Chapter 22. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION

A person may be made eligible during a prior quarter period when applying for the Freedom to Work program, as described under Article 3. Notes Ariz. Admin. Code § R9-22-1910 New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repe…

A. As a condition of eligibility, an applicant or member shall: 1. Pay the premium required under subsection (B). 2. Not have any unpaid premiums for more than one month's premium amount. B. The Administration shall process premiums under R9-31-1409 through R9-31-1419 with the fo…

A. person is not eligible for AHCCCS medical coverage if the person is: 1. An inmate of a public institution if federal financial participation (FFP) is not available, or 2. Age 22 through age 64 and is residing in an ICF/IID except when allowed under the Administration's Section…

An applicant or member shall meet the following eligibility criteria: 1. Disabled. As a condition of eligibility, an applicant or member shall be disabled. Disabled means a person who has been determined disabled by the Department of Economic Security, Disability Determination Se…

As a condition of eligibility for the Medically Improved Group, a member shall: 1. Be employed. Under this Section, employed means an individual who: a. Earns at least the minimum wage and works at least 40 hours per month, or b. Has gross monthly earnings at least equal to those…

The Administration shall enroll members under Article 17 of this Chapter. If a member has not paid a required premium, the Administration shall not grant a guaranteed enrollment period. Notes Ariz. Admin. Code § R9-22-1921 New Section made by exempt rulemaking at 9 A.A.R. 95, eff…

A. Redetermination. Except as provided in subsection (B), the Administration shall complete a redetermination of eligibility at least once a year. B. Change in circumstance. The Administration shall complete a redetermination of eligibility if there is a change in the member's ci…

In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Chapter have the following meaning unless the context explicitly requires another meaning: "AZ-NBCCEDP" means the Arizona programs of the National Breast and Cervical Cancer Early Detection Pr…

A. Confidentiality. The Administration shall maintain the confidentiality of a woman's records and shall not disclose a woman's financial, medical, or other confidential information except as allowed under R9-22-512. B. Covered services. A woman who is eligible under this Article…

A. General. To be eligible under this Article, a woman shall meet the requirements of this Article and:1. Be screened for breast and cervical cancer through AZ-NBCCEDP; 2. Be less than 65 years of age; 3. Be ineligible for Title XIX under Articles 14 and 15 in this Chapter and un…

A. Breast cancer. Coverage for treatment for breast cancer under this Article shall conclude on the last provider visit for the specific treatment of the cancer or at the end of hormonal therapy for the cancer, whichever is later. For purposes of this subsection treatment means: …

A. Application. A woman may apply for eligibility under this Article by submitting a complete application. B. Submitting the application. The woman may complete and submit an application at the time of the AZ-NBCCEDP screening. The AZ-NBCCEDP staff may mail or fax the application…

A. Eligibility determination. The Administration shall determine eligibility under this Article and send the notice under subsection (B) or (C) within seven days of receiving a complete application. B. Approval. If a woman meets all the eligibility requirements in this Article, t…

AEligibility is effective on the first day of the month that all eligibility requirements are met, including the period described under R9-22-303 . 1. The first day of the month in which a application is made; or 2. The first day of the first month the woman meets all the eligibi…

A. Redetermination. Except as provided in subsection (B), the Administration shall redetermine eligibility at least once a year. If a woman continues to meet the requirements of eligibility for the Breast and Cervical Cancer Treatment Program under this Article, the Administratio…

In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning: "Anticipatory guidance" means a person responsible for a child receives information and guidance of …

A. For the purposes of this Article, the following definitions apply: 1. "Authorization" means written, verbal, or electronic authorization by:a. The Administration for services rendered to a fee-for-service member, or b. The contractor for services rendered to a prepaid capitate…

A. Experimental services are not covered. A service is not experimental if: 1. It is generally and widely accepted as a standard of care in the practice of medicine in the United States and is a safe and effective treatment for the condition for which it is intended or used. 2. T…

A. A contractor, fee-for-service provider or noncontracting provider shall render inpatient general hospital services including: 1. Hospital accommodations and appropriate staffing, supplies, equipment, and services for: a. Maternity care, including labor, delivery, and recovery …

A.A primary care provider, attending physician, or practitioner shall provide primary care provider services within the provider's scope of practice under A.R.S. Title 32. A member may receive primary care provider services in an inpatient or outpatient setting including at a min…

A. Organ and tissue transplant services are covered for a member if prior authorized and coordinated with the member's contractor, or the Administration. Only the following transplants are covered for individuals 21 years of age or older: 1. Heart, including transplants for the t…

A. The Administration or a contractor shall cover dental services for a member less than 21 years of age under R9-22-213. B. For individuals age 21 years of age or older, the Administration or a contractor shall cover medical and surgical services furnished by a dentist only to t…

Laboratory, radiology, and medical imaging services are covered services if: 1. Prescribed by the member's attending physician, practitioner, primary care provider or a dentist, or prescribed by a physician or practitioner upon referral from the primary care provider or dentist. …

A.An inpatient or outpatient provider, including a hospital, clinic, other appropriately licensed health care facility, and pharmacy may provide covered pharmaceutical services. B.The Administration or a contractor shall require a provider to make pharmaceutical services: 1. Avai…

