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 American Indian fee-for-service members is under Article 16 of this Chapter.

C. A contractor or RBHA shall provide behavioral health services under Articles 12 and 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 services as specified in 9 A.A.C. 22, Articles 2 and 12.

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 if a provider fails to obtain prior authorization as specified in this Article and Article 7 of this Chapter for non-emergency services. The Administration or a contractor shall not provide prior authorization for services unless the provider submits documentation of the medical necessity of the treatment along with the prior authorization request.

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). Amended by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

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.

3. Providers are not required to obtain prior authorization from the Administration for the following inpatient hospital services:

a. Dialysis shunt placement,

b. Arteriovenous graft placement for dialysis,

c. Angioplasties or thrombectomies of dialysis shunts,

d. Angioplasties or thrombectomies of arteriovenous graft for dialysis,

e. Hospitalization for vaginal delivery that does not exceed 48 hours,

f. Hospitalization for cesarean section delivery that does not exceed 96 hours, and

g. Other services identified by the Administration through the Provider Participation Agreement.

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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

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

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

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;

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.

B. Prior authorization from the Administration for a member is required for services listed in subsections (A)(4) through (11) and (14); except for:

1. Dialysis shunt placement,

2. Arteriovenous graft placement for dialysis,

3. Angioplasties or thrombectomies of dialysis shunts,

4. Angioplasties or thrombectomies of arteriovenous grafts for dialysis,

5. Eye surgery for the treatment of diabetic retinopathy,

6. Eye surgery for the treatment of glaucoma,

7. Eye surgery for the treatment of macular degeneration,

8. Home health visits following an acute hospitalization (limited up to five visits),

9. Hysteroscopies, (up to two, one before and one after, when associated with a family planning diagnosis code and done within 90 days of hysteroscopic sterilization),

10. Physical therapy subject to the limitation in subsection A.A.C. R9-22-215(C),

11. Facility services related to wound debridement,

12. Apnea management and training for premature babies up to the age of 1, and

13. Other services identified by the Administration through the Provider Participation Agreement.

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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

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 a newborn's date of birth and end with the last day of the month in which a newborn turns age 1. Deemed newborn status does not preclude a child from applying for Title XIX and being approved.

C. Enrollment choice for a newborn. A newborn shall be enrolled with a mother's enrollment choice as specified in contract.

D. Notification of enrollment. The Administration shall notify a mother of a newborn's enrollment and provide a mother an opportunity to select an enrollment choice as specified in R9-31-306(A)(1).

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).

R9-31-310. Notice Requirements

A. Applications. Upon completion of a determination of eligibility or ineligibility for any child in the household, the Administration shall issue a written notice to an individual who initiated the application. This notice shall include a statement of the intended action, an explanation of a person's hearing rights as specified in 9 A.A.C. 31, Article 8, and:

1. If approved, the notice shall contain the name and effective date of eligibility for each approved applicant;

2. If denied, the notice shall contain:

a. The name of each ineligible applicant,

b. The effective date of the denial,

c. The reasons for ineligibility including appropriate income calculations and income standard when the reason for the denial is based on excess income,

d. The legal authority supporting the reason for ineligibility, and

e. The resource or reference materials where the legal authority citations are found.

B. Terminations.

1. When the Administration proposes a termination of Title XXI eligibility, the Administration shall provide a member with:

a. Advance notice at least 10 days before the effective date of the adverse action except as provided in subsection (B)(1)(b).

b. Adequate notice no later than the date of adverse action when a member:

i. Voluntarily withdraws and indicates an understanding of the results of the action,

ii. Becomes an inmate of a public institution as specified in R9-31-303(I),

iii. Dies and the Administration has verification of the death,

iv. Has whereabouts that are unknown and the Administration's loss of contact is confirmed by returned mail from the post office with no forwarding address, or

v. Is approved for Title XIX.

2. In addition to the requirements listed in subsection (A)(2), the termination notice shall include an explanation of a member's right to continued Title XXI coverage pending a request for hearing as provided in 9 A.A.C. 31, Article 8 and 14.

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).

ARTICLE 4. REPEALED

R9-31-401. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Section repealed by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-402. 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 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-403. 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 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-404. 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 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-405. 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 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-406. 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 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-407. 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 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

ARTICLE 5. GENERAL PROVISIONS AND STANDARDS

R9-31-501. General Provisions and Standards - Related Definitions

Definitions. In this Chapter, unless the context explicitly requires another meaning terms are defined in R9-31-101 or cross-referenced to the location of the definition.

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 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4). Amended by final rulemaking at 14 A.A.R. 4408, effective January 3, 2009 (Supp. 08-4).

R9-31-502. Pre-existing Conditions

A contractor shall comply with the pre-existing condition requirements in A.A.C. R9-22-502.

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 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4). Error to Section heading corrected to reflect amendment made at 11 A.A.R. 4295 (Supp. 08-3). Amended by final rulemaking at 14 A.A.R. 4408, effective January 3, 2009 (Supp. 08-4).

R9-31-503. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Section repealed by final rulemaking at 8 A.A.R. 3350, effective July 15, 2002 (Supp. 02-3).

R9-31-504. Marketing; Prohibition Against Inducements; Misrepresentations; Discrimination; Sanctions

A contractor or any person or entity acting as the contractor's marketing representative shall follow the requirements in A.A.C. R9-22-504.

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 11 A.A.R. 4295, effective December 5, 2005
(Supp. 05-4).

R9-31-505. 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).

R9-31-506. Reserved

R9-31-507. 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 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by final rulemaking at 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-508. 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).

R9-31-509. Transition and Coordination of Member Care

The Administration or a contractor shall conduct transition and coordination of member care as described in A.A.C. R9-22-509.

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 11 A.A.R. 4295, effective December 5, 2005
(Supp. 05-4).

R9-31-510. 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).

R9-31-511. 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 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by final rulemaking at 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-512. Release of Safeguarded Information

The Administration, a contractor, provider, and noncontracting provider shall meet the requirements specified in A.A.C. R9-22-512 regarding release of safeguarded information for an applicant or member.

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 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-513. 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 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by final rulemaking at 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-514. 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).

R9-31-515. Reserved

R9-31-516. Reserved

R9-31-517. Reserved

R9-31-518. Information to Enrolled Members

A contractor shall provide information to enrolled members as described under R9-22-518.

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 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-519. Reserved

R9-31-520. 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).

