Form Fa-001 - Application For Benefits (Page 2 of 31) in pdf

Do you need help with this application? Visit

or call 1-855-HEA-PLUS (432-7587).

Program Information:

You can use this application to apply for one or more programs. Each program has a symbol. On the application, look for

the symbol for the program(s) you want to apply for and answer those questions. These are the symbols you will see on

this application:

= Health Insurance Costs (AHCCCS Medical Assistance, Medicare Savings Program, Tax Credits)

= Nutrition Assistance

= Cash Assistance

= Tuberculosis Control

What is AHCCCS Medical Assistance?

AHCCCS stands for Arizona Health Care Cost Containment System, and it is the State of Arizona’s Medicaid

program. AHCCCS can provide medical benefits and help with Medicare costs to Arizona residents who meet

certain income and other eligibility standards.

AHCCCS Medical Assistance covers the following medical services:



Prescription Medication*

 Medical Supplies

• Chemotherapy



Doctor's Office Visits**

 Medically Necessary Transportation

• Emergency Medical Care



Laboratory and X-ray Services

 Medically Necessary Specialist Care

• Rehabilitation Services



Hospital Services

 Behavioral Health Care

• 90 days of nursing care

services



Dialysis

 Immunizations (shots)

AHCCCS prescription coverage is limited for people who have Medicare.

** Wellness visits for people age 21 and over are not covered.

What is Medicare Savings Program?

Medicare Savings Program may pay:

 Medicare deductibles and copayments

 Medicare Part A premium

 Automatic Extra Help for Medicare Part D prescription expenses

 Medicare Part B premium

What are Nutrition Assistance benefits?

Nutrition Assistance benefits help low-income families or individuals buy food for a healthier diet. If you have

little or no money, you may be eligible for Emergency Nutrition Assistance benefits. Be sure to answer the

Emergency Nutrition Assistance benefits questions on page 2 of this application.

What is Cash Assistance?

Cash Assistance gives temporary cash benefits to low income families. Parents or relatives of dependent

children who are in their care may be eligible. Some families may qualify for a one-time lump sum cash

assistance payment. We will determine if you qualify for this payment option.

What is Tuberculosis Control?

Tuberculosis Control gives cash support to individuals who are determined unable to work by the Department of

Health Services as a result of communicable Tuberculosis.

What if I am not eligible for AHCCCS Medical Assistance?

If you are not eligible for AHCCCS Medical Assistance, you may be eligible for federal tax credits to help with

your health insurance premiums. If you are not eligible for any programs through AHCCCS, we will send your

information to the federal Health Insurance Marketplace to see about health insurance tax credits.

FA-001 (12-17)

Page B

Form Fa-001 - Application For Benefits Page 2

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