A.   Chapter Contents

This chapter contains the following topics:

Topic

301.00    Types of Services

301.01   Medical Services

301.02   Behavioral Health Services

301.03   EPSDT Services

301.04   Family Planning Services

301.05   Long Term Care Services

301.06   Case Management Services

301.07   Medicare Cost Sharing

302.00    Service Packages

302.01   AHCCCS Medical Service Package

302.02   ALTCS Service Package

302.03   Emergency Service Package

302.04   Family Planning Extension Services Package

302.05   Medicare Cost Sharing Packages

302.06   SSDI - Temporary Medical Coverage Service Package

B.   Introduction

In this chapter you will find:

• A general description of the types of health services provided by AHCCCS Health Insurance;

• Descriptions of the "service packages" that customers receive; and

• How to help a customer who has issues about covered services.

A.   Types of Services

AHCCCS Health Insurance covers:

• Medical services (MS 301.01);

• Behavioral health services (MS 301.02);

• Early Periodic Screening Diagnosis and Treatment (EPSDT) services (MS 301.03);

• Family planning services (MS 301.04);

• Long term care services (MS 301.05);

• Case management (MS 301.06); and

• Medicare cost sharing (MS 301.07).

A.   Definition

Medical services are services provided for the prevention, diagnosis and treatment of health problems.

B.   Inpatient Hospital Services

Hospital accommodations and appropriate staffing, supplies and services are provided for:

• Maternity care, including labor, delivery, recovery room, birthing center and newborn nursery;

• Neonatal intensive care unit;

• Intensive care unit;

• Surgery;

• Nursery and related services;

• Routine care; 

• Emergency behavioral health services;

• Laboratory services

• Radiology and medical imaging services

• Anesthesiology services;

• Rehabilitation services;

• Prescriptions;

• Respiratory therapy;

• Blood and blood derivatives; and

• Medical supplies and equipment.

C.   Primary Care Provider Services

A physician or a practitioner may provide primary care provider services.  

Services may be provided in an inpatient or an outpatient setting. 

Within the provider's scope of practice, the primary care provider may provide:

• Periodic health examinations;

• Evaluation and diagnostic workup;

• Medically necessary treatment;

• Prescriptions for medication and medically necessary supplies and equipment;

• Referrals to specialists when medically necessary;

• Covered preventative heath services;

• Covered immunizations;

• Patient education; and

• Home visits when medically necessary.

D.   Laboratory,
Radiology
And Medical
Imaging Services

Laboratory fees, radiology and medical imaging services are covered when they are prescribed by the customer's primary care provider, attending physician, practitioner or dentist, or when prescribed by a dentist or practitioner to whom the customer has been referred by the primary care physician. 

These services may be provided in a hospital, clinic, physician's office or other health care facility.

E.   Dental Services

Covered dental services include:

• Emergency dental services for a customer who is 21 years of age or older;

• Medically necessary dentures; and

• Dental diagnosis and elimination of oral infection prior to transplantation of organs or tissues. 

Dental services for customers under the age of 21 are covered under E.P.S.D.T. (MS 301.03).

F.   Prescription Medication

Prescription medication is a covered service when the medication is prescribed by:

• The customer's primary care provider;

• An attending physician;

• A practitioner;

• A dentist; or

• A specialist to whom the customer was referred by the primary care physician.

G.   Emergency Services

The following emergency services are covered and available 24 hours per day:

• Emergency room services;

• Emergency medical services;

• Emergency behavioral health services; and

• A behavioral health evaluation if required to evaluate or stabilize an acute episode of mental disorder or substance abuse.

H.   Transportation Services

The following transportation services are covered:

• Emergency ambulance services;

• Air ambulance services under specific circumstances;

• Medically necessary non-emergency transportation limited to the cost of transporting the customer to the appropriate provider capable of meeting the customer's medical needs;

• The cost of transportation provided by a family or household member, friend or neighbor when the transportation services are authorized by the Administration or the customer's contractor, the person providing the transportation is a registered AHCCCS provider, and no other appropriate transportation is available; and

• The following services are covered when a customer has approved prior authorization to receive health care services from a health care service site outside the customer's service area or county of residence:

·     The cost of transportation, meals and lodging for the customer;

·     The cost of transportation, meals and lodging for a family member who accompanies the customer; and

·     Payment for an escort who is not a family member who accompanies the customer.

I.   Medical Supplies, Durable Equipment, and Orthotic and Prosthetic Devices

Medical supplies mean consumable items that are designed specifically to meet a medical purpose. Medical supplies are covered when they are essential to the customer's health.

