TITLE 9. HEALTH SERVICES

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended effective June 6, 1989 (Supp. 89-2). Amended effective July 13, 1992 (Supp. 92-3). Amended effective November 5, 1993 (Supp. 93-4). Section repealed; new Section adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 5 A.A.R. 369, effective January 6, 1999 (Supp. 99-1). Amended by final rulemaking at 5 A.A.R. 874, effective March 4, 1999 (Supp. 99-1). Subsection (A)(69) amended to correct a printing error, filed in the Office of the Secretary of State August 13, 1999 (Supp. 99-3). Amended by final rulemaking at 6 A.A.R. 200, effective December 13, 1999 (Supp. 99-4). Amended by final rulemaking at 6 A.A.R. 2461, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 6 A.A.R. 3365, effective August 7, 2000 (Supp. 00-3). Amended by exempt rulemaking at 7 A.A.R. 4691, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 444, effective January 10, 2002 (Supp. 02-1). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 8 A.A.R. 3340, effective July 15, 2002 (Supp. 02-3). Amended by final rulemaking at 9 A.A.R. 3810, effective October 4, 2003 (Supp. 03-3). Amended by final rulemaking at 10 A.A.R. 1312, effective May 1, 2004 (Supp. 04-1). Amended by final rulemaking at 11 A.A.R. 3165, effective October 1, 2005 (Supp. 05-3). Amended by final rulemaking at 11 A.A.R. 4286, effective December 5, 2005 (Supp. 05-4). Amended by final rulemaking at 13 A.A.R. 1090, effective May 5, 2007 (Supp. 07-1).

R9-28-102. Covered Services Related Definitions

Definitions. The following words and phrases, in addition to definitions contained in A.R.S. §§ 36-2901 and 36-2931, and 9 A.A.C. 22, Article 1, have the following meanings unless the context of the Chapter explicitly requires another meaning:

"Bed hold" means a 24 hour per day unit of service that is authorized by an ALTCS case manager or designee during a period of short-term hospitalization or therapeutic leave that meets the requirement specified in 42 CFR 483.12.

"Behavior intervention" means the planned interruption of a member's inappropriate behavior using techniques such as reinforcement, training, behavior modification, and other systematic procedures intended to result in more acceptable behavior.

"Respite care" means a short-term service provided in a NF or a home and community based service setting to an individual if necessary to relieve a family member or other person caring for the individual.

"Room and board" means lodging and meals.

"Scope of services" means the covered, limited, and excluded services under Articles 2 and 12 of this Chapter.

"Ventilator dependent," for purposes of ALTCS eligibility, means an individual is medically dependent on a ventilator for life support at least six hours per day and has been dependent on ventilator support as an inpatient in a hospital, NF, or ICF-MR for at least 30 consecutive days.

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 2461, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 9 A.A.R. 3810, effective October 4, 2003 (Supp. 03-3).

R9-28-103. Preadmission Screening Related Definitions

Definitions. The following words and phrases, in addition to definitions contained in A.R.S. §§ 36-2901 and 36-2931, and 9 A.A.C. 22, Article 1, have the following meanings unless the context of the Chapter explicitly requires another meaning:

"Developmental disability" is defined in A.R.S. § 36-551.

"PAS" means preadmission screening, which is the process of determining an individual's risk of institutionalization at a NF or ICF-MR level of care, as specified in Article 3 of this Chapter.

"Reassessment" means the process of redetermining PAS eligibility for ALTCS services as appropriate, for all members.

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 2461, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 9 A.A.R. 3810, effective October 4, 2003 (Supp. 03-3). Amended by final rulemaking at 10 A.A.R. 1312, effective May 1, 2004 (Supp. 04-1).

R9-28-104. Eligibility and Enrollment Related Definitions

Definitions. The following words and phrases, in addition to definitions contained in A.R.S. §§ 36-2901 and 36-2931, and 9 A.A.C. 22, Article 1, have the following meanings unless the context of the Chapter explicitly requires another meaning:

"211" is defined in 42 CFR 435.211.

"217" is defined in 42 CFR 435.217.

"236" is defined in 42 CFR 435.236.

"Algorithm" means a mathematical formula used by the Administration to assign a member to an EPD program contractor when the member does not make a choice and does not meet the assignment-decision process.

"ALTCS acute care services" means services, under 9 A.A.C. 22, Articles 2 and 12, that are provided to a person who meets ALTCS eligibility requirements in 9 A.A.C. 28, Article 4 but who lives in an acute care living arrangement described in R9-28-406 or who is not eligible for long-term care benefits, described in R9-28-409, due to a transfer under R9-28-409 without receiving fair consideration.

"Community spouse" means the husband or wife of an institutionalized person who has entered into a contract of marriage, recognized as valid by Arizona, and who does not live in a medical institution.

