Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs (Page 3 of 10) in pdf

RIGHTS AND RESPONSIBILITIES OF APPLICANTS/RECIPIENTS

You have the RIGHT to:

1. Be treated fairly and equally regardless of race, religion, national origin, sex, age, disability, or political beliefs.

2. To apply for AHCCCS Medical Benefits and to be given a notice that tells you if you are eligible or not.

3. Review AHCCCS manuals that show the rules and regulations of the AHCCCS program if you want to know the reason why your

application is denied.

Have all information you give regarding your eligibility kept private according to state and federal law.

5. A fair hearing if you disagree with an adverse action taken by the AHCCCS Administration. Adverse action means your application

for AHCCCS services was denied, your AHCCCS benefits were ended or your AHCCCS services were reduced. You may also

request a hearing if a decision is not made on your application within 45 days and the delay is due to AHCCCS. Your hearing will

be conducted by an Administrative Law Judge and a decision will be issued by the AHCCCS Director. You have the right to review

your case record before the hearing. You have the right to represent yourself or to have someone else represent you. If you wish

to ask for a hearing, your request must be in writing and mailed or delivered to the Office of Administrative Legal Services, 701

East Jefferson, MD 6200, Phoenix, Arizona 85034 or faxed to 602-253-9115.

You have the RESPONSIBILITY to:

Provide AHCCCS with the needed information to correctly determine your eligibility and authorize AHCCCS to investigate and

contact any sources necessary to confirm the accuracy of the information which pertains to eligibility.

Take necessary steps to obtain any annuities, pensions, retirement and disability benefits to which you may be entitled,

including, but not limited to Social Security benefits, Railroad Retirement, Veteran’s benefits and unemployment compensation.

To report payments going in or out of your trust, if you have one.

If you are eligible you MUST:

Notify the AHCCCS/ALTCS office as soon as possible but no later than within 10 days by phone, letter or in person, whenever there are any

changes in your income, address, marital status, Medicare coverage, household composition, or other circumstances which could affect your

eligibility.

2. Cooperate with Arizona or Federal personnel in the completion of a quality control review of your eligibility.

PROVIDING SOCIAL SECURITY NUMBERS and IMMIGRATION STATUS

You must provide or apply for a Social Security number (SSN) for every applicant. Immigrants who are not legally able to obtain a SSN

are not required to provide one. This is required under the Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-

369. Providing a Social Security number for someone who is not applying is optional. We will not use your SSN as your AHCCCS

identification number. Your SSN will be used to check the identity of those receiving assistance, to prevent double payments, to

determine benefits available under other programs, to verify state residency or other conditions of eligibility, and to make mass annual

changes more easily. Your SSN will be used in computer matching available through the State Income and Eligibility Verification

System (IEVS) to obtain wage, income and other information from: (a) the IRS, (b) the Social Security Administration, (c) Arizona

Department of Economic Security, and (d) other states administering TANF, Medicaid, Unemployment Insurance, Food Stamps,

Programs under Title I, X, XIV, XVI of the SSA and other state wage information collection agencies. AHCCCS will use the information

available from this computer matching to verify income and whether you have Medicare. When the information you give is

questionable, AHCCCS will verify the information by contacting other sources.

ASSIGNMENT OF RIGHTS TO OTHER BENEFITS FOR MEDICAL CARE

(Applicable only to AHCCCS Health Insurance and the Qualified Medicare Beneficiary Program)

I understand that if I am or members of my family are approved for AHCCCS benefits, AHCCCS can collect payment from any other parties who may be

responsible for paying for our health care costs. This includes:

Private or employer-sponsored health insurance (not including Medicare)

Persons, such as an absent spouse or parent, who are legally responsible for providing medical support

Private or employer-sponsored disability insurance

Private or employer-sponsored accident insurance

Insurance claims, jury awards, or legal settlements resulting from injuries

I understand that AHCCCS cannot collect more than the costs paid by AHCCCS. I also understand that I must give

information about other responsible parties and take any action needed to receive medical support. This includes

establishing paternity of my children, unless I can prove good cause not to do so.

DE-103 (Rev. 06/2017)

Page C

Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs Page 3

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