Durable medical equipment is an item or appliance that can withstand repeated use, is designed to serve a medical purpose, and is generally not useful to a person who does not have a medical condition, illness or injury. The contractor may rent or purchase the durable equipment for the customer. 

Reasonable repair or adjustment of purchased equipment is covered if the cost of repair is less than the cost of renting or purchasing another unit.

Orthotic and prosthetic devices are covered when they are essential for the habilitation or rehabilitation of the customer.

Limitations:

• Hearing aids are not covered for customers who are age 21 or older.

• Prescription lenses are not covered for customers who are age 21 or older unless they are the sole prosthetic device after a cataract removal.

J.   Therapies

Covered therapies include physical, occupational, audiology and speech therapies.

K.   Nursing Facility

Nursing facility services are covered up to 90 days in lieu of hospitalization.

L.   Home Services

Covered home health services are:

• Home health services provided in lieu of hospitalization; and

• Home health therapy services.

M.   Transplants

Covered transplants include:

• Cornea, autologous and allogenic bone marrow transplantations with related chemotherapy and/or radiotherapy;

•  Liver, kidney, heart, lung and heart/lung transplantations, with related immunosuppressant medications.

N.   Other Services

Other covered services include:

• Private duty nursing services, when medically necessary;

• Podiatry services; and

• Optometrist services.

A.   Definition

Behavioral Health Services means evaluation and treatment services for mental disorders and substance abuse.

B.   Diagnosis, Treatment and Case Management

The following diagnostic, treatment and case management services are covered:

• Emergency /crisis behavioral health services;

• Evaluation and screening;

• Laboratory and radiology services for psychotropic medication regulation and diagnosis;

• Behavior management (behavior health personal assistance, family support, peer support);

• Case management services;

• Psychosocial rehabilitation (living skills training, health promotion, pre-job training, education and development, job coaching and employment support); and

• Respite care.

C.    Therapy and Counseling

The following therapy and counseling services are covered:

• Group;

• Individual; and

• Family.

D.   Transportation

Covered behavioral health services include:

• Emergency transportation; and

• Non-emergency transportation.

E.   Services in Facilities

Behavioral health services are covered in:

• Inpatient hospitals;

• Inpatient psychiatric facilities (residential treatment facilities and sub-acute facilities);

• Institutions for Mental Disease (with limitations);

• Partial care (supervised day program, therapeutic day program and medical day program); and

• Behavioral Health Therapeutic Home.

F.   Medication

The following medications are covered:

• Methadone;

• Psychotropic medication; and

• Psychotropic medication adjustment and monitoring.

A.   Definition

The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program provides comprehensive health care for children under the age of 21 who are eligible for Medicaid.

EPSDT provides all medically necessary services to treat all physical and behavioral health disorders, defects or conditions identified in an EPSDT screening, even if the treatment is not covered for other Medicaid eligible individuals.  

Limitations and exclusions, other than the requirement for medical necessity, do not apply to EPSDT services.

NOTE: These services are also available to KidsCare children, however, not under the EPSDT program.

B.   Covered Services

The following services are covered for eligible persons under age 21:

• Health screening services;

• Complete physical exams;

• Immunizations;

• Eye exams and glasses;

• Blood lead screening;

• Emergency dental services;

• Preventive dental exams and treatments;

• Hearing tests and hearing aids;

• Cochlear implants (for children 18 months and older);

• Nutritional assessment and nutritional therapy

• Behavioral health services;

• Chiropractic services;

• Personal care services;

• Case management services;

• Organ and tissue transplant services; and

• Other necessary health care, diagnostic services and treatment. 

Some services require prior authorization.

A.   Definition

Family planning services are services provided to individuals who voluntarily choose to delay or prevent pregnancy.

B.   Covered Services

The following services are covered family planning services:

• Contraceptive counseling, medication and supplies;

• Associated medical and laboratory examinations;

• Treatment of complications resulting from contraceptive use;

• Natural family planning education;

• Postcoital emergency oral contraception within 72 hours after unprotected sexual intercourse;

• Pregnancy screening;

• Screening and treatment for sexually transmitted diseases; and

• Sterilization for both men and women.

C.   Services That Are Not Covered

The following services are not covered for the purpose of family planning:

• Infertility services;

• Abortion counseling;

• Abortions; and

• Hysterectomies.

A.   Definition

Long term care services must be medically necessary and may include:

• In-patient services provided in an institution; and

• Home and Community Based Services (HCBS).

