Proposed State Rules

AHCCCS proposed rules are published in the Arizona Administrative Register (A.A.R.) for public review. To compare the following Proposed Rule language to Final Rule, please see corresponding topic when finalized at: http://www.azahcccs.gov/PlansProviders/CurrentProviders/State/unpublishedrules.html

Note: Information provided in PDF files.

2015

Graduate Medical Education Fund (GMEF)

Thursday August 20, 2015
The AHCCCS Administration is proposing to amend A.A.C. R9-22-712.05 modify the method of allocating funds for indirect GME costs to permit payments that will cover a greater portion of the costs reported by the GME programs. Pursuant to A.R.S. § 36-2903.01(G)(9), certain public entities are permitted to transfer funds to the AHCCCS Administration to support these payments.

Rural Hospital Inpatient Fund (RHIF)

Friday August 14, 2015
The AHCCCS Administration is proposing to amend A.A.C. R9-22-712.07 to fix an unintended effect of recent budget bills, eliminate Disproportionate Share Hospital (DSH) payments from the Rural Hospital Inpatient Fund (RHIF) calculation, and to make RHIF clarifications consistent with the current protocol.

Hospital Assessment SFY 2016

Monday June 15, 2015
A.R.S. 36-2901.08 authorizes the Administration to establish, administer and collect an assessment on hospital revenues, discharges or bed days for funding a portion of the nonfederal share of the costs incurred beginning January 1, 2014, associated with eligible persons added to the program by A.R.S. 36-2901.01 and 36-2901.07. It is the agencys objective to assess only so much as is necessary to meet the estimated costs associated with the projected populations referenced in the statute. As such, it is necessary for the Administration to adjust the assessment from time to time as the Administration obtains new information to update estimations of the number of eligible persons and projections of the costs anticipated to provide coverage for those persons. The Administration is proposing a new rule to update the figures to be used as of July 1, 2015 for collecting the assessment on hospitals.

CRS Children's Rehabilitative Services Rev 2015

Friday June 12, 2015
The AHCCCS Administration is proposing to amend the current CRS rules to more precisely delineate those conditions which qualify for CRS medical eligibility as well as those conditions which do not qualify for CRS medical eligibility. It is expected that the rules will specify additional conditions that qualify for CRS medical eligibility due to the complexity of the medical condition and the need for active treatment by multiple medical specialists. Additionally, the proposed rules will clarify those medical conditions that do not qualify for CRS eligibility due to their acute nature. In those situations, members will have choice of available acute Contractors where the primary care physician can refer the member to a specialist to effectively manage the member's condition whenever necessary.

Hospital Assessment Amendment 2015

Friday March 13, 2015
A.R.S. 36-2901.08 authorizes the Administration to establish, administer and collect an assessment on hospital revenues, discharges or bed days for funding a portion of the nonfederal share of the costs incurred beginning January 1, 2014, associated with eligible persons added to the program by A.R.S. 36-2901.01 and 36-2901.07. It is the agency's objective to assess only so much as is necessary to meet the estimated costs associated with the projected populations referenced in the statute. As such, it is necessary for the Administration to adjust the assessment from time to time as the Administration obtains new information to update estimations of the number of eligible persons and projections of the costs anticipated to provide coverage for those persons. The Administration is proposing a new rule to update the figures to be used as of April 1, 2015 for collecting the assessment on hospitals.

Incontinence Brief Coverage

Thursday March 12, 2015
This rulemaking is required as a result of the May 2014 Ninth Circuit Court of Appeals Decision in Alvarez et al v Betlach. Litigation challenging AHCCCS coverage of incontinence briefs for members in the ALTCS Program was filed in federal court in 2009 by the Arizona Center for Disability Law. The lawsuit sought to compel AHCCCS to provide incontinence briefs and supplies to members in the Arizona Long Term Care Program who were age 21 years and older and who were incontinent as a result of their disabilities in order to prevent skin breakdown. The current rule applicable to this population limits coverage of incontinence briefs for members age 21 and older to circumstances when medically necessary to treat a medical condition, such as an infection, but not for preventive purposes. The Ninth Circuit Court of Appeals determined that AHCCCS is required to provide coverage of incontinence briefs prescribed for members in the Arizona Long Term Care Program who are 21 years of age and older when medically necessary to prevent skin breakdown and infection.

