Ariz. Admin. Code § R9-22-1501 - General Information

A. General. The Administration shall determine eligibility for AHCCCS medical coverage for the following applicants or members using the eligibility criteria and requirements in this Article and Article 3:

1. A person who is aged, blind, or disabled and does not receive SSI cash; and

2. A person terminated from the SSI cash program under R9-22-1505.

B. Definitions. In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

"Aged" means a person who is 65 years of age or older as specified in 42 U.S.C. 1382 c(a)(1)(A).

"Blind" means a person who has been determined blind by the Department of Economic Security, Disability Determination Services Administration, under 42 U.S.C. 1382 c(a)(2) and 42 CFR 435.530 as of October 1, 2012, which are incorporated by reference and on file with the Administration, and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW, Washington, DC, 20401. This incorporation by reference contains no future editions or amendments.

"Disabled" means a person who has been determined disabled by the Department of Economic Security, Disability Determination Services Administration, under 42 U.S.C. 1382 c(a)(3)(A) through (E) and 42 CFR 435.540 as of October 1, 2012, which are incorporated by reference and on file with the Administration, and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW, Washington, DC, 20401. This incorporation by reference contains no future editions or amendments.

C. Confidentiality. The Administration shall maintain the confidentiality of an applicant's or member's records and limit the release of safeguarded information under R9-22-512 .

D. Application process.

1. A person may apply for AHCCCS medical coverage by submitting a signed application to any Administration office or outstation location under R9-22-1406 .

2. The provisions in R9-22-1406(B), (C), and (E) apply to this Section.

3. The application date is the date a signed application is received at any Administration office or outstation location approved by the Director.

4. An applicant who files an application may withdraw the application, either orally or in writing. If an applicant withdraws an application, the Administration shall send the applicant a denial notice under subsection (G).

5. Except as provided in 42 CFR 435.911, the Administration shall determine eligibility within 90 days for an applicant applying on the basis of disability and 45 days for all other applicants.

6. If an applicant dies while an application is pending, the Administration shall complete an eligibility determination for the deceased applicant.

7. The Administration shall complete an eligibility determination on an application filed on behalf of a deceased applicant, if the application is filed in the month of the applicant's death.

E. Redetermination of eligibility for a person terminated from the SSI cash program.

1. Continuation of AHCCCS medical coverage. The Administration shall continue AHCCCS medical coverage for a person terminated from the SSI cash program until a redetermination of eligibility under subsection (E)(2) is completed.

2. Coverage group screening. The Administration shall screen a person under any coverage group under A.R.S. §§ 36-2901(6)(a)(i), (ii), (iii), (iv), and (v) and 36-2934 .

3. Eligibility decision.

a. If a person is eligible under this Article or 9 A.A.C. 28, Article 4, the Administration shall send a notice as under subsection (G) informing the applicant that AHCCCS medical coverage is approved.

b. If a person is ineligible, the Administration shall send a notice as under subsection (G) to deny AHCCCS medical coverage.

F. C. Eligibility effective date.

1. Eligibility is effective on the first day of the month that all eligibility requirements are met, including the period described under R9-22-303.

2. The effective date of eligibility for an applicant who moves into Arizona is no sooner than the date Arizona residency is established.

3. The effective date of eligibility for an inmate applying for medical coverage is the date the applicant no longer meets the definition of an inmate of a public institution.

G. Notice for approval or denial. The Administration shall send an applicant a written notice of the decision regarding the application. This notice shall include a statement of the intended action, and: 1. If approved, the notice shall contain the effective date of eligibility.

2. If approved under FESP, the notice shall also contain:

a. The emergency services certification end date,

b. A statement detailing the reason for the denial of full services,

c. The legal authority supporting the decision,

d. Where the legal authority supporting the decision can be found,

e. An explanation of the right to request a hearing, and

f. The date by which a request for hearing shall be received by the Administration.

3. If denied, the notice shall contain:

a. The effective date of the denial;

b. The reason for the denial, including specific financial calculations and the financial eligibility standard, if applicable;

c. Legal authority supporting the decision;

d. Where the legal authority supporting the decision can be found;

e. An explanation of the right to request a hearing; and

f. The date by which a request for hearing shall be received by the Administration.

