DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services
San Francisco Regional Office
90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

Tom Betlach, Director
Arizona Health Care Cost Containment System
801 East Jefferson Street
Phoenix, AZ 85034

Dear Mr. Betlach:

December 2, 2014

Enclosed for your records is an approved copy of Arizona’s State Plan Amendment (SPA) AZ-
14-0010.  This combined ABP and Medicaid SPA, which was submitted on September 12, 2014, adds insulin pumps as a covered benefit under the prosthetics sections of the ABP and the State Plan by removing it as a formerly excluded item.

This ABP and Medicaid SPA is approved effective October 1, 2014.  Attached are copies of the following pages to be incorporated into your State Plan:

•	Attachment 3.1-L:
o ABP 5, pages 1-43

•	Attachment 3.1-A Limitations, page 9

If you have any questions, please contact Cheryl Young at (415) 744-3598 or at cheryl.young@cms.hhs.gov.

Sincerely,

/s/

Hye Sun Lee
Acting Associate Regional Administrator
Division of Medicaid & Children’s Health Operations

cc: Wakina Scott
HeeYoung Ansell

AZ.0808.R00.01 -Oct 01, 2014

179)

State/Territory name:
Arizona
Transmittal Number:
Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two
di itofs : f!IiS il.)ll y ar, and 0000 = a four digit number  with leading zeros. The dashes must also be entered.
14-0010

Proposed Effective Date
10/01/2014	(mm/dd/yyyy)

Federal Statute/Reg':llation Citation
Section 1937 of the Social Security Act

Federal Budget Impact
Federal  Fiscal Year 	Amount

First Year 	2015	$822600.00

Second Year    2016 	$852800.00

Subject of Amendment
Updates benefits to add insulin pumps

Governor's Office Review
Governor's office reported  no comment
Comments  of Governor's office received
Describe:

No reply received within 45 days of submittal
Other, as specified
Describe:

Signature of State Agency Official
Submitted  By:
Theresa  Gonzales
Last Revision Date:
Sep 9, 2014
Submit  Date:
Sep 9, 2014

12/04/2014

Attachment 3.1-A Limitations
Page 9
12. 	Prescribed drugs, dentures, and prosthetic  devices; and eyeglasses prescribed  by a physician skilled in diseases of the eye or by an optometrist.

12a. 	Prescribed drugs.
Medicare  Part  D drugs  are  not covered  for  full  benefit  dual  eligible  members,  as  coverage  is provided through Medicare Part D POPs and MAPD

Prescription   drugs  for  covered  transplantation   services  shall  be  provided  in  accordance  with
AHCCCS transplantation  policies.
AHCCCS only covers over-the-counter medications in place of a covered prescription medication that is clinically appropriate, equally safe and effective, and less costly than the covered prescription medication.

In compliance  with Section  1927(b) of the Social Security  Act (the Act), the State collects drug rebates in accordance with established policy for drug rebate agreements as provided in Exhibit 12(a) to Attachment 3.1-A.

12c. 	Prosthetic devices.
Prosthetic devices are limited to devices prescribed  by a physician or other licensed practitioner to artificially  replace  missing,  deformed  or  malfunctioning   portions  of  the  body  and  which  are medically necessary to the rehabilitation of the member.

Covered  prosthetic  devices  for members age 21 and older do not include  hearing aids, cochlear implants,  bone anchored  hearing aids, percussive  vests, microprocessors  for controlled  joints for the  lower  limbs  in  addition   to  microprocessor-controlled  joints  for  the  lower  limbs,  penile implants, and vacuum devices.

Orthotic devices, which are defined as devices that are prescribed by a physician or other licensed practitioner  of the healing arts to support a weak or deformed  portion of the body, are not covered except  under  the  following  circumstances:   Halos  to  treat  cervical  fracture  instead  of  surgery; Walking boots instead of surgery or serial casting; Knee orthotics for crutch dependent ambulation instead of a wheelchair.

12d.   Eyeglasses.
Eye examinations for prescriptive lenses and the provision of prescriptive lenses under EPSDT
services.

Adult services are limited to eyeglasses and contact lenses as the sole prosthetic device after a cataract extraction.

13. 	Other  diagnostic, screening,  preventive, and rehabilitative services, i.e., other  than those provided elsewhere in the plan.

