Title 36 — Public Health and Safety

A. The administration shall establish capitation rates based on an actuarial study for the department. The capitation rate shall be based on the estimated cost of providing services pursuant to this article to members who have been determined eligible pursuant to section 36-2933.…

For program contractors pursuant to section 36-2940: 1. The administration shall make at least monthly capitation payments to the department consisting of a portion of the capitation rate provided by the federal government. Prior to making the capitation payment, the administrati…

A. Subcontracts for services rendered by providers pursuant to section 36-2940 shall be awarded through competitive statewide proposals in as nearly the same manner as that provided in section 41-2534. If there is not a sufficient number of qualified proposals, a subcontract may …

A. For each county that has a population of five hundred thousand persons or less and that was not approved as a program contractor before January 1, 1994 or that officially states that it wishes to end its status as a program contractor, the director at least every five years sh…

A. Notwithstanding any other law, beginning on October 1, 2003, each program contractor shall pay to the director of the department of insurance and financial institutions a tax equal to two percent of the total capitation, including reinsurance, and any other reimbursement paid …

A. If there is an insufficient number of qualified bids in a county pursuant to section 36-2944, or for those members not enrolled with program contractors, the director on the approval of the legal advisor of the administration may: 1. Execute discount advance payment contracts …

A. The administration shall coordinate benefits provided under this article to a member so that any costs for services payable by the system are costs avoided or recovered from any available third party payor. The administration may require that the program contractors are respon…

A. Program contractors shall establish and submit to the director for the director's approval utilization control systems comprised of prior authorization, concurrent review and retrospective review of services. B. If a member is no longer eligible for the system, the program con…

On oral or written notice from the member or person that the member or person believes the claims to be covered by the system, a provider or noncontracting provider shall not do either of the following unless the provider or noncontracting provider has verified through the admini…

To the extent that services are provided pursuant to this article, a provider or program contractor is not subject to the provisions of title 20.

B. A person meets the income requirements of this section if the person's countable income does not exceed two hundred fifty per cent of the federal poverty guidelines. The administration shall use the supplemental security income methodology. For purposes of this subsection, cou…

A. Notwithstanding any law to the contrary, a person enrolled in the Arizona long-term care system may employ another person to provide self-directed attendant care services that would otherwise be considered within the scope of nursing care pursuant to title 32, chapter 15 if: 1…

A. Each county or special health care district that is a program contractor pursuant to section 36-2940 shall establish and maintain a county or special health care district long-term care system fund as a separate fund to distinguish its revenues and its expenditures pursuant to…

A. The department shall establish and maintain a department long-term care system fund, which is a separate fund to distinguish its revenues and its expenditures pursuant to this article from other programs funded or administered by the department. Subject to legislative appropri…

If the director determines through the grievance and appeal procedure pursuant to a grievance or appeal filed by an applicant that the administration made an error in eligibility determination pursuant to section 36-2933 and a person was incorrectly determined to be ineligible to…

A. Notwithstanding section 36-2940, the director shall adopt rules which provide that the administration shall withhold or forfeit capitation payments to the program contractor pursuant to section 36-2940 if the program contractor provides inappropriate services to a person deter…

A. The administration is entitled to a lien for the charges for hospital, medical or long-term care and treatment of an injured person for which the administration or a program contractor is responsible pursuant to this article, on any and all claims for damages accruing to the p…

A. No person may present or cause to be presented to the administration or to a program contractor: 1. A claim for an item or service that the person knows or has reason to know was not provided as claimed. 2. A claim for an item or service that the person knows or has reason to …

If at any time federal monies as described in section 36-2932, subsection I, paragraph 2 are denied, not renewed or become unavailable for any reason the provisions of this article relating to the operation of the system are suspended and the director shall notify each program co…

B. Capitation rate adjustments shall be limited to utilization of existing services and inflation unless policy changes, including creation or expansion of programs, have been approved by the legislature or are specifically required by federal law or court mandate. C. The adminis…

The department shall annually determine the cost-effectiveness study rate for persons who are receiving developmental disability services pursuant to chapter 5.1 of this title and provide that rate to the Arizona health care cost containment system administration. On or before Ju…

1. "Administration" means the Arizona health care cost containment system administration. 2. "Department" means the department of economic security. 3. "Parent" means a parent of or the legally responsible individual for the minor child. 4. "Program" means the parents as paid car…

1. An electronic visit verification system that delineates that a parent or a nonparent provider is providing the direct care services. 2. Unique modifiers for delineating both: (a) Whether a parent or nonparent provided the direct care services. (b) Attendant care services and h…

B. A parent may be employed by only a single agency to provide attendant care services and habilitation services under the program.

