Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 36, Arizona Revised Statutes,
is amended by adding chapter 31, to read:
CHAPTER 31
STATE HEALTH PLAN
ARTICLE 1. GENERAL PROVISIONS
START_STATUTE36-3101. Definitions
In this chapter, unless
the context otherwise requires:
1. "Beneficiary"
means a person who is eligible for health care and benefits pursuant to the
health plan.
2. "Budget"
means the total of all categories of dollar amounts of expenditures for a
stated period authorized for an entity or a program.
3. "Capital
budget" means that portion of a budget that establishes expenditures for
either:
(a) Acquisition or addition of
substantial improvement to real property.
(b) Acquisition of tangible personal
property.
4. "Case
management" means a comprehensive program designed to meet an individual's
need for care by coordinating and linking the components of health care.
5. "Commission"
means the health care commission.
6. "Consumer
price index for medical care prices" means that index as published by the
bureau of labor statistics of the United States department of labor.
7. "Financial
interest" means an ownership interest of any amount, direct or indirect.
8. "Group
practice" means an association of health care practitioners that provides
one or more specialized health care services or a tribal or urban Indian
coalition in partnership or under contract with the federal Indian health
service that is authorized under federal law to provide health care to Native
American populations in this state.
9. "Health
care" means health care practitioner services and health facility
services.
10. "Health
care practitioner" means:
(a) A person licensed or certified
to provide health care pursuant to title 32.
(b) A person licensed or certified
by a nationally recognized professional organization and designated as a health
care practitioner by the commission.
(c) A person in a group practice of
licensed practitioners.
(d) A transportation service.
11. "Health
facility" means:
(a) A school-based clinic.
(b) An Indian health service
facility.
(c) A tribally operated health care
facility.
(d) A licensed general hospital.
(e) A special hospital.
(f) An outpatient facility.
(g) A psychiatric hospital.
(h) A laboratory.
(i) A skilled nursing facility.
(j) A nursing facility.
12. "Health
plan" means the program that is established and administered by the
commission pursuant to this chapter.
13. "Major
capital expenditure" means construction or renovation of facilities or the
acquisition of diagnostic, treatment or transportation equipment by a health
care practitioner or a health facility that costs more than an amount
recommended and established by the commission.
14. "Operating
budget" means the budget of a health facility exclusive of the facility's
capital budget.
15. "Person"
means an individual or any other legal entity.
16. "Primary
care practitioner" means an allopathic physician, osteopathic physician,
nurse practitioner, physician assistant or other health care practitioner
certified by the commission.
17. "Practitioner
budget" means the authorized expenditures pursuant to payment mechanisms
established by the commission to pay for health care furnished by health care
practitioners participating in the health plan.
18. "Transportation
service" means a person providing the services of an ambulance, helicopter
or other conveyance that is equipped with health care supplies and equipment
and that is used to transport patients to other health care practitioners or
health facilities. END_STATUTE
START_STATUTE36-3102. Health care commission; membership
A. The
health care commission is established consisting of the following members:
1. Five
public members who are appointed by the governor.
2. Two
public members who are appointed by the speaker of the house of representatives.
3. Two
public members who are appointed by the president of the senate.
B. Commission
members serve staggered five year terms that begin and end on the third Monday
in January. Commission members shall not serve for more than two successive five
year terms or for more than ten consecutive years.
C. If
requested by the commission, the appointing authority may remove a commission
member for misconduct, incompetence or neglect of duty.
D. Commission
members are eligible for reimbursement of expenses pursuant to title 38,
chapter 4, article 2 to cover necessary expenses for attending each commission
meeting or for representing the commission in an official commission approved
activity.
E. Commission
members must be residents of this state and may not have any financial interest
in any health care profession.
F. A
commission member who acts within the scope of commission duties, without
malice and in the reasonable belief that the person's action is warranted by
law is not subject to civil liability. END_STATUTE
START_STATUTE36-3103. Executive director
A. The
commission shall hire an executive director as an employee of the commission.
The executive director is responsible for the performance of the regular
administrative functions of the commission and the administration of this
chapter.
B. The
commission may hire other employees necessary to carry out this chapter and may
contract with other state agencies to carry out this chapter. END_STATUTE
START_STATUTE36-3104. Duties of the commission
The commission shall:
1. Adopt a
five year plan for the initial implementation of the health plan as prescribed
by this chapter, update that plan and adopt other long‑range and
short-range plans to provide continuity and development of the state's health
care system.
2. Design
the health plan to fulfill the purposes of and conform to the requirements of
the health plan as prescribed by this chapter for implementation beginning
January 1, 2010.
3. Provide a
program to educate the public, health care practitioners and health facilities
about the health plan and the persons eligible to receive its benefits.
4. Study and
adopt as provisions of the health plan prescribed by this chapter
cost-effective methods of providing quality health care to all beneficiaries,
giving high priority to increased reliance on:
(a) Preventive and primary care that
includes immunization and screening examinations.
(b) Providing health care in rural
or underserved areas of this state.