BH Inpatient Payment Responsibility Comment Period Closed


Friday November 11, 2014
The Administration is proposing a rulemaking to clarify an issue that has been identified through the administrative hearing process regarding contractor responsibility for covering inpatient hospital services when both medical and behavioral health services are provided during the same hospital stay. The proposed rule will clarify the reimbursement methodology. The Administration is proposing to clarify through rule, its existing policy that the RBHA is responsible for all inpatient hospital services if the principle diagnosis on the hospital claim is a behavioral health diagnosis. Those claims will be paid in accordance with a per diem fee schedule developed by ADHS and approved by AHCCCS. Hospital claims that do not have a behavioral health diagnosis as the principle diagnosis will be paid by the acute care contractor using the DRG payment methodology. This proposed amendment will benefit hospitals by clarifying to whom claims should be submitted and the amount of reimbursement that the hospital can expect. The Administration intends to initiate and implement this clarification as soon as possible to reduce billing disputes between hospitals and health plans and to reduce unnecessary administrative hearings arising from those disputes.

2014

TPL Cost Avoidance


Monday September 22, 2014
The Administration is conducting a rule-making necessary to conform AHCCCS rules to federal requirements regarding the obligation of health care providers to bill other insurance (when it is known to exist) before billing AHCCCS. With some exceptions, providers must bill legally liable third parties (like private insurance) before billing AHCCCS. However, federal regulations state that in certain circumstances – such services provided to children and pregnant women – AHCCCS must pay the provider then AHCCCS or its contractors must seek reimbursement from the third party. In addition, there are a few federal exception to the general rule that AHCCCS is the payor of last resort; for example, AHCCCS must assume primary responsibility for payment for services covered through the Indian Health Service or medical services that are provided through schools under the federal Individuals with Disabilities Education Act.

FPEP Family Planning Extension Program


Friday September 11, 2014
The Administration proposes a rule-making to repeal rules related to the Family Planning Services Extension Program (FPEP) as authorized by A.R.S. 36-2907.04 subject to the approval of a waiver from the federal government necessary to implement the program. This program provided coverage for family planning services to women who were eligible for AHCCCS during their pregnancy for a two year period following the end of their pregnancy. The federal waiver authorizing these extended benefits ended on December 31, 2013.

Hospital Presumptive Eligibility (HPE) Comment period ended - see Final Rule


Wednesday August 6, 2014
The Administration is promulgating rules to comply with the Affordable Care Act of 2010, which added 42 USC 1396a(a)(47)(B), and 42 CFR 435.1110 which requires the State Medicaid agency to allow qualifying hospitals the option to determine presumptive eligibility for Medicaid for certain individuals. This process is referred to as Hospital Presumptive Eligibility (HPE). These proposed rules are to be effective January 1, 2015

Cost Sharing Part II 2014 Comment period ended - see Final Rule


Thursday July 31, 2014
Arizona Laws 2013, First Special Session, Chapter 10 (House Bill 2010) specified changes to the AHCCCS Program which require, among other items, rule-making to establish cost sharing provisions consistent with federal law and the Federal regulations which became effective January 1, 2014, in 42 CFR part 447.50, et seq. In this rulemaking, the Agency revised the current cost sharing rules to delineate the mandatory copayment requirements for the new adult group described in R9-22-1427 (E) with income above106% of the federal poverty guidelines (FPL) subject to CMS approval. In addition, this rulemaking clarifies that members in the new adult group with incomes at or below 106% FPL are exempt from any copayments. These proposed rules also clarify existing language, update cross-references, and include various non substantive changes.

Section 36 of this Law provides a rulemaking exemption: For a period of one year from the effective date of the Act, the AHCCCS Administration is exempt from the Administrative Procedure Act 's rulemaking requirements for rules regarding cost sharing.

BH/ADHS Changes Comment period ended - see Final Rule


Thursday July 24, 2014
HB 2634 (Law 2011, Chapter 96) requires the Arizona Department of Health Services (ADHS) to reduce monetary or regulatory costs on persons or individuals receiving behavioral health services, streamline the regulation process, and facilitate licensure of integrated health programs that provide both behavioral and physical health services. The Administration cross references ADHS rules and must update its rules to correctly reference changes made by ADHS. In addition, changes recommended during a 5 year review of these rules have also been made along with any technical changes required to make the rulemaking clear.

