In Parts 1 through 3, we walked through how AHCCCS was founded, how it was built, how Arizona gets permission to run it and how the system is supposed to work.
AHCCCS 101 (Part 1): AHCCCS’ Origin Story – Why Arizona Built Medicaid Different
AHCCCS 101 (Part 2): Waivers, State Plan Amendments and Who Decides
This final part (Part 4) looks at what it’s like from a member point of view.
A member’s experience usually starts with an application through Health-e-Arizona Plus (HEAplus), the state’s online portal.
In theory, it’s a single front door for Medicaid, nutrition assistance, and other benefits. In practice, it can be hard to use.
Many users describe HEAplus as clunky and outdated (it uses a really old coding language). The screens aren’t always clear. Uploading documents can be confusing. People sometimes get stuck in loops where the system keeps asking for the same information.
Another common problem is identity verification. Some users say they can’t get past that step at all. Part of that process involves federal systems and contractors like Experian working with Centers for Medicare & Medicaid Services. But for the person trying to apply, that detail doesn’t really matter. If they can’t verify their identity, they can’t finish the application and they have a much harder time getting coverage.
Once someone is approved, they don’t just “have AHCCCS.” They’re enrolled in a health plan. If they don’t pick one, they’re auto-assigned to one.
AHCCCS uses a formula to spread new members across plans. They say their goal is to balance enrollment and keep access stable. Plans sometimes argue about whether the formula is fair, and the auto assignment of a plan can affect which doctors a member can see.
After enrollment, the member’s experience depends a lot on their health plan.
Each plan (MCO or Managed Care Organization) has its own network of doctors and providers. On paper, plans have to meet network sufficiency standards, meaning there should be enough providers. In real life, it can still be hard to find a doctor who is taking new patients or to get a quick appointment with a specialist, especially in rural places.
When a member needs care, some services are simple to get. Others need prior authorization, which means the plan has to approve the service first. This can help control costs, but it can also slow things down or lead to denials.
For people with more complex needs (like those with disabilities or serious mental illness) the system has higher expectations. Their care often involves many providers and services at the same time. AHCCCS requires plans to coordinate that care but doing it well every time is hard.
As we talked about in Part 3 – it’s not the requirement for an adequate network and care coordination – what really matters is compliance with the requirement.
If something goes wrong like a denial or a delay, members can file a grievance or an appeal. These tools are important, but they can be hard to use. Many people don’t file them because the process is confusing or takes too much time.
Another challenge is renewal (“redetermination”). Members have to prove from time to time that they still qualify. If they miss a notice or don’t send in paperwork on time, they can lose coverage even if they’re still eligible.
One common problem is that a letter is stamp mailed to the member asking them to verify their income and other resources (with 10 days to respond). If they moved apartments and didn’t update their new address, they won’t get the letter, so they don’t respond, and can lose their coverage without knowing it until they try to make a doctor’s appointment or go to an ED – so updating contact information is of prime importance for members to do.
All of this stuff connects back to how the system is designed.
Remember from the earlier parts in this series…. AHCCCS pays health plans a fixed amount per member each month. That creates pressure to manage costs. Sometimes that leads to better care and coordination. Other times, it shows up as tighter networks, more approvals, or delays that members feel.
AHCCCS provides essential coverage for millions of Arizonans. But as anybody with a health insurance plan of any kind knows (not just Medicaid members), coverage isn’t the same as access and access isn’t the same as treatment and care coordination.
I hope you found this AHCCCS 101 series informative.
In Part 1, we covered why Arizona built AHCCCS using managed care. In Part 2, we explained how waivers and State Plan Amendments let the state run and change the program.
In Part 3, we showed how AHCCCS manages its contracts and holds health plans accountable.
This final piece shows the member experience.
Note: AHCCCS is working on a new Community Engagement Portal that’s supposed to improve the AHCCCS member experience in advance of the looming work and community engagement requirements for the expansion population. They’re having some virtual sessions about their system goals this week for target populations:
Thursday, April 30 | 1:00 – 2:00 PM
[AHCCCS H.R. 1 Community Engagement Stakeholder – Option 1 (CBOs / Member Assistors)]
Friday, May 1 | 9:00 – 10:00 AM[AHCCCS H.R. 1 Community Engagement Stakeholder – Option 2 (CBOs / Member Assistors)]
