Arizona Secretary of State - Ken Bennett


 
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TITLE 9. HEALTH SERVICES

CHAPTER 7. DEPARTMENT OF HEALTH SERVICES
CHILDREN'S REHABILITATIVE SERVICES

Editor's Note: New 9 A.A.C. 7 made by final rulemaking at 10 A.A.R. 691, effective April 3, 2004. The rescinded 9 A.A.C. 7 is on file in the Office of the Secretary of State (Supp. 04-1).

Editor's Note: 9 A.A.C. 7 expired under A.R.S. § 41-1056(E) at 8 A.A.R. 4591, effective August 31, 2002. The Office of the Secretary of State publishes all Code Chapters on white paper (Supp. 02-4).

ARTICLE 1. DEFINITIONS

Article 1, consisting of Section R9-7-101, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

Section

R9-7-101. Definitions

ARTICLE 2. ELIGIBILITY

Article 2, consisting of Sections R9-7-201 through R9-7-203, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

Section

R9-7-201. Eligibility Requirements

R9-7-202. Medical Conditions

R9-7-203. Medical Ineligibility

ARTICLE 3. REFERRAL; ENROLLMENT; FINANCIAL DETERMINATION; REDETERMINATION; TERMINATION

Article 3, consisting of Sections R9-7-301 through R9-7-306, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

Section

R9-7-301. Referral

R9-7-302. Enrollment

R9-7-303. Financial Screening

R9-7-304. Payment Responsibility

R9-7-305. Identification of Household Income Group

R9-7-306. Calculating Net Income

R9-7-307. Redetermination

R9-7-308. Termination

ARTICLE 4. COVERED MEDICAL SERVICES

Article 4, consisting of Sections R9-7-401 through R9-7-421, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

Section

R9-7-401. General Requirements

R9-7-402. Audiology Services

R9-7-403. Dental and Orthodontia Services

R9-7-404. Diagnostic Testing and Laboratory Services

R9-7-405. Home Health Services

R9-7-406. Inpatient Services

R9-7-407. Medical Equipment

R9-7-408. Nursing Services

R9-7-409. Nutrition Services

R9-7-410. Outpatient Services

R9-7-411. Pharmaceutical Services

R9-7-412. Physical Therapy and Occupational Therapy

R9-7-413. Physician Services

R9-7-414. Prosthetic and Orthotic Devices

R9-7-415. Psychological Services

R9-7-416. Psychiatric Services

R9-7-417. Social Work Services

R9-7-418. Speech/Language Pathology Services

R9-7-419. Transplants

R9-7-420. Vision Services

R9-7-421. Renumbered

ARTICLE 5. COVERED SUPPORT SERVICES

Article 5, consisting of Sections R9-7-501 through R9-7-506, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

Section

R9-7-501. Advocacy Services

R9-7-502. Child Life Services

R9-7-503. Education Coordination

R9-7-504. Transition Services

R9-7-505. Transportation Services

R9-7-506. Renumbered

ARTICLE 6. REPEALED

Article 6, consisting of Sections R9-7-601 through R9-7-604, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

Section

R9-7-601. Repealed

R9-7-602. Renumbered

R9-7-603. Renumbered

R9-7-604. Renumbered

ARTICLE 7. MEMBER APPEALS

Article 7, consisting of R9-7-701, made by final rulemaking at 10 A.A.R. 3001, effective July 13, 2004 (Supp. 04-3).

Section

R9-7-701. Member Appeals

ARTICLE 1. DEFINITIONS

Article 1, consisting of Section R9-7-101, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-101. Definitions

In this Chapter, unless otherwise specified:

1. "Activity of daily living" means ambulating, dressing, bathing, showering, grooming, preparing food, toileting, eating, drinking, communicating, or moving into or out of a bed or chair.

2. "Acute" means requiring immediate medical treatment.

3. "Adult" means an individual 21 years of age or older.

4. "AHCCCS" means the Arizona Health Care Cost Containment System.

5. "Ambulation assistive device" means a walker, cane, or crutch.

6. "Applicant" means an individual requesting enrollment who is:

a. A child, or

b. An adult with cystic fibrosis or sickle cell anemia.

7. "Application packet" means the information in R9-7-302(A) and additional documentation required by the Department to determine:

a. Whether an individual is eligible for CRS; and

b. If the individual is eligible for CRS, the payment responsibility of the individual or, if the individual is a minor, the individual's parent.

8. "Biologicals" means medicinal compounds prepared from living organisms and the product of living organisms such as serums, vaccines, antigens, and antitoxins.

9. "Child" means an individual less than 21 years old.

10. "Chronic" means expected to persist over an extended period of time.

11. "Communication disorder" means an abnormality of functioning related to the ability to express or receive ideas.

12. "Concurrent review" means an ongoing process conducted by the Department at the same time as the delivery of covered medical services to a member, such as during a member's inpatient treatment by a CRS provider, to determine whether the member is receiving medically necessary, effective, and cost-efficient treatment.

13. "Covered" means authorized and provided by or through the Department.

14. "Crisis intervention service" means a behavioral health service as defined in A.A.C. R9-20-101 provided for a limited period of time to a member who is a danger to others as defined in A.A.C. R9-20-101 or a danger to self as defined in A.A.C. R9-20-101.

15. "CRS" means Children's Rehabilitative Services, a program administered by the Department to provide covered medical services and covered support services.

16 "CRS clinic" means outpatient interdisciplinary evaluation and treatment provided by more than one CRS provider at a specific location for a scheduled period of time.

17. "CRS condition" means any of the medical conditions in R9-7-202.

18. "CRS provider" means a person who is authorized by employment or written agreement with the Department to provide covered medical services to a member or covered support services to a member or a member's family.

19. "Dental hygienist" means an individual licensed under A.R.S. Title 32, Chapter 11, Article 4.

20. "Dental services" means treatment provided by a dentist or a dental hygienist.

21. "Dentist" means an individual licensed under A.R.S. Title 32, Chapter 11, Article 2.

22. "Department" means the Arizona Department of Health Services or its designee.

23. "Dependent care" means supervision and guidance provided to an individual by a person other than the individual's parent.

24. "Designee" means a person acting on behalf of the Department under the authority of the Department.

25. "Diagnosis" means a determination or identification of a CRS condition made by a physician.

26. "Earned income" means monies or other compensation received as wages, tips, salary, or commissions by an individual or profit from activities in which a self-employed individual is engaged.

27. "Eligible" means:

a. Meeting the medical and non-medical eligibility requirements in A.R.S. Title 36, Chapter 2, Article 3 and this Chapter; or

b. Meeting the requirements for obtaining Title XIX or Title XXI health care insurance.

28. "Emergency services" has the same meaning as in A.A.C. R9-10-201.

29. "Enrollment" means the Department's approval for an eligible individual to be a member.

30. "Evaluation" means an analysis of an individual's emotional, mental, physical, psychological, or social condition to make a diagnosis or to determine the individual's need for medical services or social services.

31. "Family" means a member's parent and each individual included in the member's household income group.

32. "Federal Poverty Level" means the current level of income set by the United States government, based on family size, used to determine whether an individual may receive income-based federal assistance.

33. "Fee-for-service" means reimbursement for a medical service at an established rate.

34. "Financial screening packet" means the information and documentation required by the Department to determine the payment responsibility of an individual or, if the individual is a minor, the individual's parent.

35. "Functional improvement" means an increase in an individual's ability to perform an activity of daily living.

36. "Functionally limiting" means a restriction having a significant effect on an individual's ability to perform an activity of daily living as determined by a CRS provider.

37. "Gross income" means the total of earned income and unearned income.

38. "Health care insurance" means a contractual arrangement for a person to provide, directly or indirectly, all or a portion of the medical, dental, or behavioral health care needs of an individual.

39. "Health care insurance premium" means compensation or monies paid by an individual to a person for the individual's health care insurance.

40. "Hearing aid" means a small, electronic device that amplifies sound.

41. "Hearing evaluation" means testing of an individual's hearing and an analysis of the testing to determine the type and degree of an individual's hearing loss.

42. "Hearing impairment" means any type or degree of hearing loss that interferes with an individual's development or adversely affects an individual's ability to perform activities of daily living.

43. "Hearing screening" means testing to determine whether an individual has a hearing loss.

44. "Home health services" has the same meaning as in A.R.S. § 36-151.

45. "Hospital" has the same meaning as in A.R.S. § 36-2351.

46. "Household income group" means all of the individuals whose income the Department includes when calculating an individual's or member's payment responsibility for covered services.

47. "Initial evaluation" means an examination of an applicant by a CRS provider to determine whether the applicant meets the medical eligibility requirement for enrollment.

48. "Inpatient services" means "hospital services" as defined in A.A.C. R9-10-201 that are provided to an individual who is anticipated to receive hospital services for 24 consecutive hours or more.

49. "Medical condition" means the state of an individual's physical or mental health, including the individual's illness, injury, or disease.

50. "Medical expenses" means charges incurred by an individual for:

a. Medical equipment;

b. Medication or biologicals prescribed by a physician, physician's assistant, or registered nurse practitioner;

c. Dental services;

d. Treatment by a health professional, as defined in A.R.S. § 32-3201, except a veterinarian;

e. Inpatient services;

f. Outpatient services; or

g. Health care insurance premiums for the individual.

51. "Medical service" means evaluation or treatment of a member by a CRS provider.

52. "Medically eligible" means meeting the medical eligibility requirements of A.R.S. Title 36, Chapter 2, Article 3 and this Chapter.

53. "Medically necessary" means essential for ameliorating or preventing the development or progression of a medical condition.

