Ariz. Admin. Code § R9-6-405 - Enrollment Process; Pre-approved Enrollment Status
A. The Department shall:
1. Review the documents submitted by an
applicant as required in
R9-6-404(A);
2. Determine whether the applicant is
eligible under
R9-6-403;
3. Grant or deny enrollment based on
applicant eligibility, the date of application, and the availability of funds;
and
4. Notify the applicant or the
applicant's representative of the Department's decision within five working
days after receiving the documents specified in
R9-6-404(A).
B. An applicant or the applicant's
representative shall execute any consent forms or releases of information
necessary for the Department to verify eligibility.
C. The Department shall send an applicant or
the applicant's representative a written notice of denial, setting forth the
information required under A.R.S. §
41-1092.03,
if:
1. The applicant does not qualify for
enrollment in ADAP, based on the documentation provided to establish
eligibility;
2. The documentation
submitted to the Department under R9-6-404 is found to contain false
information; or
3. The Department
does not have funds available to enroll the applicant in ADAP.
D. The Department shall grant
pre-approved enrollment status in ADAP to an applicant, lasting until the end
of the month after the month in which an applicant applied for ADAP, if:
1. The Department determines that the
applicant meets the requirement in
R9-6-403(1);
2. The applicant, whose annual
household income is an amount that may make the applicant eligible for
enrollment in AHCCCS, or the applicant's representative attests in writing that
the applicant has applied for AHCCCS enrollment but is unable to provide
documentation that 6-403 states the status of the applicant's enrollment in
AHCCCS;
3. Except as provided in
subsection (E), the applicant, who is eligible for Medicare or other health
insurance coverage, or the applicant's representative attests in writing that
the applicant has applied for, but is unable to provide documentation of,
enrollment in Medicare and a Medicare drug plan or in other health insurance
coverage, as applicable; and
4. The
applicant or the applicant's representative attests in writing that the
applicant or the applicant's representative will provide, before the end of the
period during which the applicant has pre-approved enrollment status, a missing
component of:
a. Proof of the applicant's
annual household income, according to
R9-6-404(A)(6) or
(7); or
b. Proof of residency, according to
R9-6-404(A)(8).
E. The Department shall grant pre-approved
enrollment status in ADAP, lasting until the end of the month after the month
in which an applicant may apply for Medicare or other health insurance, if the
applicant or the applicant's representative provides documentation that the
applicant would be eligible for Medicare or other health insurance coverage
during the next health insurance enrollment period, but that enrollment was
closed on the date of application for ADAP.
H. The Department may grant an extension of provisional
enrollment to an applicant beyond a 30-day provisional enrollment period if the
applicant or the applicant's representative provides documentation to the
Department that the applicant has applied for AHCCCS enrollment and, if
eligible for Medicare, a low-income subsidy and Medicare drug plan
and:
1.
AHCCCS has not yet determined whether the applicant
is eligible for AHCCCS enrollment; or
2.
If the applicant is eligible for
Medicare:
a.
The Social Security Administration has not yet
determined whether the applicant is eligible for a low-income subsidy,
or
b.
The applicant cannot enroll in a Medicare drug plan
until the next general enrollment period.
I. The Department may grant an extension of
pre-approved enrollment status to an applicant beyond the period in subsection
(D) or (E) if the applicant or the applicant's representative provides a
justification for needing more time to obtain the required documentation to
verify eligibility because of missing:
1.
Documentation of health insurance coverage;
2. Financial records to verify annual
household income, specified in
R9-6-404(A)(6);
3. Proof of residency, specified in
R9-6-404(A)(8); or
4. Viral load
test results on the laboratory report required in
R9-6-404(B)(2).
J. Based on the information
provided by an applicant about the applicant's health insurance coverage and
except as provided in
R9-6-409(F),
the Department shall:
1. For an applicant
with no health insurance coverage, provide a drug on the ADAP formulary through
the contract pharmacy;
2. For an
applicant with health insurance coverage that is inadequate, according to
R9-6-403(4)(b),
provide a drug on the ADAP formulary that is not covered by the applicant's
health insurance, as documented according to
R9-6-409(E),
through the contract pharmacy; or
3. For an applicant with health insurance
coverage that is unaffordable, according to R9-6-403(4)(c), provide a drug on
the ADAP formulary with no copayment cost to the applicant when requesting the
filling of a prescription for the drug or obtaining a refill of the drug
through ADAP.
Notes
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