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
- 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