TITLE 9. HEALTH SERVICES

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by exempt rulemaking at 6 A.A.R. 282, effective December 16, 1999 (Supp. 99-4). Amended by exempt rulemaking at 6 A.A.R. 3205, effective August 4, 2000 (Supp. 00-3). Amended by exempt rulemaking at 7 A.A.R. 4740, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 8 A.A.R. 3350, effective July 15, 2002 (Supp. 02-3). Amended by final rulemaking at 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-102. Scope of Services-related Definitions

Definitions. The words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

"Certified nurse practitioner" means a registered nurse practitioner as certified by the Arizona Board of Nursing according to A.R.S. Title 32, Ch. 15.

"Psychosocial rehabilitation services" means the same as in R9-22-102.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-103. Eligibility and Enrollment Related Definitions

Definitions. The words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

"CMDP" means Comprehensive Medical and Dental Program.

"CRS" means Children's Rehabilitative Services.

"DES" means the Department of Economic Security.

"Determination" means the process by which an applicant is approved or denied for coverage.

"Enrollment" means the process by which a person is determined eligible for and enrolled in the program.

"Head of household" means the household member who assumes the responsibility for providing eligibility information for the household unit.

"Household income" means the total gross amount of all money received by or directly deposited into a financial account of a member of the household income group as defined in R9-31-304.

"Information" means the knowledge received or communicated in written or oral form regarding a circumstance or proof of a circumstance.

"PSP" means Premium Sharing Program, established according to A.R.S. § 36-2923.01.

"Redetermination" means the periodic review of a member's continued Title XXI eligibility.

"Spouse" means the husband or wife of a Title XXI applicant or household member, who has entered into a contract of marriage, recognized as valid by Arizona.

"SSI-MAO" means Supplemental Security Income-Medical Assistance Only.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4).

R9-31-104. Reserved

R9-31-105. Repealed

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Section repealed by final rulemaking at 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-106. Request for Proposal (RFP) Related Definitions

Definitions. The words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

1. "Offeror" means a person or other entity that submits a proposal to the Administration in response to an RFP.

2. "Proposal" means all documents including best and final offers submitted by an offeror in response to a Request for Proposals by the Administration.

3. "RFP" means Request for Proposals including all documents, whether attached or incorporated by reference, which are used by the Administration for soliciting a proposal according to this Article.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3).

R9-31-107. Repealed

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 3350, effective July 15, 2002 (Supp. 02-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-108. Repealed

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 6 A.A.R. 3205, effective August 4, 2000 (Supp. 00-3). Section repealed by final rulemaking at 10 A.A.R. 822, effective April 3, 2004 (Supp. 04-1).

R9-31-109. Reserved

R9-31-110. Repealed

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Section repealed by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-111. Reserved

R9-31-112. Repealed

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 6 A.A.R. 282, effective December 16, 1999 (Supp. 99-4). Amended by exempt rulemaking at 7 A.A.R. 4740, effective October 1, 2001 (Supp. 01-3). Section repealed by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-113. Repealed

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Section repealed by exempt rulemaking at 6 A.A.R. 3205, effective August 4, 2000 (Supp. 00-3).

R9-31-114. Reserved

R9-31-115. Reserved

R9-31-116. Services for Native Americans Related Definitions

Definitions. The words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

"IGA" means intergovernmental agreement.

"IHS" means Indian Health Service.

"IHS or Tribal Facility Provider" means a person who is authorized by the IHS or Tribal Facility to provide covered services to members and:

Is an AHCCCS registered provider, and

Is certified by the IHS or Tribal Facility as meeting all applicable federal and state requirements.

"TRBHA" means a Tribal Regional Behavioral Health Authority operated by a tribal government through an IGA with ADHS for the provision of behavioral health services to a Native American member residing on reservation.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 3350, effective July 15, 2002 (Supp. 02-3).

ARTICLE 2. SCOPE OF SERVICES

R9-31-201. General Requirements

A. The Administration shall administer the Children's Health Insurance Program under A.R.S. § 36-2982.

B. Scope of services for Native American fee-for-service members is under Article 16 of this Chapter.

C. A contractor or RBHA shall provide behavioral health services under Article 12 and Article 16.

D. In addition to other requirements and limitations specified in this Chapter, the following general requirements apply:

1. Only medically necessary, cost effective, and federally- reimbursable and state-reimbursable services are covered services.