"CSRD" means Community Spouse Resource Deduction, the amount of a married couple's resources that are excluded in the eligibility determination to prevent impoverishment of the community spouse, determined under R9-28-410.

"Fair consideration" means income, real or personal property, services, or support and maintenance equal to the fair market value of the income or resources that were transferred.

"Institutionalized" means residing in a medical institution or receiving or expecting to receive HCBS that prevent the person from being placed in a medical institution determined by the PAS under R9-28-103.

"Medically eligible" means meeting the ALTCS medical eligibility criteria under 9 A.A.C. 28, Article 3.

"MMMNA" means Minimum Monthly Maintenance Needs Allowance.

"Redetermination" means a periodic review of all eligibility factors for a recipient.

"Representative" means a person other than a spouse or a parent of a dependent child, who applies for ALTCS on behalf of another person.

"Spouse" means a person legally married under Arizona law, a person eligible for Social Security benefits as the spouse of another person, or a person living with another person of the opposite sex and the couple represents themselves in the community as husband and wife.

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended effective November 4, 1998 (Supp. 98-4). Section repealed, new Section adopted by final rulemaking at 5 A.A.R. 369, effective January 6, 1999 (Supp. 99-1). Amended by final rulemaking at 6 A.A.R. 896, effective February 8, 2000 (Supp. 00-1). Amended by final rulemaking at 6 A.A.R. 2461, effective June 9, 2000 (Supp. 00-2).

R9-28-105. Repealed

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 896, effective February 8, 2000 (Supp. 00-1). Section repealed by final rulemaking at 11 A.A.R. 4286, effective December 5, 2005 (Supp. 05-4).

R9-28-106. Request for Proposals and Contract Process Related Definitions

Definitions. The following words and phrases, in addition to definitions contained in A.R.S. §§ 36-2901 and 36-2931, and 9 A.A.C. 22 Article 1, have the following meanings unless the context of the Chapter explicitly requires another meaning: "Interested Party" means an actual or prospective offeror whose economic interest may be affected substantially and directly by the issuance of a request for proposals, the award of a contract, or the failure to award a contract.

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 896, effective February 8, 2000 (Supp. 00-1).

R9-28-107. Repealed

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended effective November 4, 1998 (Supp. 98-4). Amended by final rulemaking at 6 A.A.R. 2461, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 9 A.A.R. 3810, effective October 4, 2003 (Supp. 03-3). Section repealed by final rulemaking at 11 A.A.R. 3165, effective October 1, 2005 (Supp. 05-3).

R9-28-108. Repealed

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 3365, effective August 7, 2000 (Supp. 00-3). Section repealed by final rulemaking at 10 A.A.R. 820, effective April 3, 2004 (Supp. 04-1).

R9-28-109. Repealed

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Section repealed by final rulemaking at 10 A.A.R. 1308, effective May 1, 2004 (Supp. 04-1).

R9-28-110. Reserved

R9-28-111. Behavioral Health Services Related Definitions

Definitions. The words and phrases in this Chapter, in addition to definitions contained in A.R.S. §§ 36-2901 and 36-2931, have the same meaning as specified in 9 A.A.C. 22, Article 1.

Historical Note

Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 200, effective December 13, 1999 (Supp. 99-4).

ARTICLE 2. COVERED SERVICES

R9-28-201. General Requirements

In addition to the exclusions and limitations specified in this Article, services provided to a member are covered services if:

1. Medically necessary, cost effective, and federally reimbursable;

2. Coordinated by a case manager in accordance with requirements specified in R9-28-510;

3. The provider obtains prior authorization as required by a member's program contractor or by the Administration:

a. Failure of the provider to obtain prior authorization is cause for denial.

b. Services provided during prior period coverage are exempt from prior authorization requirements;

4. Provided in facilities or areas of facilities that are licensed or certified under Article 5 of this Chapter, or meet other requirements described in Article 5 of this Chapter;

5. Rendered by AHCCCS registered providers as permitted under this Chapter and within their scope of practice; and

6. Provided at an appropriate level of care, as determined by the case manager or the primary care provider.

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Section repealed; new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2).

R9-28-202. Medical Services

The Administration or a contractor shall cover medical services specified in 9 A.A.C. 22, Article 2 for a member, subject to the limitations and exclusions specified in Article 2, unless otherwise specified in this Chapter.

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended effective June 6, 1989 (Supp. 89-2). Amended under an exemption from the provisions of the Administrative Procedure Act effective March 22, 1993; received in the Office of the Secretary of State March 24, 1993 (Supp. 93-1). Amended effective November 5, 1993 (Supp. 93-4). Section repealed; new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2).

R9-28-203. Repealed

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended effective June 6, 1989 (Supp. 89-2). Amended effective July 13, 1992 (Supp. 92-3). Amended under an exemption from the provisions of the Administrative Procedure Act effective March 22, 1993; received in the Office of the Secretary of State March 24, 1993 (Supp. 93-1). Repealed effective September 22, 1997 (Supp. 97-3).

