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A customer or representative may ask for benefits to be stopped for any AHCCCS Medical Assistance (MA) program at any time. The customer or representative can send this request by:
Mail;
Fax;
Verbal request by telephone; or
Electronically through HEAplus.
When a customer or main contact asks to stop MA, document the following:
The date of the request;
Names of all the customers covered by the request;
The specific date the customer wants the MA to stop; and
The reason the customer is asking to stop MA.
A written, signed request for withdrawal may be accepted in one of the following formats:
Voluntary Withdrawal of Application or Benefits form (DE-130);
Withdrawal or Stop Benefits/Appeals Request form (FAA-0574A);
Voluntary withdrawal option in Health-e-Arizona Plus (HEAplus); or
A signed, written request to discontinue benefits.
When a verbal request to voluntarily withdraw is made, the application is discontinued based on the verbal request. A discontinuance letter is sent to notify the person that the benefits have been withdrawn.
Eligibility will be reinstated when the customer contacts AHCCCS/DES to withdraw the request to stop benefits (or to report the request was in error) before the end of the month the action was taken.
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Term |
Definition |
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Voluntary Request to Stop MA |
When a customer or representative asks that MA benefits be stopped. |
Proof includes:
Signed statement asking for benefits to be stopped;
Documented telephone request; or
Electronic record in HEAplus.
This applies to all programs.
When the customer or representative asks that MA benefits be stopped immediately, benefits stop effective the date the action is taken.
Otherwise, benefits stop effective the first day of the following month.
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Program |
Legal Authorities |
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All Programs |
42 CFR 431.213 42 CFR 435.914 42 CFR 435.916 AAC R9-22-308; R9-22-313; R9-28-401 |