2. The Administration or a contractor may waive the covered services referral requirements of this Article.

3. Except as authorized by a contractor, a primary care provider, practitioner, or dentist shall provide or direct the member's covered services. Delegation of the provision of care to a practitioner does not diminish the role or responsibility of the primary care provider.

4. A contractor shall offer a female member direct access to preventive and routine services from gynecology providers within the contractor's network without a referral from a primary care provider.

5. A member may receive behavioral health evaluation services without a referral from a primary care provider. A member may receive behavioral health treatment services only under referral from the primary care provider, or upon authorization by the contractor or the contractor's designee.

6. A member may receive treatment that is considered the standard of care, or that is approved by the AHCCCS Chief Medical Officer after appropriate input from providers who are considered experts in the field by the professional medical community.

7. An AHCCCS registered provider shall provide covered services within the provider's scope of practice.

8. In addition to the specific exclusions and limitations otherwise specified under this Article, the following are not covered:

a. A service that is determined by the AHCCCS Chief Medical Officer to be experimental or provided primarily for the purpose of research;

b. Services or items furnished gratuitously; and

c. Personal care items, except as specified in R9-31-212.

9. Medical or behavioral health services are not covered if provided to:

a. An inmate of a public institution;

b. A person who is a resident of an institution for the treatment of tuberculosis; or

c. A person who is in an IMD at the time of application, unless provided under Article 12 of this Chapter.

E. The Administration or a contractor may deny payment of non-emergency services if prior authorization is not obtained under this Article and Article 7 of this Chapter. The Administration or a contractor shall not reimburse services that require prior authorization unless the provider documents the diagnosis and treatment.

F. Prior authorization is not required for services necessary to evaluate and stabilize an emergency medical condition.

G. Under A.R.S. § 36-2989, a member shall receive covered services outside of the GSA only if one of the following applies:

1. A member is referred by a primary care provider for medical specialty care out of the contractor's area. If the member is referred outside of the GSA to receive an authorized medically necessary service, a contractor shall also provide all other medically necessary covered services for the member;

2. There is a net savings in service delivery costs as a result of going outside the GSA that does not require undue travel time or hardship for a member or the member's family; or

3. The contractor authorizes placement in a nursing facility located outside of the GSA;

H. If a member is traveling or temporarily residing outside of the GSA, covered services are restricted to emergency care services, unless otherwise authorized by the contractor.

I. A contractor shall provide at a minimum, directly or through subcontracts, the covered services specified in this Chapter and in contract.

J. The restrictions, limitations, and exclusions in this Article do not apply to a contractor if the contractor elects to provide noncovered services.

1. The Administration shall not consider the costs of providing a noncovered service to a member in the development or negotiation of a capitation rate.

2. A contractor shall pay for noncovered services from administrative revenue or other contractor funds that are unrelated to the provision of services under this Chapter.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by exempt rulemaking at 7 A.A.R. 4740, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 3246, effective October 1, 2005 (Supp. 05-3). Amended by final rulemaking at 13 A.A.R. 3276, effective September 11, 2007 (Supp. 07-3).

R9-31-202. Reserved

R9-31-203. Reserved

R9-31-204. Inpatient General Hospital Services

A contractor, fee-for-service provider, or noncontracting provider shall render inpatient general hospital services including:

1. Hospital accommodations and appropriate staffing, supplies, equipment, and services for:

a. Maternity care, including labor, delivery, recovery room, birthing center, and newborn nursery;

b. Neonatal intensive care unit (NICU);

c. Intensive care unit (ICU);

d. Surgery, including surgery room and recovery room;

e. Nursery and related services;

f. Routine care; and

g. Emergency behavioral health services under 9 A.A.C. 31, Article 12.

2. Ancillary services as specified by the Director and included in contract:

a. Laboratory services;

b. Radiological and medical imaging services;

c. Anesthesiology services;

d. Rehabilitation services;

e. Pharmaceutical services and prescription drugs;

f. Respiratory therapy;

g. Blood and blood derivatives; and

h. Central supply items, appliances, and equipment not ordinarily furnished to all patients which are customarily reimbursed as ancillary services.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).

