Q and A Regarding the Arizona Health Care Cost Containment System AHCCCS, Arizona’s Medicaid Program
The subject of this article was prompted by a recent list serve request for resources, information or guidance on the impact of personal injury settlements on AHCCCS eligibility, to which I responded as follows:
“Determining for which program a claimant is eligible for AHCCCS medical assistance is not a straightforward matter. It depends on whether they have a disability or not, are eligible by virtue of being eligible for Supplemental Security Income (SSI-cash assistance for someone who has been determined disabled by the SSA), are an adult versus child, are a single person, are a household or budget group or part of a household or budget group of multiple individuals, their countable income (earned and unearned), their countable resources, etc. I recommend always working with an attorney who is knowledgeable about such matters.”
What followed was multiple emails from various members asking additional questions regarding financial eligibility for AHCCCS medical assistance-the genesis for this Q and A.
Q: How is financial eligibility for AHCCCS medical assistance determined?
A: This is a loaded question and at the crux of it is the category or particular program through which an individual (and his/her household) is eligible for such assistance. The programs include:
- Arizona Long Term Care System – ALTCS
- Supplemental Security Income-Medical Assistance Only
- Medicare Savings Program
- Freedom to Work
- Adult
- Caretaker Relative
- Transitional Medical Assistance
- Pregnant Woman
- Child
- KidsCare
- SSI Cash
- Breast and Cervical Cancer Treatment Program
- Title IV-E Foster Care and Adoption Subsidy
- Transplant Extended Eligibility Program
- Hospital Presumptive Eligibility
Bet you never knew so many AHCCCS programs existed!
Q: Don’t all of these programs base financial eligibility on income?
A: Yes, but some also base financial eligibility on resources and when it comes to income, the applicable income limits vary and how income is calculated or determined is distinct. For example, the gross monthly income limit for an individual who is ALTCS-eligible is currently $2,742 whereas for an individual who is on the Adult program, it is presently $1,616.
Moreover, for the Adult program, the Modified Adjusted Gross Income (MAGI) policy is used to determine income eligibility. The MAGI policy is based on federal tax rules for determining adjusted gross income (AGI), with some modification (including sources of income not included in AGI while excluding others).
MAGI considers the income not just of the individual or Adult who is eligible for assistance, but also those in his/her budget group. Who is include in a budget group depends on the age of the person, whether or not the person is married, who lives with the person, and whether the person files taxes or is claimed as a tax dependent.
ALTCS, on the other hand, does not use the MAGI policy to determine income eligibility nor does the income of any other individual ultimately factor into eligibility (although it may factor into what is called Share of Cost which is essentially a co-payment).
And because that doesn’t complicate matters enough, AHCCCS also distinguishes between earned and unearned income (including how unearned income is paid or received, e.g., vendor payments), as well as types of income (structured settlement annuity1 versus in-kind income and in-kind support and maintenance).
Q: So which programs count resources for purposes of determining financial eligibility for AHCCCS?
A: Only one program counts resources for purposes of determining financial eligibility for AHCCCS and that is ALTCS. ALTCS provides long term care services as well as acute medical assistance to individuals who qualify medically as well as financially. Some resources are excluded and not counted for purposes of eligibility such as the primary residence and a car. The applicable countable resource limit depends on whether the individual is single, in which case it is $2,000, or married. If married, the limit varies and, in 2023, ranges from $29,724 to $148,620 plus an additional $2,000. This calculation is the topic for another day!
Individuals who are eligible for Supplemental Security Income (SSI) are categorically or automatically eligible for AHCCCS medical benefits. Although AHCCCS does not determine eligibility for individuals who are eligible for SSI benefits, it is important to note that to be eligible for SSI benefits, an individual must qualify as “disabled” and satisfy the income as well as resource eligibility requirements for that program.
Q: How does someone figure out the particular AHCCCS program for which an individual is eligible?
A: You can always start with the individual’s AHCCCS insurance card. However, it will not tell you much unless the individual is ALTCS-eligible. If ALTCS-eligible, the card will note “LTC” for “long term care” or “DDD” for “Division of Developmental Disabilities”. Note, DDD is the AHCCCS Program Contractor for individuals who have a developmental disability and qualify for services through DDD as well as qualify medically and financially for ALTCS benefits.
The more reliable source of information to verify AHCCCS eligibility and the particular program for which an individual is eligible for medical assistance are notices from the agency that is determining and redetermining their eligibility, whether it be AHCCCS, the Arizona Department of Economic Security (ADES), or in the case of those who are eligible for SSI benefits, the Social Security Administration (SSA).
Q: What is Hospital Presumptive Eligibility?
A: Based on provisions in the Affordable Care Act (ACA), the Hospital Presumptive Eligibility (HPE) process allows qualified hospitals to temporarily enroll persons who are likely to qualify for AHCCCS medical assistance for full AHCCCS benefits immediately. Proof of eligibility is not required at the time but the approval period is temporary. It begins on the date the HPE is approved and continues until the earlier of (1) the last day of the month after the month the HPE is approved if a full AHCCCS application is not submitted by this date, or (2) the date a decision is made on a full AHCCCS application when the application is submitted by the last day of the HPE period. Confusing, to say the least, but bottom line is that coverage is temporary unless the individual promptly applies for standard coverage under another program and otherwise qualifies!
Q: What is the Public Health Emergency (PHE) and its status?
A: When it comes to Medicaid or AHCCCS, the PHE refers to the continuance or maintenance of AHCCCS coverage since the start of the COVID-19 pandemic in 2020 regardless of an individual’s eligibility. During this time, AHCCCS has not conducted regular renewals of eligibility at which time it would typically verify continued eligibility for medical assistance.
The PHE ends April 1, 2023, and, as such, AHCCCS will begin to conduct regular Medicaid renewals as of that date. What this means is that AHCCCS will begin disenrolling individuals who no longer meet AHCCCS eligibility requirements beginning April 1, 2023.
It is important for individuals who are eligible for AHCCCS medical assistance to make sure their mailing address, phone number and email address are correct (log into their account at www.healthearizonaplus.gov or call Health-e-Arizona Plus at 1-855-HEA-PLUS), that they keep an eye out for a letter from AHCCCS regarding renewal of coverage, and respond to any requests from AHCCCS for more information on a timely basis. If determined to be no longer eligible for AHCCCS medical assistance, the individual will receive a notice of when his/her enrollment will end, information on how to appeal that decision, and information about other health care coverage options available from Healthcare.gov.
Q: Back to the original question on the list serve that was the genesis of this article, how does a personal injury settlement impact AHCCCS eligibility?
A: So, now you know the answer. It depends! But, in general, a personal injury settlement will be income in the month of receipt (or when it first becomes available2) and a resource if retained thereafter (unless structured but then consider the treatment of the payments by AHCCCS3). Technically, the individual will likely be over the applicable income limit in the month of receipt or first availability. If the individual is eligible for ALTCS (or AHCCCS because he/she is eligible for SSI benefits), a personal injury settlement will be a countable resource in the following month that will potentially disqualify him/her from benefits unless advance planning is done.
Q: What is the ultimate takeaway?
A: Do not try to navigate your client’s eligibility for AHCCCS medical assistance without the knowledge and experience of an attorney who is intimately familiar with the myriad of AHCCCS programs and their quagmire of eligibility requirements! A lot is at stake-their eligibility and your peace of mind!
