Ariz. Admin. Code § R9-6-404 - Initial Application Process
A. An applicant for initial enrollment in
ADAP or the applicant's representative shall submit to the Department the
following application packet:
1. An
application in a Department-provided format, completed by the applicant or the
applicant's representative, containing:
a. The
applicant's name, date of birth, and gender;
b. Except as provided in subsection
(A)(1)(c), the applicant's residential address and mailing address;
c. If the applicant is in non-permanent
housing, the address of a person that has agreed to receive written
communications for the applicant;
d. If applicable, the address in Arizona to
which the applicant would want drugs to be shipped;
e. If applicable, the name of the applicant's
representative and the mailing address of the applicant's representative, if
different from the applicant's mailing address;
f. Either:
i. The telephone number of the applicant or a
person that has agreed to receive telephone communications for the applicant,
or
ii. An email address for the
applicant;
g. The number
of individuals in the applicant's household that can be claimed on the
applicant's income taxes and the names and ages of the individuals;
h. The names of individuals, other than the
persons specified in subsection (A)(1)(s)(v), with whom the applicant
authorizes the Department to speak about the applicant's enrollment in
ADAP;
i. The applicant's annual
household income;
j. The
applicant's race and ethnicity;
k.
Whether the applicant or an adult in the applicant's household:
i. Is employed;
ii. Is self-employed;
iii. Is receiving regular monetary payments
from a source not specified in subsection (A)(1)(k)(i) or (ii) and, if so, an
identification of the source of the monetary payments; or
iv. Is using a source not specified in
subsections (A)(1)(k)(i) through (iii) or savings to assist the applicant in
obtaining food, water, housing, or clothing for the applicant and if so, an
identification of the source;
l. Whether the applicant is receiving health
insurance coverage from AHCCCS and:
i. If so,
the name of the AHCCCS health plan and the date enrolled; and
ii. If the applicant's eligibility
determination for AHCCCS is pending, the date the application for AHCCCS was
submitted;
m. Whether the
applicant is eligible for Medicare health insurance coverage and, if not, the
date on which the applicant will be eligible for Medicare health insurance
coverage;
n. If the applicant is
eligible for Medicare health insurance coverage, whether:
i. The applicant, or the applicant's
representative has applied for a low-income subsidy for the applicant and, if
so, the date of the application for the low-income subsidy; and
ii. Either:
(1) The applicant or the applicant's
representative has applied for a Medicare drug plan for the applicant and, if
so, the date of the application for the Medicare drug plan; or
(2) The applicant is enrolled in a Medicare
drug plan;
o.
Whether the applicant or the applicant's spouse has or is eligible to enroll in
health insurance coverage other than AHCCCS or Medicare that would pay for
drugs on the ADAP formulary;
p. If
the applicant or the applicant's spouse is eligible to enroll in health
insurance coverage other than Medicare that would pay for drugs on the ADAP
formulary but enrollment is closed, the date the next health insurance
enrollment period begins;
q.
Whether the applicant is eligible to receive benefits from:
i. The Indian Health Service or a clinic
operated by a sovereign tribal nation, or
ii. The Veterans Health
Administration;
r.
Whether the applicant is living in non-permanent housing or is in another
situation in which the applicant's financial records to verify annual household
income, as specified in subsection (A)(6), are not available to the
applicant;
s. A statement by the
applicant or the applicant's representative confirming that the applicant or
the applicant's representative:
i.
