ALTCS eligibility policy and procedure manual

              Welcome to the Eligibility Policy Manual

This manual was first published on our internal web site, the AHCCCS Infonet, in September 2004. The primary purpose of the Eligibility Policy Manual is to provide AHCCCS Eligibility staff with detailed policy and instructions to enable them to make accurate eligibility decisions for the following AHCCCS Health Insurance programs: ? AHCCCS Freedom to Work; ? Arizona Long Term Care System (ALTCS); ? Breast and Cervical Cancer Treatment Program (BCCTP); ? Medicare Cost Sharing Programs (QMB, SLMB and QI-1); ? Supplemental Security Income Medical Assistance Only (SSI MAO). This manual also provides an overview of all health insurance programs of the Arizona Health Care Cost Containment System Administration (AHCCCS). You may notice some slightly different formatting in a few of the chapters. We are in the process of converting to a consistent format throughout the entire manual but still wanted to make it available to users as soon as possible. In order to reduce costs associated with issuing a paper manual, we plan to stop distributing updates to the paper manual effective July 1, 2005. Therefore, AHCCCS will not endorse the accuracy of information contained in the hard copy paper manual after that. You will have immediate access to the most current policy by using this on-line manual.

Availability



Our New Manual



This manual is available to AHCCCS staff internally through the AHCCCS Infonet. Beginning July 1, 2005, this manual is also available to the public through the AHCCCS public web site. Staff at the SSI MAO Office or at any of the ALTCS offices must allow the public to view this manual in the office upon request.



Notice to the Public



This manual consists of: ? Substantive policy statements, and ? Internal staff instructions (for AHCCCS staff only). The following statement regarding the substantive policy statements is required by ARS 41-1091: This substantive policy statement is advisory only. A substantive policy statement does not include internal procedural documents that only affect the internal procedures of the agency and does not impose additional requirements or penalties on regulated parties or include confidential information or rules made in accordance with the Arizona administrative procedure act. If you believe that this substantive policy statement does impose additional requirements or penalties on regulated parties, you may petition the agency under Arizona Revised Statutes section 41-1003 for a review of the statement.



Policy Changes



AHCCCS staff are notified of changes in the manual through on-line Eligibility Policy Manual Transmittals. When updates are issued, the Program Support Administration sends an email to all AHCCCS eligibility staff that provides a link to the transmittal in the on-line transmittal history directory. They can also view the transmittal history by clicking on the link below the Table of Contents on the Eligibility Manual home page. No electronic or paper notice of updates will be issued to the public. The transmittal history, with links to all transmittals issued to AHCCCS staff, is also available to the public from the Table of Contents on the Eligibility Manual Home Page.



Forms



(AHCCCS staff only)



Access to agency forms is only available to AHCCCS staff. A link to AHCCCS eligibility forms that are not produced through ACE is available below the Table of Contents on the Infonet version of the manual. For each form AHCCCS staff may: ? Read the form instructions; ? Print a copy of the form in English (or Spanish, when available); or ? Compete the form using a form template in English (or Spanish, when available).



Other Manuals



The KidsCare Manual contains eligibility policy for the KidsCare (KC) and Health Insurance for Parents (HIFA) programs. Health Care Group Administration maintains eligibility policy for Health Care Group (HCG). The AIM BIG manual contains eligibility policy for the AHCCCS Health Insurance programs for which the Department of Economic Security (DES) determines eligibility: ? Families with Children; ? Medical Expense Deduction (MED); ? Pregnant Women; ? S.O.B.R.A. Child; ? Title IV-E Foster Care and Adoption Subsidy; and ? Young Adults Transitional Insurance (YATI).



Navigational Tools

On-line Advantages



The on-line format allows you to locate information easily and quickly in a variety of ways. AHCCCS staff have the ability to search the eligibility policy manual for information using key words or phrases. The search function on the agency's public web site looks through the entire AHCCCS site for the word or phrase requested.



Table of Contents



The table of contents expands to provide a listing of the sections and subsections within each chapter. Advantage Using the Table of Contents is the quickest way to locate information when you know the approximate location of the policy and just need to look it up to read the details. Disadvantage You could miss reading information in other subsections, sections or chapters that is also relevant to your topic.



Hyperlinks



A hyperlink is a manual reference, phrase or Internet address that is underlined and appears in blue that you can click on to directly go to that manual reference, phrase or Internet address.



Hyperlinks to Other Manual Sections



Hyperlinks to other sections of the Eligibility Policy Manual begin with "MS" followed by a section/subsection number. Click on the hyperlink to read the other section of the manual that is referenced. In general the hyperlinks will lead you to definitions or related policy that will clarify the policy you are reading. Clicking on the "Back" button in your web browser's toolbar to return to the previous page.



Hyperlinks to Processes



(AHCCCS staff only)



Hyperlinks to processes are phrases that usually beginning with "How to..." that provide procedures or processing instructions related to the policy. Process hyperlinks are only available to AHCCCS staff through the agency's internal Infonet and are not enabled from the AHCCCS public website. AHCCCS staff can click on the hyperlink to view the referenced process. Clicking on the Back button on the toolbar will return you to the previous section.



Hyperlinks to External Websites



This manual provides hyperlinks to sites on the internet that may provide additional information, such as legal references or tools such as the Kelly Blue Book, to help the Eligibility Specialist. These links are available to the public as well as AHCCCS staff. Please read the AHCCCS Web Site Privacy Policy Statement Disclaimer at: http://www.ahcccs.state.az.us/Site/WebPrivacyStatement.asp



Printing



This online version of the manual wasn't designed to be printed, as one of our primary reasons for creating it was to eliminate printing expenses. Pressing the print key on your web browser will print the entire web page where the section of the manual you are viewing is found. In most cases, this will result in several pages of unwanted printed material.



Problems and Comments



Please let us know if you find: ? A non-functional hyperlink; ? A manual section hyperlink that does not appear to go to a relevant section; ? A hyperlink to a site on the Internet that is non-functional or has been changed or removed. (Please do not report instances where the site is temporarily unavailable due to maintenance or construction); ? A place where a hyperlink is needed; ? Typos, grammatical errors, omissions; or ? Policy that is not clear. Contact the Program Support Administration at: eligibilitypolicymanual@ahcccs.state.az.us .



Arizona Health Care Cost Containment System

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AHCCCS Eligibility Policy Manual



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Welcome to the Eligibility Policy Manual (PDF, 46K)



Table of Contents

100 - AHCCCS Health Insurance Overview 200 - Where Does Eligibility Policy Come From? 300 - Covered Services 400 - AHCCCS Health Insurance Programs and Coverage Groups 500 - Non-Financial Conditions of Eligibility 600 - Income 700 - Resources 800 - Trusts 900 - Transfers 1000 - Preadmission Screening (PAS) 1100 - Enrollment



1200 - Customer Costs 1300 - Applications 1400 - Renewals 1500 - Changes 1600 - Customer Rights 1700 - Eligibility Hearings 1800 - Fraud and Abuse 1900 - Estate Recovery Transmittal History Back to Top



Members & Applicants



| Your Right to Privacy



| Programs by Group | Programs A - Z



How to apply | Get an application | Application Process | Income Requirements | List of Health Plans Office Locations | Forms | Brochures | Community Partners | Helpful Links



Arizona Department of Economic Security (ADES) Arizona Department of Health Services (ADHS)

View



Healthcare Group of Arizona (HCG) Centers for Medicare & Medicaid Services (CMS)



Web Site Privacy Policy | Contact AHCCCS | Site Map AHCCCS, 801 E. Jefferson, Phoenix, AZ 85034, (602) 417-4000



Send your Member and Provider questions and comments to the Public Information Office. Copyright 2003 Arizona Health Care Cost Containment System (AHCCCS), All Rights Reserved This page was last modified on Tuesday, May 16, 2006 at 10:07:49 AM To report broken links or to report a technical problem with this Web site, contact the AHCCCS Webmaster.



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Eligibility Policy Manual



100.00



AHCCCS Health Insurance Overview



A. Chapter Contents



This chapter contains the following topics:



Topic 101.00What is AHCCCS Health Insurance? 102.00Who Can Qualify for AHCCCS Health Insurance? 103.00How to Apply for AHCCCS Health Insurance 104.00Agencies and Organizations Participating in AHCCCS 104.01The AHCCCS Administration 104.02The Department of Economic Security 104.03The Social Security Administration 104.04Arizona Department of Health Services 104.05Office of Administrative Hearings 104.06 Native American Organizations: Tribes, Native American Community Health Center (NACHC), and Indian Health Services (IHS) 105.00Arizona's Method of Service Delivery 106.00AHCCCS Health Insurance Implementation Milestones By reading this overview chapter, you will learn about: ? AHCCCS Health Insurance; ? The five AHCCCS Health Insurance programs; ? Who can qualify for AHCCCS Health Insurance; ? Agencies and organizations participating in AHCCCS Health Programs; ? Arizona's method of service delivery; and ? Implementation milestones that relate to eligibility for AHCCCS Health Insurance.



B. Introduction



101.00



What is AHCCCS Health Insurance?



A.AHCCCS Health Insurance



Arizona Health Care Cost Containment System (AHCCCS) Health Insurance was established by the State of Arizona to provide health care for Arizona residents. There are five health insurance programs available under the AHCCCS Administration: ? Arizona's Medicaid ? KidsCare ? Health Insurance for Parents ? Medicare Cost Sharing ? Healthcare Group



B.What is Medicaid?



The Centers for Medicare and Medicaid Services (CMS) is the federal agency that oversees the Medicaid programs. CMS was formerly called the Health Care Financing Administration (HCFA). Medicaid is a jointly funded, Federal-State health insurance program for certain low-income and needy people. It is also known as Title XIX of the Social Security Act, which provides for federal grants to the states for medical assistance programs. AHCCCS is responsible for submitting a written State Plan, which assures that Arizona's Medicaid program will be administered in conformance with the federal requirements of the Social Security Act and provides a basis for Financial Federal Participation (FFP). The table below lists Arizona's Medicaid coverage groups and a brief description of each coverage group in alphabetical order.



Medicaid Coverage Group Description AHCCCS Care (AC) Available to single, individual, or married couples who do not qualify for traditional Medicaid programs because they are not age 65 or older, blind, or disabled and do not have any dependent children. (MS 401.00.) AHCCCS Freedom to Work Available to working individuals who have a disability. (FTW) Individuals may be eligible for Long Term Care Services or AHCCCS Medical Services. (MS 402.00) Arizona Long Term Care Available to individuals who are elderly, physically or System (ALTCS) developmentally disabled and have a medical need for longterm care services. (MS 403.00) Breast and Cervical Cancer Available to women under age 65 who are screened and Treatment Program (BCCTP) diagnosed as needing medical treatment for breast cancer, cervical cancer or a pre-cancerous cervical lesion by one of the programs in the Arizona National Breast and Cervical Cancer Early Detection Program (AZ-NBCCEDP). (MS 404.00) Deemed Newborns Available for up to one year of coverage for children born to mothers receiving Medicaid (Title XIX) medical services as long as the child continuously lives with the mother in the State of Arizona. Eligibility begins on the child's date of birth and ends with the last day of the month in which the child turns age one. (MS 405.00)



Families with Children (AFC) Available to families that include deprived, dependent children. Coverage under AFC is based on requirements in Section 1931 of the Social Security Act. Therefore, it is sometimes referred to as "1931". (MS 406.00) Families whose AFC benefits are terminated due to: ? Employment payments, may be eligible for an additional six months after becoming ineligible due to excess income. ? Receipt of or increase in child support payments, may be eligible for an additional four months after becoming ineligible due to excess income. Available to individuals, couples, or families without children whose income exceeds the Medicaid limits may be eligible after deducting their medical expenses from their income. (MS 410.00) Available to pregnant women beginning with any month of pregnancy through the 60-day postpartum period. (MS 412.00) Note: Women who lose S.O.B.R.A. eligibility receive Family Planning Services for up to 24 months. Available to individuals who are enrolled with a health plan for the first time and become ineligible prior to 6 months of enrollment. Customers in the following coverage groups receive continued AHCCCS coverage under the guarantee enrollment period, providing the customer does not voluntarily withdraw, is eligible when enrolled, is not an inmate of a public institution or adopted, and remains an Arizona resident. ? AHCCCS Care (MS 401.00); ? Families with Children (MS 406.00); ? Breast and Cervical Cancer Treatment Program (MS 404.00); ? AHCCCS Freedom to Work (MS 402.00); ? Supplemental Security Income (MS 414.00); ? Supplemental Security Income Medical Assistance Only (MS 415.00); ? S.O.B.R.A. Child (MS 413.00); ? Pregnant Women (MS 412.00); ? Title IV-E Foster Care and Adoption Subsidy (MS 416.00); and ? Young Adult Transitional Insurance (MS 417.00). Note: The six-month guarantee does not apply to customers receiving Long Term Care services.