54. "Medication" has the same meaning as "drug" in A.R.S. § 32-1901.

55. "Member" means an individual who receives covered medical services and covered support services from the Department through CRS.

56. "Minor" means an individual who is:

a. Under 18 years of age and is not:

i. Married; or

ii. Emancipated, as specified in A.R.S. Title 12, Chapter 15;

b. Incompetent, as determined by a court of competent jurisdiction; or

c. Incapable of giving consent for medical services due to a limitation in the individual's cognitive function as determined by a physician.

57. "Net income" means an individual's gross income minus the deductions in R9-7-306(C).

58. "Nursing services" has the same meaning as in A.R.S. § 36-401.

59. "Nutrition" means food and liquid required for a human body's maintenance and growth.

60. "Occupational therapy" has the same meaning as in A.R.S. § 32-3401.

61. "Orthotic device" means equipment used by an individual to preserve, restore, or develop the individual's musculoskeletal system including the individual's extremities or spine.

62. "Outpatient services" means evaluating, monitoring, or treating an individual at a hospital, physician's office, or CRS clinic for less than 24 hours.

63. "Parent" means a biological or adoptive mother or father of a child, or an individual who is a court-appointed legal guardian or custodian of an individual.

64. "Payment agreement" means a form containing an individual's or member's signed, written promise to pay for covered medical services according to the terms on the form.

65. "Payment responsibility" means that portion of the cost for medical services that an individual or member is required to pay and has agreed to pay according to a signed written agreement.

66. "Person" has the same meaning as in A.R.S. § 1-215 and includes a governmental agency.

67. "Pharmaceutical services" means medications and biologicals ordered by a physician, dentist, physician's assistant, or registered nurse practitioner.

68. "Physical therapy" has the same meaning as in A.R.S. § 32-2001.

69. "Physician" means an individual licensed under A.R.S Title 32, Chapter 13 or Chapter 17.

70. "Physician services" has the same meaning as "practice of medicine" in:

a. A.R.S. § 32-1401, for a physician licensed under A.R.S. Title 32, Chapter 13;

b. A.R.S. § 32-1800, for a physician licensed under A.R.S. Title 32, Chapter 17.

71. "Physician's assistant" has the same meaning as in A.R.S. § 32-2501.

72. "Prior authorization" means a written approval signed by the Department or the Department's designee before a covered service is provided to a member.

73. "Prosthetic device" means equipment used as a substitute for a diseased or missing part of the human body.

74. "Provide" means to directly or indirectly under the terms of a contract make available or furnish medication, medical equipment, or services in this Chapter to an applicant or a member.

75. "Psychiatric services" means physician services provided by a psychiatrist.

76. "Psychiatrist" has the same meaning as in A.R.S. § 36-501.

77. "Psychological services" has the same meaning as in A.R.S. § 32-2061.

78. "Psychologist" means an individual licensed under A.R.S. Title 32, Chapter 19.1.

79. "Psychosocial evaluation" means an analysis of an individual's mental and social conditions to determine the individual's need for social services.

80. "Qualified alien" has the same meaning as in A.R.S. § 36-2903.03(I).

81. "Redetermination" means a decision made by the Department regarding whether a:

a. Member meets the requirements in R9-7-201, or

b. Member's payment responsibility is changed.

82. "Refer" means to inform CRS in writing of an individual who may be eligible for CRS.

83. "Referral source" means a person who refers an individual to CRS.

84. "Registered nurse practitioner" has the same meaning as in A.R.S. § 32-1601.

85. "Retrospective review" means the process conducted by the Department following the completion of the delivery of covered medical services to a member to determine if the member received medically necessary, effective, and cost-efficient treatment.

86. "School" means a:

a. Charter school as defined in A.R.S. § 15-101,

b. Private school as defined in A.R.S. § 15-101,

c. School as defined in A.R.S. § 15-101, or

d. Child care facility as defined in A.R.S. § 36-881.

87. "Session" means a period of time during which a member continuously receives a specific treatment from a CRS provider.

88. "Social work services" has the same meaning as "practice of social work" in A.R.S. § 32-3251.

89. "Social worker" means an individual licensed under A.R.S. Title 32, Chapter 33, Article 5.

90. "Supervision and guidance" means assistance provided to an individual to safeguard the individual's health and safety or to perform an activity of daily living.

91. "Support service" means non-medical assistance provided by a CRS provider to a member or a member's family without charge to the member or the member's family.

92. "Title XIX" means the Federal Medicaid Program, 42 U.S.C. 1396 through 1396v, a health care insurance program administered jointly by the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services and, in Arizona, by AHCCCS, through which an eligible individual receives health care, excluding provisions in the Federal Medicaid Program for an individual who is not a U.S. citizen or qualified alien.

93. "Title XXI" means the State Children's Health Insurance Program, 42 U.S.C. 1397aa through 1397jj, through which an eligible individual receives health care insurance that is administered by AHCCCS, excluding provisions in the State Children's Health Insurance Program for an individual who is not a U.S. citizen or qualified alien.

94. "Total parenteral nutrition" means the intravenous infusion of nutrients required by an individual into the individual through a catheter.

95. "Treatment" means a procedure or method used to cure, improve, or palliate an injury, an illness, or a disease.

96. "Unearned income" means monies received by an individual for which the individual did not perform labor.

97. "Utilization management" means the processes by which the Department determines medically necessary, effective, and cost-efficient covered medical services and treatment for a member, including:

a. Prior authorization,

b. Concurrent review, and

c. Retrospective review.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

ARTICLE 2. ELIGIBILITY

Article 2, consisting of Sections R9-7-201 through R9-7-203, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-201. Eligibility Requirements

A. An individual is eligible to enroll for CRS if the individual:

1. Has one of the medical conditions in R9-7-202;

2. Except as provided in subsection (B), is a child;

3. Is one of the following:

a. A U.S. citizen, or

b. A qualified alien who meets the requirements of A.R.S. § 36-2903.03(B), and

4. Is living in Arizona.

B. The Department may enroll an adult, who is not eligible for Title XIX health care insurance, in CRS if:

1. The adult has cystic fibrosis and monies are appropriated to the Department under A.R.S. § 36-143, or

2. The adult has sickle cell anemia and monies are appropriated to the Department under A.R.S. § 36-797.44.

C. The Department shall continue a member's enrollment in CRS if the member:

1. And, if the member is a minor, the member's parent comply with the requirements in this Chapter;

2. Meets the requirements in subsections (A)(1), (A)(2), and (A)(4); and

3. Meets the requirements in subsection (A)(3) or has continuously been a member since August 5, 1999.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-202. Medical Conditions

An individual is medically eligible for CRS, only if the individual has:

1. One or more of the following cardiovascular system medical conditions:

a. Congenital heart defect,

b. Cardiomyopathy,

c. Valvular disorder,

d. Arrhythmia,

e. Conduction defect,

f. Rheumatic heart disease that is not in the acute phase,

g. Renal vascular hypertension,

h. Arteriovenous fistula, and

i. Kawasaki disease with coronary artery aneurysm;

2. One or more of the following endocrine system medical conditions:

a. Hypothyroidism,

b. Hyperthyroidism,

c. Adrenogenital syndrome,

d. Addison's disease,

e. Hypoparathyroidism,

f. Hyperparathyroidism,

g. Diabetes insipidus,

h. Cystic fibrosis, and

i. Panhypopituitarism;

3. One or more of the following genitourinary system medical conditions:

a. Vesicoureteral reflux, with at least mild or moderate dilatation and tortuosity of the ureter and mild or moderate dilatation of renal pelvis;

b. Ectopic ureter;

c. Ambiguous genitalia;

d. Ureteral stricture;

e. Complex hypospadias;

f. Hydronephrosis;

g. Deformity and dysfunction of the genitourinary system secondary to trauma after the acute phase of the trauma has passed;

h. Pyelonephritis when treatment with drugs or biologicals has failed to cure or ameliorate and surgical intervention is required;

i. Multicystic dysplastic kidneys;

j. Nephritis associated with lupus erythematosis; and

k. Hydrocele associated with a ventriculo-peritoneal shunt;

4. One or more of the following ear, nose, or throat medical conditions:

a. Cholesteatoma;

b. Chronic mastoiditis;

c. Deformity and dysfunction of the ear, nose, or throat secondary to trauma, after the acute phase of the trauma has passed;

d. Neurosensory hearing loss;

e. Congenital malformation;

f. Significant conductive hearing loss due to an anomaly in one ear or both ears equal to or greater than a pure tone average of 30 decibels, that despite medical treatment, requires a hearing aid;

g. Craniofacial anomaly that requires treatment by more than one CRS provider; and

h. Microtia that requires multiple surgical interventions;

