Overview of Arizona Medicaid Services, Due Process Rights, and the Changing Landscape of AHCCCS

1. Overview of Arizona Medicaid Services, Due Process Rights, and the Changing Landscapeof AHCCCS Presenter: Sarah E. Kader Staff AttorneyArizona Center for Disability Law

2. Outline of Training • Overview of Medicaid & AHCCCS • Update on Medicaid Expansion • Affordable Care Act Overview • Questions

3. Arizona Center for Disability Law • Non-profit public interest law firm AND Protection and Advocacy (P&A) agency for Arizona • Part of network of agencies ‒ one in every state and territory ‒ providing protection to people with disabilities through legally based advocacy • Funded primarily through federal grants • Dedicated to protecting the rights of individuals with physical, mental, psychiatric, sensory and cognitive disabilities

4. Types of Services Provided by the Center • Information and advice regarding legal rights • Representation of individuals in negotiations, administrative proceedings, and court • Impact litigation to remedy systemic problems • Investigation of abuse and neglect allegations • Outreach and training on legal rights and self-advocacy • Technical assistance to groups and individuals on disability-related legal issues • Advocacy for policy and legal reforms that benefit people with disabilities

5. OVERVIEW OFMEDICAID

6. Medicaid • A joint federal and state program that provides health care for people with low incomes and limited resources • Enacted in 1965 as part of President Johnson’s War on Poverty • Consists of acute care services, long term care services, and behavioral health services • Medicaid Act = Title 19 of Social Security Act, 42 U.S.C. 1396-1396v

7. Who Does Medicaid Serve? Largest public health insurer covers 1 in 10 Americans As of June 2011: • 52.6 million enrolled • 13.9 million aged and disabled enrolled • 233,000 aged and disabled enrolled in Arizona Kaiser Commission on Medicaid Facts: http://www.kff.org/medicaid/upload/8050-05.pdf

8. MedicaidFramework and Principles

9. Medicaid Act Principles • Statewide • Medical Necessity (but no federal definition) • Not experimental • Open-ended federal funding of necessary services • Amount, duration, and scope – sufficient to achieve purpose • No discrimination based on condition

10. Medicaid Act Principles • Comparability of services between and within eligibility groups • Reasonable promptness (i.e. no waiting lists) • Freedom of Choice of Provider (but providers not mandated to participate) – does not apply in AZ • Equal Access to Services - enlist enough providers so that services are broadly available • Due Process Guarantees

11. Medicaid Eligibility- 4 Requirements • Limited income/resources • Citizenship or proper immigration status • State residency • Must fit into category of eligibility • Mandatory and Optional categories

12. MedicaidServices

13. Mandatory Medicaid Services 42 U.S.C. §1396d • Inpatient and outpatient hospital services • Physician services • Laboratory and x-ray services • Home health services for individuals entitled to receive nursing facility services • Early and Periodic Screening, Diagnosis, and Treatment Services (EPSDT)

14. EPSDT Services42 U.S.C. §1396d(r) • Mandatory service for children and youthunder 21 • Established by Congress in 1967 with intent to be the “nation’s largest preventative health program for children,” amended in 1989 to broaden scope of services • Intended to be a comprehensive package of screening, diagnostic, and treatment services

15. EPSDT Services • All necessary health care to “correct or ameliorate” physical or mental problems or conditions 42 U.S.C. 1396d(a) • Covers all medically necessary services, even if service is not in the state plan and/or is not provided to adults

16. Optional Medicaid Services42 U.S.C. §1396d • Clinic services • Private duty nursing services • Prescription drugs • Physical, occupational, speech, hearing, and language therapy • Home health services for individuals not eligible for nursing facility services

17. MEDICAID INARIZONA

18. Medicaid in ArizonaThe Basics • Arizona Health Care Cost Containment System (AHCCCS; pronounced “Access”) ‒ single state Medicaid agency. • Entire AHCCCS program run as statewide managed care system; most states are fee-for-service. • Arizona has a Section 1115 Waiver from the federal government (CMS) which exempts it from key requirements of the Social Security Act (Medicaid Act).

