016.06.17 Ark. Code R. 027

Current through Register Vol. 49, No. 9, September, 2024

Rule 016.06.17-027 - Emergency: Eligibility

Summary of Changes

The Medicaid State Plan has been revised for determining eligibility for certain existing categories and new group of eligibles using the Medicaid Modified Adjusted Gross Income (MAGI) methodology effective January 1, 2014. Also establishes the new mandatory groups in accordance with Federal law.

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What happens next? We will process your application for Medicaid, ARKids First or the Health Care Independence Program and send you a notice to tell you if your application for coverage has been approved or denied and provide Instructions on the next steps needed to complete your health coverage application. If you are not eligible for any of these programs, we will screen your application for potential eligibility for tax credits to help pay for health insurance premiums and then transfer your information to the Health Insurance Marketplace. We will provide instructions on how to complete the application process on the notice we send to you.

APPENDIX A for DCO-151/152

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APPENDIX B for DCO-151/152

'American Indian or/Alasfca Native family Member, (AI/AN),

Complete this appendix if you or a family member are an American Indian or Alaska Native, Submit this with your Application for Health Coverage.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

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Attachment 2.6-A

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

ELIGIBILITY CONDITIONS AND REQUIREMENTS

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21.RESERVED

22. Respiratory care services (in accordance with Section 1902(e)(9)(A) through (C) of the Act).

Respiratory care for ventilator-dependent individuals means services that are not otherwise available under the State's Medicaid plan, provided on a part-time basis in the recipient's home by a respiratory therapist or other health care professional trained in respiratory therapy to an individual who?

a. Is medically dependent on a ventilator for life support at least 6 hours per day;

b. Has been so dependent for at least a number of consecutive days (number is based on maximum number of days authorized under the State plan, whichever is less) as an inpatient in one or more hospitals, NFs, orlCFs/MR;

c. Except for the availability of respiratory care services, would require respiratory care as an inpatient in a hospital, NF, or ICF/MR and would be eligible to have payment made for inpatient care under the State plan;

d. Has adequate social support services to be cared for at home;

e. Wishes to be cared for at home; and

f. Receives services under the direction of a physician who is familiar with the technical and medical components of home ventilator support, and who has medically determined that in-home care is safe and feasible for the individual.

1. Ventilator Equipment (i.e., ventilator, suction pump, oxygen concentrator, liquid oxygen, liquid oxygen walker and reservoir, ventilator supplies and hospital bed) including 24-hour availability of respiratory therapy and equipment maintenance, with prior authorization.

2.Respiratory therapy/treatment services for ventilator-dependent recipients under age 21, with prior authorization.

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATESOTHER TYPES OF CARE

RESERVED

21. Respiratory care services (in accordance with section 1920(e)(9)(A) through (C) of the Act).

1. See reimbursement methodology for respiratory therapy services for ventilator-dependent recipients under age 21 on Attachment 4.19-B, Page lj.

2. Ventilator equipment - Reimbursement is based on the lower of the amount billed or the Title XIX maximum charge allowed.

The Title XIX maximum is based on the following:

(a) The volume control ventilator and accessories are based on the LP-6 manufacturer's price (Aequitron Medical - October 1,1986) for new equipment and 75% of the LP-6 manufacturer's price (Aequitron Medical - October 1, 1986) for used equipment.

(b) The suction pump is based on Medicare's rate in effect in August 1987 for new equipment. Used equipment is based on 75% of Medicare's rate.

(c) The negative pressure ventilator and accessories are based on the manufacturer's price plus 10% for the maintenance, delivery, set up, emergency call, 24/hr/day, 7 day/week availability.

(d) The oxygen concentrator, liquid oxygen, liquid oxygen walker and reservoir, hospital bed and nebulizer are based on the DME Fiscal Year 1981 Medicare median.

(e) The ventilator supplies are based on the manufacturer's price.

(f) The pressure support ventilator is based on the 2007 Medicare rate.

The reimbursement methodology includes a provision for adjustments based on legislative committee review, as required,

016.06.17 Ark. Code R. 027

4/13/2015