Medicaid Benefits: Online Database

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Acute Care Services

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Products and Devices

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Institutional Care

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Benefits by State: Arizona (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes		Yes		Fee for service	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes				Fee for service	CN & MN
Federally Qualified Health Center Services
Yes		Yes	Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN	Fee for service	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes		Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day		Prospective tiered per diem, psych admissions paid all-inclusive per diem	CN & MN
Outpatient Hospital Services
Yes	$5/non-emergency visit in ER	Specified surgical procedures, rehab services	Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN	All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes				Fee for service	CN & MN
Rural Health Clinic Services
Yes		Specified services	Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN	Fee for service	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service	CN & MN
Chiropractor Services
No
Dental Services
Yes			Limited to emergency treatment for relief of pain and infection	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes				Fee for service	CN & MN
Nurse Midwife Services
Yes			Physician back-up required	Fee for service at 90% of physician fee	CN & MN
Nurse Practitioner Services
Yes				Fee for service at 90% of physician fee	CN & MN
Optometrist Services
Yes			Limited to emergency eye care and treatment of medical conditions, vision exam limited to post-cataract surgery services	Fee for service	CN & MN
Physician Services
Yes	$1/office visit			Fee for service	CN & MN
Podiatrist Services
Yes		Yes	Routine foot care covered only for specified systemic conditions and limited to 2 visits/3 months	Fee for service	CN & MN
Psychologist Services
Yes				Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes				AWP-16%, plus $1.90 dispensing fee	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes		Yes	Outpatient coverage limited to ALTCS members - see state-specific FN	Fee for service	CN & MN
Physical Therapy Services
Yes		Yes	Rehab potential required	Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
Yes		Yes	Outpatient services limited to ALTCS members - see state-specific FN	Fee for service	CN & MN
Products and Devices
Dentures
Yes		Yes	Must be medically necessary to alleviate a health problem	Fee for service	CN & MN
Eyeglasses
Yes			Limited to post-cataract surgery items	Fee for service	CN & MN
Hearing Aids
No
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items, depending on cost	1 med equipment purchase of the same type/2 years	Fee for service using Medicare payment ceilings	CN & MN
Prosthetic and Orthotic Devices
Yes		Specified services or items, items costing more than established amounts		Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes			Specified age and gender criteria for clinical screening, health education and immunizations	Fee for service	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes				Fee for service	CN & MN
Targeted Case Management
Yes				Capitated rate	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		See service_specific FN See state-specific FN	See state-specific FN	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	Yes		Fee for service	CN & MN
Hospice Care
Yes			Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
Yes	Yes	Coverage limited to ALTCS members - see state-specific FN	Fee for service using time units	CN & MN
Private Duty Nursing Services
Yes	Yes		Fee for service	CN & MN
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		12 hosp leave days/year, 9 therapeutic leave days/year	Acute Care program - capitated payment through contractor, ALTCS program - prospective acuity-based per diem or negotiated rate for heavy care residents and certain facilities	CN & MN
Inpatient Psychiatric Services, under age 21
Yes			Acute Care program - capitated payment through contractor, ALTCS program - prospective acuity-based per diem or negotiated rate for heavy care residents and certain facilities	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes		12 hosp leave days/year, 9 therapeutic leave days/year	Acute Care program - capitated payment through contractor, ALTCS program - prospective acuity-based per diem or negotiated rate for heavy care residents and certain facilities	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes	Admission	Acute Care program members limited to 90 days for convalescence/year - see state-specific FN, ALTCS members have no LOS limit but are limited to 12 hosp leave days/year and 9 therapeutic leave days/year	Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes	Yes		Prospective cost based per diem up to Medicare limits for facility, fee for service for practitioners	CN & MN

Notes: This State has an approved Section 1115 Waiver from CMS under which it provides services in a program called the Arizona Health Care Cost Containment System (AHCCCS). The program includes an Acute Care program and a companion program for long-term care services (in institutional and alternative residential settings as well as home and community based care) called the Arizona Long-Term Care System (ALTCS). All Acute Care program members, whether receiving care on a fee for service basis or through enrollment in a managed care organization, are eligible for the same array of acute care services. All ALTCS members, whether receiving care on a fee for service basis or through enrollment in a managed care organization, are eligible for the same array of acute and long-term care services. The State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in a program called Freedom to Work. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group, as well as certain others, with income above the FPL pay an income-based monthly premium. The majority of the State’s Medicaid beneficiaries are enrolled in contracted managed care organizations through which they receive health care services. The copayment requirements shown on the tables apply to all populations as appropriate, although there are populations for which the copayments are waived. Providers are required to obtain prior approval from the AHCCCS Administration for specified services for the fee for service populations or from the State’s contracted managed care organizations for the managed care populations. Major differences in coverage limitations between the Acute Care program and the ALTCS program are noted on the tables.