Section R9-22-710. Payments for Non-hospital Services

A.      Capped fee-for-service. The Administration shall provide notice of changes in methods and standards for setting pay- ment rates for services in accordance with 42 CFR 447.205, December 19, 1983, incorporated by reference and on file with the Administration and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW, Washington, DC, 20401. This incorporation by reference con- tains no future editions or amendments.

1.        Non-contracted services. In the absence of a contract that specifies otherwise, a contractor shall reimburse a pro- vider or noncontracting provider for non-hospital services according to the Administration's capped-fee-for-service schedule.

2.        Procedure codes. The Administration shall maintain a current copy of the National Standard Code Sets man- dated under 45 CFR 160 (October 1, 2004) and 45 CFR 162 (October 1, 2004), incorporated by reference and on

file with the Administration and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW, Washington, DC, 20401. This incor- poration by reference contains no future editions or amendments.

a.         A person shall submit an electronic claim consistent with 45 CFR 160 (October 1, 2004) and 45 CFR 162 (October 1, 2004).

b.        A person shall submit a paper claim using the National Standard Code Sets as described under 45 CFR 160 (October 1, 2004) and 45 CFR 162 (Octo- ber 1, 2004).

c.         The Administration may deny a claim for failure to comply with subsection (A) (2) (a) or (b).

3.        Fee schedule. The Administration shall pay providers, including noncontracting providers, at the lesser of billed charges or the capped fee-for-service rates specified in subsections (A)(3)(a) through (A)(3)(d) unless a different fee is specified in a contract between the Administration and the provider, or is otherwise required by law.

a.         Physician services. Fee schedules for payment for physician services are on file at the central office of the Administration for reference use during custom- ary business hours.

b.        Dental services. Fee schedules for payment for den- tal services are on file at the central office of the Administration for reference use during customary business hours.

c.         Transportation services. Fee schedules for payment for transportation services are on file at the central office of the Administration for reference use during customary business hours. For dates of service beginning:

i.         October 1, 2012 through September 30, 2013, the Administration and its contractors shall reimburse ambulance services at 68.59 percent of the ADHS rates that are in effect as of August 2, 2012.

ii.        October 1, 2013 through September 30, 2014, the Administration and its contractors shall reimburse ambulance services at 68.59 percent of the ADHS rates that are in effect as of August 2, 2013.

iii.      October 1, 2014 through September 30, 2015, the Administration and its contractors shall reimburse ambulance services at 74.74 percent of the ADHS rates that are in effect as of August 2, 2014.

d.        Medical supplies  and durable medical equipment (DME). Fee schedules for payment for medical sup- plies and DME are on file at the central office of the Administration for reference use during customary business hours. The Administration shall reimburse a provider once for purchase of DME during any two-year period, unless the Administration deter- mines that DME replacement within that period is medically necessary for the member. Unless prior authorized by the Administration, no more than one repair and adjustment of DME shall be reimbursed during any two-year period.

B.       Pharmacy services. The Administration shall not reimburse pharmacy services unless the services are provided by a phar- macy having a subcontract with a Pharmacy Benefit Manager (PBM) contracted with AHCCCS. Except as specified in sub- section (C), the Administration shall reimburse pharmacy ser- vices according to the terms of the contract.

C.      FQHC Pharmacy reimbursement.

1.        For purposes of this Section the following terms are defined:

a.         “340B Drug Pricing Program” means the discount drug purchasing program described in 42 U.S.C 256b.

b.        “340B Ceiling Price” means the maximum price that drug manufacturers can charge covered entities par- ticipating in the 340B Drug Pricing Program as reported by the drug manufacturer to HRSA.

c.         “340B entity” means a covered entity, eligible to participate in the 340B Drug Pricing Program, as defined by the Health Resources and Human Ser- vices Administration.

d.        “Actual Acquisition Cost (AAC)” means the pur- chase price of a drug paid by a pharmacy net of dis- counts, rebates, chargebacks and other adjustments to the price of the drug. The AAC excludes dispens- ing fees.

e.         “Contracted Pharmacy” means an arrangement through which a 340B entity may contract with an outside pharmacy to provide comprehensive phar- macy services utilizing medications subject to 340B pricing.

f.         “Dispensing Fee” means the amount paid for the professional services provided by the pharmacist for dispensing a prescription. The Dispensing Fee does not include any payment for the drugs being dis- pensed.

g.        “Federally Qualified Health Center” means a public or private non-profit health care organization that has been identified by HRSA and certified by CMS as meeting the criteria under sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act and receives funds under section 330 of the Public Health Service Act.

h.        “Federally Qualified Health Center Look-Alike” means a public or private non-profit health care organization that has been identified by HRSA and certified by CMS as meeting the definition of “health center” under section 330 of the Public Health Service Act, but does not receive grant fund- ing under section 330.

i.         “FQHC or FQHC Look-Alike pharmacy” means a pharmacy that dispenses drugs to FQHC or FQHC- LA patients and that is owned and/or operated by an FQHC/FQHC-LA or by an entity that reports the costs of an FQHC/FQHC-LA on its Medicare Cost Report, whether or not collocated with an FQHC or an FQHC Look-Alike.

