3.1 Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and Low Income
3.1.4 Did you know…?
3.1.6-A. Title XIX/XXI screening and eligibility
3.1.6-B. Reporting requirements for Title XIX/XXI Eligibility Screening
3.1.6-C. Medicare Part D Prescription Drug coverage and "Limited
Income Subsidy (LIS) program" eligibility
3.1.6-D. What if a person refuses to participate
with the screening and/or application process for Title XIX/XXI or
enrollment in a Part D plan?
Eligibility status is essential for knowing the types of behavioral
health services a person may be able to access. In Arizona’s
public behavioral health system, a person may:
- Be eligible
for Title XIX (Medicaid) or Title XXI covered services;
- Not qualify
for Title XIX/XXI services but be eligible for services as
a person determined to have a serious mental illness (SMI);
- Be covered
under another health insurance plan, or “third party; (including Medicare and plans available via the Federal health Insurance Marketplace), or
- Be without
insurance or entitlement status and asked to pay a percentage
of the cost of services.
current eligibility and enrollment status is one of the first things
a Tribal/Regional Behavioral Health Authority (T/RBHA) or behavioral health provider does upon receiving a request
for behavioral health services. For persons who are not Title XIX
or Title XXI eligible, a financial screening and eligibility application
must be filed with the appropriate eligibility agency (e.g., The
Arizona Health Care Cost Containment System (AHCCCS), the Department
of Economic Security (DES).
Beginning January 1, 2006, Medicare
eligible behavioral health recipients, including persons who are
dually eligible for Medicare (Title XVIII) and Medicaid (Title
XIX/XXI), started receiving Medicare Part D prescription drug benefits
through Medicare Prescription Drug Plans (PDPs) or Medicare
Advantage Prescription Drug Plans (MA-PDs). The T/RBHA must develop and make available to their providers policies and procedures that include information indicating whether the T/RBHA is part of any Medicare Advantage plan network to provide the Medicare Part D benefit.
information will assist providers of covered services in:
and interpreting eligibility and enrollment information;
financial screenings and assisting persons with applying for
Title XIX or other benefits; and
potential eligibility for Medicare Part D Prescription Drug
coverage and the Low Income Subsidy (LIS) program.
The following citations can serve as additional resources for this
To whom does this apply?
This standard applies to all persons who are currently or potentially
eligible for Title XIX or Title XXI behavioral health services.
Did you know…?
- The Arizona
Health Care Cost Containment System’s (AHCCCS’) Application
for Health Insurance (see the Assisting Behavioral Health Recipients
with AHCCCS Eligibility Manual) was designed to make the application
process easier. Applicants can fill out the application and it
will be routed to the correct eligibility determination office.
The application also permits a person to apply for all AHCCCS
programs for all family members on one application form. If the
results of the eligibility screening indicate that a person may
be eligible for the Medicare Part D prescription drug benefit or
Title XIX in order to continue to receive
services, the applicant’s application must be submitted within
ten working days to the SSA, DES or AHCCCS, which shall
determine the applicant's eligibility.
- In most cases,
an eligibility determination is completed within 45 days after
the date of application, unless the person is pregnant (completed
within 20 days) or in an inpatient hospital at the time of application
(completed within 7 days).
- It is preferred
and advantageous to use a person’s AHCCCS identification
number as opposed to the person’s social security number
when inquiring about a person’s current eligibility status.
- Title XIX funding is not available to cover drugs
available through Medicare Part D for persons dually eligible for Medicare and Medicaid.
- Medicare Part D Prescription Drug
coverage is a voluntary benefit, but eligible persons who do not
enroll in a Part D plan MAY not have access to prescription drug
coverage through the T/RBHA.
- To identify methods for accessing and interpreting Title XIX eligibility
- For persons who are not Title XIX
eligible, describe the procedures to screen persons for Title XIX
eligibility and, if indicated, apply for AHCCCS health insurance
- To identify and assist persons eligible for Medicare with
enrolling in a Part D plan and with applying for the Low Income
program to pay the cost sharing of Medicare Part D.
Title XIX/XXI screening and eligibility
What is the
the person’s Title XIX or Title XXI eligibility;
those persons who are not Title XIX or Title XXI eligible, screen
for potential Title XIX or other eligibility; and
indicated by the screening tool, assist persons with applications
for a Title XIX or Title XXI eligibility determination.
