------------------------------------------------------------- ¦ REFERENCE TITLE: AHCCCS; diabetes; self-management training ¦ ------------------------------------------------------------- ¦ ¦ ¦ ¦ ¦ ¦ ¦ State of Arizona ¦ ¦ Senate ¦ ¦ Forty-fifth Legislature ¦ ¦ First Regular Session ¦ ¦ 2001 ¦ ¦ ¦ ------------------------------------------------------------- ¦ SB 1204 ¦ ------------------------------------------------------------- ¦ Introduced by ¦ ¦ Senators Gerard, Hartley, Solomon: Hellon, Nichols ¦ -------------------------------------------------------------
AN ACT
AMENDING SECTION 36-2907, ARIZONA REVISED STATUTES; RELATING TO THE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Section 36-2907, Arizona Revised Statutes, is amended to read:
36-2907. Covered health and medical services; definitions; modifications; related delivery of service requirements
A. Unless modified pursuant to this section, the following health and medical services shall be provided pursuant to provider contracts awarded under this article:
1. Inpatient hospital services that are ordinarily furnished by a hospital for the care and treatment of inpatients, that are medically necessary and that are provided under the direction of a physician or a primary care practitioner. For the purposes of this section, "inpatient hospital services" excludes services in an institution for tuberculosis or mental diseases.
2. Outpatient health services which THAT are medically necessary and
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 but do not include
occupational therapy, or speech therapy for eligible persons who are twenty-one years of
age or older.
3. Other laboratory and X-ray services ordered by a physician or a primary care practitioner.
4. Medications which THAT are medically necessary and ordered on
prescription by a physician or a dentist licensed pursuant to title 32, chapter 11.
5. Emergency dental care and extractions.
6. Medical supplies, equipment and prosthetic devices, not including hearing aids, ordered by a physician or a primary care practitioner or dentures ordered by a dentist licensed pursuant to title 32, chapter 11. Beginning on July 1, 1998, 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.
7. Treatment of medical conditions of the eye excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses.
8. Early and periodic health screening and diagnostic services as required by section 1905(r) of title XIX of the social security act, as amended by section 6043 of the omnibus budget reconciliation act of 1989, for eligible persons under the age of twenty-one years with treatment benefits limited to those otherwise specified in this chapter.
9. Family planning services that do not include abortion or abortion counseling. If a prepaid capitated provider elects not to provide family planning services, this election does not disqualify the provider from delivering all other covered health and medical services under this chapter. In that event, the administration may contract directly with another provider, including an outpatient surgical center or a noncontracting provider, to deliver family planning services to a member who is enrolled with the prepaid capitated provider that elects not to provide family planning services.
10. Podiatry services performed by a podiatrist licensed pursuant to title 32, chapter 7 and ordered by a primary care physician or primary care practitioner.
11. Transplants as authorized in this paragraph that are medically necessary and not experimental, as determined by the administration. The following transplants are authorized:
(a) For individuals eligible for services pursuant to section 36-2901, paragraph 4, subdivision (b), medically necessary heart, liver, kidney, cornea and autologous and allogeneic bone marrow transplants and immunosuppressant medications for these transplants ordered on prescription by a physician licensed pursuant to title 32, chapter 13 or 17.
(b) For individuals eligible for services pursuant to section 36-2901, paragraph 4, subdivision (b), medically necessary lung and heart-lung transplants and immunosuppressant medications for these transplants ordered on prescription by a physician licensed pursuant to title 32, chapter 13 or 17 but only if monies are available pursuant to section 36-2921, subsection A, paragraph 1.
(c) For individuals eligible for services pursuant to section 36-2901, paragraph 4, subdivisions (a), (c) and (h), medically necessary kidney and cornea transplants and immunosuppressant medications for these transplants ordered on prescription by a physician licensed pursuant to title 32, chapter 13 or 17.
(d) For individuals eligible for services pursuant to section 36-2901, paragraph 4, subdivisions (a), (c) and (h), medically necessary heart, liver, heart-lung, lung and autologous and allogeneic bone marrow transplants and immunosuppressant medications for these transplants ordered on prescription by a physician licensed pursuant to title 32, chapter 13 or 17, but only if monies are available pursuant to section 36-2921, subsection A, paragraph 1.
(e) For persons who are eligible for services pursuant to section 36-2901,
paragraph 4, subdivision (a), (b), (c) and OR (h), any other transplant
authorized by the director but only if monies are available pursuant to section 36-2921,
subsection A, paragraph 1.
