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MEDICARE SAVINGS PROGRAMS You can apply online by (Arizona Health Care Cost Containment System)

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APPLICATION FOR AHCCCS MEDICAL ASSISTANCE AND
MEDICARE SAVINGS PROGRAMS
You can apply online by using Health-e-Arizona Plus at
www.healthearizonaplus.gov
Keep Pages A, B, C, D, E, F, and G for your records
If you are over age 65, blind or disabled, or if you are eligible for Medicare, use this application to apply for
AHCCCS Medical Assistance and/or Medicare Savings Programs. Or, you can apply online at
www.healthearizonaplus.gov.
How can I qualify for AHCCCS Medical Assistance?
• Your gross monthly income can be no more than $1,133 for an individual or $1,526 for a couple (after a
$20 standard deduction and other allowed deductions if you have earned income and/or dependent
children).
• You must be a resident of the state of Arizona and a United States citizen or a non-citizen who meets
Medicaid requirements.
• You must apply for pension, disability or retirement benefits if potentially available to you.
• If you are under age 65 and not receiving Social Security Disability income, a disability determination will
be part of your application process.
How can I qualify for a Medicare Savings Program?
If you are receiving or eligible for Medicare Part A, use this application to apply for help with your
Medicare premium(s), copayments and deductibles. There are three Medicare Savings Programs. Each
one has a different income limit and different benefits.
Medicare
Savings
Program
Qualified Medicare
Beneficiary (QMB)
Specified Low-Income
Beneficiary (SLMB)
Qualified
Individual – 1 (QI-1)
General
Eligibility
Requirements:
• You must be a resident of the state of Arizona.
• You must be a United States citizen or a non-citizen who meets Medicaid
requirements.
• You must apply for pension, disability or retirement benefits if potentially
available to you.
Monthly
Income Limits
(after allowed
deductions):
Individual
Individual
Couple
Individual
Couple
$0 - $1,133 $0 - $1,526
$1,133.01-
$1,359
$1,526.01-
$1,831
$1,359.01-
$1,529
$1,831.01-
$2,060
Specific
Requirements:
Receiving or eligible for
Medicare Part A
Receiving
Medicare Part A
Receiving
Medicare Part A
What is the
Benefit?
• Pays your Medicare Part B
Premium
• Pays your Medicare
Part A Premium (if not free)
• Pays your Medicare
coinsurance
• Pays your Medicare
Deductibles*
• Pays your Medicare Part B
Premium
• Pays your Medicare
Part B Premium
*If you are enrolled with a Medicare HMO, your co-pays will also be paid. If you elect additional coverage
from a Medicare HMO, you will be responsible for any additional premiums and costs.
DE-103 (Rev. 01/2022) Page A
What services does AHCCCS Medical Assistance cover?
• Prescription medication*
• Medical supplies
• Medically necessary transportation
• Doctor’s office visits
• Chemotherapy
• Medically necessary specialist care
• Hospital services
• Behavioral health care
• Laboratory and X-ray services
• Dialysis
• Immunizations (shots)
• Rehabilitation services
• 90 days of nursing care
services
• Emergency medical care
* AHCCCS prescription coverage is limited for people who have Medicare.
What does AHCCCS Medical Assistance cost?
Premiums
Most people do not have to pay a monthly premium for AHCCCS Medical Assistance. Some people
with income too high to qualify for AHCCCS Medical Assistance with no monthly premium may be
able to get it by paying a monthly premium. If you have to pay a premium, the monthly premium
amounts are:
• $10 - $70 for KidsCare
• $10 - $35 per person for employed people with disabilities
American Indians and Alaskan Natives: Per federal law, American Indians enrolled with a federally
recognized tribe, children and grandchildren of American Indians enrolled with a federally recognized
tribe and certain Alaskan Natives do not have to pay a premium. To get AHCCCS Medical
Assistance at no cost, you must give us proof of tribal enrollment.
Co-payments
A co-payment is the amount you pay a health care provider when you receive a medical service.