5. One or more of the following musculoskeletal system medical conditions:

a. Achondroplasia;

b. Hypochondroplasia;

c. Diastrophic dysplasia;

d. Chondrodysplasia;

e. Chondroectodermal dysplasia;

f. Spondyloepiphyseal dysplasia;

g. Metaphyseal and epiphyseal dysplasia;

h. Larsen syndrome;

i. Fibrous dysplasia;

j. Osteogenesis imperfecta;

k. Rickets;

l. Enchondromatosis;

m. Juvenile rheumatoid arthritis;

n. Seronegative spondyloarthropathy;

o. Orthopedic complications of hemophilia;

p. Myopathy;

q. Muscular dystrophy;

r. Myoneural disorder;

s. Arthrogryposis;

t. Spinal muscle atrophy;

u. Polyneuropathy;

v. Chronic stage bone infection;

w. Chronic stage joint infection;

x. Upper limb amputation;

y. Syndactyly;

z. Kyphosis;

aa. Scoliosis;

bb. Congenital spinal deformity;

cc. Congenital cervical spine abnormality;

dd. Developmental cervical spine abnormality;

ee. Hip dysplasia;

ff. Slipped capital femoral epiphysis;

gg. Femoral anteversion and tibial torsion that is:

i. For an individual less than eight years of age, associated with a neuromuscular disorder that is a CRS condition; or

ii. For an individual eight years of age or older, causing significant functional impairment, as determined by a CRS provider;

hh. Legg-Calve-Perthes disease;

ii. Lower limb amputation, including prosthetic sequelae of cancer;

jj. Metatarsus adductus;

kk. Leg length discrepancy of five centimeters or more;

ll. Metatarsus primus varus;

mm. Dorsal bunions;

nn. Collagen vascular disease;

oo. Benign bone tumor;

pp. Deformity and dysfunction secondary to musculoskeletal trauma if:

i. The patient was 15 years of age or younger at the time of initial injury, and

ii. The deformity and dysfunction is not in the acute phase;

qq. Osgood Schlatter's disease that requires surgical intervention; and

rr. Complicated flat foot, such as rigid foot, unstable subtalar joint, or significant calcaneus deformity;

6. One or more of the following gastrointestinal system medical conditions:

a. Tracheoesophageal fistula;

b. Anorectal atresia;

c. Hirschsprung's disease;

d. Diaphragmatic hernia;

e. Gastroesophageal reflux that has failed treatment with drugs or biologicals and requires surgery;

f. Deformity and dysfunction of the gastrointestinal system secondary to trauma, after the acute phase of the trauma has passed;

g. Biliary atresia;

h. Congenital atresia, stenosis, fistula, or rotational abnormalities of the gastrointestinal tract;

i. Cleft lip;

j. Cleft palate;

k. Omphalocele; and

l. Gastroschisis;

7. One or more of the following nervous system medical conditions:

a. Uncontrolled seizure disorder, in which there have been more than two seizures with documented adequate blood levels of one or more medications;

b. If the individual is not eligible for Title XIX or Title XXI health care insurance and does not have other health care insurance, simple or controlled seizure disorders;

c. Cerebral palsy;

d. Muscular dystrophy or other myopathy;

e. Myoneural disorder;

f. Neuropathy, hereditary or idiopathic;

g. Central nervous system degenerative disease;

h. Central nervous system malformation or structural abnormality;

i. Hydrocephalus;

j. Craniosynostosis of a sagittal suture, a unilateral coronal suture, or multiple sutures in a child less than 18 months of age;

k. Myasthenia gravis, congenital or acquired;

l. Benign intracranial tumor;

m. Benign intraspinal tumor;

n. Tourette's syndrome;

o. Residual dysfunction after resolution of an acute phase of vascular accident, inflammatory condition, or infection of the central nervous system;

p. Myelomeningocele, also known as spina bifida;

q. Neurofibromatosis;

r. Deformity and dysfunction secondary to trauma in an individual 15 years of age or less at the time of the initial injury;

s. Sequelae of near drowning, after the acute phase; and

t. Sequelae of spinal cord injury, after the acute phase;

8. One or more of the following ophthalmological medical conditions:

a. Cataracts;

b. Glaucoma;

c. Disorder of the optic nerve;

d. Non-malignant enucleation and post-enucleation reconstruction;

e. Retinopathy of prematurity; and

f. Disorder of the iris, ciliary bodies, retina, lens, or cornea;

9. One or more of the following respiratory system medical conditions:

a. Anomaly of the larynx, trachea, or bronchi that requires surgery; and

b. Nonmalignant obstructive lesion of the larynx, trachea, or bronchi;

10. One or more of the following integumentary system medical conditions:

a. A craniofacial anomaly that is functionally limiting,

b. A burn scar that is functionally limiting,

c. A hemangioma that is functionally limiting,

d. Cystic hygroma, and

e. Complicated nevi requiring multiple procedures;

11. One or more of the following genetic and metabolic medical conditions:

a. Amino acid or organic acidopathy,

b. Inborn error of metabolism,

c. Storage disease,

d. Phenylketonuria,

e. Homocystinuria,

f. Hypothyroidism,

g. Maple syrup urine disease, and

h. Biotinidase deficiency;

12. Sickle cell anemia or other hemoglobinopathy; or

13. A medical condition, other than one of the conditions in R9-7-203, that, as determined by the Department:

a. Requires specialized treatment similar to the type and quantity of treatment a medical condition in subsections (1) through (12) requires,

b. Is as likely to result in functional improvement with treatment as a medical condition listed in subsections (1) through (12), and

c. Requires long-term follow-up of the type and quantity required for a medical condition listed in subsections (1) through (12).

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-203. Medical Ineligibility

An individual who does not have one or more of the medical conditions in R9-7-202, and who has one or more of the following medical conditions, is not medically eligible for CRS:

1. The following cardiovascular system medical conditions:

a. Essential hypertension;

b. Premature atrial, nodal or ventricular contractions that are of no hemodynamic significance;

c. Arteriovenous fistula that is not expected to cause cardiac failure or threaten loss of function; and

d. Benign heart murmur;

2. The following endocrine system medical conditions:

a. Diabetes mellitus,

b. Isolated growth hormone deficiency,

c. Hypopituitarism encountered in the acute treatment of a malignancy, and

d. Precocious puberty;

3. The following genitourinary system medical conditions:

a. Nephritis, infectious or noninfectious;

b. Nephrosis;

c. Undescended testicle;

d. Phimosis;

e. Hydrocele not associated with a ventriculo-peritoneal shunt;

f. Enuresis;

g. Meatal stenosis; and

h. Hypospadias involving isolated glandular or coronal aberrant location of the urethralmeatus without curvature of the penis;

4. The following ear, nose and throat medical conditions:

a. Tonsillitis,

b. Adenoiditis,

c. Hypertrophic lingual frenum,

d. Nasal polyp,

e. Cranial or temporal mandibular joint syndrome,

f. Simple deviated nasal septum,

g. Recurrent otitis media,

h. Obstructive apnea,

i. Acute perforation of the tympanic membrane,

j. Sinusitis,

k. Isolated preauricular tag or pit, and

l. Uncontrolled salivation;

5. The following musculoskeletal system medical conditions:

a. Ingrown toenail;

b. Back pain with no structural abnormality;

c. Ganglion cyst;

d. Flat foot other than complicated flat foot;

e. Fracture;

f. Popliteal cyst;

g. Femoral anteversion and tibial torsion unless:

i. For an individual less than eight years of age, associated with a neuromuscular disorder that is a CRS condition; or

ii. For an individual eight years of age or older, causing significant functional impairment as determined by a CRS provider;

h. Simple bunion; and

i. Carpal tunnel syndrome;

6. The following gastrointestinal system medical conditions:

a. Malabsorption syndrome, also known as short bowel syndrome,

b. Crohn's disease,

c. Hernia other than a diaphragmatic hernia,

d. Ulcer disease,

e. Ulcerative colitis,

f. Intestinal polyp,

g. Pyloric stenosis, and

h. Celiac disease;

7. The following nervous system medical conditions:

a. Headaches;

b. Central apnea secondary to prematurity;

c. Near sudden infant death syndrome;

d. Febrile seizures;

e. Occipital plagiocephaly, either positional or secondary to lambdoidal synostosis;

f. Trigonocephaly secondary to isolated metopic synostosis;

g. Spina bifida occulta;

h. Near drowning in the acute phase; and

i. Spinal cord injury in the acute phase;

8. The following ophthalmologic medical conditions:

a. Simple refraction error,

b. Astigmatism,

c. Strabismus, and

d. Ptosis;

9. The following respiratory system medical conditions:

a. Respiratory distress syndrome,

b. Asthma,

c. Allergies,

d. Bronchopulmonary dysplasia,

e. Emphysema,

f. Chronic obstructive pulmonary disease, and

g. Acute or chronic respiratory condition requiring venting for the neuromuscularly impaired;

10. The following integumentary system medical conditions:

a. A deformity that is not functionally limiting,

b. Simple nevi,

c. Skin tag,

d. Port wine stain,

e. Sebaceous cyst,

f. Isolated malocclusion that is not functionally limiting,

g. Pilonidal cyst,

h. Ectodermal dysplasia, and

i. A craniofacial anomaly that is not functionally limiting;

11. The following medical conditions:

a. Allergies;

b. Anorexia nervosa or obesity;

c. Autism;

d. A burn other than a burn scar that is functionally limiting;

e. Cancer;

f. Chronic vegetative state;

g. Deformity and dysfunction secondary to trauma or injury if:

i. The trauma or injury occurred on or after the individual's 16th birthday, or

ii. Three months have not passed since the trauma or injury;

h. Depression or other mental illness;

i. Developmental delay;

j. Dyslexia or other learning disabilities;

k. Failure to thrive;

l. Hyperactivity;

m. Attention deficit disorder;

n. Leg length discrepancy of less than five centimeters at skeletal maturity; and

o. Immunodeficiency, such as AIDS and HIV.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

ARTICLE 3. REFERRAL; ENROLLMENT; FINANCIAL DETERMINATION; REDETERMINATION; TERMINATION

Article 3, consisting of Sections R9-7-301 through R9-7-306, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-301. Referral

A. To refer an individual, a referral source shall submit to the Department the following information:

1. The individual's:

a. Name;

b. Date of birth;

c. Home address; and

d. Contact information, such as a telephone number or e-mail address;

2. If known to the referral source, the individual's Social Security number;

3. If the individual is a minor, the name of a parent of the individual;

4. If known to the referral source, whether the individual is:

a. A U.S. citizen, or

b. A qualified alien;

5. The name, address, and telephone number of the referral source;

6. The relationship of the referral source to the individual;

7. If known to the referral source:

a. The individual's diagnosis, and

b. The name of the individual's physician; and

8. If known to the referral source, whether the individual has:

a. Title XIX health care insurance,

b. Title XXI health care insurance, or

c. Other health care insurance.