(c) In-home and community-based
alternatives to institutional health care.
(d) Case management services if
appropriate.
5. Establish
compensation methods for health care practitioners and health facilities and
adopt standards and procedures for negotiating and entering into contracts with
participating health care practitioners and health facilities.
6. Annually,
and for those projected future periods the commission believes appropriate,
establish health plan budgets.
7. Establish
capital budgets for health facilities, limited to capital expenditures subject
to the requirements of this chapter, and include in those budgets:
(a) Standards and procedures for
determining the budgets.
(b) A requirement for prior approval
by the commission for major capital expenditures by a health facility.
8. Negotiate
and enter into health care reciprocity agreements with other states and
countries and negotiate and enter into health care agreements with out‑of‑state
health care practitioners and health facilities.
9. Develop
claims and payment procedures for health care practitioners, health facilities
and claims administrators and include provisions to ensure timely payments and
provide for payment of interest if reimbursable claims are not paid within a
reasonable time.
10. In
conjunction with other state agencies similarly charged, establish a system to
collect and analyze standard health data and other data necessary to improve
the quality, efficiency and effectiveness of health care and to control costs
of health care in this state. The system shall include data on the following:
(a) Mortality, including accidental
causes of death.
(b) Natality.
(c) Morbidity.
(d) Health behavior.
(e) Physical and psychological
impairment and disability.
(f) Health care system costs and
health care availability, utilization and revenues.
(g) Environmental factors.
(h) Availability, adequacy and
training of health care personnel.
(i) Demographic factors.
(j) Social and economic conditions
affecting health.
(k) Health outcomes.
(l) Other factors as determined by
the commission.
11. Standardize
data collection and specific methods of measurement across databases and use
scientific sampling or complete enumeration for reporting health information.
12. Establish
a health care delivery system that is efficient to administer and that
eliminates unnecessary administrative costs.
13. Adopt
rules necessary to implement and monitor a preferred drug list, bulk purchasing
or other mechanism to provide prescription drugs and a pricing procedure for
nonprescription drugs, durable medical equipment and supplies, eyeglasses,
hearing aids and oxygen.
14. Establish
a pharmacy and therapeutics committee to:
(a) Conduct concurrent, prospective
and retrospective drug utilization review.
(b) Conduct pharmacologic research
and analysis of clinical safety, efficacy and effectiveness of drugs.
(c) Consult with specialists in
appropriate fields of medicine for therapeutic classes of drugs.
(d) Recommend therapeutic classes of
drugs, including specific drugs within each class to be included in the
preferred drug list.
(e) Identify appropriate exclusions
from the preferred drug list.
(f) Conduct periodic clinical
reviews of preferred, nonpreferred and new drugs.
15. Study
and evaluate the adequacy and quality of health care furnished pursuant to this
chapter, the cost of each type of service and the effectiveness of cost containment
measures in the health plan.
16. Study
and monitor the migration of persons to this state to determine if persons with
costly health care needs are moving to this state to receive health care, and
if migration appears to threaten the financial stability of the health plan,
recommend to the legislature changes in eligibility requirements, premiums or
other changes that may be necessary to maintain the financial integrity of the
health plan.
17. Establish
and approve changes in coverage benefits and benefit standards in the health
plan.
18. Conduct
necessary investigations and inquiries.
19. Adopt
rules necessary to implement, administer and monitor the operation of the
health plan.
20. Adopt
rules to establish a procurement process for services and property.
21. Meet as
needed, but not less than once every month.
22. Submit
an annual report to the governor, the speaker of the house of representatives
and the president of the senate and provide a copy of this report to the
secretary of state and the director of the Arizona state library, archives and
public records. The report shall include the following:
(a) A summary of information about
health care needs, health outcomes, health care services, health care
expenditures, revenues received and projected revenues and other relevant
issues relating to the health plan, the initial five year plan and future
updates of that plan and other long-range and short-range plans.
(b) Recommendations on methods to
control health care costs and improve access to and the quality of health care
for state residents, as well as recommendations for legislative action. END_STATUTE
START_STATUTE36-3105. Commission authority
The commission has the
authority necessary to carry out the powers and duties pursuant to this
chapter. The commission retains responsibility for its duties but may delegate
authority to the executive director except, that the authority to take the
following actions is expressly reserved to the commission:
1. Approve
the commission's budget and plan of operation.
2. Approve
the health plan and make changes in the health plan, but only after legislative
approval of those changes pursuant to section 36-3121.
3. Adopt
rules and conduct both rule making and adjudicatory hearings in person or by
use of an administrative law judge.
4. Issue
subpoenas to persons to appear and testify before the commission and to produce
documents and other information relevant to the commission's inquiry and
enforce this subpoena power through an action in the superior court.
5. Make
reports and recommendations to the legislature.
6. Subject
to the requirements of section 36-3112, apply for program waivers from any
governmental entity if the commission determines that the waivers are necessary
to ensure the participation by the greatest possible number of beneficiaries.