Hospital Assessment Amendment Comment period ended - see Final Rule


Thursday May 15, 2014
A.R.S. 36-2901.08, enacted by 2013 law, authorizes the Administration to establish, administer and collect an assessment on hospital revenues, discharges or bed days for funding a portion of the nonfederal share of the costs incurred beginning January 1, 2014, associated with eligible persons added to the program by A.R.S. 36-2901.01 and 36-2901.07. The Administration is proposing a new rule to update the figures to be used as of State Fiscal Year 2015 for the process for establishing, administering and collecting the assessment on hospitals, this new assessment pays for a full year for the expansion population.

Laws 2013, 1st Special Session, Chapter 10 added an exemption to the Administrative Procedure Act for purposes of the administration and implementation of the hospital assessment: A.R.S. 41-1005 (A)(32) exempts the Administration from Title 41, Chapter 6 of the Arizona Revised Statutes (the Arizona Administrative Procedure Act) for purposes of implementing and establishing the hospital assessment; however, that provision requires the Administration to provide public notice and an opportunity for public comment at least thirty days before doing so. Laws 2013, 1st Special Session, Chapter 10 provides: Sec. 44. Intent; hospital assessment It is the intent of the legislature that: 1. The requirement that the hospital assessment established pursuant to section 36-2901.08, Arizona Revised Statutes, as added by this act, be subject to approval by the federal government does not adopt federal law by reference.

Essential Health Care Benefits (EHB) or (AHB) Comment period ended - see Final Rule


Friday March 7, 2014
The Administration must conduct a rule-making to implement the elements of Arizona Laws 2013, First Special Session, Chapter 10 (House Bill 2010), that relate to changes to covered services regarding well exams, and other cost-effective services. In addition to “clean up” of rules related to scope of services, such as updating cross-references and non-substantive changes to improve clarity. The provisions are necessary to comply with federal or state requirements.

DRG - Diagnostic Related Groups Comment period ended - see Final Rule


Friday March 7, 2014
Arizona Laws 2013, Chapter 202, section 3, amended A.R.S. 36-2903.01.G.12 to require the AHCCCS administration to "adopt a diagnosis-related group based hospital reimbursement methodology consistent with title XIX of the social security act for inpatient dates of service on and after October 1, 2014." The statutory and regulatory provisions of Medicaid (Title XIX of the Social Security Act) provide state 's significant flexibility with respect to hospital reimbursement methodologies; however, the Medicaid Act, at 42 U.S.C. 1396a(a)(30)(A), requires that the State must adopt payment methodologies "as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area."

In addition, the choices reflected in this proposed rule were based other design considerations such as achieving budget neutrality (recognizing that funding is not unlimited the methodology was designed to be budget neutral compared to past aggregate reimbursement for these services) and adaptability (whether the methodology facilitates adapting to changes in utilization and future service models).

Nursing Facility Assessment Amendment 2 | Comment period ended - see Final Rule


Friday February 28, 2014
A.R.S. 36-2999.52 authorizes the Administration to administer a provider assessment on health care items and services provided by nursing facilities and to make supplemental payments to nursing facilities for covered Medicaid expenditures. The Administration is proposing an amendment to rule to revise the process for calculating the nursing facility assessment using Uniform Accounting Report data submitted to the Arizona Department of Health Services and amending the dollar amounts used to calculate the assessment. In addition, the proposed rules update terminology and clarify language in both the assessment and supplemental payment sections so that the methodology is more concise and understandable.