13a.   Diagnostic Services.
Genetic testing is not covered unless the results of the genetic tests are necessary to differentiate between  treatment  options.   Genetic  testing  is not  covered  to  determine  specific  diagnoses  or syndromes  when such  determination   would  not definitively  alter  the  medical  treatment  of  the member.

TN No. 14-0010
Supercedes
TN No. 14-003

Approval Date:_0_£_(_0_2_20_14_ 	Effective Date: October 1, 2014

Attachment 3.1-L-

OMB Control Number: 0938‐1148
OMB Expiration date: 10/31/2014

Benefits Description	ABP5

The state/territory proposes a “Benchmark-Equivalent” benefit package. No

Benefits Included in Alternative Benefit Plan

Enter the specific name of the base benchmark plan selected:

United Health Care EPO

Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved.  Otherwise, enter
“Secretary-Approved.” Secretary-Approved

■    Essential Health Benefit 1: Ambulatory patient services	Collapse All	
Benefit Provided:	Source:

Physician Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Family Planning Services and Supplies	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:

Hospice Care	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: Same as Medicare	Same as Medicare
Scope Limit:
Same as Medicare. As required by section 2302 of the Affordable Care Act, individuals less than 21 years of age may receive concurrent curative and palliative hospice care treatment.		

Other information regarding this benefit, including the specific name of the source plan if it is not the base
benchmark plan:	Remove		
Benefit Provided:	Source:
Outpatient hospital services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Outpatient hospital services are services ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Transportation: Non-Emergency	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Non-emergency ambulance transportation is available for transport to and from facilities where medical treatment is being provided. Trips that exceed 100 miles require prior authorization

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Clinic Services: Non-Urgent	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit		

Scope Limit:

No Limit	Remove

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:

Home health services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

Home health services meet the requirements of 42 CFR 440.70.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Med/surg services furnished by a dentist	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Services not covered by this benefit: dental cleanings, routine dental exams, dental restorations including crowns and fillings and extractions, pulpotomies, root canals, and the construction or delivery of partial dentures.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Services covered by a dentist must be related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw and include examination of the oral cavity, required radiographs, complex oral surgical procedures such as treatment of maxillofacial fractures.		
Add		

TN# 14-0010

Approval Date: 12/2/2014	Effective Date: 10/1/2014

■    Essential Health Benefit 2: Emergency services	Collapse All	
Benefit Provided:	Source:
Transportation: Emergency Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No limit	No limit
Scope Limit:
Air ambulance services are limited in scope as defined in the Medicaid State Plan including point of pickup inaccessible by ground, great distances or obstacles to get person to nearest hospital, medical condition requires faster transport.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Clinic Services: Urgent and Emergent Care	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limits

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Outpatient Hospital: Emergency Services	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit		
TN# 14-0010	Approval Date: 12/2/2014	Effective Date: 10/1/2014	

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
This service includes urgent care that may be non-emergent, but is determined in accordance with
AHCCCS to require prompt medical attention.

Remove

Add

■    Essential Health Benefit 3: Hospitalization	Collapse All	
Benefit Provided:	Source:
Inpatient Hospital Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Inpatient hospital services include services in inpatient psychiatric facilities, provided to EPSDT eligible persons < 21 years in accordance with 42 CFR 441.150.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Inpatient hospital services are services provided for evaluation or treatment of conditions that cannot be adequately treated on an ambulatory basis as defined by the Medicaid state plan. This benefit includes Occupational Therapy and Speech, Hearing, and Language Disorder Services for members 21+		
Benefit Provided:	Source:
Organ Transplant Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: Prior Authorization	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
AHCCCS doesn't cover the following transplants for persons 21+:Pancreas only transplants,Partial pancreas transplants, including islet cell transplants,Intestine transplants (Visceral), Any transplant not listed in the Medicaid state Plan.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Medically necessary transplant services meeting nationally recognized criteria for non-experimental,non- investigational organ or tissue transplants are available to AHCCCS members.		
Benefit Provided:	Source:
Nursing Facility Services: Sub Acute or Rehab	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit:

90 days per contract year	none		

Scope Limit:

Nursing facility services are provided under acute care and the ALTCS transitional program when	Remove hospitalization would be necessary if nursing facility services are not provided.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Non Emergency Transportation- In-Patient Only	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: Prior Authorization	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Non-emergency ambulance transportation is available for transport to and from facilities where medical treatment is being provided.