7. Apply for
and accept grants, loans and donations.
8. Acquire
or lease real property and make improvements on it and acquire by lease or by
purchase tangible and intangible personal property.
9. Dispose
of and transfer personal property, but only at public sale after adequate
notice.
10. Appoint
and prescribe the duties of employees, fix their compensation, pay their
expenses and provide an employee benefit program.
11. Establish
and maintain banking relationships, including establishment of checking and
savings accounts.
12. Enter
into agreements with employers to provide health care services for the
employers' employees or retirees. This chapter does not reduce or eliminate
benefits to which the employee or retiree is entitled. END_STATUTE
START_STATUTE36-3106. Advisory boards
The commission may
establish advisory boards to assist it in performing its duties. Advisory
boards shall assist the commission in matters requiring the expertise and
knowledge of the advisory boards' members. END_STATUTE
START_STATUTE36-3107. Health care delivery regions
The commission shall
establish health care delivery regions in this state based on geography and
health care resources. The regions may have differential fee schedules,
budgets, capital expenditure allocations or other features to encourage the
provision of health care in rural and other underserved areas or to otherwise
tailor the delivery of health care to fit the needs of a region or a part of a
region. END_STATUTE
START_STATUTE36-3108. Health plan
A. After
notice and public hearing, including taking public comment and the reports of
the regional councils, the commission, in conjunction with other appropriate
state agencies, shall adopt a five year health plan and review it at regular
intervals for possible revision.
B. The
health plan shall be designed to provide comprehensive, necessary and
appropriate health care benefits, including preventive health care and primary,
secondary and tertiary health care for acute and chronic conditions. The
health plan may provide for certain health care services to be phased in as the
health plan budget allows.
C. Pursuant
to the phase-in requirements of subsection B of this section, the commission
shall provide for coverage of the following health care services:
1. Preventive
health services.
2. Health
care practitioner services.
3. Health
facility inpatient and outpatient services.
4. Laboratory
tests and radiology procedures.
5. Hospice
care.
6. In-home,
community-based and institutional long-term care services.
7. Prescription
drugs.
8. Inpatient
and outpatient mental and behavioral health services.
9. Drug and
other substance abuse services.
10. Preventive
and prophylactic dental services, including an annual dental examination and
cleaning.
11. Vision
appliances, including medically necessary contact lenses.
12. Medical
supplies, durable medical equipment and selected assistive devices, including
hearing and speech assistive devices.
13. Experimental
or investigational procedures or treatments as specified by the commission.
D. Covered
health care does not include:
1. Surgery
for cosmetic purposes other than for reconstructive purposes.
2. Medical
examinations and medical reports prepared for purchasing or renewing life
insurance or participating as a plaintiff or defendant in a civil action for
the recovery or settlement of damages.
3. Orthodontic
services and cosmetic dental services except those cosmetic dental services
necessary for reconstructive purposes.
E. The
health plan shall specify the health care to be covered and the amount, scope
and duration of benefits.
F. The
health plan shall contain provisions to control health care costs so that
beneficiaries receive comprehensive, high-quality health care consistent with
available revenue and budget constraints.
G. The
health plan shall phase in beneficiaries as their participation becomes
possible through contracts, waivers or federal legislation. The health plan
may provide for certain preventive health care to be offered to residents of
this state regardless of a person's eligibility to participate as a
beneficiary.
H. The five
year plan as well as other long-range and short-range plans adopted by the
commission shall be reviewed by the regional councils and the commission
annually and revised as necessary. Revisions shall be adopted by the
commission pursuant to section 36-3104. In projecting services under the
health plan, the commission shall take all reasonable steps to ensure that
long-term care and dental care are provided at the earliest practicable times
consistent with budget constraints. END_STATUTE
START_STATUTE36-3109. Long-term care
A. Not later
than one year after the effective date of this chapter, the commission shall
appoint an advisory long-term care committee made up of representatives of
health care consumers, practitioners and administrators to develop a plan for
integrating long-term care into the health plan. The committee shall report
its plan to the commission not later than one year after its
appointment. Committee members are eligible to receive reimbursement
of expenses pursuant to title 38, chapter 4, article 2.
B. The
long-term care component of the health plan shall provide for case management
and noninstitutional services if appropriate.
C. Subject
to the requirements of sections 36-3131 and 36-3132, this section does not
affect long-term care services paid through private insurance or state or
federal programs.
D. This
section does not prevent the commission from including long‑term care
services from the inception of the health plan. END_STATUTE
START_STATUTE36-3110. Mental and behavioral health services
A. Not later
than one year after appointment of the executive director, the commission shall
appoint an advisory mental and behavioral health services committee made up of
representatives of mental and behavioral health care consumers, practitioners
and administrators to develop a plan for coordinating mental and behavioral
health services within the health plan. The committee shall report its plan to
the commission not later than one year after its
appointment. Committee members are eligible to receive reimbursement
of expenses pursuant to title 38, chapter 4, article 2.
