AHCCCS OverviewA Brief History and Outline of County Nexus tothe State Run Medicaid ProgramDan Bogert16

AHCCCS OverviewContentsArizona Healthcare Cost Containment System . 1History of the Arizona Healthcare Cost Containment System . 1AHCCCS and Medicaid . 4Master Settlement Agreement . 5Proposition 204 . 7Expansion of Medicaid & AHCCCS Eligibility. 8Long-term Care . 10History of Arizona Long-term Care . 10Payments . 14County Payments . 14Payments to Hospitals . 15i

Arizona Health Care Cost Containment SystemHistory of the Arizona Health Care Cost Containment SystemOverviewEstablished in 1982, the Arizona Health Care Cost Containment System (AHCCCS) serves asArizona’s Medicaid program. As of July 1, 2015, AHCCCS provided healthcare coverage for1,746,175 members, almost 26 percent of Arizona’s total population (Figure 1). 1,2,3 Theprogram is a prepaid capitation system in which contractors administer patient care at a predetermined rate set by the state. State, county and federal funds are used to pay for costsassociated with maintaining the program. 0000Percentage of Arizona's Population30.00%2,000,000AHCCS 199519931991198919870.00%1985Arizona Healthcare Cost Containment SystemAHCCCS Population Compared to Percent of Arizona'sPopulationPercentage of Arizona PopulationFigure 11Arizona Healthcare Cost Containment System: Population Statistics (1985-2014)Arizona Population estimates: U.S. Census Bureau, Population Division Inter-decennial Estimates of the Resident Population for the UnitedStates, Regions, States, and Puerto Rico32015 Arizona Population estimate: Arizona Department of Administration, Office of Employment & Population Statistics 12/7/2012442 U.S.C. § 1396b(a), 1396d(b): Enacted by the Social Security Amendments of 1965, [“an amount equal to 75 per centum of so much of thesums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as areattributable to compensation or training of skilled professional medical personnel, and staff directly supporting such personnel, of the Stateagency or any other public agency;”] f21

Healthcare Pre-1982Counties have had a long history of providing health care to indigent or dependent poor.Preceding Arizona becoming a state, the Arizona Territorial Revised Statutes of 1901 requiredcounties to erect offices and maintain hospitals to provide care.5 Some of the services countiesprovided were medical care, medicine, food and lodging. The programs remained largelyunchanged preceding the enactment of AHCCCS.Medical assistance legislation was a core issue for President John F. Kennedy upon his electionin 1960, increasing the national discussion around healthcare. In his State of the UnionMessage in 1963, Kennedy called on the Congress to enact a health insurance program underthe Social Security Act. Though the session ended without a substantive resolution, the Eightyninth Congress convened in 1965 with the intent of considering the legislation.6 Shortlythereafter, President Lyndon Johnson signed into law the Social Security Amendments of 1965,which in turn enacted the federal Medicaid program. By 1972, 49 states had joined theMedicaid system while Arizona continued to serve the indigent through a system of county-runhealth care programs that had remained largely unchanged since territorial days. Thesecounty-run programs held the counties financially responsible for indigent care and due toArizona’s lack of a Medicaid system, made federal funds unavailable. Though a Medicaidprogram had been authorized by the Arizona State Legislature in 1974, continued delays inimplementation and a lack of funding led to the authorization being repealed in 1977.Cochise County v. DandoyIn 1977, the Arizona Department of Health Services (DHS) attempted to force implementationof Medicaid by ordering the counties to budget and levy funds to finance the program. DHSdirected each of the, then fourteen,7 county boards of supervisors to include in their annualbudget, and levy taxes for, their share of the Medicaid program.In response, the counties brought a special action suit against DHS, Cochise County v. Dandoy. 8Counties argued that the Medicaid program could not be implemented without legislativeappropriations, citing Laws 1976, Ch. 132 § 4, 9 and, therefore, counties should not bemandated to levy taxes regarding Medicaid.DHS argued that county interpretation of section 4 was too broad and viewed section 4 as “aminor fiscal measure prohibiting the expenditure of state funds for staff until funds areappropriated”.105Revised Statutes of Arizona Territory 1901Wilbur J. Cohen and Robert M. Ball, Social Security Amendments of 1965: Summary and Legislative History [After President Kennedy’sassassination in 1963, Vice-President Lyndon Johnson assumed Presidential duties.]7Yuma County held jurisdiction of what is today La Paz County until 19848Apache County was originally listed as a petitioner in the lawsuit, however Apache County chose to join Pima County in a respondent rolebetween DHS and the remaining 12 counties9Laws 1976, Ch. 132 § 4: ["The hiring of staff necessary to provide medical assistance services as authorized by title 36, chapter 21, article 1,Arizona Revised Statutes, shall begin July 1, 1977 and shall be subject to legislative appropriation."]10Cochise County v. Dandoy, 116 Ariz. 53 (Ariz. 1977)62