Medical Expense Deduction (MED)



Pregnant Women



Six Month Guarantee



S.O.B.R.A. Child



Available to children up to their 19thbirthday. S.O.B.R.A. is named for the Sixth Omnibus Reconciliation Act, which created this coverage group. (MS 413.00) Supplemental Social Available to individuals receiving SSI cash benefits from the Security Income (SSI) Cash Social Security Administration (SSA) because they are age 65 or older, blind or disabled. (MS 414.00) Supplemental Social Available to certain individuals who may not be eligible for Security Income Medical SSI Cash assistance may be determined eligible for SSI MAO. Assistance Only (SSI MAO) These customers must be age 65 or older, blind, or disabled to receive AHCCCS medical services under the SSI Non-cash coverage group. (MS 415.00) Title IV-E Foster Care and Available to customers with an adoption assistance agreement Adoption Subsidy or foster care maintenance payments under the provisions of Title IV-E of the Social Security Act. They are deemed to meet the non-medical conditions of eligibility for ALTCS. (MS 416.00) Young Adult Transitional Available to any individual under age 21 who was in DES Insurance (YATI) foster care when turning 18 years old. (MS 417.00)



C.What is KidsCare?



KidsCare is Arizona's version of the State Children's Health Insurance Program (SCHIP) authorized by the addition of Title XXI to the Social Security Act. It is a federal and state program providing health care services to children under age 19. Based on federal laws, a customer who is eligible for Medicaid cannot be approved for Title XXI coverage. If the customer is screened to be potentially eligible for Medicaid, the Department of Economic Security (DES) or another AHCCCS office completes the eligibility determination for Medicaid. KidsCare is a federal block grant program. An eligible child who becomes ineligible for KidsCare is guaranteed a one-time, 12-month period of enrollment unless the child became ineligible due to: ? Age; ? Moving out of Arizona; ? Other health insurance coverage; ? Non-payment of the required premium; or ? The child becomes an inmate in a public institution. (MS 409.00)



Health Insurance for Parents is for parents of KidsCare and S.O.B.R.A. eligible children. It D.What is is authorized by a Health Insurance Flexibility and Accountability Demonstration (HIFA) Health 1115 Waiver. This program is funded by Title XXI funds. (MS 407.00) Insurance for Parents?



E.What is Medicare Cost Sharing?



Medicare is a Federal Health Insurance Program under Title XVIII of the Social Security Act. The customer pays part of the insurance and the federal government subsidizes the rest. The Medicare Cost Sharing programs help the customer reduce the cost of their Medicare related expenses. The Medicare Cost Sharing Programs include: ? Qualified Medicare Beneficiary (QMB), ? Specified Low Income Medicare Beneficiaries (SLMB), ? Qualified Individual-1 (QI-1), and ? Qualified Working Individuals (QDWI).



Note: Some individuals may be eligible for AHCCCS Medical Services and a Medicare Cost Sharing Program at the same time. (MS 411.00)



F. What is Healthcare Group



Healthcare Group was created by the Arizona legislature, effective January 1, 1988, to provide an affordable health care option for small employers. A self-employed individual or employers with 50 or fewer employees are eligible to participate in Healthcare Group by purchasing health care insurance for their employees dependents through participation AHCCCS health plans. Employers contract directly with the selected health plan and choose the benefit level and cost sharing option that is suitable for their organization. (MS 408.00)



102.00



Who Can Qualify for AHCCCS Health Insurance?



A.Customers Who Qualify for AHCCCS Health Insurance



The table below presents a variety of customer situations and the appropriate AHCCCS program or coverage group the customer may qualify for, as well as where the customer can apply for AHCCCS Health Insurance.



IF the customer is... Age 65 or older, blind, or disabled, and in need of long term care services Age 65 or older, blind, or disabled An employed person with a disability A child



He/she may qualify for... ALTCS AHCCCS Medical Services Medicare Cost Sharing AHCCCS Freedom to Work S.O.B.R.A. AHCCCS for Families KidsCare AHCCCS for Families S.O.B.R.A. AHCCCS Health Insurance for Children



By applying at... An ALTCS Office The SSI MAO Office The SSI MAO Office The SSI MAO Office or an ALTCS office A DES Office The KidsCare Office A DES Office A DES Office ? The KidsCare Office; or ? A DES Office A DES Office A DES Office



A family with dependent children Pregnant An adult with children



An adult without children AHCCCS Care A person or family with Medical Expense Deduction (MED) excessive medical expenses



A women age 18-64 Breast and Cervical Cancer diagnosed with breast or Treatment Program cervical cancer through the National Breast and Cervical Cancer Early Detection Program Self-employed or a small Healthcare Group business employer



Arizona Department of Health Services (ADHS), Well Woman Health Check Program Call (602) 417-6717 or (800) 545-0676 outside metro Phoenix or visit the website



www.healthcaregroupaz.com



103.00



How to Apply for AHCCCS Health Insurance



A.Who Can Apply



Anyone can apply for AHCCCS Health Insurance.



B.How to Apply



How a customer applies for AHCCCS Health Insurance depends on the type of services the customer needs. The Application for AHCCCS Health Insurance (AH-001) is available for printing from the AHCCCS website http://www.ahcccs.state.az.us/Publications/Forms/ Member/UniversalApp/ApplicationforAHCCCSHealthInsurance.pdf. Other applications are available upon request at any AHCCCS or DES eligibility office. To locate the closest AHCCCS office go to: http://www.ahcccs.state.az.us/ Services/locations.asp To locate the DES office that serves your community, go to: http://www.de. state.az.us/faa/contact.asp



IF you need... Long term care services



AND you are... ? Age 65 or older; or ? Blind; or ? Disabled



THEN you... ? Call or go to the nearest ALTCS office; or ? Send a Request for Application for AHCCCS Long Term Care Services (DE-101) to the nearest ALTCS office. Send an Application for AHCCCS Health Insurance (AH-001) to the AHCCCS SSI-MAO Office.



Medical services



? Age 65 or older; or ? Blind; or ? Disabled Pregnant Applying for children



Apply at the nearest Department of Economic Security office. Send an Application for AHCCCS Health Insurance (AH-001) to KidsCare or DES.



Applying for children and parents



? Send an Application for AHCCCS Health Insurance (AH-001) to KidsCare; or



Help with Medicare costs



? Apply at the nearest Department of Economic Security Office. Applying for adults without Apply at the nearest Department of Economic Security office. children Send an Application for AHCCCS ? Age 65 or older; or Health Insurance (AH-001) to the AHCCCS SSI-MAO Office. ? Blind; or ? Disabled



104.00



Agencies and Organizations Participating in AHCCCS Health Insurance



A.Introduction There are several agencies in the state of Arizona who work with the AHCCCS



Administration to provide services and assistance in the eligibility process to AHCCCS customers who are applying for AHCCCS Health Insurance. The other agencies responsible for working with the AHCCCS Administration include: ? The Department of Economic Security (DES); ? The Social Security Administration (SSA); ? The Arizona Department of Health Services (ADHS); ? The Office of Administrative Hearings (OAH); and ? Native American Organizations.



104.01



The AHCCCS Administration (AHCCCSA)



A. Responsibilities



The AHCCCS Administration (AHCCCSA) supervises the planning, implementation, and continued operation of the Arizona Health Care Cost Containment System (AHCCCS). The responsibilities of the AHCCCSA include: ? Oversight of the AHCCCS health care system; ? Administering some health insurance programs; ? Monitoring and coordinating other agencies, which are responsible for determining eligibility for some AHCCCS health insurance programs; ? Contracting with health plan networks and providers; ? Monitoring the quality of care provided by participating health care providers; and ? Maintaining the state's database of eligible members.



B.Mission



Reaching across Arizona to provide comprehensive, quality health care for those in need.



C.Vision



Shaping tomorrow's managed health care...from today's experience, quality, and innovation.



D.AHCCCS Code of Conduct



? We treat all people with courtesy and respect. ? Our decisions are not made in isolation from each other, or from our business partners. ? We listen, we learn. ? We tell the truth, we are accurate and we are consistent with what we communicate internally and externally. ? We consider all questions valuable. ? We expect each employee to continuously examine our business processes, and to suggest improvements. ? We expect each other to think outside the box, color outside the lines and make an occasional mess. ? We are ethical in all our dealings.



E.AHCCCS Core Values



The AHCCCS core values are:



Value Passion Community Quality Respect Accountability



Description Good health is a fundamental need of everyone. This belief drives us, inspires and energizes our work. Health care is fundamentally local. We consult and work with, are culturally sensitive to and respond to the unique needs of each community we serve. Quality begins as a personal commitment to continual and rigorous improvement, self-examination, and change based on proper data and quality improvement practices. Each person with whom we interact deserves our respect. We value ideas for change, and we learn from others. We are personally responsible for our actions and understand the trust our government has placed on us. We plan and forecast as accurately as possible. Solid performance standards measure the integrity of our work. We tell the truth and keep our promises. We embrace change, but accept that not all innovation works as planned. We learn from experience. Our mission requires good communication among interdependent areas inside and outside the agency. Internally, we team up within and across divisions. Externally, we partner with different customers as appropriate. We lead primarily in two ways: by setting the standards by which other programs can be judged, and by developing and nurturing our own future leaders.



Innovation Teamwork



Leadership



F.Division of The largest division within the AHCCCSA is the Division of Member Services (DMS). DMS assists eligible individuals in obtaining health care through eligibility and enrollment Member processes. Services

DMS includes: ? Assistant Director's Staff ? ALTCS Eligibility Administration (AEA); ? Acute Care Eligibility Administration (ACEA); ? Program Support Administration (PSA); ? Office of Automation; ? Member Services Administration; and ? Quality Compliance Administration (QCA). The table below describes the sections of the Assistant Director's staff and their functions. G.Assistant Director's Staff Staff Executive Support Function ? Oversees, directs and coordinates with DES for Title XIX eligibility policy and Title XXI related issues; ? Coordinates with Social Security for Title XIX SSI-related eligibility issues; and ? Coordinates and prepares areas of law development for the Division of Member Services. Administrative Support ? Oversees the development of the DMS budget and monitors expenditures; ? Coordinates the acquisition and maintenance of facilities; and ? Provides administrative support to special projects. Administrative ? Oversees and processes all personnel actions for the division; and Services Administration ? Identifies, develops and delivers training on personnel related issues for supervisors and mangers.



H.ALTCS Eligibility Administration (AEA)



The ALTCS Eligibility Administration (AEA) has staff located in 16 field offices statewide. The AEA determines eligibility for: ? ALTCS; ? Medicare Cost Sharing Programs; ? SSI Non-cash individuals who are ineligible for ALTCS; and ? AHCCCS Freedom to Work.



I. Acute Care Eligibility Administration (ACEA)



The Acute Care Eligibility Administration (ACEA) offices are located in Phoenix. The staff determines eligibility for: ? KidsCare; ? SSI MAO, including: ؠSSI MAO Specialty Groups: 1. 2. 3. 4. ؠؠPickle; Disabled Children (DC); Disabled Adult Children (DAC); and Disabled Widow Widower (DWW)



Exparte reviews of eligibility for customers who lose SSI cash; and Federal Emergency Services (FES) under SSI non-cash;



? Medicare Cost Sharing Programs; ? Breast and Cervical Cancer Treatment Program; and ? QI-1 reapplications. The AHCCCS Central Screening Unit (CSU) in the ACEA receives the Application for AHCCCS Health Insurance from other eligibility offices, providers, and the public. The CSU also retrieves applications from the Health-E-Arizona website. The CSU screens the application and routes the application to the correct eligibility office for an eligibility decision.



J. Program Support Administration (PSA)



The table below describes the sections of the Program Support Administration (PSA) and their function



Section Office of Eligibility Policy and Training



Function ? Develops policy for ALTCS, Medicare Cost Sharing, SSI MAO, KidsCare, and Health Insurance for Parents programs; ? Clarifies policy issues and responds to questions from the AEA and ACEA staff, other AHCCCS divisions, and the public; and ? Produces and maintains eligibility manuals and forms. ? Provides clerical, financial, and medical eligibility training to the AEA and the ACEA staff.



Hearing Coordination



The Eligibility Hearing Coordinator in PSA coordinates and assists the eligibility offices with the hearing process. See MS 1700for the Hearing Coordinator's responsibilities.



K.Office of Automation



The Office of Automation: ? Provides technical assistance through the Technical Service Center to the AEA and the ACEA for all automated systems used in the process of determining eligibility. These systems include: ؠؠؠKidsCare Eligibility Determination System (KEDS) Client Assessment and Tracking System (CATS) AHCCCS Customer Eligibility (ACE)



? Completes systems testing; ? Develops and maintains system manuals for the AEA and the ACEA staff; ? Participates in new system development; and ? Creates and maintains tables in the ACE, KEDS, and CATS systems.



L.Member Services Administration



The table below describes the sections of the Member Services Administration and their function.



Section Function Member File Integrity System (MFIS) ? Monitors the AHCCCS recipient database (PMMIS); ? Resolves eligibility and enrollment problems related to data transmission from other agencies; and ? Oversees the Medicare buy-in process. Communications Center (includes the ? Verifies member eligibility status for providers; and AHCCCSA Notifications Unit) ? Oversees enrollment changes. Technical Operations Production Staff ? Monitors the system on a daily basis; (TOPS) ? Monitors other systems that interface with PMMIS; and ? Reviews reports from the recipient subsystem and health plans.



M.Quality Compliance Administration



The Quality Compliance Administration conducts a process required by Federal / State government to provide an accurate measurement of the accuracy of applications approved and denied for AHCCCS Medical Benefits and ALTCS Programs. By reviewing a sample of eligibility determinations, the QCA review process establishes if medical assistance determinations meet the requirements of Federal regulations and waivers, state statutes, the state plan and intergovernmental agreements. Based on the elements of factual eligibility, QCA tracks error and deficiency trends and helps develop a corrective action plan. The table below describes the sections of the Quality Compliance Administration and their function.