B. The
mental and behavioral health services component of the health plan shall
provide for case management and noninstitutional services if appropriate.
C. The
health plan shall not impose treatment limitations or financial requirements on
the provision of mental and behavioral health benefits if identical limitations
or requirements are not imposed on coverage of benefits for other conditions.
D. Subject
to the requirements of sections 36-3131 and 36-3132, this section does not
limit mental and behavioral health services paid through private insurance or
state or federal programs. END_STATUTE
START_STATUTE36-3111. Medicaid coverage; agreements
The commission may
enter into appropriate agreements with other state agencies for the purpose of
furthering the goals of this chapter. These agreements may provide for certain
services provided pursuant to title XIX and title XXI of the social security
act to be administered by the commission to implement the health plan. END_STATUTE
START_STATUTE36-3112. Health plan coverage; conditions of
eligibility for beneficiaries; exclusions
A. An
individual is eligible as a beneficiary of the health plan if the individual
physically resides in this state as of the date of application for enrollment
in the health plan and if the individual has a current intention to remain in
this state and not to reside elsewhere. A dependent of an eligible individual
is included as a beneficiary.
B. Individuals
covered under the following governmental programs shall not be brought into
coverage:
1. Federal retiree health plan beneficiaries.
2. Active
duty and retired military personnel.
3. Individuals
covered by the federal active and retired military health programs.
C. Federal
Indian health service or tribally operated health care program beneficiaries
shall not be brought into coverage except through agreements with:
1. Indian
communities.
2. Consortia
of Indian communities.
3. A federal
Indian health service agency subject to the approval of the Indian communities
located in that agency.
D. An
employer that provides health care benefits for its employees after retirement,
including coverage for payment of health care supplementary coverage if the
retiree is eligible for medicare, may agree to participate in the health plan
if there is no loss of benefits under the retiree health benefit coverage. An
employer that participates in the health plan shall contribute to the health
plan for the benefit of the retiree, and the agreement shall ensure that the
health benefit coverage for the retiree is restored if the retiree becomes
ineligible for health plan coverage.
E. The
commission shall prescribe by rule conditions under which other persons in this
state may be eligible for coverage pursuant to the health plan. END_STATUTE
START_STATUTE36-3113. Health plan coverage of nonresident
students
A. Except as
provided in subsection B, an educational institution shall purchase coverage
under the health plan for its nonresident students through fees assessed to
those students. The governing body of an educational institution shall
set the fees at the amount determined by the commission.
B. A
nonresident student at an educational institution may satisfy the requirement
for health care coverage by proof of coverage under a policy or plan in another
state that is acceptable to the commission. The student shall not be assessed
a fee in that case.
C. The
commission shall adopt rules to determine proof of an individual's eligibility
for the health plan or a student's proof of nonresident health care coverage. END_STATUTE
START_STATUTE36-3114. Removing ineligible persons
The commission shall
adopt rules to provide procedures for removing persons who are no longer
eligible for coverage. END_STATUTE
START_STATUTE36-3115. Eligibility card; use; misuse of care;
violation; classification
A. A
beneficiary shall receive a card as proof of eligibility. The card shall be
electronically readable and shall contain a picture or electronic image,
information that identifies the beneficiary for treatment, billing and payment
and other information the commission deems necessary. The use of a
beneficiary's social security number as an identification number is not
permitted.
B. The
eligibility card is not transferable. A beneficiary who lends the
beneficiary's card to another and an individual who uses another's card are
jointly and severally liable to the commission for the full cost of the health
care provided to the user. The liability shall be paid in full within one year
after final determination of liability. Liabilities established pursuant to
this section shall be collected in a manner similar to that used for collection
of delinquent taxes.
C. A
beneficiary who lends the beneficiary's card to another or an individual who
uses another's card after being determined liable pursuant to subsection B of a
previous misuse is guilty of a class 2 misdemeanor. A beneficiary who is
convicted of A third or subsequent conviction is guilty of a class 6 felony. END_STATUTE
START_STATUTE36-3116. Primary care practitioner; right to
choose; access to services
A. Except as
otherwise prescribed by law, a beneficiary may choose a primary care
practitioner.
B. The
primary care practitioner is responsible for providing health care practitioner
services to the patient except for:
1. Services
in medical emergencies.
2. Services
for which a primary care practitioner determines that specialist services are
required, in which case the primary care practitioner must advise the patient
of the need for and the type of specialist services.
C. Except as
otherwise provided in this section, health care practitioner specialists shall
be paid pursuant to the health plan only if the patient has been referred by a
primary care practitioner. This subsection does not prevent a
beneficiary from obtaining the services of a health care practitioner
specialist and paying the specialist for services provided.
D. The
commission by rule shall specify when and under what circumstances a
beneficiary may self-refer, including self-referral to a chiropractic
physician, a doctor of oriental medicine, mental and behavioral health service
practitioners and other health care practitioners who are not primary care
practitioners.