Step #1-Accessing Title XIX/XXI or other eligibility information
contracted providers who need to verify the eligibility and
enrollment of an AHCCCS member can use one of the alternative verification
processes 24 hours a day, 7 days a week. These processes include:
web-based verification. (Customer Support 602-417-4451)
This web site allows the providers to verify eligibility and
enrollment. To use the web site, providers must create an
account before using the applications. To create an account, go
https://azweb.statemedicaid.us/Home.asp and follow the
prompts. Once the providers have an account they can view
eligibility and claim information (claim information is limited
to FFS). Batch transactions are also available. There is no
charge to providers to create an account or view transactions. For technical Web-based issues, contact AHCCCS Customer Support at 602-417-4451, Monday – Friday 7:00 a.m. to 5:00 p.m.;
AHCCCS’ contracted Medical Electronic Verification Service
The AHCCCS member card can be “swiped” by providers to
automatically access the AHCCCS Prepaid Medical Management System (PMMIS) for up to date
eligibility and enrollment. For information on MEVS, contact the
MEVS vendor: Emdeon at 1-800-444-4336;
Interactive Voice Response (IVR) system.
IVR allows unlimited verification information by entering the
AHCCCS member’s identification number on a touch-tone telephone.
This allows providers access to AHCCCS’ PMMIS system for up to
date eligibility and enrollment. Maricopa County providers may
also request a faxed copy of eligibility for their records.
There is no charge for this service. Providers may call IVR
within Maricopa County at (602) 417-7200 and all other counties
at 1-800-331-5090, and
- Medifax. Medifax allows providers to use a PC or
terminal to access the AHCCCS’ PMMIS system for up to date
eligibility and enrollment information. For information on EVS,
contact Emdeon at 1-800-444-4336.
If a person’s
Title XIX or Title XXI eligibility status still cannot be determined
using one of the above methods, a behavioral health provider must:
- Call the
Gila River Intake and Enrollment Manager at (602)
528-7942 for assistance during normal business hours (8:00 am
through 5:00 pm, Monday-Friday); or
- Call the AHCCCS Verification Unit,
which is open Monday through Friday, from 7:00 a.m. to 7:00 p.m.
The Unit is closed Saturdays and Sundays and on the following
holidays: New Year's Day, Memorial Day, Independence Day,
Thanksgiving Day and Christmas Day. Callers from outside
Maricopa County can call 1-800-962-6690 or call (602) 417-7000 in
Maricopa County and remain on the line for the next available
representative. When calling the AHCCCS Verification Unit, the
provider must be prepared to provide the
verification unit operator the following information:
- The provider’s identification number;
recipient’s name, date of birth, AHCCCS identification
number and social security number (if known); and
Step #2-Interpreting eligibility information
A provider will access two important pieces of
information when using the eligibility verification methods described
in Step #1: The
AHCCCS Codes and Values (CV) Reference System includes a key code index that may be used by providers to interpret AHCCCS AHCCCS eligibility key codes and/or AHCCCS
T/RBHAs must ensure that providers have access to and are familiar with the codes as they may help indicate provider responsibility for the delivery of Title XIX/XXI covered services.
If Title XIX
or Title XXI eligibility status and behavioral health provider responsibility
is confirmed, the behavioral health provider must provide any needed
covered behavioral health services in accordance with the ADHS/DBHS
Provider Manual and the
ADHS/DBHS Covered Behavioral Health Services Guide.
There are some
instances that a person may be Title XIX eligible but the ADHS/DBHS
behavioral health system is not responsible for providing covered
behavioral health services. This includes persons enrolled as elderly
or physically disabled (EPD) under the Arizona Long Term Care
System (ALTCS) Program and persons
eligible for family planning services only through the Sixth
Omnibus Reconciliation Act (SOBRA) Extension
Program. A person who is Title XIX eligible through ALTCS must be
referred to their ALTCS case manager to arrange for provision of
Title XIX behavioral health services. However, ALTCS-EPD individuals
who are deternimed to have Serious Mental Illness
may also receive Non-Title XIX SMI services from the T/RBHA. ALTCS-Division
of Developmental Disabilities (DDD) persons’ behavioral health
services are provided through the ADHS/DBHS behavioral health
If the person
is not currently Title XIX eligible, proceed to step
#3 and conduct a screening for Title XIX or other eligibility.
Step #3-Screening for Title XIX/XXI eligibility
When and who to screen for Title XIX or other eligibility?
The T/RBHA or provider must screen all non-Title
XIX/XXI persons using
Health-e-Arizona PLUS (HEAPlus) online application:
- Upon initial
request for behavioral health services, and;
- At least
annually or during each Federal Health Insurance Marketplace open enrollment period thereafter, if still receiving behavioral health services;
- When significant
changes occur in the person’s financial status.
is not required at the time an emergency service is delivered but
must be initiated within 5 days of the emergency service if the
person seeks or is referred for ongoing behavioral health services.
conduct a screening for Title XIX
or other eligibility?