R9-28-204. Institutional Services

A. Institutional services are provided in:

1. A NF;

2. An ICF-MR; or

3. A facility identified in R9-28-1105(A)(1)(b), (B), or (C).

B. The Administration and a contractor shall include the following services in the per diem rate for a facility listed in subsection (A):

1. Nursing care services;

2. Rehabilitative services prescribed as a maintenance regimen;

3. Restorative services, such as range of motion;

4. Social services;

5. Nutritional and dietary services;

6. Recreational therapies and activities;

7. Medical supplies and non-customized durable medical equipment under 9 A.A.C. 22, Article 2;

8. Overall management and evaluation of a member's care plan;

9. Observation and assessment of a member's changing condition;

10. Room and board services, including supporting services such as food and food preparation, personal laundry, and housekeeping;

11. Non-prescription and stock pharmaceuticals; and

12. Respite care services not to exceed 30 days per contract year.

C. Each facility listed in subsection (A) is responsible for coordinating the delivery of at least the following auxiliary services:

1. Under 9 A.A.C. 22, Article 2:

a. Attending physician, practitioner, and primary care provider services;

b. Pharmaceutical services;

c. Diagnostic services under A.A.C. R9-22-208;

d. Emergency medical services; and

e. Emergency and medically necessary transportation services.

2. Therapy services under R9-28-206.

D. Limitations. The following limitations apply:

1. A private room in a NF, ICF-MR, or facility identified in R9-28-1105(A)(1)(b), (B), or (C) is covered only if:

a. The member or has a medical condition that requires isolation, and

b. The member's primary care provider or attending physician provides written authorization;

2. Each ICF-MR shall meet the standards in A.R.S. § 36-2939(B)(1), and in 42 CFR 483, Subpart I, February 28, 1992, incorporated by reference and on file with the Administration and the Office of the Secretary of State. This incorporation by reference contains no future editions or amendments;

3. Bed hold days as authorized by the Administration or its designee for a fee-for-service provider shall meet the following criteria:

a. Short-term hospitalization leave for a member age 21 and over is limited to 12 days per AHCCCS contract year, and is available if a member is admitted to a hospital for a short stay. After the short-term hospitalization, the member is returned to the institutional facility from which leave is taken, and to the same bed if the level of care required can be provided in that bed; and

b. Therapeutic leave for a member age 21 and older is limited to nine days per AHCCCS contract year. A physician order is required for therapeutic leave from the facility for one or more overnight stays to enhance psycho-social interaction, or as a trial basis for discharge planning. After the therapeutic leave, the member is returned to the same bed within the institutional facility;

c. Therapeutic leave and short-term hospitalization leave are limited to any combination of 21 days per contract year for a member under age 21;

4. The Administration or a contractor shall cover services that are not part of a per diem rate but are ALTCS covered services included in this Article, and deemed necessary by a member's case manager or the case manager's designee if:

a. The services are ordered by the member's primary care provider; and

b. The services are specified in a case management plan under R9-28-510;

5. A member age 21 through 64 is eligible for behavioral health services provided in a facility under subsection (A)(3) that has more than 16 beds, for up to 30 days per admission and no more than 60 days per contract year as allowed under the Administration's Section 1115 Waiver with CMS and except as specified by 42 CFR 441.151, May 22, 2001, incorporated by reference and on file with the Administration and the Office of the Secretary of State. This incorporation by reference contains no future editions or amendments; and

6. The limitations in subsection (D)(5) do not apply to a member:

a. Under age 21 or age 65 or over, or

b. In a facility with 16 beds or less.

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended subsections (A) and (D) effective June 6, 1989 (Supp. 89-2). Amended effective November 5, 1993 (Supp. 93-4). Section repealed; new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by exempt rulemaking at 7 A.A.R. 4691, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2).

R9-28-205. Home and Community Based Services (HCBS)

A. Subject to the availability of federal funds, HCBS are covered services if provided to a member residing in the member's own home or an alternative residential setting. Room and board services are not covered in a HCBS setting.

B. The case manager shall authorize and specify in a case management plan any additions, deletions, or changes in home and community based services provided to a member or in accordance with R9-28-510.