E. The
commission by rule shall specify the conditions under which a beneficiary may
select a specialist as a primary care practitioner. END_STATUTE
START_STATUTE36-3117. Discrimination prohibited
A health care
practitioner or health facility shall not discriminate against or refuse to
furnish health care to a beneficiary on the basis of age, race, color, income
level, national origin, religion, gender, sexual orientation, gender identity,
disabling condition or payment status. This section does not require a health
care practitioner or health facility to provide services to a beneficiary if
the practitioner or facility is not qualified to provide the needed services or
does not offer them to the general public. END_STATUTE
START_STATUTE36-3118. Claims review
A. The commission shall adopt rules to provide a
comprehensive claims review program. The procedures and standards used in the
program shall be disclosed in writing to applicants, beneficiaries, health care
practitioners and health facilities at the time of application to or
participation in the health plan.
B. The
decision to approve or deny a claim based on a technicality shall be made in a
timely manner and shall not exceed time limits established by rule of the
commission. A final decision to deny payment for services based on medical
necessity or utilization shall be based on a recommendation made by a health
care professional having appropriate and adequate qualifications to make the
recommendation. A denial of a claim for payment of a medical specialty service
based on medical necessity or utilization shall be made only after a written
recommendation for denial is made by a member of that medical specialty with
credentials equivalent to those of the practitioner.
C. The fact
of and the specific reasons for a denial of a health care claim shall be
communicated promptly in writing to both the practitioner and the beneficiary
involved. END_STATUTE
START_STATUTE36-3119. Quality of care; health care
practitioner and health facilities; practice standards
A. The
commission shall adopt rules to establish and implement a quality improvement
program that monitors the quality and appropriateness of health care provided
by the health plan, including evidence-based best practices, outcome
measurements, consumer education and patient safety. The commission shall set
standards and review benefits to ensure that effective, cost-efficient, high
quality and appropriate health care is provided under the health plan.
B. The
commission shall review and adopt professional practice guidelines developed by
state and national health care and specialty organizations, federal agencies
for health care policy and research and other organizations as it deems
necessary to promote the quality and cost‑effectiveness of health care
provided through the health plan.
C. The
quality improvement program shall include an ongoing system for monitoring
patterns of practice. The commission shall appoint a health care practice
advisory committee consisting of health care practitioners, health facilities
and other knowledgeable persons to advise the commission and staff on health
care practice issues. The committee may appoint subcommittees and task forces
to address practice issues of a specific health care practitioner discipline or
a specific kind of health facility if the subcommittee or task force includes
practitioners of substantially similar specialties or types of
facilities. The advisory committee shall provide to the commission
recommended standards and guidelines to be followed in making determinations on
practice issues.
D. With the
advice of the health care practice advisory committee, the commission shall
establish a system of peer education for health care practitioners or health
facilities determined to be engaging in aberrant patterns of practice pursuant
to subsection B. If the commission determines that peer education efforts have
failed, the commission may refer the matter to the appropriate licensing or
certifying board.
E. The
commission shall provide by rule the procedures for recouping payments or
withholding payments for health care determined by the commission with the
advice of the health care practice advisory committee or subcommittee to be
medically unnecessary.
F. The
commission by rule may provide for the assessment of administrative penalties
for up to three times the amount of excess payments if it finds that excessive
billings were part of an aberrant pattern of practice. Administrative
penalties shall be deposited in the state general fund.
G. After
consultation with the health care practice advisory committee, the commission
may suspend or revoke a health care practitioner's or health facility's
privilege to be paid for health care provided under the health plan based on
evidence clearly supporting a determination by the commission that the
practitioner or facility engages in aberrant patterns of practice, including
inappropriate utilization, attempts to unbundle health care services or other
practices that the commission deems a violation of this chapter or rules
adopted pursuant to this chapter. For the purposes of this subsection,
"unbundle" means to divide a service into components in an attempt to
increase or with the effect of increasing compensation from the health plan.
H. The
commission shall report a suspension or revocation of the privilege to be paid
for health care pursuant to this chapter to the appropriate licensing or
certifying board.
I. The
commission shall report cases of suspected fraud by a health care practitioner
or a health facility to the attorney general or to the county attorney of the
county where the health care practitioner or health facility operates for
investigation and prosecution. END_STATUTE
START_STATUTE36-3120. Judicial review
A person who is
specifically and directly aggrieved by a final decision of the commission may
seek judicial review of the decision pursuant to title 12, chapter 7, article
6. END_STATUTE
START_STATUTE36-3121. Health plan budget
A. The
commission shall develop an annual health plan budget. The budget
shall be the commission's recommendation for the total amount to be spent by
the plan for covered health care services in the next fiscal year.
B. Unless
otherwise provided by legislative act, the health plan budget shall be within
projected annual revenues. The commission shall implement the health plan
budget.
C. In
developing the health plan budget, the commission shall provide that credit be
taken in the budget for all revenues produced for health care in this state
pursuant to any law other than this chapter.