Understands that, if the annual household income of the applicant is at an
amount that may make the applicant eligible for enrollment in AHCCCS, the
applicant or the applicant's representative is required to submit to the
Department documentation stating the applicant's status for enrollment in
AHCCCS before the end of the month after the month in which the applicant
applied for ADAP, if not provided to the Department with the
application;
ii. Except as provided
in R9-6-405(E), if
the applicant is eligible for Medicare, understands that the applicant or the
applicant's representative is required to submit to the Department proof of
enrollment in a Medicare drug plan before the end of the month after the month
in which the applicant applied for ADAP, if not provided to the Department with
the application;
iii. Except as
provided in
R9-6-405(E), if
the applicant is eligible for Medicare and the annual household income of the
applicant is less than 175% of the poverty level, understands that the
applicant or the applicant's representative is required to submit to Department
documentation of the applicant's status for a low-income subsidy before the end
of the month after the month in which the applicant applied for ADAP, if not
provided to the Department with the application;
iv. Except as provided in
R9-6-405(E), if
the applicant or the applicant's spouse has or is eligible for health insurance
coverage other than AHCCCS or Medicare, understands that the applicant or the
applicant's representative is required to submit to the Department information
about the health insurance coverage to enable the Department to determine if
the health insurance coverage is inadequate, according to
R9-6-403(4)(b), or
unaffordable, according to
R9-6-403(4)(c),
before the end of the month after the month in which the applicant applied for
ADAP, if not provided to the Department with the application;
v. Grants permission to the Department to
discuss the information provided to the Department under subsection (A) with:
(1) AHCCCS, for the purpose of determining
AHCCCS eligibility;
(2) Medicare
and the Social Security Administration, for the purpose of determining
eligibility for a low-income subsidy and enrollment in a Medicare drug
plan;
(3) The applicant's HIV-care
provider or designee;
(4) The
contract pharmacy or a pharmacy at which the applicant or the applicant's
representative may request a drug through ADAP, to assist with drug
distribution;
(5) Other providers
of services for persons living with HIV that are funded through Ryan
White;
(6) Other providers of
HIV-related services, as applicable to the applicant; and
(7) Any other entity as necessary to
establish eligibility for enrollment in ADAP or assist with drug distribution
to the applicant or payment of prescription co-payment costs;
vi. Understands that the applicant
or the applicant's representative is required to submit to the Department proof
of the applicant's annual household income as part of the application;
and
vii. Understands that the
applicant or the applicant's representative is required to notify the
Department of changes specified in
R9-6-406(A);
t. A statement by the applicant or
the applicant's representative attesting that:
i. To the best of the knowledge and belief of
the applicant or the applicant's representative, the information and documents
provided to the Department in the application packet is accurate and
complete;
ii. The applicant meets
the eligibility criteria specified in
R9-6-403; and
iii. The applicant or applicant's
representative understands that eligibility does not guarantee that the
Department will be able to provide drugs and understands that an individual's
enrollment in ADAP may be terminated as specified in
R9-6-408; and
u. The dated signature of the applicant or
the applicant's representative;
2. The information specified in subsection
(B), completed by the applicant's HIV-care provider in a Department-provided
format;
3. If the annual household
income of the applicant is an amount that may make the applicant eligible for
enrollment in AHCCCS, a copy of documentation from AHCCCS, dated within 60
calendar days before the date of application, stating the status of the
applicant's eligibility for enrollment in AHCCCS;
4. If the applicant is eligible for Medicare,
a copy of valid documentation stating:
a. The
applicant's enrollment in a Medicare drug plan; and
b. If the applicant's annual household income
is at or below 175% of the poverty level, the status of the applicant's
eligibility for a low-income subsidy;
5. If the applicant or the applicant's spouse
has or is eligible for health insurance coverage other than AHCCCS or Medicare:
a. Information about the health insurance
coverage to enable the Department to determine whether the health insurance
coverage is inadequate, according to
R9-6-403(4)(b), or
unaffordable, according to
R9-6-403(4)(c);
and
b. If the applicant has other
health insurance coverage, documentation confirming the health insurance
coverage;
6. Except as
provided in subsection (C), proof of the applicant's annual household income,
including the following items as applicable to the applicant's household:
a. An income tax return submitted by the
applicant for the previous tax year to the U.S. Internal Revenue Service or the
Arizona Department of Revenue;
b.
If an income tax return in subsection (A)(6)(a) is not available, for each job
held by an adult in the household:
i. Paycheck
stubs from within 60 calendar days before the date of application, or
ii. A statement from the employer listing
gross wages for the 30 calendar days before the date of application;
c. If an income tax return in
subsection (A)(6)(a) is not available, from each self-employed adult in the
household, documentation of the net income from self-employment, such as:
i. The Internal Revenue Service Forms 1099
prepared for the previous tax year for the self-employed adult in the
household;
ii. A profit and loss
statement for the self-employed adult's business, covering a period ending no
earlier than three months before the date of application; or
iii. Bank statements from the self-employed
adult's checking and savings accounts, covering a period ending no earlier than
three months before the date of application; and
d. Documentation showing the amount and
source of any regular monetary payments received by an adult in the household
from sources other than those specified in subsection (A)(6)(a) through
subsection (A)(6)(c);
7.
