Member FAQ's

• Renewal Process (except ALTCS – see #2 below)

  Before the end of each customer’s eligibility period, AHCCCS and DES use eligibility data from the prior application and the Federal and State Hubs to determine eligibility. If there is enough information available to determine that the customer is still eligible, an approval letter is sent.

  If eligibility cannot be determined using available data or the information indicates that the customer is no longer eligible, the customer must provide information needed to complete the renewal process. The customer is sent a pre-populated renewal form with a Request for Information letter describing the information needed to complete the renewal. Customers who do not provide the requested information by the due date will have their eligibility stopped.

  When a customer is no longer eligible for the program he or she currently is enrolled in, the customer will be screened for eligibility in any other MA program.

  The process is completed through Health-e-Arizona Plus (HEAplus).

• For ALTCS customers, financial and non-financial conditions of eligibility are reviewed by:

  • A face-to-face interview;
  • An interview by phone; or
  • Mail

• Customer Assistance

  If needed, eligibility workers and other staff will help the customer with the renewal process. Customers can also have someone of their choice help them with the renewal process. This includes:

  • Going with the customer to the local office;
  • Helping the customer fill out the application; and
  • Representing the customer

• Customer Cooperation

  Customers and their representatives must cooperate in the renewal process. This includes:

  • Providing information;
  • Reporting changes; and
  • Taking any action needed to qualify for the MA program

• Opportunity to Register to Vote

  The National Voter Registration Act (NVRA) of 1993 and Arizona Revised Statue (ARS) require that public assistance offices provide applicants and customers with an opportunity to register to vote at the time of renewal.

The processing period begins the day after the application date and ends on the date that the decision letter is mailed. For the application to be timely, the letter must be mailed within the processing time frame.

The mailing date is the first business day after the decision has been processed in the system. Letters are printed after close of business on the date of the decision and mailed the following work day.

When the processing period ends on a weekend or holiday, the letters are mailed prior to the weekend or holiday.

Processing Period Extensions

The application processing period may be extended beyond the processing time frame when:

• The customer’s income is over the limit for the application month and the following month, but there is a reasonable expectation that the customer will be income-eligible in the third month;
• When the customer appears to be eligible but documentation from a third-party is needed to make the eligibility determination and the third party has not responded. The customer and eligibility worker must continue to take all actions needed to get the information;
• When a for a Policy Clarification Request (PCR) is needed that will affect the eligibility decision;
• When a Disability Determinations Services Administration (DDSA) decision is pending; or
• When the customer requests more time to get documentation or proof needed for the eligibility decision.

Determination and Eligibility Begin Dates

In general, eligibility for AHCCCS Medical Assistance is determined on a month-by-month basis. A customer may be eligible or ineligible for any specific month.

Rules that affect all programs:

• For a person that moves to Arizona from out-of-state, Medical Assistance eligibility cannot start any earlier than the date of the move to Arizona.
• For a person that has been in jail, prison or another detention facility, Medical Assistance eligibility cannot start any earlier than the date the person no longer meets the definition of an inmate.
• For a newborn child, Medical Assistance eligibility cannot start any earlier than the newborn’s date of birth.

Otherwise, the date eligibility starts varies by program. See the table below:

Difficulty of Care Income Exclusion

Some individuals receive income because they provide personal care or attendant care to an ALTCS (Arizona Long Term Care Services) member who resides in their home. The monies (income) received for providing personal care or attendant care services are NOT counted toward AHCCCS eligibility in some instances.

Income is usually included when determining Medicaid eligibility, however, income earned for providing attendant care or personal care services to an ALTCS member living in the same home is considered a Difficulty of Care payment. Income that meets the conditions of a Difficulty of Care payment is not counted against eligibility for some AHCCCS programs.

AHCCCS uses electronic sources to obtain income information. These sources do not identify income from providing attendant or personal care to an ALTCS member living with the caregiver as difficulty of care payments. Therefore, these payments may not have been excluded in the income calculation.

If you receive Difficulty of Care payments and have been denied or discontinued for being over the income limit, please contact AHCCCS at 602-417-5010 to report this income as Difficulty of Care income.

For tax purposes, if you need to verify that the person you are caring for is enrolled in ALTCS, please contact us by phone or email.
Phone: (602) 417-4230
Toll Free: (855) 842-7619
E-mail: dmpsocaservicedesk@azahcccs.gov

What is Medicare?

Medicare is a Federal health insurance program that is available to most US citizens and legal residents who are:

• Age 65 or over;
• Persons of any age with permanent kidney failure; and
• Certain disabled individuals

There are four parts or benefit packages in the Medicare program.