D. The
health plan shall include a maximum amount or percentage for administrative
costs, and this maximum, if a percentage, may change in relation to the total
costs of services provided under the health plan. For the sixth and subsequent
calendar years of operation of the health plan, administrative costs shall not
exceed five per cent of the health plan budget. END_STATUTE
START_STATUTE36-3122. Payments to health care practitioners;
copayments
A. The
commission shall prepare a practitioner budget. Consistent with the
practitioner budget, the health plan shall provide payment for all covered
health care rendered by health care practitioners. A variety of payment plans,
including fee-for-service, may be adopted by the commission. Payment plans
shall be negotiated with practitioners as provided by rule. If negotiation
fails to develop an acceptable payment plan, the disputing parties shall submit
the dispute for judicial review pursuant to section 36‑3120.
B. Supplemental
payment rates may be adopted to provide incentives to help ensure the delivery
of needed health care in rural and other underserved areas throughout the
state.
C. An annual
percentage increase in the amount allocated for practitioner payments in the
budget shall not be greater than the annual percentage increase in the consumer
price index for medical care prices published by the bureau of labor statistics
of the United States department of labor using the year before the year in
which the health plan is implemented as the baseline year. The
annual limitation in this subsection may be adjusted up or down by the
commission based on a showing of special and unusual circumstances in a hearing
before the commission.
D. Payment,
or the offer of payment whether or not that offer is accepted, to a health care
practitioner for services covered by the health plan shall be payment in full
for those services. A health care practitioner shall not charge a beneficiary
an additional amount for services covered by the plan.
E. The
commission may establish a copayment schedule if a required copayment is
determined to be an effective cost-control measure. A copayment shall not be
required for preventive health care. If a copayment is required, the health
care practitioner shall not waive it and if it remains uncollected, the health
care practitioner shall demonstrate a good faith effort to have collected the
copayment. END_STATUTE
START_STATUTE36-3123. Payments to health facilities;
copayments
A. A health
facility shall negotiate an annual operating budget with the commission. The operating
budget shall be based on a base operating budget of past performance and
projected changes upward or downward in costs and services anticipated for the
next year. If a negotiated annual operating budget is not agreed on, a health
facility shall submit the budget for judicial review pursuant to section
36-3120. An annual percentage increase in the amount allocated for a health
facility operating budget shall not be greater than the change in the annual
consumer price index for medical care prices, published annually by the bureau
of labor statistics of the United States department of labor. The annual
limitation in this subsection may be adjusted up or down by the commission
based on a showing of special and unusual circumstances in a hearing before the
commission.
B. Supplemental
payment rates may be adopted to provide incentives to help ensure the delivery
of needed health care services in rural and other underserved areas as
prescribed in section 36-2352, subsection A, paragraph 2, throughout the state.
C. Each
health care practitioner employed by a health facility shall be paid from the
facility's operating budget in a manner determined by the health facility.
D. The
commission may establish a copayment schedule if a required copayment is determined
to be an effective cost-control measure. A copayment shall not be required for
preventive care. If a copayment is required, the health facility shall not
waive it and if it remains uncollected, the health facility shall demonstrate a
good faith effort to have collected the copayment. END_STATUTE
START_STATUTE36-3124. Health resource certificate;
commission rules; requirement for review
A. The
commission shall adopt rules stating when a health facility or health care
practitioner participating in the health plan must apply for a health resource
certificate, how the application will be reviewed, how the certificate will be
granted, how an expedited review is conducted and other matters relating to
health resource projects.
B. Except as
provided in subsection F, a health facility or health care practitioner
participating in the health plan shall not make or obligate itself to make a
major capital expenditure without first obtaining a health resource
certificate.
C. A health
facility or health care practitioner shall not acquire through rental, lease or
comparable arrangement or through donation all or a part of a capital project
that would have required review if the acquisition had been by purchase unless
the project is granted a health resource certificate.
D. A health
facility or health care practitioner shall not engage in component purchasing
in order to avoid the requirements of this section.
E. The
commission shall grant a health resource certificate for a major capital
expenditure or a capital project undertaken pursuant to subsection C only if
the project is determined to be needed.
F. This
section does not apply to:
1. The
purchase, construction or renovation of office space for health care
practitioners.
2. Expenditures
incurred solely in preparation for a capital project, including architectural
design, surveys, plans, working drawings and specifications and other related
activities, but those expenditures shall be included in the cost of a project
for the purpose of determining whether a health resource certificate is
required.
3. Acquisition
of an existing health facility, equipment or practice of a health care
practitioner that does not result in a new service being provided or in
increased bed capacity.
4. Major
capital expenditures for nonclinical services if the nonclinical services are
the primary purpose of the expenditure.
5. The
replacement of equipment with equipment that has the same function and that
does not result in the offering of new services.