Section



Function



ALTCS DES Management Evaluation (ME) Pre-Determination Quality Compliance (PDQC) Multi-Programs (MP)



Reviews determinations for long-term care and related SSI-MAO non-cash. Reviews determinations for all Title XIX programs administered by DES-FAA. Performs management evaluation reviews of DES eligibility sites to determine whether local office practices and operations contribute to error-free and timely determinations. Provides investigative services for applications of hospitalized individuals in Maricopa and Pima counties prior to DES determination. Investigations target error prone elements and inconsistent or questionable information. Reviews determinations for AHCCCS Freedom to Work, Breast and Cervical Cancer Treatment and SSI-MAO non-cash. Assists in the KidsCare Quality Assurance (QA) process.



N.Other AHCCCS Divisions



The table below lists the other divisions within the AHCCCSA and describes their function.



Division Office of Strategic Planning &Projects



Function ? Develops the agency's strategic plan and roadmap; ? Conducts agency needs assessment; ? Prioritizes projects; ? Identifies collaborative opportunities; and ? Serves as a liaison with other agencies and stakeholders to further agency objectives. ? Functions as the primary liaison with the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicaid and KidsCare programs; ? Responsible for the State Plan, 1115 and HIFA Waivers; ? Coordinates the agency's administrative rules and intergovernmental agreements; ? Monitors and analyzes Federal and State legislation; ? Tracks and monitors all AHCCCS related legislation; and ? Serves as a liaison with legislature and staff. ? Procures and manages grants; and



Office of Intergovernmental Relations



Federal Projects &Grants



? Manages special agency projects. Division of Business and Finance ? Develops and monitors the agency budget and manages (DBF) agency funds; ? Oversees the contractor responsible for third party liability (TPL) collections; ? Oversees the contractor responsible for estate recovery; and ? Collects premiums for the AHCCCS program



Information Services Division (ISD)



? Develops and maintains all automation services necessary to support the functions of the agency; and ? Supports the telephone, mainframe, and PC networks. ? Accepts eligibility appeals; ? Coordinates hearing dates and forwards all gathered information to the Arizona Office of Administrative Hearings (OAH): ? Investigates member, provider, and contractor grievances and makes recommendations to the Director; ? Reviews, approves, and oversees grievance procedures adopted by health plans, program contractors, and other agencies; and ? Reviews trusts referred by the AEA and the ACEA staff. ? Monitors contract performance of health plans and program contractors; ? Develops rates for capitated plans and nursing homes; and ? Develops and monitors the behavioral health program. ? Develops medical policy for acute and long-term care programs; ? Oversees utilization and quality management, case management services reviews, fee-for-service network development, transplants, and emergency services; and



Office of Legal Assistance (OLA)



Division of Health Care Management (DHCM)



Division of Fee for Service Management (DFSM)



? Processes claims. Office of Program Integrity (OPI) ? Conducts criminal investigations relating to allegations of provider and member fraud; ? Conducts program audits; and ? Is responsible for internal investigations. ? Develops small business program; ? Negotiates contracts and monitors compliance of Healthcare Group health plans; ? Markets Healthcare Group; and ? Is Responsible for Healthcare Group eligibility and enrollment



Healthcare Group



Human Resources &Development ? Provides hiring lists and oversees the hiring process and (HRD) employee performance; ? Oversees employee benefit programs including Employee Wellness, insurance, long and short term disability; ? Maintains official employee records; ? Promotes employee and organizational development through AHCCCS Overview, New Employee Workshop, personal computer classes; and the AHCCCS Leadership Academy (ALA). Public Information Office &Office ? Responsible for press relations, community relations of Community Resources and Native American relations; and ? Issues communications to AHCCCS employees. ? Oversees the Office of the Director in Tucson; ? Serves as a link to the congressional legislative and Governor's offices and community advocacy groups on matters affecting agency policies, legislation and constituent services; and ? Is the agency representative to the Arizona Mexican Commission on border issues.



Office of the Director Southern Region Congressional Relations &Advocacy.



104.02



The Department of Economic Security (DES)



A.DES Participation



The Department of Economic Security (DES) is responsible for determining AHCCCS medical services eligibility for families, pregnant women and children, including Title IV-E Foster Care or Adoption Subsidy.



B.DES Divisions



There are several divisions within DES that participate with AHCCCS programs. The table below describes the primary functions of each of these divisions. Administration Family Assistance Administration (FAA) Function The FAA determines eligibility for: ? AHCCCS Health Insurance; ? Cash assistance; ? Kinship Foster Care; ? General Assistance; ? Tuberculosis Control; ? Supplemental Payment Program; ? Refugee Cash Assistance; ? Refugee Medical Assistance Programs; and



Division of Developmental Disability (DDD)



? Food stamps. DDD is the ALTCS program contractor for all developmentally disabled individuals statewide and is responsible for: ? Providing a variety of services to persons who have specific disabilities; ? Making eligibility determinations for DDD services on referrals from ALTCS; and ? Screening and referring developmentally disabled participants to ALTCS to obtain ALTCS funding for services provided by DDD. DDSA is the only agency in Arizona authorized to make disability determinations for the Social Security Administration and for the AHCCCSA. ? CMDP is contracted with AHCCCS as a health plan to provide medical services to foster children who meet the Title IV-E or Medicaid eligibility criteria. The CSEA is committed to helping children receive the support they are due. When a child does not receive financial support from one or both parents, the CSEA helps by: ? Locating the non-custodial parent; ? Establishing legal paternity; ? Establishing the legal support order; and ? Enforcing support orders and collecting child support payments and medical support. DCYF is responsible for ? Determining foster care eligibility for children in the care and custody of DES, and ? Determining eligibility for Adoption Subsidy payments.



Disability Determination Services Administration (DDSA) Comprehensive Medical Dental Program (CMDP) Child Support Enforcement Administration (CSEA)



Division of Children, Youth, and Families (DCYF)



104.03



The Social Security Administration (SSA)



A.SSA Participation



The Social Security Administration (SSA) is responsible for determining eligibility for SSI Cash assistance. SSI Cash recipients are automatically eligible for AHCCCS medical services, but must also be determined to be medically eligible if ALTCS services are needed. The Social Security Administration also determines eligibility for Medicare, the Federal health insurance program for the aged and disabled.



B.The Wire Third-Party Query System (WTPY)



The SSA maintains the Wire Third-Party Query System (WTPY) to provide a way for eligibility staff to request information from SSA using an on-line system. SSA replies in the form of an electronic transmission. AHCCCS formats the information to a hard copy printout (WTPY) that is printed in the eligibility office. The WTPY is the primary method of verifying: ? The Social Security Number; ? Receipt of Social Security Retirement, Survivor's, or Disability Benefits; ? Receipt of Supplemental Security Income; and ? Medicare benefits.



B. Medicare Cost Sharing Outreach



Annually, the SSA identifies people who are receiving Medicare and Social Security Retirement or Disability income, who may be eligible for the Medicare Cost Sharing programs. Letters are sent to tell these people that they may qualify for programs that provide help by paying all or part of the Medicare Part A and Part B premiums, or coinsurance and deductibles. They tell people to apply at the AHCCCS eligibility office to find out if they qualify.



104.04



Arizona Department of Health Services (ADHS)

AHCCCS contracts with the Arizona Department of Health Services (ADHS) to provide behavioral health services. In addition, the ADHS Division of Behavioral Health Services (BHS) and Children's Rehabilitative Services(CRS): ? Screen for potential Title XIX and XXI eligibility; ? Assist customers who screen potentially eligible for AHCCCS Health Insurance in the application process; and ? Refer the application to the appropriate eligibility agency for an eligibility determination.



A.Arizona Department of Health Services (ADHS) Participation



B.Division of ADHS/BHS subcontracts with the Regional Behavioral Health Authorities (RBHA), which Behavioral coordinate the delivery of behavioral health services to eligible customers. Behavioral health services are services provided for the evaluation and diagnosis of a mental health Health or substance abuse condition, and the planned care, treatment, and rehabilitation of the Services customer. BHS ensures that a customer's behavioral health services are provided in (BHS) collaboration with the primary care provider.



C. Regional Behavioral Health Authorities (RBHA)



In addition to providing behavioral health services to eligible customers, the Regional Behavioral Health Authorities conduct outreach and screen for potential Title XIX or XXI eligibility.



D.The ADHS Seriously Mentally Ill (SMI) Outreach



ADHS contracts with AHCCCS to obtain all necessary information needed to determine eligibility for Seriously Mentally Ill (SMI) customers through a statewide outreach process. The ADHS Outreach Worker: ? Assists customers in completing the Application for AHCCCS Health Insurance; ? Explains the AHCCCS application process and eligibility requirements; ? Submits the applications and documentation to AHCCCS; ? Tracks the status of customers' applications; ? Provides information AHCCCS needs to determine if the customer meets the categorical requirement of "disabled"; ? Helps the customer complete the renewal process; and ? Helps the customer access services.



E. Children's Rehabilitative Services (CRS)



Children's Rehabilitative Services (CRS) provides medical treatment, rehabilitation, and related support services to medically and financially qualified individuals who have certain medical, disabling or potentially disabling conditions that have the potential for functional improvement. CRS screens program applicants for potential Title XIX and Title XXI eligibility prior to providing services financed with CRS state funds. The applicant must cooperate in the AHCCCS application process to receive CRS services. CRS may provide emergency services while the AHCCCS application is pending. If the customer is not eligible for Title XIX and Title XXI programs, CRS may provide services through state funds.



F. ADHS Well Woman Healthcheck Program (WWHP) and Cooperation in the Breast and Cervical Cancer Treatment Program (BCCTP)



ADHS administers the Well Woman Healthcheck Program (WWHP) to provide screening and diagnosis of breast and cervical cancer. However, the WWHP is not funded to cover the treatment. WWHP refers women who need treatment and appear to be eligible for the BCCTP to AHCCCS. WWHP case managers help a woman complete an Application for AHCCCS Health Insurance when her breast and/or cervical cancer screening shows a strong indication of cancer. WWHP sends the Application for AHCCCS Health Insurance to AHCCCS within 24 hours after receiving the completed application. Designated AHCCCS Eligibility Specialists complete the eligibility determination under the BCCTP after receiving the Application for AHCCCS Health Insurance and screening verification from the WWHP.



104.05



Office of Administrative Hearings (OAH)

An Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH) conducts eligibility hearings. The hearings are held at 1400 West Washington in Phoenix, Arizona. Do not contact OAH directly unless you are asked to do so. Customers or their representatives may contact OAH at (602) 542-9826 or toll free (877) 203-0226 if they have any questions or concerns. You may also direct a customer to the OAH website at http://www.azoah.com.



A.OAH Participation



B. Reponsibilities of OAH



OAH: ? Appoints an Administrative Law Judge (ALJ) to conduct the hearing. Any party may file a motion to disqualify an ALJ for bias, prejudice, personal interest or lack of technical expertise necessary for a hearing; ? Sets the date for the hearing, in conjunction with the Office of Legal Assistance (OLA); ? Provides an interpreter if the complainant requests one; and ? Provides reasonable accommodation for special needs. See MS 1700for more information about the hearing process.



104.06 Native American Organizations: Tribes, Native American Community Health Center (NACHC), and Indian Health Services, (IHS)

A.Tribe Participation

As of April 1, 1999, six tribes have signed Intergovernmental Agreements with AHCCCS to deliver case management services and to provide or arrange for services to Native Americans who reside on reservation and are approved for ALTCS. These tribal contractors must ensure their members have access to the full range of ALTCS services. These tribes are: ? Gila River Indian Community; ? Navajo Nation; ? Pascua Yaqui Tribe; ? San Carlos Apache Tribe; ? White Mountain Apache Tribe; and ? Tohono O'Odham Nation. There are two tribal programs that receive funding from the Centers for Disease Control and Prevention (CDC) to provide Breast and Cervical cancer screening and diagnosis under the AZ-NBCCEDP. These two programs are: ? The Hopi Women's Health Program; and ? The Navajo Nation Breast and Cervical Cancer Prevention Program. In April 1997, AHCCCS signed an agreement with Native American Community Health B.Native Center (NACHC) to provide ALTCS services to Native American ALTCS members who have American on-reservation status and the tribe does not participate as a program contractor. Community Health Center



C.Indian Health Services (IHS)



The Indian Health Services (IHS) is an agency within the Department of Health and Human Services that is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services grew out of the special government-to-government relationship between the federal government and Indian tribes. Native Americans have the option of enrolling with Indian Health Services as their health plan if approved for AHCCCS medical services.