The Arizona Supreme Court ruled that the forced implementation would not come into effectuntil legislation was passed to properly appropriate money for the program. In his opinion,Justice Hays stated “[T]here can be little doubt that unless the legislature provides thenecessary funds, a program cannot function, and for the legislature to fail to provide the fundsis not a use of the appropriations function for legislative purposes”.11Rising CostsBy 1981, political differences within state government led to a rift between the state legislatureand the Governor’s office. Following continued attempts to initiate a Medicaid program fromthe Executive Tower, counties began introducing alternative indigent health care plans tomitigate the soaring costs, which had risen from 58.6 million in 1975 to 122.6 million in 1980,a 110 percent increase in five years. Originally, Governor Bruce Babbitt vetoed legislationcreating and funding an Arizona Medicaid program due to disagreements with the legislatureover the consideration of the Veteran and Native American populations. The legislature arguedthat the Indian Health Services (IHS) and Veterans’ Administration (VA) clinics providedadequate care for those populations. 12 Fiscal pressures were beginning to take a toll on countybudgets, and projections at the time expected counties to pay upwards of 250 million (roughly 550 million in 2014 dollars) for indigent care by 1985.13 In November of 1981, GovernorBabbitt called on the legislature to convene for a special session to initiate a compromisepackage.Arizona Health Care Cost Containment SystemOn November 18, 1981, during the 35th Legislature’s 4th Special Session, S.B. 1001 was signedinto law, creating and funding the Arizona Health Care Cost Containment System (AHCCCS)within DHS. After numerous negotiated waivers with the U.S. Department of Health andHuman Services (HHS), including the exclusion of home and Long-term Care (LTC) services, andlimiting psychiatric care, which counties would continue to provide, AHCCCS officially beganoperations on October 1, 1982, to administer prepaid capitated care.County LiabilitiesFollowing the creation of AHCCCS, counties were required to contribute to the funding of theprogram; provide and allocate costs for eligibility workers to ensure the patient qualified for theAHCCCS program; and be financially liable for the first 48 hours of treatment (48 hour retro) foran AHCCCS-eligible patient.Until 2001, determining whether an uninsured patient was eligible for AHCCCS was considereda county responsibility. Eligibility workers were county employees, paid for by the counties,tasked with the enrollment and application process of the indigent. Upon determination by the11Cochise County v. Dandoy, Op: Justice HaysKunasek, Carl, Former Senator, Arizona State Senate. Interview January 17, 200813County Supervisors Association: AHCCCS Overview (2004)123

county that the applicant was eligible for AHCCCS, the county would issue a certification andprovide the application to the AHCCCS administrator. This function shifted from the counties tothe state with the approval of Proposition 204 in 2000 (Please see Proposition 204 for moreinformation).AHCCCS and MedicaidAHCCCS operates under the 1115 Research and Demonstration waiver granted by HHS givingstates the flexibility to design and improve their own programs.14 With this waiver in place, thestate can operate a statewide, managed care system requiring all patients to enroll in acontracted Health Plan.Since its inception, AHCCCS and a “traditional Medicaid program” have held striking differences.For example, in a “traditional Medicaid program,” a patient chooses a doctor or health careprovider, with the provider receiving fees for the services. With AHCCCS, members are enrolledinto a health care program contracted by the agency, and are then assigned a physician withinthe program who provides the member with general health services. AHCCCS then pays theprovider regardless of whether services were provided, or at what level they were provided.At its core, AHCCCS consists of a network of contracts between healthcare providers. Based ona prepaid capitation mechanism, a contractor receives a pre-determined amount from the statebased on the number of patients enrolled under the provider’s supervision. Ultimately, it is theprovider’s job to manage the member’s care within those financial constraints.A primary care physician acts as the “gatekeeper” physician within each plan. The“gatekeeper’s” primary objective is to assure a high quality of care and contain costs byreducing unnecessary services and encouraging preventive care, which is less expensive overtime.By 1984, AHCCCS was removed from DHS and established as its own independent agency,responsible for ensuring that their programs comply with federal and state law. Additionally,the agency is tasked with awarding contracts, enrolling members and regulating healthcarepolicy within the state.While the legislation establishing AHCCCS proved difficult to craft, experts regarded theprogram as a “model of innovative public policy”. 15 A 1989 report by Stanford ResearchInternational indicated that in the first five years of existence, AHCCCS program costs were 6percent less than traditional Medicaid, while still providing a higher quality of health care forchildren and better access for routine care. 16 Similarly, a study by the Flinn Foundation, section 1115 DemonstrationsHall, J. S., & Hollinshead, M. S. (2000). Connecting public policy and management: The Arizona Health Care Cost Containment Systemexperiment. Albany, NY: Nelson A. Rockefeller Institute of Government.16Evaluation of the Arizona Healthcare Cost Containment System: Final Report. (1989). Washington, DC: Government Printing Office.154

