TAILIEUCHUNG - Application for AHCCCS Health Insurance

These types of policies give rise to an annual charge as well as to the other charges that arise on a gain. In general, a Personal Portfolio Bond (PPB) is a life insurance policy where the benefits payable are determined by the value of certain property chosen directly or indirectly by the policyholder , rather than investment funds generally available to other policyholders. The charge will arise if the policy is a PPB at the end of the insurance year . You are treated as having made a gain of an amount equal to 15 per cent of premiums paid, with the premiums paid being treated. | You can apply online at You can get more information on our programs at Application for AHCCCS Health Insurance Use this application to ask for medical coverage for yourself someone in your family or for someone you are representing. Tear off pages A B C and D and keep for your records. AHCCCS Covered Medical Services Doctor s Visits Specialist Care Transportation to Doctor1 Hospital Services Emergency Care Pregnancy Care Podiatry Services Surgery Services Immunizations shots Physical Exams Behavioral Health1 Family Planning Lab and X-rays Prescriptions2 Dialysis Annual well women exams Glasses1 Vision Exams1 Dental Screening1 Dental Treatment1 Hearing Exams1 Hearing Aids1 See page c for more information about how you get medical services. 1Coverage of these services may be limited depending on the program. 2 Prescription coverage is limited for people who have Medicare. You can also use this form to ask for help with your Medicare premiums coinsurance and deductibles if you have or could have Medicare. This is called Medicare Cost Sharing. Eligibility specialists from AHCCCS DES or KidsCare will review your application for AHCCCS Health Insurance. They will contact you if they need more information. What does AHCCCS Health Insurance Premiums Most people do not have to pay a monthly premium for aHccCs Health Insurance. Some people with income too high to qualify for AHCCCS Health Insurance with no monthly premium may be able to get it by paying a monthly premium. If you have to pay a premium the premium amounts are 10 - 70 per household for all children 10 - 35 per person for employed people with disabilities cost you Co-Payments A co-payment is the amount you pay a health care provider when you receive a medical service. Co-payments for services are as follows Physician visits 0 to 1 Non-emergency use of the Emergency Room 0 to 1 Native Americans and Alaskan Natives Per federal law Native Americans enrolled with a federally

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