KidsCare Manual

Chapter 800: AHCCCS Health Insurance for Parents

801 General Information

802 Eligibility Requirements

803 Application Process

804 DES Interface

805 Enrollment

806 Premiums

807 Hearings

808 Changes

809 Discontinuances

801 General Information

A. Background Information

AHCCCS received a waiver under the Health Insurance Flexibility and Accountability Demonstration (HIFA) to receive federal funding for:

Parents of KidsCare or S.O.B.R.A. eligible children with family income over 100% FPL and at or below 200% FPL (AHCCCS Health Insurance for Parents); and
Adults over age 18 without dependent children with income at or below 100% FPL (AHCCCS Care).

B. Effective Date

AHCCCS Health Insurance for Parents is effective January 1, 2003.

C. Limited Availability

Federal funding for AHCCCS Health Insurance for Parents is limited. Therefore, we have a limit on the number of parents we can approve. When the limit is reached, the program will be closed and we will deny applications. If the parent is denied eligibility because the program is closed, the parent is not entitled to hearing rights.

802 Eligibility Requirements

A. Eligibility Requirements

The parent must meet the following eligibility requirements:

Be the parent or stepparent of a child who is receiving KidsCare or S.O.B.R.A. coverage (DES determines eligibility for parents of S.O.B.R.A. children. See 804.);
Live with the eligible child (in the KidsCare Income Group or Budgetary Unit) (Chapter 700);
Be willing to pay the monthly premium (806);
Provide or apply for a Social Security Number (207.2);
Arizona residency (Chapter 400);
Not an inmate of a penal institution (Chapter 400);
Not a patient in an Institution for Mental Disease (Chapter 400);
Meet the citizen/non-citizen requirements (Chapter 500);
No group or health insurance coverage (Chapter 600);
No group or health insurance coverage within the last 3 months (waiver of the three month period of ineligibility due to a serious or chronic illness does not apply) (Chapter 600);
Not eligible for the State Employees Health Plan (Chapter 600);
Not be potentially eligible for Medicaid (Chapter 600);
Cooperate with Medicaid requirements (Chapter 200); and
Payment of the premium (premium hardship waivers do not apply).

B. Dual Eligibility

A parent may be eligible for AHCCCS Health Insurance for Parents and have a child eligible for S.O.B.R.A. and a child eligible for KidsCare. In this situation, eligibility as a parent of a KidsCare eligible child takes precedence. Therefore, if a parent is in PMMIS as a S.O.B.R.A. parent and the parent is eligible as a KidsCare parent, approve eligibility. For more information about dual eligibility, see 804.

803 Application Process

A. Valid Application

In addition to the requirements in 202.2.B, for the application to be valid for AHCCCS Health Insurance for Parents, the parent must be willing to pay the premium. If the parent is not willing to pay the premium, do not register the application for the parent in ACE, unless the parent is a Native American. If the parent is not willing to pay the premium, the parent may still be eligible for Medicaid.

B. Required Signatures on the Application

At least one of the child(ren)'s parents applying for AHCCCS Health Insurance for Parents must sign the application.

If no one signed the application, the application will be scanned and registered. However, the application cannot be approved until a valid signature is obtained.

C. Voluntary Withdrawal

The PI may withdraw an application at any time, either in writing or orally. The PI may request withdrawal of the entire application or withdraw the application for a specific applicant. Follow the procedures in 203.4 if the PI wishes to withdraw the application.

D. Willingness to Pay

The Application for AHCCCS Health Insurance includes a question that asks if someone is willing to pay the premium. The household has the option of indicating the willingness to pay the premium for all members of the household, no members of the household, or to list the members of the household for which someone is willing to pay the premium.

IF the...	THEN...
Parent applies using a previous version of the Application for AHCCCS Health Insurance or another application form	Contact the PI to determine if someone is willing to pay the premium. Document the answer by annotating in Fortis and entering ACE Comments, including the name of the person, date, and time. If you are unable to contact the PI, do not consider the application a valid application for AHCCCS Health Insurance for Parents.
Willingness to pay question is left blank	Contact the PI to determine if someone is willing to pay the premium. Document the answer by annotating in Fortis and entering ACE Comments, including the name of the person, date, and time. If you are unable to contact the PI, do not consider the application a valid application for AHCCCS Health Insurance for Parents.
PI indicates that no one is willing to pay the premium for a child	Register the application in ACE. Determine eligibility and the premium amount for the child. If the child is eligible for KidsCare with no premium, approve KidsCare. Refer to DES if potentially Medicaid eligible. If the child is eligible for KidsCare with a premium, or is ineligible for KidsCare, and is not potentially Medicaid eligible, deny the application for Not Willing to Pay the Premium (UP) and deny Medicaid using the appropriate Medicaid denial reason. If the child is eligible for KidsCare with a premium and is potentially Medicaid eligible, refer the application to DES. Do not approve KidsCare.
PI indicates that no one is willing to pay the premium for a parent	Do not consider the parent an applicant for AHCCCS Health Insurance for Parents.
PI indicates that someone is willing to pay the premium for a child	Register the application in ACE. Determine eligibility and the premium amount for the child. If the child is eligible for KidsCare with a premium and is potentially Medicaid eligible, approve KidsCare and refer the application to DES.
PI indicates that someone is willing to pay the premium for a parent	Register the application in ACE. Determine eligibility and the premium amount for the parent. If the parent is potentially Medicaid eligible, deny or discontinue AHCCCS Health Insurance for parents and refer the application to DES. Do not approve AHCCCS Health Insurance for Parents.

