Section R9-22-306. Administration, Administration’s designee or Member Responsibilities

A.      The Administration or its designee is responsible for the fol- lowing:

1.        The Administration or its designee shall determine eligi- bility within 90 days for an applicant applying on the basis of disability and 45 days for all other applicants, unless:

a.         The agency cannot reach a decision because the applicant or an examining physician delays or fails to take a required action, or

b.        When there is an administrative or other emergency beyond the agency’s control.

2.        If an applicant dies while an application is pending, the Administration or its designee shall complete an eligibil- ity determination for the deceased applicant.

3.        The Administration or its designee shall complete an eli- gibility determination on an application filed on behalf of a deceased applicant.

4.        During the application process the Administration or its designee shall provide information to the applicant or member explaining the requirements to:

a.         Cooperate with DCSS in establishing paternity and enforcing medical support, except in circumstances when good cause under 42 CFR 433.147 exists for not cooperating;

b.        Establish good cause for not cooperating with DCSS in establishing paternity and enforcing medical sup- port, when applicable;

c.         Report a change listed under subsection (B)(3)(c) no later than 10 days from the date the applicant or member knows of the change;

d.        Send to the Administration or its designee any medi- cal support payments resulting from a court order;

e.         Cooperate with the Administration or its designee's assignment of rights and securing payments received from any liable party for a member's medical care.

5.        Offer to help the applicant or member to complete the application form and to obtain the required verification;

6.        Provide the applicant or member with information explaining:

a.         The eligibility and verification requirements for AHCCCS medical coverage;

b.        The requirement that the applicant or member obtain and provide a SSN to the Administration or its des- ignee;

c.         How the Administration or its designee uses the SSN;

7.        Explain to the applicant or member the practice of exchange of eligibility and income information through the electronic service established by the Secretary;

8.        Explain to the applicant and member the right to appeal an adverse action under R9-22-315;

9.        Use any information provided by the member to complete data matches with potentially liable parties;

10.     Explain the eligibility review process;

11.     Explain the AHCCCS pre-enrollment process;

12.     Use the Systematic Alien Verification for Entitlements (SAVE) process to verify qualified alien status;

13.     Provide information regarding the penalties for perjury and fraud on the application;

14.     Review any verification items provided by the applicant or member and inform the member of any additional ver- ification items and time-frames within which the appli- cant or member shall provide information to the Administration or its designee;

15.     Explain to the applicant or member the applicant's and member's responsibilities under subsection (B);

16.     Transfer the applicant’s information to other insurance affordability programs as described under 42 CFR 435.1200(e) when the applicant does not qualify for Med- icaid;

17.     Attain a written record of a collateral contact: such as a verbal statement from a representative of an agency or organization, or an individual with actual knowledge of the information;

18.     Complete a review of eligibility:

a.         Any time there is a change in a member's circum- stance that may affect eligibility,

b.        For a member approved for the MED program under R9-22-1435 through R9-22-1440 before the end of the six-month eligibility period,

c.         Of each member's continued eligibility for AHC- CCS medical coverage once every 12 months;

19.     The Administration or its designee shall discontinue eli- gibility and notify the member of the discontinuance under R9-22-307 if the member:

a.         Fails to comply with the review of eligibility,

b.        Fails to comply under 42 CFR 433.148 with the requirements and conditions of eligibility under this Article regarding assignment of rights and coopera- tion of establishing paternity and obtaining medical support, or

c.         Does not meet the eligibility requirements; and

20.     Redetermine eligibility for a person terminated from the SSI cash program.

a.         Continuation of AHCCCS medical coverage. The Administration shall continue AHCCCS medical coverage for a person terminated from the SSI cash program until a redetermination of eligibility is com- pleted.

b.        Coverage group screening. Before terminating a per- son from the SSI cash program, the Administration shall determine if the person is eligible for coverage as a person described in A.R.S. §§ 36-2901(6)(a)(i) through (vi) or 36-2934.

c.         Eligibility decision.

i.         If a person is eligible under this Article or 9

A.A.C. 28, Article 4, the Administration shall send a notice informing the applicant that AHCCCS medical coverage is approved.

ii.        If a person is ineligible, the Administration shall send a notice to deny AHCCCS medical coverage.

B.       Applicant and Member Responsibilities.

1.        An applicant or a member shall authorize the Administra- tion or its designee to obtain verification for initial eligi- bility or continuation of eligibility.