R9-31-205. Attending Physician, Practitioner, and Primary Care Provider Services

A. A primary care provider shall provide primary care provider services within the provider's scope of practice under A.R.S. Title 32. A member may receive primary care provider services in an inpatient or outpatient setting including at a minimum:

1. Periodic health examination and assessment,

2. Evaluation and diagnostic workup,

3. Medically necessary treatment,

4. Prescriptions for medication and medically necessary supplies or equipment,

5. Referral to a specialist or other health care professional if medically necessary as specified in A.R.S. § 36-2989,

6. Patient education,

7. Home visits if medically necessary,

8. Covered immunizations, and

9. Covered preventive health services.

B. As specified in A.R.S. § 36-2989, a second opinion procedure may be required to determine coverage for surgery. Under this procedure, documentation must be provided by at least two physicians as to the need for the proposed surgery for the member.

C. The following limitations and exclusions apply to physician and practitioner services and primary care provider services:

1. Specialty care and other services provided to a member upon referral from a primary care provider are limited to the services or conditions for which the referral is made, or for which authorization is given by the contractor;

2. A member's physical examination is not a covered service if the physical examination is to obtain one or more of the following:

a. Qualification for insurance,

b. Pre-employment physical evaluation,

c. Qualification for sports or physical exercise activities,

d. Pilot's examination (Federal Aviation Administration),

e. Disability certification to establish any kind of periodic payments,

f. Evaluation to establish third-party liabilities, or

g. Physical ability to perform functions that have no relationship to primary objectives of the services listed in subsection (A).

3. The following services are excluded from AHCCCS coverage:

a. Infertility services, reversal of surgically induced infertility (sterilization), and gender reassignment surgery;

b. Pregnancy termination counseling services;

c. A pregnancy termination, unless authorized under federal law;

d. A service or item furnished solely for cosmetic purposes;

e. A hysterectomy, unless determined to be medically necessary; and

f. Licensed midwife services for prenatal care and home birth.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).

R9-31-206. Organ and Tissue Transplantation Services

The following organ and tissue transplantation services shall be covered for a member as specified in A.R.S. § 36-2989 if prior authorized and coordinated with a member's contractor:

1. Kidney transplantation;

2. Simultaneous Kidney/Pancreas transplant;

3. Cornea transplantation;

4. Heart transplantation;

5. Liver transplantation;

6. Autologous and allogeneic bone marrow transplantation;

7. Lung transplantation;

8. Heart-lung transplantation;

9. Other organ transplantation if the transplantation is required by federal law and if other statutory criteria are met; and

10. Immunosuppressant medications, chemotherapy, and other related services.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4).

R9-31-207. Dental Services

Medically necessary dental services are provided for children under age 19 under A.R.S. § 36-2989 and R9-22-213.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).

R9-31-208. Laboratory, Radiology, and Medical Imaging Services

An AHCCCS-registered provider shall provide laboratory, radiology, and medical imaging services for children under age 19, under A.R.S. § 36-2989 and R9-22-208.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).

R9-31-209. Pharmaceutical Services

Pharmaceutical services are provided for children under age 19 under R9-22-209.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).

R9-31-210. Emergency Medical Services

A. Emergency medical services shall be provided based on the prudent layperson standard to a member by licensed providers registered with AHCCCS to provide services under A.R.S. § 36-2989.

B. The provider of emergency services shall verify eligibility and enrollment status through the Administration to determine the need for notification to a contractor or a RBHA for a member and to determine the party responsible for payment of services rendered.

C. Access to an emergency room and emergency medical services shall be available 24 hours per day, seven days per week in each contractor's service area. The use of examining or treatment rooms shall be available when required by a physician or practitioner for the provision of emergency services.

D. Behavioral Health Evaluation provided by a psychiatrist or psychologist shall be covered as an emergency service, so long as it meets the requirements of 9 A.A.C. 31, Article 12.

E. Emergency services do not require prior authorization but providers shall comply with the following notification requirements:

1. Providers and noncontracting providers furnishing emergency services to a member shall notify the member's contractor within 12 hours of the time the member presents for services;

2. If a member's medical condition is determined not to be an emergency medical condition under Article 1 of this Chapter, the provider shall notify the member's contractor before initiation of treatment and follow the prior authorization requirements and protocol of the contractor regarding treatment of the member's nonemergent condition. Failure to provide timely notice or comply with prior authorization requirements of the contractor constitutes cause for denial of payment.

F. A provider and a noncontracting provider shall request authorization from a contractor for post stabilization services. A contractor shall pay for the post stabilization services if:

1. The service is pre-approved by a contractor, or

2. A contractor does not respond to an authorization request within the time-frame under 42 CFR 438.114.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 7 A.A.R. 4740, effective October 1, 2001 (Supp. 01-3).