B.   Institutional Services

Institutional services are provided by the following types of facilities, depending on the medical needs of the patient:

Type of Facility

Description

Nursing Facility (NF)

Provides care for individuals who require round-the-clock skilled nursing care and related services, but do not require hospitalization. The care is needed to ensure the individual receives treatment, medication, a therapeutic diet and rehabilitative nursing under the direction of a physician.

Intermediate Care Facilities for the Mentally Retarded (ICF-MR)

Specialized care centers designed to meet the specific needs of the mentally retarded or persons with related conditions.

Residential Treatment Centers

(RTC)

In-patient psychiatric facilities for individuals under age 21, or under age 22 if admitted before age 21, including the Arizona State Hospital (ASH)

Institutions for Mental Diseases (IMD)

Psychiatric Hospitals such as the ASH and Behavioral Health Centers Level I containing 17 or more beds.

Persons under the age of 21 who reside in an IMD are eligible until the person reaches age 21 (or age 22 if admitted before age 21).

Customers age 65 or older who reside in an IMD are eligible without any time limitation.

Persons between the ages of 21 and 64 can be determined eligible for ALTCS but only for 30 days per occurrence and 60 days per contract year (July 1- June 30),

Hospice

An in-patient hospice provides pain relief, symptomatic management, care and supportive services to terminally ill individuals and their family members.

C.   Home and Community Based Services (HCBS)

HCBS are services that prevent institutionalization. 

They are provided in the customer's home or in an alternative residential setting such as an Adult Foster Care Home; an Assisted Living Home; an Assisted Living Center, or in a group home for the developmentally disabled.

HCBS services are based on the medical needs of the patient and include:

Type of Service

Description

Adult Day Health Care Services

Planned care, supervision and activities, personal care, training in personal living skills, meals and health monitoring in a group setting, for a portion of each day.

Attendant Care

Assistance with homemaking, personal care, general supervision and companionship.

Day Treatment and Training for the Developmentally Disabled

Supervision, training, therapeutic activities and counseling to develop skills in independent living, communication and socialization.

Emergency Alert System

Monitoring devices/systems for customers who are unable to access assistance in an emergency situation and/or live alone.

Extended Supported Employment Services

A variety of support services to enable developmentally disabled customers enrolled in the ALTCS transitional program maintain employment.

Home Delivered Meals

Prepared meals delivered to the home of an elderly or physically disabled individual.

Home Health Services

Nursing services, home health aide, occupational therapy, physical therapy, respiratory therapy and speech therapy.

Home Modifications

Physical modifications to the home that are medically necessary to enable the customer to function with greater independence.

Homemaker Services

Assistance with activities such as cleaning, shopping, meal preparation and laundry.

Hospice

In-home supportive care and counseling for terminally ill customers and their families and caregivers.

Habilitation Services

A variety of training and therapy services for the developmentally disabled.

Nutritional Assessments and Nutritional Therapy

Dietary assessment of customers age 21 or older whose health status may be improved with nutritional intervention. Nourishment to complete daily dietary requirements or supplement to the customer's daily nutritional and caloric intake when determined medically necessary.

Personal Care

Assistance with activities of daily life such as dressing, bathing, eating and mobility.

Respite

Short-term or intermittent care and supervision to provide rest and relief for the family members or other persons caring for an elderly or disabled individual.

Transportation

Transportation to and from approved health care and maintenance activities such as doctor's visits or therapy sessions.

A.   Definition

Case management is the coordination and management of ALTCS services by a case manager. 

B.   Who Provides Case Management Services?

ALTCS program contractors are responsible for providing long term care, acute care, behavioral health services and case management services to enrolled customers. The program contractor assigns a case manager to each ALTCS customer. The case manager, in conjunction with the primary care provider, develops a plan for the overall management of the customer's care.

C.   Covered Services

The Case Manager ensures that appropriate services to meet the customer's needs are identified, planned, obtained, provided, recorded and monitored. 

Case Management includes the following services:

Service

Description

Gatekeeping

The case manager assesses the customer's placement and services to make sure they are appropriate to meet the customer's needs.

Service planning

Using the results of the Pre-Admission Screening (PAS) and the gatekeeping assessment, the case manager identifies services that will meet the customer's needs in the most cost-effective manner. 

The case manager develops a service plan for the customer that is mutually agreed upon by the customer and the customer's guardian or authorized representative. 

If the customer does not have a primary care provider, the case manger coordinates efforts to obtain one.

Service provision

The case manager authorizes, obtains and coordinates the ALTCS services specified in the customer's service plan.

Monitoring

The case manager monitors the services provided to the customer to ensure the services are provided according to the service plan. The case manager resolves problems the customer has regarding services. 