19. ALTCS: Long Term Care Delivery System • Arizona Long Term Care System (ALTCS) ‒ pronounced “Alltecs”. • Serves two populations: • Elderly and Physically Disabled (EPD), and • Developmentally Disabled (DD). • Eight health care plans provide long term care ‒ DDD is one of them. • ALTCS members get behavioral health and acute care services from ALTCS health plan.

20. DDD Rule Exceptions Acute Care Services • DDD/ALTCS members are assigned to an AHCCCS acute health plan. Behavioral Health Services • DDD/ALTCS members receive behavioral health services from RBHA system.

21. Impact of Home and Community Based Services HCBS services have dramatically reduced the numbers of ALTCS members living in nursing homes, as shown below: 1989 2005 Nursing homes 95+% 36% HCBS 5% 64%

22. AHCCCS Cost-Containment • Lowest pharmacy rates in country. • Third in the nation for lowest cost per Medicaid enrollee. • Arizona spends $3,035 per member per year, $976 less than the national average.

23. AHCCCS/ALTCS Eligibility Generally • No disability requirements for acute care AHCCCS. • ALTCS has financial and disability requirements: • Must be at risk of institutionalization. • Pre-Admission Screening Test (PAS) measures risk of institutionalization. • EPD PAS A.A.C. R9-28-304 • DD PAS A.A.C. R9-28-305

24. AHCCCS Enrollment • AHCCCS provides Medicaid services to more than 1 million Arizonans. • Serves 18% of Arizona population. • 11% of AHCCCS population is Native American.

25. Getting Servicesfrom AHCCCS andALTCS

26. AHCCCS Coverage Requirements For AHCCCS/ALTCS to cover a service, it must be: • A covered service • Medically necessary • Cost-effective • Non-Experimental • Federally reimbursable (i.e. can get FFP) A.A.C. R9-22-201(B)

27. AHCCCS Acute Care Covered Services • Physician services • Prescription drugs • Hospital Services • Transportation to medical services • Physical, occupational, speech therapies • Durable medical equipment and supplies • EPSDT services • Behavioral health services • Emergency care • Pregnancy care • Dialysis • X-Rays • Lab work • Surgery • Organ Transplants

28. ALTCS Covered Services • All AHCCCS acute care services • Behavioral health services • EPSDT services • Nursing home services • ICF/MR (intermediate care facility for the mentally retarded)

29. ALTCS HCBS Services • Case management • Speech, physical, and occupational therapies • Personal care • Attendant care • Respite • Habilitation • Home modifications • Medical equipment & supplies • Emergency alert system • Transportation • Home delivered meals • DD day care • Assisted living facilities • Home health Aid and Nurse

30. Medically Necessary No federal definition of medically necessary “Medically necessary” means a covered service provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, or other adverse health condition or their progression, or to prolong life.” Arizona Definition: A.A.C. R9-22-101(B)

31. Cost-Effective • Arizona does not define “cost-effective” in statute, regulation or policy. • For ALTCS members: • Generally argue that services under the cost of institutionalized care are cost-effective. • Use Cost-Effectiveness Study – measures cost of nursing home case against cost of services inthe community.

32. Non-Experimental For a service to be non-experimental, it must be associated with treatment or diagnostic evaluation and: • Generally and widely accepted as a standard of care in the practice of medicine in the United States; OR • Peer-reviewed articles in medical journals published in the United States that support the safety and effectiveness of the service; OR • If no articles, and for a rare, novel or relatively unknown service, the weight of opinions from specialists who provide the service and attest to the safety and effectiveness of the service. A.A.C. R9-22-101(B)

33. Standard of Care Means a medical procedure or process that is accepted as treatment for a specific illness, or injury, medical condition through custom, peer review, or consensus by the professional medical community. A.A.C. R9-22-101(B)

34. MEDICAID DUEPROCESSREQUIREMENTS

35. Due Process Guarantees Right to Medicaid due process protected by the Due Process Clause of Constitution Holding that when welfare benefits may be terminated, beneficiary has due process rights to an effective notice and pre-termination hearing. Goldberg v. Kelly, 397 U.S. 254, 266 (1970)