C. Home and community based services include the following:

1. Home health services provided on a part-time or intermittent basis. These services include:

a. Nursing care;

b. Home health aide;

c. Medical supplies, equipment, and appliances;

d. Physical therapy;

e. Occupational therapy;

f. Respiratory therapy; and

g. Speech and audiology services;

2. Private duty nursing services;

3. Medical supplies and durable medical equipment, including customized DME, as described in 9 A.A.C. 22, Article 2;

4. Transportation services to obtain covered medically necessary services;

5. Adult day health services provided to a member in an adult day health care facility licensed under 9 A.A.C. 10, Article 5, including:

a. Supervision of activities specified in the member's care plan;

b. Personal care;

c. Personal living skills training;

d. Meals and health monitoring;

e. Preventive, therapeutic, and restorative health related services; and

f. Behavioral health services, provided either directly or through referral, if medically necessary;

6. Personal care services;

7. Homemaker services;

8. Home delivered meals, that provide at least one-third of the recommended dietary allowance, for a member who does not have a developmental disability under A.R.S. § 36-551;

9. Respite care services for no more than 720 hours per contract year;

10. Habilitation services including:

a. Physical therapy;

b. Occupational therapy;

c. Speech and audiology services;

d. Training in independent living;

e. Special development skills that are unique to the member;

f. Sensory-motor development;

g. Behavior intervention; and

h. Orientation and mobility training;

11. Developmentally disabled day care provided in a group setting during a portion of a 24-hour period, including:

a. Supervision of activities specified in the member's care plan;

b. Personal care;

c. Activities of daily living skills training; and

d. Habilitation services; and

12. Supported employment services provided to a member in the ALTCS transitional program under R9-28-306 who is developmentally disabled under A.R.S. § 36-551.

Historical Note

Adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2).

R9-28-206. ALTCS Services that may be Provided to a Member Residing in either an Institutional or HCBS Setting

The Administration shall cover the following services if the services are provided to a member within the limitations listed:

1. Occupational and physical therapies, speech and audiology services, and respiratory therapy:

a. The duration, scope, and frequency of each therapeutic modality or service is prescribed by the member's primary care provider or attending physician;

b. The therapy or service is authorized by the member's contractor or the Administration; and

c. The therapy or service is included in the member's case management plan.

2. Medical supplies, durable medical equipment, and customized durable medical equipment, which conform with the requirements and limitations of 9 A.A.C. 22, Article 2;

3. Ventilator dependent services:

a. Inpatient or institutional services are limited to services provided in a general hospital, special hospital, NF, or ICF-MR. Services provided in a general or special hospital are included in the hospital's unit tier rate under 9 A.A.C. 22, Article 7;

b. A ventilator dependent member may receive the array of home and community based services under R9-28-205 as appropriate.

4. Hospice services:

a. Hospice services are covered only for a member who is in the final stages of a terminal illness and has a prognosis of death within six months;

b. Covered hospice services for a member are those allowable under 42 CFR 418.202, December 20, 1994, incorporated by reference and on file with the Administration and the Office of the Secretary of State. This incorporation by reference contains no future editions or amendments; and

c. Covered hospice services do not include:

i. Medical services provided that are not related to the terminal illness; or

ii. Home delivered meals.

d. Medicare is the primary payor of hospice services for a member if applicable.

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended effective June 6, 1989 (Supp. 89-2). Amended effective July 13, 1992 (Supp. 92-3). Amended effective November 5, 1993 (Supp. 93-4). Section repealed; new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2).

ARTICLE 3. PREADMISSION SCREENING (PAS)

R9-28-301. Definitions

A. Common definitions. In addition to definitions contained in A.R.S. Title 36, Chapter 29, and 9 A.A.C. 28, Article 1, the words and phrases in this Article have the following meanings for an individual who is elderly or physically disabled (EPD) or developmentally disabled (DD) unless the context explicitly requires another meaning:

"Applicant" is defined in A.A.C. R9-22-101.

"Assessor" means a social worker as defined in this subsection or a licensed registered nurse (RN) who:

Is employed by the Administration to conduct PAS assessments,

Completes a minimum of 30 hours of classroom training in both EPD and DD PAS for a total of 60 hours, and

Receives intensive oversight and monitoring by the Administration during the first 30 days of employment and ongoing oversight by the Administration during all periods of employment.

"Current" means belonging to the present time.

"Disruptive behavior" means inappropriate behavior by the applicant or member including urinating or defecating in inappropriate places, sexual behavior inappropriate to time, place, or person or excessive whining, crying, or screaming that interferes with an applicant's or member's normal activities or the activities of others and requires intervention to stop or interrupt the behavior.

"Frequency" means the number of times a specific behavior occurs within a specified interval.

"Functional assessment" means an evaluation of information about an applicant's or member's ability to perform activities related to:

Developmental milestones,

Activities of daily living,

Communication, and

Behavior.

"Immediate risk of institutionalization" means the status of an applicant or member under A.R.S. § 36-2934(A)(5) and as specified in A.R.S. § 36-2936 and in the Administration's Section 1115 Waiver with Centers for Medicare and Medicaid Services (CMS).

"Intervention" means therapeutic treatment, including the use of medication, behavior modification, and physical restraints to control behavior. Intervention may be formal or informal and includes actions taken by friends or family to control the behavior.