R9-31-521. 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 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by final rulemaking at 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-522. Quality Management/Utilization Management (QM/UM) Requirements

A contractor shall comply with Quality Management/Utilization Management (QM/UM) requirements as described under A.A.C. R9-22-522.

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 11 A.A.R. 4295, effective December 5, 2005 (Supp. 05-4).

R9-31-523. 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).

R9-31-524. 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).

R9-31-525. Reserved

R9-31-526. Reserved

R9-31-527. Reserved

R9-31-528. Reserved

R9-31-529. Reserved

ARTICLE 6. RFP AND CONTRACT PROCESS

R9-31-601. General Provisions

A. The Director has full operational authority to adopt rules and to use the appropriate rules for contract administration and oversight of contractors under A.R.S. § 36-2986. The Administration shall administer the program under A.R.S. § 36 -2982.

B. The Administration shall award contracts under A.R.S. § 36-2986 to provide services under A.R.S. § 36-2989.

C. The Administration shall follow the provisions under 9 A.A.C. 22, Article 6 for members, unless otherwise specified in this Chapter.

D. The Administration is exempt from the procurement code under A.R.S. § 36-2988 and § 41-2501.

E. The Administration and contractors shall retain all contract records for five years under A.R.S. § 36-2986 and dispose of the records under A.R.S. § 41-2550.

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. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-602. RFP

The RFP for a contractor serving members who qualify for the program shall be under A.R.S. § 36-2986 and A.A.C. R9-22-602.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-603. Contract Award

The contract award shall be under A.R.S. § 36-2986 and A.A.C. R9-22-603.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-604. Contract or Proposal Protests; Appeals

Contract or proposal protests or appeals shall be under A.A.C. R9-22-604.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-605. Waiver of Contractor's Subcontract with Hospitals

A waiver of a contractor's subcontract with a hospital shall be under A.A.C. R9-22-605.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

R9-31-606. Contract Compliance Sanction

The Administration shall follow sanction provisions under A.A.C. R9-22-606.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1).

ARTICLE 7. STANDARDS FOR PAYMENTS

R9-31-701. Standards for Payments Related Definitions

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

"Covered charges" means billed charges that represent medically necessary, reasonable, and customary items of expense for Title XXI-covered services that meet medical review criteria of the Administration or contractor.

"Medical review" means a review involving clinical judgment of a claim or a request for a service before or after it is paid or rendered to ensure that the services provided to the member are medically necessary and covered services and that the provider obtains required authorizations. The criteria for medical review are established by the contractor based on medical practice standards that are updated periodically to reflect changes in medical care.

"Outlier" means a hospital claim or encounter in which the Title XXI inpatient hospital days of care have operating costs per day that meet the criteria in A.A.C. R9-22-712.

"Tiered per diem" means a payment structure in which payment is made on a per-day basis depending upon the tier into which the Title XXI inpatient hospital day of care is assigned.

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. 452, effective January 10, 2002 (Supp. 02-1). Section repealed; new Section made by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-701.10. General Requirements

The following Sections of A.A.C. Chapter 22, Articles 2 and 7 are applicable to reimbursement for AHCCCS-covered services provided to a member under the KidsCare program, except that the term "Children's Health Insurance Program Fund" shall be substituted for "AHCCCS fund" and "A.R.S. § 36-2986" shall be substituted for "A.R.S. § 36-2903:"

1. Scope of the Administration's and Contractor's Liability, R9-22-701.10;

2. Charges to Members, R9-22-702;

3. Payments by the Administration and Payments by Contractors, R9-22-703 and R9-22-705;

4. Payments for Newborns, R9-22-707;

5. Contractor's Liability to Hospitals for the Provision of Emergency and Post-stabilization Care, R9-22-709;

6. Payments for Non-hospital Services, R9-22-710;

7. Copayments, R9-22-711;

8. Specialty Contracts, R9-22-712(G)(3), R9-22-712.01(10) and Article 2;

9. Overpayment and Recovery of Indebtedness, R9-22-713;

10. Payments to Providers, R9-22-714;

11. Hospital Rate Negotiations, R9-22-715;

12. Contractor Performance Measure Outcomes, R9-22-719; and

13. Reinsurance, R9-22-720.

Historical Note

New Section made by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-702. 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). Amended by final rulemaking at 11 A.A.R. 3246, effective October 1, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-703. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). 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).

R9-31-704. 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).

R9-31-705. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 11 A.A.R. 3171, effective October 1, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-706. Reserved

R9-31-707. 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 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-708. Reserved

R9-31-709. 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. 452, effective January 10, 2002 (Supp. 02-1). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-710. Repealed

Historical Note

New Section made by final rulemaking at 11 A.A.R. 3854, effective November 12, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-711. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by final rulemaking at 8 A.A.R. 3350, effective July 15, 2002 (Supp. 02-3). Amended by exempt rulemaking at 9 A.A.R. 4560, effective October 1, 2003 (Supp. 03-4). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-712. Reserved

R9-31-713. 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).

R9-31-714. Repealed

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-715. 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 11 A.A.R. 3171, effective October 1, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-716. 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. 452, effective January 10, 2002 (Supp. 02-1). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-717. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Section repealed by final rulemaking at 11 A.A.R. 3171, effective October 1, 2005 (Supp. 05-3).

R9-31-718. Repealed

Historical Note

New Section made by final rulemaking at 8 A.A.R. 452, effective January 10, 2002 (Supp. 02-1). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-719. Repealed

Historical Note

New Section made 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).

ARTICLE 8. REPEALED

Article 8, consisting of Sections R9-31-801 through R9-31-803 and Exhibit A, repealed by final rulemaking at 10 A.A.R. 822, effective April 3, 2004. The subject matter of Article 8 is now in 9 A.A.C. 34 (Supp. 04-1).

R9-31-801. 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; new Section adopted 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).

R9-31-802. 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; new Section adopted 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).

R9-31-803. 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; new Section adopted 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).

R9-31-804. 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).

Exhibit A. Repealed

Historical Note

New Exhibit adopted by exempt rulemaking at 6 A.A.R. 3205, effective August 4, 2000 (Supp. 00-3). Exhibit repealed by final rulemaking at 10 A.A.R. 822, effective April 3, 2004 (Supp. 04-1).

ARTICLE 9. REPEALED

R9-31-901. 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 12 A.A.R. 4494, effective January 6, 2007 (Supp. 06-4).

