Free Declaration - District Court of Arizona - Arizona

EXHIBIT 17 TO SUPPLEMENTAL DECLARATION OF ELLEN KATZ

Case 2:03-cv-02506-EHC

Document 138-3

Filed 03/10/2008

Page 1 of 3

AHCCCS ELIGIBILITY REQUIREMENTS April 1, 2008
Eligibility Criteria
Where to Apply Household Monthly Income by 1 Household Size (After Deductions) Resource Limits (Equity) Social Security # Special Requirements

General Information
Benefits

Coverage for Children
S.O.B.R.A. Children Under Age 1 S.O.B.R.A. Children Ages 1 ­ 5 S.O.B.R.A. Children Ages 6 ­ 19 DES/Family Assistance Office Child living alone Call 1-800-352-8401 for the Child living with 1 parent Child living with 2 parents nearest office DES/Family Assistance Office Child living alone Call 1-800-352-8401 for the Child living with 1 parent Child living with 2 parents nearest office ½ of 1/3 of ½ of 1/3 of ½ of 1/3 of $1,214 $1,634 $2,054 $1,153 $1,552 $1,9512 $ 8672 $1,167 $1,467 N/A Required N/A AHCCCS Medical Services3 AHCCCS Medical Services3 AHCCCS Medical Services3

N/A

Required

N/A

DES/Family Assistance Office Child living alone Call 1-800-352-8401 for the Child living with 1 parent or spouse nearest office Child living with 2 parents Mail to KidsCare 920 E. Madison, MD 500 Phoenix, Arizona 85034

N/A

Required

N/A Not eligible for Medicaid No health insurance coverage within last 3 months Not available to State employees, their children, or spouses $10-35 monthly premium covers all eligible children only Premium included in parent's if parent is covered under Health Insurance for Parents

KidsCare Children Under Age 19

1 $1,734 2 $2,334 3 $2,934 4 $3,534 Add $600 per Add'l person

N/A

Required

AHCCCS Medical Services3

Coverage for Families or Individuals
AHCCCS for Families with Children DES/Family Assistance Office Call 1-800-352-8401 for the nearest office 1 $ 867 2 $1,167 3 $1,467 4 $1,767 Add $300 per Add'l person $ 867 $1,167 Family includes a child deprived of parental support due to absence, death, disability, unemployment or underemployment AHCCCS Medical Services3

N/A

Required

AHCCCS Care DES/Family Assistance Office Applicant living alone Call 1-800-352-8401 for the Applicant living with spouse (AC) nearest office DES/Family Assistance Office Call 1-800-352-8401 for the nearest office or Mail to KidsCare 920 E. Madison, MD 500 Phoenix, Arizona 85034 DES/Family Assistance Office Call 1-800-352-8401 for the nearest office

½ of

N/A

Required

Ineligible for any other categorical Medicaid coverage Ineligible for any categorical Medicaid coverage Parent living with a child who is eligible under S.O.B.R.A. or KidsCare. No health insurance coverage within last 3 months Not for State employees, their children, or spouses Monthly premium of 3% to 5% of income for all covered parents and KidsCare Children $15-$25 per parent enrollment fee before coverage can begin Ineligible for any other Medicaid coverage. May deduct allowable medical expenses from income

AHCCCS Medical Services3

Health Insurance for Parents

1 $1,734 2 $2,334 3 $2,934 4 $3,534 Add $600 per Add'l person 1 $ 347 2 $ 467 3 $ 587 4 $ 707 Add $120 per Add'l person

N/A

Required

AHCCCS Medical Services3

Medical Expense Deduction (MED)

$100,000 No more than $5,000 liquid

Required

AHCCCS Medical Services3

Coverage for Women
S.O.B.R.A. Pregnant For a pregnant woman expecting one baby: Applicant living alone DES/Family Assistance Office Applicant living with: Call 1-800-352-8401 for the 1 parent or spouse 2/3 of nearest office Applicant living with 2 parents 1/2 of (Limit increases for each expected child) Well Women Healthcheck Program Call 1-888-257-8502 for the nearest office $1,750 $2,200 $2,650 N/A Required Need proof of pregnancy AHCCCS 3 Medical Services