Non-emergency transportation is only for in-patient services.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Trips that exceed 100 miles require prior authorization		
Add		

■    Essential Health Benefit 4: Maternity and newborn care	Collapse All	
Benefit Provided:	Source:
Extended Services for Pregnant Woman	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:

Nurse-Midwife	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limits
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Inpatient Hospital: Maternity	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit		

Other information regarding this benefit, including the specific name of the source plan if it is not the base
benchmark plan:	Remove		
Benefit Provided:	Source:

Physician: Maternity	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Add		

Essential Health Benefit 5: Mental health and substance use disorder services including	Collapse All
■    behavioral health treatment	
Benefit Provided:	Source:
Rehab: Inv, Grp &/or Family Therapy and Counseling	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

BHT's are limited to providing this service under an ADHS/DBHS licensed agency.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Inpatient Hospital : Mental Health Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

Not IMD Facilities.‘The IMD payment exclusion applies’

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Inpatient Hospital:Substance Abuse Detoxification	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

Not IMD Facilities.‘The IMD payment exclusion applies’		

Other information regarding this benefit, including the specific name of the source plan if it is not the base
benchmark plan:	Remove		
Benefit Provided:	Source:
Outpatient Hospital: Mental Health Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

Not IMD Facilities

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Outpatient Hospital:Substance Abuse Rehabilitation	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

Not IMD Facilities

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Add		

■    Essential Health Benefit 6: Prescription drugs
Benefit Provided:
Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark.

Prescription Drug Limits (Check all that apply.): Limit on days supply
Limit on number of prescriptions
Limit on brand drugs Other coverage limits Preferred drug list

Authorization: No

Provider Qualifications: State licensed

Coverage that exceeds the minimum requirements or other:
The State of Arizona's ABP prescription drug benefit plan is the same as under the approved Medicaid state plan for prescribed drugs.

■    Essential Health Benefit 7: Rehabilitative and habilitative services and devices	Collapse All	
Benefit Provided:	Source:

Physical therapy	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit:

30 Outpatient Visits Per Year	None.

Scope Limit:
Out-patient physical therapy is limited to 15 visits per contract year for rehabilitative purposes and 15 visits per contract year for habilitative purposes.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
The Physical Therapy benefit includes 15 visits per contact year for rehabilitation and 15 visits per contract year habilitation services.		
Benefit Provided:	Source:

Prosthetic Devices	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

See Other Information

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Covered prosthetic devices for members 21 and older do not include hearing aids, percussive vests, microprocessors for controlled joints for the lower limbs, in addition to microprocessor-controlled joints for the lower limbs penile implants and vacuum devices.		
Benefit Provided:	Source:
Medical supplies, equipment & appliances for home	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit		

TN# 14-0010	Approval Date: 12/2/2014	Effective Date: 10/1/2014	

Scope Limit:

Personal care items including items for personal cleanliness, body hygiene, and grooming are not covered	Remove unless needed to treat a medical condition.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		
Benefit Provided:	Source:
Rehab: Psychosocial Rehabilitation	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Rehabilitative Services to teach independent living skill, social and communication skills to persons to promote the maximum reduction of behavioral health symptoms and/or restoration of an individual to his/ her best age appropriate functional level for the purposes of maximizing the person's ability to live independently and function in the community.		
Benefit Provided:	Source:
Rehab: Home Care Training to Home Care Client	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limits	No Limits
Scope Limit:
HCTC services can only be provided for no more than three adults in an Adult Therapeutic Foster Home licensed by ADHS/OBHL or home licensed by federally recognized Indian tribes that attest to CMS via AHCCCS that they meet equivalent requirements.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
These services are provided by behavioral health therapeutic home providers and are designed to maximize the member's ability to live and participate in the community and to function independently, including assistance in the self-administration of medication and any ancillary services (such as living skills and health promotion) indicated by the member's treatment plan as appropriate.		
TN# 14-0010	Approval Date: 12/2/2014	Effective Date: 10/1/2014	

Supersedes

Remove		
Benefit Provided:	Source:
Rehab: Supported Employment Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State
Certified Community Service Agency.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
These services are designed to assist a person or group of persons with a medical/behavioral health condition that enables a member to function in the workplace. These services include supporting the member's ability to manage mental health related symptoms, facilitate recovery from mental illness; assist with personal, community and social competencies, and to aid members to establish and navigate environmental supports.		
Benefit Provided:	Source:

Rehab: Health Promotion	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limits	No Limits
Scope Limit:
BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State
Certified Community Service Agency.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Education and training provided to a group of persons and/or their families related to the enrolled member's treatment plan on health related topics such as the nature of illness, relapse and symptom management, medication management, stress management, safe sex practices, HIV education and healthy lifestyles		
Add		

■    Essential Health Benefit 8: Laboratory services

Benefit Provided:

Other laboratory and x-ray services.