ARTICLE 10. FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES

R9-31-1001. Definitions

The definitions in A.R.S. § 36-2981, A.A.C. R9-22-1001, and A.A.C. R9-31-101 apply 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). Section repealed; new Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1002. General Provisions

AHCCCS is the payor of last resort unless specifically prohibited by applicable state or federal law.

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; new Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1003. Cost Avoidance

The provisions in A.A.C. R9-22-1003 apply to this Section except:

1. Replace the reference to "Article 2," with 9 A.A.C. 31, Article 2; and

2. This Section applies to Title XXI covered services.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1004. Member Participation

The provisions in A.A.C. R9-22-1004 apply to this Section.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1005. Collections

The provisions in A.A.C. R9-22-1005 apply to this Section except:

1. Replace the reference to "Article 2," with 9 A.A.C. 31, Article 2;

2. This Section applies to Title XXI fee-for-service and reinsurance payments.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1006. AHCCCS Monitoring Responsibilities

With the exception of long-term care insurance, the provisions in A.A.C. R9-22-1006 apply to this Section.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1007. Notification for Perfection, Recording, and Assignment of Title XXI liens

The provisions in A.A.C. R9-22-1007 apply to this Section.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1008. Notification Information for Liens

The provisions in A.A.C. R9-22-1008 apply to this Section.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

R9-31-1009. Notification of Health Insurance Information

The provisions in A.A.C. R9-22-1009 apply to this Section.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1152, effective May 1, 2004 (Supp. 04-1).

ARTICLE 11. CIVIL MONETARY PENALTIES AND ASSESSMENTS

R9-31-1101. Basis for Civil Monetary Penalties and Assessments for Fraudulent Claims

AHCCCS shall use the provisions in 9 A.A.C. 22, Article 11 for the determination and collection of penalties, assessments, and penalties and assessments.

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 10 A.A.R. 3067, effective September 11, 2004 (Supp. 04-3).

R9-31-1102. 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. 3067, effective September 11, 2004 (Supp. 04-3).

R9-31-1103. 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. 3067, effective September 11, 2004 (Supp. 04-3).

R9-31-1104. 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. 3067, effective September 11, 2004 (Supp. 04-3).

ARTICLE 12. BEHAVIORAL HEALTH SERVICES

R9-31-1201. General Requirements

General requirements. The following general requirements apply to behavioral health services provided under this Article, subject to all exclusions and limitations:

1. Administration. The program shall be administered as specified in A.R.S. § 36-2982.

2. Provision of services. Behavioral health services shall be provided as specified in A.R.S. § 36-2989 and this Chapter.

3. Definitions. The following definitions apply to this Article:

a. "Agency" for the purposes of this Article, means the same as in A.A.C. R9-22-1201.

b. "Behavior management services" means the same as in A.A.C. R9-22-1201.

c. "Behavioral health adult therapeutic home" means the same as in A.A.C. R9-22-1201.

d. "Behavioral health therapeutic home care services" means the same as in A.A.C. R9-22-1201.

e. "Behavioral health evaluation" means the same as in A.A.C. R9-22-1201.

f. "Behavioral health medical practitioner" means the same as in A.A.C. R9-22-1201.

g. "Behavioral health professional" means the same as in A.A.C. R9-20-101.

h. "Behavioral health service" means the same as in A.A.C. R9-22-1201.

i. "Behavioral health technician" means the same as in A.A.C. R9-22-1201.

j. "Certified psychiatric nurse practitioner" means the same as in A.A.C. R9-22-1201.

k. "Client" means the same as in A.A.C. R9-22-1201.

l. "Cost avoid" means the same as in A.A.C. R9-22-1201.

m. "Health care practitioner" means the same as in A.A.C. R9-22-1201.

n. "Licensee" means the same as in A.A.C. R9-22-1201.

o. "OBHL" means the same as in A.A.C. R9-20-101.

p. "Partial care" means the same as in A.A.C. R9-22-1201.

q. "Physician assistant" means the same as in A.A.C. R9-22-1201.

r. "Psychiatrist" means the same as in A.A.C. R9-22-1201.

s. "Psychologist" means the same as in A.A.C. R9-22-1201.

t. "Qualified behavioral health service provider" means the same as in A.A.C. R9-22-1201.

u. "Residual functional deficit" means the same as in A.A.C. R9-22-1201.

v. "Respite" means the same as in A.A.C. R9-22-1201.

w. "Substance abuse" means the same as in A.A.C. R9-22-102.

x. "TRBHA" or "Tribal Regional Behavioral Health Authority" means the same as in A.A.C. R9-22-1201.

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; new Section adopted 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). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1202. ADHS and Contractor Responsibilities

A. ADHS responsibilities. Behavioral health services shall be provided by a RBHA through a contract with ADHS/DBHS. ADHS/DBHS shall contract with a RBHA for the provision of behavioral health services in R9-22-1205 for all Title XXI members as specified in A.R.S. § 36-2989. ADHS/DBHS, the RBHA's, TRBHA's or subcontractors shall provide behavioral health services to Title XXI members in accordance with R9-22-1202.

B. ADHS/DBHS may contract with a TRBHA for the provision of covered behavioral health services for Native American members. Native American members may receive covered behavioral health services:

1. From an IHS facility,

2. From a TRBHA, or

3. From a RBHA when referred off-reservation.

C. ADHS/DBHS, the RBHA's, TRBHA's, subcontractors of ADHS/DBHS, and AHCCCS acute care contractors shall cooperate as specified in contract when a transition from one entity to another becomes necessary.

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; new Section adopted 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). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1203. Eligibility for Covered Services

A. Eligibility for covered services. A member determined eligible under A.R.S. § 36-2981 shall receive medically necessary covered services specified in R9-22-1205.

B. Limitations. Behavioral health services are covered as specified in R9-22-201 and R9-22-1205.

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; new Section adopted 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). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1204. General Service Requirements

A. Services. Behavioral health services include both mental health and substance abuse services.

B. Medical necessity. A service shall be medically necessary as under R9-31-201.

C. Prior authorization. A provider shall comply with the prior authorization requirements of the contractor and the following:

1. Emergency behavioral health services. A provider is not required to obtain prior authorization for emergency behavioral health services.

2. Non-emergency behavioral health services. When a member's behavioral health condition is determined not to require emergency behavioral health services, the provider shall follow the prior authorization requirements of a contractor.

D. Experimental services. Experimental services and services that are provided primarily for the purpose of research are not covered.

E. Gratuities. A service or an item, if furnished gratuitously to a member, is not covered and payment to a provider shall be denied.

