AHCCCS 101 & How You Can Influence Arizona’s Medicaid Program

Arizona’s Medicaid program is largely run under a ‘managed care’ model. AHCCCS contracts with several managed care organizations or MCOs. Those contracted MCOs are responsible for developing a network of providers and ensuring their enrolled members are able to get the healthcare services they’re entitled to receive.

AHCCCS’ main job is to make sure their contractors (the MCOs) are doing their job and following AHCCCS’ requirements (and to make sure taxpayers are getting their ‘money’s worth’ from AHCCCS’ contractors).

Moneywise, the system is largely a ‘capitated model’ meaning each contractor gets a certain amount of money per enrolled member per month. How much the MCOs get per person per month depends on the category the person is in.

For example, AHCCCS pays a certain amount of money per month to the contractors’ healthy kids without special needs. That would be a pretty low amount per member per month. Kids with special needs like developmental disabilities would come with a lot more money per month.  Healthy adults would come in with a certain amount per month that would be modest…  but that dollar figure is a lot higher for adults that have been diagnosed with a Serious Mental Illness for example.

You can see why regulatory oversight is so important! I mean the contractors get a certain amount per person per month and if they spend less than that per person, they will make a profit.

That would be a good thing if the MCO’s healthcare provider network is doing a good job keeping their enrolled people healthy by catching things early.  But… if the managed care organization is making a profit because their network of providers is really thin, and people can’t find a doctor to make an appointment – that would be bad.

Likewise, if one of their contractors is making a lot of money because they aren’t providing needed services to their adults with a serious mental illness (like supported housing, supported employment etc.) then that would be super bad. After all – AHCCCS is paying them a certain amount per person per month with the expectation they’ll actually be providing those services. It’s also bad because the people entitled to those services unnecessarily suffer.

So you can see why it’s so important for AHCCCS to be a good ‘regulator’ and continually make sure that their contractors are doing their job, providing the required services, contracting with an adequate network of providers and that taxpayers aren’t getting ripped off.

One of the primary regulatory tools AHCCCS has are called Administrative Claims Financial and Operational policies aka “ACOMs”…. which are the things their contractors (MCOs) need to follow as a condition of getting AHCCCS money.

When contractors don’t comply with AHCCCS’ expectations they can impose an “Administrative Action” like a Notice of Concern, Notice to Cure, a mandate for a Corrective Action Plan, or financial sanctions. Here’s a summary of the various Administrative Actions takes to regulate their contractors.

See Guides & Manuals for Health Plans and Providers

From time-to-time AHCCCS makes changes to the expectations they have for their contractors. They do that by changing those ACOMs. Those changes can be very significant. Think about it. When AHCCCS changes the contractual expectations, it can affect the care that all 2.5 million persons enrolled in AHCCCS. Why? Because those changes affect the expectations AHCCCS has for their contractors – and those contractors will then change the expectations they have for their provider network – and ultimately the experiences AHCCCS members have.

Right now, AHCCCS has 27 of their ACOMs out for public comment. Here’s the website with the open ACOM modification proposals: AHCCCS ACOM Comment Portal. Five of the ACOM changes have comment deadlines this Thursday including changes in expectations for maternal and child health, services for folks with a serious mental illness (including eligibility determination), waste fraud and abuse and how they’ll assign new members to contractors (MCOs)

It’s important for people who are ‘in the know’ to keep up with the proposed changes and provide comments to AHCCCS – as some of the changes to these ACOM expectations can have profound impacts on how services are provided and the quality of care that AHCCCS members get.

If you’re a subject matter expert – or an advocate for persons who receive services, please take the time to check out AHCCCS’ proposed changes and comment on them! Even minor changes to some of these policies can have a huge impact on real people.

Here’s a quick summary of the proposed changes that have a comment deadline this week:

AMPM EXHIBIT 400-3 – Maternal & Child Health

This one makes changes in the expectations AHCCCS has for their contractors for members who are pregnant.

ACOM POLICY 103 – Fraud Waste and Abuse

This one completely overhauls AHCCCS’ auditing expectations for the contractors and changes reporting expectations and the way contractors are expected to interact with AHCCCS’ Office of the Inspector General.