In this article, unless the context otherwise requires: 1. "Administration" means the Arizona health care cost containment system administration. 2. "Contractor" means a person or entity that has a prepaid capitated contract with the administration pursuant to section 36-2904 to …

A. Subject to continued federal financial participation as provided in sections 36-2919 and 36-2958, the director shall plan for and take all steps necessary to implement the qualified medicare beneficiary program under title XIX of the social security act, as amended. B. The adm…

A. The administration shall determine the eligibility of all applicants who may be eligible as qualified medicare beneficiaries only. The administration shall ensure that the calculation of income eligibility requirements is in accordance with federal law and the section 1115 wai…

A. For purposes of this section all contractors and program contractors are required to provide services to members. B. For a member who is dually eligible the director may implement a policy permitting a choice of contractors or program contractors to the extent the director dee…

The administration shall determine the eligibility of all persons who are specified low income medicare beneficiaries in accordance with federal law. The administration shall pay the monthly premiums under part B of title XVIII of the social security act on behalf of each specifi…

A. The administration shall determine the eligibility of all persons who are determined to be qualifying individuals pursuant to section 36-2971, paragraphs 12 and 13. B. The administration shall pay the medicare part B monthly premiums on behalf of each qualifying individual 1 a…

In this article, unless the context otherwise requires: 1. "Administration" means the Arizona health care cost containment system administration. 2. "Contractor" means a health plan that contracts with the administration to provide hospitalization and medical care to members acco…

A. The children's health insurance program is established for children who are eligible pursuant to section 36-2981, paragraph 6. The administration shall administer the program. All covered services shall be provided by health plans that have contracts with the administration pu…

A. The administration shall establish a streamlined eligibility process for applicants to the program and shall issue a certificate of eligibility at the time eligibility for the program is determined. Eligibility shall be based on gross household income for a member as defined i…

A. If the director determines that federal and state monies appropriated for the program are insufficient, the administration shall immediately notify the governor, the president of the senate and the speaker of the house of representatives and may stop processing all new applica…

1. Contract administration and oversight of contractors. 2. Development of a complete system of accounts and controls for the program, including provisions designed to ensure that covered health and medical services provided through the system are not used unnecessarily or unreas…

A. For inpatient hospital services, the administration shall reimburse the Indian health service or a tribal facility based on the reimbursement rates for the Indian health service as published annually in the federal register. For outpatient services, the administration shall re…

A. To the extent possible, the administration shall use contractors that have a contract with the administration pursuant to article 1 of this chapter or qualifying plans to provide services to members who qualify for the program. B. The administration has full authority to amend…

A. Except as provided in this section, health and medical services prescribed in section 36-2907 are covered services and include: 1. Inpatient hospital services that are ordinarily furnished by a hospital for the care and treatment of inpatients, that are medically necessary and…

A. The administration shall develop standards of care that each contractor shall use to monitor the quality of health care received by members. B. The director shall periodically determine whether each contractor has properly adopted and implemented standards to ensure the qualit…

A. A person shall not provide or cause to be provided false or fraudulent information on an application for eligibility pursuant to this article. B. A person who violates subsection A of this section, who is determined eligible for services pursuant to this article and who would …

A. All contractors and noncontracting providers shall advise the director or the director's designee immediately in a written report of any cases of suspected fraud or abuse. The director shall review the report and conduct a preliminary investigation to determine if there is a s…

A. A person shall not present or cause to be presented to this state or to a contractor: 1. A claim for a medical service or any other item that the person knows or has reason to know was not provided as claimed. 2. A claim for a medical service or any other item that the person …

A. The director shall include in the monthly report submitted to the president of the senate and the speaker of the house of representatives pursuant to section 36-2920 the following information about the program: 1. The actual year to date expenditures and projected annual expen…

A. The children's health insurance program fund is established. The administration shall administer the fund and shall use fund monies to pay administrative and program costs associated with the operation of the program established by this article. B. Separate accounting shall be…

A. A qualifying plan, as defined in section 36-2981, may elect to participate in the children's health insurance program established pursuant to this article, subject to all requirements established in this article and in accordance with section 36-2989. B. The director of the Ar…

(Rpld. 10/1/31) In this article, unless the context otherwise requires: 1. "Continuing care retirement community" means an entity that provides nursing facility services and assisted living or independent living services on a contiguous campus that is either registered as a life …

(Rpld. 10/1/31) A. Beginning October 1, 2012, the administration shall charge a quality assessment on health care items and services provided by nursing facilities in order to obtain federal financial participation in the services provided pursuant to this chapter. The administra…

(Rpld. 10/1/31) A. The nursing facility assessment fund is established consisting of the following: 1. Monies received by the administration from nursing facility assessments pursuant to this article. 2. Federal monies and federal matching monies received by the administration as…

(Rpld. 10/1/31) A. Each nursing facility shall pay a quality assessment as prescribed pursuant to this article. The administration shall determine the assessment rate prospectively for the applicable fiscal year on a per resident day basis, exclusive of medicare resident days. Th…

(Rpld. 10/1/31) A. A nursing facility is eligible for quarterly nursing facility adjustments based on nursing facility days from the most recent cost report before the start of the fiscal year. If cost report data is unavailable for a nursing facility, the administration may use …