302 Types of AHCCCS Medical Assistance Service Packages

 

Policy

AHCCCS coverage is provided in the following service packages:

·        AHCCCS Medical Assistance Service Package;

·        ALTCS Service Package;

·        Emergency Service Package;

·        Medicare Savings Programs (QMB, SLMB and QI-1) Service Packages; and

·        Transplant Extended Eligibility Program Medical Assistance Service Package.

See Chapter 1200 for information on customer costs.

 

1)    AHCCCS Medical Assistance Service Package

The AHCCCS Medical Assistance Service Package includes:

·        Medical Services;

·        Behavioral Health Services;

·        EPSDT Services for Medicaid eligible children under age 21;

·        Family Planning Services; and

·        Payment of the Part B Medicare premium (for most persons receiving Medicare Part B).

Most customers receive all medically necessary services from a Prepaid Health Plan (PHP).  This excludes payment of the Medicare Part B premium.  AHCCCS Administration pays the Medicare Part B premiums of eligible customers.  This is done through the buy-in process.

Native Americans living on-reservation have the option of receiving services by enrolling in the American Indian Health Program (AIHP).  Services may be provided by:

·        Indian Health Services (IHS);

·        A tribally operated facility; or

·        An Urban Indian Health Clinic.

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

 

2)    ALTCS Service Package

ALTCS customers may be eligible for a:

·        Full ALTCS service package; or

·        Limited ALTCS service package.

The full ALTCS service package includes the following services:

·        Case Management;

·        Medical Services;

·        Behavioral Health Services;

·        Family Planning Services;

·        Long Term Care Services;

·        EPSDT Services for Medicaid eligible children under age 21; and

·        Payment of the Part B Medicare premium (for persons receiving Medicare Part B, except those eligible under AHCCCS Freedom to Work).

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

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

·        The customer resides in a living arrangement in which Long Term Care Services benefits cannot be provided (MA521);

·        The customer has equity value in a home that exceeds the amount in MA705K; or

·        The customer has made an uncompensated transfer that makes him or her ineligible to receive Long Term Care Services (Chapter 900).

NOTE      In some cases, the type of care may impact the type of service package a customer receives:

Federal regulations specify that Medicaid funds cannot be used to pay a spouse for providing care to their spouse. However, AHCCCS received a waiver that allows the ALTCS Program Contractors to pay spouses for attendant, homemaker and personal care services provided to a spouse who receives ALTCS benefits.  This waiver was implemented effective October 1, 2007.

Paid hours are based on the customer’s needs but cannot exceed 40 hours in a 7 day period.  Hours and wages vary by each individual case. 

Member directed models or options allow members to have more control over how services are provided, including services like attendant care, personal care and housekeeping. The models are not a service, but rather define the way in which services are delivered. Member-directed options are available to most Arizona Long Term Care System members who live in their own home. Including Self Directed Attendant Care and Agency with Choice.

For information on Self Directed Attendant Care, see http://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap1300.pdf.

For information on Agency with Choice, see https://www.azahcccs.gov/PlansProviders/CurrentProviders/SDAC.html

 

3)    Emergency Service Package

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

All emergency services are paid by AHCCCS Administration on a fee-for-service basis.

 

4)    Medicare Savings Program Packages

There are three Medicare Savings Plan (MSP) packages:

·        Qualified Medicare Beneficiary (QMB);

·        Specified Low-Income Medicare Beneficiary (SLMB); and

·        Qualified Individual-1 (QI-1).

Each MSP program has its own set of benefits:

 

Program

Benefits Paid

QMB

·        Medicare Part A premiums;

·        Medicare Part B premiums;

·        Medicare deductibles; and

·        Medicare coinsurance

SLMB

Medicare Part B premiums

QI-1

Medicare Part B premiums

 

A customer’s MSP benefits are paid by different entities.  This depends on the following factors:

·        What MSP the customer qualifies for (QMB, SLMB or QI-1);

·        Whether or not the customer also qualifies for another service package; and

·        Whether or not the customer is a Native American who has chosen to enroll with AIHP or a tribal contractor.

The table below provides an overview of payment administration.

If the customer qualifies for...

And...

Then...

QMB only

 

AHCCCS Administration pays all QMB benefits.  The customer is not approved for the:

·        AHCCCS Medical Assistance Services Package; or

·        Long Term Care Service Package.

QMB and AHCCCS Medical Services

The customer is enrolled with an AHCCCS Health Plan

The health plan is responsible for paying:

·        All services by network providers included in the AHCCCS Medical Services Package (except the Medicare premiums); and

·        The Medicare deductibles and coinsurance.

AHCCCS Administration pays the Medicare Part A and/or Part B premiums through the Buy-in process.

The customer is a Native American and is enrolled with IHS

AHCCCSA pays:

·        For all services included in the AHCCCS Medical Services Package and the Medicare deductibles and coinsurance on a fee-for-service basis; and

·        The Medicare Part A and/or Part B premiums through the buy-in process.