AMPM POLICY 320-O – Behavioral Health Assessments, Service and Treatment Planning

This ACOM change makes massive changes to behavioral health services planning, including very different expectations for AHCCCS’ ‘fee-for-service’ programs (American Indian Health Plan). Note: It looks like some of these changes are geared to prevent the fraud perpetrated during the Ducey Administration in the AIHP.

AMPM POLICY 320-P – Eligibility Determination for Individuals with a Serious Mental Illness

This ACOM policy change proposed big changes in the way eligibility determinations are made for persons with a Serious Mental Illness.

ACOM POLICY 314 – Auto Assignment Algorithm

When people newly qualify for AHCCCS they can pick the managed care organization they want to manage their care. If people don’t pick a health plan then AHCCCS picks one for them (called auto assignment). This ACOM change shifts the way AHCCCS makes those decisions by rewarding health plans who have good results on their provider and member surveys.

8th Annual Rural Women’s Health Symposium! August 17 & 18: Prescott Resort and Conference Center

This year’s theme for the 8th Annual Rural Women’s Health Symposium is Supporting Rural Communities: Resilient & Refocused.

Rural communities have faced many challenges in the past few years. The Symposium hopes to strengthen your efforts by bringing people back together in person and focusing on supporting rural communities to overcome these hardships. The goal is to explore ways we can support providers, healthcare workers, and community members in serving rural women. The Symposium is a chance to learn from each other and share best practices as leaders, advocates, and experienced community members.

More information and registration here: 2023 Rural Women’s Health Symposium – AACHC

New Opportunities for Schools to Provide Behavioral Health & Other Services

Schools have been able to bill AHCCCS for medically necessary services they provide in schools if the child is a Medicaid member, and the services are included in the kid’s individualized education plan or IEP. IEPs are a set of goals and expectations that are individually developed for kids in schools.

A couple of years ago AHCCCS developed a State Plan Amendment that would allow schools more flexibility and dropped the requirement that kids have an IEP or 504 plan.

An 504 plan allows the school to give accommodation to students who may have a disability affecting their learning. It’s unlike an IEP because you can have any disability. In order to have an IEP, students need to qualify for the services under specific categories.


Under the new rules, services can be documented in “… any other documented individualized health or behavioral health plan or as otherwise determined medically necessary.”

See the State Plan Amendment

The new State Plan Amendment is a potential game-changer for schools that want to augment the behavioral health (or other services) they want to provide for their students. The services can be provided to any student that’s an AHCCCS member – even if they don’t have an IEP… opening up possibilities to meet behavioral health needs of students even if they don’t have a disability.

The list of potentially covered services are:

  1. Speech-Language Pathology Services
  2. Occupational Therapy Services
  3. Physical Therapy Services
  4. Nursing Services
  5. Specialized Transportation Services
  6. Behavioral Health Services
  7. Personal Care Services
  8. Audiology Services
  9. Physician Services
  10. Nurse Practitioner Services

To get reimbursed the school provides need to meet AHCCCS’ service definitions and at document the ‘other documented individualized health or behavioral health plan’.

Schools are reimbursed the lesser of AHCCCS’ fee-for-service schedule or the amount billed by the school minus an AHCCCS administrative fee. 

I’m not sure how many schools are taking advantage of the new flexibilities built into the new State Plan Amendment provisions. I’ve pitched the idea of doing a story to a couple journalists- so we’ll see if anybody follows up and sheds some light on this.

I don’t expect Superintendent of Public Instruction Tom Horne to pay any attention to this or to encourage public schools to participate. Let’s just say he has other priorities like eliminating nonexistant critical race theory, encouraging even more participation in the private and homeschool voucher program and ‘classroom discipline’.

Arizona Medicaid School Based Claims FAQs

FDA Approves First Nonprescription Daily Oral Contraceptive

Last week the AZ Board of Pharmacy’s rules allowing Pharmacists to Dispense Contraceptives w/o a Physician Prescription became effective. This week brought a potentially bigger change- FDA’s approval of Opill (norgestrel) – a tablet for nonprescription use to prevent pregnancy. This is the first time FDA has approved a daily oral contraceptive approved for use without a prescription.

