Reimbursement/Eligibility Work Group
Please use this blog to facilitate ideas and discussion. The following issues have been identified by the Work Group Chairs as top priorities:
1) ALTCS PAS Tool
2) DDD and DBHS eligibility for services; how does behavioral health fit in with Steven’s Law?
3) “Hab M” Program
Welcome to the AZ Autism Coalition Eligibility Work Group Blog. Here are some resources regarding eligibility for AzEIP, DDD, DBHS & AHCCCS (ALTCS Title XIX & KidsCare Title XXI). It is important that we have a solid foundation regarding the current eligibility criteria when discussing any proposed policy change. We look forward to a very productive year.
Aaron Blocher-Rubin, Diedra Freedman & Lisa Glow
AZ Autism Coalition Eligibility Work Group Moderators
Snap 211.com – AzEIP Resource Guide
http://www.snap211.com/org/programs/20026390.html
AzEIP Eligibility
https://www.azdes.gov/azeip/tabs.asp see
2008 Child File Audit Review Guide (for Service Coordination and/or Service Provision)
Navigating The Systems – DDD
http://www.cpes.com/advocacyresources/navigating_ddd_system.pdf
DDD Eligibility
https://www.azdes.gov/ddd/downloads/policyproc_pdfs/500.pdf
Hab M/B Program Eligibility
https://www.azdes.gov/ddd/reference/New_Hab-B_Service_Codes.asp
DBHS Eligibility
http://www.magellanofaz.com/azmem-en/forprov/provider_manual.aspx
AHCCCS/ALTCS Eligibility Medicaid Title XIX
http://www.azsos.gov/public_services/Title_09/9-28.pdf
ALTCS DD Preadmission Screening Manual
http://www.ahcccs.state.az.us/Publications/Eligibility/chapter1000/appendix_10b.pdf
AHCCCS KidsCare Eligibility Title XXI
http://www.azsos.gov/public_services/Title_09/9-31.htm
DBHS/ Eligibility
http://www.azdhs.gov/bhs/ahcccs_eligibility/index.htm
Procedures
http://www.azdhs.gov/bhs/ahcccs_eligibility/procedures.pdf
Other Resources
National Council of State Legislatures
http://ncsl.org/
Georgetown University Health Policy Institute Center for Children and Families
http://ccf.georgetown.edu/
The Kaiser Family Foundation Commission on Medicaid and the Uninsured
http://www.kff.org/about/kcmu.cfm
The National Early Childhood Technical Assistance Center
http://www.nectac.org/partc/partc.asp
U.S. Department of Education IDEA
http://idea.ed.gov/explore/home
Hi,
My name is Cinder McDonald, I’m a member of this workgroup, and I’m a parent of a sixteen year old child with High Functioning Autism who receives services through the Behavioral Health system. Even though my daughter has always had a clear and profound developmental disability, Arizona’s DDD/ALTCS eligibility rules exclude her and many other children like her known as the “Gap children”. At the moderators’ request, I’m including information on DBHS, the Behavioral Health system and its eligibility.
To the best of my knowledge, there is no state-wide guide to navigating the system comparable to the DDD guide. I did find a AZ State Senate Issue Paper that gives a good high level overview of the AZ Behavioral Health system. http://www.azleg.state.az.us/briefs/Senate/BEHAVIORAL%20HEALTH%20SERVICES.pdf
There are a number of minor ways to become eligible for care through the Behavioral Health system, but there are 3 major ways. The first way is to become eligible for AHCCCS, generally by meeting a low income requirement. If a family of a child cannot meet the low income requirement and the child has no insurance, then they might be eligible for Kidscare (income limits are slightly higher – up to 200% of federal poverty level), where they pay a small monthly premium. The third option is limited to adults only and is called Title XXI (Seriously Mentally Ill) or SMI. While there is a diagnosis requirement and a risk assessment, there is no low income requirement.
This is what I want to make clear…the ONLY people with severe disabilities in AZ who have to meet a low income requirement for treatment are children in the Behavioral Health System living with their biological families. DDD families do NOT have to meet an income requirement, Seriously Mentally Ill Adults do NOT have to meet an income requirement, and children living apart from their biological parents are eligible for AHCCCS. This means that families whose children are not eligible for DDD/ALTCS are often forced to make extreme decisions in order to get care for their children. My family is one of those, and thus my interest in being a part of this workgroup.
