Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective June 16, 1992 (Supp. 92-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 6 A.A.R. 3372, effective August 7, 2000 (Supp. 00-3). Amended by exempt rulemaking at 7 A.A.R. 4357, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-102. Dually Eligible

Under A.R.S. § 36-2971, a person determined eligible under Article 2 of this Chapter for QMB, may also be eligible for Acute Care services provided for in 9 A.A.C. 22 or ALTCS services provided for in 9 A.A.C. 28.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

ARTICLE 2. ELIGIBILITY

R9-29-201. General

A. Eligibility determination. AHCCCS shall determine eligibility for a QMB, SLMB, or QI-1 under this Article.

B. Confidentiality. AHCCCS shall maintain the confidentiality of a person's financial information except as provided under Article 5.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-202. Opportunity to Apply

The Administration shall provide the opportunity to apply without delay.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective June 16, 1992 (Supp. 92-2). Section repealed; new Section adopted effective April 14, 1998 (Supp. 98-2). Section repealed; new Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-203. How to File an Application

A. Written application. To apply for the MCS Program, a person shall submit a written application form prescribed by AHCCCS to any AHCCCS office or outstation location approved by AHCCCS.

B. Who shall submit. An application shall be submitted by a person listed in A.A.C. R9-22-1405(B).

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Section repealed; new Section adopted effective April 14, 1998 (Supp. 98-2). Section repealed; new Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-204. Date of Application

The date of application is the date a signed application is received at an AHCCCS office or outstation location approved by AHCCCS.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Repealed effective April 14, 1998 (Supp. 98-2). New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-205. Complete Application

AHCCCS shall determine whether an application is complete under A.A.C. R9-22-1405(E).

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-206. Assistance with Application

A. Applicant's representative. AHCCCS shall allow a person of an applicant's choice to accompany, assist, and represent the applicant in the application process.

B. Assistance by AHCCCS. If requested, AHCCCS shall help a person complete an application.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-207. Assignment of Rights

A person determined eligible for QMB benefits assigns rights to medical benefits to which the person is entitled under operation of law to AHCCCS, under A.R.S. §§ 36-2903 and 36-2972.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-208. Medical Support Obligation

To be eligible for QMB, a person shall provide information necessary to establish paternity and enforce medical support obligations, when requested by AHCCCS.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-209. Social Security Number (SSN)

To be eligible for MCS a person shall furnish a SSN or apply for a SSN.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-210. Citizenship

To be eligible for MCS, a person shall be a United States citizen or a qualified alien under A.R.S. § 36-2903.03.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-211. Residency

To be eligible for MCS, a person shall be a current resident of this state.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-212. Income Calculation

AHCCCS shall calculate income under A.A.C. R9-22-1503.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-213. Income Standards

To be eligible, a person's income shall meet the following federal poverty levels (FPL), adjusted annually:

1. QMB. Income is equal to or less than 100 per cent of the FPL.

2. SLMB. Income is greater than 100 per cent but less than 120 per cent of the FPL.

3. QI-1. Income is at least 120 per cent but less than 135 per cent of the FPL.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-214. Application for Other Benefits

To be eligible for MCS, a person shall apply for other benefits, if requested by AHCCCS.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-215. Institutionalized Person

The provisions in A.A.C. R9-22-1402 apply to this Article for an institutionalized person.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-216. Resources

Resources mean property that a person owns including, but not limited to cash, financial accounts, real property, vehicles, trusts, and life insurance. Resources are not considered in determining a person's MCS eligibility.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-217. Verification

To be eligible for MCS, a person shall provide verification, or authorize the release of verification, for all information necessary to complete the determination of eligibility.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-218. Medicare Requirements

To be eligible for MCS, a person shall either be receiving Medicare Part A benefits or determined conditionally entitled to Medicare Part A benefits by the Social Security Administration. A person may request that the Social Security Administration determine the person to be conditionally entitled to Medicare Part A if the person is required to pay a Part A premium. A person who is conditionally entitled to Medicare Part A is not enrolled in Part A unless approved for QMB.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-219. Eligibility Determination

AHCCCS shall make an eligibility determination within 45 days of the date of application.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-220. Notice of Eligibility Determination

A. Notice. AHCCCS shall send an applicant written notice of the eligibility decision. The notice shall include a statement of the action and an explanation of the person's hearing rights specified in Article 5.

B. Approval. If AHCCCS determines that the applicant is eligible, the notice shall contain the effective date of eligibility.

C. Denial. If AHCCCS determines that the applicant is not eligible, the notice shall contain:

1. The effective date of the decision;

2. A statement detailing the reason for the decision, including specific financial calculations and the financial eligibility standard if applicable; and

3. The legal authority supporting the decision.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-221. Effective Date of Eligibility

A. QMB. The effective date of eligibility is the first day of the month following the month in which AHCCCS makes the eligibility decision.

B. SLMB and QI-1. The effective date of eligibility is the first day of the first month AHCCCS determines the person is eligible under this Article, but no earlier then the first day of the month of application.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-222. Discontinuance

A. Discontinuance. AHCCCS shall discontinue a person's eligibility if any of the conditions of eligibility under this Article are not met.