Hospital Assessment | Comment period ended - see Final Rule


Friday December 13, 2013
A.R.S. 36-2901.01, adopted by Initiative Measure Proposition 204 in the 2000 general election, includes individuals with income up to 100% of the federal poverty level as part of the definition of persons eligible for health care coverage through AHCCCS. Due to the lack of available funding, effective July 8, 2011, the Administration closed the program to new enrollment for persons described by A.R.S. 36-2901.01 who were not also described in the Arizona State Plan for Medicaid. Arizona Laws 2013, 1st Special Session, Chapter 10, Section 5, added A.R.S. 36-2901.07, which expanded the definition of eligible persons to include individuals with income between 100% and 133% of the federal poverty level

A.R.S. 36-2901.08, also enacted in the same section of the 2013 law, authorizes the Administration to establish, administer and collect an assessment on hospital revenues, discharges or bed days for funding a portion of the nonfederal share of the costs incurred beginning January 1, 2014, associated with eligible persons added to the program by A.R.S. 36-2901.01 and 36-2901.07. The Administration is proposing a new rule to describe the process for establishing, administering and collecting the assessment on hospitals. A.R.S. 41-1005 (A)(32) exempts the Administration from Title 41, Chapter 6 of the Arizona Revised Statutes (the Arizona Administrative Procedure Act) for purposes of implementing and establishing the hospital assessment; however, that provision requires the Administration to provide public notice and an opportunity for public comment at least thirty days before doing so.

2013

Health Care Group Program | Comment period ended - see Final Rule


Friday November 22, 2013
Arizona Laws 2013, First Special Session, Chapter 10 (House Bill 2010), relates to the operation of the Arizona Health Care Cost Containment System. That act made changes to the program which requires rulemaking repealing the Health Care Group program.

This provision is necessary to comply with federal or state requirements that contain dates certain for compliance. The Health Care Group program will no longer have an appropriation as described under A.R.S. 36-2912.01 and will cease to exist January 1, 2014. New enrollment into Health Care Group ceased August 1, 2013.

Cost Sharing | Comment period ended - see Final Rule


Friday November 22, 2013
Arizona Laws 2013, First Special Session, Chapter 10 (House Bill 2010) specified changes to the AHCCCS Program which require, among other items, rule-making to establish cost sharing provisions consistent with federal law. In this rulemaking, the Agency revised the current cost sharing rules to incorporate exemptions of certain populations from cost sharing requirements specified in final federal regulations which will become effective January 1, 2014. In addition, this rulemaking repeals cost sharing requirements which apply to AHCCCS Waiver populations which will no longer exist beginning January 1, 2014. To clarify cost sharing requirements generally, this rulemaking also includes revision of language, updates to various cross-references, and non substantive changes. In the future, the AHCCCS Administration intends to promulgate other cost sharing provisions in subsequent rulemakings

Section 36 of this Law provides a rulemaking exemption: For a period of one year from the effective date of the Act, the AHCCCS Administration is exempt from the Administrative Procedure Act 's rulemaking requirements for rules regarding cost sharing. However, a thirty day advance notice and public comment period are required.

Medicaid Eligibility Changes | Comment period ended - see Final Rule


Friday September 20, 2013
The Administration is promulgating rule amendments as result of the Affordable Care Act of 2010 and Arizona Laws 2013, First Special Session, Chapter 10 (House Bill 2010). Expansion of eligibility for: Children 6-18 to 133% of FPL, Former foster care children from ages 21 to 26, Childless adults up to 133% (including restoring Prop 204 populations – up to 100% - and adding 100-133% per ARS 36-2901.07); Income determinations based on “modified adjusted gross income”; Changes to processes for determining and redetermining eligibility including changes to accommodate on line applications and internet-based verification of income, citizenship and alien status, state residence, and other eligibility factors; and miscellaneous changes to clarify and conform to federal requirements. These proposed rules are to be effective January 1, 2014.

Prior Quarter Eligibility | Comment period ended - see Final Rule


Mon May 6, 2013
42 CFR 435.914 requires the Administration to provide Prior Quarter (PQ) eligibility. A.R.S. 36-2903 (A) provides reimbursement responsibility for care provided during an eligibility period. Currently, the Administration is waived from providing PQ eligibility. The waiver expires December 31, 2013. The Administration will need to implement prior quarter eligibility requirements effective January 1, 2014.