R9-31-211. Transportation Services

The Administration shall provide transportation services under A.A.C. R9-22-211.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4).

R9-31-212. Durable Medical Equipment, Orthotic and Prosthetic Devices, and Medical Supplies

As specified in A.R.S. § 36-2989, DME, orthotic and prosthetic devices, and medical supplies, including incontinence briefs, are covered services if provided in compliance with requirements of this Chapter and A.A.C. R9-22-212. For purposes of this Section, where the term "AHCCCS services" is used in R9-22-212, it is replaced with the term "Title XXI services."

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 13 A.A.R. 3276, effective September 11, 2007 (Supp. 07-3).

R9-31-213. Health Risk Assessment and Screening Services

A. As authorized by A.R.S. § 36-2989, the following services shall be covered for a member:

1. Screening services, including:

a. Comprehensive health, behavioral health and developmental histories;

b. Comprehensive unclothed physical examination;

c. Appropriate immunizations according to age and health history; and

d. Health education, including anticipatory guidance.

2. Vision services including:

a. Diagnosis and treatment for defects in vision,

b. Eye examinations for the provision of prescriptive lenses, and

c. Provision of prescriptive lenses.

3. Hearing services, including:

a. Diagnosis and treatment for defects in hearing,

b. Testing to determine hearing impairment, and

c. Provision of hearing aids.

B. All providers of services shall meet the following standards:

1. Provide services by or under the direction of, the member's primary care provider or dentist.

2. Perform tests and examinations as specified in contract and under 42 CFR 441, Subpart B, January 29, 1985, which is incorporated by reference and on file with the Office of the Secretary of State and the Administration. This incorporation by reference contains no future editions or amendments.

3. Refer members as necessary for dental diagnosis and treatment, and necessary specialty care.

4. Refer members as necessary for behavioral health evaluation and treatment services as specified in 9 A.A.C. 31, Article 12.

C. A contractor shall meet the following additional conditions for members:

1. Provide information to members and their parents or guardians concerning services; and

2. Notify members and their parents or guardians regarding the initiation of screening and subsequent appointments according to the AHCCCS Administration Periodicity Schedule.

D. A contractor, primary care provider, attending physician, or practitioner shall refer a member with special health care needs under A.A.C. R9-7-301 to CRS.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4).

R9-31-214. Reserved

R9-31-215. Other Medical Professional Services

The following medical professional services are covered services if a member receives these services in an inpatient, outpatient, or office setting as follows:

1. Dialysis;

2. The following family planning services if provided to delay or prevent pregnancy:

a. Medications,

b. Supplies,

c. Devices, and

d. Surgical procedures.

3. Family planning services are limited to:

a. Contraceptive counseling, medication, supplies, and associated medical and laboratory examinations, including HIV blood screening as part of a package of sexually transmitted disease tests provided with a family planning service; and

b. Natural family planning education or referral;

4. Midwifery services provided by a nurse practitioner certified in midwifery;

5. Podiatry services if ordered by a member's primary care provider as specified in A.R.S. § 36-2989;

6. Respiratory therapy;

7. Ambulatory and outpatient surgery facilities services;

8. Home health services in A.R.S. § 36-2989;

9. Private or special duty nursing services if medically necessary and prior authorized;

10. Rehabilitation services including physical therapy, occupational therapy, speech therapy, and audiology provided under this Article;

11. Total parenteral nutrition services, (which are the provision of total caloric needs by intravenous route for individuals with severe pathology of the alimentary tract);

12. Inpatient chemotherapy;

13. Outpatient chemotherapy; and

14. Hospice care under R9-22-213.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).

R9-31-216. NF, Alternative HCBS Setting, or HCBS

Services provided in a NF, including room and board, alternative HCBS setting, or HCBS shall be covered as specified in A.A.C. R9-22-216.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 13 A.A.R. 3276, effective September 11, 2007 (Supp. 07-3).

ARTICLE 3. ELIGIBILITY AND ENROLLMENT

R9-31-301. General Requirements

A. Administration. The Administration shall administer the program as specified in A.R.S. § 36-2982.

B. Operational authority. The Director has full operational authority to adopt rules or to use the appropriate rules for the development and management of an eligibility and enrollment system as specified in A.R.S. § 36-2986.

