Ariz. Admin. Code § 9-6-405

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

Section R9-6-405 - Enrollment Process; Pre-approved Enrollment Status

A. The Department shall:

1. Review the documents submitted by an applicant as required in R9-6-404(A);

2. Determine whether the applicant is eligible under R9-6-403;

3. Grant or deny enrollment based on applicant eligibility, the date of application, and the availability of funds; and

4. Notify the applicant or the applicant's representative of the Department's decision within five working days after receiving the documents specified in R9-6-404(A).

B. An applicant or the applicant's representative shall execute any consent forms or releases of information necessary for the Department to verify eligibility.

C. The Department shall send an applicant or the applicant's representative a written notice of denial, setting forth the information required under A.R.S. § 41-1092.03, if:

1. The applicant does not qualify for enrollment in ADAP, based on the documentation provided to establish eligibility;

2. The documentation submitted to the Department under R9-6-404 is found to contain false information; or

3. The Department does not have funds available to enroll the applicant in ADAP.

D. The Department shall grant pre-approved enrollment status in ADAP to an applicant, lasting until the end of the month after the month in which an applicant applied for ADAP, if:

1. The Department determines that the applicant meets the requirement in R9-6-403(1);

2. The applicant, whose annual household income is an amount that may make the applicant eligible for enrollment in AHCCCS, or the applicant's representative attests in writing that the applicant has applied for AHCCCS enrollment but is unable to provide documentation that 6-403 states the status of the applicant's enrollment in AHCCCS;

3. Except as provided in subsection (E), the applicant, who is eligible for Medicare or other health insurance coverage, or the applicant's representative attests in writing that the applicant has applied for, but is unable to provide documentation of, enrollment in Medicare and a Medicare drug plan or in other health insurance coverage, as applicable; and

4. The applicant or the applicant's representative attests in writing that the applicant or the applicant's representative will provide, before the end of the period during which the applicant has pre-approved enrollment status, a missing component of:

a. Proof of the applicant's annual household income, according to R9-6-404(A)(6) or (7); or

b. Proof of residency, according to R9-6-404(A)(8).

E. The Department shall grant pre-approved enrollment status in ADAP, lasting until the end of the month after the month in which an applicant may apply for Medicare or other health insurance, if the applicant or the applicant's representative provides documentation that the applicant would be eligible for Medicare or other health insurance coverage during the next health insurance enrollment period, but that enrollment was closed on the date of application for ADAP.

F. The Department shall provide an applicant to whom the Department has granted pre-approved enrollment status in ADAP with the drugs on the ADAP formulary during the period during which the applicant has pre-approved enrollment status.

G. Except as specified in subsection (I), to continue ADAP enrollment beyond the period in subsec- tion (D) or (E) during which the applicant has pre-approved enrollment status, an applicant or the applicant's representative shall provide to the Department, before the end of the period, documentation that establishes eligibility according to R9-6-403.

H. Except as specified in subsection (I), if an applicant with pre-approved enrollment status or the applicant's representative fails to provide documentation as required in subsection (G) to the Department before the end of the period during which the applicant has pre-approved enrollment status, the Department shall send the applicant or the applicant's representative a written notice of denial, setting forth the information required under A.R.S. § 41-1092.03.

I. The Department may grant an extension of pre-approved enrollment status to an applicant beyond the period in subsection (D) or (E) if the applicant or the applicant's representative provides a justification for needing more time to obtain the required documentation to verify eligibility because of missing:

1. Documentation of health insurance coverage;

2. Financial records to verify annual household income, specified in R9-6-404(A)(6);

3. Proof of residency, specified in R9-6-404(A)(8); or

4. Viral load test results on the laboratory report required in R9-6-404(B)(2).

J. Based on the information provided by an applicant about the applicant's health insurance coverage and except as provided in R9-6-409(F), the Department shall:

1. For an applicant with no health insurance coverage, provide a drug on the ADAP formulary through the contract pharmacy;

2. For an applicant with health insurance coverage that is inadequate, according to R9-6-403(4)(b), provide a drug on the ADAP formulary that is not covered by the applicant's health insurance, as documented according to R9-6-409(E), through the contract pharmacy; or

3. For an applicant with health insurance coverage that is unaffordable, according to R9-6-403(4)(c), provide a drug on the ADAP formulary with no copayment cost to the applicant when requesting the filling of a prescription for the drug or obtaining a refill of the drug through ADAP.

Ariz. Admin. Code § R9-6-405

Adopted as an emergency effective January 12, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-1). Emergency expired. Readopted without change as an emergency effective May 9, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-2). Amended and readopted as an emergency effective August 8, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-3). Emergency expired. Readopted as an emergency and subsection (B), Paragraph (2) corrected effective November 16, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-4). Emergency expired. Adopted without change as a permanent rule effective May 22, 1989 (Supp. 89-2). Renumbered from R9-6-805 and amended effective October 19, 1993 (Supp. 93-4). Former Section R9-6-405 renumbered to R9-6-406; new Section R9-6-405 renumbered from R9-6-404and amended by final rulemaking at 8 A.A.R. 1953, effective April 3, 2002 (Supp. 02-2). Amended by final rulemaking at 13 A.A.R. 3329, effective November 10, 2007 (Supp. 07-3). Amended by final rulemaking at 25 A.A.R. 3614, effective 12/3/2019.