TITLE 9. HEALTH SERVICES

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

ARTICLE 2. ELIGIBILITY

Article 2, consisting of Sections R9-7-201 through R9-7-203, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-201. Eligibility Requirements

A. An individual is eligible to enroll for CRS if the individual:

1. Has one of the medical conditions in R9-7-202;

2. Except as provided in subsection (B), is a child;

3. Is one of the following:

a. A U.S. citizen, or

b. A qualified alien who meets the requirements of A.R.S. § 36-2903.03(B), and

4. Is living in Arizona and intends to continue living in Arizona.

B. The Department may enroll an adult, who is not eligible for Title XIX health care insurance, in CRS if:

1. The adult has cystic fibrosis and monies are appropriated to the Department under A.R.S. § 36-143, or

2. The adult has sickle cell anemia and monies are appropriated to the Department under A.R.S. § 36-797.44.

C. The Department shall continue a member's enrollment in CRS if the member:

1. And, if the member is a minor, the member's parent comply with the requirements in this Chapter;

2. Meets the requirements in subsections (A)(1), (A)(2), and (A)(4); and

3. Meets the requirements in subsection (A)(3) or has continuously been a member since August 5, 1999.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-202. Medical Conditions

An individual is medically eligible for CRS, only if the individual has:

1. One or more of the following cardiovascular system medical conditions:

a. Congenital heart defect,

b. Cardiomyopathy,

c. Valvular disorder,

d. Arrhythmia,

e. Conduction defect,

f. Rheumatic heart disease that is not in the acute phase,

g. Renal vascular hypertension,

h. Arteriovenous fistula, and

i. Kawasaki disease with coronary artery aneurysm;

2. One or more of the following endocrine system medical conditions:

a. Hypothyroidism;

b. Hyperthyroidism;

c. Adrenogenital syndrome;

d. Addison's disease;

e. Hypoparathyroidism;

f. Hyperparathyroidism;

g. Diabetes insipidus;

h. Cystic fibrosis;

i. For an individual who was a member before November 1, 1995, panhypopituitarism with a deficiency of growth hormone; and

j. For an individual who became a member or applies for enrollment after November 1, 1995, panhypopituitarism with a deficiency of growth hormone and two other pituitary hormones;

3. One or more of the following genitourinary system medical conditions:

a. Vesicoureteral reflux, with at least mild or moderate dilatation and tortuosity of the ureter and mild or moderate dilatation of renal pelvis;

b. Ectopic ureter;

c. Ambiguous genitalia;

d. Ureteral stricture;

e. Complex hypospadias;

f. Hydronephrosis;

g. Deformity and dysfunction of the genitourinary system secondary to trauma after the acute phase of the trauma has passed;

h. Pyelonephritis when treatment with drugs or biologicals has failed to cure or ameliorate and surgical intervention is required;

i. Multicystic dysplastic kidneys;

j. Nephritis associated with lupus erythematosis; and

k. Hydrocele associated with a ventriculo-peritoneal shunt;

4. One or more of the following ear, nose, or throat medical conditions:

a. Cholesteatoma;

b. Chronic mastoiditis;

c. Deformity and dysfunction of the ear, nose, or throat secondary to trauma, after the acute phase of the trauma has passed;

d. Neurosensory hearing loss;

e. Congenital malformation;

f. Significant conductive hearing loss due to an anomaly in one ear or both ears equal to or greater than a pure tone average of 30 decibels, that despite medical treatment, requires a hearing aid;

g. Craniofacial anomaly that requires treatment by more than one specialist; and

h. Microtia that requires multiple surgical interventions;

5. One or more of the following musculoskeletal system medical conditions:

a. Achondroplasia;

b. Hypochondroplasia;

c. Diastrophic dysplasia;

d. Chondrodysplasia;

e. Chondroectodermal dysplasia;

f. Spondyloepiphyseal dysplasia;

g. Metaphyseal and epiphyseal dysplasia;

h. Larsen syndrome;

i. Fibrous dysplasia;

j. Osteogenesis imperfecta;

k. Rickets;

l. Enchondromatosis;

m. Juvenile rheumatoid arthritis;

n. Seronegative spondyloarthropathy;

o. Orthopedic complications of hemophilia;

p. Myopathy;

q. Muscular dystrophy;

r. Myoneural disorder;

s. Arthrogryposis;

t. Spinal muscle atrophy;

u. Polyneuropathy;

v. Chronic stage bone infection;

w. Chronic stage joint infection;

x. Upper limb amputation;

y. Syndactyly;

z. Kyphosis;

aa. Scoliosis;

bb. Congenital spinal deformity;

cc. Congenital cervical spine abnormality;

dd. Developmental cervical spine abnormality;

ee. Hip dysplasia;

ff. Slipped capital femoral epiphysis;

gg. Femoral anteversion and tibial torsion that is:

i. For an individual less than eight years of age, associated with a neuromuscular disorder that is a CRS condition; or

ii. For an individual eight years of age or older, causing significant functional impairment, as determined by a CRS provider;

hh. Legg-Calve-Perthes disease;

ii. Lower limb amputation, including prosthetic sequelae of cancer;

jj. Metatarsus adductus;

kk. Leg length discrepancy of five centimeters or more;

ll. Metatarsus primus varus;

mm. Dorsal bunions;

nn. Collagen vascular disease;

oo. Benign bone tumor;

pp. Deformity and dysfunction secondary to musculoskeletal trauma if:

i. The patient was 15 years of age or younger at the time of initial injury, and

ii. The deformity and dysfunction is not in the acute phase;

qq. Osgood Schlatter's disease that requires surgical intervention; and

rr. Complicated flat foot, such as rigid foot, unstable subtalar joint, or significant calcaneus deformity;

