Page 13, strike lines 31 through 45
Strike page 14
Page 15, strike lines 1 through 15, insert:
"Sec. 4. Section 36-2907, Arizona Revised
Statutes, is amended to read:
START_STATUTE36-2907. Covered health and medical services; modifications;
related delivery of service requirements; definition
A. Subject to the limitations and exclusions
specified in this section, contractors shall provide the following medically
necessary health and medical services:
1. Inpatient hospital services that are ordinarily
furnished by a hospital for the care and treatment of inpatients and that are
provided under the direction of a physician or a primary care
practitioner. For the purposes of this section, inpatient hospital
services exclude services in an institution for tuberculosis or mental diseases
unless authorized under an approved section 1115 waiver.
2. Outpatient health services that are ordinarily
provided in hospitals, clinics, offices and other health care facilities by
licensed health care providers. Outpatient health services include services
provided by or under the direction of a physician or a primary care
practitioner.
3. Other laboratory and x‑ray services ordered
by a physician or a primary care practitioner.
4. Medications that are ordered on prescription by a
physician or a dentist licensed pursuant to title 32, chapter 11. Persons who
are dually eligible for title XVIII and title XIX services must obtain
available medications through a medicare licensed or certified medicare
advantage prescription drug plan, a medicare prescription drug plan or any
other entity authorized by medicare to provide a medicare part D prescription
drug benefit.
5. Medical supplies, durable medical equipment and
prosthetic devices ordered by a physician or a primary care practitioner.
Suppliers of durable medical equipment shall provide the administration with
complete information about the identity of each person who has an ownership or
controlling interest in their business and shall comply with federal bonding
requirements in a manner prescribed by the administration.
6. For persons who are at least twenty‑one
years of age, treatment of medical conditions of the eye, excluding eye
examinations for prescriptive lenses and the provision of prescriptive lenses.
7. Early and periodic health screening and
diagnostic services as required by section 1905(r) of title XIX of the social
security act for members who are under twenty‑one years of age.
8. Family planning services that do not include abortion
or abortion counseling. If a contractor elects not to provide family planning
services, this election does not disqualify the contractor from delivering all
other covered health and medical services under this chapter. In that event,
the administration may contract directly with another contractor, including an
outpatient surgical center or a noncontracting provider, to deliver family
planning services to a member who is enrolled with the contractor that elects
not to provide family planning services.
9. Podiatry services ordered by a primary care
physician or primary care practitioner.
10. Nonexperimental transplants approved for title
XIX reimbursement.
11. Ambulance and nonambulance transportation,
except as provided in subsection G of this section.
12. Hospice care.
13. Beginning
October 1, 2014, medically necessary chiropractic services as described in
section 32‑925 that are ordered by a primary care physician pursuant to
rules adopted by the administration.
B. The limitations and exclusions for health and
medical services provided under this section are as follows:
1. Circumcision of newborn males is not a covered
health and medical service.
2. For eligible persons who are at least twenty‑one
years of age:
(a) Outpatient health services do not include
occupational therapy or speech therapy.
(b) Prosthetic devices do not include hearing aids,
dentures, bone anchored hearing aids or cochlear implants. Prosthetic devices,
except prosthetic implants, may be limited to twelve thousand five hundred
dollars per contract year.
(c) Insulin pumps, percussive vests and orthotics
are not covered health and medical services.
(d) Durable medical equipment is limited to items
covered by medicare.
(e) Podiatry services do not include services performed
by a podiatrist.
(f) Nonexperimental transplants do not
include pancreas only transplants.
(g) Bariatric surgery procedures, including
laparoscopic and open gastric bypass and restrictive procedures, are not
covered health and medical services.
C. The system shall pay noncontracting providers
only for health and medical services as prescribed in subsection A of this
section and as prescribed by rule.