• Hospital Insurance (Medicare Part A);
• Supplementary Medical Insurance (Medicare Part B);
• Medicare Advantage (Medicare Part C); and
• Medicare Voluntary Prescription Drug Coverage (Medicare Part D).

The local Social Security Administration offices take applications for Medicare and the Part D Extra Help program.

There are three situations when a customer will be automatically enrolled in Medicare Part B

• When an individual is age 65 and receives Social Security or Railroad Retirement benefits, the person is automatically enrolled in Medicare Part A and B beginning with the first day of the month the individual attains age 65.
• When an individual is under age 65 and receives Social Security Disability Insurance or Railroad Retirement disability benefits, enrollment automatically begins effective with the 25th month after the beginning of the receipt of such disability benefits.
• When an individual has end-stage renal disease (ESRD) treated by a kidney transplant or a regular course of dialysis, automatic enrollment is the first month of ESRD eligibility.

Special Enrollment Period for Part B

A beneficiary is eligible for the Part B special enrollment period if:

• The beneficiary or their spouse is currently working, and the beneficiary is covered by a group health plan based on that work; or
• The beneficiary is disabled and the beneficiary or a family member is working, and the beneficiary is covered by a group health plan based on that work.

The beneficiary can enroll in Part B anytime while the beneficiary has group health plan coverage based on current employment or during the 8-month period that begins the month after the employment ends, or the group health plan coverage ends, whichever happens first.

If the beneficiary has COBRA coverage, they must enroll during the 8-month period that begins the month after the employment ends. This Special Enrollment Period does not apply to people with End Stage Renal Disease.

If the beneficiary waited to enroll in Part B because they had health insurance while volunteering outside of the U.S. for a tax exempt organization for at least a year, the beneficiary can enroll during the 6-month period that begins the first month that any one of the following happens:

• The beneficiary is no longer volunteering outside the US;
• The sponsoring organization is no longer tax exempt; or
• The beneficiary no longer has health insurance coverage outside the US.

What does Medicare Part B cover?

• Physician's services;
• Inpatient and outpatient medical services and supplies;
• Physical and speech therapy;
• Consultant care;
• Outpatient hospital care for hospital and medical care;
• Diagnostic procedures;
• Durable medical equipment, prosthetic devices;
• Diabetic self-testing devices; and
• Laboratory tests.

What are Medicare Part B Cost Sharing Responsibilities?

There are three costs associated with Part B coverage:

• A monthly premium;
• A deductible each year before Medicare starts to pay its share; and
• A coinsurance (co-payment) amount a person may be required to pay once their annual deductible has been met.

Beneficiaries are responsible for the “excess charge”. An excess charge is any amount above the allowable charge.

Many persons purchase supplemental or Medigap insurance to protect against excess charges and co-payments.

Some doctors can choose to accept the Medicare allowable charge as payment in full. In other situations, doctors are required to accept the Medicare payment as payment in full.

Example:

Before treating the beneficiary, Medicare-approved providers who agree to accept the Medicare Private Fee-for-Service Plan’s terms and conditions of payment must bill the plan for the beneficiary’s covered health care services.

The Medicare Private Fee-for-Service Plan beneficiary is only required to pay the co-payment or coinsurance amount allowed by the plan for the type(s) of service(s) the beneficiary received from the provider.

However, some Medicare Private Fee-for-Service Plans allow providers to charge the beneficiary up to 15% over the plan’s payment amount for services. This 15% balance billing amount applies to providers who have a written contract with the Medicare Private Fee-for-Service Plan or who have met certain company conditions.

How do Medicare and Medicaid Work Together?

AHCCCS Medical Assistance is a joint Federal and State program that helps pay medical costs for beneficiaries with limited income and resources. What is covered depends on whether a person is a full dual eligible or a deemed dual eligible.

People with Medicaid may get coverage for services that are not fully covered by Medicare. For example, a person may get coverage for nursing home and home health care.

NOTE Prescription drugs are not covered by Medicaid when the customer is entitled to or enrolled in a Medicare Part D plan.

For details on how Medicare and AHCCCS Health Insurance work together see Chapter 200 of the AHCCCS Contractor Operations Manual (ACOM).

State Buy-In and Buy-Out

Medicare beneficiaries are eligible for State buy-in or buy-out depending on their income.

Buy-In:

It normally takes three months after approval of AHCCCS Medicare Savings Program (MSP) benefits or certain Medicaid programs for the Social Security Administration (SSA) to stop taking the Part B premium amount out of the beneficiary's SSA check.