"Limited or occasional" means a small portion of an entire task or assistance for the task if the assistance is required less than daily.

"Medical assessment" means an evaluation of an applicant's or member's medical condition and the applicant's or member's need for medical services.

"Medical or nursing services and treatments" or "services and treatments" means specific, ongoing medical, psychiatric, or nursing intervention used actively to resolve or prevent deterioration of a medical condition. Durable medical equipment and activities of daily living assistive devices are not treatment unless the equipment or device is used specifically and actively to resolve the existing medical condition.

"Physical participation" means an applicant's or member's active participation.

"Physically lift" means actively bearing some part of an applicant's or member's weight during movement or activity and excludes bracing or guiding activity.

"Physician consultant" means a physician who contracts with the Administration.

"Social worker" means an individual with two years of case management-related experience or a baccalaureate or master's degree in:

Social work,

Rehabilitation,

Counseling,

Education,

Sociology,

Psychology, or

Other closely related field.

"Special diet" means a diet planned by a dietitian, nutritionist, or nurse that includes high fiber, low sodium, or pureed food.

"Toileting" means the process involved in an applicant's or member's managing of the elimination of urine and feces in an appropriate place.

"Vision" means the ability to perceive objects with the eyes.

B. EPD. In addition to definitions contained in subsection (A), the following also apply to an applicant or member who is EPD:

"Aggression" means physically attacking another, including:

Throwing an object,

Punching,

Biting,

Pushing,

Pinching,

Pulling hair,

Scratching, and

Physically threatening behavior.

"Bathing" means the process of washing, rinsing, and drying all parts of the body, including an applicant's or member's ability to transfer to a tub or shower and to obtain bath water and equipment.

"Continence" means the applicant's or member's ability to control the discharge of body waste from bladder and bowel.

"Dressing" means the physical process of choosing, putting on, securing fasteners, and removing clothing and footwear. Dressing includes choosing a weather-appropriate article of clothing but excludes aesthetic concerns. Dressing includes the applicant's or member's ability to put on artificial limbs, braces, and other appliances that are needed daily.

"Eating" means the process of putting food and fluids by any means into the digestive system.

"Elderly" means an applicant or member who is age 65 or older.

"Emotional and cognitive functioning" means an applicant's or member's orientation and mental state, as evidenced by aggressive, self-injurious, wandering, disruptive, and resistive behaviors.

"EPD" means an applicant or member who is elderly and physically disabled.

"Grooming" means an applicant's or member's process of tending to appearance. Grooming includes: combing or brushing hair; washing face and hands; shaving; oral hygiene (including denture care); and menstrual care. Grooming does not include aesthetics such as styling hair, skin care, nail care, and applying cosmetics.

"Mobility" means the extent of an applicant's or member's purposeful movement within a residential environment.

"Orientation" means an applicant's or member's awareness of self in relation to person, place, and time.

"Physically disabled" means an applicant or member who is determined physically impaired by the Administration through the PAS assessment as allowed under the Administration's Section 1115 Waiver with CMS.

"Resistiveness" means inappropriately obstinate and uncooperative behaviors, including passive or active obstinate behaviors, or refusing to participate in self-care or to take necessary medications. Resistiveness does not include difficulties with auditory processing or reasonable expressions of self-advocacy.

"Self-injurious behavior" means repeated self-induced, abusive behavior that is directed toward infliction of immediate physical harm to the body.

"Sensory" means of or relating to the senses.

"Transferring" means an applicant's or member's ability to move horizontally or vertically between two surfaces within a residential environment, excluding transfer for toileting or bathing.

"Wandering" means an applicant's or member's moving about with no rational purpose and with a tendency to go beyond the physical parameter of the residential environment.

C. DD. In addition to definitions contained in subsection (A), the following also apply to an applicant or member who is DD:

"Acute" means an active medical condition having a sudden onset, lasting a short time, and requiring immediate medical intervention.

"Aggression" means physically attacking another, including:

Throwing objects,

Punching,

Biting,

Pushing,

Pinching,

Pulling hair, and

Scratching.

"Ambulation" means the ability to walk and includes quality of the walking and the degree of independence in walking.

"Associating time with an event and an action" means an applicant's or member's ability to associate a regular event with a specific time-frame.

"Bathing or showering" means an applicant's or member's ability to complete the bathing process including drawing the bath water, washing, rinsing, and drying all parts of the body, and washing the hair.

"Caregiver training" means training received by a direct-care staff person or caregiver for special health care procedures that are normally performed or monitored by a licensed professional, such as a registered nurse. These procedures may include ostomy care, positioning for medical necessity, use of an adaptive device, or respiratory services such as suctioning or a small volume nebulizer treatment.

"Chronic" means a medical condition that is always present, occurs periodically, or is marked by a long duration.