D. The director shall adopt rules necessary to
limit, to the extent possible, the scope, duration and amount of services,
including maximum limitations for inpatient services that are consistent with
federal regulations under title XIX of the social security act (P.L. 89‑97;
79 Stat. 344; 42 United States Code section 1396 (1980)). To the extent possible
and practicable, these rules shall provide for the prior approval of medically
necessary services provided pursuant to this chapter.
E. The director shall make available home health
services in lieu of hospitalization pursuant to contracts awarded under this
article. For the purposes of this subsection, "home health services"
means the provision of nursing services, home health aide services or medical
supplies, equipment and appliances that are provided on a part‑time or
intermittent basis by a licensed home health agency within a member's residence
based on the orders of a physician or a primary care practitioner. Home health
agencies shall comply with the federal bonding requirements in a manner
prescribed by the administration.
F. The director shall adopt rules for the coverage
of behavioral health services for persons who are eligible under section 36‑2901,
paragraph 6, subdivision (a). The administration shall contract with
the department of health services for the delivery of all medically necessary
behavioral health services to persons who are eligible under rules adopted
pursuant to this subsection. The division of behavioral health in
the department of health services shall establish a diagnostic and evaluation
program to which other state agencies shall refer children who are not already
enrolled pursuant to this chapter and who may be in need of behavioral health
services. In addition to an evaluation, the division of behavioral
health shall also identify children who may be eligible under section 36‑2901,
paragraph 6, subdivision (a) or section 36‑2931, paragraph 5 and shall
refer the children to the appropriate agency responsible for making the final
eligibility determination.
G. The director shall adopt rules for the provision
of transportation services and rules providing for copayment by members for
transportation for other than emergency purposes. Subject to
approval by the centers for medicare and medicaid services, nonemergency
medical transportation shall not be provided except for stretcher vans and
ambulance transportation. Prior authorization is required for
transportation by stretcher van and for medically necessary ambulance
transportation initiated pursuant to a physician's direction. Prior
authorization is not required for medically necessary ambulance transportation
services rendered to members or eligible persons initiated by dialing telephone
number 911 or other designated emergency response systems.
H. The director may adopt rules to allow the
administration, at the director's discretion, to use a second opinion procedure
under which surgery may not be eligible for coverage pursuant to this chapter
without documentation as to need by at least two physicians or primary care
practitioners.
I. If the director does not receive bids within the
amounts budgeted or if at any time the amount remaining in the Arizona health
care cost containment system fund is insufficient to pay for full contract
services for the remainder of the contract term, the administration, on notification
to system contractors at least thirty days in advance, may modify the list of
services required under subsection A of this section for persons defined as
eligible other than those persons defined pursuant to section 36‑2901,
paragraph 6, subdivision (a). The director may also suspend services or may
limit categories of expense for services defined as optional pursuant to title
XIX of the social security act (P.L. 89‑97; 79 Stat. 344; 42 United
States Code section 1396 (1980)) for persons defined pursuant to section 36‑2901,
paragraph 6, subdivision (a). Such reductions or suspensions do not apply to
the continuity of care for persons already receiving these services.
J. Additional, reduced or modified hospitalization
and medical care benefits may be provided under the system to enrolled members
who are eligible pursuant to section 36‑2901, paragraph 6, subdivision
(b), (c), (d) or (e).
K. All health and medical services provided under
this article shall be provided in the geographic service area of the member,
except:
1. Emergency services and specialty services
provided pursuant to section 36‑2908.
2. That the director may permit the delivery of
health and medical services in other than the geographic service area in this
state or in an adjoining state if the director determines that medical practice
patterns justify the delivery of services or a net reduction in transportation
costs can reasonably be expected. Notwithstanding the definition of physician
as prescribed in section 36‑2901, if services are procured from a
physician or primary care practitioner in an adjoining state, the physician or
primary care practitioner shall be licensed to practice in that state pursuant
to licensing statutes in that state similar to title 32, chapter 13, 15, 17 or
25 and shall complete a provider agreement for this state.
