1103 Fee-For-Service

• Is eligible to have medical bills paid during the three months prior to application (Prior Quarter)

• Is eligible for Federal Emergency Services (FES);

• Enrolls with American Indian Health Program (AIHP);

• Is eligible for Hospital Presumptive Eligibility (HPE);

• Has less than 30 days of prospective eligibility; or

• Is eligible only for a retroactive period of eligibility.

• The customer is eligible for ALTCS services only during the prior period.

Example:

The customer dies before ALTCS is approved but is eligible for ALTCS services in the prior period. ALTCS services are paid on a fee-for-service basis.

• The customer is enrolled with a tribal contractor, or there is no tribal or EPD program contractor serving the customer’s geographical service area.

• The Assistant Director of the Division of Member Services approves (on a case-by-case basis) fee-for-service payment for long term care services during the prior period for a customer who:

  • Was enrolled with an AHCCCS Complete Care (ACC) plan when ALTCS was approved; and

  • The AHCCCS Complete Care (ACC) plan’s responsibility for paying for nursing facility services for a 90-day period per contract year ended prior to the date the ALTCS approval was processed.

AIHP is responsible for paying fee-for-service claims submitted for American Indians who have chosen not to enroll in an acute capitated health plan. If the American Indian customer does not choose a plan and lives within the bounds of the tribal nation, the customer will be automatically enrolled in AIHP.

Emergency services provided to immigrants who are eligible for Medicaid except for their immigration status

Temporary coverage for people who are likely to qualify for AHCCCS Medical Assistance. See MA417 for details.

NOTE     Eligibility for HPE is determined by qualified hospitals

AAC R9-22-1702

AAC R9-28-416

AAC R9-22-1601