AHCCCS sends notification of approval for buy-ins to CMS on a monthly basis. The file goes to CMS on the 24th or 25th of each month. CMS processes the file and responds the 5th of the following month on the acceptance or rejection of the individual records. This process applies to all determinations made by AHCCCS.

If the buy-in is accepted, the premium change will occur within a one month cycle. Delays usually arise when there is a demographic or other discrepancy between CMS and the AHCCCS Administration. Once the discrepancy has been resolved and the record resubmitted to CMS the following month, the buy-in will be processed.

Once SSA has been notified, the regular SSA check will be increased to repay the beneficiary for the premiums which were deducted after MSP benefits were approved.

The rebate may come in the form of a separate check depending on when the change is processed by SSA or if the individual does not receive Social Security benefits.

Buy-Out:

When the State stops paying the Part B premium and or other costs associated with Medicare, the beneficiary is responsible to pay those costs.

The beneficiary will be notified by AHCCCS in writing stating the date that we will no longer pay the Medicare costs for the beneficiary when the customer is discontinued from a MSP.

AHCCCS sends notification of all buy-outs to CMS on the 24th or 25th of each month.

Since it may take one to three months for the buy-out to be processed, the beneficiary may have two or three month’s premiums withheld from one month’s Social Security benefits when Medicare processes the buy-out.

Medically necessary, cost effective, federally reimbursable medications prescribed by a physician, physician’s assistant, nurse practitioner, dentist or other AHCCCS approved practitioner and dispensed by a licensed AHCCCS registered pharmacy are covered for members. Contractors are required to cover all medically necessary, clinically appropriate, cost effective medications that are federally and state reimbursable.

AHCCCS has developed a list of medications that must be available to all members when medically necessary. The Minimum Referred Prescription Drug List (MRPDL) specifies medications that are available without prior authorization as well as medication that have specific quantity limits, or require step therapy and/or prior authorization prior to dispensing to AHCCCS members. The Contractors’ medications lists shall include these medications and any additional drugs necessary to meet the needs of the Contractor’s specific patient populations. However, please note that the MRPDL is not an all-inclusive list of medications for the AHCCCS FFS and MCO Contractor Health Plans.

The list of covered medications is available for viewing at the link below:

AHCCCS MRPDL

The following are not covered under the AHCCCS Pharmacy Benefit:

• Medication prescribed for the treatment of a sexual or erectile dysfunction, unless prescribed to treat a condition other than a sexual or erectile dysfunction and the medication has been approved by the Food and Drug Administration for the specific condition.
• Medications that are personally dispensed by a physician, dentist or other provider except in geographically remote areas where there is no participating pharmacy or when accessible pharmacies are closed.
• Drugs classified as Drug Efficacy Study Implementation (DESI) drugs by the Food and Drug Administration
• Outpatient medications for members under the Federal Emergency Services Program.
• Medical Marijuana.
• Drugs covered under Medicare Part D for AHCCCS members eligible for Medicare whether or not the member receives Medicare Part D coverage.

AHCCCS covers the following for AHCCCS members who are eligible to receive Medicare:

• Medically necessary barbiturates except those prescribed for the treatment of epilepsy, cancer or a chronic mental health condition, and
• Over-the-counter medications that are not covered as part of the Medicare Part D prescription drug program and meet the requirements described in A, #4 of this Policy may be covered as part of the Contractor’s step therapy program.

Are there copayments required for prescriptions?

For a list of optional and mandatory copayments, please visit What are the Copayments?

Prior Period Coverage

AHCCCS provides Prior Period Coverage for the period of time prior to the Title XIX member’s enrollment with the Contractor during which time the member is eligible for covered services. Prior Period Coverage refers to the time frame from the effective date of AHCCCS eligibility (usually the first day of the month of application) until the date the member is enrolled with the Contractor. Once AHCCCS eligibility is approved, the Contractor receives notification from AHCCCS of the member’s enrollment. Irrespective of the date of the member’s enrollment with the Contractor, the Contractor is responsible for payment of all claims for medically necessary covered services, including behavioral health services and services provided by the Integrated RBHA, received during Prior Period Coverage. Contractors receive a Prior Period Coverage capitation for the cost of Prior Period Coverage.

Services received during Prior Period Coverage are paid by the Contractor. As mentioned above, the time period for Prior Period Coverage is from the effective date of AHCCCS eligibility until the date of enrollment with the Contractor.