L. Covered outpatient services shall be
subcontracted by a primary care physician or primary care practitioner to other
licensed health care providers to the extent practicable for purposes including,
but not limited to, making health care services available to underserved areas,
reducing costs of providing medical care and reducing transportation costs.
M. The director shall adopt rules that prescribe the
coordination of medical care for persons who are eligible for system services.
The rules shall include provisions for the transfer of patients, the transfer
of medical records and the initiation of medical care.
N. For the purposes of this section,
"ambulance" has the same meaning prescribed in section 36‑2201.
END_STATUTE
Sec. 5. Section 36-2953, Arizona Revised
Statutes, is amended to read:
START_STATUTE36-2953. Department long‑term care system fund; uniform
accounting
A. The department shall establish and maintain a
department long‑term care system fund which is a separate fund to
distinguish its revenues and its expenditures pursuant to this article from
other programs funded or administered by the department. Subject to
legislative appropriation, the fund shall be used to pay administrative and
program costs associated with the operation of the system. The
department long‑term care system fund shall be divided as follows:
1. An account for eligibility determination pursuant
to section 36‑2933, if the administration enters into an interagency
agreement with the department pursuant to section 36‑2933, subsection E.
2. An account for the provision of long‑term
care services as prescribed in section 36‑2939, subsections A and B.
B. The department long‑term care system fund
shall be comprised of:
1. Monies paid by the administration pursuant to the
contract.
2. Amounts paid by third party payors.
3. Gifts, donations and grants from any source.
4. State appropriations for the department long‑term
care system pursuant to this article.
5. Interest on monies deposited in the long‑term
care system fund.
C. The department shall submit a prospective long‑term
care budget as prescribed by the administration.
D. The administration shall prescribe a uniform
accounting system for the fund established pursuant to subsection A of this
section. Technical assistance shall be provided by the
administration to the department in order to facilitate the implementation of
the uniform accounting system.
E. The department shall submit an annual audited
financial and programmatic report for the preceding fiscal year as required by
the administration. The report shall include beginning and ending
fund balances, revenues and expenditures including specific identification of
administrative costs for the system. The report shall include the
number of members served by the system and the cost incurred for various types
of services provided to members in a format prescribed by the director.
F. The department shall submit additional
utilization and financial reports as required by the director.
G. The director shall make at least an annual review
of the department's records and accounts.
H. All
monies in the department long‑term care system fund that are unexpended
and unencumbered at the end of the fiscal year revert to the state general fund
on or before June 30 of that fiscal year. The transfer amount may be adjusted
for reported but unpaid claims and estimated incurred but unreported claims,
subject to approval by the administration.END_STATUTE"
Renumber to conform
Page 15, between lines 29 and
30, insert:
"Sec. 8. AHCCCS; chiropractic services;
expenditure limitation
Notwithstanding section 36‑2907,
Arizona Revised Statutes, as amended by this act, for fiscal year 2014‑2015,
the Arizona health care cost containment system administration shall provide
medically necessary chiropractic services as described in section 32‑925,
Arizona Revised Statutes, but shall limit the general fund costs associated
with these services to not more than $1,000,000 in that fiscal year."
Renumber to conform
Page 16, line 27, strike "county shall reimburse
the"; strike "for"
Strike lines 28, 29 and 30, insert "may determine the
percentage of the costs to be reimbursed by the county. It is the intent of
the legislature that the department of health services not increase the
percentage rate of the county share of costs in fiscal year 2014‑2015,
relative to fiscal year 2013‑2014."
Page 18, line 5, strike "greater" insert
"less"; strike ", the administration"
Strike lines 6, 7 and 8
Line 9, strike "$89,877,700"
Line 22, after the period insert "The disproportionate
share hospital payment attributed to the Maricopa county special health care
district may not exceed $89,877,700."
Page 24, line 4, strike "three" insert
"two"
Amend title to conform
Bill
Number: S.B. 1491