36. Medicaid Due Process Rights • Written notice of denial/termination/reduction • File appeal, even without written notice • Expedited decision • Fair hearing • Representation at hearing • Review evidence prior to hearing and get copies • Present evidence and cross examine witnesses • Continuation of existing services pending hearing; liablefor costs, if you lose • Timely, written decision ‒ within 90 days of appeal • Reimbursement for costs if services pending appeal if wrongly denied

37. AHCCCS Administrative Appeals andHearings Process

38. AHCCCS/ALTCS Service Denial Appeals Process Step 1: Request Service Step 2: Notice of Action Step 3: Notice of Appeal Decision Step 4: Fair Hearing Step 5: ALJ Decision Step 6: AHCCCS Director’s Decision Step 7: Appeal to Superior Court

39. Requesting a Service:Letter of Medical Necessity • Key to effectively requesting AHCCCS services. • Letter from member’s doctor or specialist that outlines reasons why member needs service. • When requesting LMN, include: • signed release, and • “How to Write Effective Letter of Medical Necessity”‒ general statements that member “will benefit” or thatdoctor “supports” treatment are not enough.

40. Notice of Action (NOA) • Must be issued within 14 days of service request. • Failure to provide NOA within timeframe constitutes a denial. • Time frame may be extended by 14 days. • NOA Contents: • Legal and factual reasons for denial, termination or reduction • Where to file appeal

41. Right to Continuationof Services • Filing deadline: 10 days from NOA • Must involve termination, suspension,or reduction of current services. • Original authorization period has not expired. • If beneficiary loses, liable for cost of services. A.A.C. R9-34-224

42. Practice Tip: Requesting an Appeal • Filing Deadlines: • 60 days after Notice of Action, OR • 10 days after NOA to request continuing services; • Can be filed even if NOA not issued. • Appeal letter can request the following: • Expedited resolution of appeal • Continuing services pending appeal • Copy of health plan file • Right to give additional info to plan

43. Notice of Appeal Resolution • Issued by health plan within 30 days of letter of appeal • 14 day extension available • Must: • Advise member how to request fair hearing. • Provide legal and factual reasons for decision.

44. Right to Expedited Appeal Resolution • Beneficiary or physician requests after Noticeof Action • Standard: “taking the time for standard resolution could seriously jeopardize the enrollee’s life or health, or ability to attain, maintain, or regain maximum function” • Must resolve within three working days A.A.C. R9-34-214 and 215

45. Practice Tip:Requesting Fair Hearing • Filing Deadline: 30 days from date of Notice of Appeal Resolution • Letter should include: • Request for hearing; • Statement of issue(s) for hearing, including due process concerns; • Request for copy of appeal file; • Signed release and designation of representative;and • Restatement of any request for continuing services, expedited hearing, or reimbursement.

46. Right to Expedited Hearing • Beneficiary or physician requests after Notice of Expedited Appeal Resolution. • AHCCCS Director makes decision three working days after receiving ALJ recommended decision. A.A.C. R9-34-219 and 220

47. Office of Administrative Hearings The Fair Hearing

48. Office of Administrative Hearings (OAH) • Independent agency that conducts AHCCCS and ALTCS fair hearings. • Hearing conducted by Administrative Law Judge (ALJ). • OAH offices in Tucson and Phoenix.

49. Medicaid Beneficiary’s Right to Attend Hearing • Beneficiary has right to attend hearing in person or by phone. • If beneficiary does not have transportation and wants to attend in person, health plan must provide transportation to hearing. 42 CFR 431.250(f)(1) • Send request letter to health plan and copy OAH and AHCCCS.

50. Standard & Burden of Proof • Standard of Proof • Preponderance of the evidence – used in civil cases. More likely to be true than not true. • Burden of Proof • Generally on the Complainant; • HOWEVER, if health plan terminated or reduced existing service, should argue that plan should have burden of showing that Complainant had change in health condition that justifies change in services (case law from other states).