6. One or more of the following gastrointestinal system medical conditions:

a. Tracheoesophageal fistula;

b. Anorectal atresia;

c. Hirschsprung's disease;

d. Diaphragmatic hernia;

e. Gastroesophageal reflux that has failed treatment with drugs or biologicals and requires surgery;

f. Deformity and dysfunction of the gastrointestinal system secondary to trauma, after the acute phase of the trauma has passed;

g. Biliary atresia;

h. Congenital atresia, stenosis, fistula, or rotational abnormalities of the gastrointestinal tract;

i. Cleft lip;

j. Cleft palate;

k. Omphalocele; and

l. Gastroschisis;

7. One or more of the following nervous system medical conditions:

a. Uncontrolled seizure disorder, in which there have been more than two seizures with documented adequate blood levels of one or more medications;

b. If the individual is not eligible for Title XIX or Title XXI health care insurance and does not have other health care insurance, simple or controlled seizure disorders;

c. Cerebral palsy;

d. Muscular dystrophy or other myopathy;

e. Myoneural disorder;

f. Neuropathy, hereditary or idiopathic;

g. Central nervous system degenerative disease;

h. Central nervous system malformation or structural abnormality;

i. Hydrocephalus;

j. Craniosynostosis of a sagittal suture, a unilateral coronal suture, or multiple sutures in a child less than 18 months of age;

k. Myasthenia gravis, congenital or acquired;

l. Benign intracranial tumor;

m. Benign intraspinal tumor;

n. Tourette's syndrome;

o. Residual dysfunction after resolution of an acute phase of vascular accident, inflammatory condition, or infection of the central nervous system;

p. Myelomeningocele, also known as spina bifida;

q. Neurofibromatosis;

r. Deformity and dysfunction secondary to trauma in an individual 15 years of age or less at the time of the initial injury;

s. Sequelae of near drowning, after the acute phase; and

t. Sequelae of spinal cord injury, after the acute phase;

8. One or more of the following ophthalmological medical conditions:

a. Cataracts;

b. Glaucoma;

c. Disorder of the optic nerve;

d. Non-malignant enucleation and post-enucleation reconstruction;

e. Retinopathy of prematurity; and

f. Disorder of the iris, ciliary bodies, retina, lens, or cornea;

9. One or more of the following respiratory system medical conditions:

a. Anomaly of the larynx, trachea, or bronchi that requires surgery; and

b. Nonmalignant obstructive lesion of the larynx, trachea, or bronchi;

10. One or more of the following integumentary system medical conditions:

a. A craniofacial anomaly that is functionally limiting,

b. A burn scar that is functionally limiting,

c. A hemangioma that is functionally limiting,

d. Cystic hygroma, and

e. Complicated nevi requiring multiple procedures;

11. One or more of the following genetic and metabolic medical conditions:

a. Amino acid or organic acidopathy,

b. Inborn error of metabolism,

c. Storage disease,

d. Phenylketonuria,

e. Homocystinuria,

f. Hypothyroidism,

g. Maple syrup urine disease, and

h. Biotinidase deficiency;

12. Sickle cell anemia or other hemoglobinopathy; or

13. A medical condition, other than one of the conditions in R9-7-203, that, as determined by a regional medical director:

a. Requires specialized treatment similar to the type and quantity of treatment a medical condition in subsections (1) through (12) requires,

b. Is as likely to result in functional improvement with treatment as a medical condition listed in subsections (1) through (12), and

c. Requires long-term follow-up of the type and quantity required for a medical condition listed in subsections (1) through (12).

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-203. Medical Ineligibility

An individual who has one or more of the following medical conditions, but does not have one or more of the medical conditions in R9-7-202, is not medically eligible for CRS:

1. The following cardiovascular system medical conditions:

a. Essential hypertension;

b. Premature atrial, nodal or ventricular contractions that are of no hemodynamic significance;

c. Arteriovenous fistula that is not expected to cause cardiac failure or threaten loss of function; and

d. Benign heart murmur;

2. The following endocrine system medical conditions:

a. Diabetes mellitus,

b. Isolated growth hormone deficiency,

c. Hypopituitarism encountered in the acute treatment of a malignancy, and

d. Precocious puberty;

3. The following genitourinary system medical conditions:

a. Nephritis, infectious or noninfectious;

b. Nephrosis;

c. Undescended testicle;

d. Phimosis;

e. Hydrocele not associated with a ventriculo-peritoneal shunt;

f. Enuresis;

g. Meatal stenosis; and

h. Hypospadias involving isolated glandular or coronal aberrant location of the urethralmeatus without curvature of the penis;

