to verify age/date of birth:

• A WTPY when the customer is receiving Title II or Title XIV benefits: If a discrepancy exists between the date of birth listed on the WTPY and the date of birth listed on the customer's birth certificate, the date listed on the birth certificate takes precedence. However, if there is a discrepancy between the date of birth listed on the SSA records (WTPY, etc.) and any document other than a birth certificate, the SSA record takes precedence, provided the customer is in active pay status.

• A Marital Status and Family Profile Document issued by the Navajo Nation, a Tribal Family Census Card issued by the Bureau of Indian Affairs or a Tribal ID Card;

• An original or certified copy of a birth record issued by a U.S. or foreign country, state or local government;

• A religious record established before age 5 that shows age or date of birth;

• A hospital birth record; or

• A notification of birth registration.

If none of the documents above exist, or are not readily available, use any of the following types of documents that are at least one year old and show the customer's name and date of birth:

• Delayed birth record;

• Statement, signed by a physician or midwife who was in attendance at the time of birth, as to the date of the birth shown on the applicant's record;

• Bible or other family record (caution applicant not to remove the page; we must examine the publication);

• U.S. Passport;

• School record;

• Church or other religious record;

• Military record;

• Insurance policy;

• Marriage record;

• Applicant's child's birth certificate showing the applicant's name and age;

• Driver's license;

• State identity card;

• Voter registration card;

• Any other record which shows age or date of birth; for example, hospital treatment record, labor union or fraternal organization record, permits, licenses, poll tax receipts, etc.

F. Documentation

Place a copy of the WTPY response and/or proof documents in the case record. 

If there was any discrepancy related to age that needed to be resolved, document it in the Comments window.

G. Related Forms/ Notices

There are no specific forms related to this eligibility requirement.

H. Program Database Instructions

BCCTP: Enter the customer's date of birth in the BCCTP database. 

FTW: Enter the customer's date of birth in the FTW database.

I. System Instructions

Enter date of birth in ACE under the Identification menu in the Personal Data window on the Demographic tab.

A. Requirement

Age 65 or older is one of the three SSI categorical elements (aged, blind, or disabled) that link a customer to the eligibility methodology used by the SSI program. A customer must be linked to at least one of the three categorical elements in order to meet the conditions of eligibility for the ALTCS or SSI MAO programs.

B. Programs and Legal Authorities

This requirement applies to the following programs:

Program

Legal Authorities

ALTCS

• 42 USC 1396d(a)(iii)

• 20 CFR 404.715, 20 CFR 404.716, 42 CFR 435.520

• ARS 36-2934

• AAC R9-28-402

SSI MAO

• 42 USC 1396d(a)(iii)

• 20 CFR 404.715, 20 CFR 404.716, 42 CFR 435.520

• ARS 36-2934

• AAC R9-22-1505

C. Definition

Aged means a person is age 65 years or older. An individual is considered to be 65 years of age on the first moment of the day before the 65^th anniversary of his or her birth.

EXAMPLE: Mr. C was born on July 22, 1938. He is considered to be age 65 on July 21, 2003.

D. Proof

Use any of the following documents which contain the customer's name and date of birth to verify age/date of birth:

• WTPY: If a discrepancy exists between the date of birth listed on the WTPY and the date of birth listed on the customer's birth certificate, the date listed on the birth certificate takes precedence. However, if there is a discrepancy between the date of birth listed on the SSA records (WTPY, etc.) and any document other than a birth certificate, the SSA record takes precedence, provided the customer is in active pay status.

• A Marital Status and Family Profile Document issued by the Navajo Nation, a Tribal Family Census Card issued by the Bureau of Indian Affairs or a Tribal ID Card;

• An original or certified copy of a birth record issued by a U.S. or foreign country, state or local government;

• A religious record established before age 5 showing age or date of birth;

• A hospital birth record; or

• A notification of birth registration.

If none of the documents above exist, or are not readily available, use any of the following types of documents that show the customer's name and date of birth and are at least one year old:

• Delayed birth record;

• Statement, signed by a physician or midwife who was in attendance at the time of birth, as to the date of the birth shown on the applicant's record;

• Bible or other family record (caution applicant not to remove the page; we must examine the publication);

• U.S. Passport;

• School record;

• Church or other religious record;

• Military record;

• Insurance policy;

• Marriage record;

• Applicant's child's birth certificate showing the applicant's name and age;

• Driver's license;

• State identity card;

• Voter registration card; or

• Any other record which shows age or date of birth; for example, hospital treatment record, labor union or fraternal organization record, permits, licenses, poll tax receipts, etc.