Here are additional links about DBHS, Magellan and AHCCCS/Kidscare. If requested, I will track down links for the other RBHAs.
a. ADHS/DBHS Policies and Procedures Manual, which contains administrative requirements, http://www.azdhs.gov/bhs/policy.htm.
b. ADHS/DBHS Covered Behavioral Health Services Guide, (178pgs) which provides a full description of covered behavioral health services, including definitions, service standards, provider qualifications, code specific information and billing limitations for each service. It specifies funding sources that shall be used to reimburse the provision of covered behavioral health services based upon eligibility of the person and the permissible reimbursement for Title XIX and Title XXI funding. http://www.azdhs.gov/bhs/bhs_gde.pdf.
c. ADHS/DBHS Provider Manual, which contains service delivery policies, procedures and expectations for providers. Provider Network Organizations will utilize their Contractor-specific version of the Provider Manual for the provision of covered behavioral health services The ADHS/DBHS Provider Manual is located at http://www.azdhs.gov/bhs/provider/provider_main.htm.
Specific to Developmental Disorders, there is this:
Pervasive Developmental Disorders and Developmental Disabilities- Practice Improvement Protocol 16 (7/8/05)
http://www.azdhs.gov/bhs/guidance/pdddd.pdf
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Magellan’s consumer handbook:
http://www.magellanofaz.com/azmem-en/azprogserv/maricopa%20handbook%20english.pdf
Magellan’s list of Covered Benefits (No definitions though)
http://www.magellanofaz.com/azmem-en/azprogserv/bh_benefits.pdf
Magellan’s Contract w/DBHS (see Eligibility Populations on pg 35-38, also see pg 107, section d. “Outreach requirement”)
http://www.azdhs.gov/bhs/contracts/mar/mac/pdf/magellan.pdf
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AHCCCS/Kidscare Quick Eligibility Grid
http://www.ahcccs.state.az.us/Publications/Reference/IncomeLimits/EligibilityRequirements.pdf
AHCCCS Eligibility Policy Manual
http://www.ahcccs.state.az.us/Publications/Eligibility/chapter100.asp
AHCCCS/Kidscare Overview
http://www.ahcccs.state.az.us/Publications/KidsCare/Chapter100/kc_chap100.asp#100%20Program%20Overview
Kidscare Info Sheet
http://www.ahcccs.state.az.us/Community/FactSheets/FamilyPremiumsEnglish_4-07.pdf
Kidscare Eligibility Manual
http://www.ahcccs.state.az.us/Publications/KidsCare/index.asp
Social Security Administration Program Operations Manual (or POMS) Table of Contents
https://secure.ssa.gov/apps10/poms.nsf/partlist!OpenView
POMS for Eligibility
https://secure.ssa.gov/apps10/poms.nsf/subchapterlist!openview&restricttocategory=05005
Social Science Research Network (Searchable database of social science research articles & papers, there may be a charge to download some material depending upon the source)
http://www.ssrn.com/
AltLaw (Free legal search engine for Federal Court Appellate decisions & the US Code )
http://altlaw.org/
The National Academy Press
Read more than 3,700 books online FREE! More than 1900 PDFs now available for sale
http://www.nap.edu/
Educating Children with Autism (This book along with the NYS Early Intervention Practice Manual Report of the Recommendations see http://www.health.state.ny.us/community/infants_children/early_intervention/autism/index.htm recommends a minimum of 25 hours of one to one therapy per week for children with ASD)
Committee on Educational Interventions for Children with Autism
Catherine Lord and James P. McGee, Editors
Division of Behavioral and Social Sciences and Education
National Research Council
http://www.nap.edu/openbook.php?isbn=0309072697
2005-2007 Master List of State Government Programs – an inventory of programs & subprograms from the AZ Executive, Legislative & Judicial branches of government.
http://www.ospb.state.az.us/documents/102006_MasterList2005-2007.pdf
AZ State Employee Directory
http://ebook.state.az.us/
Regarding post #6 – No longer available online – link doesn’t work & no new url available at this time
2005-2007 Master List of State Government Programs – an inventory of programs & subprograms from the AZ Executive, Legislative & Judicial branches of government.
http://www.ospb.state.az.us/documents/102006_MasterList2005-2007.pdf
The Georgetown University Law Center has developed a website archive on the ADA: http://www.law.georgetown.edu/archiveada/. This site serves as a comprehensive, online archive of documents and history related to the Americans with Disabilities Act of 1990 (ADA) and the ADA Amendments Act of 2008 (ADAAA). Here you can find the text of the law, legislative history, congressional hearings, Supreme Court cases, federal regulations, policy and advocacy documents and additional information related to the passage of the original ADA and the ADAAA. The majority of these documents are explained or cited in the ADA Amendments Act of 2008, an article by Chai Feldblum, Kevin Barry and Emily Benfer (click here to view documents as cited in the article). The article also provides an overview and history of the ADA and ADAAA.
