Proposed State Rules

AHCCCS proposed rules not exempted from the rulemaking requirements of Title 41, Chapter 6, Arizona Revised Statutes 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.

2019

SFY2020 Hospital Assessment

Thursday, May 30, 2019
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 updates its estimate of the number of eligible persons and projected cost associated with coverage for those persons. The Administration is proposing a new rule to update the figures to be used as of July 1, 2019 for collecting the assessment from hospitals.

At the assessment rates in the current rule, the Administration estimates that it would collect $287 million over the course of a state fiscal year. The amendments reflected in this proposed rule adjust the assessment rates such that the Administration anticipates the collection of $331 million for the State Fiscal Year ending June 30, 2020. This amount corresponds to the amount of non-federal funds estimated to be necessary to cover the cost of providing care to the estimated 434,000 eligible individuals described in A.R.S. §36-2901.08(A) for State Fiscal year ending June 30, 2020.

As required by A.R.S. § 36-2901.08(B), the assessment has been established in a manner consistent with federal regulations at 42 C.F.R. Part 433 Subpart B so that the assessment does not cause a reduction in federal financial participation.

2018

DRG ACC Integration

Friday, November 2, 2018
This rulemaking will amend an AHCCCS DRG payment regulation to align with programmatic functions following AHCCCS Complete Care (ACC) integration October 1, 2018. This rulemaking will amend the definition of “administrative day” to authorize MCO payment to acute care hospitals at a level similar to reimbursement of these providers before the delivery system change to ACC integration. For claims with a primary diagnosis of behavioral health, acute care hospitals will receive reimbursement under the DRG methodology where, under the proposed rulemaking, this provider type will be able to qualify for payment under the revised definition of administrative day. This change will promote consistency of inpatient hospital reimbursement following ACC integration for providers serving members when claims with a primary diagnosis of behavioral health are filed.

Prior Quarter Coverage

Friday, September 7, 2018
42 CFR 435.915 requires the Administration to provide Prior Quarter (PQ) eligibility. Prior quarter eligibility is when a person who applies for AHCCCS may also qualify for Title XIX eligibility in any one of the three previous months prior to application. While A.R.S. § 36-2903(A) provides that the system’s reimbursement responsibility is prospective from the date of the eligibility determination, AHCCCS has implemented prior quarter coverage to ensure federal financial participation for Arizona’s Medicaid Program. Although AHCCCS had previously obtained federal approval waiving compliance from prior quarter coverage eligibility, as of January 1, 2014, AHCCCS was required by CMS to implement prior quarter eligibility. However, the Administration is seeking a new waiver from CMS so that the Administration is not required to provide Title XIX eligibility for any of the three previous months prior to the month of application except for pregnant women (including 60 days post-partum) and children under age 19.

Behavioral Health Inpatient Facilities

Friday, July 13, 2018
During the 2018 legislative session, the Arizona legislature enacted A.R.S. § 36-2905.03 which provided that non-contracted behavioral health inpatient facilities (BHIF’s) would be reimbursed at 90% of the contracted rate. This rulemaking is an effort to codify and clarify which facilities this statute applies to.

AHCCCS intends to encourage contracting between providers and all contractors to best serve AHCCCS members who require inpatient stays, regardless of whether the BHIF is contracted. The amended rule will encourage competition among BHIF’s and Contractors, expand provider networks, promote administrative efficiencies, and authorize AHCCCS to more efficiently and effectively reimburse BHIF’s for inpatient stays. Current federal and state statutory provisions do not prohibit such a change. The proposed rulemaking will also limit AHCCCS Program expenditures to BHIF’s in this State by extending applicability of the 90% reimbursement to all AHCCCS Contractors responsible for payments to non-contracted BHIF’s. As a result, the rulemaking supports payments to BHIF’s that are consistent with efficiency, economy, and quality of care, promoting the fiscal health of the State.

Graduate Medical Education Reimbursement

Friday, July 13, 2018
A.R.S. § 36-2903.01 requires the Administration to describe in rule how Graduate Medical Education (GME) funds are calculated and distributed. The intention of this rulemaking is to modify the method of allocating funds for indirect GME costs. 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 distributions. The Centers for Medicare and Medicaid Services (CMS) require the AHCCCS Administration to annually update the amount allocated to each hospital in the State Plan. Before AHCCCS may make GME payments, a State Plan Amendment (SPA) must be submitted and approved by CMS.