"Clarity of communication" means an ability to speak in recognizable language or use a formal symbolic substitution, such as American-Sign Language.

"Climbing stairs or a ramp" means an applicant's or member's ability to move up and down stairs or a ramp.

"Community mobility" means the applicant's or member's ability to move about a neighborhood or community independently, by any mode of transportation.

"Crawling and standing" means an applicant's or member's ability to crawl and stand with or without support.

"DD" means developmentally disabled.

"Developmental milestone" means a measure of an applicant's or member's functional abilities, including:

Fine and gross motor skills,

Expressive and receptive language,

Social skills,

Self-help skills, and

Emotional or affective development.

"Dressing" means the ability to put on and remove an article of clothing. Dressing does not include the ability to put on or remove braces nor does it reflect an applicant's or member's ability to match colors or choose clothing appropriate for the weather.

"Eating or drinking" means the process of putting food and fluid by any means into the digestive system.

"Expressive verbal communication" means an applicant's or member's ability to communicate thoughts with words or sounds.

"Food preparation" means the ability to prepare a simple meal including a sandwich, cereal, or a frozen meal.

"Hand use" means the applicant's or member's ability to use both hands, or one hand if an applicant or member has only one hand or has the use of only one hand.

"History" means a medical condition that occurred in the past, regardless of whether the medical condition required treatment in the past, and is not now active.

"Personal hygiene" means the process of tending to one's appearance. Personal hygiene may include: combing or brushing hair, washing face and hands, shaving, performing routine nail care, oral hygiene including denture care, and menstrual care. This does not include aesthetics such as styling hair, skin care, and applying cosmetics.

"Physical interruption" means immediate hands-on interaction to stop a behavior.

"Remembering an instruction and demonstration" means an applicant's or member's ability to recall an instruction or demonstration on how to complete a specific task.

"Resistiveness or rebelliousness" means an applicant's or member's inappropriate, stubborn, or uncooperative behavior. Resistiveness or rebelliousness does not include an applicant's or member's difficulty with processing information or reasonable expression of self-advocacy that includes an applicant's or member's expression of wants and needs.

"Rolling and sitting" means an applicant's or member's ability to roll and sit independently or with the physical support of another person or with a device such as a pillow or specially-designed chair.

"Running or wandering away" means an applicant or member leaving a physical environment without notifying or receiving permission from the appropriate individuals.

"Self-injurious behavior" means an applicant's or member's repeated behavior that causes injury to the applicant or member.

"Verbal or physical threatening" means any behavior in which an applicant or member uses words, sounds, or action to threaten harm to self, others, or an object.

"Wheelchair mobility" means an applicant's or member's mobility using a wheelchair and does not include the ability to transfer to the wheelchair.

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended subsection (C) effective June 6, 1989 (Supp. 89-2). Amended effective July 13, 1992 (Supp. 92-3). Amended effective November 5, 1993 (Supp. 93-4). Section repealed by emergency action, new Section adopted by emergency action, subsection (A) effective June 30, 1995, subsection (B) effective September 1, 1995, pursuant to A.R.S. § 41-1026, valid for 180 days; entire Section filed in the Secretary of State's Office June 30, 1995 (Supp. 95-2). Section repealed by emergency action, new Section adopted again by emergency action with changes effective January 2, 1996, pursuant to A.R.S. § 41-1026, valid for 180 days (Supp. 96-1). Emergency expired June 1, 1996. Section in effect before emergency action restored. Section repealed; new Section adopted effective January 14, 1997 (Supp. 97-1). Amended by final rulemaking at 7 A.A.R. 5824, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 12 A.A.R. 4007, effective October 5, 2006 (Supp. 06-4).

R9-28-302. General Provisions

To qualify for services described in A.R.S. § 36-2939:

1. An applicant shall meet the financial criteria described in Article 4, and

2. AHCCCS shall determine that the applicant is at immediate risk of institutionalization under the PAS assessment as specified in this Article.

Historical Note

New Section adopted by emergency action, subsection (A) effective June 30, 1995, subsection (B) effective September 1, 1995, pursuant to A.R.S. § 41-1026, valid for 180 days; entire Section filed in the Office of the Secretary of State June 30, 1995 (Supp. 95-2). New Section adopted again by emergency action with changes effective January 2, 1996, pursuant to A.R.S. § 41-1026 (Supp. 96-1). Emergency expired June 1, 1996. New Section adopted effective January 14, 1997 (Supp. 97-1). Amended by final rulemaking at 7 A.A.R. 5824, effective December 7, 2001 (Supp. 01-4).

R9-28-303. Preadmission Screening (PAS) Process

A. The assessor shall use the PAS instrument to determine whether the following applicants or members are at immediate risk of institutionalization:

1. The assessor shall use the PAS instrument prescribed in R9-28-304 to assess an applicant or member who is EPD except as specified in subsection (A)(2) for a physically disabled applicant or member who is less than six years old. After assessing a physically disabled child age six years to less than 12 years, the assessor shall refer the child for physician consultant review under R9-28-303.

