Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.1 Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and Low Income Subsidy

3.1.1 Introduction
3.1.2 References
3.1.3 Scope
3.1.4 Did you know…?
3.1.5 Objectives
3.1.6 Procedures
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?

3.1.1 Introduction
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.

Determining 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.

The following information will assist providers of covered services in:

  • Accessing and interpreting eligibility and enrollment information;
  • Conducting financial screenings and assisting persons with applying for Title XIX or other benefits; and
  • Assessing potential eligibility for Medicare Part D Prescription Drug coverage and the Low Income Subsidy (LIS) program.

3.1.2 References
The following citations can serve as additional resources for this content area:

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3.1.3 Scope
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.

3.1.4 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.

3.1.5 Objectives

  • 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 and
  • To identify and assist persons eligible for Medicare with enrolling in a Part D plan and with applying for the Low Income Subsidy (LIS) program to pay the cost sharing of Medicare Part D.

3.1.6 Procedures

3.1.6-A. Title XIX/XXI screening and eligibility

What is the Screening Process?

  • First…Verify the person’s Title XIX or Title XXI eligibility;
  • Next…for those persons who are not Title XIX or Title XXI eligible, screen for potential Title XIX or other eligibility; and
  • Finally…as indicated by the screening tool, assist persons with applications for a Title XIX or Title XXI eligibility determination.

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Step #1-Accessing Title XIX/XXI or other eligibility information
T/RBHA 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:

  • AHCCCS’ 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 to: 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 (MEVS). 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;
    • The recipient’s name, date of birth, AHCCCS identification number and social security number (if known); and
    • Dates of service(s).

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 rate codes.

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 (SMI) 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 system.

If the person is not currently Title XIX eligible, proceed to step #3 and conduct a screening for Title XIX or other eligibility.

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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; and
  • When significant changes occur in the person’s financial status.

A screening 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.

To 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 PM 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.

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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;

Documentation 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 www.medicare.gov. 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 1-800-432-4040.

Applying for the Low Income Subsidy (LIS)
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 following means:

Reporting Part D enrollment and LIS applications
T/RBHAs and providers must track Part D enrollment and LIS application status fpr Medicare eligible behavioral health recipients. ADHS/DBHS has developed 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.

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3.1.6-D. 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 plan
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.

Arizona state 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 determination; and
  • 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 Section 4.2, Behavioral Health Medical Records Standards).

Special 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 ADHS 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)).

For all 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.

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3.1 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

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