Breast & Cervical Cancer Treatment Program

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 3 Medical Services

Revised Eff. 04/01/2008

Case 2:03-cv-02506-EHC

Document 138-3

Filed 03/10/2008

Page 2 of 3

AHCCCS ELIGIBILITY REQUIREMENTS April 1, 2008
Application
Where to Apply Household Monthly Income by Household Size (After Deductions) 1

Eligibility Criteria
Resource Limits (Equity) Social Security Number Special Requirements

General Information
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 $2,000 Individual4 $2,000 Individual $3,000 Couple N/A 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 3 Medical Services , Nursing Facility, Home & Community Based Services, and Hospice AHCCCS 3 Medical Services AHCCCS 3 Medical Services AHCCCS Medical Services3 Nursing Facility, Home & Community Based Services, and Hospice

$ 1,911 Individual

SSI CASH

Social Security Administration Mail to SSI MAO 701 E Jefferson MD 400 Phoenix, Arizona 85034 Mail to: 701 E Jefferson MD 7004 Phoenix, AZ 85034 602-417-6677 1-800-654-8713 Option 6 Mail to: SSDI-TMC 700 E Jefferson Phoenix, AZ 85034 602-417-6692 1-877-654-8713 ext 76692

$ 637 Individual $ 955 Couple

Required

Age 65 or older, blind, or disabled

SSI MAO

$ 867 Individual $1,167 Couple

Required

Age 65 or older, blind, or disabled Must be working and either disabled or blind Must be age 16 through 64 Premium may be $0 to $35 monthly

Freedom to Work

$2,167 Individual Only Earned Income is Counted

N/A

Required

+

Need for Nursing home level of care or equivalent is required for Long Term Care (Nursing Facility, Home & Community Based Services, or Hospice)

No income limit SSDITemporary Medical Coverage

N/A

Required Receiving Social Security Diasability Income Not eligible for Medicare No Other health insurance coverage Premium may be $60 to $300 monthly AHCCCS 3 Medical Service

Important Notice About the SSDI-Temporary Medical Coverage Program http://www.azahcccs.gov/Services/Programs/SSDI -TMCNotice.pdf
Coverage for Medicare Beneficiaries

QMB

SLMB

QI-1

Mail to SSI MAO 701 E Jefferson MD 400 Phoenix, Arizona 85034 Or call 602-417-7000 or 1-800-654-8713 for the nearest ALTCS office Mail to SSI MAO 701 E Jefferson MD 400 Phoenix, Arizona 85034 Or call 602-417-7000 or 1-800-654-8713 for the nearest ALTCS office Mail to SSI MAO 701 E Jefferson MD 400 Phoenix, Arizona 85034 Or call 602-417-7000 or 1-800-654-8713 for the nearest ALTCS office

$ 867 Individual $1,167 Couple

N/A

Required

Entitled to Medicare Part A

Payment of Part A & B premiums, coinsurance, and deductibles

$ 867.01 ­ $1,040 Individual $1,167.01 ­ $1,400 Couple

N/A

Required

Entitled to Medicare Part A Not receiving Medicaid benefits

Payment of Part B premium

$ 1,040.01 ­ $1,170 Individual $1,400.01 ­ $1,575 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 S.O.B.R.A., AF Related, AC, MED, SSI-MAO, and Long Term Care 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, child care, and educational expenses. 2 Income considered is the applicant's income, plus a share of the parent's income for a child, or a share of the spouse's income for a married person. 3 AHCCCS Medical Services include, but are not limited to, doctor's office visits, immunizations, hospital care, lab, x-rays, and prescriptions. 4 If the applicant has a spouse living in the community, between $20,880 and $104,400 of the couple's resources may be disregarded.
Revised Eff. 04/01/2008

Case 2:03-cv-02506-EHC

Document 138-3

Filed 03/10/2008

Page 3 of 3