C. Expenditure limit and enrollment

1. Title XXI will accept enrollees subject to the availability of funds. If the Director determines that monies may be insufficient for the program, the Administration shall stop processing applications for the program as specified in A.R.S. § 36-2985.

2. After the Administration has verified that funding is sufficient, it will resume processing applications as specified in A.R.S. § 36-2985.

3. The Administration shall immediately stop processing all applications and shall provide advance notice to a member that the program will terminate under A.R.S. § 36-2985.

4. A child is not entitled to a hearing under Article 8 of this Chapter, if the program is suspended or terminated.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-302. Applications

A. Availability. The provisions in A.A.C. R9-22-1405(B) apply to this Section. The Administration shall make available program applications. Any person may request a program application.

B. Submission of applications. An application is completed and submitted to the Administration:

1. In person,

2. By mail,

3. By fax, or

4. By other form approved by the Administration.

C. Date of application. The date of application is the date the Administration or its designee receives an application that:

1. Is signed by the person making the application,

2. Includes the name of the person for whom assistance is requested, and

3. Includes the address and telephone number of the person submitting the application.

D. Completed application.

1. The provisions in A.A.C. R9-22-1405(E) apply to this Section.

2. The Administration shall consider an application complete when:

a. All questions are answered,

b. An enrollment choice is included, and

c. All necessary verification is provided by an applicant or an applicant's representative.

3. If the application is incomplete, the Administration shall do one or both of the following:

a. Contact an applicant or an applicant's representative by telephone to obtain the missing information required for an eligibility determination;

b. Mail a request for additional information to an applicant or an applicant's representative, allowing 10 days from the date of the request to provide the required additional information.

E. Eligibility determination processing time.

1. When an application is complete, the Administration shall mail notification to the applicant regarding the eligibility determination no more than 30 days from the date of application except when there is an emergency beyond the Administration's control.

2. An applicant shall provide the Administration with all requested information within 10 days from the date of the written request for the information. If an applicant fails to provide the requested information and fails to request an extension of the 10 day period or the request for extension is denied, the Administration shall deny eligibility.

F. Waiting list. If the Administration stops processing an application because the monies are insufficient as specified in R9-31-301(C)(1), the Administration shall place an applicant on a waiting list and notify the applicant. When sufficient funding becomes available, the Administration shall contact an applicant on the waiting list and ask the applicant to submit a new application if the original application is more than 60 days old. The Administration shall fill spaces in the order that an application is received and approved.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 9 A.A.R. 5150, effective January 3, 2004 (Supp. 03-4).

R9-31-303. Eligibility Criteria

Eligibility. To be eligible for the program, an applicant shall meet all the following eligibility requirements:

1. Age. Is less than 19 years of age. A child's coverage shall continue through the month in which a child turns age 19 if the child is otherwise eligible;

2. Citizenship. Is a United States citizen or a qualified alien under A.R.S. § 36-2983;

3. Residency. Is a resident of the state of Arizona under A.R.S. § 36-2983. An Arizona resident is a person who currently lives in Arizona and intends to remain in Arizona indefinitely;

4. Income. Meets the income requirements in R9-31-304;

5. Cost sharing. Pays the cost sharing premium amount when premiums are required as specified in A.R.S. §§ 36-2982 and 36-2903.01;

6. Social security number (SSN). Provides a SSN or applies for a SSN within 30 days after submitting an application.

7. Assignment. Assigns rights to any first- or third-party coverage of medical care as specified in 9 A.A.C. 31, Article 10;

8. Other federal program. Is not eligible for Medicaid or other federally operated or financed health care insurance program, except the Indian Health Service as specified in A.R.S. § 36-2983;

9. Inmate of a public institution. Is not an inmate of a public institution, as specified in A.R.S. § 36-2983;

10. Patient in an institution for mental disease. Is not a patient in an institution for mental disease at the time of application, or at the time of redetermination, as specified in A.R.S. § 36-2983;

11. Other health coverage. Is not covered under:

a. An employer's group health insurance plan,

b. Family or individual health insurance, or

c. Other health insurance;

12. State health benefits. Is not a member of a family that is eligible for health benefits coverage under a state health benefit plan based on a family member's employment with a public agency in the state of Arizona;