Your co-payment amount will vary depending on which AHCCCS program you are enrolled in and
the services you need. For some AHCCCS programs, the provider can deny services if the co-
payments are not made. Co-payments for services are:
• $2.30 to $10.00 for prescriptions
• $0 to $30.00 for non-emergency use of an emergency room
• $2.30 to $3.00 for physical, occupational or speech therapy
• $3.40 to $5.00 for outpatient visits for evaluation and management services including doctor’s office
visits
Remember to report any changes in income because this may change your co-payment amount.
The following people are never asked to pay co-payments:
• Children under age 19.
• Individuals up through age 20 eligible to receive services from the Children’s Rehabilitative
Services (CRS) program.
• People who receive hospice care.
• People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services.
• American Indian members who are active or previous users of the Indian Health Service, tribal
health programs operated under Public Law 93-638 or urban Indian health programs.
• People who are acute care members and who are residing in nursing homes or residential facilities
such as an Assisted Living Home and only when the acute care member’s medical condition would
otherwise require hospitalization. The exemption from copayments for acute care members is
limited to 90 days per contract year.
In addition, co-payments are never charged for the following services for anyone:
• Hospitalizations
• Emergency services
• Family planning services and supplies
• Services paid for on a fee-for-service basis
• Pregnancy-related health care including tobacco cessation treatment for pregnant women
DE-103 (Rev. 01/2022) Page B
How does AHCCCS Medical Assistance work?
If you are approved for AHCCCS Medical Assistance, you will receive your health care from an
AHCCCS Complete Care (ACC) plan unless:
• You are American Indian and you choose American Indian Health Program as your health plan.
• You are approved for one of the Medicare Savings Programs.
• AHCCCS can only pay for your emergency services because of your status with United States
Citizenship and Immigration Services. If you are approved for emergency services only, you may
receive medical services from any provider (doctor, hospital, etc.) that has an agreement to bill
AHCCCS for covered emergency services.
How does a health plan work?
• The health plan works with health care providers (doctors, hospitals, pharmacies, etc.) to provide all
AHCCCS covered services.
• The health plan will send you a member handbook once you are enrolled.
• You can call the health plan if you have any questions about your benefits or services or if you
need an accommodation because of a disability or interpreter services. The phone number for your
health plan’s member or customer services can be found on your AHCCCS ID Card and in your
Member Handbook.
How can I get behavioral health services?
• You can go through your primary doctor, or
• Call the behavioral health telephone number on your AHCCCS ID Card.
What if I have Medicare or other health insurance?
• Be sure to tell your health plan that you have Medicare or any other health insurance.
• If your doctor does not contract with your AHCCCS Complete Care (ACC) plan, your doctor must
call the ACC plan to coordinate care or you may be responsible for any Medicare or other health
insurance co-payments or deductibles.
• If you are in an HMO, you should pick a primary doctor who works with both your HMO and your
ACC plan.
• If you have Medicare, your prescription coverage under AHCCCS is limited. If you have questions
about prescriptions, call 1-800-MEDICARE (633-4227), or your AACC plan.
What do primary doctors and specialists do?
Once enrolled, you will get a list of primary doctors in your area from the health plan. You must
choose your primary doctor or one will be assigned to you. You have the right to change your
primary doctor at any time by calling your health plan’s member or customer services. Your primary
doctor will:
• Take care of your health care.
• Be responsible for authorizing your non-emergency medical services.
• Be the first person you go to for non-emergency medical care.
• Send you to a specialist when needed.
DE-103 (Rev. 01/2022) Page C
Who Can Complete an Application?
This application may be completed by you or anyone you choose who knows or can get the information
needed to complete the application for you and your family members. The terms “applicant” and “you” on
this form refer to the person applying for AHCCCS Medical Assistance and/or Medicare Savings Program
benefits. You and your spouse can use the same application form to apply. If you have a conservator
or guardian, your conservator or guardian must complete this form for you.
Instructions to the Applicants
Check YES or NO on the application form when asked
if you are applying for AHCCCS Medical Assistance or
for help to pay Medicare costs. You can check YES to
either question or to both.
• Answer all questions on pages 1 through 6 for each
person applying.