105.00



Arizona's Method of Service Delivery



A. Enrollment with a Health Plan or Program Contractor



Customers receiving AHCCCS medical services are enrolled with a health plan or Indian tribe to receive services. AHCCCS allows customers to choose a health plan from those available in the geographic service area (GSA) in which they reside. See MS 1101.00for details about enrollment with a health plan. Customers receiving ALTCS are enrolled with a program contractor. ALTCS program contractors can be counties, private entities, the Department of Economic Security (for the developmentally disabled), certain Native American tribes, Native American Community Health, or the Arizona Healthcare Cost Containment System, depending on where in the state the service is to be provided. After enrollment, the ALTCS program contractor assigns a case manager. See MS 1103.00for details about enrollment with an ALTCS program contractor. AHCCCS was the first statewide, managed care Medicaid program in the nation to rely on health plans to deliver medical services to both the Medicaid and state funded customers. AHCCCS health plans are defined by state statute and are regulated and monitored by AHCCCS, based on strict financial and operational standards. AHCCCS delivers medical services through prepaid, capitated health plans. Enrolled members have access to care in the majority of private physician offices in Arizona. The mainstreaming of Medicaid recipients into the private physician sector is the direct result of a working partnership between AHCCCS and the health plans. See MS 302.00for details about the AHCCCS medical services package. ALTCS is unique in that all covered services are integrated into a single delivery package, coordinated and managed by the program contractors. Most counties are served by one program contractor. On June 1, 2000 AHCCCS awarded contracts to three Arizona health care companies to provide elderly and physically disabled ALTCS recipients residing in Maricopa County. This allowed a choice of ALTCS program contractors beginning October 1, 2000. This new development was initiated by the Arizona legislature in 1997 because lawmakers sought a wider choice for ALTCS members.



B.Health Plans



C.Program Contractors



D.Capitation AHCCCS prospectively pays fixed monthly capitation, which is based on the age, sex, and

Medicare status of each customer. When a health plan submits a bid to participate in the AHCCCS program, the health plan agrees to provide a specified set of services to any individual who enrolls with them for the capitation rate established by their contract with AHCCCS. Under this arrangement, health plans must absorb the loss if the medical costs for a customer exceed the monthly capitation payment made to the health plan. This creates a financial incentive for the health plan to keep their members healthy.



AHCCCS also pays program contractors prospectively on a capitated, per customer, per month basis. ALTCS capitation rates are blended rates, which include nursing facility costs, home and community based services (HCBS), AHCCCS medical services, behavioral health services, and case management services. See MS 302.05for the ALTCS and AHCCCS medical services coordination of Medicare and E. Coordination Medicaid services. of Medicare and Medicaid As a Medicaid agency, AHCCCS is the payor of last resort, which means that AHCCCS F.Payor of Last Resort requires that other responsible parties pay before AHCCCS pays. Therefore, AHCCCS



collects information about Third Party Liability (TPL) to identify anyone else that might be responsible for paying the recipient's medical expenses. Under State law, a customer automatically assigns rights to medical care support to the state when the customer signs the application.



106.00



AHCCCS Health Insurance Implementation Milestones



A.Program Implementation Milestones



The table below shows the AHCCCS program implementation milestones relevant to eligibility determinations.



Year Year One (October 1, 1982 ? September 30, 1983)



Milestone Under a contract with McAuto, AHCCCS began providing Title XIX covered services but was waived from providing some mandatory services normally covered under traditional Medicaid. (SB 1001, Chapter 1, Laws of 1981). Services were also provided to State-only funded groups: ? Medically Indigent (MI) ? Medically Needy (MN) On May 5, 1984, (HB 2551, Chapter 272, Laws of 1984) created an independent state agency, AHCCCS. On March 16, 1984, the contract with McAuto was terminated and the State took over the administration of AHCCCS. Effective January 1987, State legislation (HB 2086, Chapter 380, Laws of 1986) created the Children's Care Program which created two new eligibility groups: ? Eligible Assistance Children (EAC) ? A State-funded group of children whose household receives food stamps



Year Two (October 1, 1983 ? September 30, 1984) Year Five (October 1, 1986 ? September 30, 1987)



? Eligible Low Income Children (ELIC) ? A category of children in families not receiving food stamps with income exceeding the state MI/MN level but not the federal poverty level. On May 21, 1987, Governor Evan Mecham signed Senate Bill 1418 placing the AHCCCS program permanently in statute. The Bill also authorized the development of a Title XIX long-term care program. Year Six (October 1, Effective January 1, 1988, the S.O.B.R.A. program was implemented for 1987 ? September pregnant women and children under 5 years of age with income up to 100% of the FPL. (SB 1418, Chapter 332, Laws 1987) 30, 1988) Adopted a guaranteed enrollment period for pregnant women. (SB 1418, chapter 332, Laws 1987) Effective January 1, 1988, small companies with up to 25 employees were able to purchase health insurance in Pima, Gila, Maricopa, and Pinal counties through Healthcare Group and receive care through AHCCCS Health Plans. (SB1001, Chapter 1, Laws of 1981) Year Seven Effective October 1, 1988, eligibility age limits for children whose families (October 1, 1987 ? were receiving food stamps became automatically eligible for AHCCCS were raised from 6 to under 14. (SB 1418, Chapter 332, Laws of 1987) September 30, 1989) Effective October 1, 1988, eligibility age limits for S.O.B.R.A. children with incomes to over 100% FPL raised from under 5 years of age to under 6 years of age. (SB 1183, Chapter 3, Laws of 1988) Effective July 1, 1989, Qualified Medicare Beneficiaries (QMB) was added. (SB 1151, Chapter 5, Laws of 1989) The ALTCS program began in two phases: Effective December 19, 1988, the DD population was added. Effective January 1, 1989, the EPD population was added. (SB 1418, Chapter 332, Laws of 1987) Effective February 1, 1989, services are limited to Pima county for Healthcare Group.



Year Eight (October 1, 1989 ? September 30, 1990)



Effective April 1, 1990, S.O.B.R.A. pregnant women, children and infants income limits increased from 100% FPL to 133% FPL. Effective July 1, 1990, S.O.B.R.A. was initially raised to 130% FPL. (SB 1348, Chapter 293, Laws of 1989) However, federal law raised S.O.B.R.A. to 130% FPL in the interim, making it necessary to pass State legislation to comply with federal law effective April 1, 1990. (HB 2249, Chapter 27, Laws of 1989) HCFA set home and community based services capitation at 15% of the Elderly and Physically Disabled population. In January 1990, services for Healthcare Group expanded to Cochise county and in April 1990 to Maricopa county. Effective October 1, 1990, expansion of S.O.B.R.A. eligibility from 133% FPL to 140% FPL for pregnant women and infants. (HB 2351, Chapter 333, Laws of 1990) Effective January 1, 1991, QMB eligibility increased to individuals with incomes up to 100% FPL. (SB 1140, Chapter 213, Laws of 1991) Effective July 1, 1991, OBRA 90 mandates adopted: infants retain eligibility for 12 months if the mother would be eligible if still pregnant; and, children born on or after September 30, 1983, with incomes up to 100% FPL eligible up to age 18. (SB 1140, Chapter 213, Laws of 1991) HCFA set home and community based services capitation at 18% of the total budget for the EPD population. Effective August 1991, the limitation on the number of employees in a company is expanded from 25 to 40 employees for Healthcare Group. (HB 2077, Chapter 299, Laws of 1991) Optional Medicaid children (section 1902(r)(2) of the Social Security Act) up to age 14 added July 1, 1992 (no bill) Home and community based services capitation set at 25% of the EPD population. Home and community based services set at 30% of the EPD population. Effective January 1, 1993, the Specified Low Income Beneficiaries (SLMB) created by the Omnibus Reconciliation Act (OBRA 90) was added. Effective March 1, 1993, services under Healthcare Group expanded to the remaining 11 Arizona counties. Home and community based services set at 35% of the EPD population.



Year Nine (October 1, 1990 ? September 30, 1991)



Year Ten (October 1, 1991 ? September 30, 1992) Year Eleven (October 1, 1992 ? September 30, 1993)



Year Twelve (October 1, 1993 ? September 30, 1994) Year Thirteen (October 1, 1994 ? September 30, 1995)



On August 1, 1995, Family Planning Services Extension Program was implemented. This program allows women to continue receiving only family planning services for up to 24 months after losing S.O.B.R.A. eligibility. ALTCS developed a new-age specific PAS for the DD population. On September 1, 1995, ALTCS adopted a functional level PAS for ALTCS members who fail the at-risk of institutionalization test at redetermination. Persons who pass the new PAS could continue in the program and receive HCBS. (SB 1325, Chapter 322, Laws of 1994) HCBS capitation set at 40% of the EPD population. Added waivers to: ? Streamline and simplify acute and ALTCS eligibility requirements; and ? Permit S.O.B.R.A. newborns to remain Medicaid eligible for the first 12 months after birth without consideration of the mother's continued Medicaid eligibility. Effective July 1, 1996, MI/MN eligibility is denied for Medicare eligible applicants and members who reside in a county where a Medicare HMO operates. On October 1, 1995, the Adult Care Home Pilot program began permitting a limited number of EPD individuals to receive HCBS in an adult home setting.



Year Fourteen (October 1, 1995 ? September 30, 1996)



Year Fifteen (October 1, 1996 ? September 30, 1997)



Effective July 20, 1996, Supportive Residential Living Centers were added as a permanent setting. Pursuant to federal Welfare Reform legislation, Arizona enacted eligibility legislation for qualified non-citizens and undocumented persons. Waiver: ? Acting on a 1996 initiative passed by voters, AHCCCS submitted a request to HCFA to extend acute care Title XIX eligibility to low income adults and children with income up to 100% of the FPL and to implement a Medical Expense Deduction program for persons with medical bills. Annual enrollment, previously provided for all members during a period in August, changed to annual enrollment based on the member's enrollment anniversary date. HCBS capitation is set at 45% of EPD population. Adult Care Homes become a permanent alternative setting for ALTCS members under a new category of licensure known as "assisted living facilities". In February, Healthcare Group implemented the Premium Sharing Pilot program in four counties for 3 years. The program provides health care for low-income persons for a monthly premium that is based on a sliding scale. Effective July 1, 1998, Qualified Individual-1 (QI-1) (SLMB) created by the Balanced Budget Act of 1997 was added.



Year Sixteen (October 1, 1997 ? September 30, 1998)



For the first time since the inception of the ALTCS/EPD program in January 1989, members in Maricopa county will be provided with a choice of program contractors effective October 1, 2000. In April 2000, HCFA removed the ALTCS program's HCBS capitation retroactively to October 1, 1999. The capitation had been in place since the beginning of the ALTCS program and had been steadily increased. Removal of the capitation permits the agency to respond to growth in services such as alternative residential living facilities, an increasingly popular option for individuals. Year Nineteen In November 2000, Arizona voters approved Proposition 204, the Healthy (October 1, 2000 ? Arizona Initiative, which expanded eligibility under AHCCCS to 100% of the September 30, FPL. In January 2001, the Centers for Medicaid and Medicare Services 2001) (CMS) approved AHCCCS' waiver request to expand eligibility to 100% of the FPL and eliminate prior quarter coverage to new enrollees with both the acute care and ALTCS program. October 1, 2001 Proposition 204 was implemented, increasing the AHCCCS Year income limit to 100% of the FPL. Counties stopped determining AHCCCS eligibility and the MI/MN, ELIC and EAC programs stopped. These Twenty programs were replaced by the new AHCCCS Care and Medical Expense Deduction (MED). (October 1, 2001 ? On January 1, 2002 AHCCCS implemented the Breast &Cervical Cancer Treatment Program. Applicants are referred by the agencies of the September 30, 2002 National Breast and Cervical Cancer Early Detection Program. Effective July 1,2002 the Arizona Department of Corrections and the AHCCCS Administration entered into an agreement to provide AHCCCS Medical Services to inmates for the duration of their inpatient hospitalization. The Arizona legislature expanded the Alzheimer's Treatment Assistive Living Facility Pilot Project and extended it to October 2005. On December 31, 2002, federal funding for the Qualified Individual (QI-2) Year Medicare Cost Sharing program ended and the program terminated. Twenty-One (October 1, 2002 ? September 30, 2003 On January 1, 2003 AHCCS implemented the AHCCCS Freedom to Work program for employed people with disabilities whose income is too high to qualify for medical benefits under other AHCCCS programs. On September 30, 2003 the Premium Sharing Program ended.



Year Seventeen (October 1, 1998 ? September 30, 1999) Year Eighteen (October 1, 1999 ? September 30, 2000)



On November 1, 1998, AHCCCS implemented KidsCare, Arizona's Children's Health Insurance Program (CHIP), which received approval from HCFA on September 18, 1998.



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Eligibility Policy Manual



200.00



Where Does Eligibility Policy Come From?

This chapter contains the following topics:



A. Chapter Contents



Topic 201.00Federal Authorities 202.00State Authorities 203.00The AHCCCS 1115 Waiver 204.00The State Plan



B.Introduction The Office of Eligibility Policy develops the policy contained in this manual using the

following authorities: ? Federal and state government; ? Waivers; ? State Plan; and ? Directives from executive management.



201.00



Federal Authorities



A.Introduction The federal authorities are the major framework for the Medicaid, ALTCS, Medicare Cost

Sharing, and KidsCare programs. The federal government provides options to states to develop these programs. The states use these options to individualize the programs for each state. Federal authorities used to develop eligibility policy for the Medicaid and KidsCare programs include: ? Public Laws; ? Social Security Act (the Act); ? United States Code (USC); ? Code of Federal Regulations; ? State Medicaid Manual;



? CMS Guidance; ? CMS Letters to State Medicaid Directors; ? Social Security Administration's Program Operations Manual (POMS); and ? Federal Register.



B.Public Law A Public Law is a printing of the full text of a new law or an amendment to an existing law

after it has been enacted by Congress and signed by the President. Public Laws are later codified (collected and arranged) in the U.S. Code along with all other Federal Laws.