B. If an individual has Title XIX, Title XXI, or other health care insurance, a referral source shall submit to the Department:

1. The information in subsection (A);

2. Documentation from a physician who evaluated the individual, stating the individual's diagnosis; and

3. Diagnostic test results that support the individual's diagnosis.

C. If an individual does not have Title XIX, Title XXI, or other health care insurance, a referral source shall submit to the Department:

1. The information in subsection (A);

2. If the individual has not been evaluated by a physician, the reason the referral source believes that the individual may have a CRS condition; and

3. If the individual has been evaluated by a physician:

a. Documentation from the physician who evaluated the individual, stating the individual's diagnosis; and

b. If available, diagnostic test results that support the individual's diagnosis.

D. The Department shall provide written notice of the Department's eligibility determination to a referral source and the referred individual within 14 days from the date of receipt of a referral.

E. If the Department determines that the individual has a CRS condition and may be eligible for CRS, the Department shall provide the individual or, if the individual is a minor, the individual's parent:

1. A written notice that the individual has a CRS condition and that:

a. The individual may be eligible for CRS;

b. The Department will not enroll the individual in CRS until the individual:

i. Completes and submits to the Department the application packet required in R9-7-302(A);

ii. Complies with the financial screening requirements in R9-7-303, if applicable; and

iii. Completes and submits to the Department the payment agreement described in R9-7-304(A); and

c. If the Department does not receive the documents in subsection (E)(1)(b) within 90 days from the date of the notice in subsection (E)(1), the Department shall consider the application withdrawn.

2. Information about CRS, including:

a. An overview of CRS,

b. The medical services and support services covered by CRS,

c. The grievance and appeal process,

d. The enrollment requirements in R9-7-301 and R9-7-302 and an explanation of the enrollment process,

e. The financial screening requirements in R9-7-303 and an explanation of the financial screening process, and

f. The percentage of the Federal Poverty Level established according to R9-7-304(C) by which the Department determines a member's payment responsibility and an explanation of the Department's process to determine a member's payment responsibility;

3. The application packet required in R9-7-302(A);

4. The financial screening packet described in R9-7-303; and

5. The payment agreement described in R9-7-304(A).

F. If the Department determines that the individual is not eligible for CRS, the Department shall provide the individual or, if the individual is a minor, the individual's parent a written notice that:

1. Informs the individual or, if the individual is a minor, the individual's parent of the reason why the individual is not eligible for CRS; and

2. Complies with A.R.S. § 41-1092.03.

G. If the Department determines the referral source did not submit the information and documentation required in subsections (A) through (C):

1. The Department shall provide a written notice to the referral source and the referred individual that:

a. Identifies the missing information or documentation;

b. Requests the referral source or referred individual to submit the missing information or documentation within 90 days from the date of the notice; and

c. Informs the referral source and referred individual that, if the Department does not receive the information or documentation within 90 days from the date of the notice, the Department shall consider the referral withdrawn.

2. If the Department receives the information or documentation requested in subsection (G)(1) within 90 days of the notice in that subsection, the Department shall, within 14 days from the date of receipt of the requested information or documentation, make an eligibility determination and provide notice according to this Section.

3. If the Department does not receive the information or documentation requested in subsection (G)(1) within 90 days of the notice in that subsection, the Department shall consider the referral withdrawn.

H. If the Department determines that further diagnostic testing or an initial evaluation is necessary for the Department to determine whether the individual has a CRS condition, the Department shall provide the individual or, if the individual is a minor, the individual's parent:

1. A written notice that:

a. Further diagnostic testing or an initial evaluation of the individual is necessary in order for the Department to determine whether the individual has a CRS condition; and

b. If applicable, includes the name and contact information for the person the individual can contact in order to schedule further diagnostic testing or an initial evaluation; and

c. Informs the individual or, if the individual is a minor, the individual's parent that, if the Department does not receive the results of further diagnostic testing within 90 days from the date of the notice, or the individual does not receive an initial evaluation within 90 days from the date of the notice, the Department shall consider the referral withdrawn;

2. Information about CRS, including:

a. An overview of CRS,

b. The medical services and support services covered by CRS,

c. The grievance and appeal process,

d. The enrollment requirements in R9-7-301 and R9-7-302 and an explanation of the enrollment process,

e. The financial screening requirements in R9-7-303 and an explanation of the financial screening process, and

f. The percentage of the Federal Poverty Level established according to R9-7-304(C) by which the Department determines a member's payment responsibility and an explanation of the Department's process to determine a member's payment responsibility;

3. The application packet required in R9-7-302(A);

4. The financial screening packet described in R9-7-303; and

5. The payment agreement described in R9-7-304(A).

I. If an individual receives the notice in subsection (H)(1) that further diagnostic testing is necessary, the individual shall:

1. If the individual has Title XIX or Title XXI health care insurance, request that AHCCCS complete the diagnostic testing and send the results of the diagnostic testing to the Department;

2. If the individual has other health care insurance that provides the diagnostic testing, request and complete the diagnostic testing and submit the results of the diagnostic testing to the Department; or

3. If the individual does not have health care insurance or has health care insurance that does not provide the diagnostic testing:

a. Complete and submit to the Department the payment agreement described in R9-7-304(A) before the individual receives the diagnostic testing; and

b. Contact the person indicated in the notice in subsection (H)(1)(b) to schedule the diagnostic testing, if applicable.

J. If an individual receives the notice in subsection (H)(1) that an initial evaluation is necessary, the individual shall:

1. Complete and submit to the Department the payment agreement described in R9-7-304(A) before the individual receives an initial evaluation; and

2. Contact the person indicated in the notice in subsection (H)(1)(b) to schedule an initial evaluation.

K. If the Department receives the results of further diagnostic testing within 90 days from the date of the notice in subsection (H)(1), or the individual receives an initial evaluation within 90 days from the date of the notice in subsection (H)(1), the Department shall, within 14 days from the date of receipt of the results of further diagnostic testing or the completion of the individual's initial evaluation, make an eligibility determination and provide notice according to this Section.

L. If the Department does not receive the results of further diagnostic testing within 90 days from the date of the notice in subsection (H)(1), or the individual does not receive an initial evaluation within 90 days from the date of the notice in subsection (H)(1), as applicable, the Department shall consider the referral withdrawn.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-302. Enrollment

A. An applicant for enrollment in CRS shall submit:

1. The following information:

a. The applicant's name, home address, mailing address, birth date, and marital status;

b. If the applicant has a Social Security number, the applicant's Social Security number;

c. Contact information for the applicant, such as a telephone number, cellular telephone number, or e-mail address;

d. Whether the applicant has a legal guardian;

e. Whether the applicant is an emancipated minor;

f. If the applicant is a minor, the following information for the applicant's parent:

i. Name, home address, mailing address, and contact information such as a telephone number, cellular telephone number, or e-mail address; and

ii. If the parent is employed, the parent's employer, work address, and work telephone number;

g. A statement that the applicant or, if the applicant is a minor, a parent on behalf of the applicant requests the applicant's enrollment in CRS; and

h. The signature of the applicant or, if the applicant is a minor, the signature of the applicant's parent, and the date signed;

2. If the applicant has a legal guardian, a copy of the court document indicating the applicant's legal guardian;

3. If the applicant is an emancipated minor, a copy of the court document indicating that the applicant is an emancipated minor;

4. If the applicant has Title XIX or Title XXI health care insurance:

a. The applicant's valid AHCCCS identification number or a copy of the applicant's valid AHCCCS identification card; and

b. An assignment of Title XIX or Title XXI health care insurance benefits, as applicable, to the Department;

5. If the applicant does not have Title XIX or Title XXI health care insurance:

a. Except as provided in subsection (A)(5)(b), as proof of the applicant's age and that the applicant is a U.S. citizen, a copy of any of the following documents that include the applicant's birth date:

i. A certified copy of a birth certificate,

ii. A naturalization certificate reflecting U.S. citizenship,

iii. A current or expired U.S. passport, or

iv. A certificate of U.S. citizenship;

b. If the applicant is a qualified alien, written documentation containing the applicant's birth date that verifies that the applicant:

i. Is a qualified alien, and

ii. Meets the requirements of A.R.S. § 36-2903.03(B);

c. As proof that the applicant resides in Arizona, a copy of any of the following documents, issued in the name of the applicant, the spouse of the applicant, or an adult with whom the applicant lives:

i. A United States Post Office record that contains the applicant's current Arizona address;

ii. An Arizona rent or mortgage receipt for the applicant's current Arizona address;

iii. An Arizona lease for the applicant's current Arizona address;

iv. A written statement that the applicant currently lives at an Arizona nursing care institution licensed under A.R.S. Title 36, Chapter 4, signed by the administrator of the Arizona nursing care institution;

v. A current Arizona motor vehicle operator's license;

vi. A current Arizona motor vehicle registration;

vii. A current pay stub from an Arizona employer;

viii. An Arizona utility bill for the applicant's current Arizona address;

ix. An Arizona telephone directory listing for the applicant's current Arizona address;

x. A certified copy of a religious record that contains the applicant's current Arizona address;

xi. A certified copy of a school record that contains the applicant's current Arizona address; or

xii. An affidavit signed by the applicant or, if the applicant is a minor, by the applicant's parent certifying that:

(1) None of the documents in subsections (A)(5)(c)(i) through (xi) are available, and

(2) The applicant currently lives in Arizona; and

d. Unless the application packet is being submitted for redetermination according to R9-7-307(A)(1), the applicable financial screening packet described in:

i. R9-7-303(A), or

ii. R9-7-303(B).

