3.21.1 Introduction
3.21.2 References
3.21.3 Scope
3.21.4 Did you know…?
3.21.5 Definitions
3.21.6 Objectives
3.21.7 Procedures
3.21.7-A: General Requirements
3.21.7-B: What populations have been prioritized?
3.21.7-C: What covered services are available?

3.21.1 Introduction
In Arizona’s public behavioral health system, persons may be eligible for, or entitled to, services as Title XIX (Medicaid), Title XXI (KidsCare) or as a person determined to have a serious mental illness (SMI). Non-Title XIX/XXI funds are available but limited and the behavioral health services offered through this fund source are not considered entitlements. As such, each Regional and Tribal Behavioral Health Authority (T/RBHA) must implement priorities for Non-Title XIX/XXI funded service delivery. Non-Title XIX/XXI funds include, but are not limited to:

• Center for Mental Health Services (CMHS) and Substance Abuse Prevention and Treatment Performance Partnership (SAPT) block grants;
• State appropriations; and
• County funds.

This section is intended to describe ADHS/DBHS expectations regarding the prioritization and expenditure of Non-Title XIX/XXI funds. Typically, ADHS/DBHS establishes a set of general priorities and allows the T/RBHAs to specifically delineate how these funds will be utilized in each geographic service area (GSA).

Effective January 1, 2006, Medicare eligible behavioral health recipients, including persons who are dually eligible for Medicare (Title XVIII) and Medicaid (Title XIX/XXI), will receive Medicare Part D prescription drug benefits through Medicare Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA-PDs). Prescription drug coverage for Medicare eligible behavioral health recipients enrolled in Part D will be based on Part D plans’ formularies. State funds will be used to pay or reimburse Medicare Part D cost sharing for behavioral health recipients who are dual eligible or Non-Title XIX Medicare eligible and determined to have a Serious Mental Illness (SMI). Payment of any Medicare Part D cost sharing or any Medicare Part D excluded or non-covered drugs for Non-Title XIX eligible, Non-SMI behavioral health recipients is based on available funding as determined by the Tribal and Regional Behavioral Health Authority (T/RBHA).

3.21.2 References
The following citations can serve as additional resources for this content area:

• 42 CFR Part 400
• 42 CFR Part 403
• 42 CFR Part 411
• 42 CFR Part 417
• 42 CFR Part 422
• 42 CFR Part 423
• A.R.S. § 36-3408
• ADHS/RBHA Contracts
• ADHS/Gila River Health Care Corporation Intergovernmental Agreement
• ADHS/Pascua Yaqui Behavioral Health Program Intergovernmental Agreement
• Section 3.4, Co-payments
• Section 3.1, Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program including Medicare Part D Prescription Drug Coverage and the Limited Income Subsidy Program
• Section 3.13, Covered Behavioral Health Services
• Section 3.5, Third Party Liability and Coordination of Benefits
• Substance Abuse Prevention and Treatment Performance Partnership Block Grant

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3.21.3 Scope
To whom does this apply?

All behavioral health recipients.

3.21.4 Did you know?

Although, the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) allows each T/RBHA to set priorities for how Non-Title XIX/XXI funds will be allocated within the T/RBHA’s GSA, ADHS/DBHS has required that T/RBHAs prioritize the following services:

• Crisis services;
• Services for SAPT Block Grant populations;
• Non-SMI court-ordered treatment;
• Services to enrolled members who have lost Title XIX/XXI eligibility; and
• Cost sharing, and under limited circumstances, prescription drug coverage for dual eligible persons and Non-Title XIX/XXI Medicare eligible persons determined to have a Serious Mental Illness.

3.21.5 Definitions
Institutionalized individual

Medical institution

3.21.6 Objectives
To communicate covered services and populations that have been prioritized for non-Title XIX/XXI funding.

3.21.7 Procedures

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3.21.7-A. General Requirements

• Information about Non-Title XIX/XXI funded service priorities must be available to persons immediately upon request.
• When providing Non-Title XIX/XXI funded behavioral health services to persons, behavioral health providers must assess the person’s ability to contribute to the cost of services per Section 3.4, Co-payments. This assessment is not required when Non-Title XIX/XXI funding is used for prescription drugs or cost sharing of Medicare Part D Prescription Drug coverage for Medicare eligible persons.

3.21.7-B: What populations have been prioritized?
Substance Abuse Prevention and Treatment (SAPT) Performance Partnership Block Grant Populations
The following populations are prioritized and covered under the SAPT Block Grant:
First…Pregnant injection drug users;
Then…Pregnant substance abusers;
Then…Other injection drug users; and
Finally…All other persons in need of substance abuse treatment.

