KidsCare Manual
Chapter 100: Program Overview
Table of Contents
100 Program Overview
101 AHCCCS Background Information
102 AHCCCS Administration
103 AHCCCS Program
104 KidsCare Background Information
105 KidsCare Services
106 Individual Rights
This chapter provides background information on AHCCCS, the divisions
within AHCCCS, the different AHCCCS programs, and the KidsCare program.
The Arizona Health Care Cost Containment System (AHCCCS) was established
November 1981 and is funded by State and Federal funds. AHCCCS provides
coverage under Title XIX and Title XXI of the Social Security Act (Medicaid
and KidsCare). AHCCCS also covers indigent persons who can not qualify for
Medicaid or KidsCare under of the state's health care program.
Unlike traditional Medicaid, which pays for services on a fee-for-service
basis, AHCCCS pays a monthly capitation amount to health plans or program
contractors which provide managed health to the enrolled members.
The AHCCCS Administration supervises the planning, implementation, and
continued operation of AHCCCS.
DMS assists eligible individuals in obtaining health care through
eligibility and enrollment processes. DMS is divided into two bureaus (see
Appendix A for the DMS organization chart).
A. Bureau of Eligibility
1. Field Operations consists of 16 ALTCS offices, the KidsCare Office, the
SSI MAO Unit, the QA Unit, and the Medical Eligibility QC Unit. They determine
eligibility for ALTCS, Medicare Cost Sharing, KidsCare, and SSI MAO programs.
The Medical Eligibility QC Unit conducts quality control reviews of medical
eligibility for long term care services.
2. Program Support consists of the Office of Eligibility Training, the
Office of Automation, the Office of Eligibility Policy, and the Office of
Legal Support.
a. The Office of Eligibility Training provides clerical and financial and
medical eligibility training to Field Operations staff.
b. The Office of Automation provides assistance with KEDS, LEDS, and CATS
system problems. They complete system testing and develop and maintain system
manuals.
c. The Office of Eligibility Policy develops policy for ALTCS, Medicare
Cost Sharing, SSI MAO, KidsCare, and the State Funded (County) AHCCCS
programs. They provide technical assistance, clarify policy issues, and
respond to questions for Field Operations staff, the 15 Counties, other AHCCCS
Divisions, and the public. See 102.3 for policy clarification request
procedures.
d. The Office of Legal Support coordinates the appeals process, reviews
trust documents, and provides legal support to Field Operations staff. See
Chapter 1500 for more information about support provided during the hearing
process.
B. Bureau of Member Services
1. Member File Integrity Services (MFIS) maintains the AHCCCS member
database (PMMIS). To request changes to a member's file in PMMIS that can not
be made in KEDS, telephone the Technical Service Center (see forms
instructions for KC-620).
2. The Communications Center enrolls members in health plans and verifies
member eligibility status for providers. The Communications Center also
oversees annual open enrollment changes.
3. The Member Services Unit researches and corrects member eligibility
status and enrollment problems.
4. Technical Operations Production Support (TOPS) monitors the system on a
daily basis. TOPS reviews reports from the subsystem and health plans and
monitors APIS, SDX, and KidsCare system interfaces with PMMIS.
A. The Division of Business and Finance (DBF) develops and monitors the
agency budget and manages agency funds. DBF processes payroll, monitors third
party liability contracts and estate recovery, pays contractors, processes
claims, and oversees purchasing and facility management. DBF also issues and
reviews responses to Requests for Proposals (RFPs) from potential service
providers and contractors for services.
B. The Information Services Division (ISD) develops and maintains all
automation services necessary to support the functions of the agency. ISD
supports the telephone, mainframe, and PC networks.
C. The Office of Legal Assistance (OLA) conducts eligibility appeals and
evidentiary hearings. OLA investigates member, provider and contractor
grievances and makes recommendations to the Director. OLA also reviews,
approves, and oversees grievance procedures adopted by Health Plans, Program
Contractors, and other agencies.
D. The Office of Managed Care (OMC) conducts financial eligibility quality
control reviews, develops and monitors the behavioral health program, monitors
contract performance of health plans and program contractors, and develops
rates for capitated plans and nursing homes. The Member Fraud Investigations
Unit within OMC investigates allegations of fraud or abuse by a KidsCare
recipient.