C.Social Security Act



The Social Security Act covers all aspects of Social Security. AHCCCS authorizes health care coverage in compliance with three titles of the Act. The table below provides a description of each title. Title XVI



Description Title XVI of the Act is the Supplemental Security Income program for the aged, blind, and disabled individuals who have low income. AHCCCS uses this Title for SSI-MAO and ALTCS. XIX Title XIX of the Act refers to Medicaid. It identifies the mandatory and optional coverage groups and the basic conditions of eligibility for each. XXI Title XXI provides funds to states to enable them to initiate and expand the provision of children's health insurance to uninsured, low-income children. KidsCare is Arizona's State Children's Health Insurance Program. With federal approval, AHCCCS uses Title XXI to provide coverage under other AHCCCS programs (MS 203.00.E.). See http://www.ssa.gov/OP_Home/ssact/comp-toc.htmto view the Social Security Act. The USC contains federal law made by Congress. It is a consolidation and codification by D.United States Code subject matter of the general and permanent laws of the United States. (USC) See http://www.access.gpo.gov/uscodeto view the USC.



E.Code of Federal Regulations (CFR)



The CFR is a codification of general and permanent rules (regulations) that have been previously published in the Federal Register. The CFR provides more detail about conditions of eligibility than the USC. AHCCCS Health Insurance programs and coverage groups are described in: ? 42 CFR - Public Health; ? 20 CFR - Supplemental Security Income; and ? 45 CFR - Public Welfare. See http://www.gpoaccess.gov/fr/index.htmlto view the CFR.



F.State Medicaid Manual (SMM)



The SMM is developed by the Centers for Medicare and Medicaid Services (CMS). Its purpose is to provide policy guidance for the Medicaid requirements contained in the CFR. See http://www.cms.hhs.gov/manuals/pub45/pub_45.aspto view the State Medicaid Manual.



G.Center for Medicare and Medicaid (CMS) Guidance



CMS issues State Medicaid Director letters to all Directors of State Medicaid agencies. They provide information and/or guidance to the states on Medicaid and State Children's Health Insurance Program (SCHIP) topics. See http://www.cms.hhs.gov/states/letters/default.aspto view Medicaid related letters. See http://www.cms.hhs.gov/schip/sho-letters/to view SCHIP related letters. CMS Rulings are final decisions of the Administrator that clarify complex or unclear provisions of the law or regulations relating to Medicaid or SCHIP. See http://www.cms.hhs.gov/rulings/to view CMS Rulings.



H.SSA's Program Operations Manual (POMS) I. Federal Register



POMS is the internal operating instructions used by SSA to process claims for Social Security benefits. The Office of Eligibility Policy uses POMS to assist in developing eligibility policy for ALTCS and SSI-MAO. See http://policy.ssa.gov/poms.nsf/aboutpomsto view POMS. The Federal Register is the official daily publication of the U.S. government which contains new regulations, changes to the Code of Federal Regulations, and legal notices issued by Federal agencies and the President. For example, the Federal Benefit Rate (FBR) and Federal Poverty Level (FPL) limits are published annually in the Federal Register. Policy specialists review the Federal Register every day and provide written summaries of new information to executive management. See http://www.gpoaccess.gov/fr/index.htmlto view the Federal Register.



202.00



State Authorities



A.Introduction State laws are developed based on the Federal laws and regulations made by Congress

and the Federal government. The Office of Eligibility Policy researches several state authorities to develop eligibility policy.



B.Arizona Revised Statutes (ARS)



The ARS are made by the Arizona legislature and are equivalent to the Federal Laws in the USC. The following AHCCCS related statutes are located in Title 36, Chapter 29: ? Article 1 Medicaid and Healthcare Group; ? Article 2 ALTCS; ? Article 3 QMB; and ? Article 4 Children's State Health Insurance Program (KidsCare). See http://www.azleg.state.az.us/ArizonaRevisedStatutes.aspto view the ARS.



C.Arizona Administrative Code (AAC)



The AAC is commonly referred to as the Rules. The AAC is developed by the responsible state agency and approved by the Governor's Regulatory Review Council (GRRC). The AAC provides more detail than the ARS. The AHCCCS related rules are located in Title 9: ? Chapter 22 Medicaid; ? Chapter 27 Healthcare Group; ? Chapter 28 ALTCS; ? Chapter 29 QMB; and ? Chapter 31 KidsCare. See http://www.azsos.gov/Rules_and_regulations.htmto view the AAC.



The AAR is the official publication of the State of Arizona which contains rules approved by D.Arizona Administrative the GRRC but not yet published in the AAC. Register (AAR) See http://www.sosaz.com/aarto view the AAR.



E.Eligibility Policy and Procedure Manuals



Each state is required to maintain Eligibility Policy and Procedure Manuals for all of the programs and coverage groups. Arizona's Eligibility Policy and Procedure Manuals are developed and maintained by the following agencies:



Agency: AHCCCS, Office of Eligibility Policy



Eligibility Policy and Procedures for: ? ALTCS ? SSI-MAO ? Medicare Cost Sharing ? KidsCare ? Health Insurance for Parents ? Breast &Cervical Cancer Treatment Program ? AHCCCS Freedom to Work Healthcare Group ? AHCCCS For Families with Children ? S.O.B.R.A. ? AHCCCS Care ? MED



AHCCCS, Healthcare Group Administration Department of Economic Security, Family Assistance Administration



203.00 The AHCCCS 1115 Waiver



A.The AHCCCS 1115 Waiver



States must comply with Title XIX and Title XXI of the Act. Since AHCCCS began on October 1, 1982, the agency has been exempt from specific provisions of the SSA under an 1115 Research and Demonstration Waiver. The number 1115 refers to section 1115 of the Act.



B.What is in The AHCCCS 1115 Waiver contains: the AHCCCS 1115 Waiver?? Provisions in the Act from which AHCCCS is waived;

? Expenditure authority for certain items under section 1903 of the Act; ? Terms and conditions that AHCCCS must fulfill, which includes documents and reports that must be submitted during the year; ? Approved federal budget amounts; and ? Four attachments that outline financial, legislative, and budget neutrality requirements.



C.Title XIX Eligibility Waivers



The AHCCCS waivers frequently change in response to the changing health care needs of Arizonians. AHCCCS has waivers under the authority of section 1115 (a)(1) of the Act that are related to Title XIX eligibility, which means that certain eligibility requirements are waived. The waivers related to eligibility for all customers include: ? To grant eligibility no earlier than the application month rather than up to 3 months prior to the month of application (Prior Quarter); and ? To exclude hospitalized non-ALTCS recipients from the post eligibility share of cost requirements.



The waivers related to eligibility for customers who are age 65 or older, blind or disabled and whose eligibility is based on a coverage group related to SSI include: ? To exclude certain income in the ALTCS post eligibility calculation of income that is disregarded in the ALTCS eligibility determination; ? To exclude infrequent income when determining eligibility; ? To not wait 30 days to use the special income limit (300% FBR) for the ALTCS coverage group described in 42 CFR 435.336; ? To disregard the value of inkind support and maintenance as income (ISM); ? To disregard the income and resources of responsible relatives for ALTCS in the month of separation; ? To use couple budgeting;



? To disregard certain resources in the eligibility determination for ALTCS; ? To disregard the value of certain resources as of the 1stday of the month; and ? To substitute the Preadmission Screening (PAS) for a disability determination for ALTCS.



D.Title XIX Method of Service Delivery Waivers



AHCCCS also has authority under section 1115 (a)(1) of the Act to waive requirements related to Arizona's method of service delivery. These waivers include: ? To impose co-payments on mandatory services for certain individuals except children or pregnant women enrolled in AHCCCS; ? To give the State greater flexibility in provider reimbursement and to make capitated payments, which is called reimbursement agreement; ? To restrict freedom of choice to AHCCCS contractors, which permits AHCCCS to operate a managed care system; ? To receive payment for outpatient drugs without complying with OBRA 90 drug rebate revisions; and ? To exclude customers who are hospitalized for over 30 days and who are not at risk of institutionalization from automatically being enrolled in the ALTCS program.



E.Title XXI Waiver



Under the Health Insurance Flexibility and Accountability Act (HIFA) demonstration initiative, AHCCCS modified the 1115 waiver to use Title XXI funds to expand coverage to: ? Adults over age 18 without dependent children with adjusted net family income at or below 100% FPL; and ? Parents of children eligible for KidsCare or S.O.B.R.A. individuals with gross family income above 100% FPL and at or below 200% FPL, who are not eligible for Medicaid.



204.00



The State Plan



A.Definition Arizona has a Medicaid State Plan and a KidsCare State Plan. A State Plan is a of the State comprehensive written contract between AHCCCS and the Centers for Medicare and Medicaid Services (CMS) that describes the nature and scope of its Medicaid programs. Plan



B.Purpose of the State Plan



The State Plan assures that Arizona will administer the Medicaid and KidsCare programs according to federal requirements under provisions of the Social Security Act and provides a basis for Federal Financial Participation (FFP). The CMS has the responsibility for approval of the State Plan at the federal level.



AHCCCS is Arizona's state agency with the responsibility for the State Plan. AHCCCS C.AHCCCS Responsibility submits amendments to reflect changes in federal law, regulation, policy, or court



decisions. The methods used for determining eligibility for AHCCCS programs or coverage groups may be modified by Arizona's waiver or by Arizona's Medicaid State Plan or KidsCare's State Plan.



D.Medicaid State Plan



The Medicaid State Plan is divided into seven sections: ? Single State Agency Organization; ? Coverage and Eligibility; ? Services: General Provisions; ? General Program Administration; ? Personnel Administration; ? Financial Administration; and ? General Provisions. See www.cms.gov/medicaid/stateplans/toc.asp?state=AZto view Arizona's Medicaid State Plan.



E.KidsCare State Plan



The KidsCare State Plan is divided into 12 sections: ? General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements; ? General Background and Description of State Approach to Child Health Coverage and Coordination; ? Methods of Delivery and Utilization Controls; ? Eligibility Standards and Methodology; ? Outreach; ? Coverage Requirements for Children's Health Insurance; ? Quality and Appropriateness of Care; ? Cost Sharing and Payment; ? Strategic Objectives and Performance Goals and Plan Administration; ? Annual Reports and Evaluations; ? Program Integrity; and



? Applicant and Enrollee Protections. See http://www.cms.hhs.gov/schip/stateplans/chipaz.asp?state=AZto view the KidsCare State Plan.



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Eligibility Policy Manual



300.00



Covered Services



A.Chapter Contents



This chapter contains the following topics:



Topic 301.00



302.00



Types of Services 301.01 Medical Services 301.02 Behavioral Health Services 301.03 EPSDT Services 301.04 Family Planning Services 301.05 Long Term Care Services 301.06 Case Management Services 301.07 Medicare Cost Sharing Service Packages 302.01 AHCCCS Medical Service Package 302.02 ALTCS Service Package 302.03 Emergency Service Package 302.04 Family Planning Extension Services Package 302.05 Medicare Cost Sharing Packages



B.Introduction In this chapter you will find:

? A general description of the types of health services provided by AHCCCS Health Insurance; ? Descriptions of the "service packages" that customers receive; and ? How to help a customer who has issues about covered services.



301.00



Types of Services



A.Types of Services



AHCCCS Health Insurance covers: ? Medical services (MS 301.01); ? Behavioral health services (MS 301.02); ? Early Periodic Screening Diagnosis and Treatment (EPSDT) services (MS 301.03); ? Family planning services (MS 301.04); ? Long term care services (MS 301.05); ? Case management (MS 301.06); and ? Medicare cost sharing (MS 301.07).



301.01



Medical Services



A.Definition Medical services are services provided for the prevention, diagnosis and treatment of

health problems.



B.Inpatient Hospital Services



Hospital accommodations and appropriate staffing, supplies and services are provided for: ? Maternity care, including labor, delivery, recovery room, birthing center and newborn nursery; ? Neonatal intensive care unit; ? Intensive care unit; ? Surgery; ? Nursery and related services; ? Routine care; ? Emergency behavioral health services; ? Laboratory services ? Radiology and medical imaging services ? Anesthesiology services; ? Rehabilitation services;



? Prescriptions; ? Respiratory therapy; ? Blood and blood derivatives; and ? Medical supplies and equipment.



C.Primary Care Provider Services



A physician or a practitioner may provide primary care provider services. Services may be provided in an inpatient or an outpatient setting. Within the provider's scope of practice, the primary care provider may provide: ? Periodic health examinations; ? Evaluation and diagnostic workup; ? Medically necessary treatment; ? Prescriptions for medication and medically necessary supplies and equipment; ? Referrals to specialists when medically necessary; ? Covered preventative heath services; ? Covered immunizations; ? Patient education; and ? Home visits when medically necessary.



D.Laboratory, Laboratory fees, radiology and medical imaging services are covered when they are prescribed by the customer's primary care provider, attending physician, practitioner or Radiology dentist, or when prescribed by a dentist or practitioner to whom the customer has been And Medical referred by the primary care physician. Imaging Services



These services may be provided in a hospital, clinic, physician's office or other health care facility.



E.Dental Services



Covered dental services include: ? Emergency dental services for a customer who is 21 years of age or older; ? Medically necessary dentures; and ? Dental diagnosis and elimination of oral infection prior to transplantation of organs or tissues. Dental services for customers under the age of 21 are covered under E.P.S.D.T. (MS 301.03).



F. Prescription Medication



Prescription medication is a covered service when the medication is prescribed by: ? The customer's primary care provider; ? An attending physician; ? A practitioner; ? A dentist; or ? A specialist to whom the customer was referred by the primary care physician.