• If you need more room, attach additional sheets of
paper to provide all requested details.
• Read page E for an explanation of your rights and
responsibilities and providing a social security
number.
• Sign the application.
• Attach all requested verification when you send your
application.
• Keep pages A, B, C, D, E, F, and G for your records
and mail pages 1 through 6 to the MA-SP Office:
AHCCCS Medical Assistance
Specialty Programs (MA-SP)
801 East Jefferson Street
Phoenix, AZ 85034
FAX: 602-258-4619
• If you are applying for AHCCCS Medical
Assistance, read page G and choose an
AHCCCS Complete Care (ACC) plan.
• If you have any questions regarding these
programs, or need help filling out the
application, please call:
• If you are calling from area codes (480, 602
or 623) dial (602) 417-5010 and choose
option 5.
• If calling from area codes (520, 760 or 928)
dial toll free 1-800-528-0142.
After we receive your application, we will either
contact you for additional information or, if your
application is complete, make a decision about
whether you qualify. We will send you a notice
explaining the decision.
DE-103 (Rev. 01/2022) Page D
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.
4. 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, 801 East Jefferson, MD 6200, Phoenix, Arizona
85034 or faxed to 602-253-9115.
You have the RESPONSIBILITY to:
1. 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.
2. 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.
3. To report payments going in or out of your trust, if you have one.
If you are eligible you MUST:
1. 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.
DE-103 (Rev. 01/2022) Page E
ASSIGNMENT OF RIGHTS TO OTHER BENEFITS FOR MEDICAL CARE
(Applicable only to AHCCCS Medical Assistance 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. 01/2022) Page F
How to choose a health plan
You need to choose an AHCCCS Complete Care (ACC) health plan that serves your county.
• All ACC plans provide the same covered medical services.
• Before choosing an ACC plan, check with your doctor, pharmacy or hospital to see if they work
with the ACC plan that you want. If you want more information about the doctors, specialists or
hospitals that work with an ACC plan that serves your county, call the number listed below for the
ACC plan or visit the ACC plan’s website.
• American Indian members may choose from American Indian Health Program or an ACC plan.
• If you do not choose an ACC plan, one will be assigned to you.
• If you have been enrolled in an ACC plan within the past 90 days, you may be enrolled with your
previous ACC plan.
• If you need help selecting an ACC plan you may speak to a Beneficiary Support Specialist by
calling (602) 417-7100 from area codes (480), (602), and (623) or 1-(800)-334-5283 from area
codes (520) and (928).
Geographic Service Area (GSA)
Available AHCCCS Complete Care (ACC) Health Plans
North
• Apache
• Coconino
• Mohave
• Navajo
• Yavapai
• American Indian Health Program
• Care1st Health Plan
• Health Choice Arizona
Central
• Maricopa
• Gila
• Pinal, excluding ZIP codes
85542, 85192, and 85550
• American Indian Health Program
• Arizona Complete Health - Complete Care Plan (formerly
Health Net Access)
• Banner-University Family Care
• Molina Complete Care
• Mercy Care
• Health Choice Arizona
• UnitedHealthcare Community Plan
South
• Cochise
• Graham
• Greenlee
• La Paz
• Pima
• Santa Cruz
• Yuma
• ZIP codes 85542,
85192, and 85550
• American Indian Health Program
• Arizona Complete Health - Complete Care Plan (formerly
Health Net Access)
• Banner-University Family Care
• UnitedHealthcare Community Plan (Pima County Only)
Health Plan Name
Phone Number
Website
American Indian Health Program
Maricopa County:
602-417-7100
All other counties:
1-800-334-5283
www.azahcccs.gov/AmericanIndians/AIHP/
Arizona Complete Health -
Complete Care Plan (formerly
Health Net Access)
1-888-788-4408
www.azcompletehealth.com/completecare
Banner-University Family Care
1-800-582-8686
www.bannerufc.com/acc
Care1st Health Plan
1-866-560-4042
www.care1staz.com
Molina Complete Care
1-800-424-5891
www.mccofaz.com
Mercy Care
1-800-624-3879
www.mercycareaz.org
Health Choice Arizona
1-800-322-8670
www.healthchoiceaz.com
UnitedHealthcare Community Plan
1-800-348-4058
www.uhccommunityplan.com
DE-103 (Rev. 01/2022) Page G
AHCCCS APPLICATION FORM
Are you applying for AHCCCS Health Insurance?