F. GSA. Behavioral health services rendered to a member shall be provided within the RBHA's GSA except when:

1. A contractor's primary care provider refers a member to another area for medical specialty care,

2. A member's medically necessary covered service is not available within the GSA, or

3. A net savings in behavioral health service delivery costs can be documented by the RBHA for a member. Undue travel time or hardship shall be considered for a member or a member's family.

G. Travel. If a member travels or temporarily resides outside of a behavioral health service area, covered services are restricted to emergency behavioral health care, unless otherwise authorized by a member's RBHA.

H. Non-covered services. If a member requests a behavioral health service that is not covered by Title XXI or is not authorized by a RBHA or TRBHA, the behavioral health service may be provided by an AHCCCS registered behavioral health service provider under the provisions of R9-22-702.

I. Referral. If a member is referred outside of a RBHA or TRBHA GSA to receive authorized medically necessary behavioral health services, the RBHA or TRBHA is responsible for reimbursement, if the claim is otherwise payable under these rules.

J. Restrictions and limitations.

1. The restrictions, limitations, and exclusions in this Article do not apply to a contractor, ADHS/DBHS, or a RBHA when electing to provide a noncovered service.

2. Room and board is not a covered service unless provided in an inpatient, Level 1, sub-acute, or residential facility under R9-22-1205.

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; new Section adopted 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). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1205. Scope of Behavioral Health Services

The provisions of R9-22-1205 apply to the scope and coverage of behavioral health services under this Article, but an applicant or member is not eligible to receive covered behavioral health services if in an IMD at the time of application or at the time of redetermination.

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; new Section adopted 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). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1206. General Provisions and Standards for Service Providers

A. The provisions of R9-22-1206 apply to the general provisions and standards for a behavioral health service provider under this Article.

B. A qualified behavioral service provider shall comply with all requirements under Article 5 of this Chapter and 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). Section repealed; new Section adopted 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). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1207. General Provisions for Payment

A. Payment to ADHS/DBHS. The Administration shall make a monthly capitation payment to ADHS/DBHS based on the number of acute care members at the beginning of each month. ADHS/DBHS' administrative costs shall be incorporated into the capitation payment.

B. Claims submissions.

1. ADHS/DBHS shall require all service providers to submit clean claims no later than the time-frame specified in ADHS/DBHS' contract with the Administration.

2. Behavioral health service providers shall submit claims according to the payment provisions in A.A.C. R9-22-1207.

C. Prior authorization. Payment to a provider for behavioral health services or items requiring prior authorization may be denied if a provider does not obtain prior authorization from a RBHA, ADHS/DBHS, a TRBHA, or a contractor.

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; new Section adopted by exempt rulemaking at 6 A.A.R. 282, effective December 16, 1999 (Supp. 99-4). Amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

R9-31-1208. Repealed

Historical Note

New Section adopted 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). Section repealed by final rulemaking at 13 A.A.R. 1103, effective May 5, 2007 (Supp. 07-1).

ARTICLE 13. REPEALED

Article 13, consisting of Sections R9-31-1301 through R9-31-1309, repealed by final rulemaking at 10 A.A.R. 822, effective April 3, 2004. The subject matter of Article 13 is now in 9 A.A.C. 34 (Supp. 04-1).

R9-31-1301. 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).

R9-31-1302. 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).

R9-31-1303. 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).

R9-31-1304. 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).

R9-31-1305. 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).

R9-31-1306. 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).

R9-31-1307. 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).

R9-31-1308. 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).

R9-31-1309. 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).

ARTICLE 14. PREMIUMS FOR A CHILD DETERMINED ELIGIBLE UNDER ARTICLE 3

R9-31-1401. Purpose

This Article contains the requirements for the payment of a premium for a child determined eligible under Article 3 of this Chapter to the Administration by a member and the processing of a premium by the Administration.

Historical Note

New Section adopted by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Section repealed; new Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1402. Premium Amount for a Member who is a Child Determined Eligible Under Article 3 of this Chapter

A. For the purposes of this Article, a premium is a monthly amount that an enrolled member pays to the Administration to remain eligible for Title XXI.

B. When the household income is greater than 100 percent of the FPL and less than or equal to 150 percent of the FPL, the monthly premium is $10 for one eligible child and $15 for two or more eligible children.

C. When household income is greater than 150 percent of the FPL and less than or equal to 175 percent of the FPL, the monthly premium payment is $40 for one eligible child and $60 for two or more eligible children.

D. When household income is greater than 175 percent of the FPL and less than or equal to 200 percent of the FPL, the monthly premium is $50 for one eligible child and $70 for two or more eligible children.

E. A household's premium payments as specified in this Section shall not exceed five percent of a household's gross income.

F. A member's newborn is enrolled immediately upon the Administration receiving notification of the child's birth. Upon enrollment, the household's premium is redetermined.

G. To remain eligible, the premium amount shall be paid according to this Article.

H. Native Americans are exempt from paying premiums.

I. When a premium is paid for a household including the parents of a child eligible under Article 3 as described in Article 17, no separate premium is charged for the child under this Section.

Historical Note

New Section adopted by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 9 A.A.R. 4560, effective October 1, 2003 (Supp. 03-4). Amended by exempt rulemaking at 10 A.A.R. 504, effective February 1, 2004 (Supp. 04-1). Amended by exempt rulemaking at 10 A.A.R. 2887, effective July 1, 2004 (Supp. 04-2). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4). Amended by exempt rulemaking at 12 A.A.R. 4900, effective January 1, 2007 (Supp. 06-4). Amended by exempt rulemaking at 15 A.A.R. 876, effective June 1, 2009 (Supp. 09-2).

R9-31-1403. Repealed

Historical Note

New Section adopted 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). Section repealed by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1404. Hardship Exemption for a Member who is a Child Determined Eligible Under Article 3 of This Chapter

A. Definitions. The following definitions apply to this Section:

1. "Major expense" means the expense is more than 10 percent of the household's countable income under R9-31-304.

2. "Medically necessary" has the same meaning as defined in A.A.C. R9-22-101.

B. Hardship exemption. The Administration shall provide information to the head of household regarding the request for a hardship exemption. The Administration shall grant a hardship exemption from the disenrollment requirements under A.R.S. § 36-2982 for a household who:

1. Is no longer able to pay the premium due to one of the hardship criteria in subsection (C), and

2. Submits a written request for a hardship exemption and provides all necessary written information at the time of request.

