Section R9-28-206. ALTCS Services that may be Provided to a Mem- ber Residing in either an Institutional or HCBS Setting

The Administration shall cover the following services if the ser- vices are provided to a member within the limitations listed:

1.        Occupational and physical therapies, speech and audiol- ogy services, and respiratory therapy:

a.         The duration, scope, and frequency of each thera- peutic modality or service is prescribed by the mem- ber’s primary care provider or attending physician;

b.        The therapy or service is authorized by the mem- ber’s contractor or the Administration; and

c.         The therapy or service is included in the members case management plan;

d.        AHCCCS will not cover more than 15 outpatient physical therapy visits for the contract year with the exception of the required Medicare coinsurance and deductible payment as described in 9 A.A.C. 29, Article 3.

2.        Medical supplies, durable medical equipment, and cus- tomized durable medical equipment, which conform with the requirements and limitations of 9 A.A.C. 22, Article 2 and as described under R9-28-202 for persons in HCBS settings;

3.        Ventilator dependent services:

a.         Inpatient or institutional services are limited to ser- vices provided in a general hospital, special hospital, NF, or ICF-MR. Services provided in a general or special hospital are included in the hospital’s unit tier rate under 9 A.A.C. 22, Article 7;

b.        A ventilator dependent member may receive the array of home and community based services under R9-28-205 as appropriate.

4.        Hospice services:

a.         Hospice services are covered only for a member who is in the final stages of a terminal illness and has a prognosis of death within six months;

b.        Covered hospice services for a member are those allowable under 42 CFR 418.202, December 20, 1994, incorporated by reference and on file with the Administration and the Office of the Secretary of State. This incorporation by reference contains no future editions or amendments; and

c.         Covered hospice services do not include:

i.         Medical services provided that are not related to the terminal illness, or

ii.        Home delivered meals.

d.        Medicare is the primary payor of hospice services for a member if applicable.

Historical Note

Adopted effective October 1, 1988, filed September 1,

1988 (Supp. 88-3). Amended effective June 6, 1989

(Supp. 89-2). Amended effective July 13, 1992 (Supp.

92-3). Amended effective November 5, 1993 (Supp. 93- 4). Section repealed; new Section adopted effective Sep- tember 22, 1997 (Supp. 97-3). Amended by final

rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 16

A.A.R. 1664, effective October 1, 2010 (Supp. 10-3). Amended by final rulemaking at 21 A.A.R. 1243, effec-

tive July 7, 2015 (Supp. 15-3).