If the applicant or the applicant's representative has stated according to
subsection (A)(1)(k)(iv) that the applicant has no source of regular monetary
payments and is unable to provide any of the documentation specified in
subsection (A)(6), the following, in a Department-provided format, completed
and signed within 30 calendar days before the date of application, containing:
a. Information completed by the applicant or
the applicant's representative stating whether:
i. An adult in the applicant's household
receives money from intermittent work performed by the adult in the household
for which no paycheck stub is received and, if so, the average monthly
earnings, and the adult's occupation;
ii. The applicant is living in non-permanent
housing;
iii. The applicant is
receiving assistance from another individual; and
iv. The applicant has another source of
assistance for obtaining food, water, housing, and clothing, and, if so, an
identification of the source;
b. A statement by the applicant or the
applicant's representative attesting that, to the best of the knowledge and
belief of the applicant or the applicant's representative, the information
submitted under subsection (A)(7)(a) is accurate and complete; and
c. The dated signature of the applicant or
the applicant's representative; and
8. Proof that the applicant is a resident of
Arizona that includes:
a. One of the following
that shows the Arizona residential address specified according to subsection
(A)(1)(b) and the name of the applicant or an adult in the applicant's
household:
i. Documentation issued by a
governmental entity related to the applicant's eligibility for benefits, dated
within 60 calendar days before the date of application;
ii. Valid documentation from the Social
Security Administration or the Department of Veterans Affairs related to the
applicant's eligibility for benefits;
iii. A property tax statement for the most
recent tax year issued by a governmental entity;
iv. A homeowners' association assessment or
fee statement, dated within 60 calendar days before the date of
application;
v. A valid lease
agreement;
vi. A mortgage statement
for the most recent tax year;
vii.
A letter issued by an entity providing non-permanent housing to the applicant,
dated within 30 calendar days before the date of application;
viii. Any document or mail dated within 60
calendar days before the date of application and received by the applicant,
including a utility bill, check stub, or statement of direct deposit issued by
an employer, a bank or credit union statement, a credit card statement, a
mobile telephone company billing statement, a billing statement or receipt from
an HIV-care provider's office, or a document from an insurance
company;
ix. A non-expired Arizona
driver license issued by the Arizona Department of Transportation's Motor
Vehicle Division within the previous 12 months;
x. A non-expired Arizona vehicle registration
issued by the Arizona Department of Transportation's Motor Vehicle Division
within the previous 12 months;
xi.
A non-expired Arizona identification card issued by the Arizona Department of
Transportation's Motor Vehicle Division within the previous 12 months;
or
xii. A tribal enrollment card or
other type of tribal identification; or
b. If the applicant is unable to produce
documentation that satisfies subsection (A)(8)(a), one of the following that
includes the name of the applicant or an adult in the applicant's household and
is dated within 30 calendar days before the date of application:
i. A written statement issued by the
applicant's case manager verifying that the applicant is living in
non-permanent housing and a resident of Arizona;
ii. A written statement issued by the
applicant's case manager indicating that the case manager has conducted a home
visit with the applicant at the Arizona residential address specified according
to subsection (A)(1)(b); or
iii. A
written statement issued by the applicant's HIV-care provider, verifying that
the applicant is a resident of Arizona
9. If the applicant or the
applicant's representative has stated according to subsection (A)(7) that the
applicant receives assistance from another individual, a letter from the
individual to support the statement of the applicant or the applicant's
representative.
B. The HIV-care provider of an applicant for
initial enrollment in ADAP shall provide:
1.
The following information for the applicant in a Department-provided format:
a. The applicant's name;
b. The HIV-care provider's name, business
address, telephone number, email address, fax number, and professional license
number;
c. A statement that the
applicant has been diagnosed with HIV infection;
d. A list of each drug prescribed for the
applicant by the HIV-care provider;
e. A statement by the HIV-care provider
attesting that, to the best of the HIV-care provider's knowledge and belief,
the information provided to the Department as specified in subsection (B) is
accurate and complete; and
f. The
dated signature of the HIV-care provider;
2. Documentation confirming HIV-infection of
the applicant; and
3. A copy of the
most recent laboratory report of a test for viral load and, if available,
CD4-T-lymphocyte count conducted for the applicant.
C. If an applicant or the applicant's
representative stated in subsection (A)(1)(r) that the applicant is in a
situation in which the applicant's financial records to verify annual household
income, as required in subsection (A)(6), are not available to the applicant,
the applicant or the applicant's representative may submit to the Department a
statement describing the applicant's situation and provide whatever
documentation the applicant has available to demonstrate the applicant's annual
household income.
Notes
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