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People designated Seriously Mentally Ill (SMI) cannot be charged Copays

Accessibility, Health Care, Mental Health

Copays are amounts paid out of pocket, directly to a healthcare provider for their healthcare services. While copays may seem like a regular part of visits to the doctor’s office or pharmacy, there are several reasons why individuals may be exempt from copays. One of these reasons is a Seriously Mentally Ill (SMI) designation. If you are designated as SMI and enrolled in an AHCCCS health plan, you are not responsible for copays for any medication, doctor’s visits, or other healthcare services. 

If you are wrongly charged a copay, the first thing you should do is file an appeal with your health plan. This is called the SMI Appeal process. The appeal is filed with your health plan. If you are unsure how to contact your AHCCCS health plan, check here on AHCCCS’s website.

You, your representative, or your behavioral health provider must file the appeal within 60 days after being charged the copay to your AHCCCS health plan.

In your appeal, you must include a brief statement of the reasons for the appeal. For example, if you are appealing a copay for medication, your reason is that as an individual designated as SMI, you do not have to pay copays. Your appeal should also include the remedy you want. For example, you could request a refund for the copay you were charged.

If you file an appeal past the 60day deadline and your health plan denies your request because it is late, you can ask AHCCCS to review the denial within 10 days. AHCCCS will then make a decision within 15 days, and if their decision is in your favor, your appeal will move forward. But don’t wait.  The best practice is appeal within the deadline.

The appeal process takes 30 days, but if you and your behavioral health provider think that the standard appeal process could harm you or your health, you may request an expedited appeal. Your healthcare services (medication, appointments, and other services) will continue during the appeal if you request continuing services within 10 days of the date the services were denied or a copay was charged. It is best to request continuing services at the same time you file your appeal.

When the health plan makes a decision about your appeal, they will send you a Notice of Appeal Resolution explaining the reason for the decision, and giving you information about your right to a hearing and continuing services. You may ask for a hearing if your appeal is denied by sending a written request for a hearing to the health plan within 30 days of the Notice of Appeal Resolution. More information about the appeal process for individuals designated as SMI, along with a sample appeal document, can be found here.

Follow these steps each time you are wrongly charged a copay.  For example, if this month you go to the pharmacy and are charged a copay for three medications that you pick up, you can file one appeal to challenge the three co-pays.  But if you go to the pharmacy two months later and are charged a copay again, file a new appeal.

If your providers have a pattern of charging co-pays or AHCCCS does not fix the problem and you need further assistance, you can call Disability Rights Arizona to complete an intake at 602-274-6287 on Mondays, Tuesdays, Thursdays, and Fridays from 9:00 AM to 1:00 PM, or complete an online intake form.

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