B. Notice. AHCCCS shall follow the discontinuance notice requirements under R9-22-1413.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-223. Redetermination

A. QMB and SLMB. AHCCCS shall redetermine a person's eligibility for QMB or SLMB at least one time every 12 months.

B. QI-1. A person receiving QI-1 benefits shall reapply each calendar year.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-224. Reporting Changes

A person eligible under this Article shall report to an ALTCS or Social Security Insurance Medical Assistance Only office the following changes for the person, the person's spouse, or the person's dependent children:

1. A change of address;

2. An admission to, or discharge from, a public institution, as specified in R9-22-1402;

3. A change in household composition;

4. A change in income;

5. A determination of eligibility for other benefits;

6. A death;

7. A change in marital status;

8. A change in Arizona state residency;

9. A change in citizenship or alien status;

10. Receipt of a SSN;

11. A change in Medicare receipt or eligibility; and

12. For QMB recipients, a change in first- or third-party liability that may be responsible for payment of all or a portion of the person's medical costs.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

ARTICLE 3. BENEFITS AND SERVICES

R9-29-301. QMB Only

A. QMB benefits. A person determined eligible as a QMB only member shall receive payment of:

1. Medicare Part A premium,

2. Medicare Part B premium, and

3. Medicare coinsurance and Medicare deductible for Medicare covered services under Title XVIII of the Act.

B. Payment of QMB only benefits.

1. The Administration shall:

a. Pay Medicare Part A and Part B premiums, and

b. Pay the coinsurance and deductible to the provider.

2. The Administration shall not pay:

a. More than the Medicare-approved amounts, or

b. Coinsurance or deductible to a member.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-302. Dually Eligible Member

A. Covered services. A person determined to be a dually eligible member shall receive medical services and provisions under 9 A.A.C. 22, Article 2, or services and provisions under 9 A.A.C. 28, Article 2, in addition to the Medicare-related payments under R9-29-301(A).

B. Payment responsibilities. AHCCCS shall pay the Medicare Part A and Part B premiums. The contractor shall pay the coinsurance and deductibles in accordance with the contract with AHCCCS.

C. Member responsibilities. A dually eligible member who receives services under 9 A.A.C. 22, Article 2 or 9 A.A.C. 28, Article 2 from a provider within the contractor's network is not liable for any Medicare coinsurance, deductible, or copayment associated with those services and is not liable for any balance.

D. Coordination of prescription drug benefit with Medicare Part D. Notwithstanding subsections (A) through (C), services do not include pharmaceutical services to the extent limited under 42 U.S.C. 1396u-5(d). A contractor is not liable for any Medicare coinsurance, deductible, or copayment associated with pharmaceutical services subject to the limitation under 42 U.S.C. 1396u-5(d).

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4). Amended by final rulemaking at 12 A.A.R. 864, effective March 7, 2006 (Supp. 06-1).

R9-29-303. SLMB and QI-1

AHCCCS shall pay Medicare Part B premiums.

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

ARTICLE 4. CONTRACTOR, PROVIDER, AND NONCONTRACTING PROVIDER REQUIREMENTS

R9-29-401. Contractor, Provider, and Noncontracting Provider Requirements

A. For dually eligible members, a contractor is responsible for benefits and services under R9-29-302(B) and either 9 A.A.C. 22 or 9 A.A.C. 28, as applicable.

B. A contractor shall pay a copayment for services provided to a dually eligible member by or under referral from the member's primary care physician or primary care practitioner, under A.R.S. § 36-2974.

C. Providers and noncontracting providers shall submit all claims for copayments, deductibles, and coinsurance for services rendered to a QMB-only member under A.R.S. § 36-2904(H).

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-402. Repealed

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Repealed effective April 14, 1998 (Supp. 98-2).

R9-29-403. Repealed

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Repealed effective April 14, 1998 (Supp. 98-2).

Editor's Note: The following Section was repealed effective April 14, 1998 (Supp. 98-2), but the text was inadvertently not removed. It is now removed (Supp. 01-2).

R9-29-404. Repealed

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Repealed effective April 14, 1998 (Supp. 98-2).

ARTICLE 5. GRIEVANCE AND APPEAL PROCESS

R9-29-501. General Provisions for a Grievance and a Request for Hearing

A request for hearing under this Chapter shall comply with A.A.C. R9-22-801 and R9-22-802. For the purposes of this Article, "hearing" means an administrative hearing under Title 41, Chapter 6, Article 10.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Section repealed; new Section adopted by final rulemaking at 6 A.A.R. 3372, effective August 7, 2000 (Supp. 00-3). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-502. Repealed

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Section repealed; new Section adopted by final rulemaking at 6 A.A.R. 3372, effective August 7, 2000 (Supp. 00-3). Section repealed by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-503. Eligibility Hearing for an Applicant or a Member

An eligibility hearing for a member or an applicant under this Chapter shall comply with A.A.C. R9-22-803.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Section repealed; new Section adopted by final rulemaking at 6 A.A.R. 3372, effective August 7, 2000 (Supp. 00-3). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-504. Repealed

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Repealed effective April 14, 1998 (Supp. 98-2).

ARTICLE 6. FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES

R9-29-601. First- and Third-party Liability and Recoveries

A. The provisions specified in 9 A.A.C. 22, Article 10 apply to this Section. For the purposes of this Article, "third-party liability" means the resources available from a person, entity, or program that is or may be, by agreement, circumstance, or otherwise, liable to pay all or part of the medical expenses incurred by an applicant or member.

B. AHCCCS shall not be liable for payment of coinsurance and deductibles when Medicare denies payment.

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).

R9-29-602. Repealed

Historical Note

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Section repealed by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4).