C. Hardship criteria. To be eligible for a hardship exemption, a household shall have:

1. Medically necessary expenses or health insurance premiums that:

a. Are not covered under Medicaid or other insurance, and

b. Exceed 10 percent of the household's countable income under R9-31-304;

2. Unanticipated major expense, related to maintaining a residence for the household or transportation for work;

3. A combination of medically necessary expenses under subsection (C)(1) and unanticipated major expenses under subsection (C)(2) that exceed 10 percent of the household's countable income under R9-31-304; or

4. Experienced the death of a household member during the month the premium was not paid.

D. Written hardship exemption request. The Administration shall not consider a hardship exemption unless the Administration receives the written request and information under subsection (C) by the due date specified in the Administration's notice that explains the undue hardship exemption requirements.

E. Notification. The Administration shall notify the head of household of the approval or denial of the request for exemption and discontinuance under R9-31-310, no later than 10 days from the date the Administration received the request.

F. Appeal and Request for hearing. The head of household may appeal and request a hearing concerning the discontinuance and denial of the hardship exemption.

Historical Note

New Section adopted by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Former Section R9-31-1404 renumbered to R9-31-1405; new Section R9-31-1404 made by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Amended by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1405. Repealed

Historical Note

New Section adopted by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Former Section R9-31-1405 renumbered to R9-31-1406; new Section R9-31-1405 renumbered from R9-31-1404 and amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1406. Repealed

Historical Note

New Section adopted by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Former Section R9-31-1406 renumbered to R9-31-1407; new Section R9-31-1406 renumbered from R9-31-1405 and amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1407. Repealed

Historical Note

Renumbered from R9-31-1406 and amended by final rulemaking at 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1408. Repealed

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Section repealed by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1409. Payment Due Date for Current Month

The monthly premium payment is due on the 15th day of the month for coverage of that month. This would be considered a current payment.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1410. Payment Received Date

A payment is considered received on the date that the Administration receives and credits the payment to the member's account.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1411. Past Due Payment

A. Past due payment date. A payment is considered past due if the Administration receives the payment after the 15th day of the month.

B. Payment not received. If payment for a month is not received in full by the last working day of the month in which the payment is due, the Administration shall include the past and current due amounts in the next billing statement.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1412. Payment Type

A premium shall be paid to the Administration by a:

1. Cashier's check,

2. Personal check,

3. Money order,

4. Electronic debit, or

5. Other form approved by the Administration.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1413. Returned Check

The Administration shall not accept a personal check when the premium has been previously paid with a personal check that was returned to the Administration because of insufficient funds.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1414. Payment In Advance

A premium may be paid in advance.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1415. Reimbursement of a Premium

A. A premium paid in advance is nonrefundable, unless the member is disenrolled at least 15 days prior to the month of coverage.

B. A premium paid during an appeal and request for hearing process is applied as specified in R9-31-1419.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 9 A.A.R. 4560, effective October 1, 2003 (Supp. 03-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1416. Allocation of Payment for an Eligible Member

Except for payments specified in R9-31-1419 of this Article, all payments received for eligible members shall first be applied to any past due amounts for prior months owed to the Administration for a child determined eligible under Article 3 of this Chapter, next to the unpaid enrollment fee for a parent eligible under Article 17, and then to the past due amounts for prior months owed to the Administration for a parent determined eligible under Article 17 of this Chapter. Any remaining amounts shall first be applied to the amount due for the current month for a child eligible under Article 3 of this Chapter and then to the amount due for the current month for a parent, eligible under Article 17 of this Chapter.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1417. Change in Premium Amount

A. When there is a decrease in the premium amount and the change is processed by the 25th day of the month, then the effective date of the change shall begin on first day following the month in which the amount of the premium change is processed.

B. When there is a decrease in the premium amount and the change is processed after the 25th day of the month, then the effective date of the change shall begin on the first day of the second month in which the amount of the premium change is processed.

C. When there is an increase in the premium amount, the effective date of the change shall begin with the first month following advance notice of at least ten days.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1418. Discontinuance for Failure to Pay Premium

A. Discontinuance notice. The Administration shall send an adverse action notice to discontinue eligibility if the Administration does not receive the past and current due premium amounts by the 15th day of the current month. The Administration shall follow the discontinuance notice requirements under R9-31-310(B).

B. Discontinuance rescinded. The Administration shall rescind the discontinuance and continue eligibility if the past due amount for at least one prior month is received by the Administration in full before the effective date of the discontinuance.

C. Discontinuance of eligibility. Except as provided in R9-31-1419, the Administration shall discontinue eligibility on the effective date of the discontinuance if the past due amount for at least one prior month is not received by the Administration in full before the effective date of the discontinuance.

D. Notwithstanding subsection (A), the Administration shall not discontinue eligibility for the enrolled members of the household until the Administration has not received, by the 15th day of the month in which the Administration sends the adverse action notice, premium amounts due for the past two months and the current month for persons who:

1. Have been continuously eligible since June 2004,

2. Were required to pay a premium under R9-31-1402(B) for the month of July 2004,

3. Were required to pay any premium under R9-31-1402 for the month of August 2004, and

4. As of August 31, 2004, had not paid the premiums required for July 2004 and August 2004.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 10 A.A.R. 3895, effective August 30, 2004 (Supp. 04-3). Amended by exempt rulemaking at 10 A.A.R. 4268, effective October 1, 2004 (Supp. 04-3). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1419. Premium Payment During the Appeal and Request for Hearing Process

A. Discontinuance of eligibility. To receive coverage from the time an appeal and request for hearing is filed for a discontinuance of eligibility until a Director's decision is made.

1. A member shall:

a. File an appeal and request for hearing prior to the effective date of the discontinuance.

b. Submit the full monthly premium amount to the Administration prior to the date of the discontinuance, and

c. Continue to pay the full monthly premium amount each month during the hearing process.

2. Failure of the member to pay the full premium shall result in the loss of eligibility effective the first of the next month.

3. If the decision is upheld, the Administration shall not refund any premium amounts that have been paid during the hearing process.

B. Increase in premium amount. To stop the Administration from increasing the premium amount from the time an appeal and request for hearing is filed until a Director's decision is made.

1. A member shall file an appeal and request for hearing prior to the effective date of the action. The member shall pay the lower premium amount until the decision is made.

2. If the decision to increase the premium is upheld, the member shall be responsible for paying the higher premium retroactively from the proposed effective date of the increase in the premium amount that is being appealed.

C. Imposition of a premium. To receive coverage from the time an appeal and request for hearing is filed for an imposition of a premium until a Director's decision is made.