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3.21.7-C: What covered services are available?
Each T/RBHA has developed service priorities to guide the expenditure of non-Title XIX/XXI funds.

T/RBHA specific priorities for Non Title XIX/XXI funded services
The Gila River RBHA has prioritized the following Non Title XIX/XXI funded services;

Crisis Services;
Services for SAPT Block Grant Population;
Room and Board for members receiving care and treatment in Level II and Level III behavioral health facilities; and
Services to RBHA enrolled members who have lost their Title XIX/XXI eligibility.

3.21.7-D: Medicare Part D Prescription Drug Coverage
Beginning on January 1, 2006, behavioral health recipients who are eligible for Medicare Part D Prescription Drug coverage must access most prescription drug coverage through Medicare, rather than through the T/RBHA. Medicare eligible persons will continue to access excluded Medicare Part D drugs through their T/RBHA. Medicare eligible persons must enroll with a Prescription Drug Plan (PDP) or Medicare Advantage-Prescription Drug Plan (MA-PD) to access the Medicare Part D Prescription Drug coverage.

Medicare Part D Cost Sharing
Behavioral health recipients will be subject to the cost sharing requirements of Medicare Part D. The cost sharing requirements will vary depending on the Part D Plan the person enrolls with and the person’s income and resources. Medicare Part D cost sharing includes premiums, deductibles, co-payments and/or co-insurance.

Until this change, behavioral health recipients have not been subjected to cost sharing or limited formularies for prescription drug coverage through the T/RBHAs. Medicare Part D cost sharing may impose financial difficulties on some persons. ADHS/DBHS intends to ensure that behavioral health recipients continue to have access to medically necessary prescription drugs. There are circumstances in which the T/RBHA will use state funds to pay a person’s cost sharing for Medicare Part D or to pay for prescription drugs not accessible through Medicare

Part D. In other circumstances, state funds may be used to pay a person’s cost sharing for Medicare Part D or to pay for prescription drugs not accessible through Medicare Part D, based on available funding as determined by the T/RBHA.

The T/RBHAs can pay cost sharing of Medicare Part D with state funds according to the following table. PM Attachment 3.21.2, Benefits and Costs, describes all of the cost sharing requirements of Medicare Part D based on income and resources.

* Dual eligibles may have a premium if they select a plan with a premium that is greater than the amount subsidized by the federal government.

In some cases, payment of a Part D premium to avoid disenrollment of the person by the Part D plan can be made by the T/RBHA with state funds. Behavioral health recipients who do not have the Part D premium automatically deducted from their Social Security checks are able to have their premium paid for by the T/RBHA. If the T/RBHA does make a premium payment on behalf of a person, the T/RBHA can recommend that the person request that the premium be withheld from his/her social security check, if he/she receives one. This request must be made directly to his/her Part D plan. The T/RBHA must submit payment directly to the Part D plan and not to the behavioral health recipient. (See billing information in the ADHS/DBHS Covered Behavioral Health Services Guide, section II.D.9., Non-Medically Necessary Covered Services). T/RBHAs will use state funds to cover premiums for dual eligibles and non-Title XIX/XXI, SMI persons who are in jeopardy of losing Part D coverage. T/RBHAs are responsible for managing the use of state funds to cover Part D premiums.

Limited Income Subsidy (LIS) or “Extra help”
Medicare eligible persons with income below 150% of the Federal Poverty Limit (FPL) and resources below $11,500 for an individual and $23,000 for a couple may be eligible for a program called the Limited Income Subsidy (LIS), or “extra help”. This “extra help” is a program in which the federal government pays all or a portion of the cost sharing of Medicare Part D for eligible persons (see PM Attachment 3.21.2 for the cost sharing that is covered by the “extra help”). Behavioral health recipients who are on both Medicare and Medicaid (dual eligibles) automatically receive this “extra help”. Behavioral health recipients eligible for Medicare and Medicare Savings Programs available through AHCCCS to pay their Medicare Part A and/or B cost sharing (QMB, SLMB or QI-1) also automatically receive this “extra help.”

In the interest of minimizing the use of state funds, T/RBHAs or providers must assist any persons identified who may qualify for the “extra help” with completing an application. Applications can be obtained and submitted through the following methods:

• On-line at https://s044a90.ssa.gov/apps6z/i1020/main.html;
• By calling 1-800-772-1213;
• In person at a Social Security Administration local office; or
• By mailing a paper application to the SSA.