YES
NO
Are you applying for help to pay Medicare costs? YES NO
APPLICANT INFORMATION
First Name
MI
Last Name
Social Security Number
Date of Birth
Male
Female
Medicare Claim Number
Are you a U.S. Citizen?
❑Yes, a U.S. citizen
❑No, not a U.S. citizen
If no, what number is on
your immigration card?
A__________________
What is your immigration status?
❑Lawful Permanent Resident (LPR)
❑Asylee
❑Refugee
❑American Indian Born in Canada
❑ Cuban-Haitian Entrant
❑ Hmong or Laotian Highlander
❑Victim of Trafficking
❑Afghan/Iraqi Special Immigrant
❑Battered Alien
❑Conditional Entrant
❑Deportation Withheld
❑Indefinite Detainee
❑Parolee for at Least One Year
❑ Citizen of Republic of the
Marshall Islands
❑ Citizen of Federated States of
Micronesia
❑ Citizen of Republic of Palau
❑Other:
____________________________
Home Address
City
State
Zip Code
Mailing Address (if different)
City
State
Zip Code
Home Phone Number
Work Phone Number
Message Number
Email Address
What language do you speak? English Spanish Other ________________
What language do you read?
English
Spanish
Other ________________
Ethnic Group - Optional (will not affect eligibility) ❑ Hispanic ❑ Non-Hispanic Latino
Race - (Select one or more) (Optional)
White
Asian
Native American
Black/African American
Hawaiian or other Pacific Islander
Alaska Native
Check your current Marital Status:
Never Married Married Divorced
Common-Law Widowed
Effective Date of Current Marital Status:
If married, do you and your spouse live together? Yes
No
If NO, date of separation: __________
Did anyone you are applying for receive medical services in the last three months and need help with
these expenses? Yes No If so, who? _____________________________________________
What months? ____________________ ___ ________________________ __________________ __
Is the person needing help with medical expenses pregnant or had a pregnancy end in the last 5 months?
Yes No
Accommodations for Printed Letters
Does the customer, authorized representative, or legal guardian have a visual impairment that requires an
alternative format for printed letters?
No Yes If yes, who needs the accommodation:
If yes, what kind of alternative format do you need? Please choose one option:
Letters in HEAplus account (note: this person must have an HEAplus account)
Readable PDF sent by secure email
Large print: larger print letters sent by U.S. mail will be provided Arial 24 point font.
Other:
Authorized Representative
If you want to allow someone else to represent you or you have a legal guardian, provide the
information below.
Representative’s Name: ___________________________________________________________
Is representative your legal guardian? Yes No
Representative’s Mailing Address: ___________________________________________________
Zip Code:State:City: _______________________ ____ __________
Representative’s Phone Number: ____________________________________________________
What is the representative’s preferred language to speak?
____________________________________________________ English Spanish Other:
What is the representative’s preferred language to read?
____________________________________________________ English Spanish Other:
My representative would like to get information about this application by:
Email: Yes No Email address: _________________________________________________
Text: Yes No Number to text (standard text rates apply): ___________________________
If ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the
mailing address provided.
DE-103 (Rev. 01/2022) Page 2
By signing below, I, the customer, give
permission for the person listed above as my
representative to act on my behalf in the process
of qualifying me for AHCCCS Medical
Assistance, help with Medicare costs, Nutrition
Assistance, Cash Assistance, and/or
Tuberculosis Control. I, therefore:
• Give permission for my representative to
complete and sign my application.
• Give permission for my representative to
provide any documents requested, including
personal information.
• Give permission to my representative to sign
on my behalf to permit other people,
businesses, or agencies to give personal
information about me to DES and/or
AHCCCS, including protected health
information needed to determine if I am
disabled.