G. Emergency Services



The following emergency services are covered and available 24 hours per day: ? Emergency room services; ? Emergency medical services; ? Emergency behavioral health services; and ? A behavioral health evaluation if required to evaluate or stabilize an acute episode of mental disorder or substance abuse.



H. Transportation Services



The following transportation services are covered: ? Emergency ambulance services; ? Air ambulance services under specific circumstances; ? Medically necessary non-emergency transportation limited to the cost of transporting the customer to the appropriate provider capable of meeting the customer's medical needs; ? The cost of transportation provided by a family or household member, friend or neighbor when the transportation services are authorized by the Administration or the customer's contractor, the person providing the transportation is a registered AHCCCS provider, and no other appropriate transportation is available; and ? The following services are covered when a customer has approved prior authorization to receive health care services from a health care service site outside the customer's service



area or county of residence:

?



The cost of transportation, meals and lodging for the customer;



? The cost of transportation, meals and lodging for a family member who accompanies the customer; and ? Payment for an escort who is not a family member who accompanies the customer.



I. Medical Supplies, Durable Equipment, and Orthotic and Prosthetic Devices



Medical supplies mean consumable items that are designed specifically to meet a medical purpose. Medical supplies are covered when they are essential to the customer's health. Durable medical equipment is an item or appliance that can withstand repeated use, is designed to serve a medical purpose, and is generally not useful to a person who does not have a medical condition, illness or injury. The contractor may rent or purchase the durable equipment for the customer. Reasonable repair or adjustment of purchased equipment is covered if the cost of repair is less than the cost of renting or purchasing another unit. Orthotic and prosthetic devices are covered when they are essential for the habilitation or rehabilitation of the customer. Limitations: ? Hearing aids are not covered for customers who are age 21 or older. ? Prescription lenses are not covered for customers who are age 21 or older unless they are the sole prosthetic device after a cataract removal.



J. Therapies Covered therapies include physical, occupational, audiology and speech therapies.



K.Nursing Facility



Nursing facility services are covered up to 90 days in lieu of hospitalization.



L.Home Services



Covered home health services are: ? Home health services provided in lieu of hospitalization; and ? Home health therapy services.



M. Transplants



Covered transplants include: ? Cornea, autologous and allogenic bone marrow transplantations with related chemotherapy and/or radiotherapy; ? Liver, kidney, heart, lung and heart/lung transplantations, with related immunosuppressant medications.



N.Other Services



Other covered services include: ? Private duty nursing services, when medically necessary; ? Podiatry services; and ? Optometrist services.



301.02



Behavioral Health Services



A.Definition Behavioral Health Services means evaluation and treatment services for mental disorders

and substance abuse.



B.Diagnosis, The following diagnostic, treatment and case management services are covered: Treatment ? Emergency /crisis behavioral health services; and Case Management

? Evaluation and screening; ? Laboratory and radiology services for psychotropic medication regulation and diagnosis; ? Behavior management (behavior health personal assistance, family support, peer support); ? Case management services; ? Psychosocial rehabilitation (living skills training, health promotion, pre-job training, education and development, job coaching and employment support); and ? Respite care.



C.Therapy and Counseling



The following therapy and counseling services are covered: ? Group; ? Individual; and ? Family.



D.Transportation Covered behavioral health services include:

? Emergency transportation; and ? Non-emergency transportation.



E.Services Behavioral health services are covered in: in Facilities

? Inpatient hospitals; ? Inpatient psychiatric facilities (residential treatment facilities and sub-acute facilities); ? Institutions for Mental Disease (with limitations); ? Partial care (supervised day program, therapeutic day program and medical day program); and ? Therapeutic foster care.



F.Medication The following medications are covered:

? Methadone; ? Psychotropic medication; and ? Psychotropic medication adjustment and monitoring.



301.03



EPSDT Services



A.Definition The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program provides



comprehensive health care for children under the age of 21 who are eligible for Medicaid. EPSDT provides all medically necessary services to treat all physical and behavioral health disorders, defects or conditions identified in an EPSDT screening, even if the treatment is not covered for other Medicaid eligible individuals. Limitations and exclusions, other than the requirement for medical necessity, do not apply to EPSDT services. NOTE:These services are also available to KidsCare children, however, not under the EPSDT program.



B.Covered Services



The following services are covered for eligible persons under age 21: ? Health screening services; ? Complete physical exams; ? Immunizations; ? Eye exams and glasses; ? Blood lead screening; ? Emergency dental services; ? Preventive dental exams and treatments; ? Hearing tests and hearing aids; ? Cochlear implants (for children 18 months and older); ? Nutritional assessment and nutritional therapy ? Behavioral health services; ? Chiropractic services; ? Personal care services; ? Case management services; ? Organ and tissue transplant services; and ? Other necessary health care, diagnostic services and treatment. Some services require prior authorization.



301.04



Family Planning Services



A.Definition Family planning services are services provided to individuals who voluntarily choose to

delay or prevent pregnancy.



B.Covered Services



The following services are covered family planning services: ? Contraceptive counseling, medication and supplies; ? Associated medical and laboratory examinations; ? Treatment of complications resulting from contraceptive use; ? Natural family planning education; ? Postcoital emergency oral contraception within 72 hours after unprotected sexual intercourse; ? Pregnancy screening; ? Screening and treatment for sexually transmitted diseases; and ? Sterilization for both men and women.



C.Services The following services are not covered for the purpose of family planning: That Are Not ? Infertility services; Covered

? Abortion counseling; ? Abortions; and ? Hysterectomies.



301.05



Long Term Care Services



A.Definition Long term care services must be medically necessary and may include:

? In-patient services provided in an institution; and ? Home and Community Based Services (HCBS).



B.Institutional Institutional services are provided by the following types of facilities, depending on the medical needs of the patient: Services

Type of Facility Nursing Facility (NF) Description Provides care for individuals who require round-the-clock skilled nursing care and related services, but do not require hospitalization. The care is needed to ensure the individual receives treatment, medication, a therapeutic diet and rehabilitative nursing under the direction of a physician.



Intermediate Care Facilities for the Mentally Retarded (ICFMR) Residential Treatment Centers (RTC) Institutions for Mental Diseases (IMD)



Specialized care centers designed to meet the specific needs of the mentally retarded or persons with related conditions. In-patient psychiatric facilities for individuals under age 21, or under age 22 if admitted before age 21, including the Arizona State Hospital (ASH) Psychiatric Hospitals such as the ASH and Behavioral Health Centers Level I containing 17 or more beds.



Persons under the age of 21 who reside in an IMD are eligible until the person reaches age 21 (or age 22 if admitted before age 21).



Customers age 65 or older who reside in an IMD are eligible without any time limitation.



Hospice



Persons between the ages of 21 and 64 can be determined eligible for ALTCS but only for 30 days per occurrence and 60 days per contract year (July 1 ? June 30), An in-patient hospice provides pain relief, symptomatic management, care and supportive services to terminally ill individuals and their family members.



C.Home and Community Based Services (HCBS)



HCBS are services that prevent institutionalization. They are provided in the customer's home or in an alternative residential setting such as an Adult Foster Care Home; an Assisted Living Home; an Assisted Living Center, or in a group home for the developmentally disabled. HCBS services are based on the medical needs of the patient and include:



Type of Service Description Adult Day Health Care Planned care, supervision and activities, personal care, training in Services personal living skills, meals and health monitoring in a group setting, for a portion of each day. Attendant Care Assistance with homemaking, personal care, general supervision and companionship. Day Treatment and Supervision, training, therapeutic activities and counseling to Training for the develop skills in independent living, communication and Developmentally socialization. Disabled Emergency Alert Monitoring devices/systems for customers who are unable to System access assistance in an emergency situation and/or live alone.



A variety of support services to enable developmentally disabled customers enrolled in the ALTCS transitional program maintain employment. Home Delivered Meals Prepared meals delivered to the home of an elderly or physically disabled individual. Home Health Services Nursing services, home health aide, occupational therapy, physical therapy, respiratory therapy and speech therapy. Home Modifications Physical modifications to the home that are medically necessary to enable the customer to function with greater independence. Homemaker Services Assistance with activities such as cleaning, shopping, meal preparation and laundry. Hospice In-home supportive care and counseling for terminally ill customers and their families and caregivers. Habilitation Services A variety of training and therapy services for the developmentally disabled. Nutritional Dietary assessment of customers age 21 or older whose health Assessments and status may be improved with nutritional intervention. Nutritional Therapy Nourishment to complete daily dietary requirements or supplement to the customer's daily nutritional and caloric intake when determined medically necessary. Personal Care Assistance with activities of daily life such as dressing, bathing, eating and mobility. Respite Short-term or intermittent care and supervision to provide rest and relief for the family members or other persons caring for an elderly or disabled individual. Transportation Transportation to and from approved health care and maintenance activities such as doctor's visits or therapy sessions.



Extended Supported Employment Services



301.06



Case Management Services



A.Definition Case management is the coordination and management of ALTCS services by a case

manager.



B.Who Provides Case Management Services? C.Covered Services



ALTCS program contractors are responsible for providing long term care, acute care, behavioral health services and case management services to enrolled customers. The program contractor assigns a case manager to each ALTCS customer. The case manager, in conjunction with the primary care provider, develops a plan for the overall management of the customer's care.



The Case Manager ensures that appropriate services to meet the customer's needs are identified, planned, obtained, provided, recorded and monitored. Case Management includes the following services:



Service Gatekeeping



Description The case manager assesses the customer's placement and services to make sure they are appropriate to meet the customer's needs.



Service planning



Using the results of the Pre-Admission Screening (PAS) and the gatekeeping assessment, the case manager identifies services that will meet the customer's needs in the most cost-effective manner.



The case manager develops a service plan for the customer that is mutually agreed upon by the customer and the customer's guardian or authorized representative.



Service provision Monitoring



Reassessment



If the customer does not have a primary care provider, the case manger coordinates efforts to obtain one. The case manager authorizes, obtains and coordinates the ALTCS services specified in the customer's service plan. The case manager monitors the services provided to the customer to ensure the services are provided according to the service plan. The case manager resolves problems the customer has regarding services. The case manager revises and modifies the customer's service plan as needed.



For example, the case manager arranges appropriate HCBS services for a customer who is being discharged from a hospital, nursing facility or other institutional facility.



301.07



Medicare Cost Sharing



A.Definition Medicare Cost Sharing includes payments of the following Medicare related costs:

? Medicare Part A Premiums; ? Medicare Part B Premiums; and ? Medicare coinsurance and deductibles. The following Medicare related costs may be covered depending on the service package for B.Medicare Related Costs which the customer qualifies: Cost Description



Medicare Part A premium



The monthly premium for Medicare hospital insurance that covers inpatient hospitalization, limited skilled nursing facility payments, home health care and hospice care.



Medicare Part B premium



Medicare hospital insurance is free to most Medicare eligible individuals, but some people must pay a monthly premium to enroll. The monthly premium for Medicare medical insurance which helps pay for doctor's services and other medical services and supplies that are not covered by Medicare Part A such as ambulance services and outpatient hospital care, X-rays and laboratory tests.



Deductibles Coinsurance



Payment of a monthly premium is required for everyone enrolled in Medicare Part B. The amount of medical bills a Medicare recipient must pay each year before Medicare begins paying. The portion of a medical bill that the Medicare recipient is responsible for paying after meeting the deductible. Medicare generally pays 80% of the bill and the coinsurance is the remaining 20%.



302.00



Service Packages



A.Service Packages



AHCCCS coverage is provided in the following service packages: ? AHCCCS Medical Services Package (MS 302.01); ? ALTCS Service Package (MS 302.02); ? Emergency Service Package (MS 302.03); ? Family Planning Extension Services Package (MS 302.04); ? QMB (MS 302.05); ? QMB and AHCCCS Medical Services Package (MS 302.05); ? QMB and ALTCS Medical Services Package (MS 302.05); ? SLMB (MS 302.05); ? QI-1 (MS 302.05); and ? QDWI (MS 302.05).



302.01



AHCCCS Medical Service Package



A.Service Package



The AHCCCS Medical Services package of services includes: ? Medical Services (MS 301.01); ? Behavioral Health Services (MS 301.02); ? EPSDT Services for Medicaid eligible children under age 21 (MS 301.03); ? Family Planning Services (MS 301.04); and ? Payment of the Part B Medicare premium (for individuals receiving Medicare Part B, except those eligible under AHCCCS Freedom to Work) (MS 301.07).



Most customers receive all medically necessary services, except payment of the Medicare B.How Services are Part B premium, from a Prepaid Health Plan (PHP). PHPs receive monthly capitation from AHCCCSA and are responsible for providing and paying for the medical, behavioral health, Provided EPSDT and family planning services the customer receives. Native Americans living on-reservation have the option of receiving medical, behavioral health, EPSDT and family planning services through Indian Health Services (IHS). AHCCCSA reimburses IHS on a fee-for-service basis. AHCCCSA pays the Medicare Part B premiums (for Medicare eligible customers) through the buy-in process.



C.Service Problems



When a customer complains about services or requests help resolving a service issue, use one or more of the following options: ? Advise the customer to contact the health plan or IHS to try to work out a satisfactory solution; ? Advise the customer to call the DMS Client Advocate at (602) 417-4230; ? Advise the customer to call the DMS Member Services Unit at (602) 417-7070 or from outside the Phoenix area 1-800-654-8713, ext. 77070; and ? If the customer has received written notice that requested services have been denied or services have been changed, remind the customer of the right to file a grievance with AHCCCS and/or with the health plan (if enrolled with a health plan). The written notice contains instructions about filing grievances.