1. A member shall file an appeal and request for hearing in accordance with the time-frame as specified in R9-34-107.

2. A member shall pay the premium as billed by the Administration.

3. If the decision determines the imposition of the premium is incorrect then the premium will be refunded to the member.

D. Method of payment. To continue coverage a member shall pay the premium by:

1. Cashier's check,

2. Money order, or

3. Other form approved by the Administration.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1420. Payment of a Premium

When a member was discontinued with an unpaid premium, the parent or other responsible person shall pay the past due premium amounts for a child to the Administration before eligibility for the child under this Article can be approved.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

ARTICLE 15. RESERVED

ARTICLE 16. SERVICES FOR AMERICAN INDIANS

R9-31-1601. General Requirements

A. An American Indian who is a member may receive:

1. Covered acute care services specified in this Chapter from:

a. Indian Health Service (IHS) under A.R.S. § 36-2982 if IHS has a signed agreement with the Administration,

b. A Tribal Facility under A.R.S. § 36-2982,

c. A contractor under A.R.S. § 36-2901, or

d. An AHCCCS registered provider.

2. Covered behavioral health care services as specified in this Chapter from:

a. IHS under A.R.S. § 36-2982 if IHS has a signed agreement with the Administration,

b. A Tribal Facility under A.R.S. § 36-2982, or

c. A RBHA or TRBHA.

B. IHS, a Tribal facility, or a referred provider shall meet the requirements in this Chapter and A.A.C. Chapter 22, Articles 2 and 7 to receive reimbursement for AHCCCS-covered services. Title 9 A.A.C. 22, Articles 2 and 7 are applicable to reimbursement for AHCCCS-covered services provided to an American Indian member under the KidsCare program, except that the term "IHS," "Tribal facility," or "referred provider" is substituted for "provider."

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 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1). Amended by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1602. 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 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). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1603. 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. 2365, effective May 9, 2002 (Supp. 02-2). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1604. 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). Subsection labeling in subsection (A) amended to correct manifest typographical error (Supp. 01-3). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1605. 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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1606. 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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1607. 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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1608. 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. 2365, effective May 9, 2002 (Supp. 02-2). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1609. 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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1610. 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 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1611. 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. 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). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1612. 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. 2365, effective May 9, 2002 (Supp. 02-2). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1613. 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. 2365, effective May 9, 2002 (Supp. 02-2). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1614. 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 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. 4195, effective November 6, 2007 (Supp. 07-4). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1615. 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 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1616. 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 10 A.A.R. 4660, effective January 1, 2005 (04-4). Amended by final rulemaking at 11 A.A.R. 3854, effective November 12, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-1617. 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. 2365, effective May 9, 2002 (Supp. 02-2). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-1618. 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 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 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).

R9-31-1619. 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 11 A.A.R. 3171, effective October 1, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-1620. 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). Amended by final rulemaking at 11 A.A.R. 3246, effective October 1, 2005 (Supp. 05-3). Section repealed by final rulemaking at 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-1621. 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).

R9-31-1622. 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 7 A.A.R. 5846, effective December 7, 2001 (Supp. 01-4). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

R9-31-1623. 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 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Section repealed by final rulemaking at 8 A.A.R. 3350, effective July 15, 2002 (Supp. 02-3).

R9-31-1624. 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 13 A.A.R. 671, effective April 7, 2007 (Supp. 07-1).

R9-31-1625. 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 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). Section repealed by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).

ARTICLE 17. ELIGIBILITY, ENROLLMENT AND COST SHARING FOR A PARENT

Article 17, consisting of Sections R9-31-1701 through R9-31-1724, made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1701. General

A. Purpose. This Article contains the criteria to determine the eligibility, enrollment, and cost sharing for a parent under A.R.S. §§ 36-2982, 36-2983 and Laws 2006, Ch. 331, § 32. Unless otherwise noted in this Chapter, the provisions of this Chapter apply to a parent eligible under this Article.

B. Expenditure limit and enrollment

1. Eligibility of a parent shall be based on the FPL established in Laws 2006, Ch. 331, § 32, subject to the availability of monies. If the Director determines that monies are insufficient for the program, the eligibility agency shall suspend accepting new applications and shall deny all pending applications.

2. If the federal government eliminates federal funding for the program, the eligibility agency shall deny all pending applications and shall discontinue an eligible parent after providing advance notice that the program shall terminate under A.R.S. § 36-2985.

3. A parent is not entitled to a hearing under R9-31-1724 of this Article, if the program is suspended or terminated.

C. Definition

1. For the purposes of this Article, a child is:

a. A child, except for a deemed newborn, under A.R.S. § 36-2901(6)(a)(ii), who is determined eligible under 9 A.A.C. 22, Article 14, or

b. A child, except for a deemed newborn, under A.R.S § 36-2981(6) who is determined eligible under Article 3 of this Chapter. A child in the guaranteed enrollment period under R9-31-307 or a newborn under R9-31-309, is not considered a child under this Article.

2. For the purposes of this Article, a parent is defined under Laws 2006, Ch. 331, § 32 and also includes a stepparent. A parent of an 18 year old child under subsection (C)(1)(a) is not eligible under this Article.

3. For the purposes of this Article, eligibility agency means either DES or the Administration, whichever agency made the eligibility determination for the child.

D. Services. A parent eligible under this Article shall receive medically necessary services under 9 A.A.C. 22, Article 2.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4). Amended by exempt rulemaking at 12 A.A.R. 4900, effective January 1, 2007 (Supp. 06-4).

R9-31-1702. Application

A. Application form. A parent who wants to apply for eligibility under this Article shall apply using an application approved by the Administration.

B. Application process. For a parent of a child under R9-31-1701(C)(1)(a), the Administration shall process an application under A.A.C. R9-22-1405(A) through (F), R9-22-1411(A) and (C), and R9-22-1407. For a parent of a child under R9-31-1701(C)(1)(b), the Administration shall process an application under R9-31-302(A) through (E).

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by final rulemaking at 9 A.A.R. 5150, effective January 3, 2004 (Supp. 03-4).

R9-31-1703. Parent Eligibility Criteria

To be eligible, a parent shall be a parent of, and living with, a child as defined in R9-31-1701(C).