Authorization: None

Source:

State Plan 1905(a) Provider Qualifications:
Medicaid State Plan

Collapse All

Remove

Amount Limit:

No Limit

Duration Limit:

No Limit

Scope Limit:

See Other Information

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Laboratory, x-ray, and medical imaging services. Genetic testing is not covered unless the result of the genetic tests are necessary to differentiate between treatment options. Genetic testing is not covered to determine specific diagnoses or syndromes when such determination would not definitively alter the medical treatment of the member.

Add

■    Essential Health Benefit 9: Preventive and wellness services and chronic disease management	Collapse All

The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).	
Benefit Provided:	Source:

Preventative Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
“A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM) are included in this benefit.		
Benefit Provided:	Source:

Screening Services	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
“A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM) are included in this benefit.		
Benefit Provided:	Source:
Rehab Services: Peer Support Services	State Plan 1905(a)		

TN# 14-0010	Approval Date: 12/2/2014	Effective Date: 10/1/2014	

Authorization:	Provider Qualifications:

None	Medicaid State Plan	Remove

Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Services provided by persons who have been consumers of the behavioral health system and who are at least 18 years old.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Peer support may involve assistance with more effectively utilizing the service delivery system such as assisting with developing plans of care, accessing supports, partnering with professionals, overcoming service barriers or assisting the member to understand and cope with the member's disability, behavior coaching, role modeling and mentoring.		
Benefit Provided:	Source:
Rehab Services: Family Support/Home Care Training	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
These services include face to face interactions with a member's family and are directed toward restoration, enhancement, or maintenance of the family functioning to increase their ability to effectively interact and care for the member in the home and community when relevant to the member's treatment plan. May involve support activities such as assisting the family to adjust to the member's disability, developing skills to effectively interact and/or manage the member, understanding the causes and treatment of behavioral health issues, understanding and effectively utilizing the system, or planning long term care for the
member.		
Benefit Provided:	Source:
Rehab Services Living Skills Training	State Plan 1905(a) Authorization:	Provider Qualifications: None	Medicaid State Plan		

Amount Limit:                                                               Duration Limit:

No Limit                                                                         No Limit                                                                             Remove

Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
These services are provided for the restoration, enhancement, maintenance, and assistance in obtaining age appropriate independent living, social, and communication skills to members and/or their families in order to maximize the member's ability to live and participate in the community and to function independently.		
Benefit Provided:	Source:

Respite	Secretary-Approved Other	Remove

Authorization:	Provider Qualifications: None	Other
Amount Limit:	Duration Limit:

600 hours per year	none

Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
The respite benefit is authorized under the 1115 Research and Demonstration Waiver for the Arizona
Health Care Cost Containment System		
Benefit Provided:	Source:

Case Management	State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Other
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:		

Benefit Provided:

Other practitioners' srvs:Other practitioners' srv

Authorization: None

Source:

State Plan 1905(a) Provider Qualifications:
Medicaid State Plan

Remove

Amount Limit:

No Limit

Duration Limit:

No Limit

Scope Limit:

No Limit

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
Other practitioners' services provided by: I. Respiratory Therapists
ii. Certified Nurse Practitioners
iii. Certified Registered Nurse Anesthetists
iv. Non-physician First Surgical Assistants and Physician Assistants
v. Licensed midwives within the limitations provided in the AHCCCS policy and Procedures
vi. Licensed affiliated practice dental hygienists practicing within the scope of
Arizona's state practice act.
vii. Licensed Pharmacists employed by an AHCCCS-registered pharmacy and acting within the scope of their practice may administer seasonal flu and pneumococcal vaccines and anaphylaxis agents.
viii. Non-physician behavioral health professionals, as defined in rule, when the services are provided by the following state-licensed practitioners: social workers, physician
assistants, psychologists, counselors, registered nurses, psychiatric nurse practitioners, marriage and family therapists, and substance abuse counselors.