• Agree to give information about my personal
circumstances to my representative.
• Agree to allow my representative to assign
all my rights to medical reimbursement
claims to AHCCCS on my behalf.
By signing below, I, the representative, agree to act on
the customer’s behalf. I also agree to:
• Provide only truthful and complete information under
penalty of perjury.
• Fill in and sign needed forms.
• Obtain and give to DES and/or AHCCCS all
information needed to determine if the customer can
qualify for help with healthcare costs, help with
Medicare costs, Nutrition Assistance, Cash
Assistance, and/or Tuberculosis Control, such as the
customer’s Social Security number, income, assets,
citizenship, residency, medical insurance, and
information about the customer’s spouse, minor
children, and parents (if the customer is a minor
child).
• Tell DES and/or AHCCCS right away if the customer:
• Has an increase or decrease in income;
• Has an increase or decrease in assets;
•
Changes ownership of assets, including opening or
closing financial accounts;
• Has a change in address; or
• Has a change in health insurance or the amount of
premiums paid.
If I am determined eligible, this authorization will stay in effect until I or my representative tells you to stop it.
This authorization will expire when my application for assistance is withdrawn or denied, or when my
eligibility ends. However, this authorization will continue during any time while I am contesting my eligibility
in an administrative hearing or court proceeding.
Printed name of Applicant:
______________________________________
Signature of Applicant:
______________________________________
Date: __________________________________
Printed name of Representative:
______________________________________
Signature of Representative:
______________________________________
Date: _________________________________
DE-103 (Rev. 01/2022) Page 3
SPOUSE’S INFORMATION, If living together
Spouse’s First and Last Name
Spouse’s Date of Birth
Spouse’s Social Security Number
(optional if not applying)
Is your spouse applying for AHCCCS Medical Assistance? Yes No
Is your spouse applying for help to pay Medicare Costs? Yes No
Does your spouse need help paying for medical bills Yes No
from the last three months?
What months? ____________________ _________ _____________
If applying, Spouse’s
Medicare Claim Number
If applying, Ethnic Group of Spouse (Optional) Hispanic Non-Hispanic Latino
If applying, Race of Spouse (Select one or more) (Optional)
White Asian Native American
Black/ African American Alaska Native Hawaiian or other Pacific Islander
If applying, is your spouse a U.S.
Citizen?
❑Yes, a U.S. citizen
❑No, not a U.S. citizen
If no, what number is on your
immigration card?
A__________________
What is your spouse’s immigration
status?
❑Lawful Permanent Resident (LPR)
❑Asylee
❑Refugee
❑American Indian Born in Canada
❑ Cuban-Haitian Entrant
❑ Hmong or Laotian Highlander
❑Victim of Trafficking
❑Afghan/Iraqi Special Immigrant
❑Battered Alien
❑Conditional Entrant
❑Deportation Withheld
❑Indefinite Detainee
❑Parolee for at Least
One Year
❑ Citizen of Republic of
the Marshall Islands
❑ Citizen of Federated
States of Micronesia
❑ Citizen of Republic of
Palau
❑Other:
____________________
DEPENDENT CHILDREN INFORMATION
Do you have any unmarried children living with you who are under age 18 or under
age 22 and a student?
If YES, list below. If you need more space, attach a separate piece of paper with
the information requested.
No
Yes
Child’s Full Name
(Last, First)
Child’s Date of
Birth
Child’s Social Security
Number (optional)
Type of School, if
Student
NON-FINANCIAL INFORMATION Applicant
Spouse
(if applying)
1. Do you live in Arizona? Yes No Yes No
2. Do you receive Medicare Part A?
Yes
No
Yes
No
3. Do you receive Medicare Part B?
Yes
No
Yes
No
4. Have you been determined blind or disabled by the Social Security
Yes
No
Yes
No
5. If you answered NO to number 4 and you are under age 65, do you
have a disability that has kept or will keep you from working for at
least 12 months?
Yes No Yes No
6. Are you a person under age 65 who has lost Title II Social Security
Disability benefits because of earnings?