B. The Department shall provide to an applicant within seven days from the date of the receipt of the application packet required in subsection (A) a written notice of:

1. The Department's enrollment determination; and

2. If applicable, the Department's determination of the applicant's payment responsibility.

C. If the Department determines that an applicant is eligible to enroll in CRS and has complied with the requirements in this Section, the Department shall provide the applicant or, if the applicant is a minor, the applicant's parent:

1. A written notice that:

a. The applicant is eligible to enroll in CRS once the Department has received a completed payment agreement from the applicant; and

b. If the applicant does not submit to the Department a completed payment agreement within 90 days from the date of the notice, the Department shall consider the application withdrawn; and

2. The payment agreement described in R9-7-304(A).

D. An applicant who is eligible to enroll in CRS and has complied with the requirements in this Section shall submit to the Department the completed payment agreement described in R9-7-304(A).

E. Except as provided in subsection (I), if the Department receives a completed payment agreement from an applicant who is eligible to enroll in CRS and has complied with the requirements in this Section, the Department shall:

1. Enroll the applicant in CRS; and

2. Provide the applicant or, if the applicant is a minor, the applicant's parent, a written notice that:

a. The applicant is enrolled in CRS, and

b. Includes the name and contact information for the person the member can contact to schedule a medical service with a CRS provider.

F. If the Department determines that an applicant did not submit the information and documentation required in subsection (A):

1. The Department shall provide a written notice to the applicant or, if the applicant is a minor, the applicant's parent that:

a. Identifies the missing information or documentation;

b. Requests the applicant or, if the applicant is a minor, the applicant's parent to submit the missing information or documentation within 90 days from the date of the notice; and

c. Informs the applicant or, if the applicant is a minor, the applicant's parent that, if the Department does not receive the information or documentation within 90 days from the date of the notice, the Department shall consider the application withdrawn.

2. If the Department requests information or documentation according to subsection (F)(1) and receives the information or documentation requested within 90 days of the notice in that subsection, the Department shall, within seven days from the date of receipt of the requested information or documentation, make an enrollment determination and provide notice according to this Section.

G. If the Department determines that an applicant is not eligible to enroll in CRS, the Department shall provide the applicant or, if the applicant is a minor, the applicant's parent a written notice that:

1. Informs the applicant or, if the applicant is a minor, the applicant's parent of the reason why the applicant is not eligible to enroll in CRS; and

2. Complies with A.R.S. § 41-1092.03.

H. The Department shall consider an application withdrawn if the Department does not receive:

1. The application packet required in subsection (A) within 90 days from the date of the notice in R9-7-301(E)(1),

2. The information or documentation requested according to subsection (F)(1) within 90 days of the date of the notice in that subsection, or

3. A completed payment agreement described in R9-7-304(A) within 90 days from the date of the notice in subsection (C)(1).

I. If the Department receives a completed payment agreement from an applicant who is eligible to enroll in CRS and has complied with the requirements in this Section and the applicant is receiving inpatient services, the Department shall:

1. Provide the applicant or, if the applicant is a minor, the applicant's parent a written notice:

a. Stating that the Department will not enroll an applicant while the applicant is receiving inpatient services, and

b. Requesting that the Department be notified when the applicant is no longer receiving inpatient services; and

2. When the Department receives notice that the applicant is no longer receiving inpatient services, enroll the applicant according to subsection (E).

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-303. Financial Screening

A. A financial screening packet for an individual who is not eligible for Title XIX or Title XXI health care insurance and is not applying for state funding under A.R.S. § 36-263 shall contain the following information:

1. The individual's name and birth date;

2. If the individual has a Social Security number, the individual's Social Security number;

3. A statement from the individual that the individual has reviewed the requirements provided by the Department for eligibility for Title XIX and Title XXI health care insurance, and the individual is not eligible for Title XIX or Title XXI health care insurance; and

4. The signature of the individual or, if the individual is a minor, the signature of the individual's parent, and the date signed;

B. A financial screening packet for an individual who may be eligible for Title XIX or Title XXI health care insurance and is applying for state funding under A.R.S. § 36-263 shall contain:

1. The following information:

a. The individual's name and birth date;

b. If the individual has a Social Security number, the individual's Social Security number;

c. The individual's marital status;

d. The names and ages of all individuals in the individual's household income group;

e. The annual gross income of the individual's household income group;

f. Whether the individual has health care insurance other than Title XIX or Title XXI health care insurance;

g. If the individual has health care insurance other than Title XIX or Title XXI health care insurance, for each health care insurance company:

i. The health care insurance company's name, billing address, and telephone number; and

ii. For the individual's health care insurance, the individual's policy or plan number, health care insurance identification number, effective or end date, and type of services paid for by the health care insurance; and

h. The signature of the individual or, if the individual is a minor, the signature of the individual's parent, and the date signed;

2. Copies of the following documentation for each individual in the individual's household income group, if applicable:

a. If the individual in the household income group is employed, the individual's:

i. Pay stubs for the 30 days before the date the applicant submitted the application packet required in R9-7-302(A), or

ii. If the individual cannot provide pay stubs, a written statement from the individual's employer confirming the individual's income from that employer;

b. If the individual in the household income group is self-employed, the individual's:

i. Federal tax return, including a schedule C, most recently filed by the individual; or

ii. Most recent quarterly financial statement signed and dated by the individual;

c. Documented evidence of all unearned income received by the individual, such as cancelled checks or court orders for child support payments; and

d. Documented evidence of all medical expenses incurred by the individual during the 12 months before the date the individual submitted the individual's CRS application;

3. If applicable, documented evidence of:

a. Any court award or settlement related to the individual's CRS condition, and

b. Expenditures from the court award or settlement made for medical services for the individual; and

4. If applicable, documented evidence of all current dependent care expenses for the individual, including:

a. The name and age of each dependent for whom the individual incurred dependent care expenses, and

b. The amount and frequency of dependent care expenses incurred for each dependent.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Section repealed; new Section made by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-304. Payment Responsibility

A. A payment agreement shall contain the following information:

1. The individual's or member's name;

2. The individual's or member's date of birth;

3. If the Department has determined the individual's or member's payment responsibility, the individual's or member's payment responsibility;

4. A promise to pay the cost of covered medical services not paid by any third-party payor;

5. An assignment of insurance benefits; and

6. The signature of the individual or, if the individual is a minor, the signature of the individual's parent, and the date signed;

B. The Department shall determine an individual's or member's payment responsibility for covered medical services by:

1. Identifying the individual's or member's household income group;

2. Calculating the net income of the individual's or member's household income group; and

3. Determining whether the net income of the individual's or member's household income group is:

a. Less than the percentage established according to subsection (C), or

b. Greater than or equal to the percentage established according to subsection (C).

C. The Department shall establish annually, based on the amount of funding appropriated to CRS under A.R.S. §§ 36-261(A)(5)(h) and 36-261(A)(5)(l) and the Department's projected cost to administer CRS and provide covered medical services and covered support services for the subsequent 12 months, the percentage of the Federal Poverty Level to be used to determine an individual's or member's payment responsibility according to this Section.

D. The Department shall not require an individual, whose household income group's net income is less than the percentage established according to subsection (C), to pay for a covered medical service.

E. An individual whose household income group's net income is greater than or equal to the percentage established according to subsection (C) shall pay for a covered medical service an amount not to exceed the AHCCCS capped fee-for-service rate for the covered medical service.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Section repealed; new Section renumbered from R9-7-604 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-305. Identification of Household Income Group

A. At the time of application or redetermination, the Department shall identify a member's household income group as:

1. If the member is living with a parent of the member, that parent's household income group;

2. If the member is living with an individual other than a parent of the member and a parent of the member claims the member as a dependent for tax purposes for the current tax year, that parent's household income group; or

3. If the member is living with an individual other than a parent of the member and neither parent claims the member as a dependent for tax purposes, the household income group of the individual with whom the member lives.

B. The Department shall consider as a household income group any of the following who are living together:

1. A married couple and children of either or both,

2. An unmarried couple and children of either or both;

3. A married couple when both are over the age of 21 years;

4. A married couple when either one or both are under the age of 21 years with no children;

5. A single parent and the single parent's children;

6. An applicant or a member between the ages of 18 years and 21 years; or

7. If living with an applicant or a member, one of the groups in subsections (B)(1) through (B)(5), the applicant or member, and:

a. The applicant's or member's spouse,

b. A child of the applicant's or member's spouse,

c. A child of the applicant or member, and

d. The other parent of the applicant's or member's child.

C. In addition to the individuals in subsection (B), the Department shall include in a household income group an individual who is not living with the household if:

1. The individual is absent from the household:

a. For 30 consecutive days or less;

b. To seek or maintain employment;

c. To serve in the military; or

d. To attend an educational institution, and the parent of the individual claims the individual as a dependent on the parent's income tax return; or

2. The parent of the individual claims the individual as a dependent on the parent's income tax return.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Section R9-7-305 renumbered to R9-7-307; new Section renumbered from R9-7-602 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-306. Calculating Net Income

A. Except as provided in subsection (B), a household income group's gross income includes all the earned income and unearned income of the individuals in the household income group.

