Gila River Health Care Corporation
Gila River Health Care Corporation
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.21 Service Prioritization for Non-Title XIX/XXI Funding


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: Medicare Part D Prescription Drug Coverage

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. As such, each Regional and Tribal Behavioral Health Authority (T/RBHA) must implement priorities for Non-Title XIX/XXI funded service delivery.

This section is intended to describe the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) expectations regarding the prioritization and expenditure of Non-Title XIX/XXI funds. Typically, ADHS/DBHS establishes a set of state-level priorities based on requirements of federal, state, and local funding that ensures standardization in availability of Non-Title XIX/XXI funded services across the state. ADHS/DBHS allows the T/RBHAs to delineate prioritization of any remaining Non-Title XIX/XXI funds within each geographic service area (GSA).

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

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3.21.3 Scope
To whom does this apply?

All enrolled behavioral health recipients.

3.21.4 Did you know?

The ADHS/DBHS receives limited Non-Title XIX/XXI service funds from a variety of sources. Non-Title XIX/XXI service fund sources include, but are not limited to:

  • Center for Mental Health Services (CMHS) and Substance Abuse Prevention and Treatment (SAPT) Federal Block Grants;
  • State appropriations for children, adults *including persons determined to have a Serious Mental Illness), substance abuse treatment and prevention;
  • County and city funds;
  • Other state agency funding agreements; and
  • Other Non-Title XIX/XXI funds as made available periodically for targeted activities.

Non-Title XIX/XXI service funds do not include discretionary grant funds for specific grant projects.

3.21.5 Definitions
Dual Eligible

Medicare Advantage Prescription Drug Plan (MA-PD)

Prescription Drug Plan (PDP)

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

The ADHS/DBHS requires adherence to the following statewide priorities for Non-Title XIX/XXI funded service delivery1:

  1. Requirements of CMHS and SAPT block grants (see Section 3.19, Special Populations)
  2. Requirements of state appropriations, county, and city funds with designated uses (see applicable IGAs and ISAs);
  3. Services for Non-Title XIX/XXI adults determined to have a Serious Mental Illness (SMI), including evaluation for Serious Mental Illness determination;
  4. Medicare Part D prescription drug coverage costs for persons determined to have a Serious Mental Illness and dual eligibles who are determined to have a Serious Mental Illness; and,
  5. Behavioral health crisis system services, including emergency department response for Non-Title XIX/XXI, Non-SMI individuals.
  • All other Non-Title XIX/XXI services and eligible individuals are covered according to regionally defined priorities and as funding is available;
  • Behavioral health providers must ensure that information about Non-Title XIX/XXI funded service priorities is available to persons immediately upon request;
  • Behavioral health providers must ensure that all services are based on an individual service plan; and,
  • 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, Premiums and Co-payments.

1 Coverage of Non-Title XIX/XXI, Non-SMI services is based on available funding.

3.21.7-B: Medicare Part D Prescription Drug Coverage
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 (see Section 3.1, Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program, regarding how to provide assistance to behavioral health recipients with Medicare Part D enrollment).

Medicare eligible behavioral health recipients, who are not dual eligible persons determined to have SMI, 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 (see the Part D Voluntary Prescription Drug Benefit Program – Benefits and Costs for People with Medicare for specific Part D costs). Medicare Part D cost sharing includes premiums, deductibles, co-payments and/or co-insurance.

State funds will be used to pay or reimburse Medicare Part D co-payments and premiums for behavioral health recipients who are dual eligible and determined to have a Serious Mental Illness. Dual eligible persons automatically receive the Limited Income Subsidy (LIS) and do not have deductibles or coinsurance requirements for Part D coverage. Dual eligible persons may have a premium if they select a plan with a premium that is greater than the amount covered with the Limited Income Subsidy. When covering the Part D premium, 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).  

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 persons2:

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

Non-covered Medicare Part D drugs

Part D plans may choose to leave certain medications off the plan formulary. As such, behavioral health recipients may be prescribed drugs that are not available through his/her Part D plan (or AHCCCS, for persons who are dual eligible). Medicare will not cover excluded drugs, but non-covered Part D drugs may be covered through Medicare after going through the exceptions and appeals processes. T/RBHAs and/or behavioral health providers must assist behavioral health recipients with requesting an exception from the Part D plan to acquire a drug not on a Part D plan’s formulary. When Title XIX/XXI eligible persons determined to have a Serious Mental Illness have utilized all options to have the Part D plan cover a drug not on the plan’s formulary (e.g., exception, redetermination of benefits and appeal), T/RBHAs may cover the drug if the drug is medically necessary and on the T/RBHA formulary (see PM Section 3.16, Medication Formulary). If coverage of the drug is denied, a Notice of Action must be provided in accordance with PM Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons.

2 Medicare Part D prescription drug coverage is subject to change, and drugs that are no longer excluded will be covered under Medicare, not Medicaid.

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3.21 Service Prioritization for Non-Title XIX/XXI Funding
Last Revised: 12/15/2009
Effective Date: 12/15/2009

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