Other practitioners' services: Other practitioners' services

Add

■    Essential Health Benefit 10: Pediatric services including oral and vision care	Collapse All	
Benefit Provided:	Source: Medicaid  State Plan EPSDT Benefits
State Plan 1905(a)	Remove

Authorization:	Provider Qualifications: None	Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:

Only provided to individuals under 21 years of age

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:
EPSDT covered services include services that correct or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening process when those services fall within the optional and
mandatory categories of “Medical Assistance” as defined in the Medicaid Act. Services covered under EPSDT include categories of services in the Federal Law even when they are not listed as covered services in the AHCCCS State Plan, AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost effective.		
Add		

Other Covered Benefits from Base Benchmark	Collapse All

Base Benchmark Benefits Not Covered due to Substitution or Duplication	Collapse All	
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Physician Services- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Physician Services for diagnostic and treatment services were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of physician services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Family Planning Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Family Planning Services for contraception and voluntary sterilization  were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of family planning services and supplies for individuals of child bearing age from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Hospice Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Hospice Services that meet the physical, psychological, spiritual and social needs of dying persons and their families were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of hospice care from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Ambulance Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Ambulance Services to/from an appropriate provider or facility for emergencies and non-emergency inter- facility transfer were mapped to the 'Ambulatory Services', 'Emergency Services', and 'Hospitalization' EHB categories. The services are a duplication of transportation: emergency services and transportation: non-emergency services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Urgent Care-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Urgent Care for the medical, surgical, hospital and related health care services and testing which are not emergency services were bundled, along with emergency services and mapped to the 'emergency services' EHB category. The services are a duplication of clinic services: urgent and emergent care from the existing state Medicaid plan.		

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Emergency Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Emergency services for the sudden onset of medical or behavioral conditions that manifests itself by acute symptoms were bundled, along with urgent care and mapped to the 'emergency services' EHB category. The bundled services are a duplication of outpatient hospital:emergency hospital services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Inpatient Hospital Services- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Inpatient hospital services for services that cannot be adequately treated on an ambulatory basis or in another Participating Health Care Facility were mapped to the 'hospitalization' EHB category. The services are a duplication of inpatient hospital from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Outpatient Facility Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Outpatient facility services for services provided on an outpatient basis were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of outpatient hospital services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Organ Transplant Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Organ transplant services (not including pancreas only transplants) for the transplant of human organs and tissue were mapped to the 'hospitalization' EHB category. The services are a duplication of organ transplant services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Subacute Care-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Subacute care including but not limited to hospital-based skilled nursing facilities and free standing skilled nursing facilities were mapped to the 'hospitalization' EHB category. The services are a duplication of nursing facility: sub acute or rehab services from the existing state Medicaid plan.		

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Maternity Care Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Maternity care services include medical, surgical and hospital care for the term of the pregnancy, upon delivery and during the postpartum period were mapped to the 'maternity and newborn care' EHB category. The services are a duplication of extended services for pregnant women from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Prenatal Care and Program Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Prenatal care and program services include medical, surgical and hospital care for the term of the pregnancy were mapped to the 'maternity and newborn care' EHB category. The services are a duplication of extended services for pregnant womenfrom the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Midwife Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Midwife services provided by a certified midwife were mapped to the 'maternity and newborn care' EHB
category. The services are a duplication of nurse-midwife services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Cosmetic Surgery-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Cosmetic Surgery for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury was mapped to the 'hospitalization' EHB category. The service is a duplication of inpatient hospital services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Bariatric Surgery -Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Bariatric Surgery for individuals with a BMI > 35, at least one co-morbidity related to obesity and who were previously unsuccessful with medical treatment for obesity was mapped to the 'hospitalization' EHB category. The service is a duplication of inpatient hospital services from the existing state Medicaid plan.		