1. For an individual in the household income group who is not self-employed, the Department shall calculate an individual's income using the documents required in R9-7-303(B)(2)(a); and

2. For an individual in the household income group who is self-employed, the Department shall calculate an individual's income using the individual's federal tax return or most recent quarterly financial statement required in R9-7-303(B)(2)(b).

B. Gross income does not include:

1. The items in A.A.C. R9-22-1420(C), and

2. The first $50.00 per month per child of child support payments received by an individual in the household income group.

C. When calculating net income, the Department shall deduct the following from the gross income of the household income group described in R9-7-305:

1. For each month the household income group received earned income, a deduction for dependent care that is equal to the AHCCCS allowable deduction in A.A.C. R9-22-1420(F)(2)(b), if the individual who received dependent care is living in the household;

2. For each individual in the household income group who earned income, an allowance of $90.00 for each month the individual earned income; and

3. Medical expenses that are:

a. Incurred by the individual during the 12 months before the individual submitted to the Department the application packet required in R9-7-302(A), and

b. Not subject to any third-party payment or reimbursement.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Section R9-7-306 renumbered to R9-7-308; new Section renumbered from R9-7-603 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-307. Redetermination

A. At any time, the Department may, to redetermine whether a member remains eligible for CRS or a member's payment responsibility, request that a member or, if the member is a minor, the member's parent submit all or part of the following information or documentation:

1. To determine whether a member remains eligible for CRS, the application packet required in R9-7-302(A);

2. If the member does not have Title XIX or Title XXI health care insurance, to determine a member's payment responsibility, the financial screening packet described in R9-7-303; or

3. If the member has Title XIX or Title XXI health care insurance, to determine whether the member remains eligible for AHCCCS, the member's valid AHCCCS identification number or a copy of the member's valid AHCCCS identification card.

B. The Department shall provide written notice of the Department's request in subsection (A) to the member or, if the member is a minor, the member's parent:

1. Requesting all or part of the information or documentation described in subsection (A); and

2. Informing the member or, if the member is a minor, the member's parent that if the Department does not receive the information or documentation in subsection (A) within 30 days from the date of the notice, the Department:

a. Will not provide a covered service to the member; and

b. If applicable, may terminate the member's enrollment according to R9-7-308.

C. The Department shall, at least once every 12 months:

1. If a member does not have Title XIX or Title XXI health care insurance, redetermine a member's payment responsibility; or

2. If a member has Title XIX or Title XXI health care insurance, redetermine whether a member remains eligible for Title XIX or Title XXI health care insurance.

D. If the Department sends the notice in subsection (B), the member or, if the member is a minor, the member's parent shall submit the requested information or documentation to the Department within 30 days of the request.

E. If the Department receives the information in subsection (A)(1) from the member within 30 days, the Department shall determine the member's eligibility as provided in Article 2.

F. If the Department does not receive the information or documentation in subsection (A)(1) from the member within 30 days, or the Department determines that a member is no longer eligible for CRS, the Department shall provide the member or, if the member is a minor, the member's parent a written notice that:

1. Informs the member that the Department is terminating the member's enrollment according to R9-7-308 because:

a. The Department has determined that the member is no longer eligible for CRS, or

b. The member did not comply with the requirements in R9-7-307 to verify that the member remains eligible for CRS; and

2. Complies with A.R.S. § 41-1092.03.

G. If the Department receives the information or documentation in subsection (A)(2) from the member and, if applicable, the information or documentation is received within 30 days from the date of the notice in subsection (B), the Department shall redetermine the member's payment responsibility for covered medical services by:

1. Identifying the individual's or member's household income group;

2. Calculating the net income of the individual's or member's household income group;

3. Determining whether the net income of the member's household income group is:

a. Less than the highest percentage established according to R9-7-304(C) since the member most recently enrolled in CRS, or

b. Greater than or equal to the highest percentage established according to R9-7-304(C) since the member most recently enrolled in CRS.

H. If the Department does not receive the information or documentation in subsection (A)(2) within 30 days, the Department shall provide the member or, if the member is a minor, the member's parent a written notice that the member is required to comply with the requirements in this Section before the Department provides a covered service to the member.

I. If the Department determines that a member who does not have Title XIX or Title XXI health care insurance may be eligible for Title XIX or Title XXI health care insurance, the Department shall provide the member or, if the member is a minor, the member's parent a written notice that:

1. The member is required to apply for Title XIX or Title XXI health care insurance;

2. If the member does not apply for Title XIX or Title XXI health care insurance within six months after the date of the notice, the Department may terminate the member's enrollment; and

3. The member is required to apply for Title XIX or Title XXI health care insurance before the Department will provide a covered service to the member.

J. If the Department sends the notice in subsection (I), the member shall apply for Title XIX or Title XXI health care insurance:

1. Before the Department will provide a covered service to the member; or

2. Within six months after the date of the notice, if the member is not scheduled to receive a covered service within six months after the date of the notice.

K. At any time, a member or, if the member is a minor, the member's parent may request a redetermination of the member's payment responsibility by submitting to the Department:

1. A written request for redetermination, and

2. The information or documentation in subsection (A)(2).

L. Within 30 days from the date of the Department's determination under subsection (G), the Department shall provide the member or, if the member is a minor, the member's parent:

1. A written notice of the Department's redetermination; and

2. If applicable, a revised payment agreement.

M. If the Department changes a member's payment responsibility as a result of a redetermination, and the member does not have Title XIX or Title XXI health care insurance, the member or, if the member is a minor, the member's parent shall sign and submit a revised payment agreement before the Department provides a covered service to the member.

N. The Department shall consider a member to have been enrolled in CRS during any period of 90 days or less in which the member was not enrolled in CRS for the purpose of redetermining the member's payment responsibility according to this Section.

Historical Note

New Section R9-7-307 renumbered from R9-7-305 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-308. Termination

A. The Department shall terminate a member's enrollment if:

1. The Department determines the member does not meet the eligibility requirements in R9-7-201;

2. The member does not attend the member's first scheduled appointment with a CRS provider after enrollment; or

3. The member or, if the member is a minor, the member's parent:

a. Requests a termination of the member's enrollment; or

b. Fails to comply with:

i. The requirements in R9-7-307, or

ii. The signed payment agreement described in R9-7-304(A).

B. If the Department terminates a member's enrollment, the Department shall:

1. Provide the member or, if the member is a minor, the member's parent a written notice of termination that complies with A.R.S. § 41-1092.03; and

2. If the Department has the name of the member's physician other than a CRS provider, provide the member's physician a written notice of the member's termination.

Historical Note

New Section R9-7-308 renumbered from R9-7-306 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

ARTICLE 4. COVERED MEDICAL SERVICES

Article 4, consisting of Sections R9-7-401 through R9-7-421, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-401. General Requirements

A. Except as provided in R9-7-307(J) and (M), the Department shall provide a medical service described in R9-7-402 through R9-7-420 to a member if the Department determines that the medical service:

1. Is medically necessary,

2. Is related to the member's CRS condition, and

3. Is provided consistent with utilization management practices established by the Department.

B. If a member requires a medical service that meets the requirements of subsection (A) and the medical service is not available in Arizona, the Department shall provide the medical service in another state if:

1. Two physicians, who are CRS providers, practicing a specialty related to the member's CRS condition, each submit in writing to the Department:

a. A recommendation that the Department provide the medical service in another state; and

b. A statement that:

i. The medical service is life-saving for the member; or

ii. The member is expected to experience, as a result of the medical service, significant functional improvement; and

2. A physician who is the Department's designee provides written authorization before the provision of the medical service outside the state of Arizona.

C. The Department may provide a medical service in a state that borders Arizona if the member's residence is closer to a CRS provider in the state that borders Arizona than to a CRS provider located within Arizona.

D. If the Department provides a member a medical service in another state, the Department shall not provide:

1. Lodging for the member or member's family;

2. Transportation for a member's family; or

3. Transportation for a member, except as provided in R9-7-406(B).

E. If the Department receives from a member, who received a recommendation for treatment from a CRS provider, a request for a second recommendation for treatment, the Department shall:

1. Provide a second recommendation for treatment from a different CRS provider; or

2. If the Department is unable to provide a second recommendation for treatment from a different CRS provider, provide a second recommendation for treatment from another provider other than a CRS provider designated by the Department.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-402. Audiology Services

A. If the requirements in R9-7-401 are met, the Department shall provide audiology services to a member who has, as determined by a CRS provider, a:

1. Hearing impairment, or

2. CRS condition that poses a risk for hearing impairment.

B. If the requirements in subsection (A) are met, the Department shall provide the following audiology services:

1. A hearing screening;

2. A hearing evaluation;

3. Audiometric testing;

4. The selection, fitting, and dispensing of hearing aids;

5. After the hearing evaluation in subsection (B)(2), a follow-up hearing evaluation;

6. A replacement hearing aid once every three years, or sooner if the replacement hearing aid is for a member who:

a. Experiences a change in hearing level, as determined by a CRS provider;

b. Has a hearing aid stolen and submits to the Department a copy of a police report about the theft; or

c. Loses a hearing aid, and the Department has not replaced the hearing aid within the previous 12 months due to loss;

7. An implantable bone conduction device;

8. A cochlear implant; and

9. A tactile hearing aid.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-402 repealed; new Section renumbered from R9-7-403 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-403. Dental and Orthodontia Services

A. If the requirements in R9-7-401 are met, the Department shall provide dental services to a member who has one of the following medical conditions:

1. A cleft lip;

2. A cleft palate;

3. A cerebral spinal fluid diversion shunt at risk for subacute bacterial endocarditis;

4. A cardiac condition that causes the member to be at risk for subacute bacterial endocarditis;

5. Dental complications that are a result of treatment for a CRS condition; or

6. A functional malocclusion causing:

a. Mastication and swallowing abnormalities that affect the nutritional status of the individual, resulting in growth abnormalities;

b. A respiratory problem that restricts the member's breathing, such as dynamic or static airway obstruction; or

c. A communication disorder that cannot be further improved by speech therapy alone and that does not have a primary etiology other than the malocclusion, as determined by a CRS provider.