12. Medically necessary ambulance and nonambulance transportation.
13. OUTPATIENT SELF-MANAGEMENT TRAINING AND EDUCATION, INCLUDING MEDICAL NUTRITION THERAPY, FOR THE TREATMENT OF INSULIN-DEPENDENT DIABETES, INSULIN-USING DIABETES, GESTATIONAL DIABETES AND NONINSULIN-USING DIABETES. THE TRAINING AND EDUCATION MUST BE PROVIDED BY A CERTIFIED, REGISTERED OR LICENSED HEALTH CARE PROVIDER WHO HAS EXPERTISE IN DIABETES.
14. THE FOLLOWING EQUIPMENT AND SUPPLIES FOR THE TREATMENT OF DIABETES:
(a) BLOOD GLUCOSE MONITORS.
(b) BLOOD GLUCOSE MONITORS FOR THE LEGALLY BLIND.
(c) TEST STRIPS FOR GLUCOSE MONITORS AND VISUAL READING AND URINE TESTING STRIPS.
(d) INSULIN PREPARATIONS AND GLUCAGON.
(e) INSULIN CARTRIDGES.
(f) DRAWING UP DEVICES AND MONITORS FOR THE VISUALLY IMPAIRED.
(g) INJECTION AIDS.
(h) INSULIN CARTRIDGES FOR THE LEGALLY BLIND.
(i) SYRINGES AND LANCETS INCLUDING AUTOMATIC LANCING DEVICES.
(j) PRESCRIBED ORAL AGENTS FOR CONTROLLING BLOOD SUGAR THAT ARE INCLUDED ON THE PLAN FORMULARY.
(k) TO THE EXTENT COVERAGE IS REQUIRED UNDER MEDICARE, PODIATRIC APPLIANCES FOR PREVENTION OF COMPLICATIONS ASSOCIATED WITH DIABETES.
(l) ANY OTHER DEVICE, MEDICATION, EQUIPMENT OR SUPPLY FOR WHICH COVERAGE IS REQUIRED UNDER MEDICARE. THE COVERAGE REQUIRED IN THIS SUBDIVISION IS EFFECTIVE SIX MONTHS AFTER THE COVERAGE IS REQUIRED UNDER MEDICARE.
B. The system shall pay nonproviders only for health and medical services as prescribed in subsection A of this section and as prescribed by rule.
C. The director shall adopt such rules as are necessary to limit, to the extent
possible, the scope, duration and amount of services, including maximum limitations for
inpatient services which 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.
D. The director shall make available home health services in lieu of
hospitalization pursuant to provider 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,
which 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. Beginning on July 1, 1998, home health agencies shall comply with the
federal bonding requirements in a manner prescribed by the administration.
E. The director shall adopt rules for the coverage of behavioral health services for persons who are eligible under section 36-2901, paragraph 4, subdivision (b) and persons who are eligible for services under section 1903(v) of the social security act. 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 4, subdivision (b) or section 36- 2931, paragraph 5 and shall refer the children to the appropriate agency responsible for making the final eligibility determination. Behavioral health services for persons who are eligible under section 36-2901, paragraph 4, subdivisions (a), (c), (h) and (j) are limited to emergency care in settings approved by the director and in accordance with administration rules.
F. The director shall adopt rules for the provision of transportation services for members and persons who are entitled to retroactive emergency coverage under section 36- 2909 and rules providing for copayment by members for transportation for other than emergency purposes. Prior authorization shall not be 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.
G. The director may adopt rules to allow the administration, at the director's discretion, to utilize 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.
H. 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 may, upon ON notification to system providers and counties
at least thirty days in advance, 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 4, subdivision (b). 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 4, subdivision
(b). Such reductions or suspensions shall not apply to the continuity of care for
persons already receiving such services. Any decision to reduce services for members
other than those persons defined pursuant to section 36-2901, paragraph 4, subdivisions
(a), (b), (c) and (h) shall be made independently from any other modification of
services. If such services are reduced, modified or suspended pursuant to this
subsection, counties shall not be required to provide the affected services to members or
eligible persons.
I. 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 4, subdivision (d), (e), (f) or (g).
J. All health and medical services provided under this article shall be provided in the county of residence 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 county of residence in this state or in an adjoining state if he determines that medical practice patterns justify the delivery of services in other than the county of residence or a net reduction in transportation costs can reasonably be expected. Notwithstanding section 36-2901, paragraph 8, 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.
K. 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.
L. The director shall adopt rules which TO prescribe the coordination of
medical care for persons who are eligible for both system covered services and county
services. The rules shall include provisions for the transfer of patients, the transfer
of medical records and the initiation of medical care.