Currently, indirect GME costs are calculated two different ways and the AHCCCS Administration allocates indirect GME based on the greatest of these two methodologies. Children’s hospitals are unable to submit information to the Centers for Medicare and Medicaid Services on the Medicare Cost Reports Worksheet E, Part A. Since AHCCCS uses information on Worksheet E, Part A as one way to calculate the Indirect GME costs, there is only one methodology for calculating indirect GME costs for children’s hospitals.

AHCCCS proposes allowing an alternative method for calculating Indirect GME for children’s hospitals whereby a median per resident total indirect GME cost is determined for all hospitals which supply such information on the Medicare Cost Report. The median per resident total indirect cost would then be multiplied by the number of allocated residents at a children’s hospital and the Medicaid utilization percent used to determine the direct GME component.

Childrens' Rehabilitative Services Rulemaking

Friday, June 1, 2018
Through this rulemaking, the Agency proposes three major types of changes to these rules. This rulemaking will remove existing references to a singular CRS contractor and replace them with references to plural contractors, as well as remove references to the CRS program and replace them with references to CRS services. These changes are necessary since all MCO’s will be responsible for supplying these services as of October 1, 2018. Finally, R9-22-1306 will be repealed because there will no longer be a transition out of the CRS program since services to treat members with CRS conditions will be provided through all MCO’s rather than through a single CRS Contractor for the State.

In addition, to clarify the scope of services available to members, MCO’s are required to provide all services to eligible members, including Children’s Rehabilitative Services and behavioral health services when medically necessary. Failure to promulgate these changes may result in unnecessary financial and administrative burdens on Contractors and the AHCCCS Program, diminished member choice, reduced competition, and narrower provider networks available to members.

Differential Adjusted Payments 2019

Friday, June 1, 2018
AHCCCS Differential Adjusted Payment (DAP) initiatives are strategically designed to reward quality outcomes and reduce growth in the cost of health care. The objective of DAP delineated in this proposed rulemaking is to reward hospital providers that have taken designated actions to improve patients’ care experience, improve members’ health, and reduce the growth of the cost of care. Hospitals which satisfy the requirements delineated in rule will receive increased payments from the AHCCCS Administration and Contractors for inpatient and outpatient services. The proposed DAP rules represent the AHCCCS Administration’s expanding efforts to enhance accountability of the health care delivery system. The proposed rulemaking will amend and clarify rules specifying requirements for receipt of DAP for qualifying hospitals for both inpatient and outpatient services for the time period of October 1, 2018 through September 30, 2019. The proposed rulemaking will authorize AHCCCS to continue rewarding innovative activities and broaden the reach of the present model, emphasizing improved patient care and reduced growth in the cost of care.

Trauma Fund Rulemaking

Friday, June 1, 2018
The proposed rulemaking will clarify that a “level I trauma center” refers to any acute care hospital designated by the Arizona Department of Health Services (ADHS) as a level I trauma center, a provisional level I trauma center, or an initial level I trauma center. Hospitals designated by ADHS as a “provisional level I trauma center” or “initial level I trauma center” are operating as level I trauma center in every way, except verification by the American College of Surgeons which takes 12-18 months to achieve. The amended rule will eliminate the ambiguity of this definition and will allow provisional and initial level I trauma centers to receive money from the Proposition 202 Trauma Fund for unrecovered trauma center readiness costs. It will also allow provisional and initial level I trauma centers to receive a larger payment through the Outpatient Capped Fee Schedule pursuant to A.A.C. R9-22-712.35(C) which uses the same definition for level I trauma center.

SFY2019 Hospital Assessment

Tuesday, May 29, 2018
A.R.S. 36-2901.08 authorizes the AHCCCS 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 as 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, 2018 for collecting the assessment on hospitals.