B. If the requirements in R9-7-401 are met, the Department shall provide orthodontia services and devices to a member who has one of the following medical conditions:

1. A cleft palate; or

2. A functional malocclusion causing:

a. Mastication and swallowing abnormalities that affect the nutritional status of the individual, resulting in growth abnormalities;

b. A respiratory problem that restricts the member's breathing, such as dynamic or static airway obstruction; or

c. A communication disorder that cannot be further improved by speech therapy alone and that does not have a primary etiology other than the malocclusion, as determined by a CRS provider.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-403 renumbered to R9-7-402; new Section renumbered from R9-7-404 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-404. Diagnostic Testing and Laboratory Services

A. If the requirements in R9-7-401 are met, the Department shall provide diagnostic testing or laboratory services to a member as ordered by a CRS provider.

B. The Department shall provide diagnostic testing and laboratory services, ordered by a CRS provider, to determine if a member has a CRS condition in addition to the CRS condition diagnosed at the time of the member's enrollment.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-404 renumbered to R9-7-403; new Section renumbered from R9-7-405 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-405. Home Health Services

A. If the requirements in R9-7-401 are met, the Department shall provide total parenteral nutrition to a member, as ordered by a CRS provider, in preparation for a procedure or surgery related to the member's CRS condition.

B. If the requirements in R9-7-401 are met, after a member's hospitalization, or instead of hospitalization, the Department shall provide the following home health services:

1. An evaluation of the member's need for home health services,

2. Intravenous therapy,

3. Wound care,

4. Administration of medications,

5. Monitoring the member's vital signs to determine whether the member's vital signs are within the range established as acceptable for the member by a CRS provider,

6. Monitoring oxygen administration to determine whether the member's breathing is within the range established as acceptable for the member by a CRS provider,

7. Physical therapy,

8. Occupational therapy,

9. Enterostomy care,

10. Urethral catheter insertion and care, and

11. Instruction for the provision of home health services to the member or the member's caregivers.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-405 renumbered to R9-7-404; new Section renumbered from R9-7-406 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-406. Inpatient Services

A. If the requirements in R9-7-401 are met, the Department shall provide inpatient services to a member who requires hospitalization related to the member's CRS condition.

1. If, after being hospitalized, a member's hospitalization is no longer related to the member's CRS condition or to complications related to the member's treatment for the member's CRS condition, the Department shall not provide inpatient services to the member.

2. If a member requires inpatient services to determine whether the member has ventricular infection or ventricular shunt failure, the Department shall provide inpatient services until the date the physician who is the Department's designee determines that the member does not have ventricular infection or ventricular shunt failure.

B. If the requirements in R9-7-401 are met, the Department shall provide transportation for a member who is receiving inpatient services from a hospital that is a CRS provider to another hospital that is a CRS provider.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-406 renumbered to R9-7-405; new Section renumbered from R9-7-407 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-407. Medical Equipment

A. If the requirements in R9-7-401 are met and subject to the limitations in this Section, the Department shall provide the medical equipment indicated in this Section to a member as ordered by a CRS provider.

B. The Department shall provide to a member:

1. A wheelchair,

2. An ambulation assistive device, or

3. A tilt-in-space wheelchair only if a change in the member's position is necessary to provide medically necessary services such as tracheotomy care or feeding.

C. The Department shall not provide a member with:

1. A wheelchair or an ambulation assistive device if the wheelchair or ambulation assistive device is for use at school only,

2. A second non-motorized wheelchair if the member already has a non-motorized wheelchair that is operational, or

3. A second ambulation assistive device if the member already has an ambulation assistive device that is operational.

D. The Department shall provide a tray for a member's wheelchair if a CRS provider states in writing that the member's use of the tray is likely to result in the member's functional improvement.

E. The Department shall provide a cranial modeling band for a member who:

1. Is 24 months of age or younger;

2. Has undergone CRS-approved cranial modeling surgery; and

3. Demonstrates postoperative progressive loss of surgically achieved correction that, without intervention, may require additional remodeling surgery.

F. The Department shall provide a stroller for a member if a CRS provider determines that the stroller is medically necessary to provide modified seating for positioning the member.

G. Unless approved by a physician who is the Department's designee, the Department shall provide oxygen and related services for no more than 30 consecutive days to a member.

H. The Department shall replace or make a change to the medical equipment provided to a member if the replacement or change is:

1. Recommended by a CRS provider; and

2. Necessary due to a change in the member's physical size, functional level, physical safety, or medical condition.

I. Except as provided in subsection (K), in addition to subsection (H), the Department shall replace medical equipment provided to a member if the medical equipment:

1. As determined by a CRS provider, is not safe to operate and cannot be repaired to be safe to operate;

2. Is stolen and the member or, if the member is a minor, the member's parent submits to the Department:

a. A written request for replacement medical equipment, and

b. A copy of a written police report about the stolen medical equipment; or

3. Is lost and has not been replaced by the Department within the previous 12 months due to loss.

J. Except as provided in subsection (K), the Department shall repair a member's medical equipment if:

1. The Department determines that the medical equipment, if not repaired, would be provided according to this Section;

2. The Department determines that the repair to the medical equipment is medically necessary; and

3. The repair is to:

a. Medical equipment provided by the Department; or

b. Medical equipment that, although not provided to the member by the Department, has been determined by a CRS provider to be safe, appropriate, and medically necessary for the member.

K. The Department shall not repair or replace medical equipment according to subsection (I) or (J) if the need for repair or replacement is due to the member's misuse of the medical equipment.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-407 renumbered to R9-7-406; new Section renumbered from R9-7-408 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-408. Nursing Services

If the requirements in R9-7-401 are met, the Department shall provide nursing services to a member.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-408 renumbered to R9-7-407; new Section renumbered from R9-7-409 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-409. Nutrition Services

A. If the requirements in R9-7-401 are met, the Department shall provide the following nutrition services to a member:

1. An evaluation of the member's nutritional needs;

2. Total parenteral nutrition according to R9-7-405(A);

3. If ordered by a CRS provider:

a. Nutrition, other than listed in subsection (B), for the treatment of a metabolic disorder; and

b. Medical equipment or a commercial product for providing nutrition through a tube; and

4. If ordered by a CRS provider for a member with cystic fibrosis, and not available through a source other than CRS, a commercial product:

a. For a member who is not receiving nutrition through a tube, that supplies 50% of the member's daily caloric need; and

b. For a member who is receiving nutrition through a tube, that supplies 100% of the member's daily caloric need; and

B. The Department shall not provide:

1. Lactose-free nutrition for galactosemia,

2. A nutrition formula or a milk product used for the purpose of combining with a modified amino acid formula, or

3. Low protein nutrition.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-409 renumbered to R9-7-408; new Section renumbered from R9-7-410 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-410. Outpatient Services

If the requirements in R9-7-401 are met, the Department shall provide the following outpatient services to a member:

1. Outpatient surgery by a CRS provider;

2. Diagnostic testing and laboratory services allowed in R9-7-404;

3. Emergency services in a hospital that is a CRS provider;

4. CRS clinics;

5. Evaluation and treatment by a CRS provider at a location other than a CRS clinic.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-410 renumbered to R9-7-409; new Section renumbered from R9-7-411 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-411. Pharmaceutical Services

A. If the requirements in R9-7-401 are met, the Department shall provide pharmaceutical services to a member.

B. The Department shall provide growth hormone therapy ordered by a physician only for a member who has been diagnosed by a CRS provider with panhypopituitarism.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-411 renumbered to R9-7-410; new Section renumbered from R9-7-412 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-412. Physical Therapy and Occupational Therapy

If the requirements in R9-7-401 are met, the Department shall provide physical therapy or occupational therapy to a member only if the member:

1. Is unable to obtain physical therapy or occupational therapy through a source other than CRS or another health care insurance provider, and

2. Is expected to experience a functional improvement as a result of the physical therapy or occupational therapy.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-412 renumbered to R9-7-411; new Section renumbered from R9-7-413 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-413. Physician Services

If the requirements in R9-7-401 are met, the Department shall provide physician services to a member.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-413 renumbered to R9-7-412; new Section renumbered from R9-7-414 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-414. Prosthetic and Orthotic Devices

A. If the requirements in R9-7-401 are met, and subject to the limitations in subsection (B), the Department shall provide a prosthetic device or an orthotic device to a member to enhance the member's ability to perform an activity of daily living.

B. The Department shall not provide:

1. A myoelectric prosthetic device, or

2. Prosthetic shoes.

C. The Department shall replace or change a prosthetic device or orthotic device provided to a member if the replacement or change is:

1. Recommended by a CRS provider;

2. Necessary due to a change in the member's physical size, functional level, physical safety, or medical condition.

D. Except as provided in subsection (F), and in addition to subsection (C), the Department shall replace a prosthetic device or orthotic device provided to the member if the prosthetic device or orthotic device:

1. As determined by a CRS provider, is not safe to operate and cannot be repaired to be safe to operate;

2. Is stolen and the member or, if the member is a minor, the member's parent submits to the Department:

a. A written request for a replacement prosthetic device or orthotic device, and

b. A copy of a police report about the stolen prosthetic device or orthotic device; or

3. Is lost and has not been replaced by the Department within the previous 12 months due to loss.

E. Except as provided in subsection (F), the Department shall repair a prosthetic device or orthotic device provided to a member by the Department if the Department determines that the repair is safe, appropriate, and medically necessary for the member.