13. Prior health insurance coverage. Has not been covered by health insurance during the previous three months unless that health insurance was discontinued due to the involuntary loss of employment or other involuntary reason as specified in A.R.S. § 36-2983. The three months of ineligibility due to previous insurance coverage shall not apply to:

a. A newborn as defined in R9-31-309;

b. A Title XIX member as specified in 9 A.A.C. 22, Article 1;

c. An applicant who is seriously ill under R9-31-101 or chronically ill under A.R.S. § 36-2983;

d. A member under this Article who loses insurance coverage;

e. A CRS member; or

f. A Native American member receiving services from IHS or a Tribal Facility.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by exempt rulemaking at 9 A.A.R. 4560, effective October 1, 2003 (Supp. 03-4). Amended by final rulemaking at 9 A.A.R. 5150, effective January 3, 2004 (Supp. 03-4).

R9-31-304. Income Eligibility

A. Income standard. The combined gross income of the household income group members as specified in subsection (C) shall not exceed the percentage of the appropriate FPL under A.R.S. § 36-2981 for the Title XXI household income group size.

B. Calculating monthly income. The Administration shall calculate monthly income under A.A.C. R9-22-1419.01(B) through 1419.04.

C. Title XXI household income group.

1. For this Section:

a. "Child" means a person less than 19 years of age or an unborn child.

b. "Parent" means a biological, adoptive, or step parent.

2. The following related persons, when residing together, constitute a Title XXI household income group:

a. A married couple and children of either one or both;

b. An unmarried couple with a common child and at least one other child of either one or both;

c. A married couple when one or both are under age 19 with no child;

d. A single parent and the single parent's child;

e. A child who does not live with a parent; and

f. The following persons, when living with a child:

i. A spouse of the child;

ii. A child of the spouse child;

iii. A child of the child; and

iv. The other parent of a child of the child.

3. A member of the household income group who is absent from a household shall be included in the child's household income group if absent:

a. For 30 days or less,

b. For the purpose of seeking employment or to maintain a job,

c. For serving in the military, or

d. For an educational purpose and the child's parent claims the child as a dependent on the parent's income tax return.

D. Income disregards. When determining gross income of the household, the Administration shall disregard the following:

1. Income specified in 20 CFR 416, Appendix to subpart K as of June 6, 1997, which is incorporated by reference and on file with the Office of the Secretary of State and the Administration. This incorporation by reference contains no future editions or amendments;

2. Income paid according to federal law that prohibits the use of the income when determining eligibility for public benefits;

3. Money received as the result of the conversion of an asset;

4. Income tax refunds; and

5. An amount equal to the expenses of producing self-employment income from the gross self-employment income.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 9 A.A.R. 5150, effective January 3, 2004 (Supp. 03-4).

R9-31-305. Verification

Verification. An applicant or a member shall provide the Administration with verification or authorize the release of verification to the Administration of all information necessary to complete the determination of eligibility.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4).

R9-31-306. Enrollment

A. Selection choices.

1. Except as provided in subsections (A)(3), (4), and (5), at the time of application, an applicant shall select from the following enrollment choices:

a. A contractor which includes a contractor or a qualifying plan as defined in A.R.S. § 36-2981, or

b. The IHS as specified in A.R.S. § 36-2982. If a member is enrolled with the IHS, a member may elect to receive covered services from a participating Tribal Facility.

2. Except as provided in subsections (A)(3), (4), and (5), coverage shall not begin until a Title XXI enrollment choice is made.

3. The Administration shall enroll a member with CMDP when a member is a foster care child according to A.R.S. § 8-512.

4. When a Title XIX member becomes ineligible for Title XIX and DES determines the member eligible for Title XXI with no break in coverage,

a. The Title XXI member shall remain enrolled with the Title XIX contractor; and

b. The Administration shall send the Title XXI member a notice explaining the member's right to choose as specified in subsection (A)(1).

5. When an applicant applies for Title XIX through DES and DES determines the applicant ineligible for Title XIX but eligible for Title XXI, the Administration shall enroll the applicant for Title XXI as follows:

a. If a Title XIX contractor pre-enrollment choice is pending at the time the Administration receives the Title XXI approval from DES, the Administration may:

i. Enroll member with the Title XIX contractor, and

ii. Notify the member of the member's enrollment and provide the member an opportunity to select an enrollment choice as specified in subsection (A)(1).

b. If there is no pending Title XIX choice at the time the Administration receives the Title XXI approval from DES, the Administration shall pend the Title XXI decision and obtain a choice from the member as specified in subsection (A)(1).

