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ALTCS local offices have authority to approve a request to change enrollment to another ALTCS Health Plan when:
Incorrect information was provided to the customer or representative or the agency made an error when the customer was enrolled.
Customer enrolled or was automatically enrolled with a ALTCS Health Plan that does not contract with that customer’s medical providers or facility;
Lack of initial enrollment choice for a customer living in either Maricopa or Pima Counties;
Lack of annual enrollment choice because the customer did not receive notice of annual enrollment;
Customer requests to be enrolled with the same ALTCS Health Plan as other family members;
Continuity of institutional or residential setting when the customer’s ALTCS Health Plan terminates their contract with the long-term care medical institution or HCBS community facility; and
Failure by AHCCCS staff to correctly apply the 90-Day re-enrollment policy.
An ALTCS office may receive an enrollment change request from:
The customer or the customer's representative; or
The current ALTCS Health Plan. The current ALTCS Health Plan contacts the ALTCS local office when the customer or representative requests an enrollment change through the current ALTCS Health Plan and claims one of the situations described in this Subsection.
This situation exists when the customer or representative made an enrollment choice based on incorrect information regarding facility, residential setting, primary care physician or other provider contracting with the chosen ALTCS Health Plan based on information provided at the ALTCS Health Plan's website, marketing materials or agency error.
Incorrect information includes omissions or failure to divulge network limitations and restrictions in the ALTCS Health Plan's marketing material or database submissions.
This situation exists when the customer enrolled or was automatically enrolled with an ALTCS Health Plan that does not contract with that customer’s medical providers or facility, but another ALTCS Health Plan does.
See How to Evaluate a Health Plan Change Request for details.
Lack of initial enrollment choice exists when an ALTCS customer:
Has a fiscal county of Maricopa, Gila, Pinal, or Pima;
Was entitled to enrollment choice; and
Was, for any reason, not given a choice of ALTCS Health Plans during the application process.
Lack of enrollment choice means the customer was entitled to participate in an Annual Enrollment Choice, but
Was not sent an Annual Enrollment Choice notice; or
Was sent an Annual Enrollment Choice notice but the notice was not received; or
Was sent an Annual Enrollment Choice notice but was unable to participate in the annual enrollment choice due to circumstances beyond the customer's control. For example, the customer or representative was hospitalized or the anniversary date fell within a 90-day disenroll/enroll period.
A family continuity of care issue exists when the customer, either through auto-assignment or the choice process is not enrolled with the same ALTCS Health Plan as other family members. Family members, especially married couples, may request, for continuity of care, to be enrolled with the same ALTCS Health Plan.
An enrollment change may be approved when the customer's ALTCS Health Plan terminates their contract with the institutional or alternative residential setting in which the customer lives, and the customer or the customer's representative requests to change to a ALTCS Health Plan who does contract with the customer's institutional or alternative residential setting. The customer must be enrolled and living in the facility at the time of the contract termination.
If the provider (nursing facility or alternative residential setting) terminates the contract, instruction from the Program Support Administration is required before the Benefits and Eligibility Specialist makes any enrollment change.
This situation exists when the customer:
Lost ALTCS eligibility and was disenrolled;
Was subsequently reapproved for ALTCS within 90-days of the disenrollment date; and
Was enrolled with a different ALTCS Health Plan.
To correct this situation, the customer is re-enrolled with the ALTCS Health Plan he or she was enrolled with prior to the disenrollment.
See How to Evaluate the Request for Enrollment Changes for details.
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Term |
Definition |
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90 Day Re-enrollment Rule |
If the customer was enrolled with an AHCCCS Complete Care (ACC) plan within the 90 days prior to the current approval date, the customer is automatically re-enrolled with the same health plan. |
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Anniversary Month |
The month that coverage first goes into effect becomes its anniversary month each year. |
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Annual Enrollment Choice |
Annual enrollment choice is a two-month process that allows a customer to select a new AHCCCS Complete Care (ACC) plan:
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Choice Month |
The first month of annual enrollment choice is the customer’s choice month. During this month the customer has the option to change to a different ALTCS Health Plan. |
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Family Continuity of Care |
The customer requests to be enrolled with the same ALTCS Health Plan as other family members. |
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Transition Month |
The second month of annual enrollment choice is the ALTCS Health Plan's transition month. This period allows ALTCS Health Plans to arrange for the transition in case management and providers. |
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Program |
Legal Authorities |
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ALTCS |
ARS 36-2933 AAC R9-28-413 |