E. Documentation

Place a copy of the WTPY response and/or proof documents in the case file; and 

If there was any discrepancy related to age that needed to be resolved, document it in the Comments window.

F. Related Forms

There are no specific forms related to this eligibility requirement.

G. System Instructions

Enter date of birth in ACE under the Identification menu in the Personal Data window on the Demographic tab.

A. Requirement

Under Arizona law, AHCCCS is the payer of last resort unless specifically prohibited by federal or state laws. Recoveries from third party sources are important to the financial integrity of the AHCCCS program because they reduce overall program costs. Therefore, the customer is required to:

• Assign his or her rights to medical benefits from 1^st and 3^rd party liability sources to the State of Arizona (MS 504.01);

• Cooperate in identifying sources of medical care coverage and providing information to enable AHCCCS to pursue 1^st and 3^rd parties who may be liable to pay for covered services (MS 504.02); and

• Cooperate with the Child Support Enforcement Administration (CSEA) in establishing paternity and obtaining medical care support from an absent parent for legal dependents (MS 504.03).

B. Programs and Legal Authorities

This requirement applies to the following programs. 

Program

Legal Authorities

ALTCS

SSI/MAO

QMB

42 USC 1396k

42 CFR 433.145

42 CFR 433.146

42 CFR 435.610

AAC R9-28-401

AAC R9-29-201

AAC R9-22-1502

A.R.S. 36-2903.F

A. Requirement

The customer is required to assign his or her rights to medical benefits from 1^st and 3^rd party liability sources to the State of Arizona.

B. Definitions

The following definitions apply to this requirement:

Term

Definition

Assignment of rights

The person who signs an AHCCCS application form assigns rights to medical benefits to the State of Arizona on behalf of all applicants.

First party liability

1st-party liability means the resources available from any insurance or other coverage obtained directly or indirectly by a customer that provides benefits directly to the customer and is liable to pay all or part of the expenses for medical services incurred by the Administration, a contractor, or a customer.

Third party liability (TPL)

Third party liability means the responsibility of a person, entity or program to pay for all or a portion of a customer's medical costs from injury, disease or disability.

Third party liability includes:

• Health and dental insurance;

• Proceeds from insurance;

• Proceeds from lawsuits;

• Other medical settlements, claims or benefits; and

• Medical care support for a child from an absent parent (MS 504.03). 

C. Proof

In Arizona, by law, signature of the application assigns rights to medical benefits to the State of Arizona

D. Documentation

The customer or representative's signature on the application is documentation that this requirement has been fulfilled.

E. Related Forms/ Notices

By signing the application forms, the customer is agreeing to cooperate in identifying and assigning all TPL sources. Application forms include:

• The Application for AHCCCS Health Insurance (ACE);

• The Application for AHCCCS Health Insurance (AH-001);

• Request for AHCCCS Long Term Care Services (ACE-101);

• Application for AHCCCS Medical Benefits (DE-101);or

• Application for AHCCCS Medical Services and Medicare Cost Sharing Programs (DE-103)

A. Requirement

The customer or representative is required to cooperate in identifying sources of medical care coverage and providing information to enable AHCCCS to pursue 1^st and 3^rd parties who may be liable to pay for covered services

B. Definition

Cooperation means providing sufficient information about a TPL source to enable AHCCCS to collect payments for covered services.

C. Proof

Proof is giving AHCCCS the information needed to complete the:

• Health Insurance detail window; and/or

• Injury window and detail windows

If the TPL is

Then proof of cooperation is

Medical insurance

Providing the name, address and telephone number of the insurance carrier, the policy number, the name of the policyholder and that person's relationship to the customer, and coverage effective dates.

Accident insurance

Providing specifics regarding the accident to enable completion of the Injury Referral form (DE-124), including:

• The name address and phone number of the individual responsible for damages,

• The name of the insurance carrier, the policy number, and

• The name of the policyholder.

Lawsuit settlement

Providing specifics regarding the accident, claim or settlement including the name, address and telephone number of:

• The customer's attorney; and

• The individual or entity responsible for damages or coverage

D. Documentation

Document information about TPL by:

• Completing the ACE Health Insurance detail window and/or the Injury window.

