Ariz. Admin. Code § 9-28-204

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-28-204 - Institutional Services

A. Institutional services are provided in:

1. A NF;

2. An ICF-MR; or

3. A facility identified in R9-28-1105(A)(1)(b), (B), or (C).

B. The Administration and a contractor shall include the following services in the per diem rate for a facility listed in subsection (A):

1. Nursing care services;

2. Rehabilitative services prescribed as a maintenance regimen;

3. Restorative services, such as range of motion;

4. Social services;

5. Nutritional and dietary services;

6. Recreational therapies and activities;

7. Medical supplies and non-customized durable medical equipment under 9 A.A.C. 22, Article 2;

8. Overall management and evaluation of a member's care plan;

9. Observation and assessment of a member's changing condition;

10. Room and board services, including supporting services such as food and food preparation, personal laundry, and housekeeping;

11. Non-prescription and stock pharmaceuticals; and

12. Respite care services not to exceed 600 hours per benefit year.

C. Each facility listed in subsection (A) is responsible for coordinating the delivery of at least the following auxiliary services:

1. Under 9 A.A.C. 22, Article 2:

a. Attending physician, practitioner, and primary care provider services;

b. Pharmaceutical services;

c. Diagnostic services under A.A.C. R9-22-208;

d. Emergency medical services; and

e. Emergency and medically necessary transportation services.

2. Therapy services under R9-28-206.

D. Limitations. The following limitations apply:

1. A private room in a NF, ICF-MR, or facility identified in R9-28-1105(A)(1)(b), (B), or (C) is covered only if:

a. The member or has a medical condition that requires isolation, and

b. The member's primary care provider or attending physician provides written authorization;

2 Each ICF-MR shall meet the standards in A.R.S. § 36-2939(B)(1), and in 42 CFR 483, Subpart I, February 28, 1992, incorporated by reference, on file with the Administration and available from the U.S. Government Printing Office, 732 N. Capitol St., N.W., Washington, D.C. 20401. This incorporation contains no future editions or amendments;

3 Bed hold days as authorized by the Administration or its designee for a fee-for-service provider shall meet the following criteria:

a Short-term hospitalization leave for a member age 21 and over is limited to 12 days per AHCCCS benefit year, and is available if a member is admitted to a hospital for a short stay. After the short-term hospital-ization, the member is returned to the institutional facility from which leave is taken, and to the same bed if the level of care required can be provided in that bed; and

b Therapeutic leave for a member age 21 and older is limited to nine days per AHCCCS benefit year. A physician order is required for therapeutic leave from the facility for one or more overnight stays to enhance psycho-social interaction, or as a trial basis for discharge planning. After the therapeutic leave, the member is returned to the same bed within the institutional facility;

c Therapeutic leave and short-term hospitalization leave are limited to any combination of 21 days per benefit year for a member under age 21;

4. The Administration or a contractor shall cover services that are not part of a per diem rate but are ALTCS covered services included in this Article, and deemed necessary by a member's case manager or the case manager's designee if:

a. The services are ordered by the member's primary care provider; and

b. The services are specified in a case management plan under R9-28-510;

5 A member age 21 through 64 is eligible for behavioral health services provided in a facility under subsection (A)(3) that has more than 16 beds, for up to 30 days per admission and no more than 60 days per benefit year as allowed under the Administration's Section 1115 Waiver with CMS and except as specified by 42 CFR 441.151, May 22, 2001, incorporated by reference, on file with the Administration and available from the U.S. Government Printing Office, 732 N. Capitol St., N.W., Washington, D.C. 20401. This incorporation contains no future editions or amendments; and

6. The limitations in subsection (D)(5) do not apply to a member:

a. Under age 21 or age 65 or over, or

b. In a facility with 16 beds or less.

Ariz. Admin. Code § R9-28-204

Adopted effective October 1, 1988, filed September 1, 1988 (Supp. 88-3). Amended subsections (A) and (D) effective June 6, 1989 (Supp. 89-2). Amended effective November 5, 1993 (Supp. 93-4). Section repealed; new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by exempt rulemaking at 7 A.A.R. 4691, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 2356, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 17 A.A.R. 1876, effective October 1, 2011 (Supp. 11-3). Amended by final rulemaking at 19 A.A.R. 2758, effective October 8, 2013.