Arizona in 1995 found high-satisfaction rates and an increase in private-sector physician andhospital usage. 17Master Settlement Agreement18In November of 1998, a Master Settlement Agreement (MSA) was reached between cigarettemanufacturers and 46 states, including Arizona, the District of Columbia and six territories torecover the health care costs to treat illnesses resulting from use of tobacco products byresidents. The MSA requires the four largest cigarette manufactures known as OriginalParticipating Manufacturers (OPMs) and Subsequent Participating Manufactures (SPMs)participating in the MSA to make significant payments to states in perpetuity and placesrestrictions on marketing and advertising of cigarettes. Since signing the MSA on November 23,1998, through FY 2015, Arizona has received more than 1.69 billion in settlement payments.Funds received from the MSA are deposited into the Tobacco Litigation Settlement Fund andallocated to a variety of sources based on the current fiscal year’s budget pursuant to ArizonaLaw. 19 The director of AHCCCS is required to use the monies to fund expanded eligibility andprograms established by Prop. 204 (please see Proposition 204 section for more information).Any funds remaining may be appropriated by the legislature to programs that benefit thehealth of Arizona residents.The MSA requires states to implement the model statutes provision and requires states toensure Non-participating Manufacturers (NPM) of tobacco make deposits into an escrowaccount based on total cigarettes sold. Laws 2000, Chapter 83 § 1 enacted requirementsoutlined in the model statutes by establishing an NPM escrow account, directing the ArizonaDepartment of Revenue (ADOR) to regulate the enforcement of tobacco excise taxes andcreating penalties for noncompliance with the MSA.To aid in the enforcement of the model statutes, state law was further amended to outlinecertification requirements for NPMs and to direct the state Attorney General (AG) to establishregulations to implement the statute. 20 The AG’s office maintains a directory of all tobaccomanufactures that are certified and in compliance with statute. The AG’s office also establishedthe Tobacco Enforcement Unit created to ensure the state receives the annual payments. Fundallocation has varied based on the litigation requirements associated with the MSA.ADOR receives funds to enforce luxury tax and audits for the state to comply with the modelstatutes provision within the MSA requiring states to ensure NPMs make deposits. Withoutproper enforcement, states can have a portion of their MSA payment reduced based on the loss17Henry J. Kaiser Family Foundation and the Flinn Foundation of Arizona: Intergovernmental Health Policy Project: Applying the Lessons ofArizona’s Medicaid Managed Care Program, AHCCCS (1995)18State of Arizona, Joint Legislative Budget Committee. (2015). Master Settlement Agreement - JLBC Staff Program Summary. Phoenix, AZ: JointLegislative Budget Committee.19A.R.S. § 36-2901.02: /ars/36/02901-02.htm&Title 36&DocType ARS20A.R.S. § 44-7111: /ars/44/07111.htm&Title 44&DocType ARS5

