Page 2

Revised Eff. February 2026 AHCCCS ELIGIBILITY REQUIREMENTS February 1, 2026

Application Eligibility Criteria General Information

Where to Apply Household Monthly Income by Household Size (After Deductions) 1 Resource Limits (Equity) Social Security Number Special Requirements Benefits

Coverage for Elderly or Disabled People Long Term Care ALTCS Office Call 602-417-7000 or 1-800-654-8713 for the nearest office

300% FBR $2,982 Individual $2,000 Individual3 Required  Requires nursing home level of care or equivalent  May be required to pay a share of cost  Estate recovery program for the cost of services received after age 55 AHCCCS Medical Services2, Nursing Facility, Home & Community Based Services, and Hospice SSI CASH Social Security Administration 100% FBR $994 Individual $1,491 Couple $2,000 Individual $3,000 Couple Required  Age 65 or older, determined to be blind, or have a disability AHCCCS Medical Services2 SSI MAO www.healthearizonaplus.gov or mail an application to AHCCCS P.O. Box 25520 SSI MAO, MD 15022 Phoenix, AZ 85002-5520 100% FPL $1,330 Individual $1,804 Couple N/A Required  Age 65 or older, determined to be blind, or have a disability AHCCCS Medical Services2 Freedom to Work www.healthearizonaplus.gov or mail an application to AHCCCS P.O. Box 25520 SSI MAO, MD 15022 Phoenix, AZ 85002-5520 602-417-6677 1-800-654-8713 Option 6 250% FPL $3,325 Individual Only Earned Income is Counted N/A Required  Must be working and either determined to be blind or have a disability  Must be age 16 through 64  Premium may be $0 to $35 monthly AHCCCS Medical Services2 + Need for Nursing home level of care or equivalent is required for Long Term Care (Nursing Facility, Home & Community Based Services, or Hospice) Nursing Facility, Home & Community Based Services, and Hospice

Coverage for Medicare Beneficiaries QMB www.healthearizonaplus.gov or mail an application to AHCCCS P.O. Box 25520 SSI MAO, MD 15022 Phoenix, AZ 85002-5520 100% FPL

$1,330 Individual

$1,804 Couple N/A Required  Entitled to Medicare Part A Payment of Part A & B premiums, coinsurance, and deductibles SLMB www.healthearizonaplus.gov or mail an application to AHCCCS P.O. Box 25520 SSI MAO, MD 15022 Phoenix, AZ 85002-5520 120% FPL $1,330.01- $1,596.00 Individual $1,804.01- $2,164.00 Couple N/A Required  Entitled to Medicare Part A Payment of Part B premium QI-1 www.healthearizonaplus.gov or mail an application to AHCCCS P.O. Box 25520 SSI MAO, MD 15022 Phoenix, AZ 85002-5520 135% FPL $1,596.01-$1,796.00 Individual $2,164.01-$2,435.00 Couple N/A Required  Entitled to Medicare Part A  Not receiving Medicaid benefits Payment of Part B premium Applicants for the above programs must be Arizona residents and either U.S. citizens or qualified immigrants. Applicants may need to provide documentation of U.S. Citizenship or immigrant status. Applicants for the Children, Caretaker Relative, Pregnant Women, Adult, and SSI-MAO, who do not meet the citizen/immigrant status requirements may qualify for Emergency Services. NOTES: 1. Income deductions vary by program but may include work expenses and educational expenses. 2. AHCCCS Medical Services include, but are not limited to, doctor’s office visits, immunizations, hospital care, lab, x-rays, and prescriptions. 3. If the applicant has a spouse living in the community, between $32,532 and $162,660 of the couple’s resources may be disregarded. 4. *Each additional” approximate amounts only.