What services does AHCCCS Health Insurance cover? What does AHCCCS Health Insurance cost you?

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1 What services does Health Insurance cover? Doct s Visits* Specialist Care Hospital Services Emergency Care Pregnancy Care Surgery** Covered Medical Services Immunizations (shots) Family Planning Lab and X-rays Prescriptions Dialysis Annual Well Women Exams Transptation to Doct** Glasses** Vision Exams** Dental Services** Hearing Exams** Hearing Aids** Behavial Health *Wellness visits f people age and over are not covered. **Coverage of these services may be limited depending on the service requested, your age the program. What does Health Insurance cost you? Premiums Most people do not have to pay a monthly premium f Health Insurance. Some people with income too high to qualify f Health Insurance with no monthly premium may be able to get it by paying a monthly premium. If you have to pay a premium, the premium amounts are: $0 - $70 per household f all children. $0 - $5 per person f employed people with disabilities. Native Americans and Alaskan Natives Per federal law, Native Americans enrolled with a federally recognized tribe and certain Alaskan Natives do not have to pay a KidsCare premium. To get KidsCare at no cost, you must give us proof of tribal enrollment. Co-payments A co-payment is the amount you pay a health care provider when you receive a medical service. Your co-payment amount will vary depending on which program you are enrolled in and the services you need. F some programs, the provider can deny services if the co-payments are not made. Co-payments f services are: $.0 to $0.00 f prescriptions $0 to $0.00 f non-emergency use of an emergency room $.0 to $5.00 f outpatient visits f evaluation and management services including docts office visits $.0 to $.00 f physical, occupational speech therapy $0 to $.00 per one way trip f taxis ride, non-emergency medical transptation, and Taxi ride to obtain medical services (f adults in Maricopa and Pima counties only) Remember to rept any changes in income because this may change your co-payment amount. Co-payments (cont.) The following persons are never asked to pay co-payments: under age 9 People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services Individuals up through age 0 eligible to receive services from the s Rehabilitative Services (CRS) program People who are acute care members and who are residing in nursing homes, residential facilities such as an Assisted Living Home and only when the acute care member s medical condition would otherwise require hospitalization. The exemption from copayments f acute care members is limited to 90 days per contract year. People who receive hospice care People who are enrolled in the Arizona Long Term Care System People who are eligible f Medicare Savings Programs only. Copayments referenced in this section means copayments charged under Medicaid (). It does not mean a person is exempt from Medicare copayments. American Indian members who are active previous users of the Indian Health Service, tribal health programs operated under P.L. 9-68, urban Indian health programs In addition, co-payments are never charged f the following services f anyone: Hospitalizations Emergency services Family Planning services and supplies Pregnancy related health care including tobacco cessation treatment f pregnant women Services paid f on a fee f service basis How does Health Insurance wk? If you are approved f Health Insurance, you will receive your health care from an Health Plan unless: You are Native American and you choose American Indian Health Program as your health plan; You are just asking f help with your Medicare costs. If you are approved f one of the Medicare Cost Sharing programs, may pay your Medicare premiums and Medicare coinsurance and deductibles, can only pay f your emergency services because of your status with the Bureau of Citizenship and Immigration Services. If you are approved f emergency services only, you may receive medical services from any provider (doct, hospital, etc.) that has an agreement to bill f covered emergency services. How Does a Health Plan Wk? The health plan wks with the health care providers (docts, hospitals, pharmacies, etc.) to provide all covered services. The health plan will send you a member handbook once you are enrolled. You can call the health plan if you have any questions about your benefits services if you need an accommodation because of a disability interpreter services. The phone number f your health plan s member customer services can be found on your ID Card and in your Member Handbook. How Can I Get Behavial Health Services? You can go through your primary doct, Call the behavial health telephone number on your ID Card. Your Primary Doct and Specialists You must choose your primary doct one will be assigned to you. Once enrolled, you will get a list of primary docts in your area from the health plan. Your primary doct will: Take care of your health care. Be the first person you go to f non-emergency medical care. Be responsible f authizing your non-emergency medical services. Send you to a specialist when needed. You have the right to change your primary doct at any time by calling your Health Plan s member customer services. AH-800 (Rev 07/)