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Breast Reconstruction and Prostheses-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Breast Reconstruction and Breast Prostheses following a mastectomy were mapped to the 'Hospitalization' and 'Rehabilitative and Habilitative and Devices EHB categories. The services are a duplication of inpatient hospital services and prosthetics from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Inpatient Mental Health Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Inpatient Mental Health Services provided by a participating hospital for the treatment and evaluation of mental health during an inpatient stay were mapped to the 'mental health and substance abuse disorder services/behavioral health treatment' EHB category. The services are a duplication of inpatient hospital: mental health services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Outpatient Mental Health Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Outpatient Mental Health Services provided by a participating providers for the treatment and evaluation of mental health on an outpatient basis in an individual, group or structured group therapy program were mapped to the 'mental health and substance abuse disorder services/behavioral health treatment' EHB category. The services are a duplication of outpatient hospital: mental health services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Outpatient SA Rehabilitation Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Outpatient Substance Abuse Rehabilitation Services provided by a participating provider for the treatment and diagnosis of abuse or addiction to alcohol and/or drugs on an outpatient basis in an individual, group, structured group or intensive outpatient therapy program were mapped to the 'mental health and substance abuse disorder services/behavioral health treatment' EHB category. The services are a duplication of outpatient hospital: substance abuse rehabilitation services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Residential MH/SA Treatment Services-Duplication

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Residential MH/SA Treatment Services for voluntary and court-ordered residential substance abuse for mental health and substance abuse treatment were mapped to the 'mental health and substance abuse		

disorder services/behavioral health treatment' EHB category. The services are a duplication of individual, group and/or family therapy and counseling: services from the existing state Medicaid plan.
Remove		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
SA Detoxification Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Substance Abuse Detoxification Services for detoxification and related medical ancillary services when required for the diagnosis and treatment of addiction to alcohol and/or drugs, and medication management when provided in conjunction with a consultation were mapped to the 'mental health and substance abuse disorder services/behavioral health treatment' EHB category. The services are a duplication of inpatient hospital: substance abuse detoxification services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Diagnostic Testing,Lab and Radiology Services- Dup	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Diagnostic testing, including labratory and radiology services were mapped to the 'laboratory services' EHB category. The services are a duplication of other laboratory and x-ray services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Short-term Rehabilitative Therapy-OP-Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Short term rehabilitative services including PT, OT, SP, and cardiac rehabilitation limited to 60 visits per member per year were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. Health promotion, home care training to home care client, supported employment services and psychosocial rehabilitation from the existing Medicaid plan were used for substitution purposes related to benefit limitations.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Foot Orthotics-Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Foot Orthotics as defined by section 7.20 diabetic services and supplies were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. Health promotion, home care training to home care client, supported employment services and psychosocial rehabilitation from the existing Medicaid plan were used for substitution purposes related to benefit limitations.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
External Prosthetic Appliances-Duplication		

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate
section 1937 benchmark benefit(s) included above under Essential Health Benefits:	Remove
External prosthetic appliances used as a replacement or substitute for a missing body part and are necessary
for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of prosthetic devices from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Durable Medical Equipment (DME)-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
DME services for the medical or surgical treatment of an illness or injury were mapped to the
'Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of medical supplies, equipment, and appliances suitable for use in the home from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Chiropractic Care Services- Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Chiropractic services including the conservative management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain and improve function were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. Health promotion, home care training to home care client, supported employment services and psychosocial rehabilitation  from the existing Medicaid plan were used for substitution purposes.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Hearing Aids- Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Hearing aid devices limited to $1,500 per ear, per plan year were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. Health promotion, home care training to home care client, supported employment services and psychosocial rehabilitation from the existing Medicaid plan were used for substitution purposes.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Ostomy Supplies-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Ostomy supplies which are medically appropriate for care and cleaning of a temporary or permanent ostomy were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of medical supplies, equipment, and appliances suitable for use in the home from the existing state Medicaid plan.		

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Internal Prosthetic/Medical Appliances-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Internal prosthetic/medical appliances are prosthetics and appliances as permanent or temporary internal aids and supports for nonfunctional body parts, were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of prosthetic devices from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Oxygen and the Oxygen Delivery System-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Oxygen and the Oxygen Delivery System was mapped to the 'preventative and wellness services and chronic disease management' EHB category. The services are a duplication of the home health benefit from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Medical Supplies-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Medical supplies include Medically Appropriate supplies which may be considered disposable, however, are required for a Member in a course of treatment for a specific medical condition were mapped to the
'Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of medical supplies, equipment, and appliances suitable for use in the home from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Compression Garments-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Compression garments for the treatment of lymphedema were mapped to the 'Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of medical supplies, equipment, and appliances suitable for use in the home from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Immunizations-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Immunizations were mapped to the 'preventative and wellness services and chronic disease management' EHB category. The services are a duplication of preventative services from the existing state Medicaid plan.		