H. Reporting and verifying changes.

1. An applicant or a member shall report to the Administration the following changes for the applicant or member, the applicant's or member's spouse, and the applicant or member's dependent children:

a. Change of address;

b. Change in the household's members;

c. Change in income;

d. Death;

e. Change in marital status;

f. Change in school attendance;

g. Change in Arizona state residency; and

h. Any other change that may affect the member's or applicant's eligibility.

2. A member shall report to the Administration the following changes:

a. Admission to a penal institution,

b. Change in U.S. citizenship or immigrant status,

c. Receipt of a Social Security number, and

d. Change in first- or third-party liability that may contribute to the payment of all or a portion of the person's medical costs.

3. A person other than a member or an applicant who reports a change to the Administration either orally or in writing shall include the:

a. Name of the affected applicant or member;

b. Description of the change;

c. Date the change occurred;

d. Name of the person reporting the change; and

e. Social Security or case number of the applicant or member, if known.

4. An applicant or a member shall provide verification of changes if requested by the Administration.

5. An applicant or a member shall report anticipated changes in eligibility to the Administration as soon as the person knows that the change will occur.

6. An applicant or a member shall report an unanticipated change to the Administration within 10 days following the date the change occurred.

I. Processing of changes and redeterminations. If a member receives AHCCCS medical coverage under subsection (A), the Administration shall redetermine the member's eligibility at least once every 12 months or more frequently when changes occur that may affect eligibility.

J. Actions that may result from a redetermination or change. In processing a redetermination or change, the Administration shall determine whether there should be:

1. No change in eligibility,

2. Discontinuance of eligibility if a condition of eligibility is no longer met, or

3. A change in the program under which a person receives AHCCCS medical coverage.

K. Notice of discontinuance.

1. Contents of notice. The Administration shall issue a notice when it takes action to discontinue a member's eligibility. The notice shall contain the following information:

a. A statement of the action that is being taken;

b. The effective date of the action;

c. The reason for the discontinuance, including specific financial calculations and the financial eligibility standard if applicable;

d. The legal authority that supports the action proposed by the Administration;

e. Where the legal authority supporting the decision can be found;

f. An explanation of the right to request a hearing; and

g. The date by which a hearing request shall be received by the Administration and the right to continue medical coverage pending appeal.

2. Advance notice of changes in eligibility. Advance notice means a notice of proposed action that is issued to the member at least 10 days before the effective date of the proposed action. Except under subsection (K)(3), the Administration shall issue an advance notice when an adverse action is taken to suspend, reduce or discontinue eligibility.

3. Exceptions from advance notice. The Administration shall issue a notice to a member to discontinue eligibility no later than the effective date of the action if:

a. The member provides to the Administration a clearly written statement, signed by that member, that:

i. Services are no longer wanted; or

ii. Gives information that requires a discontinuance or reduction of services and indicates that the member understands that this is the result of supplying the information;

b. The member provides information to the Administration that requires a discontinuance of eligibility and a member signs a written statement waiving advance notice;

c. The member cannot be located and mail sent to the member's last known address has been returned as undeliverable under 42 CFR 431.213(d) subject to reinstatement of discontinued eligibility;

d. The member has been admitted to a public institution where a member is ineligible for coverage;

e. The member has been approved for Medicaid in another state; or

f. The Administration receives information confirming the death of the member.

L. Request for hearing. An applicant or member may request a hearing under Chapter 34 for any of the following adverse actions:

1. Complete or partial denial of eligibility,

2. Discontinuance or reduction of AHCCCS medical coverage, or

3. Delay in the eligibility determination beyond the time-frames listed in R9-22-1501(D) .

M. Assignment of rights. A person determined eligible assigns rights to all types of medical benefits to which the person is entitled under operation of law under A.R.S. § 36-2903 .

Notes

Ariz. Admin. Code § R9-22-1501

New Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Section repealed; new Section made by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 9 A.A.R. 5123, effective January 3, 2004 (Supp. 03-4). Amended by exempt rulemaking at 10 A.A.R. 23, effective December 9, 2003 (Supp. 03-4). Amended by exempt rulemaking at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-4). Amended by final rulemaking at 11 A.A.R. 4942, effective December 31, 2005 (Supp. 05-4). Amended by final rulemaking at 19 A.A.R. 3309, effective November 30, 2013. Amended by final rulemaking at 20 A.A.R. 193, effective 1/7/2014.