016.06.06 Ark. Code R. 029
Program Services | Coverage Limits on Benefit | Prior Authorization/ PCP Referral | Co-payment/ Coinsurance |
Ambulance (Emergency Only) | Medical Necessity | None | $10 per trip |
Ambulatory Surgical Center | Medical Necessity | PCP Referral | $10 per visit |
Certified Nurse-Midwife | Medical Necessity | PCP Referral | $10 per visit |
Chiropractor | Medical Necessity | PCP Referral | $10 per visit |
Dental Care (No Orthodontia) | Routine dental care | None | $10 per visit |
Durable Medical Equipment | Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance | PCP Referral and Prescription | 20% of Medicaid allowed amount per DME item |
Emergency Dept. Ser | vices | ||
Emergency | Medical Necessity | None | $10 per visit |
Non-Emergency | Medical Necessity | PCP Referral | $10 per visit |
Assessment | Medical Necessity | None | $10 per visit |
Family Planning | Medical Necessity | None | None |
Federally Qualified Health Center (FQHC) | Medical Necessity | PCP Referral | $10 per visit |
Home Health | Medical Necessity (10 visits per state fiscal year (July 1 through June 30) | PCP Referral | $10 per visit |
Hospital, Inpatient | Medical Necessity | PA on stays over 4 days if age 1 or over | 20% of first inpatient day |
Hospital, Outpatient | Medical Necessity | PCP referral | $10 per visit |
Immunizations | All per protocol | PCP or Administered by ADH | None |
Laboratory & X-Ray | Medical Necessity | PCP Referral | $10 per visit |
Medical Supplies | Medical Necessity Limited to $125/mo unless benefit extension is approved | PCP Prescriptions | None |
Mental and Behavioral Health, Outpatient | Medical Necessity | PCP Referral PA on treatment services | $10 per visit |
Nurse Practitioner | Medical Necessity | PCP Referral | $10 per visit |
Physician | Medical Necessity | PCP referral to specialist and inpatient professional services | $10 per visit |
Podiatry | Medical Necessity | PCP Referral | $10 per visit |
Prenatal Care | Medical Necessity | None | None |
Prescription Drugs | Medical Necessity | Prescription | $5 per prescription (Must use generic and rebate manufacturer, if available) |
Preventive Health Screenings | All per protocol | PCP Administration or PCP Referral | None |
Rural Health Clinic | Medical Necessity | PCP Referral | $10 per visit |
Speech Therapy | Medical Necessity | PCP Referral | $10 per visit |
Vision Care | |||
Eye Exam | One (1) routine eye exam (refraction) every 12 months | None | $10 per visit |
Eyeglasses | One (1) pair every 12 months | None | None |
Refer to your Arkansas Medicaid provider manual for prior authorization and PCP referral procedures.
ARKids First-B participant cost-sharing is capped at 5% of the family's gross annual income.
Co-payment or coinsurance will apply to all ARKids First-B Waiver services, with the exception of immunizations, preventive health screenings, family planning, prenatal care, eyeglasses and medical supplies. Co-payments orcoinsurancel range from $5.00 per prescription to 20% of the first day's hospital Medicaid per diem.
Effective July 1, 2006, ARKids First-B families will have an annual cumulative cost-sharing maximum of 5% of their gross family income; the annual period is July 1 through June 30 (state fiscal year (SFY). The ARKids First-B participant's annual cumulative cost-sharing maximum will be recalculated and the cumulative cost sharing counter will be reset to zero on July 1 each year.
The cost sharing provision will require providers to check and be alert to certain details about the ARKids First-B participants cost sharing obligation in order for this process to work smoothly. The following is a list of guidelines for providers:
Reimbursement for services provided to ARKids First-B participants is based on the current Medicaid reimbursement methodology of the corresponding Medicaid program or service.
ARKids First-B family's annual 5% cost-sharing maximum
When Providers Are Required To Refund a Co-pay or Coinsurance
Providers will be required to refund to ARKids First-B families the amount that the provider collected from the family for cost-sharing if, at the time the claim is submitted and processed, the system determines that the family's cumulative cost-sharing maximum has been met. This may happen even though the family was required to provide cost-sharing on the date of service, when the provider waits a period of time to submit the claim to Medicaid.
Example: The family has not met its cost-sharing maximum on the date of service so the provider collects the required cost-share amount. The provider submits the claim two months later. In the interim, the family's annual cumulative cost-sharing maximum has been met and the family will not be required to cost-share again until the next SFY. The system cannot track cost-sharing until the claim is processed. In this case, even though the family was required to cost-share on the date of service, that amount is not in the system until the claim is processed. On the date the claim processed, the family had met its obligation for cost-sharing (i.e. other claims were processed), so the provider will need to refund to the family the amount that the family paid. There will be a statement on the remittance advice that states that the cost-sharing maximum has been met and that Medicaid is paying the full Medicaid allowed rate for the service.
016.06.06 Ark. Code R. 029