016.06.11 Ark. Code R. 027
Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.
Program Services | Benefit Coverage and Restrictions | Prior Authorization/ PCP Referral* | Co-payment/ Coinsurance/ Cost Sharing Requirement** |
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 - PA for inter-periodic screens | $10 per visit |
Durable Medical Equipment | Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance/cost-share. Covered items are listed in Section 262.120 | PCP Referral and Prescription | 20% of Medicaid allowed amount per DME item cost-share |
Emergency Dept. Services | |||
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 | PCPor Administered by ADH | None |
Laboratory & X-Ray | Medical Necessity | PCP Referral | $10 per visit |
Medical Supplies | Medical Necessity Benefit of $125/mo. Covered supplies listed in Section 262.110 | PCP Prescriptions PA required on supply amounts exceeding $125/mo | 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 | Up to $5 per prescription (Must use generic and rebate manufacturer, if available)*** |
Preventive Health | All per protocol | PCP Administration | None |
Screenings | or PCP Referral | ||
Rural Health Clinic | Medical Necessity | PCP Referral | $10 per visit |
Speech Therapy | Medical Necessity | PCP Referral | $10 per visit |
4 evaluation units (1 unit =30 min) per state fiscal year | Authorization required on extended benefit of | ||
4 therapy units (1 unit=15 min) daily | services | ||
Substance Abuse Treatment Services (SATS) | Medical Necessity i | Psychiatrist or Physician Prescription (See Section 221.000 of SATS manual) Prior Authorization required for all substance abuse treatment services, except codes H0001 &T1007 when billed with no modifier. Codes H0001 & T1007 require prior authorization when billed with a modifier (See Section 231.100 of SATS manual). Prior Authorization required on | $10 per visit |
i | extended benefit of services (See Section 230.000 of SATS manual) | ||
Vision Care | |||
Eye Exam | One (1) routine eye exam (refraction) every 12 months | None | $10 per visit |
Eyeglasses | One (1) pair every 12 | None | None |
"Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.
"ARKids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.
***ARKids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription.
Substance Abuse Treatment Services procedure codes may be billed by Medicaid enrolled Substance Abuse Treatment Services providers for ARKids First-B beneficiaries. Refer to Section II of the Substance Abuse Treatment Services provider manual for service definitions, information regarding reimbursement, prior authorization and extension of benefits and other information.
Title XXI Allotment Neutrality Budget Template for Section 1115 DemonstrationsATTACHMENT B
Note: A Federal Fiscal Year (FFY) is October 1 through September 30.
016.06.11 Ark. Code R. 027