DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, MD 21244-1850	CENTERS FOR MEDICARE & MEDICAID SER 1CES
CENTER FOR MEDICAID & CHIP SERVICES

Financial Management  Group

APR 0 S 2015

Tom Betlach, Director
Arizona Health Care Cost Containment System 801 E. Jefferson
Phoenix, AZ 85034

RE: Arizona SPA 14-013A Dear Mr. Betlach:
We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 14-013A. This amendment increases the rates for freestanding psychiatric hospitals effective October  1, 2014.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C.	sis to inform you that Medicaid State plan amendment TN 14-013A is approved effective October 1, 2014. We are enclosing the HCFA- 179 and the amended plan pages.

If you have any questions, please call Blake Holt at (415) 744-3754 or Mark Wong at (415) 744- 3561.

Sincerely,

k-r-- Timothy Hill -1:-v-' Director           O

Enclosures

CENTERS	MEDICARE  AND
TRANSMITTAL AND NOTICE OF APPROVAL OF	1. TRANSMITTAL NUMBER:
STATE PLAN MATERIAL	14-013A

OMB NO. 0938-0193
2. STATE
Arizona

FOR: Centers for Medicare and Medicaid Services	3. PROGRAM IDENTIFICATION: TITLE XIX OF THE
SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR
CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES
5. TYPE OF PLAN MATERIAL (Check One):

PROPOSED EFFECTIVE DATE
October 1, 2014

DNEW STATE PLAN	0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

42 CFR 447 Subpart C	FFY  15:  $140,535
FFY 16: $140,535

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:	9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION
OR ATTACHMENT (If Applicable):

Art. 4.19-A, page 11.	Same

SUBJECT OF AMENDMENT:

Updates rates for freestanding psychiatric hospitals for the period beginning October 1, 2014.

GOVERNOR'S REVIEW (Check One):
IZ! GOVERNOR'S OFFICE REPORTED NO COMMENT	0 OTHER, AS SPECIFIED:
0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED
0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

SIGNATURE OF STATE AGENCY OFFICIAL:	16. RETURN TO:

Monica Coury
801 E. Jefferson, MD#4200
f--;-;;	---------------1 Phoenix, Arizona 85034

Assistant  Director
15. DATE SUBMITTED:

CENTERS FOR MEDICARE AND MEDICAID SERVICES

OMB NO. 0938-0193

Attachment 4.19-A
Page 11

STATE OF ARIZONA

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES INPATIENT HOSPITAL CARE

B. Out-of-State Hospitals

Out-of-state hospitals providing covered services (excluding organ and transplantation services) to persons eligible for AHCCCS are paid by multiplying covered charges by the most recent state-wide urban cost-to-charge ratio (CCR). The CCR is updated annually by AHCCCS, with an October 1 effective date, using the most current Medicare cost-to-charge ratios published or placed on display by CMS by August 31 ofthat year.

Out-of-state hospitals providing covered organ and transplantation services to persons eligible for AHCCCS are paid based upon a fixed price per type of transplant with stop-loss provisions. Reimbursement rates are negotiated using the out of state provider's home state Medicaid reimbursement as a benchmark. At no time will payment exceed the hospital's billed charges.

PAYMENT TO FREESTANDING PSYCHIATRIC HOSPITALS

Psychiatric hospitals are paid a statewide per diem fee. AHCCCS rates were set as of October 1, 2014, and are effective for dates of admission on or after that date. AHCCCS rates for payments to freestanding psychiatric hospitals, including freestanding psychiatric hospitals that function solely as detoxification facilities, are published on the agency's website at http://www.azahcccs.gov/commercial!Downloads/FFSrates/Behaviora1Health/BehavioralHealthRates201 4100l.pdf

APPEALS PROCEDURES

Facilities may appeal rates within the limits of Arizona statute through the AHCCCS grievance and appeals process. Facilities may also informally request a rate review.

TN No. 14-013A
Supersedes
TN No. 11-018

Approval DateAPR 0 8 2013	Effective Date: October l,2014