2 What if I Have Medicare Other Health Insurance? Be sure to tell your health plan that you have Medicare any other health insurance. If your doct does not contract with your health plan, your doct must call the health plan to codinate care you may be responsible f any Medicare other health insurance co-payments deductibles. If you are in an HMO, you should pick a primary doct who wks with both your HMO and your health plan. If you have Medicare, your prescription coverage under is limited. If you have questions about prescriptions, call -800-MEDICARE (6-7), your health plan. AH-800 (Rev 07/) How To Choose a Health Plan Your ID Card Your ID Card has your unique ID number. Show the card when you get medical care (you may need to show a picture ID as well). Docts, hospitals and pharmacists use your ID Card to obtain faster verification of your eligibility. Keep your ID Card with you at all times. Keep your ID Card in a safe place. Do not let anyone else use your ID Card you may be prosecuted. YOU NEED TO CHOOSE A HEALTH PLAN THAT SERVES YOUR COUNTY. All health plans provide the same covered medical services. Review the health plans f your county listed below. Native Americans may choose American Indian Health Program an Health Plan. Befe choosing, check with your doct, pharmacy hospital, to see if they contract with (wk with) the plan that you want. If you want me infmation about the docts, specialists hospitals that contract with a health plan that serves your county, call the number listed below f the health plan ask your Eligibility Specialist f the health plan s list of health care providers. If you do not choose a health plan, one will be assigned to you. If you have been enrolled in an health plan within the past 90 days, you may be enrolled with your previous health plan. APACHE COUNTY UnitedHealthcare Community Plan Health Choice Arizona American Indian Health Program If your zip code is 859, you must choose from among the health plans listed under Navajo COCHISE COUNTY University Family Care UnitedHealthcare Community Plan American Indian Health Program COCONINO COUNTY UnitedHealthcare Community Plan Health Choice Arizona American Indian Health Program If your zip code is , you must choose from among the health plans listed under Yavapai GILA COUNTY Health Choice Arizona University Family Care American Indian Health Program GRAHAM COUNTY University Family Care UnitedHealthcare Community Plan American Indian Health Program If your zip code is 856, you must choose from among the health plans listed under Cochise GREENLEE COUNTY University Family Care UnitedHealthcare Community Plan American Indian Health Program LA PAZ COUNTY UnitedHealthcare Community Plan University Family Care American Indian Health Program MARICOPA COUNTY Health Net of Arizona Care st Arizona Health Choice Arizona UnitedHealthcare Community Plan Mercy Care Plan Maricopa Health Plan American Indian Health Program MOHAVE COUNTY UnitedHealthcare Community Plan Health Choice Arizona American Indian Health Program If your zip code is 86, you must choose from the health plans listed under Yavapai NAVAJO COUNTY UnitedHealthcare Community Plan Health Choice Arizona American Indian Health Program PIMA COUNTY UnitedHealthcare Community Plan Health Choice Arizona Care st Arizona University Family Care Mercy Care Plan American Indian Health Program If your zip code is 8565, you must choose from among the health plans listed under Santa Cruz PINAL COUNTY Health Choice Arizona University Family Care American Indian Health Program If your zip code is , you must choose from among the health plans listed under Maricopa If your zip code is 859 you must choose from among the health plans listed under Gila SANTA CRUZ COUNTY University Family Care UnitedHealthcare Community Plan American Indian Health Service YAVAPAI COUNTY UnitedHealthcare Community Plan University Family Care American Indian Health Program If your zip code is 85, , you must choose from among the health plans listed under Maricopa If your zip code is 865 you must choose from among the health plans listed under Coconino YUMA COUNTY UnitedHealthcare Community Plan University Family Care American Indian Health Program IMPORTANT When you have chosen a health plan you can either: Give your choice to your eligibility specialist, OR Call to pre-enroll. From area codes 80, 60 6 call (60) from area codes call When you call to pre-enroll, you will need to give the following infmation: Name Sex (male female) Date of birth, and Social Security Number of all the individuals f whom you applied. If you have any questions about enrolling with an health plan, need an interpreter, if you are visually hearing impaired and need special accommodations to choose a health plan to understand the infmation, from area codes 80, 60 6 call (60) TDD (60) 7-9 from area codes call toll free at TDD