Nursing Facility Assessment Amendment | Comment period ended - see Final Rule


Fri April 26, 2013
A.R.S. 36-2999.52 authorizes the Administration to administer a provider assessment on health care items and services provided by nursing facilities and to make supplemental payments to nursing facilities for covered Medicaid expenditures. The Administration is proposing an amendment to rule to describe the process for estimating and distributing supplemental payments to contractors for enhanced payments to eligible nursing facilities based on bed days paid for through managed care. The rule amendments also describe the process for calculating and distributing the enhanced payments to eligible nursing facilities by the Administration for bed days paid by the Administration. In addition, the rules clarify general requirements applicable to nursing facilities in order for them to qualify for the supplemental payments.

Children's Rehabilitative Services (CRS) | Comment period ended - see Final Rule


Fri April 19, 2013
The CRS program was administered by the Arizona Department of Health Services (ADHS) until SB1619 Arizona Laws 2011 Regular Session was enacted directing the Administration to administer the CRS program. SB1619 specified that the existing CRS program rules adopted by ADHS were left in effect "until superceded by rules adopted by [AHCCCS]." The Legislature enacted this change as part of a larger initiative by ADHS and AHCCCS to better integrate conditions provided to medically eligible with CRS related conditions while at the same time streamlining the administration of the program. Therefore, AHCCCS finalized rules to transition the ADHS requirements under AHCCCS as published in the Arizona Administrative Register August 24, 2012 and Arizona Laws 2011, Regular Session, Ch. 31, 34, exempted AHCCCS from the requirements of A.R.S. Title 41, Ch.6., these rules were promulgated under exemption repealed, then repromulgated. SB1528 Laws 2012, Chapter 299, Section 7 repealed the rule-making exemption authority and Section 8 stipulated that rules adopted through the previous year 's authority would expire December 31, 2013, absent specific statutory authority for those rules.

Hospital Rates and NonER transport copay | Comment period ended - see Final Rule


Fri April 12, 2013
After an evaluation of the Agency 's overall statutory authority regarding rates and copayments, AHCCCS has determined to repromulgate these rules specifying specific statutory authority to continue measures it previously enacted consistent with Laws 2012 Chapter 299 Section 8. The intent of the rulemakings has not changed as what was described in the rulemakings posted.


Benefit Limits Repromulgation | Comment period ended - see Final Rule


Tue March 19, 2013
After an evaluation of the Agency 's overall statutory authority regarding covered services, rates, and eligibility, AHCCCS has determined that it will re-promulgate certain rules implementing “program changes” made pursuant to Laws 2011, Chapter 31, Section 34 by identifying the specific statutory authority for the rules to ensure that the rules continue beyond December 31, 2013 in accordance with Laws 2012, Chapter 299, Section 8.

Therefore, to ensure continuity of the rules previously adopted under Section 34, the AHCCCS Administration is re-promulgating the same rules which became effective October 1, 2011. No changes have been proposed to the language of the rules.


340B Pharmacy Pricing Rerun | Comment period ended - see Final Rule


Fri January 24, 2013
Due to recent legislative direction within Laws 2012, Chapter 299, Section 7 of the bill repealed the rule-making authority and Section 8 stipulated that rules adopted through the previous year 's authority would expire December 31, 2013 without specific statutory authority.

After an evaluation of our overall statutory authority regarding covered services, rates and eligibility, AHCCCS has determined that it requires statutory changes to continue measures it enacted under the Chapter 299 authority that prohibits AHCCCS from continuing after December 31, 2013 any “program changes” made pursuant to Section 34 of Senate Bill 1619. Therefore, the Administration is re-promulgating rules in regard to the 340B program.

The Veterans Health Care Act of 1992 established the 340B program in section 340B of the Public Health Service Act (PHS Act). The 340B program requires drug manufacturers participating in Medicaid to provide discounted covered outpatient drugs to certain eligible health care entities, known as covered entities. Covered entities include disproportionate share hospitals, family planning clinics, and federally qualified health centers, among others as described under 42 U.S.C. 256b(a)(4). As of October 2010, approximately 15,000 covered-entity locations were enrolled in the 340B program.

The Health Resources and Services Administration (HRSA) administers the 340B program. In 2000, HRSA issued guidance directing covered entities to refer to State Medicaid agencies ' policies for applicable billing policies in regards to 340B claims. The Centers for Medicare and Medicaid Services (CMS), which administers the Medicaid program, does not require State Medicaid agencies to set 340B policies.