ARIZONA STATE SENATE
Phoenix, Arizona
FINAL
REVISED
AHCCCS; behavioral health
services
Purpose
Makes changes to the
eligibility process and the grievance and appeals process for behavioral health
service clients under the Department of Health Services (DHS).
Background
In 1996, the Arizona Health
Care Cost Containment System (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 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
1. Requires state-funded behavioral health clients to comply annually and cooperate fully with the eligibility determination process for Title XIX services and CHIP.
2. Includes CHIP in the application process for persons who are determined to be eligible for Title XIX services.
3. 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.
4. Stipulates cooperation with the eligibility and screening determination process does not create an entitlement to services that are subject to legislative appropriation.
5. Authorizes non-Title XIX behavioral health service clients and service providers to file an appeal directly to the AHCCCS administration.
6. Requires regional behavioral health authorities (RBHA) to notify clients of their right to appeal a decision rendered by DHS directly to the AHCCCS administration.
7. Requires behavioral health service providers and RBHA clients to exhaust the RBHA grievance and appeals process before appealing a decision to either DHS or AHCCCS.
8. Makes technical changes.
9. Provides for a general effective date.
Amendments Adopted by Committee
Eliminates expanding the types of settings provided under the Arizona Long-Term Care System to developmentally disabled, elderly or physically disabled members who need institutional services.
Amendments Adopted by the House of Representatives
1. Specifies the ability to appeal a decision directly to the AHCCCS administration for an expedited hearing is only for those individuals who receive services under Medicaid.
2. Specifies the requirement of RBHAs to notify clients of their right to appeal a decision directly to the AHCCCS administration applies to decisions rendered by DHS.
3. Requires behavioral health service providers and RBHA clients to exhaust the RBHA grievance and appeal process before appealing a decision to either DHS or AHCCCS.
Senate Action House Action
HEA 1/23/01 DPA 6-0-2-0 HEA 3/19/01 DPA 8-0-0-2
3rd Read 2/12/01 30-0 3rd Read 3/26/01 56-0-4
Final Read 4/3/01 29-0-1
Signed by the Governor 4/6/01
Chapter 60
Prepared by Senate Staff
May 15, 2001