Chapter 22. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION

A. General enrollment requirements. The Administration shall enroll a member with a contractor as described in this Section, unless the member has pre-selected a contractor on the application: 1. Except as provided in subsections (A)(3), (A)(5), and (C), a member who is determine…

A. Effective date of enrollment. A member’s date of enrollment is the date enrollment action is taken by the Administration. However, if a plan change occurs for an annual enrollment choice, the effective date is the month of the member’s enrollment anniversary date. B. Financial…

A. General. 1. The Administration shall enroll a newborn child of an eligible mother with an available contractor or IHS, based on the mother’s enrollment. 2. The Administration shall auto-assign a newborn child of an eligible mother who is not enrolled with a contractor or IHS o…

A. General. Except for members enrolled with IHS or CMDP, the Administration shall provide a guaranteed enrollment period for a one-time period that begins on the effective date of the member’s initial enrollment with a contractor and ends on the last day of the fifth full calend…

“Administration” has the meaning defined in A.R.S. § 36-2901. “Affiliation” has the meaning defined in 42 C.F.R. § 424.502. “Managing employee” has the meaning defined in 42 C.F.R. § 455.101. “Member” has the meaning defined in A.R.S. § 36-2901. “Person with an ownership or contr…

A. In addition to such grounds for exclusion set for in subsections A and B of A.R.S. § 36-2930.05, the Administration, in its sole discretion, may exclude: 1. Any individual or entity which has failed to comply with any requirement, term, or condition set forth in any agreement …

A. Pursuant to A.R.S. § 36-2930.05 and 42 C.F.R. § 1002.210, any exclusion from participation in the system shall be for such period as determined in the discretion of the Administration, but in no event shall such period be less than five years. B. In determining the period of e…

A. Any exclusion of an individual or entity pursuant to A.R.S. § 36-2930.05 is an appealable agency action subject to the Uniform Administrative Appeals Procedures, A.R.S. § 41-1092, et seq. B. The Administration shall set forth in the notice of an appealable agency action requir…

A. If the period of exclusion has expired, an individual or entity may apply for reinstatement of participation in the system by submission of the following: 1. An application for participation as a provider. 2. Information to demonstrate reasonable assurances that the type of ac…

A. If an application for reinstatement is denied, the Administration shall give written notice to the requesting individual or entity. B. Within 30 days of the date on the notice of denial of reinstatement, the excluded individual or entity may submit documentary evidence and wri…

Under 42 U.S.C. 1396a(a)(10)(A)(ii)(XV) and (XVI), the Administration shall determine eligibility for AHCCCS medical services, under Article 2 of this Chapter, using the eligibility criteria and requirements under this Article for an applicant or member who is: 1. At least 16 yea…

The Administration shall comply with the confidentiality rule under R9-22-512(C). Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Amended by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

A. A person may apply by submitting an application to an Administration office. B. The application date is the date the application is received at an Administration office or outstation location approved by the Director as described under R9-22-1406(A). C. The provisions in R9-22…

The Administration shall send an applicant a written notice of the decision regarding the application. This notice shall include a statement of the action, and: 1. If approved, the notice shall contain: a. The effective date of eligibility, b. The amount the person shall pay, and…

An applicant or member shall report and verify changes, as described under R9-22-306, to the Administration. Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Amended by final rulemaking at 15 A.A.R. 220, effective March…

The processing of a redetermination or change shall result in one of the following actions: 1. No change in eligibility or premium, 2. Discontinuance of eligibility if a condition of eligibility is no longer met, 3. A change in premium amount, or 4. A change in the coverage group…

A. The requirements under R9-22-312 apply. B. Advance notice of a change in eligibility or premium amount. Advance notice means a notice of proposed action that is issued to the member at least 10 days before the effective date of the proposed action. Except under subsection (C),…

An applicant or member may request a hearing under 9 A.A.C. 34. Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Amended by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

An applicant or member shall meet the following conditions to qualify for the Freedom to Work program: 1. Furnish a valid Social Security Number (SSN); 2. Be a resident of Arizona; 3. Be a citizen of the United States, or meet requirements for a qualified alien under A.R.S. § 36-…

A person may be made eligible during a prior quarter period when applying for the Freedom to Work program, as described under Article 3. Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemak…

Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

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 9 A.A.C. 31, R9-31-1409 through R9-31-141…

Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

A. 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 Secti…

Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

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…

Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4). Section repealed by final rulemaking at 15 A.A.R. 220, effective March 7, 2009 (Supp. 09-1).

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. Historical Note New Section made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 200…

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 AZNBCCEDP; 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…

A. Eligibility is effective on the first day of the month that all eligibility requirements are met, including the period described under R9-22-303. B. The end date of eligibility: 1. For breast cancer, is 12 months after the last provider visit for a treatment specified in R9-22…

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 capitat…

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. The following limitations apply to inpatient general hospital services that are provided by FFS providers. 1. Providers shall obtain prior authorization from the Administration for the following inpatient hospital services: a. Nonemergency and elective admission, including psy…

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 mi…

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. Av…

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…