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1704. Income

To be eligible, the countable income shall be determined under R9-31-304 and shall not exceed the percentage of FPL established in Laws 2006, Ch. 331, § 32. For a parent of a child under R9-31-1701(C)(1)(a), the countable income shall include a stepparent's income if the stepparent is applying.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4). Amended by exempt rulemaking at 12 A.A.R. 4900, effective January 1, 2007 (Supp. 06-4).

R9-31-1705. Citizenship

To be eligible, a parent shall be a United States citizen or a qualified alien as specified in A.R.S. § 36-2903.03(B).

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1706. Residency

To be eligible, a parent shall be a current resident of the state of Arizona.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1707. Social Security Number (SSN)

To be eligible, a parent shall provide a SSN or apply for a SSN within 30 days after submitting an application.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1708. Age

To be eligible, a parent shall be age 19 or older.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1709. Ineligibility for Title XIX

To be eligible, a parent shall not be eligible for Title XIX under A.R.S. § 36-2901(6). A parent is not eligible under this Article if ineligibility for Title XIX is due to the parent's refusal to apply for Title XIX or the parent's noncompliance with a Title XIX eligibility requirement.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1710. Institutionalized Person

To be eligible, a parent shall not be an inmate of a public institution or a patient in an IMD under A.R.S. § 36-2983(G), unless federal financial participation is available.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1711. Other Health Coverage

To be eligible, a parent shall not be covered under an employer's group health insurance plan, family or individual health insurance, or other health insurance, including Medicare. Eligibility for the Indian Health Service is not considered other health coverage.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1712. State Health Benefits

To be eligible, a parent shall not be eligible for health coverage under a state health benefit plan based on a family member's employment with a public agency in the state of Arizona.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1713. Prior Health Insurance Coverage

To be eligible, a parent shall not have been covered by health insurance as defined in R9-31-1711 or R9-31-1712 of this Article, during the previous three months, unless that health insurance was discontinued due to the involuntary loss of employment or other involuntary reason.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1714. Repealed

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Section repealed by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1715. Repealed

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 9 A.A.R. 730, effective March 1, 2003 (Supp. 03-1). Section repealed by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4)

R9-31-1716. Verification

To be eligible, a parent shall provide verification or authorize the release of verification for all information necessary to complete the determination of eligibility.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1717. Assignment of Rights

To be eligible, a parent shall assign rights to any first- or third-party coverage of medical care as specified in Article 10 of this Chapter.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1718. Approval and Effective Date of Eligibility

A. Approval. An eligibility approval under this Article shall be determined by the Administration. The Administration shall follow the approval notice requirements in R9-31-310(A).

B. Effective date of eligibility. The effective date of eligibility is the later of one of the following:

1. The first day of the month following the eligibility determination for a determination made on or before the 25th day of the month,

2. The first day of the second month following the eligibility determination for a determination made after the 25th day of the month, or

3. The first day of the month in which the parent meets all eligibility requirements in this Article.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1719. Enrollment

There is no guaranteed enrollment period for a parent eligible under this Article.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1720. Change and Redetermination

A. Reporting a change. A parent eligible under this Article shall report the following changes to the eligibility agency:

1. An increase or decrease in income,

2. A change of address,

3. A move out of state,

4. An addition or departure of a household member,

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

6. Eligibility for health coverage under a state health benefit plan based on a family member's employment with a public agency in the state of Arizona,

7 Incarceration of a member,

8. Becoming an inpatient in an IMD, and

9. Receipt of a SSN.

B. Verification. If required verification is needed and requested by the eligibility agency as a result of a change specified in subsection (A), to determine the impact on eligibility, and is not received within 10 days, the Administration shall send a notice to discontinue eligibility.

C. Redetermination. The eligibility agency shall complete a redetermination of each parent's eligibility at least once every 12 months.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1721. Denial of Eligibility

A. For a parent of a child under R9-31-1701(C)(1)(a):

1. DES shall deny eligibility under this Article if the parent does not meet a requirement under this Article except for R9-31-1726 of this Article. DES shall follow the denial notice requirements in A.A.C. R9-22-1411(C); and

2. The Administration shall deny eligibility under this Article if the parent does not meet the requirement under R9-31-1726 of this Article. The Administration shall follow the denial notice requirements under R9-31-310(A)(2).

B. For a parent of a child under R9-31-1701(C)(1)(b), the Administration shall deny eligibility under this Article if any one of the conditions of eligibility listed in this Article is not met. The Administration shall follow the denial notice requirements under R9-31-310(A)(2).

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1722. Discontinuance of Eligibility and Notice Requirements

A. The Administration shall discontinue eligibility under this Article if any one of the conditions of eligibility listed in this Article is not met.

B. The Administration shall send an adverse action notice to discontinue eligibility if the Administration does not receive a payment that is equal to the past and current due premium amounts by the 15th day of the current month.

C. The Administration shall follow the discontinuance notice requirements under R9-31-310(B).

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1723. Newborn Eligibility

A child born to a mother eligible under R9-31-1701(C)(1)(a) shall follow the newborn eligibility under R9-22-1422. A child born to a mother eligible under R9-31-1701(C)(1)(b) shall follow the newborn eligibility under R9-31-309.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4).

R9-31-1724. Premium and Enrollment Fees

A. For the purposes of this Article:

1. A premium is a monthly payment that an enrolled member pays to the Administration to remain eligible.

2. An enrollment fee is the amount required by subsection (C)(4), which shall be paid to the Administration by a member who is a parent determined eligible under this Article. The enrollment fee and the first month's premium will be billed and due concurrently with the first month's payment.

3. To remain eligible, a parent shall pay the premium amount and enrollment fee according to this Article.

B. Premiums

1. When countable income is equal to or greater than 100 percent but less than 150 percent of the FPL, the monthly premium for the family is three percent of the countable income.

2. When countable income is equal to or greater than 150 percent but less than 175 percent of the FPL, the monthly premium for the family is five percent of the countable income.

3. When countable income is equal to or greater than 175 percent but less than or equal to 200 percent of the FPL, the monthly premium for the family is five percent of the countable income.

4. Native Americans are exempt from paying premiums.

5. When a premium is paid for a household including the parents of a child eligible under Article 3 as described in Article 17, no separate premium is charged for the child under this Section.

C. Enrollment Fees

1. A parent enrolled on or after January 1, 2005 will be charged an enrollment fee.

a. If a parent who has paid the enrollment fee does not receive coverage under this Article for a period of at least 24 months, the parent will be charged another enrollment fee if the parent is approved again under this Article.

b. If a parent who has paid the enrollment fee is discontinued under this Article for a period of less than 24 months, the parent will not be charged an enrollment fee when the parent is approved again.