95% FFS Reimbursement for Urban Hospital Program

Friday February 16, 2018
The proposed rulemaking will amend and clarify rules to provide a wider breadth of providers who may be reimbursed under the Urban Hospital Inpatient Reimbursement Program. In particular, this rulemaking is requested to allow AHCCCS to remove the exceptions for Tribal Regional Behavioral Health Authorities (TRBHA’s) and the Arizona Department of Health Services, Division of Behavioral Health Services (ADHS/BHS), currently interpreted as extending to Regional Behavioral Health Authorities (RBHA’s) as well because RBHA’s were subcontractors of ADHS/DBHS at the time the rule was last amended. Since the transfer of ADHS/DBHS duties and responsibilities to AHCCCS (Arizona Laws 2015, Chapter 195), RBHA’s and TRBHA’s contract directly with AHCCCS, and therefore, the provisions of the rule will be revised to include them in the definition of contractor for purposes of the Urban Hospital Reimbursement Program. In addition, the requirement for the Contractor to be an Urban Contractor no longer achieves the objectives AHCCCS intended. Instead, AHCCCS intends to encourage contracting between providers and all contractors to best serve AHCCCS members who require inpatient stays, regardless of whether the Contractor is urban or rural. Therefore the Urban Contractor requirement will also be removed from the rule. Also, the rule will explicitly authorize inpatient psychiatric hospitals to be included in the Urban Hospital Reimbursement Program subject to the 95% discount.

2017

PNA/Share of Cost

Friday December 15, 2017
The proposed rulemaking will amend and clarify rules to provide further flexibility as to the amount of money that may be retained in limited situations for persons who are ALTCS eligible, residents of a nursing facility, and who are responsible for court ordered spousal and/or child support. In particular, this rulemaking is requested to allow institutionalized members subject to court ordered child and/or spousal support to increase their personal needs allowance beyond the current limit of 15% of the Federal Benefit Rate (FBR) in limited circumstances.

TEFRA Lien

Friday December 15, 2017
The rulemaking is necessary to comport with federal law and to ensure that AHCCCS maximizes the opportunity for recovery of payments made for medical assistance to ALTCS members consistent with federal law. In addition, the rulemaking will likely increase State revenues and improve the fiscal health of the State by extending the imposition of TEFRA liens to members under the age of 55 years.

GME 2017

Friday September 15, 2017
A.R.S. § 36-2903.01 requires the Administration to describe in rule how Graduate Medical Education (GME) funds are calculated and distributed. The intention of this rulemaking is to modify the method of allocating funds for indirect GME costs. Under the proposed rule the Administration intends to calculate the Medicare indirect GME costs instead of relying on the amount specified on the Medicare Cost Report (MCR). The current methodology results in some hospitals receiving less GME payments than they would if the Medicare costs were calculated directly from information on the MCR. Both the Administration and CMS agree that the methodology set forth in the proposed rule more accurately reflects the Medicare share of the indirect cost of medical education.

Nursing Facility Supplemental Payments 2018

Friday September 15, 2017
The proposed rulemaking is imperative to ensure that the pass-through payments made to AHCCCS managed care contractors comport with recent changes to federal law which limits the aggregate amount of permissible pass-through payment made by the State. Failure to proceed with the proposed rulemaking to align with federal law could result in a federal compliance action and the potential loss of federal funding. Additionally, calculation of nursing facility supplemental payments using the current rule could result in the termination of reduction of supplemental payments, depriving nursing facility providers of critical revenues. The proposed rulemaking will amend the current rule to authorize two separate funding allocations for purposes of calculating nursing facility supplemental payments to be paid to providers by the spring of 2018 consistent with federal law.

DRG 2018

Friday, June 16, 2017
The DRG proposed rulemaking amends and clarifies rules specifying payments to hospitals for inpatient services under the DRG methodology. Revision to the DRG rules is necessary to ensure that payments to hospitals for inpatient services satisfy federal Medicaid provision 42 USC 1396a(a)(30)(A), requiring that payments be “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.”

This rulemaking rebases the components of the DRG system using updated claims and encounter data and incorporates related changes to policy and service adjusters in an effort to maintain cost effectiveness. In addition, the rulemaking updates the version of the All Patient Refined Diagnosis Related Group (APR-DRG) classification system established by 3M Health Information Systems that will apply for dates of discharge beginning January 1, 2018.