Yes No Yes No
DE-103 (Rev. 01/2022) Page 4
INCOME
Do you, your spouse, or your dependent children receive or expect to receive any of the following types
of income? Check YES or NO for each item.
Yes No
Employment
Income
Yes No
Veteran’s Benefits
Yes No Rental Income
No Yes
Self Employment
Income
Yes No
Annuity Income
Yes No
Mortgage/
Contract
Payments
No Yes
Social Security
Benefits
Yes No
Winnings
(Lottery/Gambling)
Yes No
Child Support/
Alimony
Yes No
Interest on financial
accounts
Yes No
Gifts/loans/
contributions
Yes No
BIA/Tribal
Assistance
Yes No Royalties/Dividends
Yes No
Disability Insurance
Yes No
Payments
from a trust
Yes No Cash Assistance
Yes No
Unemployment
Insurance
Yes No
Tips or
Commissions
Yes No Pensions
Yes No
Student Grants/
Scholarships/Loans
Yes No
Earned
Income Tax
Credit (EITC)
Yes No
Railroad
Retirement
Yes No
Payments for
Room/Board
Yes No Other:
For each item marked YES, provide all of the information requested below. If you need more
room, attach a separate piece of paper containing the requested information. SEND CURRENT
VERIFICATION OF ALL INCOME LISTED (FOR EXAMPLE, CHECK STUBS, AWARD LETTERS, THE
MOST RECENT INCOME TAX FORMS, IF SELF EMPLOYED). COPIES ARE ACCEPTABLE.
Name of Person
Receiving the Income
Type of Income
Date received or
expected to be
received
Gross Amount
(before
deductions)
How often
received?
(weekly, bi-
weekly, etc.)
Has there been a change in any of your income during the last three months or do you
expect a change in income?
If Yes, complete below. If you need more room, attach a separate piece of paper
with the information requested.
Yes
No
Date of change or expected
change
Type of income affected
What is the change?
DE-103 (Rev. 01/2022) Page 5
POTENTIAL BENEFITS
Are you or your spouse a veteran? Yes
No
Are you the widow/widower of a veteran? Yes
No
Have you, your spouse or your deceased spouse ever worked for a government agency,
or employer with a disability or pension plan?
Yes
No
If you answered YES to any of these questions, provide the following information about the veteran or
employee:
Name
Military ID Number
Date of Birth
Date of Death
Dates of employment and/or Military service
Employer’s address
Employer/Branch of Service
MEDICAL COVERAGE
Do you or your spouse have medical insurance coverage, other than Medicare?
If YES, complete the information below and SEND A COPY OF THE
INSURANCE ID CARD.
No Yes
Name of Insurance Company
Who is covered by Insurance?
Do you or your spouse have an injury or illness resulting from an accident (pedestrian,
automobile, or other vehicle, on the job, etc.)?
If YES, complete the items below:
Yes No
Name
Type of
Injury
Date of
Injury
Name and Address of Insurance or Company
Responsible for Medical
Costs due to the Injury
If eligible for AHCCCS Medical Assistance or QMB, by signing this application, I agree to assign to
AHCCCS all rights to third party payments of medical expenses, including insurance coverage, to the
extent that costs are paid by AHCCCS.
HEALTH PLAN CHOICE
If you are applying for AHCCCS Medical Assistance, choose an AHCCCS Complete Care (ACC) plan
that serves your county. See page G or a list of health plans.
Name of AHCCCS Complete Care (ACC) plan you choose (from page G):
DE-103 (Rev. 01/2022) Page 6
YOUR OPPORTUNITY TO REGISTER TO VOTE
If you are not registered to vote where you live now, would you like to apply to register to vote here
today?
Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency.
Yes No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO
REGISTER TO VOTE AT THIS TIME.
If you would like help in filling out the voter registration application form, we will help you. The decision
whether to seek or accept help is yours. You may fill out the application form in private.
If you believe that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, or your right to choose
your own political party or other political preference, you may file a complaint with the State Election
Director, Secretary of State’s Office, 1700 West Washington, Phoenix, AZ 85007, 602-542-8683.