F. The Department shall not replace or repair a prosthetic device or orthotic device according to subsection (D) or (E) if the need for replacement or repair is due to the member's misuse of the prosthetic device or orthotic device.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-414 renumbered to R9-7-413; new Section renumbered from R9-7-415 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-415. Psychological Services

A. If the requirements in R9-7-401 are met, the Department shall provide the following psychological services to a member:

1. Crisis intervention services,

2. An evaluation by a psychologist, and

3. Based on a psychologist's evaluation, a recommendation by the psychologist to a psychiatrist for psychiatric services or a psychologist for psychological services.

B. Unless approved by a physician who is the Department's designee, the Department shall not provide more than three sessions in subsection (A) per year.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-415 renumbered to R9-7-414; new Section renumbered from R9-7-416 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-416. Psychiatric Services

A. If the requirements in R9-7-401 are met, the Department shall provide psychiatric services to a member who has received an evaluation and recommendation for psychiatric services from a psychologist who is a CRS provider.

B. Unless approved by a physician who is the Department's designee, the Department shall not provide more than one session in subsection (A) per year.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-416 renumbered to R9-7-415; new Section renumbered from R9-7-417 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-417. Social Work Services

The Department shall provide the following social work services to a member or the member's family:

1. An initial psychosocial evaluation performed by a social worker no later than the date of the member's third visit to a CRS provider;

2. Subsequent psychosocial evaluations of a member and the member's family performed by a social worker based on the initial psychological evaluation and as needed throughout the member's enrollment; and

3. Recommendations, based on a psychosocial evaluation, to community resources.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-417 renumbered to R9-7-416; new Section renumbered from R9-7-418 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-418. Speech/Language Pathology Services

If the requirements in R9-7-401 are met, the Department shall provide speech/language pathology services to a member only if the member:

1. Is unable to obtain speech/language pathology services through a source other than CRS or another health care insurance provider, and

2. Is expected to experience a functional improvement as a result of the speech/language pathology services.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-418 renumbered to R9-7-417; new Section renumbered from R9-7-419 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-419. Transplants

If the requirements in R9-7-401 are met, the Department shall provide a corneal transplant or a bone-grafting transplant to a member.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-419 renumbered to R9-7-418; new Section renumbered from R9-7-420 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-420. Vision Services

If the requirements in R9-7-401 are met, the Department shall provide the following vision services to a member:

1. Eye examinations;

2. Eyeglasses;

3. Contact lenses;

4. Lens enhancements such as UV tinting and safety glass; and

5. For broken or lost eyeglasses or contact lenses, one replacement per prescription per calendar year.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-420 renumbered to R9-7-419; new Section renumbered from R9-7-421 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-421. Renumbered

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-421 renumbered to R9-7-420 by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

ARTICLE 5. COVERED SUPPORT SERVICES

Article 5, consisting of Sections R9-7-501 through R9-7-506, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-501. Advocacy Services

The Department shall provide the following advocacy services:

1. Explaining the CRS application requirements in R9-7-302 to an applicant or, if the applicant is a minor, the applicant's parent and assisting the applicant or applicant's parent in completing the application;

2. Providing CRS orientation to a member and a member's family;

3. Assisting a member and the member's family in obtaining and understanding information for making decisions about the member's medical care;

4. Assisting the member and the member's family in understanding and accessing available community resources for children and families of children with special health care needs;

5. Explaining to a member and the member's family the member's rights and responsibilities related to CRS; and

6. Collaborating with non-CRS providers, schools, and state or federal agencies on behalf of a member.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-501 repealed; new Section renumbered from R9-7-502 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-502. Child Life Services

The Department shall provide the following child life services to a member:

1. Activities in which a member is encouraged to express the member's feelings regarding the member's CRS condition and treatment related to the member's CRS condition;

2. Information provided to the member or the member's family about coping with the member's CRS condition and treatment related to the member's CRS condition;

3. Before the member's surgery and while recovering from surgery, activities designed to decrease the member's fear of surgery;

4. Information provided to the member at the member's comprehension level before a treatment to decrease the member's fears by increasing the member's understanding of the:

a. Nature of the treatment;

b. Purpose for the treatment; and

c. If applicable, the sequence in which treatments may be used; and

5. Emotional support for the member and the member's family before and during surgery or treatment.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-502 renumbered to R9-7-501; new Section renumbered from R9-7-503 by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-503. Education Coordination

The Department shall provide the following education coordination:

1. Informing the member's family about schools and instruction that may meet the member's special education needs;

2. Making recommendations to parents and schools regarding the member's special education needs;

3. Consulting with the member, the member's family, and school personnel regarding the member's transition under R9-7-504;

4. Coordinating the member's instruction with the member's teachers while the member is receiving inpatient services and after the member's hospitalization; and

5. Providing information about CRS to school and education personnel.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-503 renumbered to R9-7-502; new Section renumbered from R9-7-504 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-504. Transition Services

A. The Department shall assist a member in the member's transition from receiving covered medical services and covered support services from CRS to receiving services from another source.

B. The Department shall, at an appropriate time based on the member's age and the member's CRS condition, as determined by a CRS provider, develop and implement an on-going plan to transition the member from pediatric care to adult care that:

1. Is developed with the member, the member's family, and the member's physician; and

2. Includes a process for the transition of the member's care to a physician who provides physician services to adults.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-504 renumbered to R9-7-503; new Section renumbered from R9-7-505 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-505. Transportation Services

The Department shall provide transportation to a member:

1. From a location where a CRS provider is evaluating or treating the member to a hospital that is a CRS provider, if medically necessary to respond to an immediate threat to the life or health of the member; or

2. For a transfer between two hospitals that are CRS providers according to R9-7-406(B).

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-505 renumbered to R9-7-504; new Section renumbered from R9-7-506 and amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-506. Renumbered

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-506 renumbered to R9-7-505 by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

ARTICLE 6. REPEALED

Article 6, consisting of Sections R9-7-601 through R9-7-604, made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1).

R9-7-601. Repealed

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). Repealed by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-602. Renumbered

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-602 renumbered to R9-7-305 by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-603. Renumbered

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-603 renumbered to R9-7-306 by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

R9-7-604. Renumbered

Historical Note

New Section made by final rulemaking at 10 A.A.R. 691, effective February 3, 2004 (Supp. 04-1). R9-7-604 renumbered to R9-7-304 by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

ARTICLE 7. MEMBER APPEALS

Article 7, consisting of R9-7-701, made by final rulemaking at 10 A.A.R. 3001, effective July 13, 2004 (Supp. 04-3).

R9-7-701. Member Appeals

A. For purposes of this Article, "appeal":

1. Means a written expression of dissatisfaction with a CRS provider's intended decision not to provide a covered service to a member that is submitted to the Department by the member or, if the member is a minor, the member's parent; or

2. For a member who has Title XIX or Title XXI health care insurance, has the same meaning as in A.A.C. R9-34-202.

B. If a member has Title XIX or Title XXI health care insurance, the member and the Department shall comply with the requirements for an appeal in A.A.C. Title 9, Chapter 34, Article 2.

C. If a member does not have Title XIX or Title XXI health care insurance, the member shall comply with the requirements for an appeal in this Article.

D. If a member or, if the member is a minor, the member's parent, does not submit an appeal within 60 days from the date of a CRS provider's intended decision, the intended decision becomes final.

E. To submit an appeal of a CRS provider's intended decision not to provide covered services, a member shall submit to the Department, no later than 60 days from the date of the intended decision that is the subject of the appeal, a written notice containing:

1. The name of the member,

2. The address of the member,

3. The factual basis for the appeal, and

4. The relief requested.

F. The Department shall provide a member or, if the member is a minor, the member's parent with written notification regarding an appeal within 30 days from the date of receiving the appeal as follows.

1. If the Department determines that additional documentation or information is necessary to make a decision, the Department shall provide a written notice to the member requesting that the member provide the additional documentation or information within 14 days after the date of the request.

a. If the member submits the requested additional documentation or information in subsection (F)(1) within 14 days from the date of the Department's request, the Department shall, within 14 days from the date of receiving the requested additional documentation or information, provide notice to the member according to subsection (F)(2) or (F)(3).

b. If the member does not submit the requested additional documentation or information within 14 days from the date of the Department's request, the Department shall consider the appeal withdrawn.

2. If the Department determines that the CRS provider's intended decision does not comply with A.R.S. Title 36, Chapter 2, Article 3 or this Chapter, the Department shall reverse the intended decision and provide written notice of the Department's decision to the member and the CRS provider.

3. If the Department determines that the CRS provider's intended decision complies with A.R.S. Title 36, Chapter 2, Article 3 or this Chapter, the Department shall provide a written notice of the Department's decision to the:

a. Member that complies with A.R.S. § 41-1092.03, and

b. CRS provider.

G. A member may request a hearing on the Department's decision according to A.R.S. § 41-1092.03.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 3001, effective July 13, 2004 (Supp. 04-3). Amended by final rulemaking at 14 A.A.R. 3747, effective October 1, 2008 (Supp. 08-3).

 


Scott Cancelosi
Director
Public Services Division

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Arizona Administrative Code