The T/RBHA or provider meets with the person and
completes the AHCCCS Eligibility Screening through the
Health-e-Arizona PLUS online application for all Non-Title XIX persons. Documentation of AHCCCS eligibility screening must be included
in a person’s comprehensive clinical record upon completion after
initial screening, annual screening and screening conducted when a
significant change occurs in a person’s financial status (see
Section 4.2, Behavioral Health Medical Record Standards).
T/RBHAs must assist providers with contact information to obtain HEAPlus assistor modules and training from AHCCCS.
Once completed, the screening tool will indicate
one of two options:
If the screening tool indicates that the person does not appear
Title XIX or any other AHCCCS eligibility, the person may be provided behavioral
health services in accordance with
Section 3.4, Premiums and Co-payments and
Section 3.21, Service Prioritization for Non-Title XIX/XXI Funding. However, the person may submit the application for review by DES and/or AHCCCS regardless of the initial screening result. Additional information requested and verified by DES/AHCCCS may result in the person receiving AHCCCS eligibility and services after all.
3.1.6-B. Reporting requirements for Title XIX/XXI Eligibility Screening
The number of screenings completed for Title XIX SMI, and Federal
Health Insurance Marketplace eligibility
must be documented by providers and reported to the T/RBHA on a
monthly basis. The reporting must include the following elements:
- Number of applicants to be screened for AHCCCS eligibility;
- Number of applicant screenings for AHCCCS eligibility completed;
- Number of applicant screenings for AHCCCS eligibility to be completed;
- Number of AHCCCS eligible applicants as a result of the screening;
- Number of applicants to be screened for health coverage via the Federal Health Insurance Marketplace
- Number of applicant screenings for health coverage via the Federal health Insurance Marketplace completed
- Number of applicant screenings for health coverage via the Federal Health Insurance marketplace to be completed; and
- Number of applicants eligible for health coverage via the Federal Health Insurance Marketplace as a result of the screening;
regarding eligibility screenings completed by Gila River RBHA contracted
providers is to be submitted to the RBHA by the 15th day of each
month utilizing the reporting format above. Please submit reports
to: ATT: Behavioral Health Intake and Enrollment Manager, Hu Hu Kam Memorial
Hospital, P.O. Box 38, Sacaton, AZ 85147. Gila River RBHA contracted providers
may also contact the Intake and Enrollment Manager
at (602) 528-7942 to request technical assistance.
3.1.6-C. Medicare Part D Prescription Drug
coverage and Low Income Subsidy (LIS) program eligibility
Persons must report to the T/RBHA or provider if they are eligible,
or become eligible, for Medicare as it is considered third party
insurance. See Section 3.5, Third Party Liability and Coordination
of Benefits, regarding how to coordinate benefits for persons with
other insurance, including Medicare. If a behavioral health
recipient is unsure of Medicare eligibility, T/RBHAs or providers
may verify Medicare eligibility by calling 1-800-MEDICARE
(1-800-633-4227), with a
behavioral health recipient’s permission and needed personal information.
Once a person is determined Medicare eligible, T/RBHAs or providers
must offer assistance and provide assistance with Part D enrollment
and the LIS
application upon a behavioral health recipient’s request. T/RBHAs
and providers will be tracking Part D
enrollment and LIS application status of behavioral health
recipients and reporting tracking
activities when required by ADHS/DBHS.
Enrollment in Part D
All persons eligible for Medicare must be encouraged to and assisted
in enrolling in a Medicare Part D plan to access Medicare Part D
Prescription Drug coverage. Enrollment must be in a Prescription
Drug Plan (PDP), which is fee-for-service Medicare plan or a Medicare
Advantage Prescription Drug Plan (MA-PD), which is managed care
Medicare. Upon request, the T/RBHA or provider must assist Medicare
eligible persons in selecting a Part D plan. The Centers for
Medicare and Medicaid Services (CMS) developed webtools to assist
with choosing a Part D plan that best meets the persons’ needs. The
webtools can be accessed at
For additional information regarding Medicare Part D Prescription
Drug coverage, call Medicare at 1-800-633-4227 or the Arizona State
Division of Aging and Adult Services at 602-542-4446 or toll free at
Applying for the Low Income
LIS is a program in
which the federal government pays all or a portion of the cost
sharing requirements of Medicare Part D on behalf of the person. If
the T/RBHA or provider determines that a person may be eligible for
the LIS (see the Social Security Administration (SSA) website at www.ssa.gov for income and resource limits), the T/RBHA
or provider must offer to assist the person in completing an
application. Applications can be obtained and submitted through the
Reporting Part D enrollment and
T/RBHAs and providers must track Part D enrollment and LIS application status
fpr Medicare eligible behavioral health recipients. ADHS/DBHS
PM Form 3.1.1, Tracking of Medicare Part D Enrollment, and
PM Form 3.1.2, Tracking of Low Income Subsidy (LIS) Status,
which can be used by the T/RBHA or behavioral health provider to
track persons eligible for Medicare. This will assist the T/RBHA to
ensure that Medicare eligible persons are enrolled in a Part D plan
and apply for the limited income subsidy (LIS) program, if applicable. Providers
must report any Part D enrollment and LIS application status to
:ATTN: Behavioral Health Intake and Enrollment Manager/Gila River
Health Care Corporation, P.O. Box 38, Sacaton, AZ 85147. Gila River RBHA contracted providers may also contact the
Intake and Enrollment Manager at (602) 528-7942 to request technical
assistance. Periodically, ADHS/DBHS will request T/RBHAs to report tracking of Part D
enrollment and LIS applications. RBHAs and RBHA contracted providers must educate and encourage Non-Title SMI members to apply for health coverage from a qualified health plan using the application process located at the Federal Health Insurance Marketplace and offer assistance for those choosing to enroll during open enrollment periods and qualified life events. Members enrolled in a qualified health plan through the Federal health Insurance Marketplace may continue to be eligible for Non-Title XIX covered services that are not covered under the Federal Health Insurance Marketplace plan.