D.Customer Families who have children eligible for KidsCare are required to pay monthly premiums. Premium amounts are based on income and the number of eligible children. The monthly Costs

premium is $10 to $35. Parents of KidsCare Children who are approved for Health Insurance for Parents are required to pay a monthly premium of $15.00, $25.00 or $35.00 for each eligible parent. Customers who are approved for AHCCCS Medical Services under the AHCCCS Freedom to Work program are required to pay a monthly premium (MS 1206.00). Other Medicaid customers do not pay monthly premiums, but may be responsible for copayments for certain services (MS 1205.00).



302.02



ALTCS Service Package



A.Service Package



The full ALTCS service package includes the following services: ? Case Management (MS 301.06); ? Medical Services (MS 301.01); ? Behavioral Health Services (MS 301.02); ? Family Planning Services (MS 301.04); ? Long Term Care Services (MS 301.05); ? EPSDT Services for Medicaid eligible children under age 21 (MS 301.03); and ? Payment of the Part B Medicare premium (for individuals receiving Medicare Part B, except those eligible under AHCCCS Freedom to Work). (MS 301.07) A limited ALTCS service package includes all of the services listed above except Long Term Care Services. A customer who is financially and medically eligible for ALTCS may qualify for the Limited ALTCS Service Package when: ? The customer resides in a living arrangement in which Long Term Care Services benefits cannot be provided (MS 519.00); or ? The customer has made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services (MS 900.00). ? The customer applies for ALTCS benefits on or after July 1, 2006, and the equity value of home property exceeds $500,000 (MS 706.24).



Most customers receive all medically necessary services except payment of Medicare B.How Services are premiums from a program contractor. Provided



? Program contractors receive capitation from AHCCCSA and are responsible for providing and paying for the services the customer receives. ? AHCCCSA pays the Medicare Part B premiums (for Medicare eligible customers) through the buy-in process.



Native Americans living on-reservation have the option of receiving ALTCS services through Native American tribal contractors. ? The tribal contractors provide case management services and referrals to other services. AHCCCSA pays the tribal contractors capitation for case management and pays providers on a fee-for-service basis. ? AHCCCSA also pays the Medicare Part B premiums (for Medicare eligible customers) through the buy-in process.



C.Service Problems



When a customer complains about services or requests help resolving a service issue, use one or more of the following options: ? Advise the customer to contact the program contractor or tribal contractor to try to work out a satisfactory solution; ? Advise the customer to call the DMS Client Advocate at (602) 417-4230; ? If the customer has received written notice that requested services have been denied or services have been changed, remind the customer of the right to file a grievance with AHCCCS and/or with the program contractor or tribal contractor. The written notice must contain instructions about filing grievances; and ? With supervisory approval, complete a Client Issue Referral (DE-638).



D.Customer A customer may be required to pay a portion of his or her income each month as a Share of Cost (SOC) for the services provided by AHCCCS. The SOC amount is based on the Costs

customer's income and is determined monthly on an individual basis (MS 1201.00). A customer who is approved for ALTCS HCBS services under the AHCCCS Freedom to Work program is required to pay a monthly premium (MS 1206.00).



302.03



Emergency Service Package



A. Service Package



The emergency service package is limited to services that are required to treat an emergency medical condition. Emergency services are services that: ? Are medically necessary, and ? Result from the sudden onset of a health condition with acute symptoms, and ? Which in the absence of immediate medical attention, is reasonably likely to result in at least one of the following:

?



Placing the individual's health in serious jeopardy, or Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part.



?



?



All services are paid by AHCCCSA on a fee-for service basis. B.How Services are Provided



C.Service Problems



Advise the customer to call the Member Services Unit at (602) 417-7070.



D.Customer All services received by the customer that meet the definition of emergency medical services are paid by AHCCCSA. Costs



302.04



Family Planning Extension Services Package



A.Service Package



A woman who loses S.O.B.R.A. eligibility becomes ineligible for AHCCCS Medical Services, but may receive Family Planning Extension Services. The Family Planning Extension Service Package includes the services described in MS 301.04with the following limitations: ? Pregnancy screening is covered only when provided prior to the provision of long-term contraceptives; ? Prescription medication is covered only when associated with a medical condition related to family planning; and ? Screening for sexually transmitted diseases is covered, but treatment is not covered.



Family planning services are paid by the Prepaid Health Plan with which the customer is B.How Services are enrolled. Provided



C.Service Problems



Advise the customer to call the Member Services Unit at (602) 417-7070.



302.05



Medicare Cost Sharing Packages



A.Service Packages



There are four (4) Medicare Cost Sharing packages: ? Qualified Medicare Beneficiary (QMB); ? Specified Low-Income Medicare Beneficiary (SLMB); ? Qualified Individual-1 (QI-1); and ? Qualified Disabled Working Individual (QDWI).



B.Ways to Qualify



Except for recipients of AHCCCS Freedom to Work, customers who are eligible for the AHCCCS Medical Service Package or the Long Term Care Service Package receive payment of Medicare Part B premiums as part of these service packages. Payment is provided to Social Security through the State buy-in process. A customer may also qualify for Medicare Cost Sharing benefits by meeting the eligibility requirements for one of the Medicare Cost Sharing programs. Customers who are eligible for AHCCCS Freedom to Work may also receive QMB or SLMB if they qualify. Because QI-1 eligibility is limited to individuals who are not eligible for any other AHCCCS programs, recipients of AHCCCS Freedom to Work do not qualify for QI-1. The following benefits are associated with each of the Medicare Cost Sharing programs:



Program QMB



Benefits Paid ? Medicare Part A premiums; ? Medicare Part B premiums; ? Medicare deductibles; and ? Medicare coinsurance Medicare Part B premiums Medicare Part B premiums Medicare Part A premium



SLMB QI-1 QDWI



C.Who pays A customer's Medicare Cost Sharing benefits are paid by different entities depending on the following factors: Medicare Cost ? The Medicare Cost Sharing program for which the customer qualifies (QMB, SLMB, QI-1, Sharing

or QDWI); ? Whether or not the customer also qualifies for another service package; and ? Whether or not the customer is a Native American who has chosen to enroll with IHS or a tribal contractor.



D.QMB Only AHCCCSA pays all QMB benefits for a customer who receives QMB, and is not approved



for either the AHCCCS Medical Services Package or the Long Term Care Service Package. When a customer is eligible for AHCCCS Medical Services and QMB, and is enrolled with a health plan, the health plan receives capitation from AHCCCSA to provide services to enrolled customers and, when the customer uses the health plan's providers, is responsible for paying:



E.AHCCCS and QMB Dual



? All services included in the AHCCCS Medical Services Package (except the Medicare premiums); and ? The Medicare deductibles and coinsurance. AHCCCSA pays the Medicare Part A and /or Part B premiums through the Buy-in process. If the customer is a Native American and is enrolled with IHS, AHCCCSA pays: ? For all services included in the AHCCCS Medical Services Package and the Medicare deductibles and coinsurance on a fee-for-service basis; and ? The Medicare Part A and/or Part B premiums through the buy-in process.



F.Long Term Care and QMB Dual



When a customer is eligible for ALTCS Services and QMB, and is enrolled with a program contractor, the program contractor receives capitation from AHCCCSA to provide services to enrolled customers. When the customer uses the program contractor's providers, the program contractor is responsible for paying: ? All services included in the ALTCS Services Package (except the Medicare Part B premiums); and ? The Medicare deductibles and coinsurance. AHCCCSA pays the Medicare Part A and /or Part B premiums through the Buy-in process. If the customer is a Native American and is enrolled with a tribal contractor: ? The program contractor receives capitation from AHCCCSA for case management services; and ? AHCCCSA pays the Medicare deductibles and coinsurance and all ALTCS Services other than case management on a fee-for-service basis.



G.SLMB, QI- SLMB, QI-1 benefits may be received in combination with AHCCCS Freedom to Work. QI1 and QDWI benefits are not received in combination with any other service package. 1, &QDWI

AHCCCSA pays the Medicare Part A premiums for QDWI and the Medicare Part B premiums for SLMB and QI-1 through the Buy-in process.



H.Medicare + Choice



When a customer has replaced Medicare coverage with a Medicare+ Choice plan, payment for services may be affected.



IF the customer has Medicare+ Choice and is eligible for... QMB Only



THEN... ? AHCCCSA pays the Medicare Part A and Part B premiums, and the deductibles and coinsurance for Medicare covered services; and



? The customer pays the coinsurance related to the services that are not covered by Medicare (such as prescriptions), but are provided by the Medicare+ Choice plan. The AHCCCS Medical Services Package ? AHCCCSA pays the Part B premiums; or The ALTCS Services Package but notQMB ? The customer pays copayments to providers who are in the Medicare+ Choice network, but not in the network of the customer's AHCCCS health plan or program contractor; and ? The AHCCCS health plan or program contractor pays the copayments for medical services that are covered by the Medicare+ Choice plan when the service is included in the customer's service package and the customer uses providers in AHCCCS health plan or program contractor's network. ? The customer must obtain medical services through the Medicare+ Choice plan; ? The customer pays copayments to providers who are in the Medicare+ Choice network, but not in the network of the customer's AHCCCS health plan or program contractor; ? The AHCCCS health plan or program contractor pays:

? Deductibles and coinsurance for Medicare services that are not covered by AHCCCS (e.g., chiropractic services), or that differ in scope or duration; ? Deductibles and coinsurance for all medical services obtained through a provider who is also in the customer's AHCCCS network;



? The customer must obtain medical services through the Medicare+ Choice plan;



QMBand ? The AHCCCS Medical Services Package; or ? The ALTCS Services Package



? Copayments for pharmacy and other physicianordered medical services that are covered by the Medicare+ Choice plan as long as the provider is in the customer's AHCCCS network. After the customer reaches the Medicare+ Choice cap, the AHCCCS health plan or program contractor pays the full cost of the medical service; and



? AHCCCSA pays the Part A and/or Part B premiums.



I. Service Problems



If the customer reports that Medicare Part A or Part B buy-in has not occurred, contact the Technical Services Center if you need help resolving the problem. If a QMB only customer reports problems obtaining payment of Medicare deductibles or coinsurance, refer the customer to the Member Services Unit at (602) 417-7070. If a customer who is eligible for QMB and ALTCS reports problems obtaining payment of Medicare deductibles or coinsurance, refer the customer to the ALTCS case manager. If a customer who is eligible for QMB and AHCCCS Medical Services reports problems obtaining payment of Medicare deductibles or coinsurance, refer the customer to the AHCCCS health plan. If the customer is a Native American who is enrolled with IHS or a tribal organization and reports problems obtaining payment of Medicare deductibles or coinsurance, refer the customer to the Member Services Unit at (602) 417-7070.



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Eligibility Policy Manual



400.00



AHCCCS Health Insurance Programs and Coverage Groups



A.Chapter Contents



This chapter contains the following topics:



Topic 401.00 402.00 403.00 404.00 405.00 406.00 407.00 408.00 409.00 410.00 411.00 412.00 413.00 414.00 416.00 417.00



AHCCCS Care AHCCCS Freedom to Work Arizona Long Term Care System (ALTCS) Breast and Cervical Cancer Treatment Program (BCCTP) Deemed Newborns Families with Children Health Insurance for Parents Healthcare Group KidsCare Medical Expense Deduction (MED) Medicare Cost Sharing (MCS) Pregnant Women S.O.B.R.A. Child SSI Cash 415.00 Supplemental Security Income Medical Assistance Only (SSI MAO) Title IV-E Foster Care and Adoption Subsidy Young Adults Transitional Insurance (YATI)



B.Introduction By reading this chapter for each AHCCCS Health Insurance Program and coverage group

you will learn: ? Who determines eligibility; ? Conditions of eligibility; ? Service package; ? Enrollment; ? Customer cost; ? Funding source; ? Legal authorities; and ? PMMIS key codes.



401.00



AHCCCS Care



A.General Description



AHCCCS Care is for individuals or couples who are not eligible as a family.



B.Who Determines Eligibility?



The Department of Economic Security, Family Assistance Administration, determines eligibility for AHCCCS Care.



The conditions of eligibility for AHCCCS Care are: C. Conditions of Eligibility ? Valid application; ? Interview, if required; ? Cooperation in providing information needed for eligibility determination; ? Resident of Arizona; ? Social Security number; ? U.S. citizen or appropriate non-citizen status; ? Not in a penal institution; ? Apply for potential benefits; ? Assignment of rights to medical benefits and cooperation; and ? Income at or below 100% of the FPL.



D.Service Package



Customers eligible for AHCCCS Care receive AHCCCS Medical Services (MS 302.01). If the customer meets all eligibility requirements except U.S. citizenship or appropriate non-citizen status, the customer is eligible to receive emergency services only (MS 302.03).



E. Enrollment



Customers approved for coverage under AHCCCS Care are enrolled in an AHCCCS Health Plan (MS 1101.00). Use the following tables to determine where to refer customers with questions about enrollment.



BEFORE ENROLLMENT... IF the customer has questions about... THEN the customer can...