B. Effective date of initial enrollment.

1. For an eligibility determination completed by the 25th day of the month, enrollment shall begin on the first day of the month following the determination of eligibility.

2. For an eligibility determination completed after the 25th day of the month, enrollment shall begin on the first day of the second month following the determination of eligibility.

C. Enrollment changes.

1. If a member moves from one GSA to another GSA during the period of enrollment, enrollment changes shall occur as follows:

a. If a member's current enrollment choice is available in a member's new GSA, a member shall remain enrolled with the member's current enrollment choice.

b. If a member's current enrollment choice is not available in the new GSA, a member shall:

i. Remain enrolled with the current enrollment choice. The current enrollment choice may limit services to emergency services outside the GSA as specified in R9-31-201.

ii. Select from the enrollment choices provided in R9-31-306(A)(1) that are available in the new GSA. Once a new choice is made, a member shall be enrolled with the new choice effective with the date the Administration processes the member's enrollment choice. Covered services shall be available on the date of the enrollment change.

2. A member may change a member's enrollment choice:

a. During a member's annual enrollment choice period,

b. At any time from:

i. IHS to a contractor as specified in subsection (A)(1) of this Section; or

ii. A contractor to IHS.

c. When a member is no longer a foster care child as specified in subsection (A)(3) of this Section.

3. Except for subsection (C)(2)(c) of this Section, the effective date of the new enrollment choice is the date the Administration processes the enrollment choice. The effective date of the enrollment change from CMDP to a Title XXI choice as specified in subsection (A)(1) of this Section, shall be the first of the following month.

D. Annual enrollment choice period. A member shall have the opportunity to change enrollment no later than 12 months following the last time a member made an enrollment choice or had the opportunity to make an enrollment choice.

E. Health Insurance Portability and Accountability Act of 1996. As specified in A.R.S. § 36-2982, a Title XXI member who has been disenrolled shall be allowed to use enrollment in the Title XXI program as creditable coverage as defined in A.R.S. § 36-2984.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4).

R9-31-307. Guaranteed Enrollment

A. Guaranteed Enrollment. A child who is determined eligible for Title XXI shall be guaranteed a one-time, 12-month period of continuous coverage unless a child:

1. Attains age 19,

2. Is no longer a resident of the state,

3. Is an inmate of a public institution,

4. Is determined to have been ineligible at the time of approval,

5. Obtains private or group health coverage,

6. Is adopted and the new household does not meet the qualifications of this program,

7. Is a patient in an institution for mental diseases,

8. Has whereabouts that are unknown, or

9. Has a head of household who:

a. Does not pay cost sharing premium amount when premiums are required as specified in A.R.S. §§ 36-2982 and 36-2903.01 and as specified in this Chapter,

b. Voluntarily withdraws from the program, or

c. Fails to cooperate in meeting the requirements of the program.

B. The 12-month guaranteed period shall begin with the month an applicant is initially enrolled.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by exempt rulemaking at 9 A.A.R. 4560, effective October 1, 2003 (Supp. 03-4).

R9-31-308. Changes and Redeterminations

A. Reporting Changes. A member or a member's parent or guardian shall report the following changes to the Administration:

1. Any increase in income that will begin or continue into the following month,

2. Any change of address,

3. The addition or departure of a household member,

4. Any health coverage under private or group health insurance,

5. Employment of a member or a parent with a state agency, and

6. Incarceration of a member.

B. Verification. If required verification is needed and requested as a result of a change specified in subsection (A) of this Section to determine the impact on eligibility and is not received within 10 days, the Administration shall send a notice to discontinue eligibility for a member unless a member is within the guaranteed eligibility period as specified in R9-31-307.

C. Redeterminations. If no change is reported, the Administration shall initiate redetermination no later than the end of the 12th month after the effective date of eligibility, or the completion of the most recent redetermination decision whichever is later.

D. Termination. If the Administration determines that a child no longer meets the eligibility criteria, or a head of household fails to respond or cooperate with the redetermination of eligibility, the Administration shall terminate coverage.

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4).

R9-31-309. Newborn Eligibility

A. Eligibility. A child born to a Title XXI member, is eligible for 12 months of coverage without filing an application under Title XXI provided:

1. The child continues to live with the child's mother during the 12-month period; and

2. One of the events as specified in R9-31-307(A) does not occur.

B. Deemed Coverage. A newborn's deemed newborn coverage shall begin effective with