Example:

A member submits an AHCCCS application on April 15th, but the application is not approved for eligibility until sometime in May. The date the member is enrolled with the Contractor is shortly after the date of the eligibility determination approving AHCCCS coverage. The member’s AHCCCS eligibility is retroactive to the first day of the month of application even though enrollment with the contractor occurs at a later date. In this example, if the member is approved for coverage and May 10th is the date the member is enrolled with the Contractor, then the member’s AHCCCS eligibility is effective beginning April 1st. The Contractor is responsible for payment of AHCCCS medically necessary covered services retroactive to April 1st.

Prior Quarter Coverage

Prior Quarter Coverage is a different time period from Prior Period Coverage and refers to the timeframe PRIOR to an individual’s month of application for AHCCCS coverage. The dates of eligibility for Prior Period Coverage and Prior Quarter Coverage do NOT overlap. Prior Quarter Coverage is limited to the 3 month time period prior to the month of application.

If a member is determined to qualify for Prior Quarter Coverage, then the AHCCCS Administration (not the Contractor) will provide reimbursement for AHCCCS covered services for up to 3 months PRIOR to the month of application, if the member received AHCCCS covered services during the Prior Quarter Coverage timeframe. Prior Quarter Coverage is limited to the 3 month time period PRIOR to the month of application for any/all of the 3 months in which all AHCCCS eligibility criteria are met and the member has received a Medicaid covered service. The date of enrollment is not a consideration under Prior Quarter Coverage. Under Prior Quarter Coverage, reimbursement of all claims (acute, ALTCS, behavioral health, pharmacy etc.) will be managed through AHCCCS Fee for Service (FFS). Contractors are NOT involved or responsible in paying Prior Quarter Coverage claims

Example:

In using the example above, the member’s effective date of eligibility is April 1st . At the time of eligibility, the member will also be evaluated to see if s/he were Medicaid eligible for the 3 months prior to April: January, February, and March. If the member received AHCCCS covered services during any of the Prior Quarter Coverage months and would have qualified for AHCCCS at the time those services were received, then AHCCCS will reimburse the provider for those services.

To replace a lost AHCCCS member card, members who are enrolled with a health plan should contact their health plan directly.

Find a list of main phone numbers for AHCCCS health care plans.

Members who are NOT enrolled with a health plan should call AHCCCS at 602-417-7000 or 800-962-6690 to obtain a new member card.

What is a Certificate of Creditable Coverage?

A Certificate of Creditable Coverage is a document that proves an individual had health coverage under AHCCCS Health Insurance or KidsCare for the period of time noted on the certificate. Creditable coverage is defined under any of the following types of plans:

• A group health plan
• Medicare Part A or B
• AHCCCS Health Insurance (Medicaid)
• KidsCare (Children's Health Insurance Program)
• Military sponsored health insurance (CHAMPUS)
• Medical care program of the Indian Health Service or tribal organizations
• The federal employees’ health benefits program
• A public health plan (a plan established or maintained by a State, county, or other political subdivision of a State that provides health insurance coverage to individuals)
• A health benefit plan under the Peace Corps Act; or
• A church plan

Why Is This Needed?

A certificate may be needed if an individual:

• Becomes eligible under an employer's group health plan that excludes coverage for certain pre-existing medical conditions
• Obtains coverage under a group health plan that is not affiliated with the employer
• Is buying an individual policy
• Receives medical advice, diagnosis, care or treatment for a condition within the 6-month period prior to enrollment in the new plan

Who Can Get a Certificate?

Any person who received full coverage under AHCCCS within the last 24 months is eligible to receive a Certificate of Creditable Coverage

A non-citizen, who received ONLY emergency services, is not eligible to receive a certificate that certifies full coverage.

How to Get a Certificate?

To receive a Certificate of Coverage, a request must be made to the AHCCCS Administration Office of Client Advocacy Unit either by calling: 602-417-4230 or 855-842-7619 or by email at DMPSOCA@AZAHCCCS.gov.

• Monday through Friday 8 a.m. – 5 p.m. Mountain Standard
• AZ Relay Service for the hearing impaired 1-800-367-8939

The request must include the following:

• First and Last name of person for whom the certificate is requested
• Social Security number or the person's AHCCCS ID number (this can be found on the member's AHCCCS ID Card)
• Date of birth

For your convenience, we offer four ways for you to receive this certificate:

• Email- please provide your email address with your request
• Mail- please provide your mailing address with your request
• Fax- please provide your fax number with your request
• Pick up in person- Schedule your time to pick this up at 801 E Jefferson St Phoenix, AZ 85034

1095-B FAQ