4. The following ear, nose and throat medical conditions:

a. Tonsillitis,

b. Adenoiditis,

c. Hypertrophic lingual frenum,

d. Nasal polyp,

e. Cranial or temporal mandibular joint syndrome,

f. Simple deviated nasal septum,

g. Recurrent otitis media,

h. Obstructive apnea,

i. Acute perforation of the tympanic membrane,

j. Sinusitis,

k. Isolated preauricular tag or pit, and

l. Uncontrolled salivation;

5. The following musculoskeletal system medical conditions:

a. Ingrown toenail;

b. Back pain with no structural abnormality;

c. Ganglion cyst;

d. Flat foot other than complicated flat foot;

e. Fracture;

f. Popliteal cyst;

g. Femoral anteversion and tibial torsion unless:

i. For an individual less than eight years of age, associated with a neuromuscular disorder that is a CRS condition; or

ii. For an individual eight years of age or older, causing significant functional impairment as determined by a CRS provider;

h. Simple bunion; and

i. Carpal tunnel syndrome;

6. The following gastrointestinal system medical conditions:

a. Malabsorption syndrome, also known as short bowel syndrome,

b. Crohn's disease,

c. Hernia other than a diaphragmatic hernia,

d. Ulcer disease,

e. Ulcerative colitis,

f. Intestinal polyp,

g. Pyloric stenosis, and

h. Celiac disease;

7. The following nervous system medical conditions:

a. Headaches;

b. Central apnea secondary to prematurity;

c. Near sudden infant death syndrome;

d. Febrile seizures;

e. Occipital plagiocephaly, either positional or secondary to lambdoidal synostosis;

f. Trigonocephaly secondary to isolated metopic synostosis;

g. Spina bifida occulta;

h. Near drowning in the acute phase; and

i. Spinal cord injury in the acute phase;

8. The following ophthalmologic medical conditions:

a. Simple refraction error,

b. Astigmatism,

c. Strabismus, and

d. Ptosis;

9. The following respiratory system medical conditions:

a. Respiratory distress syndrome,

b. Asthma,

c. Allergies,

d. Bronchopulmonary dysplasia,

e. Emphysema,

f. Chronic obstructive pulmonary disease, and

g. Acute or chronic respiratory condition requiring venting for the neuromuscularly impaired;

10. The following integumentary system medical conditions:

a. A deformity that is not functionally limiting,

b. Simple nevi,

c. Skin tag,

d. Port wine stain,

e. Sebaceous cyst,

f. Isolated malocclusion that is not functionally limiting,

g. Pilonidal cyst,

h. Ectodermal dysplasia, and

i. A craniofacial anomaly that is not functionally limiting;

11. The following medical conditions:

a. Allergies;

b. Anorexia nervosa or obesity;

c. Autism;

d. A burn other than a burn scar that is functionally limiting;

e. Cancer;

f. Chronic vegetative state;

g. Deformity and dysfunction secondary to trauma or injury if:

i. The trauma or injury occurred on or after the individual's 16th birthday, or

ii. Three months have not passed since the trauma or injury;

h. Depression or other mental illness;

i. Developmental delay;

j. Dyslexia or other learning disabilities;

k. Failure to thrive;

l. Hyperactivity;

m. Attention deficit disorder;

n. Leg length discrepancy of less than five centimeters at skeletal maturity; and

o. Immunodeficiency, such as AIDS and HIV.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

ARTICLE 3. REFERRAL; ENROLLMENT; APPLICATION; REDETERMINATION; TERMINATION

Article 3, consisting of Sections R9-7-301 through R9-7-306, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-301. Referral

A. To refer an individual, a referral source shall submit to the Department a referral form containing:

1. The name, sex, home address, and home telephone number of the individual;

2. If the individual is a minor, the name of a parent of the individual;

3. If applicable, the work telephone number of the parent in subsection (A)(2);

4. The name, address, and telephone number of the referral source;

5. If the individual previously received covered medical services or covered support services, the year in which the individual received the covered medical services or covered support services, and the regional contractor responsible for providing covered medical services or covered support services to the individual;

6. Relationship of the referral source to the individual; and

7. If known to the referral source, the individual's:

a. Birth date,

b. Diagnosis, and

c. Physician.

B. If an individual has Title XIX, Title XXI, or other health care insurance, a referral source shall submit to the Department the form in subsection (A) and:

1. Documentation from a physician who evaluated the individual, stating the individual's diagnosis made by the physician; and

2. Diagnostic test results that support the individual's diagnosis made by the physician.

C. If an individual does not have Title XIX, Title XXI, or other health care insurance, a referral source shall submit to the Department the form in subsection (A) and:

1. If the individual has not been evaluated by a physician, the reason the referral source believes that the individual may be eligible for CRS; or

2. If the individual has been evaluated by a physician:

a. Documentation from the physician who evaluated the individual, stating the individual's diagnosis made by the physician; and

b. If available, diagnostic test results that support the individual's diagnosis made by the physician.