of market share by the OPMs and SPMs for the previous year’s sales. In April 2006, the statewas entitled to a 97 million payment, but only received 86.3 million due to the market sharelost in 2003. Arizona, along with other states, sued arguing the model statutes were enforced.A settlement was reached for the withheld NPM payments made from 2003-2014. Settlingstates split the monies withheld for NPM adjustments, and Arizona received a onetimesettlement of 48 million in FY 2013.Arizona took a lead role in the MSA negotiations and was awarded additional payment ascompensation. The Strategic Contribution Payments began in FY 2008 and will continuethrough FY 2017. The Strategic Contribution Payments have helped maintain the total annualpayments; however, overall MSA payments have been gradually declining (Figure 2). This couldplace an additional burden on the state and counties to make up for the decline in paymentsonce the Strategic Contribution Payments end.Tobacco Payments Received 21Fiscal YearFY 1999 - FY 2001FY 2002FY 2003FY 2004FY 2005FY 2006FY 2007FY 2008FY 2009FY 2010FY 2011FY 2012FY 2013*FY 2014FY 2015TotalMSA Payment 207,966,000 111,955,069 106,926,757 92,648,165 93,933,400 86,301,152 92,004,100 91,342,555 100,728,675 83,826,497 79,474,407 78,489,981 122,925,501 79,872,741 79,293,353 1,507,688,353*FY 2013 MSA payment includes a one-time payment of 48,090,600Strategic ContributionPayment 24,244,269 24,842,186 21,567,586 19,655,567 22,577,432 26,199,893 20,598,428 20,681,785 180,367,146Total PaymentsReceived 207,966,000 111,955,069 106,926,757 92,648,165 93,933,400 86,301,152 92,004,100 115,586,824 125,570,861 105,394,083 99,129,974 101,067,413 149,125,394 100,471,169 99,975,138 1,688,055,499Figure 221State of Arizona, Joint Legislative Budget Committee. (2015). Master Settlement Agreement - JLBC Staff Program Summary. Phoenix, AZ:Joint Legislative Budget Committee6

Proposition 204Voters approved an expansion of AHCCCS eligibility for childless adults with incomes up to 100percent of the Federal Poverty Level (FPL) in 1996 through Proposition 203 with 72 percent ofthe vote but a funding source was not identified and it was never fully implemented. 22In the general election of 2000, Proposition 204 (Prop. 204) passed with 63 percent of the vote,expanding the definition of an eligible person for AHCCCS to include individuals with incomelevels of up to 100 percent of the FPL guidelines. 23 Prior to implementation of Prop. 204,childless adults were covered by AHCCCS with incomes up to 33 percent FPL.23Prop. 204 allocated monies received from the MSA to fund the expansion. By 2025, the state isexpected to have received 3.2 billion in total tobacco settlement revenues. In short, Prop. 204controls the future uses of tobacco settlement monies the state receives. The StateConstitution restricts the legislature's ability to enact laws that use tobacco settlement moniesfor purposes other than those designated in Prop. 204.24After the implementation of Prop. 204, two new county payments were created: the BudgetNeutrality Compliance Fund (BNCF) and the Disproportionate Uncompensated Care (DUC) Pool.The BNCF helps compensate the state for the taking over all the administrative functions forAHCCCS. After Prop. 204, the counties were no longer responsible for the first 48 hours of careor determining the eligibility of program participants. The DUC pool was set up as a means tocompensate private hospitals based on uncompensated hospital emergency room care;however, the DUC pool was never implemented and the county contributions have been usedto off set the state general fund share. In return, for the removal of administrative functions,counties relinquished any and all claims to the tobacco settlement monies.In 2005, S.B. 1515 contained provisions that eliminated Maricopa County’s DUC and BNCFpayments, decreasing their Acute Care payments in exchange for the county taking over AdultProbation operations, as part of budget agreements (please see County Payments for moreinformation).22Arizona Chamber Foundation, Frequently Asked Questions Understanding AHCCCS and Proposition 204, www.azchamberfoundation.orgA.R.S. § 36 2901.01 (as amended by Prop. 204)24Ariz. Const. art. IV, pt. 1, §1( 6), (14) (amendments from Proposition 105, approved by voters in 1998)237