Approval of this progestin-only oral contraceptive pill supplies a choice for consumers to buy oral contraceptive medicine without a prescription at drug stores, convenience stores and grocery stores, as well as online.  

From the FDA’s Decision Memo: The potential benefits of an increase in the ability for consumers to prevent unintended pregnancy (with its attendant medical, economic, and societal harms) outweigh the potential risks of the product in the nonprescription setting.

The manufacturer hasn’t identified a launch price – and how big of a deal this is will in large part be tied to the price consumers would pay over the counter for the product.

Decision Memo

Opill Consumer Information

Arizona Joins US Climate Alliance

Governor Hobbs has used her authority as Governor to join the U.S. Climate Alliance. The Alliance is a bipartisan coalition of governors committed to reducing greenhouse gas emissions consistent with the goals of the Paris Agreement. Smart, coordinated state action can ensure that the United States continues to contribute to the global effort to address climate change. 

US Climate Alliance Fact Sheet

Each member state, including Arizona has to commit to:

  • Reduce collective net greenhouse gas emissions 26% by 2025 and 50% by 2030 and achieve overall net-zero GHG emissions by 2050.
  • Accelerating new and existing policies to reduce greenhouse gas pollution, building resilience to the impacts of climate change, and promoting clean energy deployment at the state and federal level.
  • Centering equity, environmental justice, and a just economic transition in their efforts to achieve their climate goals and create high-quality jobs.
  • Tracking and reporting progress to the global community in proper settings, including when the world meets to take stock of the Paris Agreement.

Did the SARS CoV2 Virus Have a Natural or Laboratory Origin? Here’s What the ‘Intelligence Community’ Says:

The COVID-19 Origin Act of 2023 told the U.S. Intelligence Community to declassify information relating to potential links between the Wuhan Institute of Virology and the origin of the COVID-19 pandemic. A summary of that information was recently released by the US government. It came from the Intelligence Community rather than scientists…  so take that into consideration as you read the report.

Report on Potential Links Between the Wuhan Institute of Virology-& COVID-19

There are several sources of Intelligence in the report including the FBI, CIA and many others. Each agency takes a different take on the origins of the COVID-19 pandemic. Those differences “… stem from differences in how agencies weigh intelligence reporting, scientific publications, intelligence and data gaps.”  

The FBI & the Department of Energy think the virus originated via a laboratory-associated incident. The National Intelligence Council and four other intelligence agencies think SARS-CoV-2 was most likely caused by natural exposure to an infected animal.

The CIA was “… unable to determine the precise origin of the COVID-19 pandemic, as both hypotheses rely on significant assumptions or face challenges with conflicting reporting”.

Almost all the intelligence agencies assessed that SARS-CoV-2 was not genetically engineered and that “… both a natural and laboratory-associated origin remain plausible hypotheses to explain the first human infection”.

We’ll probably never really find out the real answer as to the origin of the virus in part because the Chinese Government has been unwilling to fully cooperate with a full investigation of the origin of the virus.

Consider Your Public Health Wins

Kelli Donley Williams – AZPHA President

I had the opportunity to sit down with AzPHA member Gordon Jensen and board member Dr. Kara Geren for coffee recently. We came together to discuss AzPHA’s priority in improving firearm safety statewide. While we visited and shared our interest in the work, we also shared the reality that working in public health can often feel thankless. We batted around small wins over the years and how to be personally satisfied with this field, you have to have the ability to celebrate the small joys and recognize when they become big wins.  

Gordon shared with us a quote from Dan Gross, President of the Brady Campaign to Prevent Gun Violence, which ran in “The Nation’s Health in May 2015: “Our goal is not to ban guns any more than the goal of automobile safety is to ban cars. It’s simply to make the products as safe as possible and keep them out of the hands of the wrong people.”  

This comparison brought the three of us to discussing ashtrays as a standard feature in American-made vehicles. We laughed realizing ashtrays in cars are longer the norm. There wasn’t a parade for this design update, or likely even a press release. But it came after decades of public health officials crying for national changes to discourage tobacco use. Think of the countless community coalitions, neighborhood groups, voters, and more who came together to say smoking is a smelly, puking habit.*   

This isn’t a small joy, but a huge win. If you want to smoke in your car today, it is nowhere near as convenient as it once was.  