2.        Effective the later of February 1, 2012, or CMS approval of a State Plan Amendment, an FQHC or FQHC Look- Alike shall:

a.         Notify the AHCCCS provider registration unit of its status as a 340B covered entity no later than:

i.         30 days after the effective date of this Section;

ii.        30 days after registration with the Health Resources and Services Administration (HRSA) for participation in the 340B program, or

iii.      The time of application to become an AHCCCS provider.

b.        Provide the 340B pricing file to the AHCCCS Administration upon request. The 340B pricing file shall be provided in the file format as defined by AHCCCS.

c.         Identify 340B drug claims submitted to the AHC- CCS FFS PBM or the Managed Care Contractors’ PBMs for reimbursement. The 340B drug claim identification and claims processing for a drug claim submission shall be consistent with claim instruc- tions issued and required by AHCCCS to identify such claims.

3.        The FQHC and the FQHC Look-Alike pharmacies shall submit claims for AHCCCS members for drugs that are identified in the 340B pricing file, whether or not pur- chased under the 340B pricing file, with the lesser of:

a.         The actual acquisition cost, or

b.        The 340B ceiling price.

4.        The AHCCCS Fee-for-Service and Managed Care Con- tractors’ PBMs shall reimburse claims for drugs which are identified in the 340B pricing file dispensed by FQHC and FQHC Look -Alike pharmacies, whether or not pur- chased under the 340B pricing file, at the amount submit- ted under subsection (C)(3) plus a dispensing fee listed in the AHCCCS Capped Fee-For-Service Schedule unless a contract between the 340B entity and a Managed Care Contractor’s PBM specifies a different dispensing fee.

5.        Contracted pharmacies shall not submit claims for drugs dispensed under an agreement with the 340B entity as part of the 340B drug pricing program, and the AHCCCS Administration and Managed Care Contractors shall not reimburse such claims.

6.        The AHCCCS Administration and Managed Care Con- tractors shall reimburse contracted pharmacies for drugs not dispensed under an agreement with the 340B entity as part of the 340B program at the price and dispensing fee set forth in the contract between the contracted pharmacy and the AHCCCS or its Managed Care Contractors’ PBMs. Neither the Administration nor its Managed Care Contractors will reimburse a contracted pharmacy that does not have a contract with the Administration or MCO’s PBM.

7.        The AHCCCS Administration and its Managed Care Contractors shall reimburse FQHC and FCHC Look- Alike pharmacies for drugs that are not eligible under the 340B Drug Pricing Program at the price and dispensing fee set forth in their contract with the AHCCCS or its Managed Care Contractors’ PBMs.

8.        AHCCCS may periodically conduct audits to ensure compliance with this Section.

Historical Note

Adopted as an emergency effective May 20, 1982, pursu- ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82- 3). Former Section R9-22-710 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended as an emergency

effective February 23, 1983, pursuant to A.R.S. § 41- 1003, valid for only 90 days (Supp. 83-1). Amended as a permanent rule effective May 16, 1983; text of amended rule identical to emergency (Supp. 83-3). Former Section R9-22-710 repealed, new Section R9-22-710 adopted effective October 1, 1983 (Supp. 83-5). Amended effec- tive October 1, 1985. The capped fee-for-service sched- ules, deleted from Section R9-22-710, are now on file at the central office of the Administration (Supp. 85-5).

Amended subsections (B) through (D) effective October 1, 1986 (Supp. 86-5). Amended subsection (B) effective

July 1, 1988 (Supp. 88-3). Amended subsection (B) effec-

tive April 27, 1989 (Supp. 89-2). Amended under an exemption from the provisions of the Administrative Pro-

Arizona Health Care Cost Containment System - Administration

cedure Act, effective March 1, 1993 (Supp. 93-1).

Amended effective December 13, 1993 (Supp. 93-4).

Amended effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 11 A.A.R. 3830, effec- tive November 12, 2005 (Supp. 05-3). Amended by exempt rulemaking at 18 A.A.R. 212, effective February 1, 2012 (Supp. 12-1). Amended by exempt rulemaking at

18 A.A.R. 1971, effective August 1, 2012 (Supp. 12-3). Amended by exempt rulemaking at 18 A.A.R. 2630, effective October 1, 2012 (Supp. 12-4). Amended by final

rulemaking at 19 A.A.R. 1681, effective August 9, 2013 (Supp. 13-2). Amended by exempt rulemaking at 19

A.A.R. 3525, effective October 18, 2013 (Supp. 13-4)