1604 Written Letters

Policy

The customer must get a written letter on an agency form when any of the following actions occur:

·        An application for AHCCCS Health Insurance is approved or denied;

·        Eligibility is discontinued or changed; or

·        The amount the customer must pay (premiums or share of cost) is changed.

Letters must be sent to the following persons:

·        The customer, unless the customer:

o       Is a dependent child living with a parent, in which case a letter only goes to the parent; or

o       Has a legal representative, in which case a letter only goes to the legal representative;

·        The customer’s legal representative;

·        The customer’s authorized representative, responsible relative, or responsible party unless the customer and representative reside together.

Only send a letter to the customer if the representative resides at the same address as the customer.

1)    Approval Letters

An approval letter must contain the following information:

·        Type of benefit approved;

·        Date eligibility begins;

·        Amount the customer must pay in share of cost or premiums, if applicable; and

·        Date by which a fair hearing must be requested.

NOTE Hospital Presumptive Eligibility (HPE) approval letters do not include a deadline for filing a fair hearing since people applying only for HPE do not get fair hearing rights.

2)    Renewal Letters

A renewal letter must include the following information:

·        The type of benefit approved for renewal;

·        The amount the customer must pay, if applicable;

·        When customer costs or services are changing, the date the change is effective; and

·        The date by which an appeal must be requested.

3)    Denial Letters

A denial letter must include the following information:

Type of benefit denied;

Effective date of the denial;

Reason for the denial.  When the denial is because the person’s income or resources are over the limits, the notice must show how the income or resources were calculated;

·        Legal references that support the denial;

·        Date by which a fair hearing must be requested; and

·        If the application was referred to the Federally Facilitated Marketplace for a decision on other insurance affordability programs, an explanation of the referral.

NOTE Denial letters for Hospital Presumptive Eligibility (HPE) are not required to include the above denial letter information.

4)    Discontinuance Letters

A discontinuance letter must include the following information:

·        The type of benefit(s) discontinued;

·        The effective date of the discontinuance;

·        The reasons benefits are being stopped;

·        How income or resources were calculated when benefits are stopped because income or resources are over the limit;

·        The legal references that support the discontinuance;

·        The date by which an appeal must be requested; and

·        When the application was referred to the Federally Facilitated Marketplace for a decision on other insurance affordability programs, an explanation of the referral.

5)    Change Letters

A change letter must include the following information:

·        The type or level of benefit that is changing or ending, if applicable;

·        The change in the amount of the customer’s share of cost or premium, if applicable;

·        The effective date of the change;

·        The reasons for the change.  When the change is caused by the person’s income or resources, the notice must also show how the income or resources were calculated;

·        The legal references that support the change;

·        The date by which a fair hearing must be requested; and

·        If the customer was referred to the Federally Facilitated Marketplace for a decision on other insurance affordability programs, an explanation of the referral.

Definitions

Timeframes

A change that does not decrease or stop benefits or increase the customer’s costs does not require advance notice.

In most cases, a change to decrease or stop benefits or to increase the customer’s costs is effective on the first day of a future month.  There must be at least 10 days before the first day of the future month to allow for the change letter to be sent in advance.

Exceptions:

A 10-day period before the effective date of the change is not required in the following situations:

Legal Authority