E. The Office of the Medical Director (OMD) develops medical policy for
acute and long term care programs. OMD oversees utilization and quality
management, case management services reviews, FFS network development, and the
Emergency Services Program.
F. The Office of the Director (OOD) provides policy direction to the agency
and monitors the entire AHCCCS program. OOD also investigates provider fraud
and abuse. The Human Resources Administration is part of the OOD.
G. The Office of Policy Analysis and Coordination (OPAC) functions as
liaison with the Health Care Financing Administration (HCFA), maintains the
state plan, and coordinates federal reviews and waiver submissions. OPAC also
coordinates the agency's administrative rules and intergovernmental agreements
and develops and analyzes Federal and State legislation.
If the manual is unclear or a specific question is not addressed and the
supervisor and manager are unable to answer the question, submit a Policy
Clarification Request (KC-104) to the Office of Eligibility Policy. This
includes questions related to the Medicaid categories screened prior to
KidsCare eligibility.
A. Follow the forms instructions for completing and submitting the Policy
Clarification Request form.
B. Cite the relevant manual sections and submit copies of all relevant
documents.
C. Policy clarifications that are case specific may not be used for other
cases. Submit a PCR for each case to the Office of Eligibility Policy
according to the procedures on the PCR form.
AHCCCS programs consist of Medicaid and the state's health care programs.
Several agencies are responsible for determining eligibility for AHCCCS
programs.
The AHCCCS Administration determines eligibility for the Arizona Long Term
Care System, Medicare Cost Sharing programs, SSI MAO, SSI MAO linked Federal
Emergency Services, and KidsCare.
A. Arizona Long Term Care System (ALTCS)
AHCCCS was expanded by the Arizona State Legislature in 1987 to include the
ALTCS program. ALTCS was effective December, 1988 to serve the developmentally
disabled and January, 1989 for the elderly and physically disabled.
Medically necessary services include acute care, home and community based
services, institutional care, hospice, behavioral health services, and
transitional care. Eligibility requirements include, but are not limited to,
Arizona residency, U.S. citizenship or qualified alien status, Social Security
Number, income at or below 300% of the Federal Benefit Rate (FBR), resources
at or below $2,000, and medical criteria of at risk of being
institutionalized. Approved individuals are enrolled with a program
contractor which is responsible for providing services. Applicants apply at
the ALTCS Local Offices. Re-determinations of eligibility are completed
annually.
B. Medicare Cost Sharing Programs
This group includes Qualified Medicare Beneficiary (QMB), Specified Low
Income Medicare Beneficiaries (SLMB), Qualified Individual-1 (QI-1), Qualified
Individual-2 (QI-2), and Qualified Disabled Working Individuals (QDWI).
Eligibility requirements include, but are not limited to, Arizona residency,
U.S. citizenship or qualified alien status, Social Security Number, income at
or below percentages of the Federal Poverty Level (FPL) varying from 100% to
175%.
To be eligible for the QDWI program, individual resources must be at or below
$4,000, and couple resources must be at or
below $6000. The QMB, SLMB, QI-1, and QI-2 programs do not have resource
requirements.
The QI-1 and QI-2 programs are funded annually by block grants
from the federal government. Recipients of the QI-1 or QI-2 program must
reapply each year for continued benefits. When the block grant funds are depleted,
eligibility cannot be approved for any more applicants.
Applicants apply at
any of the ALTCS offices. Redeterminations of eligibility for the QMB, SLMB,
and QDWI programs are completed annually. Reapplications of the
QI-1 and QI-2 programs are processed by the SSI MAO Unit.
1. The QMB program became effective July, 1989 with the passage of the
Medicare Catastrophic Coverage Act of 1988. QMB covers aged, blind, or
disabled individuals who are entitled to Medicare Part A and have income at or
below 100% of the FPL. QMB benefits are payment of the Part A and Part B
premiums, deductibles and coinsurance.
2. The SLMB program became effective January, 1993 with the passage of the
Omnibus Budget Reconciliation Act. SLMB covers aged, blind or disabled
individuals who receive Medicare Part A, receive or are entitled to Medicare
Part B, and have income greater than 100% but less than or equal to 120% of
the FPL. The only SLMB benefit is payment of the Medicare Part B premium.