Choosing a Health Plan



? Call the eligibility office where he/she applied; ? Review the AHCCCS Application for Health Insurance (Page D); or ? Call the AHCCCS Communications Center ? Call the Health Plans



Doctors, other providers, or available services AFTER ENROLLMENT... IF the customer has questions about.... Changing a Health Plan Choosing a doctor Other providers, or available services



THEN the customer can... ? Call the AHCCCS Communications Center ? Call the Health Plan ? Call the Health Plan



The AHCCCS Communications Center telephone numbers: ? If calling from area codes 602, 623, or 480 dial (602) 417-7100 ? If calling from area codes 520 or 928 dial (800) 334-5283



F. Customer The customer does not pay a premium for AHCCCS Medical Services. However, the customer may be responsible for co-payments for certain services (MS 1205.00). Cost



G.Funding Source



AHCCCS Care is funded by federal and state funds.



Funding Source Center for Medicare and Medicaid Services (CMS) State of Arizona



Amount Effective 10/01/01 77.08% 22.92%



Type of Funds Title XXI Combination of State General Fund and Tobacco Settlement Funds.



H.Legal Authorities



The table below shows the legal authorities and the references applied to AHCCCS Care eligibility. Legal Authority 1115 Waiver Arizona Revised Statute (ARS) Arizona Administrative Code (AAC) References ARS 36-2901.01 Title 9, Chapter 22, Article 14



I. PMMIS Key Codes



Listed below are the PMMIS eligibility key codes and descriptions.



Code 463 467



Description AHCCCS Care, Income Between 40% and 100% FPL, 6-Month Guarantee AHCCCS Care, Income Less Than 40% FPL, 6-Month AHCCCS AHCCCS AHCCCS Guarantee Care, Income Between 40% and 100% FPL Care, Income Less Than 40% FPL Care, Income Less Than 40% FPL,



585 587 927



930



Emergency Services AHCCCS Care, Income Between 40% and 100% FPL, Emergency Services



402.00



AHCCCS Freedom to Work (FTW)



A.General Description



AHCCCS Freedom to Work (FTW) is for eligible individuals with disabilities who are working.



There are two FTW coverage groups:

? The Basic Coverage Group, and ? The Medically Improved Group.



B.Who Determines Eligibility?



AHCCCS Freedom to Work Eligibility Specialists in the Phoenix South office determine eligibility for Freedom to Work.



The general conditions of eligibility for AHCCCS Health Insurance for both Freedom to C.General Conditions Work coverage groups are listed below: of Eligibility ? Valid application (MS 533.00);



? Age: at least age 16, but under age 65 (MS 502.00); ? Cooperation in providing information needed for eligibility determination; (MS 510.00); ? Resident of Arizona (MS 529.00); ? Not in a penal institution (MS 523.00); ? Social Security number (MS 531.00); ? U.S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00);



? Apply for potential benefits (MS 524.00); ? Assignment of rights to medical benefits and cooperation (MS 504.00); ? Monthly countable income under 250% FPL (MS 613.00); and ? Pay the FTW premium (MS 526.00).



In addition, to qualify for the AHCCCS Medical Services Package the customer must also: ? Have too much income to be eligible for all other acute care coverage groups (MS 520.00);



In addition, to qualify for the ALTCS Services Package the customer must also: ? Have too much income or resources to be eligible for ALTCS; ? Be medically in need of long term care services (MS 1000.00); ? Reside in a setting (living arrangement) where long term care services can be provided. (MS 519.00).



D.Basic Coverage Group Special Conditions of Eligibility



In addition to meeting the general conditions of eligibility for FTW in MS 406.C, a customer must meet the following special conditions to qualify for AHCCCS Health Insurance under the Freedom to Work Basic Coverage Group: ? Disabled (MS 511.00): Disabled means: ؒeceiving Social Security Disability (SSD); ؄etermined disabled by the Disability Determination Services Administration (DDSA) in a special process that disregards employment earnings and substantial Gainful Employment (SGA); or ؆or ALTCS FTW, be determined medically eligible for ALTCS services by the PreAdmission Screening (PAS). ? Employed (MS 512.00): For the Basic Coverage Group employed means the customer: ؉s working either part-time or full time; ؉s paid for working; and ؐays Social Security and Medicare taxes either through withholding from wages or by direct payments to the IRS.



E. Medically Improved Coverage Group ? Special Conditions of Eligibility



In addition to meeting the general conditions of eligibility for FTW in MS 402.00.C, a customer must meet the following special conditions to qualify for AHCCCS Health Insurance under the Freedom to Work Medically Improved Coverage Group: ? Become ineligible for AHCCCS Health Insurance under the FTW Basic Coverage Group because his or her medical condition has improved to the point where he or she no longer meets the Disability Determination Services Administration's definition of disabled; ? Be employed (MS 512.00): For the Medically Improved Coverage Group employed means: ؅arning at least the federal minimum wage and working at least 40 hours per month, or ؈aving gross monthly earnings at least equal to the amount of the federal minimum wage and working 40 hours per month. ? To determine if the customer's earnings meet this requirement use: ؔhe gross earnings of a wage earner; or ؇ross receipts less business expenses of a self-employed individual. ? Continue to have a medically determinable severe impairment (MS 530.00).



F.Service Package



Customers eligible for Freedom to Work receive AHCCCS Medical Services (MS 302.01). Customers, who meet the ALTCS medical eligibility requirements, in addition to the financial and non-financial eligibility requirements, receive an ALTCS services package (MS 302.02). Customers who receive ALTCS services under the FTW coverage groups may qualify for the ALTCS Transitional Program (MS 1000.00). A customer who is eligible for AHCCCS Freedom to Work may also be approved for QMB or SLMB, but cannot be eligible for QI-1.



G. Enrollment



Customers approved for coverage under AHCCCS Freedom to Work are enrolled in an AHCCCS Health Plan (MS 1101.00) or Program Contractor for ALTCS (MS 1103.00). Use the following tables to determine where to refer customers with questions about enrollment. BEFORE ENROLLMENT... IF the customer has questions about... Choosing a Health Plan THEN the customer can... ? Call the eligibility office where he/she applied; ? Review the AHCCCS Application for Health Insurance (Page D); or ? Call the AHCCCS Communications Center ? Call the Health Plans



Doctors, other providers, or available services



AFTER ENROLLMENT... IF the customer has questions about.... Changing a Health Plan Choosing a doctor THEN the customer can... ? Call the AHCCCS Communications Center ? Call the Health Plan



Other providers, or available services



? Call the Health Plan



The AHCCCS Communications Center telephone numbers: ? If calling from area codes 602, 623, or 480 dial (602) 417-7100 ? If calling from area codes 520 or 928 dial (800) 334-5283



H. Customer Cost



Customers who qualify for AHCCCS Medical Services or ALTCS Services under a FTW coverage group may have to pay a premium (MS 1206.00) or Share of Cost (MS 1201.00, 1202.00and 1203.00.D). Those who pay a premium may also be responsible for certain co-payments (MS 1205.00).



J. Funding source



AHCCCS Freedom to Work is funded by federal and state funds.



Amount Effective 10/01/01 Center for Medicare and Medicaid 67.25% Services (CMS) State of Arizona 32.75% Funding Source



Type of Funds Title XIX Combination of State General Fund and Tobacco Settlement Funds.



K. Legal Authorities



The table below shows the legal authorities and the references that apply to FTW eligibility.



Legal Authority United States Code Arizona Revised Statute (ARS) Arizona Administrative Code (AAC)



References 42 USC 1396a(a)(10)(A)(ii)(XV) and 42 USC 1396a(a)(10)(A)(ii)(XVI) ARS 36-2929 and ARS 36-2950 R9-22-1901 through R9-22-1904



L.PMMIS Key Codes



Listed below are the PMMIS eligibility key codes and a description of each.



Code 393 403



Description Freedom to Work, SSI MAO, Blind Freedom to Work, SSI MAO, Disabled



482 492 725 735



Freedom Freedom Freedom Freedom



to to to to



Work, Work, Work, Work,



SSI MAO, Blind, 6-Month Guarantee SSI MAO, Disabled, 6-Month Guarantee ALTCS, Blind ALTCS, Disabled



403.00



Arizona Long Term Care System (ALTCS)



A.General Description



Arizona Long Term Care System (ALTCS) is a Medicaid program under AHCCCS. ALTCS provides long term care services to financially and medically eligible Arizonans who are elderly, physically disabled or developmentally disabled and have a medical need for long term care services.



B.Who Determines Eligibility?



The Arizona Health Care Cost Containment System Administration (AHCCCSA) determines eligibility for ALTCS.



C. Conditions of Eligibility



The conditions of eligibility for ALTCS are listed in the following chart:



IF the customer ... Is receiving or deemed to be receiving SSI Cash (MS 532.00), or is receiving Title IV-E Foster Care (MS 515.00) or Adoption Subsidy (MS 501.00)



THEN the conditions of eligibility are... ? Valid application (MS 533.00); ? Interview, if required (MS 518.00); ? Resident of Arizona (MS 529.00); ? Not in a penal institution (MS 523.00); ? Reside in an appropriate ALTCS living arrangement (MS 519.00) ? Assignment of rights to medical benefits and cooperation (MS 504.00); ? Does not have a trust which causes the resources or income to exceed the limit (MS 800.00); and



? Medical need for LTC (MS 1000.00). Is not receiving or deemed ? Valid application (MS 533.00); to be receiving SSI Cash, or is not receiving Title IV? Interview, if required (MS 518.00); E Foster Care or Adoption Subsidy ? Categorical element (age 65 years or older (MS 503.00), blind (MS 505.00), or disabled (MS 511.00)); ? Cooperation in providing information needed for eligibility determination (MS 510.00); ? Resident of Arizona (MS 529.00);



? Social Security number (MS 531.00); ? U. S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00); ? Not in a penal institution (MS 523.00); ? Reside in an appropriate ALTCS living arrangement (MS 519.00) ? Apply for potential benefits (MS 524.00); ? Assignment of rights to medical benefits and cooperation (MS 504.00); ? Resources (MS 700.00): $2000 for individual $3,000 for couple (If the applicant has a spouse living in the community, between $18,552 and $92,760 of the couple's resources may be disregarded); ? Resource Assessment (Community Spouse only ) (MS 709.00); ? Income (MS 600.00): 300% of FBR (MS 615.00.B) 100% of FBR (MS 615.00.B); and ? Medical Need for LTC (MS 1000.00). ? Valid application (533.00); ? Interview, if required (MS 518.00); ? Categorical element (child (MS 507.00) or pregnant (MS 525.00)); ? Cooperate in providing information needed for eligibility determination (MS 510.00); ? Resident of Arizona (MS 529.00); ? Social Security Number (MS 531.00); ? U. S. citizen (MS 508.00) or appropriate non-citizen status (MS 522.00); ? Not in a penal institution (MS 523.00); ? Reside in an appropriate ALTCS living arrangement (MS 519.00); ? Apply for potential benefits (MS 524.00);



Is under age 19 or is pregnant; and has resources, which exceed the ALTCS limit



? Assignment of rights to medical benefits and cooperation (MS 504.00); ? Income: the S.O.B.R.A. child level (MS 615.00.I) or S.O.B.R. A. pregnant women level (MS 615.00.J); and ? Medical Need for LTC (MS 1000.00).



D.Service Package



The type of service package a customer who is eligible for ALTCS receives depends on the customer's living arrangement and/or if the customer has refused HCBS or made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services. IF the customer ... Is residing in a living arrangement in which Long Term Care services can be received (MS 519.00) Is residing in a living arrangement in which Long Term Care services can not be received (MS 519.04) Refuses the home and community based services offered by the case manager (MS 1500.00) Has made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services (MS 900.00). Owns home property in which the equity value exceeds $500,000 (MS 706.24) THEN the service package is the... Full ALTCS service package (MS 302.02.A.)



Limited ALTCS service package (MS 302.02.A.)



E.Customer Some ALTCS customers have to pay a share of the cost of their ALTCS health insurance (MS 1201.00). Cost



F.Enrollment Customers approved for coverage under ALTCS are enrolled with an ALTCS Program

Contractor (MS 1103.00).



G.Funding Source



ALTCS is funded by federal, state and county monies.



Funding Source Center for Medicare and Medicaid Services (CMS) State of Arizona County



Amount Effective 10/01/01 67.25% 22.75% 10%



Type of Funds Title XIX State General Fund County Funds



H.Legal Authorities



The table below shows the legal authorities and the references applied to ALTCS eligibility.



Legal Authority United States Code (USC) Code of Federal Regulations (CFR) Arizona Revised Statute (ARS) Arizona Administrative Code (AAC)



References Title 42, Chapter 7, Subchapter XIX Title 42, Chapter IV, Part 435 Title 36 Chapter 29, Article 2 Title 9, Chapter 28



I. PMMIS Key Codes



Listed below are the PMMIS eligibility key codes and a description of each.



Code 040 050 060 085 090 100 120 130 140



Description ALTCS, SSI Cash, Over Age 65 ALTCS, SSI Cash, Blind ALTCS, SSI Cash, Disabled ALTCS, AFDC, Title IV-E ALTCS, SSI MAO, Over Age 65 ALTCS, AFDC MAO, Child ALTCS, AFDC, MAO, Pregnant ALTCS, SSI MAO, Blind ALTCS, SSI MAO, Disabled



404.00



Breast and Cervical Cancer Treatment Program (BCCTP)



A.General Description



The Breast &Cervical Cancer Treatment Program (BCCTP) is for women who need treatment for breast cancer, cervical cancer, or a