A.General provisions. 1. Applicability. This Section applies to emergency medical services for non-FES members. Provisions regarding emergency behavioral health services for non-FES members are in R9-22-210.01 . Provisions regarding emergency medical and behavioral health service…

A. General provisions 1. Applicability. This Section applies to emergency behavioral health services for non-FES members. Provisions regarding emergency medical services for non-FES members are in R9-22-210 . Provisions regarding emergency medical and behavioral health services f…

A. A.R.S. § 36-2903.07 establishes the Administration as the authority to administer the Trauma and Emergency Services Fund. B. The Administration shall distribute 90% of monies from the trauma and emergency services fund to a level I trauma center, as defined in subsection (F) o…

A. On or after November 1, 2003, the Administration shall distribute monies, under R9-22-2101(B), to level I trauma centers using monies available in the trauma and emergency services fund at the time of payment. The Administration shall take into consideration the proportion of …

On or after June 30 of each year, the Administration shall distribute monies available in the trauma and emergency services fund at the time of payment as follows: 1. As allocated under R9-22-2101(C) , 2. To hospitals that had an emergency department from July 1 through June 30 o…

A. Notwithstanding R9-22-2101(D), for the reporting years ending June 30, 2011 and June 30, 2012, the Administration shall distribute an amount equal to the balance of the Trauma and Emergency Services fund in the following manner: 1. Ninety percent of the amount shall be distrib…

A. Emergency ambulance services.1. A member shall receive medically necessary emergency transportation in a ground or air ambulance: a. To the nearest appropriate provider or medical facility capable of meeting the member's medical needs, and b. If no other appropriate means of t…

A. Durable medical equipment, orthotic and prosthetic devices, and medical supplies, including incontinence briefs as specified in subsection (E), are covered services to the extent permitted in this Section if provided in compliance with requirements of this Chapter; and 1. Pres…

A. The following E.P.S.D.T. services are covered for a member less than 21 years of age: 1. Screening services including: a. Comprehensive health and developmental history; b. Comprehensive unclothed physical examination; c. Appropriate immunizations according to age and health h…

A.The following medical professional services are covered services if a member receives these services in an inpatient, outpatient, or office: 1. Dialysis; 2. The following family planning services if provided to delay or prevent pregnancy:a. Medications, b. Supplies, c. Devices,…

A. Services provided in a NF, including room and board, an alternative HCBS setting as defined in R9-28-101, or a HCBS as defined in A.R.S. § 36-2939 are covered for a maximum of 90 days per contract year if the member's medical condition would otherwise require hospitalization. …

A. Definition. Notwithstanding the definition in R9-22-201, for the purposes of this Section, an emergency medical or behavioral health condition for a FES member means a medical condition or a behavioral health condition, including labor and delivery, manifesting itself by acute…

Definitions. In addition to definitions contained in R9-22-101 and A.R.S. § 36-2901, the words and phrases in this Article, Article 14 and Article 15 have the following meanings unless the context explicitly requires another meaning: "Applicant," notwithstanding R9-22-101, means …

Application process. 1. Right to apply. A person may apply for AHCCCS medical coverage by submitting an Administration-approved application to the Administration or its designee, an FAA office, or one of the following outstation locations:a. A BHS site; b. A Federally Qualified H…

A. Subject to CMS approval, prior quarter coverage eligibility shall be limited to applicants who meet the requirements in (B) and who also: 1. Are eligible during any of the three months prior to application; and 2. Received one or more covered services described in 9 A.A.C. 22,…

A. Except as provided in subsection (E), if information provided by or on behalf of an applicant or member on an application, renewal form or otherwise does not conflict with information obtained by the agency through an electronic data match, the Administration or its designee s…

As a condition of eligibility, the Administration or its designee must require applicants, and members to do the following: 1. Take all necessary steps to obtain any annuities, pensions, retirement, disability benefits to which they are entitled, unless they can show good cause f…

A. The Administration or its designee is responsible for the following: 1. The Administration or its designee shall determine eligibility within 90 days for an applicant applying on the basis of disability and 45 days for all other applicants, unless: a. The agency cannot reach a…

A. Approval. If the applicant meets all the eligibility requirements and conditions of eligibility of this Article, the Administration or its designee shall approve the application and provide the applicant with an approval notice. The approval notice shall contain: 1. The name o…

The Administration or its designee shall reopen an application or reinstate eligibility of a member when any of the following conditions are met: 1. The denial or discontinuance of eligibility was due to an administrative error, 2. The discontinuance of eligibility was due to non…

The Administration or its designee shall maintain the confidentiality of an applicant or member's records and limit the release of safeguarded information under R9-22-512 and 6 A.A.C. 12, Article 1. In the event of a conflict between R9-22-512 and 6 A.A.C. 12, Article 1, R9-22-51…

A person is not eligible for AHCCCS medical coverage if the person is: 1. An inmate of a public institution, or 2. Over age 64 and is residing in an Institution for Mental Disease under 42 CFR 435.1009 except as allowed in 42 USC 1396 d(h) or as allowed under the Administration's…

By operation of law and under A.R.S. § 36-2903, a person determined eligible assigns rights to the system medical benefits to which the person is entitled. Notes Ariz. Admin. Code § R9-22-311 New Section made by final rulemaking at 20 A.A.R. 193, effective 1/7/2014.