ARIZONA STATE SENATE
Phoenix, Arizona
AHCCCS; behavioral health
services
Purpose
Expands the types of
settings provided under the Arizona Long Term Care System (ALTCS) and makes
changes to the eligibility process and the grievance and appeals process for
behavioral health clients.
Background
ALTCS Settings
Currently, A.R.S. §36-2939
prescribes and limits the settings and services for ALTCS members who are
elderly, physically disabled or developmentally disabled. According to the Arizona Health Care Cost
Containment System (AHCCCS) administration, several factors have contributed to
the increased need for the use of more diversified settings and services in the
community. These factors include: an
increased number of elderly or physically disabled young adults and adult
members eligible for ALTCS with moderate to severe behavioral health needs; an
increased number of children who have high behavioral and/or complex medical
health needs; and consumer demand for alternatives to institutional
settings. S.B. 1148 expands the types
of settings, provided under ALTCS to elderly, physically disabled or
developmentally disabled members who need institutional services, to include
licensed or certified settings as approved by the Director of AHCCCS.
In 1996, AHCCCS was
challenged in court concerning the administration’s grievance and appeals
process relating to decisions that deny, reduce, suspend or terminate a
Medicaid beneficiary’s services that require prior authorization from a
contractor (health plan) or the administration. Before the lawsuit (Perry
vs. Kelly), a member whose services or request for services was denied,
reduced, suspended or terminated could not continue services unless the
decision was overturned; nor could the member request an expedited appeals
hearing directly to the administration. These policies conflicted with
continuation of benefit requirements under federal law.
Under the stipulated
judgment in Perry vs. Kelly, AHCCCS
is required to allow members to request an expedited appeals hearing, for
certain adverse decisions, directly to the administration instead of first
appealing the adverse decision to the contractor. The expedited appeals hearing process also allows a member to
continue benefits through the appeals process.
Additionally, the judgment requires contractors and the administration
to issue notices of adverse actions regarding services that require prior
authorization within three business days following a denial or ten business
days prior to the reduction, suspension or termination of services.
Currently, statutes for
grievances and appeals concerning behavioral health services for Medicaid
beneficiaries require them to exhaust administrative review by the contractor
and the Department of Health Services (DHS) before making a request for hearing
to AHCCCS. S.B. 1148 allows DHS to
conform its notification and grievance and appeals process to the expedited
appeals hearing process at AHCCCS for adverse decisions relating to the denial,
reduction, suspension or termination of behavioral health services.
Additionally, current
statutes do not require state-funded behavioral health clients to annually
apply for Medicaid or the children’s health insurance program (CHIP). To maximize the use of these federally
supported programs, S.B. 1148 requires the state-funded population to annually
apply for Medicaid or CHIP.
There
is no cost to the state general fund relating to the provisions of this bill.
Provisions
ALTCS Settings
1. Expands the types of settings provided under ALTCS to developmentally disabled members who need institutional services to include licensed or certified settings as approved by the Director of AHCCCS.
Behavioral Health
2. Requires state-funded behavioral health clients to comply annually and cooperate fully with the eligibility determination process for Title XIX services and CHIP.
3. Includes CHIP in the application process for persons who are determined to be eligible for Title XIX services.
4. Requires the Department of Economic Security and the AHCCCS administration to notify DHS of applicants who are denied for failure to comply with the eligibility process, and on request, of applicants who did not submit applications.
5. Stipulates cooperation with the eligibility and screening determination process does not create an entitlement to services that are subject to legislative appropriation.
6. Authorizes behavioral health service clients and service providers to file an appeal directly to the AHCCCS administration.
7. Requires regional behavioral health authorities to notify clients of their right to appeal a decision directly to the AHCCCS administration.
Miscellaneous
8. Makes technical changes.
9. Provides for a general effective date.
Prepared by Senate Staff
January 19, 2001