3. The QI-1 program became effective July, 1998 with the Balanced Budget
Act of 1997. QI-1 covers aged, blind, or disabled individuals who receive
Medicare Part A and have income greater than 120% but less than or equal to
135% of the FPL. The only QI-1 benefit is payment of the Medicare Part B
premium.
4. The QI-2 program became effective July, 1998 with the Balanced Budget
Act of 1997. QI-2 covers aged, blind, or disabled individuals who receive
Medicare Parts A and B and have income greater than 135% but less than or
equal to 175% of the FPL. The only QI-2 benefit is a single annual payment for
partial reimbursement of the Medicare Part B premium.
5. The QDWI program became effective July, 1990 with the passage of the
Omnibus Budget Reconciliation Act of 1989. QDWI covers individuals who have
lost Title II disability benefits due to earnings, continue to be disabled,
are under the age of 65 and are entitled to enroll in Medicare Part A. The
only QDWI benefit is payment of the Medicare Part A premium.
C. AHCCCS Medical Benefits (SSI MAO) Programs
The AHCCCS SSI MAO Unit determines eligibility for AHCCCS Medical Benefits. This
group includes Disabled Child (DC), Disabled Adult Child (DAC), Disabled
Widow/Widower (DWW), Pickle, SSI Non-Cash, and SSI Prior Quarter. Eligibility
requirements include, but are not limited to, Arizona residency, U.S.
citizenship or qualified alien status, Social Security Number, income at or
below 100% of the FBR, and resources at or below $2,000. SSI Non-Cash does not
have resource requirements. Eligible individuals
are enrolled with an AHCCCS Health Plan.
AHCCCS is required to determine eligibility for ongoing medical benefits
when a member loses SSI cash. This is known as the ExParte process. When a
member loses SSI, continuation of AHCCCS medical assistance is automatically
provided while the SSI MAO Unit determines if the member is eligible for
AHCCCS Medical Benefits or the QMB program, or refers the case to DES for a
determination of eligibility.
1. DC covers children who became ineligible for SSI Cash due to the change
in the definition of childhood disability in Federal Law (The Personal
Responsibility and Work Opportunity Reconciliation Act of 1996). These
children continue to be eligible for medical assistance, until age 18, if they
meet the prior definition of disability in effect August 21, 1996 and the
eligibility criteria for SSI Non-cash.
2. DAC covers individuals who are age 18 and older and receive Title II
benefits as disabled adult children on the basis of blindness or disability
that began before the individual turned 22. These individuals would otherwise
be eligible for SSI Cash except for entitlement to (or an increase in) Title
II benefits. Income eligibility is determined by subtracting the Title II
benefit from the individual's total income and comparing to 100% of the FBR.
An applicant for DAC benefits is also evaluated for the QMB program.
3. DWW covers former SSI Cash recipients who are disabled widows/widowers
(or disabled unremarried divorced spouse) who are at least 50 years old, but
are not yet 65. These individuals would still be eligible for SSI Cash except
for entitlement to (or an increase in) Title II benefits. Eligibility for the
program ends once Medicare Part A coverage begins. Income eligibility is
determined by subtracting the Title II benefit from the individual's total
income and comparing to the income limit.
4. Pickle (named after the bill's sponsor) covers individuals who receive
Title II benefits and who previously received SSI and Title II benefits
concurrently after April 1977. These individuals have lost their SSI coverage
for any reason. Income eligibility is determined by combining the amount of
Title II income received in the year in which SSI was terminated and any other
income received and comparing to the income limit. An applicant for Pickle
benefits is also evaluated for the QMB program.
5. SSI Non-Cash covers aged, blind, or disabled individuals who meet most
SSI requirements but do not receive SSI cash benefits. This includes
individuals who are eligible for SSI of less than $1.00 and, therefore,
ineligible to receive a cash payment, and individuals who receive in-kind
income that makes them income ineligible. SSI Non-Cash uses two different
income tests with different income
deductions and income limits.