D. Within 10 business days from the date of receipt of a referral:

1. If the Department determines that a individual may be eligible for CRS, the Department shall notify the referral source and provide the individual or, if the individual is a minor, the individual's parent:

a. An application form in R9-7-304(1) and a list of the documentation required in R9-7-304(2) through (11);

b. A written notice that the individual may be eligible for CRS and that:

i. After the Department receives the application form in R9-7-304(1) from the individual or, if the individual is a minor, the individual's parent, the individual is authorized to receive an initial evaluation to determine whether the individual is medically eligible for CRS;

ii. The individual or, if the individual is a minor, the individual's parent is required to participate in a eligibility interview before or during the individual's initial evaluation;

iii. The Department has scheduled an appointment for the individual's initial evaluation at a CRS clinic, the date of the individual's appointment, the address of the CRS clinic, and the procedure for rescheduling the appointment if the individual is unable to keep the scheduled appointment; and

iv. The individual is not authorized to receive covered medical services or covered support services other than the initial evaluation until the individual and, if the individual is a minor, the individual's parent comply with the application requirements in R9-7-302(B) and the Department determines that the individual meets the eligibility requirements in R9-7-201; and

c. Information about CRS, including:

i. An overview of CRS,

ii. Medical and non-medical eligibility requirements for CRS,

iii. The application requirements in R9-7-302(B), and

iv. Criteria for determining which individuals are part of a household income group;

2. If the Department determines that the individual is not eligible for CRS, the Department shall:

a. Notify the referral source; and

b. Provide the individual or, if the individual is a minor, the individual's parent a written notice that:

i. Informs the individual or, if the individual is a minor, the individual's parent that the Department has determined the individual is not eligible for CRS; and

ii. Complies with A.R.S. § 41-1092.03; or

3. If the Department determines the referral source did not submit the information and documentation required in subsection (A), the Department shall provide a written notice to the referral source that:

a. Identifies the missing documentation or information;

b. Requests the referral source to submit the missing information or documentation within 30 calendar days from the date of the notice; and

c. Informs the referral source that, if the Department does not receive the documentation or information within 30 calendar days from the date of the notice, the Department shall consider the referral withdrawn.

E. If the Department requests information or documents according to subsection (D)(3), and the Department:

1. Receives the requested documentation and information within 30 calendar days from the date of the notice in subsection (D)(3), the Department shall determine whether the individual may be eligible for CRS and notify the referral source and the individual or, if the individual is a minor, the individual's parent according to subsection (D)(1) or (D)(2) within 10 business days from the date of receipt of the requested documentation and information; or

2. Does not receive the requested documentation and information within 30 calendar days from the date of notice in subsection (D)(3), the Department shall consider the referral withdrawn.

F. If the Department determines that an individual may be eligible for CRS, the Department shall schedule the date of an initial evaluation no more than 30 calendar days after the date of the determination.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-302. Enrollment

A. An individual or, if the individual is a minor, the individual's parent may apply for enrollment after the individual or, if the individual is a minor, the individual's parent receives the notice in R9-7-301(D)(1) from the Department that the individual may be eligible for CRS.

B. To apply for enrollment:

1. An applicant or, if the applicant is a minor, the applicant's parent shall submit to the Department an application form containing the information in R9-7-304(1);

2. An applicant or, if the applicant is a minor, the applicant's parent shall submit to the Department the documentation in R9-7-304(2) through (11):

a. Before an applicant's initial evaluation, or

b. No later than 10 business days after the date an applicant attends a CRS clinic for an initial evaluation;

3. After submitting the application form in subsection (B)(1):

a. An applicant, or if the applicant is a minor, the applicant's parent shall participate in an eligibility interview; and

b. An applicant shall attend a CRS clinic for an initial evaluation; and

4. No later than 10 business days after the date an applicant attends a CRS clinic for an initial evaluation, the applicant or, if the applicant is a minor, the applicant's parent shall:

a. If the applicant is potentially eligible for Title XIX or Title XXI health care insurance, apply for the health care insurance; and

b. Sign the payment agreement in R9-7-601(B).

C. Except as provided in subsection (H), the Department shall enroll an applicant as soon as:

1. The applicant and, if applicable, the applicant's parent submit the information and documentation and meet the requirements in this Section; and

2. The Department determines the applicant is eligible for CRS.

D. If the Department enrolls an applicant, the Department shall provide the applicant or, if the applicant is a minor, the applicant's parent, a written notice that contains:

1. A statement that the applicant is enrolled in CRS; and

2. Information about CRS that includes:

a. Covered medical services and covered support services,

b. Member payment responsibility, and

c. The grievance and appeal process.

E. The Department shall not enroll an applicant if:

1. The applicant and, if the applicant is a minor, the applicant's parent does not submit the information and documentation or comply with the requirements in this Section; or

2. The Department determines that the applicant is not eligible for CRS.

F. If the Department does not enroll an applicant, the Department shall provide the applicant or, if the applicant is a minor, the applicant's parent, a written notice of denial that complies with A.R.S. § 41-1092.03.

G. The Department shall provide the written notice in subsection (D) or subsection (F) within 10 days from the date of an applicant's initial evaluation or the Department's receipt of the applicant's information and documentation in subsection (B)(2) if the applicant did not submit the information and documentation at the applicant's initial evaluation, whichever is later.