TN# 14-0010

Approval Date: 12/2/2014	Effective Date: 10/1/2014

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Routine Physical- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Routine physical, periodic routine health examinations were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of physician services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Well Woman Examinations-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Well woman examinations were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of physician services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Well Man Examinations-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Well man examinations were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of physician services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Home Health Services-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Home health services were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of  home health services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Mammograms-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Mammograms for routine and diagnostic breast care were mapped to the 'preventative and wellness services and chronic disease management' EHB category. The services are a duplication of  preventative services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Nutritional Evaluation-Duplication

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Nutritional evaluation and counseling when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition were mapped to the 'preventative and wellness services and chronic disease		

TN# 14-0010	Approval Date: 12/2/2014	Effective Date: 10/1/2014	

Supersedes

management' EHB category. The services are a duplication of  other practitioners' services from the existing state Medicaid plan.
Remove		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Prostate Screening- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Prostate screening services were mapped to the 'preventative and wellness services and chronic disease management' EHB category. The services are a duplication of  screening services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Cochlear Implants- Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Cochlear implants were mapped to the 'preventative and wellness services and chronic disease
management' EHB category. Respite care, peer support, family support/home care training and living skills training from the existing state Medicaid plan were used for substitution purposes.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Allergy Testing-Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Allergy testing were mapped to the 'preventative and wellness services and chronic disease management' EHB category. Respite care, peer support, family support/home care training and living skills training from the existing state Medicaid plan were used for substitution purposes.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Antigen Admin Desensitization/trtmnt-Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Antigen administration desensitization/treatment were mapped to the 'preventative and wellness services and chronic disease management' EHB category. Respite care, peer support, family support/home care training and living skills training from the existing state Medicaid plan were used for substitution purposes.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Generic Drugs-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Generic Drugs were mapped to ' prescription drug' EHB category. The services are a duplication of the prescription drug plan from the existing state Medicaid plan.		

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Formulary Brand Drugs- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Formulary Brand Drugs were mapped to ' prescription drug' EHB category. The services are a duplication of the prescription drug plan from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Non-Formulary Brand Drugs- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Non-Formulary Brand Drugs were mapped to ' prescription drug' EHB category. The services are a duplication of the prescription drug plan from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Case Management-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Case Management services were mapped to the 'preventative and wellness services and chronic disease management' EHB category. The services are a duplication of case management services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Cancer Clinical Trials-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Cancer Clinical Trials were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of physician services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Diabetic Services and Supplies-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Diabetic Services and Supplies were mapped to the 'ambulatory patient services' EHB category. The services are a duplication of physician services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Medical Foods/Metabolic Spplments/Gastric Form Dup

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Medical Foods/Metabolic Supplements/Gastric Formula were mapped to the 'prescription drugs' EHB		

category. The services are a duplication of prescription drug services from the existing state Medicaid plan.

Remove		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
ABA for Autism- Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
ABA for Autism were mapped to the ''Rehabilitative and Habilitative Services and Devices' EHB category. The services are a duplication of rehabilitative services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Clinic Services: Non-Urgent-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Clinic Services: Non-Urgent for medical services provided in an ambulatory clinic were mapped to the
'ambulatory patient services' EHB category. The services are a duplication of Clinic Services: Non-Urgent from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Dental Services – Accident Only-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Dental Services – Accident Only for the treatment of a fractured jaw or an injury to sound natural teeth were mapped to the ' emergency services' EHB category. The services are a duplication of emergency hospital services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Orthognathic Surgery-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Orthognathic treatment/surgery are dental and orthodontic services and/or appliances that are orthodontic in nature or change the occlusion of the teeth (external or intra-oral) were mapped to the ' ambulatory patient services' EHB category. The services are a duplication of outpatient hospital services from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Dental Confinements/Anesthesia-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Dental Confinements/Anesthesia were mapped to the ' ambulatory patient services' EHB category. The services are a duplication of outpatient hospital services from the existing state Medicaid plan.		

Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Temporomandibular Joint (TMJ) Disorder-Duplication	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Temporomandibular Joint (TMJ) Disorder were mapped to the ' ambulatory patient services' EHB category. The services are a duplication of medical and surgical services furnished by a dentist from the existing state Medicaid plan.		
Base Benchmark Benefit that was Substituted:	Source:
Base Benchmark
Pancreas Only Transplant Services- Substitution	Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:
Pancreas only transplant services were mapped to the 'hospitalization' EHB category. NEMT only for in- patient services from the existing state Medicaid plan were used for substitution purposes.		
Add		

Other Base Benchmark Benefits Not Covered	Collapse All

Other 1937 Covered Benefits that are not Essential Health Benefits	Collapse All	
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Medically Necessary Termination of Pregnancy	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limits	No Limits
Scope Limit:
Only when the pregnancy is the result of rape or incest; or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy.

Other:
Inpatient Hospital Services: Medically Necessary Termination of Pregnancy

No authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Rural Health Clinic Services	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other:
Rural health clinic services and other ambulatory services furnished by a rural health clinic (which are otherwise included in the State plan).
Rural Health Clinic Services:Rural Health Clinic Services
No authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Federally qualified health center (FQHC)	Package

Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit		

Scope Limit:

Federally qualified health center (FQHC) services and other ambulatory services that are covered under the	Remove plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA-
Pub. 45-4). Other:

Federally qualified health center (FQHC): Federally qualified health center (FQHC) No authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Optometrists' Services	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No limit	No limit
Scope Limit: No Limit
Other:

Medical care and any type of remedial care recognized under State Law- Optometrists' Services: Optometrists' Services
No authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Eyeglasses	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Adult Services are limited to eyeglasses and contact lenses as the sole prosthetic device after a cataract extraction.

Other:

Medical care and any type of remedial care recognized under State Law- Optometrists' Services:Eyeglasses
Arizona Health Care Cost Containment System
No authorization required		

Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Rehab: Screening/Evaluation/Assessment	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limits	No Limits
Scope Limit:
These services can only be provided in the following settings: office, home, urgent care facility, inpatient hospital, outpatient hospital, emergency room, inpatient psychiatric facility, community mental health center, rural health clinic,

Other:
outpatient clinic, including Federally Qualified Health Centers (FQHCs), rural substance abuse transitional agency, homeless shelter, medical day program, therapeutic day program, Level 2 behavioral health group home, and Level 3 behavioral health group home.
No authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Non-Emergency Transportation OP (Non Ambulance)	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit:
Non-emergency ambulance transportation is available for transport to and from facilities where medical treatment is being provided.

Other:
This is limited to NEMT for out-patient services
Trips that exceed 100 miles require prior authorization		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Face-to Face Tobacco Cessation  Counseling Service	Package

Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit		

Scope Limit:

No Limit	Remove

Other:
No authorization required
Family Planning Services: Face-to Face Tobacco Cessation  Counseling Service		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Tobacco Cessation for Pregnant Women	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: At least four counseling sessions per quit attempt	None
Scope Limit:

Cost sharing not imposed for Tobacco Cessation Services for pregnant women

Other:
No authorization required
Tobacco Cessation for Pregnant Women: Face-to-Face Tobacco Cessation for Pregnant Women		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Nursing facility- custodial	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit:

90 days per contract year	None

Scope Limit:

Benefit is for when hospitalization would be necessary if nursing facility services were not provided

Other:
No prior authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
ICF-IDD	Package

Authorization:	Provider Qualifications: Medicaid State Plan		

Amount Limit:	Duration Limit:

No Limit	No Limit	Remove

Scope Limit: No Limit
Other:
No prior authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Certified pediatric or family nurse practitioner's	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other:
No prior authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Licensed/State-approved freestanding birth centers	Package	Remove
Authorization:	Provider Qualifications: Medicaid State Plan
Amount Limit:	Duration Limit: No Limit	No Limit
Scope Limit: No Limit
Other:
No prior authorization required		
Other 1937 Benefit Provided:	Source:
Section 1937 Coverage Option Benchmark Benefit
Licensed/State-recognized profs in freestanding BC	Package		

Authorization:	Provider Qualifications:

Medicaid State Plan

Remove

Amount Limit:

No Limit

Duration Limit:

No Limit

Scope Limit:

No Limit

Other:
Licensed or otherwise state-recognized covered professionals providing services in the freestanding birth center
No prior authorization required

Add

Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902(a)(10)(A)(i)(VIII) of the Act.)

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1148.  The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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