E. Screening for Potential Medicaid Eligibility

Because the parent must not be potentially eligible for Medicaid, KidsCare must screen for potential Medicaid eligibility. At the time of disposition, ACE automatically refers the parent's application to DES through the TIPS process when the income worksheet shows the parent is potentially eligible for Medicaid. Deny or discontinue AHCCCS Health Insurance for Parents using the reason, "Potentially Medicaid".

804 DES Interface

A. Eligibility for Parents of S.O.B.R.A. Eligible Children

DES is responsible for determining eligibility for parents of S.O.B.R.A. eligible children. DES uses the same criteria and income group as KidsCare when determining eligibility for AHCCCS Health Insurance for Parents. However, because DES is unaware of bad debt, other Medicaid eligibility, and program availability, AHCCCS is responsible for making the final determination of eligibility.

B. Interface-Approvals/Denials

The following is an overview of the AHCCCS Health Insurance for Parents DES interface process. DES sends information daily to ACE through the TIPS interface (Chapter 900). Refer to the KidsCare ACE Procedures Manual TIPS Chapter for specific information about the DES to AHCCCS referral process.

Stage	Description
1	DES sends the following information for the parent to AHCCCS daily: AZTECS Case Number; Parent's name; Parent's AZTECS Client ID; Social Security Number; Date of Birth; Gender Address; FPL threshold (150%, 175%, or 200%); and The number of members of the income group.
2	AHCCCS updates ACE with the information.
	IF the name, date of birth, gender, and Social Security Numberâ€¦	THEN ACEâ€¦
	Match an existing case	Updates the existing case with the new address. The parent is listed in ACE as a KidsCare parent. ACE retains the S.O.B.R.A. parent information for possible future use.
	Do not match an existing case	Registers a new application.
	Partially match an existing case (e.g., last name, date of birth, and social match, but the first name does not)	Does not update an existing case. The Tech Service staff research ACE records and either match to an existing case or manually create the ACE record, as needed.
3	ACE searches DBF system to identify unpaid premiums.
	IF unpaid premiums...	THEN ACE...
	Exist	Generates the Notice to Pay Past Due Premiums; Checks DBF daily to determine if premium paid; If not paid by the 30th day, denies eligibility; and If paid, continues to Step 4.
	Do not exist	Continues to Step 4.
4	ACE searches PMMIS to determine if the individual is currently covered by Medicaid. ACE takes the following action:
	IF...	THEN ACE...
	Covered by Medicaid with no end date in PMMIS	Denies eligibility; and Sends a denial notice.
	Covered by Medicaid with an end date in PMMIS	Continues to Step 5.
	Not Covered by Medicaid	Continues to Step 5.
5	ACE searches PMMIS to determine if the program is available.
	IF the program is...	THEN ACE...
	Not available	Denies eligibility; and Sends a denial notice.
	Available	Approves eligibility using: The month following the month Medicaid coverage ends in PMMIS; or The effective date DES sends on the interface. Sends an approval notice.
6	If ACE denies the eligibility due to unpaid premiums, Medicaid eligibility, or program not available, ACE sends back the denial reason to DES through the TIPS process to update AZTECS.

C. Interface Discontinuances

If DES discontinues eligibility for a parent of a S.O.B.R.A. child, DES sends the following information to ACE on the TIPS interface:

Parent's name;
Parent's AZTECS Person ID#;
Discontinuance effective date;
Reason for discontinuance; and
Gross total household income and the number of individuals in the income group if the reason for denial is excess income.

ACE discontinues eligibility and sends the discontinuance notice.

805 Enrollment

A. Enrollment

Parents approved for AHCCCS Health Insurance for Parents are enrolled in an AHCCCS Health Plan. The parent is not required to choose a health plan prior to approval. If no health plan choice is made, Recipient automatically enrolls the parent in a health plan according to Title XIX enrollment rules.

B. Newborns

Newborns born to parents enrolled in AHCCCS Health Insurance for Parents are automatically eligible. The process for enrolling newborns depends on whether the parent is a parent of a KidsCare or S.O.B.R.A. child.

