Arizona – EPSDT

In Arizona:
 
  • As of July 1, 2011, there were 1,351,988 beneficiaries enrolled in Arizona Medicaid. Of these, 1,198,818 were enrolled in Medicaid-only managed care organizations providing physical and oral health benefits, and 124,491 were enrolled in a prepaid inpatient health plan for mental health and substance use disorders.
  • The state Medicaid agency contracts with the Department of Health Services to provide behavioral health services. The Department of Health Services contracts with Regional Behavioral Health Authorities (RBHAs) to administer care.
  • Roughly 25,000 Medicaid eligible children with complex health needs receive care through the Children’s Rehabilitative Services (CRS) program. CRS beneficiaries receive preventive and primary acute care from their Medicaid managed care plans and specialty care related to their CRS-eligible condition through a CRS provider. Arizona is currently working to create a specialty health plan for CRS children that would manage both behavioral and physical health services.
 
As of 2012, 806,416 individuals were eligible for Arizona’s Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT. According to 416 data from 2012, Arizona achieved an EPSDT screening ratio of 90% and a participation ratio of 64%. 361,724 children received dental services of any kind, with 324,750 receiving preventive dental services.
 
Last updated May 2014

 

Arizona Administrative Code defines medically necessary to mean 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 conditions or their progression, or prolong life.
As outlined in the AHCCCS Contractor Operations Manual, managed care plans are required to develop and maintain a provider Network Development and Management Plan to assure AHCCCS that services are being provided as specified.
The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, provides EPSDT Tracking Forms that must be used by providers to document all age-specific, required information related to EPSDT screenings and visits. Providers may choose to use an electronic EPSDT Tracking Form generated through AHCCCS or the provider’s electronic health record system if the electronic form includes components on the AHCCCS EPSDT Tracking form, such as:
 
  • Documentation of comprehensive physical exam
  • Age-appropriate screenings
  • Developmental surveillance
  • Anticipatory guidance
  • Social-emotional health surveillance
  • Age-appropriate lab and immunizations, and
  • Medically necessary referrals including those to the member’s dental home starting at 1 year of age, or sooner as needed, for routine biannual examinations.
Behavioral health services are carved out of Medicaid managed care in Arizona. The state Medicaid agency contracts with the Department of Health Services to provide these services, which in turn contracts with Regional Behavioral Health Authorities (RBHAs) to administer care. The state is divided into 6 geographic areas, with an RBHA responsible for administering care in each region.
 
Arizona’s Medicaid agency had made available to primary care providers three Childhood and Adolescent Behavioral Health Tool Kits for:
 
Arizona released a Request for Information in December 2013 to seek input for an integrated health care service delivery system to provide physical and behavioral health care services to maximize care coordination statewide. 
 The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, maintains a “Health Insurance for Children" web page that outlines eligibility criteria and covered services for enrollees.
Arizona Medicaid’s Medical Policy Manual outlines care coordination responsibilities of Medicaid participating primary care physicians, including:
 
  • “Referring members to providers or hospitals within the Contractor network, as appropriate, and if necessary, referring members to out-of-network specialty providers
  • Coordinating with the Contractor in prior authorization procedures for members
  • Conducting follow-up (including maintaining records of services provided) for referral services that are rendered to their assigned members by other providers, specialty providers and/or hospitals
  • Coordinating the medical care of the AHCCCS members assigned to them, including at a minimum:
    • Oversight of drug regimens to prevent negative interactive effects
    • Follow-up for all emergency services
    • Coordination of inpatient care
    • Coordination of services provided on a referral basis, and
    • Assurance that care rendered by specialty providers is appropriate and consistent with each member’s health care needs.”
 
The manual also outlines care coordination responsibilities for contractors delivering Children’s Rehabilitative Services (CRS):
 
“The CRS Contractor must establish a process to ensure coordination of care for members that includes:
  • Coordination of CRS member health care needs through a Service Plan,
  • Collaboration with providers, communities, agencies, service systems, members, and families,
  • Provide service coordination, and communication, designed to manage the transition of care for a member who no longer meets CRS eligibility requirements or makes the decision to transition to another AHCCCS Contractor after the age of 21 years.
  • Appropriate notification of pending discharge from the CRS program as described in Policy 520 of this Chapter.”
 
Arizona’s Medicaid agency and the Arizona Early Intervention Program jointly developed a process for coordinating EPSDT and early intervention services. These guidelines outline procedures for coordinating care when concerns about a Medicaid-enrolled child’s development are identified by either a primary care physician or by the Arizona Early Intervention Program.
 
Arizona also released a Request for Information in December 2013 to seek input for an integrated health care service delivery system to provide physical and behavioral health care services to maximize care coordination statewide.
Primary care providers are required to conduct an oral health screening as part of an EPSDT screening, and make referrals to dentists as needed.