6. SSI Cash Prior Quarter covers SSI Cash individuals who received a
covered medical service during the three months prior to the month of
application for SSI Cash. Applicants must have met the eligibility criteria
for SSI Non-Cash during these months. AHCCCS is notified by the Social
Security Administration of potentially eligible individuals.
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SSA determines eligibility for Supplemental Security Income (SSI Cash).
Individuals receiving SSI Cash are automatically eligible for AHCCCS medical
assistance. SSI Cash is available for eligible aged, blind, or disabled
individuals. Eligibility requirements include Arizona residency, U.S.
citizenship or qualified alien status, Social Security Number, income at or
below 100% of FBR, and resources at or below $2,000. Applicants apply at the
Social Security Administration.
The DES Family Assistance Administration (FAA) determines eligibility for
Food Stamps, Temporary Assistance to Needy Families (TANF) and Medical
Assistance Programs. The Medicaid Medical Assistance categories include AHCCCS
for Families with Children (AFC), S.O.B.R.A., Deemed Newborn, Young Adult Transitional Insurance
(YATI), AHCCCS Care, and MED. Eligibility requirements include Arizona
residency, U.S. citizenship or qualified alien status, Social Security Number,
and income and resources at or below the limit for the applicable category.
Applicants apply at the Department of Economic Security. Approved individuals
are enrolled with an AHCCCS Health Plan.
A. Family Medicaid Coverage
AHCCCS for Families with Children (AFC) covers families that include
deprived dependent children. Eligibility is determined based on criteria that
were in effect for the Aid to Families with Dependent Children (AFDC) program
before August 1996. At that time, the Personal Responsibility and Work
Opportunities Reconciliation Act (PRWORA) replaced the AFDC Cash program with
the Temporary Assistance for Needy Families program (TANF) and de-linked the
cash and medical assistance programs, requiring a separate eligibility
determination for each program. Beginning 7/1/01, the AFC income standard is
100% of the FPL. Resources are not considered in the
eligibility determination. The combined income and resources of all family
members are used to determine AFC eligibility for the family as a unit. DES
refers to this category as "1931" after the section of the Social
Security Act that authorizes it.
B. Individual Medicaid Coverage
When a family cannot meet the requirements for AFC because of excess
income, DES determines eligibility for each family member individually.
The income limit for individual coverage is based on the applicant's age
and, if the applicant is pregnant, the number of expected babies. Some or all
of the applicant's income and a portion of the income from the responsible
relatives are totaled and compared to a percentage of the appropriate limit.
The percentage is determined by the number of people whose income is
considered and whether the applicant is pregnant. See 707 for procedures to
determine income eligibility for Medicaid.
1. S.O.B.R.A. (named for the Sixth Omnibus Reconciliation Act which
created the program). In addition to receiving applications directly from the
public, DES receives applications from KidsCare which require
applicants who are potentially eligible for S.O.B.R.A. to be determined
ineligible for S.O.B.R.A. before being approved for KidsCare.
There are two categories of coverage under S.O.B.R.A.
a. The S.O.B.R.A. Pregnant category covers pregnant persons
beginning with any month of pregnancy throughout the 60 day postpartum period.
Income eligibility is based on 140% of the FPL. Resources are not considered
in the eligibility determination. The case is closed at the end of the
postpartum period and eligibility under another category is explored. In
addition to DES, applicants apply at Baby Arizona providers.
b. The S.O.B.R.A. Child category covers children under age 19.
Income eligibility is based on 140% of the FPL for children under age 1, 133%
of the FPL for children age 1-5 and 100% of the FPL for children age 6 or
older . Resources are not considered in the eligibility determination. DES
reviews eligibility every 12 months.
C. AHCCCS Care covers individuals who do not qualify for other
Medicaid programs because they are not linked to any categories (aged, blind,
disabled, child, parent, etc.). Eligibility requirements include, but are not
limited to, Arizona residency and U.S. citizenship or qualified alien status.
Eligibility can be determined for household groups or individuals following
methodologies of either the AFC or individual Medicaid coverage. Eligible
households must have income at or below 100% of the FPL. Resources are not
considered in the eligibility determination.
D. The Medical Expense Deduction (MED) program covers individuals
who do not qualify for other Medicaid programs because of excess income.