Institutionalized dual eligibles
The following medical institutions qualify to have a dual eligible behavioral health recipient’s Medicare Part D co-payments waived:

• Acute care hospital
• Psychiatric hospital – Non-Institution for Mental Disease (Non-IMD)
• Residential Treatment Center (RTC) Non-IMD
• Intermediate Care Facility for People with Mental Retardation (ICF/MR)
• Psychiatric hospital – IMD
• RTC – IMD
• Skilled Nursing Facility (SNF)

Medicare Part D co-payments are waived for dual eligible persons who are anticipated to reside for at least a full calendar month in a medical institution (identified above) that is funded by Medicaid. The waiver of co-payments applies for the remainder of the calendar year, regardless of whether the person continues to reside in a medical institution.

Effective January 1, 2006, PM Form 3.21.1, AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medical Institution that is Funded by Medicaid, must be completed and faxed to AHCCCS as soon as it is determined that a behavioral health recipient is expected to be in a medical institution that is funded by Medicaid for a full calendar month. Instructions for completing PM Form 3.21.1 are provided in PM Attachment 3.21.1, Health Plan and RBHA Medical Institution Notification for Dual Eligible Members. Notification to AHCCCS is required for the following dual eligible behavioral health recipients:

1. Recipients who have Medicare Part “B” only;
2. Recipients who have used his/her Medicare Part “A” life time inpatient benefit; and
3. Recipients who are in a continuous placement in a single medical institution or any combination of continuous medical institution placements.

Do not wait until the behavioral health recipient has been discharged from the medical institution to submit the form.

Behavioral health recipients eligible for Medicare Part D, but not enrolled
Medicare Part D is a voluntary federal benefit. Arizona state statute requires that behavioral health recipients enroll in Medicare Part D, if eligible, in order to receive publicly funded behavioral health services unless they meet one of the following exemptions:

• A person’s inability to obtain documentation required for the eligibility determination; or
• A person who is unable to, or refuses to, participate due to his/her mental status and who does not have a legal guardian. (See Section 3.1, Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance including Medicare Part D Prescription Drug Coverage and the Limited Income Subsidy Program).

T/RBHAs will use state funds to pay for prescription drugs for dual eligibles or behavioral health recipients determined to have a Serious Mental Illness who are eligible for Medicare Part D, but who are not enrolled in a Part D plan. Prior to using state funds to pay for prescription drugs, T/RBHAs must determine, on an individual basis, if the person meets one of the conditions above for not enrolling in a Medicare Part D plan.

Excluded Medicare Part D drugs
Certain drugs are excluded from coverage under Medicare Part D. Title XIX/XXI funding will continue to be available to cover the following excluded drugs for Title XIX/XXI eligible persons:

• Benzodiazepines,
• Barbiturates;
• and certain over-the-counter drugs.

T/RBHAs may use state funds to pay for these excluded drugs for Non-Title XIX/XXI behavioral health recipients determined to have a Serious Mental Illness and may cover excluded drugs for Non-Title XIX/XXI, Non-SMI persons, as funding is available and determined by the T/RBHAs.

Each Medicare Part D PDP and MA-PD develops its own medication formulary. The formulary must contain at least two drugs per therapeutic class, and Part D plans are required to cover all or substantially all drugs within the following six classes: antidepressants, antipsychotics, anticonvulsants, antiretrovirals, antineoplastics and immunosuppresants. There may be an occasion when a behavioral health recipient’s prescribed drug is not available through his/her Part D plan’s formulary. This is considered a non-covered Part D drug. Persons determined to have a Serious Mental Illness (SMI), both dual eligibles and Non-Title XIX/XXI Medicare eligible persons, must maintain access to needed behavioral health medications as required by 9 A.A.C. 21. Therefore, if a person determined to have a SMI is denied coverage of a behavioral health medication through his/her assigned Medicare Part D plan for any reason, the T/RBHA must ensure the provision of the behavioral health medication(s).

Some drugs can be obtained through the Part D plan via step therapy or prior authorization processes. Medicare eligible behavioral health recipients, other than persons determined to have a SMI, may be expected to obtain their Part D medications through these processes before a T/RBHA uses state funds to cover the medications. T/RBHAs may not use state funds to pay for prescription drugs denied by a Medicare Part D plan for other reasons, including denials due to an out-of-network Behavioral Health medical practitioner writing the prescription or denials of formulary drugs that have been subjected to a prior authorization process through the Part D plan. T/RBHAs and/or behavioral health providers may assist behavioral health recipients, if necessary, with requesting an exception from the Part D plan to acquire a drug not on a Part D plan’s formulary. When Part D plans do not grant an exception and when Part D covered drugs are not on a Part D plan’s formulary, T/RBHAs may use state funds to cover the medications. Use of state funds to cover Part D non-covered drugs, for behavioral health recipients other than persons determined to have a SMI, will be based on available funding as determined by the T/RBHA.

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3.21 Service Prioritization for Non-Title XIX/XXI Funding
Last Revised: 11/08/2005
Effective Date: 03/15/2006