G. No later
than January 1, 2009, the commission shall report to the appropriate committees
of the legislature on the capital needs of health facilities, including
facilities of state and local governments, with a focus on underserved
geographic areas with substantially below-average health facilities and
investment per capita as compared to the state average. The report shall also
describe geographic areas where the distance to health facilities imposes a
barrier to care. The report shall include a section on health care
transportation needs, including capital, personnel and training needs. The
report shall make recommendations for legislation to amend this chapter that
the commission determines necessary and appropriate. END_STATUTE
START_STATUTE36-3125. Actuarial review; audits
A. The
commission shall provide for an annual independent actuarial review of the health
plan and any funds of the commission or the plan.
B. The
commission shall provide by rule requirements for independent financial audits
of health care practitioners and health facilities.
C. The
commission, through its staff or by contract, shall perform announced and
unannounced audits, including financial, operational, management and electronic
data processing audits of health care practitioners and health facilities.
Audit findings shall be reported directly to the commission. The auditor general
may be asked by the commission to review preliminary findings or to consult
with audit staff before the findings are reported to the commission.
D. Actuarial
reviews, financial audits and internal audits are public documents after they
have been released by the commission if the reports protect private and
confidential information of a patient or practitioner. Copies of reviews,
audits and other reports shall be transmitted to the governor, the president of
the senate and the speaker of the house of representatives. The Commission
shall make these documents available on the internet and shall provide copies
of these documents to the secretary of state and the director of the Arizona state library, archives and public records. END_STATUTE
START_STATUTE36-3126. Standard claim forms for insurance
payment
The commission shall adopt standard claim forms and
electronic formats that shall be used by all health care practitioners and
health facilities that seek payment through the health plan or from private
persons, including private insurance companies, for health care services
rendered in this state. Each claim form or electronic format may indicate
whether a person is eligible for federal or other insurance programs for
payment. To the extent practicable, the commission shall require the use of
existing, nationally accepted standardized forms, formats and systems. END_STATUTE
START_STATUTE36-3127. Computerized system
The commission shall
require that all participating health care practitioners and health facilities
participate in the health plan's computer network that provides for electronic
transfer of payments to health care practitioners and health facilities,
transmittal of reports, including patient data and other statistical reports,
billing data, with specificity as to procedures or services provided to
individual patients, and any other information required or requested by the
commission. To the extent practicable, the commission shall require
the use of existing, nationally accepted standardized forms, formats and
systems. END_STATUTE
START_STATUTE36-3128. Reports required; confidential
information
A. The
commission, through the state health information system, shall require reports
by all health care practitioners and health facilities of information needed to
allow the commission to evaluate the health plan, cost‑containment
measures, utilization review, health facility operating budgets, health care
practitioner fees and any other information the commission deems necessary to
carry out its duties pursuant to this chapter.
B. The
commission shall establish uniform reporting requirements for health care
practitioners and health facilities.
C. Information
that is confidential pursuant to other provisions of law is confidential
pursuant to this chapter. Within the constraints of confidentiality, reports
of the commission are public documents. END_STATUTE
START_STATUTE36-3129. Consumer, practitioner and health
facility assistance program
A. The
commission shall establish a consumer, health care practitioner and health
facility assistance program to take complaints and to provide timely and
knowledgeable assistance to:
1. Eligible
persons and applicants about their rights and responsibilities and the COVERAGE
provided in accordance with this chapter.
2. Health
care practitioners and health facilities about the status of claims, payments
and other pertinent information relevant to the claims payment process.
B. The
commission shall establish a toll free telephone number for the consumer,
health care practitioner and health facility assistance program and shall have
persons available throughout this state to assist beneficiaries, applicants,
health care practitioners and health facilities in person. END_STATUTE
START_STATUTE36-3130. Reimbursement for out-of-state
services; health plan's right to subrogation and payment from other insurance
plans
A. A
beneficiary may obtain health care services covered by the health plan out of
state if the services are paid at the same rate that would apply if the
services were received in this state. Higher charges for those services shall
not be paid by the health plan unless the commission negotiates a reciprocity
or other agreement with the other state or with the out-of-state health care
practitioner or health facility.
B. The
health plan shall make reasonable efforts to ascertain any legal liability of
third parties who are or may be liable to pay all or part of the health care
services costs of injury, disease or disability of a beneficiary.
C. If the
health plan makes payments on behalf of a beneficiary, the health plan is
subrogated to any right of the beneficiary against a third party for recovery
of amounts paid by the health plan.
D. By
operation of law, an assignment to the health plan of the rights of a
beneficiary:
1. Is
conclusively presumed to be made of:
(a) A
payment for health care services from any person, firm or corporation,
including an insurance carrier.
(b) A
monetary recovery for damages for bodily injury, whether by judgment, contract
for compromise or settlement.
2. Is
effective to the extent of the amount of payments by the health plan.
3. Is
effective as to the rights of any other beneficiaries whose rights can legally
be assigned by the beneficiary. END_STATUTE
START_STATUTE36-3131. Private health insurance coverage
limited
A. After the
date the health plan is operating, a person shall not provide private health
insurance to a beneficiary for health care that is covered by the health plan
except for retiree health insurance plans that do not enter into contracts with
the health plan. A beneficiary may purchase supplemental benefits.