Reassessment

The case manager revises and modifies the customer's service plan as needed.

For example, the case manager arranges appropriate HCBS services for a customer who is being discharged from a hospital, nursing facility or other institutional facility.

A.   Definition

Medicare Cost Sharing includes payments of the following Medicare related costs:

• Medicare Part A Premiums;

• Medicare Part B Premiums; and

• Medicare coinsurance and deductibles.

B.   Medicare Related Costs

The following Medicare related costs may be covered depending on the service package for which the customer qualifies:

Cost

Description

Medicare Part A premium

The monthly premium for Medicare hospital insurance that covers in-patient hospitalization, limited skilled nursing facility payments, home health care and hospice care.

Medicare hospital insurance is free to most Medicare eligible individuals, but some people must pay a monthly premium to enroll.

Medicare Part B premium

The monthly premium for Medicare medical insurance which helps pay for doctor's services and other medical services and supplies that are not covered by Medicare Part A such as ambulance services and outpatient hospital care, X-rays and laboratory tests.

Payment of a monthly premium is required for everyone enrolled in Medicare Part B.

Deductibles

The amount of medical bills a Medicare recipient must pay each year before Medicare begins paying.

Coinsurance

The portion of a medical bill that the Medicare recipient is responsible for paying after meeting the deductible. Medicare generally pays 80% of the bill and the coinsurance is the remaining 20%.

A.   Service Packages

AHCCCS coverage is provided in the following service packages:

• AHCCCS Medical Services Package (MS 302.01);

• ALTCS Service Package (MS 302.02);

• Emergency Service Package (MS 302.03);

• Family Planning Extension Services Package (MS 302.04);

• QMB (MS 302.05);

• QMB and AHCCCS Medical Services Package (MS 302.05);

• QMB and ALTCS Medical Services Package (MS 302.05);

• SLMB (MS 302.05);

• QI-1 (MS 302.05); and

• QDWI (MS 302.05).

A.   Service Package

The AHCCCS Medical Services package of services includes:

• Medical Services (MS 301.01);

• Behavioral Health Services (MS 301.02);

• EPSDT Services for Medicaid eligible children under age 21 (MS 301.03);

• Family Planning Services (MS 301.04); and

• Payment of the Part B Medicare premium (for individuals receiving Medicare Part B, except those eligible under AHCCCS Freedom to Work) (MS 301.07).

B.   How Services are Provided

Most customers receive all medically necessary services, except payment of the Medicare Part B premium, from a Prepaid Health Plan (PHP). PHPs receive monthly capitation from AHCCCSA and are responsible for providing and paying for the medical, behavioral health, EPSDT and family planning services the customer receives. 

Native Americans living on-reservation have the option of receiving medical, behavioral health, EPSDT and family planning services through American Indian Health Program (AIHP). AHCCCSA reimburses AIHP on a fee-for-service basis. 

AHCCCSA pays the Medicare Part B premiums (for Medicare eligible customers) through the buy-in process.

C.   Service Problems

When a customer complains about services or requests help resolving a service issue, use one or more of the following options:

• Advise the customer to contact the health plan or AIHP to try to work out a satisfactory solution;

• Advise the customer to call the DMS Client Advocate at (602) 417-4230;

• Advise the customer to call the DMS Member Services Unit at (602) 417-7070 or from outside the Phoenix area 1-800-654-8713, ext. 77070; and

• If the customer has received written notice that requested services have been denied or services have been changed, remind the customer of the right to file a grievance with AHCCCS and/or with the health plan (if enrolled with a health plan). The written notice contains instructions about filing grievances.

D.   Customer Costs

Families who have children eligible for KidsCare are required to pay monthly premiums. Premium amounts are based on income and the number of eligible children. The monthly premium is $10 to $35.  

Parents of KidsCare Children who are approved for Health Insurance for Parents are required to pay a monthly premium of $15.00, $25.00 or $35.00 for each eligible parent.

Customers who are approved for AHCCCS Medical Services under the AHCCCS Freedom to Work program are required to pay a monthly premium (MS 1206.00).

Other Medicaid customers do not pay monthly premiums, but may be responsible for copayments for certain services (MS 1205.00).

A.   Service Package

The full ALTCS service package includes the following services:

• Case Management (MS 301.06);

• Medical Services (MS 301.01);

• Behavioral Health Services (MS 301.02);

• Family Planning Services (MS 301.04);

• Long Term Care Services (MS 301.05);

• EPSDT Services for Medicaid eligible children under age 21 (MS 301.03); and

• Payment of the Part B Medicare premium (for individuals receiving Medicare Part B, except those eligible under AHCCCS Freedom to Work). (MS 301.07) 

A limited ALTCS service package includes all of the services listed above except Long Term Care Services.

