Ariz. Admin. Code § 9-22-1702

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-22-1702 - Enrollment of a Member with an AHCCCS Contractor

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.

Ariz. Admin. Code § R9-22-1702

New Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Section repealed; new Section made by final rulemaking at 14 A.A.R. 1598, effective May 31, 2008 (Supp. 08-2).