H. If an applicant, who meets the requirements in this Section and is determined to be eligible for CRS, is receiving inpatient services, the Department shall:

1. Provide the applicant or, if the applicant is a minor, the applicant's parent a written notice:

a. Stating that the Department will not enroll an applicant while the applicant is receiving inpatient services; and

b. Requesting that the Department is notified when the applicant is no longer receiving inpatient services; and

2. When the applicant is no longer receiving inpatient services, enroll the applicant according to subsection (D).

I. If the Department requests information or documentation to determine if a member remains eligible for CRS, the member or, if the member is a minor, the member's parent shall provide the requested information or documentation to the Department within 30 calendar days of the request.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-303. Initial Evaluation; Further Diagnostic Testing

If the Department determines from an applicant's initial evaluation that further diagnostic testing is required to determine whether the applicant is medically eligible for CRS, the Department shall:

1. If the applicant has Title XIX or Title XXI health care insurance, request that AHCCCS complete the diagnostic testing and send the results of the diagnostic testing to the Department;

2. If the applicant has other health care insurance that agrees to pay the Department for the diagnostic testing, complete the diagnostic testing and submit charges for the diagnostic testing to the health insurance company;

3. If the applicant has health care insurance that does not agree to pay the Department for the diagnostic testing but provides the diagnostic testing, request that the applicant have:

a. The diagnostic testing completed through the applicant's health care insurance company, and

b. The results of the diagnostic testing sent to the Department; and

4. If the applicant does not have health care insurance or has health care insurance that does not provide or pay for the diagnostic testing, and the applicant:

a. Signs the payment agreement in R9-7-601(B), provide the diagnostic testing to the individual; or

b. Does not sign the payment agreement in R9-7-601(B), provide to the applicant or, if the applicant is a minor, the applicant's parent a written notice of denial that complies with A.R.S. § 41-1092.03.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-304. Enrollment Application

An applicant applying for enrollment or, if the applicant is a minor, a parent applying on behalf of the applicant shall submit to the Department an application packet including:

1. An application form containing:

a. The applicant's name, home address, mailing address, birth date, place of birth, and marital status;

b. If the applicant has a social security number, the applicant's social security number;

c. If the applicant has a home telephone number, the applicant's home telephone number;

d. If the applicant does not have a home telephone number, a telephone number where a message may be left for the applicant;

e. Whether the applicant has a court-appointed legal guardian or custodian;

f. If the applicant is a minor, the following information for the applicant's parent:

i. Name;

ii. Home address, mailing address, and home or message telephone number;

iii. If the parent has a social security number, the parent's social security number; and

iv. If the parent works, the parent's employer, work address, and work telephone number;

g. The names and ages of all individuals in the applicant's household income group;

h. The annual gross income of the applicant's household income group;

i. Whether the applicant has Title XIX, Title XXI, or other health care insurance;

j. If the applicant has health care insurance other than Title XIX or Title XXI health care insurance, for each health care insurance company:

i. The health care insurance company's name, billing address, and telephone number; and

ii. For the applicant's health care insurance, the applicant's policy or plan number, health care insurance identification number, effective or end date, and type of services paid for by the health care insurance;

k. Whether the applicant receives services from the:

i. DES Adoption Subsidy Program,

ii. DES Comprehensive Medical and Dental Program, or

iii. DES Division of Developmental Disabilities;

l. The signature of the applicant or, if the applicant is a minor, the signature of the applicant's parent in subsection (1)(f); and

m. The date the application form is signed;

2. If the applicant has a legal guardian, a copy of the court document indicating the applicant's legal guardian;

3. If the applicant has Title XIX or Title XXI health care insurance, the applicant's AHCCCS identification number or a copy of the applicant's AHCCCS identification card;

4. If the applicant has health care insurance other than Title XIX or Title XXI health care insurance, a copy of the applicant's health care insurance card or written documentation that the applicant has health care insurance from the health care insurance company;

5. As proof of the applicant's age, a copy of one of the following documents that includes the applicant's birth date:

a. An Immigration and Naturalization Service document,

b. A federal or state census record,

c. A hospital record of birth,

d. A certified copy of a birth certificate,

e. A military record,

f. A notification of birth registration,

g. A religious record,

h. A school record, or

i. A U.S. passport;

6. Except as provided in subsection (7), as proof of the applicant's U.S. citizenship, one of the following:

a. A certified copy of a birth certificate,

b. A certified copy of a religious record issued within three months of birth,

c. A naturalization certificate reflecting U.S. citizenship,

d. A current or expired U.S. passport,

e. A certificate of U.S. citizenship, or

f. Documentation evidencing that the individual currently has Title XIX or Title XXI health care insurance;

7. If the applicant is a qualified alien, written documentation verifying that the applicant:

a. Is a qualified alien, and

b. Meets the requirements of A.R.S. § 36-2903.03(B);

