Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 6 - DEPARTMENT OF HEALTH SERVICE - COMMUNICABLE DISEASES AND INFESTATIONS › Article 4 - AIDS DRUG ASSISTANCE PROGRAM (ADAP) › Section R9-6-404 - Initial Application Process

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant for initial enrollment in
				ADAP or the applicant's representative shall submit to the Department the
				following application packet:
1. An
				application in a Department-provided format, completed by the applicant or the
				applicant's representative, containing:
a. The
				applicant's name, date of birth, and gender;
b. Except as provided in subsection
				(A)(1)(c), the applicant's residential address and mailing address;
c. If the applicant is in non-permanent
				housing, the address of a person that has agreed to receive written
				communications for the applicant;
d. If applicable, the address in Arizona to
				which the applicant would want drugs to be shipped;
e. If applicable, the
				name of the applicant's representative and the mailing address of the
				applicant's representative, if different from the applicant's mailing
				address;
f. Either:
i. The
				telephone number of the applicant or a person that has agreed to receive
				telephone communications for the applicant, or
ii. An email address for the
				applicant;
g. The number of individuals in the applicant's
				household that can be claimed on the applicant's income taxes and the names and
				ages of the individuals;
h. The names of
				individuals, other than the persons specified in subsection (A)(1)(s)(v), with
				whom the applicant authorizes the Department to speak about the applicant's
				enrollment in ADAP;
i. The applicant's
				annual household income;
j. The applicant's race
				and ethnicity;
k. Whether the applicant or an adult in the
				applicant's household:
i. Is
				employed;
ii. Is
				self-employed;
iii. Is receiving
				regular monetary payments from a source not specified in subsection
				(A)(1)(k)(i) or (ii) and, if so, an identification of the source of the
				monetary payments; or
iv. Is using a source not specified in subsections
				(A)(1)(k)(i) through (iii) or savings to assist the applicant in obtaining
				food, water, housing, or clothing for the applicant and if so, an
				identification of the source;
l. Whether the applicant is receiving health insurance
				coverage from AHCCCS and:
i. If so, the name
				of the AHCCCS health plan and the date enrolled; and
ii. If the applicant's eligibility
				determination for AHCCCS is pending, the date the application for AHCCCS was
				submitted;
m. Whether the applicant is eligible for
				Medicare health insurance coverage and, if not, the date on which the applicant
				will be eligible for Medicare health insurance coverage;
n. If the applicant is eligible for Medicare
				health insurance coverage, whether:
i. The
				applicant, or the applicant's representative has applied for a low-income
				subsidy for the applicant and, if so, the date of the application for the
				low-income subsidy; and
ii. Either:
(1) The applicant or the applicant's
				representative has applied for a Medicare drug plan for the applicant and, if
				so, the date of the application for the Medicare drug plan; or
(2) The applicant is enrolled in a Medicare
				drug plan;
o.
				Whether the applicant or the applicant's spouse has or is eligible to enroll in
				health insurance coverage other than AHCCCS or Medicare that would pay for
				drugs on the ADAP formulary;
p. If the applicant or the applicant's spouse
				is eligible to enroll in health insurance coverage other than Medicare that
				would pay for drugs on the ADAP formulary but enrollment is closed, the date
				the next health insurance enrollment period begins;
q. Whether the applicant is eligible to
				receive benefits from:
i. The Indian Health
				Service or a clinic operated by a sovereign tribal nation, or
ii. The Veterans Health
				Administration;
r.
				Whether the applicant is living in non-permanent housing or is in another
				situation in which the applicant's financial records to verify annual household
				income, as specified in subsection (A)(6), are not available to the applicant;
s. A statement by the applicant or the applicant's
				representative confirming that the applicant or the applicant's representative:
i. Understands that, if the annual household
				income of the applicant is at an amount that may make the applicant eligible
				for enrollment in AHCCCS, the applicant or the applicant's representative is
				required to submit to the Department documentation stating the applicant's
				status for enrollment in AHCCCS before the end of the month after the month in
				which the applicant applied for ADAP, if not provided to the Department with
				the application;
ii. Except as
				provided in
				R9-6-405(E),
				if the applicant is eligible for Medicare, understands that the applicant or
				the applicant's representative is required to submit to the Department proof of
				enrollment in a Medicare drug plan before the end of the month after the month
				in which the applicant applied for ADAP, if not provided to the Department with
				the application;
iii. Except as
				provided in
				R9-6-405(E),
				if the applicant is eligible for Medicare and the annual household income of
				the applicant is less than 175% of the poverty level, understands that the
				applicant or the applicant's representative is required to submit to Department
				documentation of the applicant's status for a low-income subsidy before the end
				of the month after the month in which the applicant applied for ADAP, if not
				provided to the Department with the application;
iv. Except as provided in
				R9-6-405(E),
				if the applicant or the applicant's spouse has or is eligible for health
				insurance coverage other than AHCCCS or Medicare, understands that the
				applicant or the applicant's representative is required to submit to the
				Department information about the health insurance coverage to enable the
				Department to determine if the health insurance coverage is inadequate,
				according to
				R9-6-403(4)(b),
				or unaffordable, according to
				R9-6-403(4)(c),
				before the end of the month after the month in which the applicant applied for
				ADAP, if not provided to the Department with the application;
v.
				Grants permission to the Department to discuss the information provided to the
				Department under subsection (A) with:
(1)
				AHCCCS, for the purpose of determining AHCCCS eligibility;
(2) Medicare and the Social Security
				Administration, for the purpose of determining eligibility for a low-income
				subsidy and enrollment in a Medicare drug plan;
(3) The applicant's HIV-care provider or
				designee;
(4) The contract pharmacy
				or a pharmacy at which the applicant or the applicant's representative may
				request a drug through ADAP, to assist with drug distribution;
(5) Other providers of services for persons
				living with HIV that are funded through Ryan White;
(6) Other providers of HIV-related services,
				as applicable to the applicant; and
(7) Any other entity
				as necessary to establish eligibility for enrollment in ADAP or assist with
				drug distribution to the applicant or payment of prescription co-payment
				costs;
vi. Understands that the applicant or the applicant's
				representative is required to submit to the Department proof of the applicant's
				annual household income as part of the application; and
vii.
				Understands that the applicant or the applicant's representative is required to
				notify the Department of changes specified in
				R9-6-406(A);
t. A statement by the applicant or the applicant's
				representative attesting that:
i. To the best
				of the knowledge and belief of the applicant or the applicant's representative,
				the information and documents provided to the Department in the application
				packet is accurate and complete;
ii. The applicant meets the eligibility
				criteria specified in
				R9-6-403;
				and
iii. The applicant or
				applicant's representative understands that eligibility does not guarantee that
				the Department will be able to provide drugs and understands that an
				individual's enrollment in ADAP may be terminated as specified in
				R9-6-408;
				and
u. The dated signature of the applicant or the
				applicant's representative;