You may also get a voter registration form at https://azsos.gov/elections
PENALTY WARNING
The information provided on this form may be verified by federal, state, and local officials. If anything is
inaccurate, you may be denied benefits.
1. You must not knowingly withhold or give false information with the intent to receive or to continue
receiving AHCCCS benefits to which you are not entitled.
2. You will be required to pay back to AHCCCS any benefits you receive as a result of withholding or
giving false information and you will be subject to criminal prosecution.
It is fraud for any person to knowingly withhold information with the intent to receive or continue to receive
benefits to which he/she is not eligible. Any person found guilty of fraud may be subject to fines, criminal
prosecution, imprisonment or other penalties as provided for by applicable State and Federal laws.
RELEASE OF INFORMATION
I authorize AHCCCS to investigate and contact any sources necessary to establish eligibility and the
accuracy of financial information that pertains to AHCCCS eligibility.
STATEMENT OF TRUTH
I swear or affirm under penalty of perjury that the oral or written statements made regarding the persons
in my home, my income, and any other items that pertain to my possible eligibility for AHCCCS Medical
Assistance or Medicare Savings Program benefits are true and correct to the best of my knowledge and
that any photocopies I have provided are the same as the original. I have read and understand the
penalty warning. I have read and understand my rights and responsibilities, and providing Social Security
numbers on page E of this application. I further agree to cooperate with Arizona or Federal personnel in
the completion of a quality control review on my eligibility for benefits. I certify that the
citizenship/immigration status is correct for each person applying. I do not have to give information on
citizenship or immigration status of family members who are not applying for healthcare benefits. I
understand that my records will be kept confidential and will only be released for purposes authorized by
federal and state law.
Signature of Applicant
Date
Signature of Witness (if applicant signed
with a mark)
Date
Signature of Spouse
Date
Signature of Representative
Date
DE-103 (Rev. 01/2022) Page 7
NOTICE OF NON-DISCRIMINATION
The Arizona Health Care Cost Containment System (AHCCCS) complies with
applicable Federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex. AHCCCS does not exclude
people or treat them differently because of race, color, national origin, age,
disability, or sex. AHCCCS provides free aids and services to people with
disabilities to communicate effectively with us, such as qualified sign language
interpreters and written information in other formats (large print, audio,
accessible electronic formats, and other formats). AHCCCS provides free
language services to people whose primary language is not English, such as
qualified interpreters and information written in other languages. If you need
these services, contact the Health-e-Arizona Plus Customer Support Center at
1-855-432-7587 (TTY: 711).
If you believe that AHCCCS failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex,
you can file a grievance with the AHCCCS General Counsel. You can file a
grievance in person or by mail, fax, or email. Your grievance must be in
writing and must be submitted within 180 days of the date that the person filing
the grievance becomes aware of what is believed to be discrimination. Submit
your grievance to: General Counsel, AHCCCS Administration, Office of
Administrative Legal Services, MD 6200, 801 E. Jefferson, Phoenix, AZ 85034
Fax: 602 253 9115 Email: EqualAccess@azahcccs.gov. You can also file a
civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or
by mail at U.S. Department of Health and Human Services; 200 Independence
Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201; or by
phone: 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available
at http://www.hhs.gov/ocr/office/file/index.html.
AVISO DE NO DISCRIMINACIÓN
Arizona Health Care Cost Containment System (AHCCCS) cumple con las
leyes federales de derechos civiles aplicables y no discrimina por motivos de
raza, color, nacionalidad, edad, discapacidad o sexo. AHCCCS no excluye a las
personas ni las trata de forma diferente debido a su origen étnico, color,
nacionalidad, edad, discapacidad o sexo. AHCCCS proporciona asistencia y
servicios gratuitos a las personas con discapacidades para que se comuniquen
de manera eficaz con nosotros, como los siguientes intérpretes de lenguaje de
señas capacitados y información escrita en otros formatos (letra grande, audio,
formatos electrónicos accesibles, y otros formatos). AHCCCS proporciona
servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés,
como los siguientes intérpretes capacitados y información escrita en otros
idiomas. Si necesita recibir estos servicios, comuníquese con Health-e-Arizona
Plus Customer Support Center at 1-855-432-7587 (TTY: 711).