Tuesday, June 27, 2017
UPDATE: The document posted June 16, 2017 included a table of DRG model values that were from an earlier iteration of the financial model and do not reflect the final model. The document has been updated with the correct, final values.

Monday, August 7, 2017
UPDATE: AHCCCS has extended the comment period to 5:00p.m. August 14, 2017. AHCCCS has attached below two exhibits containing fiscal impact projections produced by Navigant Consulting for purposes of the APR-DRG Rebase.

  • Notice of Proposed Rulemaking: Title 9. Health Services, Chapter 22. AHCCCS
  • Public Hearing: August 8, 2017 1:00 p.m.
  • Comment Period Ending August 8, 2017 August 14, 2017 at 5 p.m.

    In order to provide hospitals with additional information about the proposed APR-DRG rebase and its projected fiscal impact, AHCCCS has attached two exhibits with fiscal impact projections produced by Navigant Consulting. As a result of this additional data, AHCCCS has extended the public comment period for the proposed DRG rulemaking from 5 PM August 8, 2017 to 5 PM August 14, 2017. Although the public hearing will still be held at 1 PM on August 8, 2017 public comments will now be accepted through 5PM Monday August 14, 2017.

    Fiscal Impact projections produced by Navigant Consulting for the purposes of the APR-DRG Rebase are provided in the exhibits below:

SFY2018 Hospital Assessment

Friday, May 26, 2017
A.R.S. 36-2901.08 authorizes the AHCCCS 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 as 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, 2017 for collecting the assessment on hospitals.

Value Based Purchasing (VBP)

Wednesday April 12, 2017
The proposed rulemaking will amend rules specifying requirements for receipt of AHCCCS Value Based Purchasing (VBP) Differential Adjusted Payments for qualifying hospitals for both inpatient and outpatient services for the time period of October 1, 2017 through September 30, 2018. Existing rules delineating VBP payments to hospitals are limited to the October 1, 2016 through September 30, 2017 timeframe. The VBP Differential Adjusted Payments delineated in this proposed rulemaking represent the AHCCCS Administration’s expanding efforts to enhance accountability of the health care delivery system by rewarding hospital providers that have taken designated actions to improve patients’ care experience, improve members’ health, and reduce the growth of the cost of care. Through this proposed rulemaking, inpatient VBP payments will also be extended to qualifying hospitals that are reimbursed for inpatient services on a per diem basis. Therefore, this rulemaking proposes to expand inpatient VBP payments beyond qualifying hospitals reimbursed under the diagnostic related group (DRG) methodology to also include qualifying hospitals reimbursed on a per diem basis.

2016

Reimbursement of Freestanding Emergency Departments

Friday July 15, 2016
This rulemaking is proposed as part of the AHCCCS Administration’s obligation under the federal Medicaid Act, 42 U.S.C. § 1396a(a)(30)(A), to establish methods for the reimbursement of health care providers that are consistent with efficiency, economy, quality care, and adequate access to care for persons enrolled in AHCCCS, Arizona’s implementation of the Medicaid program. Specifically, this rulemaking distinguishes services provided by a hospital-based freestanding emergency department from other hospital services and establishes the payment methodology for services provided by hospital-based freestanding emergency departments.

Nursing Facility Assessment

Friday July 15, 2016
The proposed rulemaking will amend the current rule to increase the amount of the nursing facility provider assessment charged for health care items and services provided by nursing facilities authorized by State Law ARS§36-2999.51 et seq. The statutory scheme requires the AHCCCS Administration to administer a provider assessment (also referred to as a quality assessment) on health care items and services provided by nursing facilities and to make supplemental payments to nursing facilities for covered Medicaid expenditures. As a result of the proposed rulemaking which will increase the dollar amount of the nursing facility assessment in R9-28-702, additional supplemental funding will be available to nursing facilities for covered Medicaid expenditures, thus supporting accessibility of critical health care services to vulnerable populations and enhancing the ability of nursing facilities to provide higher quality yet cost effective care to frail Arizona residents.