B. This
section does not affect insurance coverage pursuant to the federal employee
retirement income security act of 1974 unless the state obtains a congressional
exemption or a waiver from the federal government. Businesses that are covered
by that act may elect to participate in the health plan. END_STATUTE
START_STATUTE36-3132. Health plan fund; federal health
insurance program waivers; reimbursement to health plan from federal and other
health insurance programs
A. The
health plan fund is established consisting of monies received pursuant to this
chapter. The commission shall administer the fund. Monies in the fund are
continuously appropriated.
B. The
commission shall provide for the collection of premiums from eligible
beneficiaries, employers, state and federal agencies and other entities that
when combined with monies appropriated to the fund are sufficient to provide
the required health care services and to pay the expenses of the commission and
its administrative functions. All premiums and other money appropriated to the
fund shall be credited to the fund.
C. The
commission shall:
1. Apply to
the United States department of health and human services for all waivers of
requirements under health care programs established pursuant to the federal
social security act that are necessary to enable the state to deposit federal payments
for services covered by the health plan into the health plan fund and to be the
supplemental payer of benefits for persons receiving medicare benefits.
2. Except
for those programs designated in section 36-3112, identify other federal
programs that provide federal monies for payment of health care services to
individuals and apply for any waivers or enter into any agreements that are
necessary to enable the state to deposit federal payments for health care
services covered by the health plan into the health plan fund if agreements
negotiated with the federal Indian health service do not impair treaty
obligations of the United States government and other agreements negotiated do
not impair portability or other aspects of the health care coverage.
3. Seek an
amendment to the federal employee retirement income security act of 1974 to
exempt this state from the provisions of that act that relate to health care
services or health insurance, or the commission shall apply to the appropriate
federal agency for waivers of any requirements of that act if congress provides
for waivers to enable the commission to extend coverage pursuant to this
chapter to as many eligible residents of this state as possible.
D. The
commission shall seek payment to the health plan from medicaid, medicare or any
other federal or other insurance program for any reimbursable payment provided
under the plan.
E. The
commission shall seek to maximize federal contributions and payments for health
care services provided in this state and shall ensure that the contributions of
the federal government for health care services in this state will not decrease
in relation to other states as a result of any waivers, exemptions or
agreements. END_STATUTE
START_STATUTE36-3133. Voluntary purchase of other insurance
This chapter does not
prohibit the voluntary purchase of insurance coverage for health care services
not covered by the health plan or for individuals not eligible for coverage
under the health plan. END_STATUTE
START_STATUTE36-3134. Insurance rates; superintendent of
insurance duties
A. The
department of insurance shall identify premium costs associated with health
care coverage in workers' compensation and automobile medical coverage. The
department of insurance shall develop an estimate of expected reduction in
those costs based on assumptions of health care services coverage in the health
plan and shall report the findings to the senate finance committee, or its
successor committee, and the house ways and means committee, or its successor
committee, to determine the financing of the health plan.
B. The department
of insurance shall lower workers' compensation and automobile insurance
premiums on insurance policies written in this state that have a medical
payment component on the date the health plan is implemented. END_STATUTE
START_STATUTE36-3135. Temporary provision; transition period
arrangements; publicly funded health care service plans
A. A person
who, on the date benefits are available pursuant to this chapter, receives
health care benefits under private contract or collective bargaining agreement
entered into before July 1, 2009 shall continue to receive those benefits until
the contract or agreement expires or unless the contract or agreement is
renegotiated to provide participation in the health plan.
B. A person
covered by a health care plan that has its premiums paid for in any part by
public money, including money from this state, a political subdivision of this
state, a state educational institution, a public school or any other entity
that receives public money to pay health insurance premiums, shall be covered
by the health plan on the effective date that benefits are available under the
health plan. END_STATUTE
Sec. 2. Title 41, chapter 27, article 2,
Arizona Revised Statutes, is amended by adding section 41-3017.01, to read:
START_STATUTE41-3017.01. Health care commission; termination
July 1, 2017
A. The
health care commission terminates on July 1, 2017.
B. Title 36,
chapter 31 is repealed on January 1, 2018. END_STATUTE
Sec. 3. Initial terms of members of the health care commission
A. Notwithstanding section 36-3102, Arizona Revised
Statutes, as added by this act, the initial terms of members of the health care
commission are:
1. Three terms ending January, 2011.
2. Three terms ending January, 2012.
3. Three terms ending January, 2013.
B. The governor, speaker of the house of
representatives and the president of the senate shall make all subsequent
appointments as prescribed by statute.
Sec. 4. Purpose
Pursuant to section 41-2955, subsection E, Arizona Revised
Statutes, the health care commission is established to provide a comprehensive,
fair and cost-effective health care system for all Arizonans.
Sec. 5. Conforming legislation
The legislative council staff shall prepare proposed
legislation conforming the Arizona Revised Statutes to the provisions of this
act for consideration in the forty-eighth legislature, second regular session.