Si considera que AHCCCS no le proporcionó estos servicios o lo discriminó de
otra manera por motivos de origen étnico, color, nacionalidad, edad,
discapacidad o sexo, puede presentar un reclamo a AHCCCS General Counsel.
Puede presentar el reclamo en persona o por correo postal, fax o correo
electrónico. Su querella deberá presentarse por escrito en plazo de 180 días a
partir de la fecha en la que la persona que se querelle se percate de lo que le
parezca ser discrimen. Remita su querella a: General Counsel, AHCCCS
Administration, Office of Administrative Legal Services, MD 6200,801 E.
Jefferson, Phoenix, AZ 85034 o envíela por fax a: 602 253 9115 0 envíela por
correo electrónico (Email) a: EqualAccess@azahcccs.gov. También puede
presentar un reclamo de derechos civiles ante la Office for Civil Rights
(Oficina de Derechos Civiles) del Department of Health and Human Services
(Departamento de Salud y Servicios Humanos) de EE. UU. de manera
electrónica a través de Office for Civil Rights Complaint Portal, disponible en
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la
siguiente dirección o por teléfono a los números que figuran a continuación:
U.S. Department of Health and Human Services; 200 Independence Avenue,
SW; Room 509F, HHH Building;Washington, D.C. 20201;1-800-368-1019,
800-537-7697 (TDD). Puede obtener los formularios de reclamo en el sitio
web http://www.hhs.gov/ocr/office/file/index.html.
click to sign
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English
If you speak English, language assistance services, free of charge,
are available to you. Call 1-855-432-7587 (TTY: 711).
Spanish
ATENCIÓN: si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-855-432-7587 (TTY:
711).
Navajo
Apache
Ndéé k'ehgo yánłt'i'yúgo Ndéé biyát'į'híí bee kich'į' ódiihíí beegozáá áłdó' do hát'íí ileegoda. Náh
inlk'id ánt'iiyúgo béésh bich'i' nłltsogyúgo díí bik'ehgo bil ónlchííd 1-855-432-7587 (TTY: 711)
Chinese
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-432-7587（TTY：
711）
Vietnamese
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi
số 1-855-432-7587 (TTY:711).
Arabic
ﻣ:ﺔظﻮﺤﻠ ثﺪﺤﺘﺗ ﺖﻨﻛ اذإﺔﯿﺑﺮﻌﻟا.نﺎﺠﻤﻟﺎﺑ ﻚﻟ ﺮﻓاﻮﺘﺗ ﺔﯾﻮﻐﻠﻟا ةﺪﻋﺎﺴﻤﻟا تﺎﻣﺪﺧ نﺈﻓ ، ﻢﻗﺮﺑ ﻞﺼﺗا1-885-432-7587 ﻒﺗﺎھ ﻢﻗر)
:ﻢﻜﺒﻟاو ﻢﺼﻟا711.(
Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
tulong sa wika nang walang bayad. Tumawag sa 1-855-432-7587 (TTY:711).
Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-
432-7587 (TTY: 711) 번으로 전화해 주십시오.
French
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-855-432-7587 (ATS : 711).
German
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-432-7587 (TTY: 711).
Russian
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-855-432-7587 (телетайп: 711).
Japanese
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
1-855-432-
7587（TTY: 711）まで、お電話にてご連絡ください
Serbo-
Croatian/
Croatian
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam
besplatno. Nazovite 1-855-432-7587 (TTY- Telefon za osobe sa oštećenim govorom ili
sluhom: 711).
Syriac/
Assyrian
:












 
  
 
.


 
711 1-855-432-7587 (TTY: .((
Persian/
Farsi
Thai
เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-855-432-7587 (TTY:711).
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MEDICARE SAVINGS PROGRAMS You can apply online by (Arizona Health Care Cost Containment System)

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Completed 23 May 2022

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