SFY 2017 Hospital Assessment

Friday June 10, 2016
A.R.S. 36-2901.08 authorizes the AHCCCS 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 as 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, 2016 for collecting the assessment on hospitals.

Medicare Part D Prescription Coverage Extra Help Subsidy Program

Tuesday May 10, 2016
The proposed rulemaking will amend and clarify rules to ensure consistency with federal requirements. In part, the rules will be revised to specify that “in kind support” and “maintenance” are not counted as part of the income calculation for purposes of eligibility determination.

Eligibility Fraud Penalties

Wednesday April 27, 2016
A.R.S. §§ 36-2905.04 and 36-2991 provide for the control and deterrence of fraud relating to AHCCCS eligibility, including the Hospital Presumptive Eligibility (HPE) program, through the discretionary imposition of a civil penalty on those persons who obtain AHCCCS eligibility through fraudulent means. A.R.S. §§ 36-2905.04(E) and 36-2991(E) require the AHCCCS Director to adopt rules providing for the appeal of a decision to impose such a penalty. The Administration will promulgate rules necessary for the imposition and appeal of penalties resulting from eligibility fraud, including fraud associated with the HPE program.

BH Simplification Phase 1

Monday March 21, 2016
The Administration is proposing rule to implement the statutory “behavioral health simplification and integration” where the AHCCCS Administration assumes full administrative and operational responsibility for the provision of behavioral health services effective July 1, 2016. Senate Bill 1257 (Laws 2015, Chapter 195) provides for the statutory transfer of behavioral health responsibilities from the Arizona Department of Health Services (ADHS) to AHCCCS. This rulemaking delineates the responsibilities of the AHCCCS Administration to oversee the provision of behavioral health services under Title 9 Chapter 21 of the Arizona Administrative Code (AAC) for persons with a serious mental illness (SMI) as defined under R9-21-101 and A.R.S.§ 36-550.

Rules under Title 9, Chapter 21 of the AAC, first enacted in October 1993 and last amended in June 2003; apply to persons with a SMI diagnosis, regardless of Medicaid eligibility. The Administration has chosen to make changes to this Chapter in two phases. This rulemaking is the first phase, and because the Administration is assuming administrative and operational responsibility for the provision of behavioral health services to persons with a SMI diagnosis, within all rules, the terms “department”, “division”, or “director” were changed to “Administration” or “mental health agency”, where applicable, and cross-references were updated to statutes or other rule sections, as appropriate. More significant of these proposed changes includes alignment of the hearing process with the Administrative Procedure Act (APA), A.R.S. §41-1092, deletion of antiquated or inaccurate language, updating of language to reflect AHCCCS terminology, and updating of language to reflect AHCCCS organizational structure.