DDD Laws, Rules, Policy and Procedures https://www.azdes.gov/ddd/reference.asp
DDD Acronyms https://egov.azdes.gov/CMSInternet/main.aspx?menu=96&id=2774
DDD Tell Us Your Thoughts https://egov.azdes.gov/CMSInternet/forms.aspx?menu=96&ekfrm=2494&ekmensel=15074e5e_96_0_2494_6
DDD Family Services Office – Family & Consumer Ombudsman
Ralph Figueroa (602) 542-0419
Hi Diedra,
I met you and your group when you came up to Flagstaff. I coordinate an early intervention program for children up here. I work with a family that has a 2 1/2 year old on the Autism Spectrum and they have just been denied ALTCS do you have any suggestions?
thanks!
Here is the info based upon my experience as the parent of a child with autism who qualified for ALTCS at 24 months old that I share with other parents:
Obviously the best way is to be as prepared as possible before the ALTCS interview so that the child qualifies as soon as possible. Read the PAS instrument and go over it line by line using http://www.ahcccs.state.az.us/Publications/Eligibility/chapter1000/appendix_10b.pdf, the ALTCS examiner manual instructing them how to complete the PAS qualification instrument, to find the necessary 40 points per child before you meet with the ALTCS examiner. Remember, however, you don’t get to fill out the PAS instrument. The ALTCS examiner fills out the PAS based upon his/her observations and your answers to his/her questions. You need to gently influence the PAS examiner without blatantly telling them how to complete the PAS. Keep in mind that people who get told “how to do their job” don’t usually appreciate it!
If your child is denied ALTCS, you need to keep in mind that winning an administrative appeal is almost impossible (you need to show that the state is being arbitrary and capricious), but ask for a review anyway. What do you have to lose? You always can withdraw your appeal and refile a new ALTCS application at any time including on the spot during any meetings regarding your appeal. This may give you a bargaining chip with ALTCS. Since your main concern is future ALTCS qualification so that your child can get needed DDD services, you can always withdraw your appeal at any time as long as forfeiting your child’s right to back ALTCS coverage from the date of the original application isn’t an issue for you. If your child has accrued substantial unpaid medical bills since the date of your original application, this bargaining strategy may not be to your best advantage. See http://www.azdisabilitylaw.org/pdfs/H-5%20RevisedJan06.pdf for the Arizona Center for Disability Law Self Advocacy Guide. If you have any legal questions regarding your rights, please check out the ACDL website at http://www.azdisabilitylaw.org.
Upon receiving notice of denial, the first thing you need to do is send a letter to ALTCS informing them that you are appealing and requesting that ALTCS send you a copy of the child’s scored PAS. The procedure is in the book of rights they gave you and should be in your denial letter. Make sure to follow the appeal procedure to the letter. The best way to appeal an ALTCS denial is to challenge the actual PAS scoring item by item. A developmental delay diagnosis doesn’t in and of itself qualify a child for ALTCS. The key phrasing is that the child is “in danger of being institutionalized.” Also, you can orally request that ALTCS fax you a copy of the child’s scored PAS. (see http://www.ahcccs.state.az.us/publications/Eligibility/chapter1600.asp#1602.05, C. Who Needs Authorization). Don’t let ALTCS tell you they can’t fax it or that they’ll bring it when they meet with you. Demand a copy before meeting with anyone from ALTCS regarding your appeal so that you can review the scored PAS & find the necessary points to get the child qualified for ALTCS. When you receive the copy of the scored PAS, go over it line by line using http://www.ahcccs.state.az.us/Publications/Eligibility/chapter1000/appendix_10b.pdf, the ALTCS examiner manual instructing them how to complete the PAS qualification instrument and find the necessary 40 points per child. There are several parents who would be happy to speak with any parent or caregiver applying for ALTCS for a child with special needs & share their experiences. If I can be of any assistance, contact me or any other parent and we’ll be happy to share our experiences. Please share this information with anyone who may find it beneficial.
Diedra Freedman
2433 N. 125th Dr.
Avondale, AZ 85323
623.341.7085
d-f_freedman@cox.net
AHCCCS recently changed its URL. ARIZONA LONG TERM CARE SYSTEM. APPENDIX B. PREADMISSION SCREENING MANUAL. is no longer located at http://www.ahcccs.state.az.us/Publications/Eligibility/chapter1000/appendix_10b.pdf You can still view the original doc in snapshot, but if you click on it you are redirected to the new AHCCCS website at http://www.azahcccs.gov. I tried playing around with the URL, but can’t crack it. If anyone else can find this document, please let us know.
