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

May 26, 2015

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

Dear Mr. Betlach:

In our approval of Arizona State Plan Amendment (SPA) 14-013C on May 15, 2015, the footer on Attachment 4.19-B, page 5c incorrectly referenced SPA 13-017C as the superseding SPA and did not indicate the SPA to be replaced.  We have revised the page to correctly refer to SPA 14-013C as replacing SPA 13-017C and have enclosed the revised page.  No other change was made and no other SPA pages were affected. The original SPA approval date and effective date remain the
same.

If you have any questions, please have your staff contact Brian Zolynas at (415) 744-3601 or at brian.zolynas@cms.hhs.gov.

Sincerely,

/s/

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

cc:  Jessica Woodard
HeeYoung Ansell

State: ARIZONA
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OTHER TYPES OF CARE

Attachment 4.19-B Page 5c

Rate Update
Rates in effect on September 30, 2014, are updated effective October 1, 2014 in the following manner:

•	Laboratory and X-ray Services – Page 2 of Att. 4.19-B: -1.1% in aggregate
•	Behavioral Health Services in Att. 3.1-A Limitations: 4(b)(ii), 6(d)(viii), 9, and 13d  – Page 5a of Att. 4.19-B:
+2.0% uniformly
•	Physician Services – Page 5a of Att. 4.19-B: 0.0% in aggregate
•	Dental Services – Page 5b of Att. 4.19-B: 0.0% uniformly
•	Transportation Services –  Page  5b  of  Att.  4.19-B:  Emergency Ground  Ambulance Services +11.3%  in aggregate; all other transportation services 0.0% uniformly
•	Clinic Services – Page 5a of Att. 4.19-B: +4.3% in aggregate
•	Family Planning Services – Page 5a of Att. 4.19-B: +5.6% in aggregate
•	Nurse-Midwife Services – Page 5a of Att. 4.19-B: +0.2% in aggregate
•	Pediatric and Family Nurse Practitioner Services – Page 5a of Att. 4.19-B: +0.5% in aggregate
•	Other types of care furnished by all Licensed Practitioners in Att. 3.1-A, item 6d – Page 5b of Att. 4.19-B:
+0.2% in aggregate
•	Diagnostic, Screening and Preventive Services – Page 5b of Att. 4.19-B: +0.5% in aggregate
•	Respiratory Care Services – Page 5b of Att. 4.19-B: -1.9% in aggregate
•	Physical Therapy, Occupational Therapy, and Speech Therapy Services – Page 5b of Att. 4.19-B: +1.0% in aggregate
•	Prosthetic devises – Page 5b of Att. 4.19-B: +0.6% in aggregate
•	Medical Supplies, Equipment and Appliances – Page 5a of Att. 4.19-B: DMEPOS +0.7% in aggregate
•	Case Management Services – Page 6 of Att. 4.19-B: +2.0% uniformly
•	Home Health Services provided in the eligible person’s home – Page 5a of Att. 4.19-B: +2.0% uniformly
•	Private Duty Nursing Services when provided in the eligible person’s home. – Page 5b of Att. 4.19-B: +2.0%
uniformly

Payments for services provided by the Indian Health Services or Tribal 638 Health facilities are not subject to any of the rate updates described above.

TN No. 14-013C
Supercedes	Approval Date:   May 15, 2015	Effective Date:  October 1, 2014
TN No.  13-017C