8. As proof that the applicant lives in Arizona, a copy of one of the following documents issued in the name of the applicant, the spouse of the applicant, or an adult with whom the applicant lives:

a. The applicant's Title XIX or Title XXI health care insurance identification number or a copy of the applicant's current Title XIX or Title XXI health care insurance card;

b. An Arizona rent or mortgage receipt;

c. An Arizona lease for where the applicant lives;

d. A written statement that the applicant lives at an Arizona nursing care institution licensed under A.R.S. Title 36, Chapter 4 signed by the administrator of the Arizona nursing care institution;

e. An unexpired Arizona motor vehicle operator's license;

f. A current Arizona motor vehicle registration;

g. A pay stub from an Arizona employer;

h. An Arizona utility bill for where the applicant lives;

i. A current Arizona phone directory listing for where the applicant lives;

j. A United States Post Office record reflecting an Arizona address;

k. A certified copy of a religious record reflecting an Arizona address;

l. A certified copy of a school record reflecting an Arizona address; and

m. An affidavit signed by the applicant or, if the applicant is a minor, by the applicant's parent certifying that:

i. None of the documents in subsections (B)(8)(a) through (B)(8)(l) are available; and

ii. The applicant lives in Arizona;

9. As proof of an applicant's intent to continue to live in Arizona, an affidavit that contains an attestation by the applicant or, if the applicant is a minor, the applicant's parent of the applicant's intent to remain in Arizona;

10. If the applicant does not have Title XIX or Title XXI health care insurance, copies of the following documentation for each individual in the applicant's household income group, if applicable:

a. If an individual in the household income group is employed, the individual's:

i. Pay stubs for the 30 calendar days before the date on the applicant's application form,

ii. Most recent W-2 form, and

iii. Federal tax return most recently filed by the individual;

b. If an individual in the household income group is self-employed, the individual's:

i. Federal tax return, including a schedule C, most recently filed by the individual; or

ii. Most recent quarterly financial statement signed and dated by the individual;

c. Documented evidence of all unearned income received by an individual, such as cancelled checks or court orders for child support payments;

d. Documented evidence of all medical expenses incurred by an individual and paid during the 12 months before the date on the application form; and

e. Documented evidence of all unpaid medical expenses; and

11. If applicable, documented evidence of:

a. Any court award or settlement related to the applicant's CRS condition, and

b. Expenditures from the court award or settlement made for medical services for the applicant.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-305. Redetermination

A. At any time, the Department may request a member or, if the member is a minor, the member's parent to submit the information and documents in R9-7-304 to redetermine:

1. Whether a member remains eligible for CRS, or

2. A member's payment responsibility.

B. If the member has Title XIX or Title XXI health care insurance, the Department shall, no later than the member's CRS expiration date:

1. Verify that the member has Title XIX or Title XXI health care insurance, and

2. Establish a new CRS expiration date for the member that is the same as the member's Title XIX or Title XXI health care insurance expiration date.

C. If the member does not have Title XIX or Title XXI health care insurance and the net income of the member's household income group is more than 200% of the Federal Poverty Level, the member or, if the member is a minor, the member's parent shall submit, before the member's CRS expiration date, a signed payment agreement.

D. If the member does not have Title XIX or Title XXI health care insurance and the net income of member's household income group is equal to or less than 200% of the Federal Poverty Level, the member or, if the member is a minor, the member's parent shall, at least 30 calendar days before the CRS expiration date:

1. Participate in an eligibility interview with a Department representative,

2. Submit to the Department the information and documentation in R9-7-304(10), and

3. Submit to the Department a signed payment agreement.

E. The Department shall establish a new CRS expiration date for a member who does not have Title XIX or Title XXI health care insurance that is 12 months after the member's CRS expiration date if:

1. The member and, if the member is a minor, the member's parent comply with the redetermination requirements in this Section before the member's expiration date; and

2. The Department determines that the member remains eligible for CRS.

F. If the Department determines that a member is no longer eligible for CRS, the Department shall provide the member or, if the member is a minor, the member's parent a written notice that:

1. Informs the member that the member is no longer eligible for CRS, and

2. Complies with A.R.S. § 41-1092.03.

G. At any time, a member or, if the member is a minor, the member's parent may request a redetermination of the member's payment responsibility by submitting to the Department:

1. A written request for redetermination, and

2. The documentation and information in R9-7-304(10).

H. Within 30 calendar days from the date of the Department's receipt of a member's request for redetermination, the Department shall provide the member or, if the member is a minor, the member's parent:

1. A written notice of the Department's redetermination;

2. A new CRS expiration date for the member; and

3. If applicable, a revised payment agreement.

I. If the Department changes a member's payment responsibility as a result of a redetermination, and the member does not have Title XIX or Title XXI health care insurance, the member or, if the member is a minor, the member's parent shall sign and submit a revised payment agreement.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-306. Termination of Enrollment

A. The Department shall terminate a member's enrollment if:

1. The Department determines the member no longer meets the eligibility requirements in R9-7-201;

2. A member does not continue to have Title XIX or Title XXI health care insurance while the member is eligible for the Title XIX or Title XXI health care insurance; or

3. The member or, if the member is a minor, the member's parent:

a. Requests a termination of the member's enrollment; or

b. Fails to comply with the:

i. Submission requirements in R9-7-302(I) or R9-7-305; or

ii. Signed payment agreement in R9-7-601(B), if applicable.