A customer who is financially and medically eligible for ALTCS may qualify for the Limited ALTCS Service Package when:

• The customer resides in a living arrangement in which Long Term Care Services benefits cannot be provided (MS 519.00); or

• The customer has made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services (MS 900.00).

• The customer applies for ALTCS benefits on or after July 1, 2006, and the equity value of home property exceeds $500,000 (MS 706.24).

B.   How Services are Provided

Most customers receive all medically necessary services except payment of Medicare premiums from a program contractor. 

• Program contractors receive capitation from AHCCCSA and are responsible for providing and paying for the services the customer receives.

• AHCCCSA pays the Medicare Part B premiums (for Medicare eligible customers) through the buy-in process.

Native Americans living on-reservation have the option of receiving ALTCS services through Native American tribal contractors. 

• The tribal contractors provide case management services and referrals to other services. AHCCCSA pays the tribal contractors capitation for case management and pays providers on a fee-for-service basis. 

• AHCCCSA also pays the Medicare Part B premiums (for Medicare eligible customers) through the buy-in process.

C.   Service Problems

When a customer complains about services or requests help resolving a service issue, use one or more of the following options:

• Advise the customer to contact the program contractor or tribal contractor to try to work out a satisfactory solution;

• Advise the customer to call the DMS Client Advocate at (602) 417-4230;

• If the customer has received written notice that requested services have been denied or services have been changed, remind the customer of the right to file a grievance with AHCCCS and/or with the program contractor or tribal contractor. The written notice must contain instructions about filing grievances; and

• With supervisory approval, complete a Client Issue Referral (DE-638).

D.   Customer Costs

A customer may be required to pay a portion of his or her income each month as a Share of Cost (SOC) for the services provided by AHCCCS. The SOC amount is based on the customer's income and is determined monthly on an individual basis (MS 1201.00).

A customer who is approved for ALTCS HCBS services under the AHCCCS Freedom to Work program is required to pay a monthly premium (MS 1206.00).

A. Service Package

The emergency service package is limited to services that are required to treat an emergency medical condition.

Emergency services are services that:

• Are medically necessary, and

• Result from a medical condition or behavioral health condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity, including severe pain, and

• Which in the absence of immediate medical attention, is reasonably likely to result in at least one of the following:

·     Placing the individual's health in serious jeopardy, or

·     Serious impairment to bodily functions, or

·     Serious dysfunction of any bodily organ or part, or

·     Serious physical harm to another person.

B.   How Services are Provided

All services are paid by AHCCCSA on a fee-for service basis.

C.   Service Problems

Advise the customer to call the Member Services Unit at (602) 417-7070.

D.   Customer Costs

All services received by the customer that meet the definition of emergency medical services are paid by AHCCCSA.

A.   Service Package

A woman who loses S.O.B.R.A. eligibility becomes ineligible for AHCCCS Medical Services, but may receive Family Planning Extension Services.

The Family Planning Extension Service Package includes the services described in MS 301.04 with the following limitations:

• Pregnancy screening is covered only when provided prior to the provision of long-term contraceptives;

• Prescription medication is covered only when associated with a medical condition related to family planning; and

• Screening for sexually transmitted diseases is covered, but treatment is not covered.

B.   How Services are Provided

Family planning services are paid by the Prepaid Health Plan with which the customer is enrolled.

C.   Service Problems

Advise the customer to call the Member Services Unit at (602) 417-7070.

A.   Service Packages

There are four (4) Medicare Cost Sharing packages:

• Qualified Medicare Beneficiary (QMB);

• Specified Low-Income Medicare Beneficiary (SLMB);

• Qualified Individual-1 (QI-1); and

• Qualified Disabled Working Individual (QDWI).

B.   Ways to Qualify

Except for recipients of AHCCCS Freedom to Work, customers who are eligible for the AHCCCS Medical Service Package or the Long Term Care Service Package receive payment of Medicare Part B premiums as part of these service packages. Payment is provided to Social Security through the State buy-in process.

A customer may also qualify for Medicare Cost Sharing benefits by meeting the eligibility requirements for one of the Medicare Cost Sharing programs. 

Customers who are eligible for AHCCCS Freedom to Work may also receive QMB or SLMB if they qualify. Because QI-1 eligibility is limited to individuals who are not eligible for any other AHCCCS programs, recipients of AHCCCS Freedom to Work do not qualify for QI-1. 

The following benefits are associated with each of the Medicare Cost Sharing programs:

Program