Page 17,
after line 43, insert:
"Sec. 11. 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, including
occupational therapy.
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, insulin pumps 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 that are performed by a podiatrist who is licensed pursuant to title
32, chapter 7 and ordered by a primary care physician or primary care
practitioner.
10. Nonexperimental
transplants approved for title XIX reimbursement.
11. Dental
services as follows:
(a) Except
as provided in subdivision (b) of this paragraph, for persons who are at least
twenty-one years of age, emergency dental care and extractions in an
annual amount of not more than $1,000 per member.
(b) Subject
to approval by the centers for medicare and medicaid services, for persons
treated at an Indian health service or tribal facility, adult dental services
that are eligible for a federal medical assistance percentage of one hundred
percent and that are in excess of the limit prescribed in subdivision (a) of
this paragraph.
12. Ambulance
and nonambulance transportation, except as provided in subsection G of this
section.
13. Hospice
care.
14. Orthotics,
if all of the following apply:
(a) The
use of the orthotic is medically necessary as the preferred treatment option
consistent with medicare guidelines.
(b) The
orthotic is less expensive than all other treatment options or surgical
procedures to treat the same diagnosed condition.
(c) The
orthotic is ordered by a physician or primary care practitioner.
15. For
women who are at least twenty-one years of age and in any stage of
pregnancy, comprehensive dental care.
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 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 $12,500 per contract year.
(c) Percussive
vests are not covered health and medical services.
(d) Durable
medical equipment is limited to items covered by medicare.
(e) Nonexperimental
transplants do not include pancreas-only transplants.
(f) 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 acting through the regional
behavioral health authorities 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 administration acting
through regional behavioral health authorities 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 providing for 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. 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 allow 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 that are similar to title 32, chapter 13, 15, 17 or 25
and shall complete a provider agreement for this state.
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 that prescribe the coordination of medical care for
persons who are eligible for system services. The rules shall
include provisions for transferring patients and medical records and initiating
medical care.
M. For
the purposes of this section, "ambulance" has the same meaning
prescribed in section 36-2201."END_STATUTE
Renumber to
conform
Page 22,
between lines 19 and 20, insert:
"Sec. 15. Appropriations;
Arizona health care cost containment system administration; report
A.
The sum of $468,100 is appropriated from the state general fund in fiscal year
2021-2022 to the Arizona health care cost containment system administration to
provide dental services to pregnant women as prescribed by section 36-2907, subsection
A, paragraph 15, Arizona Revised Statutes, as added by this act.
B.
In addition to the appropriation made in subsection A of this section, the sum
of $3,630,600 is appropriated one time from the state general fund in fiscal
year 2021-2022 to the Arizona health care cost containment system
administration to cover costs incurred due to eligibility changes directly
related to introducing a dental benefit for pregnant women.
C.
On or before October 1, 2022, the Arizona health care cost containment system
administration shall report to the governor, the president of the senate, the
speaker of the house of representatives, the chairpersons of the health and
human services committees of the senate and the house of representatives, or their successor committees, and the
directors of the joint legislative budget committee and the governor's office
of strategic planning and budgeting the actual costs incurred to provide dental
services to pregnant women as prescribed by section 36-2907, subsection A,
paragraph 15, Arizona Revised Statutes, as added by this act, and the actual
costs incurred due to eligibility changes directly related to introducing a
dental benefit for pregnant women during fiscal year 2021-2022."
Renumber to
conform
Amend title to conform
Bill
Number: S.B. 1824