Expansion of Medicaid & AHCCCS EligibilityResponding to budget shortfalls due to the economic recession, Arizona lawmakers frozeenrollment of childless adults into the Prop. 204 program, effective July 1, 2011. This resultedin an enrollment drop of 141,000 people in 18 months.After the passage of the federal Affordable Care Act (ACA), Governor Jan Brewer pushed toexpand eligibility for AHCCCS through the FY 2014 Health and Welfare Budget Reconciliation Bill(Laws 2013, 1st Special Session, Chapter 10) to take advantage of the enhanced federalmatching funds for expanded populations.Child ExpansionPrior to the FY 2014 expansion, Arizona provided coverage for children up to 200 percent of theFPL through “KidsCare,” the state’s Children’s Health Insurance Program (CHIP). With theimplementation of the FY 2014 expansion, children between the ages of 1 and 18 are coveredup to 133 percent of the FPL through the traditional Medicaid program, while infants arecovered up to 140 percent of the FPL.Childless Adult RestorationThe expansion restored coverage for the childless adult population which had been frozen inJuly 2011 as a response to the budget crisis. Childless adults with incomes up to 100 percent ofthe FPL were eligible to re-enroll staring in January 2014, restoring Prop. 204 Medicaideligibility. The program has grown to 280,700 as of April 1, 2015 with a current match rate of89.05 percent in FY 2016. The match rate is expected to reach 90 percent in 2020.Adult ExpansionThe expansion increased Medicaid eligibility for all adults between 100 and 133 percent of theFPL effective January 1, 2014. Currently the federal government match is 100 percent, but willdecline to 90 percent by 2020. The Hospital Assessment Fund, created by the expansion,established an assessment on hospital revenue, discharges or bed days to fund the stateportion of the program covering the adult Medicaid and Prop. 204 populations after January 1,2014. There are some circuit breakers in place for this population, including eliminatingcoverage if the federal match rate falls below 80 percent, the hospital assessment is unable topay for newly eligible populations, or the ACA is repealed.8

Currently Eligible But Not EnrolledACA required all individuals to purchase health care or pay a fine after January 1, 2014 withsome exceptions. Individuals with incomes up to 400 percent of the FPL are eligible fordiscounts and subsidies available within the health insurance exchanges.AHCCCS enrollment by county is listed in (Figure 6) 25 and as of November 2015, 1,833,907individuals are enrolled, roughly 27 percent of the population. The total AHCCCS populationhas seen about a 28.23 percent growth rate since September 2013, rising from 1,316,206members to 1,833,907 as of November 2015.25Population Statistics, Arizona Department of Administration, July 1, 2014, AHCCCS Population by County, 2015 Population estimate: ArizonaDepartment of Administration, Office of Employment & Population Statistics 12/7/20129

Long-term CareHistory of Arizona Long-term CareThe exclusion of Long-term Care (LTC) from the original AHCCCS program provided furtherfinancial trouble for the counties. As counties continued to cover 100 percent of the costburden, LTC costs grew from 35 million in 1980 to 59 million in 1985, a 69 percent increase infive years.26 In 1987, the County Supervisors Association (CSA) supported LTC reform, and inturn, Governor Evan Mecham signed S.B. 1418, establishing the Arizona Long-term Care System(ALTCS), allowing the state to draw down federal Medicaid funds and to participate in thefederal LTC program.ALTCS ProgramToday, the ALTCS program is funded through a combination of five funding sources: FederalMedicaid, State General Funds, County Funds, Nursing Facility Assessment, Federal PrescriptionDrug Rebate (PDRF), and State PDRF.ALTCS provides LTC for individuals who are financially needy and at risk of institutionalization.AHCCCS administers ALTCS to the elderly and physically disabled (EDP) and the ArizonaDepartment of Economic Security administers ALTCS for the Developmentally Disabledpopulation.27Individuals may receive nursing home and community-based care by meeting certain income,savings and medical criteria. To qualify for the program, the individual must earn no more than300 percent of the Federal Benefit Rate (FBR) equating to an individual monthly income of lessthan 2,199 with no more than 2,000 in assets.28 AHCCCS looks at any assets sold over a fiveyear period to ensure assets are not sold to family or friends below fair market value. If thefindings show that assets were sold below fair market value, it will cause a delay in eligibility.29In addition, the person must be evaluated by a nurse and be determined an immediate risk ofinstitutionalization in a nursing facility. This medical evaluation is conducted using a preadmission screening tool developed by the state. 29 The purpose of the evaluation is to examineeach applicant’s ability to independently carry out activities of daily living.ALTCS is the largest financial contribution made by counties of all AHCCCS programs increasingan average of 3.3 percent annually. However, because the 2.9 percent average annual26County Supervisors Association of Arizona: ALTCS and Mandated County Contributions (2005)JLBC Staff Program Summary: Arizona Long Term Care System (July 16, 2015)28AHCCCS Eligibility Requirements, Revised Eff. February 1, resources/EligibilityRequirements.pdf29The William E. Morris Institute for Justice: Health Mental Care(pg.12)2710