Persons who refuse to participate with the screening and/or
application process for Title XIX or other AHCCCS eligibility or enrollment in a Part D
On occasion, a person may decline to participate in the AHCCCS eligibility
screening and application process or refuse to enroll in Medicare
Part D plan. In these cases, the T/RBHA or
provider must actively encourage the person to
participate in the process of screening and applying for AHCCCS
health insurance coverage or enrolling in a Medicare Part D plan.
law stipulates that persons who refuse to participate in the AHCCCS
screening and eligibility application process or to enroll in a
Medicare Part D plan are ineligible for
state funded behavioral health services (see
A.R.S. § 36-3408). As such, individuals who
refuse to participate in the AHCCCS screening and eligibility application or enrollment in
Medicare Part D, if eligible, will not be enrolled with a T/RBHA during his/her initial
request for services or will be disenrolled if the person refuses to
participate during an annual screening. The following conditions
do not constitute a refusal to participate:
- A person’s
inability to obtain documentation required for the eligibility
- A person is incapable of participating as a result of
their mental illness and does not have a legal guardian.
- A person who is enrolled in a qualified health plan through the Federal Health Insurance Marketplace and refuses to take part in the AHCCCS screening and application process will not be eligible for Non-Title XIX/XXI SMI funded services.
If a person
refuses to participate in the screening and/or application process
for Title XIX or other eligibility or to enroll in a Medicare
Part D plan, the T/RBHA or behavioral
health provider must ask the person to sign the Decline to Participate
in the Screening and/or Referral Process for AHCCCS Health Insurance or Medicare Part D Plan Enrollment form (ADHS
Policy Form 101.3 or
ADHS Policy Form
101.4, Spanish). If the person refuses to sign the form, document their
refusal to sign in the comprehensive clinical record (See
4.2, Behavioral Health Medical Records Standards).
considerations for persons with a serious mental illness (SMI)
If a person is eligible for or requesting services as a person with
SMI and is unwilling to complete the eligibility
screening or application process for Title XIX or to enroll in a Part D plan, the T/RBHA or behavioral health
provider must request a clinical consultation
by a Behavioral Health Medical Professional by contacting the person’s assigned Gila River RBHA Clinician.
If the person continues to refuse following a clinical consultation,
the T/RBHA or behavioral health provider must request that the person
sign the Decline to Participate in the Screening and/or Referral
Process for AHCCCS (Title XIX) Health Insurance or Medicare Part D
Plan Enrollment form (ADHS
Policy Form 101.3 or
Policy Form 101.4, Spanish).
Prior to the termination of behavioral health services for persons determined to have a SMI who have been receiving behavioral health services and subsequently decline to
participate in the screening/referral process, the T/RBHA must provide written notification of the
intended termination using
PM Form 5.5.1, Notice of Decision and Right to Appeal (see
PM Section 5.5,
Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)).
persons who refuse to cooperate with the AHCCCS eligibility and/or
application process or who do not enroll in a Part D plan
The T/RBHA or behavioral health provider must inform
the person who they can contact in the behavioral health system
for an appointment if the person chooses to participate in the eligibility
and/or application process in the future. The T/RBHA must develop and make available to providers policies and procedures that include specific contact information for these requests. Persons are to be encouraged
to contact their assigned Gila River RBHA Clinician or the Gila
River RBHA Clinical Manager in the event that they choose to participate
in the eligibility and/or application process at a later date.
Accessing and Interpreting Eligibility and Enrollment Information
and Screening and Applying for AHCCCS Health Insurance
including Medicare Part D Prescription Drug Coverage and the Limited
Income Subsidy Program
Last Revised: 10/1/2014
Effective Date: 10/1/2014