• Entering any additional information in the Comments window

• Completing an Injury Referral form (DE-124) if appropriate.

E. Related Forms/ Notices

By signing the AHCCCS application forms the customer agrees to cooperate in identifying and assigning of all TPL sources. Other forms may include:

• DE-124 Injury Referral Form; or

• DE-226 Third Party Liability Collateral Contact Form.

F. System Instructions

Enter TPL information in ACE under the Financial menu in the TPL window on the Health Insurance tab.

A. Requirement

The Department of Economic Security (DES), Child Support Enforcement Administration (CSEA), is responsible for medical care support enforcement. When the customer is a minor child, and one or both parents are absent from the child's household, the parent or representative who is applying for AHCCCS on behalf of the child is required to cooperate with the CSEA in:

• Obtaining medical care support or payments from the absent parent; and

• Establishing paternity of the absent parent, if necessary.

This requirement applies when the customer (including a customer who receives SSI Cash) is a child under age 18 (or age 18 when attending school and expecting to graduate by age 19).

B. Refusal to Cooperate

When the child's parent or representative is also an AHCCCS customer, refusal to cooperate with this requirement results in denial or discontinuance of the parent's or representative's AHCCCS eligibility, except when the parent or representative:

• Receives SSI-cash;

• Is under the age of 18 (or age 18 when attending school and expecting to graduate by age 19);

• Is a S.O.B.R.A.-pregnant woman; or

• Establishes good cause for non-cooperation (MS 504.04).

However, the parent or representative's refusal to cooperate in establishing paternity or obtaining medical care support from an absent parent does not affect the child's AHCCCS eligibility. 

EXAMPLE: A 45-year old woman who is receiving QMB applies for ALTCS for her minor child. She refuses to provide any information about the child's absent father and does not claim good cause. The mother's refusal to cooperate does not affect her child's ALTCS eligibility, but results in discontinuance of the mother's QMB benefits.

C. Definitions

The following definitions are related to cooperation with CSEA:

Term

Definition

Medical care support

Medical care support refers to health insurance and other medical support that is or may be available from an absent parent for the medical care of that parent's legal dependents.  

Cooperation

Cooperation means:

• Appearing at an office or court to provide information;

• Appearing as a witness;

• Paying to the state any benefits received from medical care support, health insurance, or other third-party medical coverage; and

• Taking any other reasonable steps to assist in the establishment of paternity and securing of medical support and payments.

Refusal to cooperate

Refusal to cooperate means refusing to identify, give information about, or provide verification of information concerning the absent parent.

D. Proof of Cooperation

The customer provides proof of cooperation by:

• Providing AHCCCS with information about the absent parent and the dependent child that is needed to complete the CSEA Referral and Closure Notice (DE-131).

• Cooperating with CSEA to establish paternity (if necessary) and to obtain medical care support from the absent parent.

E. CSEA Referral

Make a referral to the Child Support Enforcement Agency (CSEA) by completing a CSEA Referral and Closure form (DE-131) and forwarding it to Central Office, Technical Service Center, Mail Drop 2300. Attach copies of the Medicare and Health Insurance windows to each referral. Complete this referral when an appropriate case is opened and again when it is closed. 

EXCEPTIONS: Do not make a CSEA referral when the customer is:

• A child who receives AHCCCS for Families with Children (AFC), TANF cash, or IV-E Foster Care through DES (DES makes the referral).

• A woman in the S.O.B.R.A.-1 coverage group. (These customers do not have to cooperate in establishing paternity or in obtaining medical care support.)

F. Documentation

In the Comments window, enter information documenting:

• Discussion of this requirement with the child's parent or representative;

• Provision of the DE-133; and

• Completion of the DE-131.

File a copy of the DE-131 in the case record.

G. Related Forms/ Notices

The following forms or notices apply to this requirement:

Form/Notice

Purpose

Referral and Closure Notice (DE-131)

To notify the CSEA that:

• A child for whom medical support is required has applied for AHCCCS;

• AHCCCS has been discontinued for a child who was previously referred to CSEA;

• Good cause has been established for a child who was previously referred; or

• Information about the absent parent has changed.

Notice Concerning Good Cause for Refusal to Cooperate (DE-133)

To inform the parent or representative of a minor customer that he or she has the right to refuse to cooperate with the CSEA if a good cause for non-cooperation exists.