Whether you’re early in your career in public health, looking at retirement, or like me and somewhere in between, I hope you’ll take a moment to consider your public health wins. You are part of a bigger whole working every day to make our communities stronger, healthier, and better places to live. We’re going to keep banging on the drum and working to build new partnerships to come up with solutions. It may feel thankless somedays, but I’m grateful you’re here.  

*High fives to all Arizona kids who saw these commercials in junior high like I did and immediately swore off ever trying cigarettes. And higher fives to those at ADHS who made that statewide campaign a reality, hopefully forever reducing tobacco rates in Arizona.

Community Health Workers now Being Reimbursed via AHCCCS

Certified Community Health Workers & employed by AHCCCS registered providers can now bill for reimbursable services! Claims for covered services provided by the certified CHW or CHR need to be given by the registered AHCCCS provider. A CHW or CHR can be employed by multiple AHCCCS registered providers. AHCCCS registered providers may employ multiple CHWs or CHRs.

In order to obtain Medicaid reimbursement, the CHW needs to be certified by ADHS and may only deliver covered services within their scope of practice under specified AHCCCS registered provider types.

These provider types are listed in question 8 of the CHW/CHR Frequently Asked Questions.

The employer may only submit claims using the allowed codes for the covered services provided by its CHWs or CHRs. Additional billing guidance will be added to the AHCCCS Fee-for-Service Provider Billing Manual.

Answers to Key Questions about Integrating CHWs into the Network of Care

  • How does a CHW/CHR obtain voluntary certification?
  • What provider types can bill for CHW/CHR services?
  • How does a CHW/CHR organization become an AHCCCS-registered provider?
  • How does an employer bill for CHW/CHR services? If I have additional questions about Medicaid reimbursement for CHW/CHRs, who should I contact?

Community Cares Can Help You Address the Social Determinants of Health

Contexture (Arizona’s health information exchange) is collaborating with AHCCCS and Solari Crisis & Human Services to implement a single, statewide referral system called CommunityCares with the goal of helping to address social determinants of health needs in Arizona.

CommunityCares – Contexture

The flagship product of the CommunityCares initiative is a new technology platform that connects healthcare and community service providers, streamlines the referral process, and provides easier access to vital services. The tool even confirms when social services are actually delivered.

Partners in the network are securely connected through their “Unite Us” shared software.

Joining the network is free for community-based organizations and many organizations who are considered part of the safety net, like community health centers, tribal clinics, and mental health centers.

Using CommunityCares e-tool, community partners can build a coordinated care network, track outcomes, & find service gaps while empowering members to take ownership of their own health.

Once a network partner identifies a person’s social needs, they can send a secure electronic referral to a network partner for the needed service. Partners involved in that person’s care will have visibility into whether or not the referral is accepted and once accepted, whether or not that person received the services and what happened as a result.’

Unite Us (the technical partner) onboards and trains all partners who use the platform to ensure consistency, compliance, and accountability to the network.

Schedule a Demo with Contexture

Network partners may include community-based organizations, safety net health care providers, health systems, insurers, and other groups looking to better support people to achieve healthy outcomes. Network partners can choose to take part in whatever way works best for them and can change how they take part in the network over time.

  • Unite Us builds HIPAA, SAMHSA, 42 CFR Part 2, and FERPA-compliant networks in which proper viewing permissions are assigned for sensitive classes of information.
  • All network information is dually protected by secure technology and user procedures. The network is routinely audited for digital security.
  • Consent is needed from every person who has a client record in the network before information is shared.
There are financial incentives to participate
Milestone 1 – $2,000
Sign Access Agreement, go live on the system and opt-in to receive referrals for at least one service. User login and training required.
Milestone 2: – $3,000
Respond to 75% of referrals within two business days for six total months.
Milestone 3 – $5,000
Respond to 75% of referrals within two business days for 12 total months.

If this sounds like it’s something you or the partners you work with could benefit from visit the website at Community Cares.