AHCCCS Medical Program Article

AHCCCS Health Plans

AHCCCS Health Plans

By Southern Arizona Legal Aid, Inc.

Your Right To Medical Services

When you are found eligible for AHCCCS, you are enrolled with a Health Plan such as Mercy Care. Medical services must be approved through your Health Plan.

What services can I get from my health plan? Services or equipment medically necessary to prevent or treat disease, disability, a poor health condition, or prolong life. Most "medically necessary" services are covered, including the following:

  • Doctor's office visits
  • Specialist care, if necessary
  • Hospital services
  • Pregnancy care
  • Prescriptions and medical supplies
  • Laboratory and X-ray services
  • Medically necessary transportation
  • 24-hour emergency medical care
  • Emergency dental care
  • Physical therapy
  • Family planning but not abortion or abortion counseling except in the cases of rape or incest

Children under 21 also receive:

  • Complete physical exams
  • Shots
  • Dental screening and treatment
  • Eye exams and glasses
  • Hearing tests and hearing aids
  • Nutritional information
  • Behavioral health services for those 18, 19, or 20 years old.

What if my health plan denies a service?

Your doctor should request medically necessary health services for you such as referrals to other doctors, laboratory tests and physical therapy. If the request is denied, you and your doctor should get a letter from your Health Plan explaining the reasons for the denial. If you disagree, you should request a grievance. The denial notice should explain your grievance and appeal rights. You have 60 days to request a grievance with the Health Plan.

You can call the Health Plan to request a grievance, but it is best to request a grievance in writing. Your letter should explain the reason(s) you disagree with the Health Plan's decision. Keep a copy of your grievance letter. You should also ask your doctor to write a letter explaining why the service is medically necessary. You or your doctor should send the letter to the Health Plan right away.

What if the health plan denies my grievance?

If the Health Plan denies your grievance, you can appeal to AHCCCS within 30 days of the postmark date of the denial letter. To appeal, you should send a written appeal letter to the Health Plan. The Health Plan will send the appeal to AHCCCS.

You have a right to a hearing with an AHCCCS Judge. At the hearing, you have a right to bring witnesses (such as your doctor) and documents related to your request for services. The Judge will recommend a decision to the AHCCCS Director. The Director will accept or reject the decision. If the Director agrees with the Health Plan's denial, you have the right to ask the Director to review his decision again. After that, you can appeal the decision to State Court.

Why are some medical services denied?

Some reasons for the denial of medical services are:

  • The Health Plan says the service is not medically necessary because there is not enough information. Make sure your doctor sends a letter to the Health Plan with the reasons that the health services are medically necessary. The letter should include a description of your medical condition and it should explain what treatment has already failed. Giving the Health Plan copies of your medical records may also be helpful.
  • Your prescription is not covered on the Health Plan's drug list, called the drug formulary. Ask your doctor. There may be another drug on the formulary that you can use. If you have used drugs on the formulary that didn't help you, ask your doctor to tell the Health Plan about these drugs. Medically necessary drugs which are not on the Health Plan's formulary should be covered if no formulary drugs worked for you.
  • The Health Plan thinks services are available to you from another source, such as school or other state agency. This is an improper reason to deny services. You should contact  AHCCCS and legal services immediately for help. 

What if the health plan stops a medical service?

If your Health Plan stops a medical service or prescription you are currently getting, you have the right to request a grievance. If you request a grievance within 10 days of the date that the services were stopped, you can get the services during the grievance. However, you may be responsible for paying for the services you got during the grievance process if you lose after the entire process is over.

Can I change my doctor or my health plan?

  • You have the right to change your doctor. Call your Health Plan to get a list of doctors and to tell you what you need to do to change your doctor.
  • You can change your Health Plan for any reason once a year on your AHCCCS anniversary date. You can also ask to change in Health Plans at any time, but you must give specific reasons for your request and the Health Plan must approve the change.

Be your own advocate! Ask your doctor for help to get the services you need.

For frequently asked questions on AHCCCS, go directly to the AHCCCS website.

Revised July 2006


On 4/30/08
Kathy said
Is there a way to get a listing of pharmacies or wound care supply entities that will accept ACCHs

On 9/20/07
kaY said

On 7/21/07
Nel said
Yes, just call any doctor's office and ask them which acchs plan do they use.

On 1/6/07
Anthony said
Is there a way to find out which doctors are covered by AHCCCS before you apply for assistance?


  • Will my $1440 monthly social security disability payment disqualify me from AHCCCS? I'm single, no children. I understand the income level is $903, but I'm wondering if my disabiity income is exempt.
  • when i turned 65 disability ssd changed to ssa. on ssd i received ahcccs but today make too much money on ssa to qualify for ahcccs. my disabilities neither of which are ever going away. i cannot afford medicare advantage plans or private insurance. what can i do????
  • If I travel to Mexico for over 30 days, would I lose my AHCCCS? If so, would I have to reapply with the same waiting period as I had originally?
  • My daughter is on AHCCCS and I want to take her to Spain early next year. She has some health issues and should she need to go to the hospital will her AHCCCS cover her?
  • Is there a list of optometrist that take Ahcccs in Tucson Az?
  • who can I call for a ride to doctor
  • Where can I get a full list of providers that cover Maricopa County?
  • How do i know what doctor i can use for my newborn?
  • I would like to know why it is that my income does not count towards my stepchildren when it comes to medical? My husband is currently not working due to he has hemodialysis 3 times a week so I am the primary wage earner in the home. Because my income does not count towards them we are over income for AHCCCS for me & my husband. We had AHCCCS but now don't qualify for TMA & his copays are expensive through my insurance from work.


  • Age discrimination in the workplace. . .
  • I just helped my mother, age 89, deal with her Medicare HMO. . .
  • If you get a divorce, make sure your date of birth is on the Decree if your name is changing!. . .



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