2. A parent who was enrolled before January 1, 2005 will not be charged an enrollment fee unless the parent is discontinued under this Article and approved again.

3. Native Americans are exempt from paying the enrollment fee.

4. The enrollment fee amount:

a. For each eligible parent is $15 when countable income is less than or equal to 150 percent of the FPL.

b. For each eligible parent is $20 when countable income is greater than 150 percent of the FPL and less than or equal to 175 percent of the FPL.

c. For each eligible parent is $25 when countable income is greater than 175 percent of the FPL and less than or equal to 200 percent of the FPL.

Historical Note

New Section made by exempt rulemaking at 8 A.A.R. 5007, effective January 1, 2003 (Supp. 02-4). Amended by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4). Amended by exempt rulemaking at 12 A.A.R. 4900, effective January 1, 2007 (Supp. 06-4). Amended by exempt rulemaking at 15 A.A.R. 876, effective June 1, 2009 (Supp. 09-2).

R9-31-1725. Appeal and Request for Hearing Process

A. Denial. If DES denies a parent under R9-31-1721 of this Article, the appeal and request for hearing process shall be conducted under A.A.C. R9-22-1433. If the Administration denies a parent under R9-31-1721 of this Article, the appeal and request for hearing process shall be conducted under 9 A.A.C. 34.

B. Discontinuance. If the Administration discontinues a parent under R9-31-1722 of this Article, the appeal and request for hearing process shall be conducted under 9 A.A.C. 34.

C. Coverage for Discontinuance. Except as provided in this Section, the Administration shall discontinue eligibility on the effective date of the discontinuance if the past due amount for at least one prior month is not received by the Administration in full before the effective date of the discontinuance.

D. Discontinuance rescinded. The Administration shall rescind the discontinuance and continue eligibility if the past due amount for at least one prior month is received by the Administration in full before the effective date of the discontinuance.

E. Discontinuance of eligibility. To receive coverage from the time an appeal and request for hearing is filed for a discontinuance of eligibility until a Director's decision is made.

1. A member shall:

a. File an appeal and request for hearing prior to the effective date of the discontinuance.

b. Submit the full monthly premium amount to the Administration prior to the date of the discontinuance, and

c. Continue to pay the full monthly premium amount each month during the hearing process.

2. Failure of the member to pay the full monthly premium shall result in the loss of eligibility effective the first day of the next month.

3. If the decision is upheld, the Administration shall not refund any premium amounts that have been paid during the hearing process.

F. Increase in premium amount. To stop the Administration from increasing the premium amount from the time an appeal and request for hearing is filed until a Director's decision is made.

1. A member shall file an appeal and request for hearing prior to the effective date of the action.

2. If the decision to increase the premium is upheld, the member shall be responsible for paying the higher premium retroactively from the proposed effective date of the increase in the premium amount that is being appealed.

G. Imposition of an enrollment fee and premium. To receive coverage from the time an appeal and request for hearing is filed for an imposition of an enrollment fee and premium until a Director's decision is made.

1. A member shall file an appeal and request for hearing in accordance with the time-frame as specified in R9-34-107.

2. A member shall pay the enrollment fee and premium as billed by the Administration.

3. If the decision determines the imposition of the enrollment fee and premium is incorrect then the enrollment fee and premium will be refunded to the member.

H. Method of payment. To continue coverage a member shall pay the premium by:

1. Cashier's check,

2. Money order, or

3. Other form approved by the Administration.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1726. Payment of Outstanding Premium and Enrollment Fees

As a condition of eligibility, a parent shall be required to pay any unpaid enrollment fee and premiums owed to the Administration that were previously incurred. The unpaid enrollment fee and unpaid premiums consist of:

1. All unpaid enrollment fees and premiums for the parent that were incurred prior to becoming eligible,

2. All unpaid premiums for the parent's children, and

3. All unpaid enrollment fees and premiums for the parent's spouse with whom the parent resides, and with whom the parent resided at the time the premium and enrollment fee was incurred.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1727. Payment Due Date for Current Month

A. The monthly premium payment is due on the 15th day of the month for coverage of that month. This would be considered a current payment.

B. The enrollment fee is due with the first monthly premium payment on the 15th day of the month for coverage. This would be considered a current payment.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1728. Payment Received Date

A payment is considered received on the date that the Administration receives and credits the payment to the member's account.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1729. Past Due Payment

A. Past due payment date. A payment is considered past due if the Administration does not receive the payment by the 15th day of the month.

B. Payment not received. If payment for a month is not received in full by the last working day of the month in which the payment is due, the Administration shall include the past and current due amounts in the next billing statement.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1730. Payment Type

A premium and an enrollment fee shall be paid to the Administration by a:

1. Cashier's check,

2. Personal check,

3. Money order,

4. Electronic debit, or

5. Other form approved by the Administration.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1731. Returned Check

The Administration shall not accept a personal check when the premium or enrollment fee has been previously paid with a personal check that was returned to the Administration because of insufficient funds.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1732. Payment In Advance

A premium may be paid in advance.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1733. Reimbursement of a Premium

A. A premium paid in advance is nonrefundable, unless the member is disenrolled at least 15 days prior to the month of coverage.

B. A premium and enrollment fee paid during an appeal and request for hearing process is applied as specified in R9-31-1724.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1734. Allocation of Payment for an Eligible Member

Except for payments specified in R9-31-1724 of this Article, all payments received for eligible members shall first be applied to any past due amounts for prior months owed to the Administration for a child determined eligible under Article 3 of this Chapter, next to the unpaid enrollment fee for a parent eligible under this Article, and then to the past due amounts for prior months owed to the Administration for a parent determined eligible under this Article. Any remaining amounts shall first be applied to the amount due for the current month for a child eligible under Article 3 of this Chapter and then to the amount due for the current month for a parent, eligible under this Article.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).

R9-31-1735. Change in Premium Amount

A. When there is a decrease in the premium amount and the change is processed by the 25th day of the month, then the effective date of the change shall begin on first day following the month in which the amount of the premium change is processed.

B. When there is a decrease in the premium amount and the change is processed after the 25th day of the month, then the effective date of the change shall begin on the first day of the second month in which the amount of the premium change is processed.

C. When there is an increase in the premium amount, the effective date of the change shall begin with the first month following advance notice of at least ten days.

Historical Note

New Section made by exempt rulemaking at 11 A.A.R. 477, effective January 1, 2005 (Supp. 04-4).