enrollment growth in ALTCS is a slower growth rate than other AHCCCS populations, the shareof AHCCCS funding spent on ALTCS has declined from 26 percent in FY 2000 to 16 percent inFY 2016. 30Financial LiabilitiesIn 1990, Attorney General Robert Corbin opined that ALTCS expenditures are not excludablefrom county expenditure limits and that the monies collected were satisfying county liabilitiesto the state under the ALTCS program. 31 These payments were therefore local revenues notqualified for exemption under Article IX, Section 20, of the Arizona Constitution. In response,Maricopa County filed for an injunction in Arizona Supreme Court, which ultimately rejectedjurisdiction.In response, the Arizona State Legislature moved quickly and passed S.B. 1311 in 1991, whichamended A.R.S. § 36-2913. 32 The bill adjusted the original 1979-80 base calculation for ALTCSpayments. This adjustment was made permanent in 1993.County ContributionsFrom 1989 through 1997, counties paid the entire non-federal share of the ALTCS program,creating a significant burden on county finances. 33 ALTCS contributions steadily grew to 134 million by 1997 (Figure 3). Each county’s share of the total non-federal portion of theprogram was based off percentages from the Auditor General’s certified audit of FY 1987-1988.Counties were responsible for these payments regardless as to whether or not utilization hadincreased or decreased. Later changes reallocated payments based on utilization rates.County Contributions to ALTCS FY 1990-1997 160,000,000 140,000,000 120,000,000 100,000,000 80,000,000 60,000,000 40,000,000 20,000,00019971996199519941993199219911990 0Figure 330JLBC Staff Program Summary: Arizona Long Term Care System (July 16, 2015)AZ. Atty Gen. Op. 90-057 (June 26,1990)32A.R.S. § 36-291333County Supervisors Association: ALTCS Overview (1997)3111

Through CSA advocacy efforts H.B. 2006 has introduced and ultimately passed in the 43rdLegislature’s 2nd special session in 1997. H.B. 2006 split the future growth of the ALTCSprogram equally (50/50) between the state and counties and added in three circuit breakers forcounty contributions:Property Tax Rates:If a county’s contribution, when expressed as an imputed property tax rate per onehundred dollars of Net Assessed Value (NAV), exceeds ninety cents, the county’scontribution is reduced down to the ninety cent level, with the difference being paid bythe state.An example of this new ALTCS Contribution: NAV 1,000,000,000Pre-Circuit Breaker ALTCS Contribution 9,500,000NAVImputed Property Tax Rate ALTCS Contribution 100o The Imputed Property Tax Rate for County A is 0.95 9,500,000 1,000,000,000100 0.95NAVALTCS Contribution 0.9 100 o The new ALTCS Contribution for County A is 9,000,000 1,000,000,0000.9 100Native American Population: 9,000,000Counties with a Native American population representing at least 20 percent of the county’stotal population receive a reduction in their contribution by an amount equal to one-half thedifference between the prior year’s payment and the current year’s calculated payment. Forexample, if County A’s prior year contribution was 1,000,000, and their current yearcontribution was originally calculated to be 1,500,000, then County A’s contribution with thecircuit breaker is 1,250,000.Formula ChangeAfter the reductions generated by the above circuit breakers are taken, any county that wouldotherwise be contributing more than if their contributions were based on the Auditor General'scertified audit of FY 1987-1988, will receive a contribution reduction equal to the prior fiscalyear’s contribution plus 50 percent of the difference between the county's prior year and thecurrent year contribution based on the FY 1987-1988 audit.12

Additional Circuit BreakerIn 2005, CSA advocated for and the legislature adopted S.B. 1299, creating a fourth circuitbreaker:Per CapitaThe “per capita” circuit breaker ensures that no county is required to pay costs above thestatewide per capita contribution for the ALTCS program. If after applying the previous threecircuit breakers, a county’s per capita ALTCS contribution is above the statewide average, thenthe county will receive an additional reduction. For example, if after applying circuit breakers1-3, County A’s contributions come to 50/person and the average contribution across thestate is 40/person. County A would receive additional relief equal to the difference - ( 50 – 40

Established in 1982, the Arizona Health Care Cost Containment System (AHCCCS) serves as Arizona’s Medicaid program. As of July 1, 2015, AHCCCS provided healthcare coverage for 1,746,175 members, al