Eligibility requirements include, but are not limited to, Arizona residency
and U.S. citizenship or qualified alien status. Eligibility is determined for
household groups. Eligible households must have quarterly income at or below
40% of the FPL for three months after deducting medical bills incurred during
the month before, month of, and/or month after application and not paid by or
the responsibility of someone else. The household liquid resources must be no
more than $5,000 and the total resources no more than $100,000.
E. Newborn Medicaid Coverage
The Deemed Newborn category provides up to one year of medical coverage to
children born to mothers receiving Title XIX medical benefits. Coverage is
provided when the baby remains in Arizona with the mother. Income and
resources are not considered in the eligibility determination, as eligibility
is based on the mother's eligibility when the child is born.
F. The Young Adult Transitional Insurance (YATI) category covers 18,
19, and 20 year olds who are in foster care under the jurisdiction of the
Division of Children, Youth, and Family (DCYF) on their 18th birthday. Income
and resources are not considered in the eligibility determination.
The FES program is available to individuals who, except for failure to meet
citizenship/alien status requirements described in Chapter 500, would
otherwise meet Title XIX eligibility requirements. Individuals are not
enrolled with an AHCCCS Health Plan. They receive only emergency services on a
fee-for-service basis. The SSI MAO Unit determines FES eligibility for
individuals who would otherwise be eligible for SSI MAO linked programs. DES
determines FES eligibility for individuals who would otherwise be eligible for
one of the programs listed in 103.3, except
AHCCCS Care and MED.
The Arizona State Legislature passed legislation in May 1998 implementing
the Title XXI Arizona Children's Health Insurance Program (KidsCare). The
KidsCare program was approved by the Health Care Financing Administration (HCFA)
in September 1998 and became effective November 1, 1998.
The program was designed to decrease the number of children in Arizona who
are uninsured. Applications are processed by the AHCCCS Administration and are
screened for Medicaid eligibility in addition to KidsCare eligibility.
The program is for children under the age of 19 with household income under
the appropriate limit. Resources are not considered in the eligibility
determination.
Eligible children have a choice of an AHCCCS Health Plan in their
Geographic Service Area (GSA). Native Americans also may choose to receive
services through the Indian Health Service (IHS). The child must choose a
Health Plan or IHS before you can approve KidsCare. After approval, children
are enrolled with a provider (See 1001.1).
A. Acute Care
1. Doctor's office visits
2. Specialist care, if necessary
3. Hospital services
4. Pregnancy care
5. Prescriptions and medical supplies
6. Laboratory and X-ray services
7. 24-hour emergency medical care
8. Family planning services
9. Complete physical exams
10. Immunizations
11. Dental screening and treatment
12. Eye exam and glasses
13. Hearing tests and hearing aids
14. Emergency medical transportation
15. Non-emergency transportation.
B. Behavioral Health
Behavioral health services are described as:
1. Inpatient/outpatient mental health services;
2. Inpatient/outpatient substance abuse treatment services; and
3. Residential substance abuse treatment services.
C. Other Services
1. Nursing Care Services (for a maximum of 90 days when the medical
condition of the person indicates that nursing facility services are necessary
to prevent hospitalization)
2. Physical therapy, occupational therapy, and services for individuals
with speech, hearing, and language disorders
3. Hospice Care
4. Home Health Services
A household with children enrolled in KidsCare may be charged a monthly
premium. The premium amount depends on the Income Group's total income and
the number of children enrolled in KidsCare. For more information about
premiums, see Chapter 1100.
Health plans offer health insurance coverage to the parent or legal
guardian of a KidsCare eligible child who is enrolled with an AHCCCS Health
Plan. Family members are notified of this option on the approval notice. The
health plan sets the rates for premiums. A parent or guardian who selects
this coverage pays the entire premium. The health plan is responsible for
enrolling the members and collecting premiums.
Individuals requesting KidsCare or any other AHCCCS Medical program have
the right to:
A. Apply for KidsCare;
B. An equitable determination of eligibility;
C. Not be discriminated against on the basis of race, national origin,
religion, or by reason of handicap;
D. Have information regarding the application for KidsCare treated in a
confidential manner; and
E. Request a hearing because the KidsCare application was denied,
discontinued, or not processed in a reasonable time period.
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