Fillable Printable Eligibility Requirements
Fillable Printable Eligibility Requirements
Eligibility Requirements
Revised Eff.February 1, 2017
AHCCCS ELIGIBILITY REQUIREMENTS February 1, 2017
Where to Apply
Eligibility Criteria General Information
Household Monthly Income by
Household Size (After Deductions)
1
Resource
Limits
(Equity)
Social
Security
#
Special
Requirements
Benefits
Coverage for Children
Children
Under Age 1
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
147% FPL
1 $1,478
2 $1,990
3 $2,502
4 $3,014
................... Add $512 per Add’l person*
N/A RequiredN/A
AHCCCS
Medical Services
2
Children
Ages 1 – 5
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
141% FPL
1 $1,418
2 $1,909
3 $2,400
4 $2,891
................... Add $491 per Add’l person*
N/A
Required N/A
AHCCCS
Medical Services
2
Children
Ages 6 – 19
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
133% FPL
1 $1,337
2 $1,800
3 $2,264
4 $2,727
................... Add $463 per Add’l person*
N/A Required N/A
AHCCCS
Medical Services
2
KidsCare
Children
Under Age 19
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
200% FPL
1 $2,010
2 $2,707
3 $3,404
4 $4,100
Add $697 per Add’l person*
N/A Required
Not eligible for Medicaid
No health insurance coverage within last 3 months
Not available to State employees, their children, or spouses
$10 - $70 monthly premium covers all eligible children
AHCCCS
Medical Services
2
Coverage for Individuals
Parent &
Caretaker
Relatives
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
106% FPL
1 $1,066
2 $1,435
3 $1,804
4 $2,173
Add $369 per Add’l person*
N/A Required
AHCCCS
Medical Services
2
Adults
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
133% FPL
1 $1,337
2 $1,800
3 $2,264
4 $2,727
................... Add $463 per Add’l person*
N/A Required
19 years of age or older
Under age 65
Not entitled to Medicare
Adult’s children must have health insurance coverage
Ineligible for any other categorical Medicaid coverage
AHCCCS
Medical Services
2
Coverage for Women
Pregnant
Women
www.healthearizonaplus.gov
or
DES/Family Assistance Office
Call 1-855-HEA-PLUS for the
nearest office
156% FPL
1 $1,568
2 $2,112
3 $2,655
4 $3,198
................... Add $543 per Add’l person*
(Limit increases for each expected child)
N/A Required
AHCCCS
Medical Services
2
Breast &
Cervical
Cancer
Treatment
Program
Well Women
Healthcheck Program
Call 1-888-257-8502 for the
nearest office
N/A N/A Required
Under age 65
Screened and diagnosed with breast cancer, cervical cancer,
or a pre-cancerous cervical lesion by the Well Woman
Healthcheck Program
Ineligible for any other Medicaid coverage
AHCCCS
Medical Services
2
Revised Eff.February 1, 2017
AHCCCS ELIGIBILITY REQUIREMENTS February 1, 2017
Application Eligibility Criteria General Information
Where to Apply
Household Monthly Income by
Household Size (After Deductions)
1
Resource
Limits
(Equity)
Social
Security
Number
Special
Requirements
Benefits
Coverage for Elderly or Disabled People
Long Term
Care
ALTCS Office
Call 602-417-7000 or
1-800-654-8713
for the nearest office
300% FBR
$ 2,205 Individual
$2,000
Individual
3
Required
Requires nursing home level of care or equivalent
May be required to pay a share of cost
Estate recovery program for the cost of services received
after age 55
AHCCCS
Medical Services
2
,
Nursing Facility,
Home & Community Based
Services, and Hospice
SSI CASH Social Security Administration
100% FBR
$ 735 Individual
$1,103 Couple
$2,000
Individual
$3,000
Couple
Required Age 65 or older, blind, or disabled
AHCCCS
Medical Services
2
SSI MAO
www.healthearizonaplus.gov
or mail an application to
SSI MAO
801 E Jefferson MD 3800
Phoenix, Arizona 85034
100% FPL
$ 1,005 Individual
$1,354 Couple
N/A Required Age 65 or older, blind, or disabled
AHCCCS
Medical Services
2
Freedom to
Work
www.healthearizonaplus.gov
or mail an application to
801 E Jefferson MD 7004
Phoenix, AZ 85034
602-417-6677
1-800-654-8713 Option 6
250% FPL
$2,513 Individual
Only Earned Income is Counted
N/A Required
Must be working and either disabled or blind
Must be age 16 through 64
Premium may be $0 to $35 monthly
AHCCCS
Medical Services
2
+ Need for Nursing home level of care or equivalent is
required for Long Term Care (Nursing Facility, Home &
Community Based Services, or Hospice)
Nursing Facility,
Home & Community Based
Services, and Hospice
Coverage for Medicare Beneficiaries
QMB
www.healthearizonaplus.gov
or mail an application to
SSI MAO
801 E Jefferson MD 3800
Phoenix, Arizona 85034
100% FPL
$ 1,005 Individual
$1,354 Couple
N/A Required Entitled to Medicare Part A
Payment of
Part A & B premiums,
coinsurance, and
deductibles
SLMB
www.healthearizonaplus.gov
or mail an application to
SSI MAO
801 E Jefferson MD 3800
Phoenix, Arizona 85034
120% FPL
$ 1,005.01 – $1,206 Individual
$1,354.01 – $1,624 Couple
N/A Required Entitled to Medicare Part A
Payment of
Part B premium
QI-1
www.healthearizonaplus.gov
or mail an application to
SSI MAO
801 E Jefferson MD 3800
Phoenix, Arizona 85034
135% FPL
$1,206.01 – $1,357 lndividual
$1,624.01 – $1,827 Couple
N/A Required
Entitled to Medicare Part A
Not receiving Medicaid benefits
Payment of
Part B premium
Applicants for the above programs must be Arizona residents and either U.S. citizens or qualified immigrants and must provide documentation of identity and U.S. Citizenship or immigrant status.
Applicants for the Children, Caretaker Relative, Pregnant Women, Adult, SSI-MAO, and Long Term Care programs who do not meet the citizen/immigrant status requirements may qualify for
Emergency Services.
NOTES: 1 Income deductions vary by program, but may include work expenses and educational expenses.
2 AHCCCS Medical Services include, but are not limited to, doctor’s office visits, immunizations, hospital care, lab, x-rays, and prescriptions.
3 If the applicant has a spouse living in the community, between $23,844 and $119,220 of the couple’s resources may be disregarded.
4 *”Each additional” approximate amounts only.