2.        As a condition of eligibility, an applicant or a member shall:

a.         Provide the Administration or its designee with complete and truthful information. The Administra- tion or its designee may deny an application or dis- continue eligibility if:

i.         The applicant or member fails to provide infor- mation necessary for initial or continuing eligi- bility;

ii.        The applicant or member fails to provide the Administration or its designee with written authorization or electronic authorization to per- mit the Administration or its designee to obtain necessary initial or continuing eligibility verifi- cation;

iii.      The applicant or member fails to provide verifi- cation under R9-22-304 after the Administra- tion or its designee made an effort to obtain the necessary verification but has not obtained the necessary information; or

iv.       The applicant or member does not assist the Administration or its designee in resolving incomplete, inconsistent, or unclear informa- tion that is necessary for initial or continuing eligibility;

b.        Cooperate with the Division of Child Support Ser- vices (DCSS) in establishing paternity and enforcing medical support obligations when requested unless good cause exists for not cooperating under 42 CFR

433.147 as of October 1, 2012, which is incorpo- rated by reference, on file with the Administration, and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N. Capitol St., NW, Washington, DC, 20401. This incorporation by ref- erence contains no future editions or amendments. The Administration or its designee shall not deny AHCCCS eligibility to an applicant who would oth- erwise be eligible, is a minor child, and whose par- ent or legal representative does not cooperate with the medical support requirements or first- and third- party liability requirements under Article 10 of this Chapter; and

c.         Provide the information needed to pursue third party coverage for medical care, such as:

i.         Name of policyholder,

ii.        Policyholder's relationship to the applicant or member,

iii.      Name and address of the insurance company, and

iv.       Policy number.

3.        A member or an applicant shall:

a.         Send to the Administration or its designee any medi- cal support payments received while the member is eligible that result from a medical support order;

b.        Cooperate with the Administration or its designee regarding any issues arising as a result of Eligibility Quality Control described under A.R.S. § 36- 2903.01; and

c.         Inform the Administration or its designee of the fol- lowing changes within 10 days from the date the applicant or member knows of a change:

i.         In address;

ii.        In the household's composition;

iii.      In income;

iv.       In resources, when required under the Medical Expense Deduction (MED) program;

v.        In Arizona state residency;

vi.       In citizenship or immigrant status;

vii.     In first- or third-party liability that may contrib- ute to the payment of all or a portion of the per- son's medical costs;

viii.    That may affect the member's or applicant's eli- gibility, including a change in a woman's preg- nancy status;

ix.       Death;

x.        Change in marital status; or

xi.       Change in school attendance.

4.        As a condition of eligibility, an applicant or a member shall cooperate with the assignment of rights as required by R9-22-311. If the applicant or member receives medi- cal care and services for which a first or third party is or may be liable, the applicant or member shall cooperate with the Administration or its designee in assisting, iden- tifying and providing information to assist the Adminis- tration or its designee in pursuing any first or third party who is or may be liable to pay for medical care and ser- vices.

5.        A pregnant woman under A.R.S. § 36-2901(6)(a)(ii) is not required to provide the Administration or its designee with information regarding paternity or medical support from a father of a child born out of wedlock.

C.      Administration or its designee responsibilities at Eligibility Renewal.

1.        The Administration or its designee shall renew eligibility without requiring information from the individual if able to do so based on reliable information available to the agency, including through an electronic data match. If able to renew eligibility based on such information, the Administration or its designee shall send the member notice of:

a.         The eligibility determination; and

b.        The member’s requirement to notify the Administra- tion or its designee if any of the information con- tained in the renewal notice is inaccurate.

2.        If unable to renew eligibility, the Administration or its designee shall:

a.         Send a pre-populated renewal form listing the infor- mation needed to renew eligibility,

b.        Give the member 30 days from the date of the renewal form to submit the signed renewal form and the information needed,

c.         Send the member notice of the renewal decision under R9-22-312 or R9-22-1413(B) as applicable.

Historical Note

Adopted effective August 30, 1982 (Supp. 82-4). Former Section R9-22-306 repealed, new Section R9-22-306 adopted effective November 20, 1984 (Supp. 84-6).

Amended effective October 1, 1985 (Supp. 85-5).

Amended subsection (B), paragraphs (1) and (6) effective October 1, 1986 (Supp. 86-5). Amended subsection (B), paragraph (1) and added a new subsection (N) effective January 1, 1987, filed December 31, 1986 (Supp. 86-6). Amended subsection (B) effective October 1, 1987; amended subsection (N) effective December 22, 1987 (Supp. 87-4). Amended effective April 13, 1990 (Supp.

90-2). Amended effective September 29, 1992 (Supp. 92- 3). Amended under an exemption from the provisions of

Arizona Health Care Cost Containment System - Administration

the Administrative Procedure Act, effective July 1, 1993 (Supp. 93-3). Amended under an exemption from the pro- visions of the Administrative Procedure Act, effective October 26, 1993 (Supp. 93-4). Section repealed by final

rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). New Section R9-22-306 made by final rulemaking at 20 A.A.R. 192, effective January 7, 2014

(Supp. 14-1).