2. The assessor shall use the age-specific PAS instrument prescribed in R9-28-305 to assess an applicant or member who is physically disabled and less than six years old. After assessing the child, the assessor shall refer the child for physician consultant review under this Section.

3. The assessor shall use the PAS instrument prescribed in R9-28-305 to assess an applicant or member who is DD, except as specified in subsection (A)(4) for an applicant or member who is DD and residing in a NF. After assessing a child who is DD and less than six months of age, the assessor shall refer the child for physician consultant review under subsections (G) through (H).

4. The assessor shall use the PAS instrument prescribed in R9-28-304 for an applicant or a member who is DD and residing in a NF.

5. The assessor shall use the PAS instrument prescribed in R9-28-304 or R9-28-305, whichever is applicable, to assess an applicant or member who is classified as ventilator-dependent, under Section 1902(e)(9) of the Social Security Act.

B. For an initial assessment of an applicant who is in a hospital or other acute care setting:

1. A registered nurse assessor shall complete the PAS assessment, or

2. In the event that a registered nurse assessor is not available, a social worker assessor shall complete the PAS assessment; and

3. The assessor shall conduct the PAS assessment and determine medical eligibility when discharge is scheduled within seven days.

C. An assessor shall conduct a face-to-face PAS assessment with an applicant or member, except as provided in subsection (F). The assessor shall make reasonable efforts to obtain the applicant's or member's available medical records. The assessor may also obtain information for the PAS assessment from face-to-face interviews with the:

1. Applicant or member,

2. Parent,

3. Guardian,

4. Caregiver, or

5. Any person familiar with the applicant's or member's functional or medical condition.

D. Using the information described in subsection (C), an assessor shall complete the PAS assessment based on the assessor's education, experience, professional judgment, and training.

E. After the assessor completes the PAS assessment, the assessor shall calculate a PAS score. The assessor shall compare the PAS score to an established threshold score. The scoring methodology and threshold scores are specified in R9-28-304 and R9-28-305. Except as determined by physician consultant review as provided in subsections (G) through (J), the threshold score is the point at which an applicant or member is determined to be at immediate risk of institutionalization.

F. Upon request, from a person acting on behalf of the applicant, the Administration shall conduct a PAS assessment to determine whether a deceased applicant who was residing in a NF or who received services in an ICF-MR any time during the time period covered by the application would have been eligible to receive ALTCS benefits for those months.

G. In the following circumstances, the Administration shall request that a physician consultant review the PAS assessment, the available medical records, and use professional judgment to make the determination that an applicant or member has a developmental disability or has a nonpsychiatric medical condition that, by itself or in combination with a medical condition, places an applicant or member at immediate risk of institutionalization:

1. The PAS score of an applicant or member who is EPD is less than the threshold specified in R9-28-304, but is at least 56;

2. The PAS score of an applicant or member who is DD is less than the threshold specified in R9-28-305, but is at least 38;

3. An applicant or member scores below the threshold specified in R9-28-304, but the Administration has reasonable cause to believe that the applicant's or member's unique functional abilities or medical condition may place the applicant or member at immediate risk of institutionalization;

4. An applicant or member scores below the threshold specified in R9-28-304 and has a documented diagnosis of autism, autistic-like behavior, or pervasive developmental disorder;

5. An applicant or member who is seriously mentally ill as defined in A.R.S. § 36-550 who scores at or above the threshold specified in R9-28-304, but may not meet the requirements of A.R.S. § 36-2936. When an applicant or member who is seriously mentally ill scores at or above the threshold, the physician consultant shall exercise professional judgment to determine whether the applicant or member meets the requirements of A.R.S. § 36-2936.

6. An applicant is an AHCCCS acute care member and scores at or above the threshold specified in R9-28-304 but the Administration has reasonable cause to believe that the applicant's condition is convalescent and requires less than 90 days of institutional care;

7. An applicant or member is a physically disabled child who is at least six but less than 12 years of age;

8. An applicant or member is a physically disabled child under six years of age; and

9. An applicant is under six months of age.

H. The physician consultant shall consider the following:

1. Activities of daily living dependence;

2. Delay in development;

3. Continence;

4. Orientation;

5. Behavior;

6. Any medical condition, including stability and prognosis of the condition;

7. Any medical nursing treatment provided to the applicant or member including skilled monitoring, medication, and therapeutic regimens;

8. The degree to which the applicant or member must be supervised;

9. The skill and training required of the applicant or member's caregiver; and

10. Any other factor of significance to the individual case.

I. If the physician consultant is unable to make the determination from the PAS assessment and the available medical records, the physician consultant may conduct a face-to-face review with the applicant or member or contact others familiar with the applicant's or member's needs, including a primary care physician or other caregiver, to make the determination.