3 Under Age Ages 5 Ages 6 9 KidsCare Under Age 9 Parent & Caretaker Relatives Adults Pregnant Women Breast & Cervical Cancer Treatment Program 06% FPL $,0 $,90 $,79 Call -855-HEA-PLUS f the $,07 Add $59 per Add l person % FPL $,9 $,770 $,9 Call -855-HEA-PLUS f the $,6... Add $50 per Add l person 56% FPL Call -855-HEA-PLUS f the $,58 $,05 $,57 $,0... Add $58 per Add l person (Limit increases f each expected child) Well Women Healthcheck Program Call f the ELIGIBILITY REQUIREMENTS April, 0 Eligibility Criteria Where to t Apply Household Monthly Income by Resource Social Special Household Size (After Deductions) Limits Security Requirements (Equity) # Coverage f 7% FPL $,0 $,97 $,5 Call -855-HEA-PLUS f the $,9... Add $97 per Add l person % FPL $,7 $,89 $,6 Call -855-HEA-PLUS f the $,80... Add $77 per Add l person % FPL $,9 $,7 $,9 Call -855-HEA-PLUS f the $,6... Add $50 per Add l person 00% FPL The KidsCare program is $,95 Not eligible f Medicaid currently frozen. No new $,6 No health insurance coverage within last months applications are being $,99 Not available to State employees, their children, spouses accepted. $,975 $0 - $70 monthlyy premium covers all eligible children Add $677 per Add l person Coverage f Individuals Coverage f Women 9 years of age older Under age 65 Not entitled to Medicare Adult s children must have health insurance coverage Ineligible f any other categical Medicaid coverage Under age 65 Screened and diagnosed with breast cancer, cervical cancer, a pre-cancerous cervical lesion by the Well Woman Healthcheck Program Ineligible f any other Medicaid coveragee General Infmationn Benefits Revised Eff. April, 0

4 ELIGIBILITY REQUIREMENTS April, 0 Application Where to Apply Household Monthly Income by Household Size (After Deductions) Eligibility Criteria Resource Social Limits Security (Equity) Number Special Requirements General Infmationn Benefits Long Term Care SSI CASH Freedom to Wk ALTCS Office Call f the Social Security Administration mail an application to 80 E Jefferson MD 800 Phoenix, Arizona 850 mail an application to 80 E Jefferson MD 700 Phoenix, AZ Option 6 00% FBR $,6 Individual 00% FBR $ 7 Individual $,08 Couple 00% FPL $ 97 Individual $, Couple 50% FPL $, Individual Only Earned Income is Counted Coverage f Elderly Disabled People $,000 Individual $,000 Individual $,000 Couple Requ uired Requires nursing home level of care equivalent May be required to pay a share of cost Estate recoveryry program f the cost of services received after age 55 Age 65 older, blind, disabled Age 65 older, blind, disabled Must be wking and either disabled blind Must be age 66 through 6 Premium may be $0 to $5 monthly + Need f Nursing home level of care equivalent is required f Long Term Care (Nursing Facility, Home & Community Based Services, Hospice), Nursing Facility, Home & Community Based Services, and Hospice Nursing Facility, Home & Community Based Services, and Hospice QMB SLMB QI- mail an application to 80 E Jefferson MD 800 Phoenix, Arizona 850 mail an application to 80 E Jefferson MD 800 Phoenix, Arizona 850 mail an application to 80 E Jefferson MD 800 Phoenix, Arizona % FPL $ 97 Individual $, Couple 0% FPL $ 97.0 $, 67 Individual $,.0 $,57Couple 5% FPL $,67.0 $, lndividual $,57.0 $,770 Couple Coverage f Medicare Beneficiaries Applicants f the above programs must be Arizona residents and either U.S. citizens qualified immigrants and must provide documentation of identity and U.S. Citizenship immigrant status. Applicants f the, Caretaker Relative, Pregnant Women, Adult, SSI-MAO, and Long Term Care programs who do not meet the citizen/immigrantt status requirements may qualify f Emergency Services. NOTES: Income deductions vary by program, but may include wk expenses and educational expenses. Medical Services include, but are not limited to, doct s office visits, immunizations, hospital care, lab, x-rays, and prescriptions. If the applicant has a spouse living in the community, between $,8 and $7,0 of the couple s resources may be disregarded. Entitled to Medicare Part A Entitled to Medicare Part A Entitled to Medicare Part A Not receiving Medicaid benefits Part A & B premiums, coinsurance, and deductibles Part B premium Part B premium Revised Eff. April, 0

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