  • Article 1’s objective is to describe General Provisions that apply to this Chapter. This Article describes definitions, the applicability of the SMI requirements, how time is computed when actions are made, the establishment of the Human Rights Committees, requirements of the Office of Human Rights and Advocates, and the state protection and Advocacy system. Within this Article, we have verified the use of the definitions described, updated cross-references, and added a section to guide the person to where the definitions can be found. The Article was updated to reflect that this Chapter will apply to the Administration and all mental health agencies. Sections were stricken that are no longer applicable, such as licensing (the Administration does not license or certify these agencies)
  • Article 2’s objective is to describe the rights of persons with SMI. This Article describes Civil and Other Legal Rights, Right to Support and Treatment, Protection from Abuse, Neglect, Exploitation and Mistreatment, Restraint and Seclusion, Labor, Competency and Consent, Informed Consent, Medication, Property and Possessions, Records, Policies and Procedures of Service Providers, Notice of Rights, and Exhibits. Within this Article, no significant changes were made, except for the terms relative to the Administration assuming responsibility, cross-reference updates, and minor clarifications.
  • Article 3’s objective is to describe the Individual Service Planning for behavioral health services for person with SMI. This Article describes General Provisions, Identification, Application, and Referral for Services of Persons with Serious Mental Illness, Eligibility Determination and Initial Assessment, Interim and Emergency Services, Assessments, Identification of Potential Service Providers, Selection of Service Providers, Implementation of the Individual Service Plan, Interim Services, Inpatient Treatment and Discharge Plan, Periodic Review of Individual Service Plans, and Modification or Termination of Plans. Within this Article, no significant changes were made, except for the terms relative to the Administration assuming responsibility.
  • Article 4’s objective is to describe appeals, grievances, and requests for investigation for persons with SMI. This Article describes Appeals, General requirements, Initiating a Grievance or Investigation, Persons Responsible for Resolving Grievances and Requests for Investigations, Preliminary Disposition, Conduct of Investigation, Administrative Appeal, Further Appeal to Administrative Hearing, Notice and Records, and Miscellaneous requirements. Within this Article, there were several changes. Like the other Articles, there were updates made to reflect the terms relative to the Administration assuming responsibility, cross-reference updates, and minor clarifications. This Article, on its face, appears to have significant changes made. However, the Administration adheres to timelines and processes set forth in the APA (A.R.S. §41-1092), and much of the previous language in this Article relating to timelines was stricken and replaced with cross-references to the APA. There are also the removal of some of the processes that were used when ADHS had the responsibility, but to which the Administration does not adhere.
  • Article 5 – Article 5’s objective is to describe Court-Ordered Evaluation and Treatment for persons with SMI. This Article describes Court-Ordered Evaluations, Emergency Admissions for evaluation, Voluntary Admission, Court-Ordered Treatment, Coordination of Court-Ordered Treatment with ISP’s and ITDP;s. Review and Transfers of Court-Ordered Individuals, Requests for Notification, Voluntary Admission for Treatment, Informed Consent, Use of Psychotropic Medication, Seclusion and Restraint, and Exhibits. No changes were made to this Article.

The second phase, which will be initiated at a later date, is intended to address more substantive changes through further review of statute and relevant litigation as well as consideration of best practices for the treatment and support of persons with SMI, with particular emphasis on patient outcomes.

DRG and Value Based Purchasing(VBP)

Monday March 21, 2016
The proposed rulemaking will amend and clarify rules specifying payments to hospitals for inpatient services under the Diagnostic Related Group (DRG) methodology. Significantly, this rulemaking will also include the addition of differential adjusted payments made to hospitals for both inpatient and outpatient services which satisfy specific criteria for receipt of VBP Differential Adjusted Payments by the AHCCCS Administration as well as Managed Care Contractors. The purpose of VBP Differential Adjusted Payments is to reward hospital providers that have taken designated actions to improve patients’ care experience, improve members’ health, and reduce the growth of the cost of care. Facilities which satisfy the criteria will receive increased payments for inpatient and outpatient services. Other topics of the proposed rulemaking include addition of a high acuity pediatric policy adjustor and clarification of payments for hospitalization of members who no longer meet inpatient criteria when they cannot be safely discharged, when no other setting is available, or when members must be transferred to another hospital for sub-acute services.

Outpatient Treatment Center (OTC)

Monday March 21, 2016
The proposed rulemaking clarifies that the AHCCCS Outpatient Capped Fee-For-Service Schedule delineated in A.A.C. R9-22-712.10 through R9-22-712.50 shall apply only to payments for outpatient hospital services provided by non-IHS acute hospitals and not to payments for outpatient services of freestanding outpatient treatment centers that are affiliated with hospitals (“provider-based”) and provide emergency services. Outpatient treatment centers are a class of health care institutions without inpatient beds as defined in A.A.C. R9- 10-101(130). A subclass of outpatient treatment centers provides emergency services under A.A.C R9-10-1019 and may be subject to 42 CFR 489.24, implementing the Emergency Medical Treatment and Active Labor Act (EMTALA). Such institutions are also referred to as freestanding emergency rooms or freestanding emergency departments. Some are licensed separately from the hospital they are affiliated with while others operate under a single group license with the hospital. This proposed rulemaking clarifies that services provided by outpatient treatment centers, including provider-based freestanding outpatient treatment centers, are not outpatient hospital services which are reimbursed as specified in A.A.C. R9- 22-712.10 through R9-22-712.50. Instead, those services are reimbursed under the capped fee schedule established by the AHCCCS Administration which schedule is exempt from the requirements of rule-making under A.R.S. 41-1005(A)(9).

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.