J. The physician consultant shall state the reasons for the determination in the physician review comment section of the PAS instrument.

Historical Note

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended effective July 13, 1992 (Supp. 92-3). Amended under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1992, Ch. 301, § 61, effective July 1, 1993 (Supp. 93-3). Amended effective November 5, 1993 (Supp. 93-4). Section repealed by emergency action, new Section adopted by emergency action effective June 30, 1995, pursuant to A.R.S. § 41-1026, valid for 180 days (Supp. 95-2). Section repealed by emergency action, new Section adopted again by emergency action effective January 2, 1996, pursuant to A.R.S. § 41-1026, valid for 180 days (Supp. 96-1). Emergency expired June 1, 1996. Section in effect before emergency action restored. Section repealed; new Section adopted effective January 14, 1997 (Supp. 97-1). Former Section R9-28-303 renumbered to R9-28-304; new Section R9-28-303 made by final rulemaking at 7 A.A.R. 5824, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 12 A.A.R. 4007, effective October 5, 2006 (Supp. 06-4).

R9-28-304. Preadmission Screening Criteria for an Applicant or Member who is Elderly and Physically Disabled (EPD)

A. The PAS instrument for an applicant or member who is EPD includes the following categories:

1. Intake information category. The assessor solicits intake information category information on an applicant's or member's demographic background. The components of the intake information category are not included in the calculated PAS score.

2. Functional assessment category. The assessor solicits functional assessment category information on an applicant's or member's:

a. Need for assistance with activities of daily living, including:

i. Bathing,

ii. Dressing,

iii. Grooming,

iv. Eating,

v. Mobility,

vi. Transferring, and

vii. Toileting in the residential environment or other routine setting;

b. Communication and sensory skills, including hearing, expressive communication, and vision; and

c. Continence, including bowel and bladder functioning.

3. Emotional and cognitive functioning category. The assessor solicits emotional and cognitive functioning category information on an applicant's or member's:

a. Orientation to person, place, and time. In soliciting this information, the assessor shall also take into account the caregiver's judgment; and

b. Behavior, including:

i. Wandering,

ii. Self-injurious behavior,

iii. Aggression,

iv. Resistiveness, and

v. Disruptive behavior.

4. Medical assessment category. The assessor solicits medical assessment category information on an applicant's or member's:

a. Medical conditions that have an impact on the applicant's or member's functional ability in relation to activities of daily living, continence, and vision;

b. Medical condition that requires medical or nursing service and treatment;

c. Medication, treatment, and allergies;

d. Specific services and treatments that the applicant or member is currently receiving; and

e. Physical measurements, hospitalization history, and ventilator dependency.

B. The assessor shall use the PAS instrument to assess an applicant or member who is EPD as specified in this Section. A copy of the PAS instrument is available from the Administration. The Administration uses the assessor's PAS assessment to calculate three scores: a functional score, a medical score, and a total score.

1. Functional score.

a. The Administration calculates the functional score from responses to scored items in the functional assessment and emotional and cognitive functioning categories. For each response to a scored item, a number of points is assigned, which is multiplied by a weighted numerical value. The result is a weighted score for each response.

b. In the functional assessment matrix, all items in the following categories are scored according to subsection (C):

i. Activities of daily living,

ii. Continence,

iii. Sensory,

iv. Orientation, and

v. Behavior.

c. The sum of the weighted scores equals the functional score. The weighted score per item can range from 0 to 15. The maximum functional score attainable by an applicant or member is 166.

2. Medical score.

a. In the medical assessment matrix, all items in the following categories are scored according to:

i. Medical conditions as specified in subsection (C), and

ii. Medical or nursing services and treatments in subsection (C).

b. The Administration calculates the medical score based on the applicant's or member's:

i. Diagnosis of Alzheimer's, dementia, or organic brain syndrome (OBS);

ii. Diagnosis of paralysis; and

iii. Current use of oxygen.

c. The maximum medical score attainable by an applicant or member is 31.5.

3. Total score.

a. The sum of an applicant's or member's functional and medical scores equals the total score.

b. The total score is compared to the established threshold score as calculated under this Section. The threshold score is 60.

c. As defined in R9-28-303, an applicant or member is determined at immediate risk of institutionalization if the total score is equal to or greater than 60.

C. The following matrices represent the number of points available and the respective weight for each scored item.

1. Functional assessment points. The lowest value in the range of points available per item in the functional assessment category, zero, indicates minimal to no impairment. Conversely, the highest value indicates severe impairment.

2. Medical assessment points. The lowest value in the range of points available per item in the medical assessment category, zero, indicates that the applicant or member:

a. Does not have the scored medical condition,

b. Does not need the scored medical or nursing services, or

c. Does not receive the scored medical or nursing services.