De
Frank found it!
See p://www.ahcccs.state.az.us/shared/EligibilityManual/EligibilityManual.aspx?ID=ALTCS
AHCCCS Eligibility Policy Manual
The purpose of the Eligibility Policy Manual is to provide AHCCCS Eligibility staff with detailed policy and instructions to enable them to make accurate eligibility decisions.
* Chapter 1000: Preadmission Screening (PAS) [201KB]
o Appendix 10A, Preadmission Screening Manual for Elderly and Physically Disabled (EPD) [286KB]
+ Appendix 10A1, ALTCS Overview [12KB]
+ Appendix 10A2, PAS Tool Matrix [22KB]
+ Appendix 10A3, Scoring Flow Chart[11KB]
+ Appendix 10A4, Level of Care Matrix[14KB]
+ Appendix 10A5, Glossary of Terms [185KB]
+ Appendix 10A6, Glossary of Abbreviations [109KB]
+ Appendix 10A7, FCPI/CSRD [23KB]
o Appendix 10B, Preadmission Screening Manual for Developmentally Disabled (DD) [537KB]
+ Appendix 10B1, PAS Tool Matrix by DD Status and Age [22KB]
+ Appendix 10B2, Glossary of Terms [155KB]
+ Appendix 10B3, Glossary of Abbreviations [122KB]
* Chapter 1700: Eligibility Hearings [406KB]
o Appendix 17A, Letter to Complainant-No Hearing Scheduled [422KB]
o Appendix 17B, OAH Information Pamphlet [819KB]
o Appendix 17C, Request for Continuance Form [231KB]
o Appendix 17D, Request for Witness/Party to Appear Telephonically [250KB]
Please contact the Program Support Administration if you have questions about the AHCCCS Eligibility Policy Manual:
EligibilityPolicyManual@azahcccs.gov
AZ Joint Legislative Budget Committee
http://www.azleg.state.az.us/jlbc.htm
Proposed Budget Cuts by AZ Joint Legislative Budget Committee
http://www.azleg.gov/jlbc/AppropsBudgetOptions011509.pdf
Goldwater Institute A Fresh Start for Arizona: Proposals for Closing a Billion-Dollar Budget Gap
http://www.goldwaterinstitute.org/AboutUs/ArticleView.aspx?id=2460
President Obama’s 24 Point Agenda
http://www.whitehouse.gov/agenda/disabilities/
U.S. Supreme Court Oral Arguments
http://www.supremecourtus.gov/oral_arguments/argument_transcripts.html
StateData.info serves up disability/employment data the way you want it
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Hi all,
The state is now requiring that parents get their own scripts for therapies.
It is better for the parent and child to have a letter of medical necessity
instead of a script. Many children are having their services cut and a
script is much less effective in the fair hearing process. Here is the
details on how to write and effective letter of medical necessity provided
by Arizona Disability Law at a training attended by the Parent Mentors:
Goals of letter:
To explain to the health plan:
1. what patients needs the services
2. consequences if service is not provided
3. that services is medically necessary
General AHCCCS Definition of Medical Necessity:
Medically necessary services are those covered services that:
1. are provided by a physician or other licensed practitioner of the
healing arts within the scope of practice under state law
2. to prevent disease, disability or other adverse health conditions or
their progression, or Arizona Administrative Code (A.A.C.) R9-22-201
For AHCCCS Members Under age 21-EPSDT Requirements:
The Early periodic Screening Diagnosis and Treatment (EPSDT) provisions of
the Medicaid Act require that AHCCCS members under 21 be provided with all
health care necessary to correct or ameliorate physical and mental illnesses
and conditions even if the services is not generally covered for adults.
Arizona Administrative Code (A.A.C) R9 22-213
Contents of Effective Letter of Medical Necessity from Physicians:
1. Doctors or health care professional’s relationship with patient and
authority to make recommendation (i.e. credentials)
2. Patient’s exact diagnosis
3. Duration of patient’s condition
4. Patient’s functional limitations, capabilities and abilities (if
applicable)
5. Description of the service or item being prescribed
6. Why the requested services is MEDICALLY NECESSARY, either under the
general AHCCCS definition of medical necessity or if the AHCCCS member is
under 21, under EPSDT requirements.
7. How the use of the services or item will allow the patient to
function independently and or improve the patients health: e.g. perform
tasks n the home, improve patient’s mobility, improve muscle strength.
8. Anticipated limitations or health problems which can occur if the
series is not provided.
9. As explanation of any other rationale that provides support for the
requested services (e.g. safety, cost effectiveness, no other alternative
treatments, other treatments/services/medications etc. have been tried and
have failed.
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