IF the parent is the parent of a...	THEN...
KidsCare child	The Communications Center places the newborn in the KidsCare Parent Deemed Newborn eligibility key code; The Communications Center notifies the Technical Service Center; The Technical Service Center notifies KidsCare; and KidsCare adds the child to the case and determines eligibility for the newborn and the remaining children and parents.
S.O.B.R.A.	The Communications Center places the newborn in S.O.B.R.A. Parent Deemed Newborn eligibility key code; and AHCCCS includes the deemed newborn on the daily deemed newborn interface to DES.

C. Guarantee Period

There is no guarantee period for AHCCCS Health Insurance for Parents.

D. Eligibility Codes

The eligibility key codes for AHCCCS Health Insurance for Parents are:

Key Code	Description
327	Parent of a KidsCare Eligible Child
325	Parent of a S.O.B.R.A. Eligible Child
359	Newborn of a KidsCare Parent
447	Newborn of a S.O.B.R.A. Parent

806 Premiums

A. Overview

All parents approved for AHCCCS Health Insurance for Parents (except Native Americans and Alaska Natives) must pay a premium.

B. Premium Amounts

The premium amounts become a "family" premium when a parent is approved for AHCCCS Health Insurance for Parents. The family amount is for parents and children based on a percentage of the gross family income shown below:

FPL	Premium Amount for Families
Less than or equal to 150%	3% of the gross family income
More than 150 but less than or equal to 175%	4% of the gross family income
More than 175 but less than or equal to 200%	5% of the gross family income

C. Premium Billing Process

See Chapter 1100 for more information about premiums.

807 Hearings

A. Overview

AHCCCS is responsible for attending the hearings for:

KidsCare parent denials, discontinuances, and changes in premiums;
S.O.B.R.A. parent denials for non-payment of the premium and receipt of Medicaid;
S.O.B.R.A. parent changes in premiums; and
S.O.B.R.A. parent discontinuances for all reasons.

B. Pre-Payment of the Premium

Like KidsCare, the parent must pay a month's premium in advance to continue benefits during the appeal process.

C. Process

Follow the processes in Chapter 1500. We are currently working on developing a communication plan with DES to obtain the S.O.B.R.A. parent eligibility information needed to complete the hearing packet.

808 Changes

A. Changes Reported to AHCCCS

If the Communications Center or MFIS receives a report of a change for a parent of an eligible child, which has not already been updated, they will report the changes to either KidsCare or DES for action. Types of changes reported are:

Death;
Incarceration;
Potential health insurance;
Move out of state;
Address change;
Voluntary discontinuance; and
Loss of contact (returned AHCCCS ID cards).

B. KidsCare Parent

Process changes for a KidsCare parent using the procedures in Chapter 1200.

C. S.O.B.R.A. Parent

If you receive a report of a change and the parent is only eligible as a S.O.B.R.A. parent, tell the parent to contact their DES eligibility specialist. DES is the agency responsible for processing any changes that may affect eligibility for the S.O.B.R.A. parent.

809 Discontinuances

A. KidsCare Parent

Process discontinuances for a KidsCare parent using the procedures in Chapter 1200.

B. S.O.B.R.A. Parent

ACE discontinues eligibility and generates the discontinuance notice for a parent of a S.O.B.R.A. eligible child if the parent:

Does not pay the premium; or
Is approved for Medicaid.

ACE also discontinues eligibility and generates the discontinuance notice for a parent of a S.O.B.R.A. eligible child if DES sends the termination information on the DES interface.

C. Dual Discontinuance

Because ACE retains the S.O.B.R.A. parent eligibility information in addition to the KidsCare parent eligibility information, if you discontinue the KidsCare parent eligibility, the parent might remain eligible as a S.O.B.R.A. parent. The chart below describes the circumstances when both S.O.B.R.A. and KidsCare parent eligibility is discontinued.

IF...	THEN ACE...
KidsCare discontinues KidsCare parent eligibility for: Citizenship/Non-Citizen status; Non-payment of premium; Eligibility for Medicaid; Moved out of state; Death; Incarceration; Residing in an IMD; Voluntary discontinuance; Health insurance; Eligibility for State Employee Health Insurance; or Loss of Contact	Discontinues the S.O.B.R.A. parent eligibility; Generates the discontinuance notice; and Sends the discontinuance information to DES through the TIPS interface.
KidsCare discontinues KidsCare parent eligibility for excess income	Does not discontinue the S.O.B.R.A. parent eligibility; and ACE sends the disposition information to DES through the TIPS process.
DES discontinues S.O.B.R.A. parent eligibility for: Moved out of state; Death; Incarceration; Voluntary discontinuance; Health insurance; or Eligibility for State Employee Health Insurance.	Discontinues the KidsCare parent eligibility; and Generates the discontinuance notice.
DES discontinues S.O.B.R.A. parent eligibility for any other reason	Does not discontinue the KidsCare parent eligibility; and Tech Service Center works with the KidsCare Specialty unit, as needed, to reevaluate KidsCare eligibility.

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