Assigned to HHS & APPROP FOR COMMITTEE

 


 

 

 


ARIZONA STATE SENATE

Fifty-Sixth Legislature, Second Regular Session

 

REVISED

FACT SHEET FOR S.B. 1250

 

AHCCCS; claims

Purpose

Prohibits a contracted health care insurer from denying a claim for payment submitted by the state based on a lack of prior authorization if the Arizona Health Care Cost Containment System (AHCCCS) authorized the item or service.

Background

AHCCCS serves as Arizona's Medicaid agency which offers qualifying Arizona residents access to healthcare programs. AHCCCS's duties include: 1) developing and implementing a county-by-county system that includes access to hospitalization and medical services for members; 2) contracting, overseeing, reviewing and providing technical assistance to contactors; 3) developing a system of accounts and controls for AHCCCS to prevent the unnecessary use of covered health and medical services; 4) assisting in the formation of medical care consortiums to provide covered medical services for a county; 5) establishing and managing a system to ensure the quality of care delivered by AHCCCS; 6) establishing and managing a system to prevent fraud by members, subcontractors, contractors and noncontracting providers; 7) coordinating benefits to any member; 8) developing and maintaining outlined programs and systems; and 9) establishing the eligibility process for a Medicare low-income subsidy (A.R.S. 36-2903).

The Joint Legislative Budget Committee (JLBC) fiscal note on S.B.1250 estimates minimal fiscal impact to the state General Fund. There could be AHCCCS savings if the number of third party-approved claims increases, thereby reducing AHCCCS' liability. The magnitude of the impact would depend on the number and size of the claims third-party payers currently deny based solely on the lack of prior authorization (JLBC).

Provisions

1.   Prohibits a healthcare insurer from denying a claim submitted by the state for lack of prior authorization if AHCCCS authorized the item or service.

2.   Specifies that the claim denial prohibition does not expand the scope of coverage, benefits or rights under the policy issued by the health care insurer.

3.   Requires a health care insurer to respond, within 60 days, to any inquiries from the Director of AHCCCS regarding a submitted claim, as prescribed.

4.   Removes the requirement that AHCCCS health care insurer compliance reports be submitted to the Director of the Arizona State Library, Archives and Public Records.

5.   Makes technical and conforming changes.

6.   Becomes effective on the general effective date.

Revised

Updates the fiscal impact statement.

Prepared by Senate Research

February 16, 2024

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