B. If the Department terminates a member's enrollment, the Department shall:

1. Provide the member or, if the member is a minor, the member's parent a written notice of termination that complies with A.R.S. § 41-1092.03; and

2. If the Department has the name of the member's physician other than a CRS provider, provide the member's physician a written notice of the member's termination.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

ARTICLE 4. COVERED MEDICAL SERVICES

Article 4, consisting of Sections R9-7-401 through R9-7-421, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-401. General Requirements

A. The Department shall not provide covered medical services other than an initial evaluation until the individual and, if the individual is a minor, the individual's parent comply with the application requirements in R9-7-302(B) and the Department determines that the individual meets the eligibility requirements in R9-7-201.

B. The Department shall provide a covered service in this Section:

1. Through a regional contractor,

2. At the regional contractor's facility or a facility under contract with the regional contractor; and

3. Using a CRS provider.

C. The Department shall provide a medical service in R9-7-403 through R9-7-421 to a member if:

1. A regional medical director or the regional medical director's designee determines that the medical service:

a. Is medically necessary;

b. Is related to the member's CRS condition; and

c. Except as provided in subsection (D), is not to treat one of the conditions in R9-7-203; and

2. A CRS provider obtains prior authorization, if applicable according to R9-7-402, for the medical service.

D. If the requirements of subsection (C) are met, the Department shall provide a medical service to a member to treat the following medical conditions:

1. Sinusitis for a member with cystic fibrosis;

2. An ingrown toenail if secondary to a CRS condition;

3. Strabismus for a member with cerebral palsy, myelomeningocele, a shunt, a cataract, glaucoma, a disorder of the optic nerve, retinopathy of prematurity, or a disorder of the iris, ciliary bodies, retina, lens or cornea;

4. Enuresis if secondary to a CRS condition;

5. Otitis media in a member with cleft lip and cleft palate or a sensorineural hearing loss;

6. Nasal polyps for a member with cystic fibrosis;

7. Malabsorption syndrome for a member with cystic fibrosis;

8. Nephritis associated with lupus erythematosis;

9. Hydrocele associated with a ventriculo-peritoneal (VP) shunt;

10. A fracture caused by a CRS condition;

11. Bunions if secondary to a CRS condition;

12. Carpal tunnel syndrome if secondary to a CRS condition;

13. Refraction error for a member with an ophthalmologic CRS condition;

14. Astigmatism for a member with an ophthalmologic CRS condition; or

15. With medication for no more than 30 calendar days, depression secondary to a CRS condition.

E. If a member requires a medical service that meets the requirements of subsection (C) and the medical service is not available in Arizona, the Department shall provide the medical service in another state if:

1. Two physicians, who are CRS providers, practicing a specialty related to the member's CRS condition, each submit in writing to the Department:

a. A recommendation that the Department provide the medical service in another state; and

b. A statement that:

i. The medical service is life-saving for the member, and

ii. The member is anticipated to experience, as a result of the medical service, functional improvement and that the physician expects the functional improvement to be significant; and

2. A regional medical director and a regional contractor provide written authorization to the Department before the provision of the medical service outside the state of Arizona.

F. If the Department provides a member a medical service in another state, the Department shall not provide transportation or lodging for the member or the member's family.

G. If a member receives a recommendation for treatment from a CRS provider, the member may obtain a recommendation for treatment from a second CRS provider.

H. The Department shall provide the following medical services to a member beyond the limit specifically stated in the applicable subsection if approved by a regional medical director:

1. Home health services in R9-7-406(B),

2. Oxygen and related supplies in R9-7-408(G),

3. Nutrition services in R9-7-410(A),

4. Physical therapy and occupational therapy in R9-7-413,

5. Psychological services in R9-7-416(A),

6. Psychiatric services in R9-7-417(A), and

7. Speech/language pathology services in R9-7-419.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-402. Prior Authorization

Except in an emergency, a CRS provider shall obtain prior authorization before providing any of the following to a member:

1. Medical equipment in R9-7-408,

2. Prosthetic and orthotic devices in R9-7-415,

3. Physician services in R9-7-414 provided at a physician's office,

4. Dental services in R9-7-404 provided at a dentist's office,

5. Outpatient diagnostic testing and laboratory services in R9-7-411(2) not provided by a CRS provider,

6. Outpatient surgery in R9-7-411(1),

7. An outpatient positive emission tomography scan,

8. An implantable bone conduction device in R9-7-403(B)(7),

9. A tactile hearing aid in R9-7-403(B)(8), and

10. Admission to a hospital for inpatient services in R9-7-407.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-403. Audiology Services

A. If the requirements of R9-7-401(C) are met, the Department shall provide audiology services to a member who has, as determined by a CRS provider, a:

1. Hearing impairment, or

2. CRS condition that poses a risk for hearing impairment.

B. If the requirements in subsection (A) are met, the Department shall provide the following audiology services:

1. A hearing screening;

2. A hearing evaluation;

3. Audiometric testing;

4. The selection, fitting, and dispensing of hearing aids;

5. After the hearing evaluation in subsection (B)(2), a follow-up hearing evaluation;

6. A replacement hearing aid once every three years, or sooner if the replacement hearing aid is for a member who:

a. Experiences a change in hearing level, as determined by a CRS provider;

b. Has a hearing aid stolen and submits to the Department a copy of a police report about the theft; or

c. Loses a hearing aid, and the Department has not replaced the hearing aid within the previous 12 months due to loss;

7. An implantable bone conduction device; and

8. A tactile hearing aid.

C. The Department shall not provide a cochlear implant to a member.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-404. Dental and Orthodontia Services

A. If the requirements of R9-7-401(C) are met, the Department shall provide dental services to a member who has one of the following medical conditions:

1. A cleft lip;

2. A cleft palate;

3. A cerebral spinal fluid diversion shunt at risk for subacute bacterial endocarditis;

4. A cardiac condition that causes the member to be at risk for subacute bacterial endocarditis;

5. Dental complications that are a result of treatment for a CRS condition; or

6. A functional malocclusion causing:

a. Mastication and swallowing abnormalities that affect the nutritional status of the individual, resulting in growth abnormalities;

b. A respiratory problem that restricts the member's breathing, such as dynamic or static airway obstruction; or

c. A communication disorder that cannot be further improved by speech therapy alone and that does not have a primary etiology other than the malocclusion, as determined by a CRS provider.

B. If the requirements of R9-7-401(C) are met, the Department shall provide orthodontia services and devices to a member who has one of the following medical conditions:

1. A cleft palate; or

2. A functional malocclusion causing:

a. Mastication and swallowing abnormalities that affect the nutritional status of the individual, resulting in growth abnormalities;

b. A respiratory problem that restricts the member's breathing, such as dynamic or static airway obstruction; or

c. A communication disorder that cannot be further improved by speech therapy alone and that does not have a primary etiology other than the malocclusion, as determined by a CRS provider.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-405. Diagnostic Testing and Laboratory Services

A. If the requirements of R9-7-401(C) are met, the Department shall provide the following diagnostic testing to a member:

1. Radiology,

2. Visual evoked response,

3. Computed tomography scan,

4. Ultrasound,

5. Brainstem auditory evoked response,

6. Magnetic resonance imaging,

7. Electroencephalogram,

8. Electrocardiogram, and

9. Echocardiogram.

B. If the requirements of R9-7-401(C) are met, the Department shall provide the following laboratory services to a member:

1. A blood bank, accessible to the member,

2. Pulmonary function testing,

3. Complete blood counts, and

4. Urinalysis.

C. The Department shall provide diagnostic testing and laboratory services, as ordered by a physician, to a member to determine if the member has a CRS condition in addition to the CRS condition diagnosed at the member's initial evaluation.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-406. Home Health Services

A. If the requirements in R9-7-401(C) are met, the Department shall provide total parenteral nutrition to a member for no more than 30 calendar days before the member's hospitalization for surgery related to the member's CRS condition.

B. If the requirements in R9-7-401(C) are met, the Department shall provide home health services to a member after the member's hospitalization:

1. If a CRS provider requests that the home health services be provided where the member is located;

2. If the need for home health services is related to the member's CRS condition that was treated during the member's hospitalization; and

3. Except as provided in R9-7-401(G) for no more than 30 calendar days.

C. If the requirements in subsection (B) are met, the Department shall provide the following home health services:

1. An evaluation of the member's need for home health services,

2. Intravenous therapy,

3. Wound care,

4. Administration of medications,

5. Monitoring the member's vital signs to determine whether the member's vital signs are within the range established as acceptable for the member by a CRS provider,

6. Monitoring oxygen administration to determine whether the member's breathing is within the range established as acceptable for the member by a CRS provider,

7. Physical therapy,

8. Occupational therapy,

9. Enterostomy care,

10. Urethral catheter insertion and care, and

11. Instruction for the provision of home health services to the member or the member's caregivers.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-407. Inpatient Services

A. If the requirements in R9-7-401(C) are met, the Department shall provide inpatient services to a member who requires hospitalization related to the member's CRS condition.

1. If a member's hospitalization is no longer related to the member's CRS condition, the Department shall not provide inpatient services to the member.

2. If a member requires inpatient services to determine whether the member has ventricular infection or ventricular shunt failure, the Department shall provide inpatient services until the date the regional medical director or the regional medical director's designee determines that the member does not have ventricular infection or ventricular shunt failure.

B. If the requirements in R9-7-401(C) are met, the Department shall provide transportation for a member from one hospital that is a CRS provider to another hospital that is a CRS provider if:

1. Ordered by a CRS provider, and

2. Authorized in writing by a regional medical director.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-408. Medical Equipment

A. If the requirements of R9-7-401(C) are met and subject to the limitations in subsections (B) through (D), the Department shall provide a non-motorized wheelchair or an ambulation assistive device to a member.

B. The Department shall provide a tilt-in-space wheelchair to a member only if a change in the member's position is necessary to provide medically necessary services such as tracheotomy care or feeding.

C. The Department shall not provide a member with:

1. A wheelchair or an ambulation assistive device if the wheelchair or ambulation assistive device