QMB and ALTCS

The customer is enrolled with a Program Contractor

The program contractor is responsible for paying:

·        All services by Program Contractor providers included in the ALTCS Services Package (except the Medicare Part B premiums); and

·        The Medicare deductibles and coinsurance.

AHCCCS Administration pays the Medicare Part A and /or Part B premiums through the Buy-in process.

The customer is a Native American and is enrolled with a tribal contractor

 

·        The program contractor is responsible for case management services; and

·        AHCCCS Administration pays the Medicare deductibles and coinsurance and all ALTCS Services other than case management on a fee-for-service basis.

SLMB and AHCCCS Medical Assistance Services or ALTCS

 

AHCCCS Administration pays for Medicare Part B premiums through the Buy-in process.

QI-1 only

 

AHCCCS Administration pays for Medicare Part B premiums through the Buy-in process.

QMB Only

Medicare+Choice

·        AHCCCS Administration pays the Medicare Part A and Part B premiums, and the deductibles and coinsurance for Medicare covered services; and

·        The customer pays the coinsurance related to the services that are not covered by Medicare (such as prescriptions), but are provided by the Medicare Advantage Plans.

The AHCCCS Medical Assistance Service Package or the ALTCS Service Package (excluding QMB)

Medicare+Choice

·        AHCCCS Administration pays the Part B premiums;

·        The customer must obtain medical services through the Medicare Advantage Plans;

·        The customer pays copayments to providers who are in the Medicare Advantage Plan network, but not in the network of the customer’s AHCCCS health plan or program contractor; and

·        The AHCCCS health plan or program contractor pays the copayments for medical services that are covered by the Medicare Advantage Plans when the service is included in the customer’s service package and the customer uses providers in AHCCCS health plan or program contractor’s network.

QMB and:

·        AHCCCS Medical Assistance Service Package; or

·        ALTCS Service Package

Medicare+Choice

·        The customer must obtain medical services through the Medicare Advantage Plans;

·        The customer pays copayments to providers who are in the Medicare+ Choice network, but not in the network of the customer’s AHCCCS health plan or program contractor;

·        The AHCCCS health plan or program contractor pays:

o       Deductibles and coinsurance for Medicare services that are not covered by AHCCCS (e.g., chiropractic services), or that differ in scope or duration;

o       Deductibles and coinsurance for all medical services obtained through a provider who is also in the customer’s AHCCCS network;

o       Copayments for pharmacy and other physician-ordered medical services that are covered by the Medicare Advantage Plans as long as the provider is in the customer’s AHCCCS network.  After the customer reaches the Medicare Advantage Plans cap, the AHCCCS health plan or program contractor pays the full cost of the medical service; and

·        AHCCCSA pays the Part A and/or Part B premiums.

 

5)    Transplant Extend Eligibility Program – Medical Service Package

Customers eligible for the Transplant Extended Eligibility Program have two options as to when the customer will begin to receive medical services.  The option chosen determines the amount and duration of services that will be provided:

·        Option One – The customer can choose to receive one 12-month period of services.  The period begins the effective date of the previous AHCCCS program discontinuance.  These customers receive the full AHCCCS Medical Assistance Services package listed in section 1) of this policy.

·        Option Two – The customer can choose to reapply for AHCCCS services closer to the time the transplant will be performed.  If the customer is found to still be ineligible for any other AHCCCS program due to excess income, the customer will receive only transplant-related surgery and services.  This include up to 100 days of post-transplantation care.

Customers who choose Option One receive all medically necessary services, except payment of the Medicare Part B premium, from a Prepaid Health Plan (PHP).   

Persons choosing Option Two have transplant related medical expenses paid on a fee-for-service basis.

 

Definitions

Term

Definition

AHCCCS  Medical Assistance Service Packages

Services provided to AHCCCS Medical Assistance customers.  What services are available to a customer depend on the customer’s:

·        AHCCCS  Medical Assistance program; and

·        Coverage group.

Prepaid Health Plan (PHP)

PHPs receive monthly capitation from AHCCCS Administration.  PHPs are responsible for providing and paying for the customer’s:

·        Medical services;

·        Behavioral health services;

·        EPSDT services; and

·        Family planning services.

Indian Health Services (IHS)

IHS is an agency within the US Department of Health and Human Services.  IHS is responsible for providing federal health services to American Indians and Alaska Natives.  Native Americans have the option of enrolling with IHS as their health plan if approved for AHCCCS medical services.

AHCCCS American Indian Health Program (AIHP)

AIHP is responsible for paying fee-for-service claims submitted for Native Americans who have chosen not to enroll in an acute capitated health plan.  If the Native American member does not choose a plan and lives on the reservation, the member will be automatically enrolled in AIHP.

Emergency Services

Services that:

·        Are medically necessary;

·        Result from a medical condition or behavioral health condition.  (This includes labor and delivery.)  The condition manifests itself by acute symptoms of sufficient severity.  (This includes sever pain.); and

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

o       Placing the individual’s health in serious jeopardy;

o       Serious impairment to bodily functions;

o       Serious dysfunction of any bodily organ or part; or

o       Serious physical harm to another person.