Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION
Article 17 - ENROLLMENT
Section R9-22-1702 - Enrollment of a Member with an AHCCCS Contractor
Universal Citation: AZ Admin Code R 9-22-1702
Current through Register Vol. 30, No. 38, September 20, 2024
A. General enrollment requirements. The Administration shall enroll a member with a contractor as described in this Section, unless the member has pre-selected a contractor on the application:
1. Except as provided in subsections (A)(3),
(A)(5), and (C), a member who is determined to be eligible under this Chapter
and resides in an area served by more than one contractor, may choose an
available contractor serving the member's GSA within 30 days from the date of
notice of enrollment. A Native American member may select IHS or another
available contractor.
2. If the
member does not make a choice under subsection (A)(1), the Administration shall
immediately auto-assign the member to:
a. IHS
if the member is a Native American living on a reservation,
b. A contractor based on family continuity,
or
c. A contractor by using the
auto-assignment algorithm.
3. If the member's period of ineligibility
and disenrollment from the contractor of record is for a period of less than 90
days, the Administration shall enroll the member with the member's most recent
contractor of record, if available, except if:
a. The member no longer resides in the
contractor's GSA;
b. The
contractor's contract is suspended or terminated;
c. The member was previously enrolled with
CMDP but at the time of re-enrollment the member is not a foster care
child;
d. The member chooses
another contractor or chooses IHS, if available to the member, during the
annual enrollment choice period; or
e. The member was previously enrolled with a
contractor but at the time of re-enrollment the member is a foster care
child.
4. When the
member's disenrollment period is more than 90 days, the member may select a
contractor as described in subsection (A)(1).
5. The Administration shall not enroll a
member with a contractor if a member:
a. Is
eligible for the FESP under R9-22-1419;
b. Is eligible for less than 30 days from the
date the Administration receives notification of a member's eligibility, except
for a member who is enrolled with CMDP or IHS;
c. Is eligible only for a retroactive period
of eligibility, except for a member who is enrolled with CMDP or IHS;
or
d. Resides in an area not served
by a contractor.
B. Fee-for-service coverage. A member not enrolled with a contractor under subsection (A)(5) shall obtain covered medical services from an AHCCCS-registered provider on a fee-for-service basis under Article 7.
C. Foster care child. The Administration shall enroll a member with CMDP if the member is a foster care child under A.R.S. § 8-512.
D. Family Planning Services Extension Program. A member eligible for the Family Planning Services Extension Program under R9-22-1431, shall remain enrolled with the member's contractor of record or IHS.
E. Contractor or IHS enrollment change for a member.
1. The Administration shall change a
member's enrollment if the member requests a change to an available contractor
or IHS during an annual enrollment period. A Native American may change from an
available contractor to IHS or from IHS to an available contractor at any
time.
2. The Administration shall
approve a change in enrollment for any member if the change is a result of the
final outcome of a grievance under 9 A.A.C. 34.
3. A member may choose a different contractor
if the member moves into a GSA not served by the current contractor or if the
contractor is no longer available. If the member does not select a contractor,
the Administration shall auto-assign the member as provided in subsection
(A)(2).
4. The Administration shall
provide the member 60-day advance notice of the member's option to change plans
by the member's annual enrollment date.
5. A member may disenroll from a plan if:
a. The member moves out of the GSA;
b. The plan does not, because of moral or
religious objections, cover the service a member seeks; or
c. The member needs related services to be
performed at the same time; not all related services are available within the
network; and the member's primary care provider or another provider determines
that receiving the services separately would subject the member to unnecessary
risk.
6. For exceptions
to this Article, the Administration shall approve a change for an enrolled
member as determined by the Director.
Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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