Title 36 — Public Health and Safety

A. All contractors, subcontracted providers of care and noncontracting providers shall notify 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 investiga…

If at any time federal monies as described in section 36-2903.01, subsection B, paragraph 5 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 provide…

A. The director shall submit a monthly report to the president of the senate and the speaker of the house of representatives of the following: 1. The actual year to date expenditures and projected annual expenditures. 2. The actual member months by rate code. 3. The actual caselo…

A. Subject to the availability of monies, the medical services stabilization fund is established. The administration shall administer the fund as directed by the joint legislative budget committee pursuant to subsection E of this section. B. The fund shall be used only to offset …

A. A health care insurer shall: 1. Provide all enrollment information necessary to determine the time period in which a person who is defined as an eligible person pursuant to section 36-2901, paragraph 6, subdivision (a) or that person's spouse or dependents may be or may have b…

The department of economic security and the Arizona health care cost containment system administration shall establish and, as provided in the empower waiver, maintain a joint program that extends child care for twenty-four months and Arizona health care cost containment system b…

A. Notwithstanding any other law, the administration may enter into an agreement with other states to design, develop, install and operate an information system and related services or other administrative services. B. An agreement entered into pursuant to this section shall requ…

A. The administration shall use the cost savings generated from agreements entered into pursuant to section 36-2925 to supplement monies that are appropriated by the legislature. The administration shall use the cost savings to: 1. Subject to title 41, chapter 4, article 4, devel…

A. The intergovernmental service fund is established. The administration shall administer the fund as a continuing appropriation. On notice from the administration, the state treasurer shall invest and divest monies in the fund as provided by section 35-313, and monies earned fro…

A. The budget neutrality compliance fund is established consisting of third party liability recoveries pursuant to section 36-2913, county contributions deposited pursuant to section 11-292, subsection O and section 11-300, subsection E and appropriations. The administration shal…

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 the purposes of this subsection,…

A. The prescription drug rebate fund is established consisting of prescription drug rebate collections, interest from prescription drug rebate late payments and federal monies made available to this state for the operation of the Arizona health care cost containment system prescr…

If a member misses a scheduled appointment with a physician or primary care practitioner who provides medical services pursuant to this article without canceling the appointment before the time for which it is scheduled, the physician or primary care practitioner may prohibit the…

The intergovernmental agreements for county behavioral health services fund is established consisting of county monies received by the administration to provide behavioral health services to persons identified through agreements with the counties. The administration shall adminis…

1. 340B covered entities shall submit point-of-sale prescription and physician-administered drug claims for members for drugs that are identified in the 340B pricing file, whether or not the drugs are purchased under the 340B drug pricing program. The claims shall include a profe…

B. The administration shall administer the fund, and the fund is continuously appropriated. On notice from the administration, the state treasurer shall invest and divest monies in the fund as provided by section 35-313, and monies earned from investment shall be credited to the …

A. The administration shall exclude from participation in the system any individual or entity that meets any basis for mandatory exclusion described in 42 Code of Federal Regulations section 1001.101. B. The administration, in its sole discretion, may exclude from participation i…

A. The substance use disorder services fund is established consisting of monies appropriated to the fund, any gifts or donations to the fund and interest earned on those monies. The director shall administer the fund. B. Monies in the fund: 1. Do not revert to the state general f…

In this article, unless the context otherwise requires: 1. "Administration" means the Arizona health care cost containment system administration. 2. "Capitation rate" means a mode of payment which the program contractor receives for the delivery of services to members pursuant to…

A. The Arizona long-term care system is established. The system includes the management and delivery of hospitalization, medical care, institutional services and home and community based services to members through the administration, the program contractors and providers pursuan…

A. A person who is seeking services pursuant to this article shall submit an application for eligibility for the system to the administration which shall review the completed application to determine if the person meets the residency and if applicable, the alienage requirements a…

A. A person meets the eligibility criteria of this article and the section 1115 waiver if the person satisfies one of the following: 1. Is eligible pursuant to section 36-2901, paragraph 6, subdivision (a), item (i) or (ii) on the date of application for medical assistance under …

A. The administration has sole authority to qualify any trusts that are created pursuant to section 1917(d)(4)(A), (B) and (C) of the social security act and shall require that the trustee provide the following information and assurances when the trustee submits trust documents t…

A. The administration has sole authority to determine the effect of annuities, promissory notes, loan agreements and related financial instruments on a person's eligibility pursuant to this article. B. An irrevocable annuity purchased with an applicant's assets is treated as a tr…

A. The director shall adopt rules in accordance with state and federal law to allow the administration to file a claim against a member's estate to recover paid assistance. The administration is also entitled to a lien on a member's property to recover paid assistance the member …

A. The director shall adopt rules establishing a uniform statewide preadmission screening program to determine if a person who has met the eligibility criteria prescribed in section 36-2934 is eligible for institutional services pursuant to this article. To be eligible for instit…

A. If a person is eligible for services under article 1 of this chapter, the provider with whom the member is enrolled under article 1 of this chapter is responsible for providing services covered under article 1 of this chapter until the date of eligibility for the system specif…

A. The director shall adopt rules establishing a uniform statewide case management program to ensure the most appropriate placement and cost effective delivery of services to members by the program contractors pursuant to this article. The case management program shall include th…

A. The following services shall be provided by the program contractors to members who are determined to need institutional services pursuant to this article: 1. Nursing facility services other than services in an institution for tuberculosis or mental disease. 2. Notwithstanding …

A. The administration shall contract with the program contractors pursuant to this section or section 36-2944 using a contract as prescribed by the director. The department shall be a program contractor and provide services pursuant to this article either directly or through subc…

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…