016.06.19 Ark. Code R. 005
Exclusions
Services Not Covered for ARKids First-B Beneficiaries:
Adult Developmental Day Treatment (ADDT)
Audiological Services; EXCEPTION, Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range. (View ICD codes.)
Child Health Services/Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Diapers, Underpads and Incontinence Supplies
Early Intervention Day Treatment (EIDT)
End Stage Renal Disease Services
Hearing Aids
Hospice
Hyperalimentation
Non-Emergency
Transportation
Nursing Facilities
Orthotic Appliances and Prosthetic Devices
Personal Care
Private Duty Nursing Services
Rehabilitation Therapy for Chemical Dependency
Rehabilitative Services for Children
Rehabilitative Services for Persons with Physical Disabilities (RSPD)
Targeted Case Management
Ventilator Services
Program | Coverage |
Adult Behavioral Health Services for Community Independence | 18 or older |
Adult Developmental Day Treatment (ADDT) | Pre-School and Age 18 or Older |
Ambulatory Surgical Center | All Ages |
Audiological | Under Age 21 |
Certified Registered Nurse Anesthetist (CRNA) | All Ages |
Chiropractic Services | All Ages |
Dental Services | Under Age 21 |
Developmental Rehabilitation Services | Under Age 3 |
Durable Medical Equipment | All Ages |
Early Intervention Day Treatment (EIDT) | Under Age 21 |
End-Stage Renal Disease (ESRD) Facility Services | All Ages |
Hearing Aid Services | Under Age 21 |
Hospice | All Ages |
Hyperalimentation | All Ages |
IndependentChoices (Self-Directed Personal Assistance) | Age 18 or Older |
Inpatient Psychiatric Services | Under Age 21 |
Intermediate Care Facility Services for Individuals with Intellectual Disabilities | All Ages |
Medical Supplies | All Ages |
Nursing Facility | Under Age 21 |
Occupational, Physical and Speech-Language Therapy | Under Age 21 |
Orthotic Appliances | All Ages |
Outpatient Behavioral Health Services | All Ages |
PACE (Program of All-Inclusive Care for the Elderly) (*Participants must meet additional medical and non-medical criteria in addition to age eligibility.) | Age 55 or older* |
Personal Care | All Ages |
Podiatrist | All Ages |
Portable X-Ray | All Ages |
Prescription Drugs | All Ages |
Private Duty Nursing Services (High Technology, Non-Ventilator Dependent, EPSDT Program) | Under Age 21 |
Private Duty Nursing Services (Non-Ventilator Dependent Beneficiaries Age 21 or Older) | Age 21 or Older |
Private Duty Nursing Services (Ventilator-Dependent) | All Ages |
Prosthetic Devices | All Ages |
Rehabilitative Hospital and Extended Rehabilitative Hospital Services | All Ages |
Rehabilitative Services for Persons with Physical Disabilities (RSPD) | Under Age 21 |
Rehabilitative Services for Youth and Children | Under Age 21 |
Respiratory Care | Under Age 21 |
School-Based Mental Health Services | Under Age 21 |
Targeted Case Management for Beneficiaries of DDS Children's Services (Title V Agency) | Under Age 21 |
Targeted Case Management for DDS Children's Services (Title V Agency) who are SSI Beneficiaries and TEFRA Waiver Participants | Under Age 16 |
Targeted Case Management for Beneficiaries Age 21 or Under with a Developmental Disability | Age 21 or Under |
Targeted Case Management for Beneficiaries Age 22 or Older with a Developmental Disability | Age 22 or Older |
Targeted Case Management for Beneficiaries in the Child Health Services (EPSDT) Program | Under Age 21 |
Targeted Case Management for Beneficiaries in the Division of Children and Family Services | Under Age 21 |
Targeted Case Management for Beneficiaries in the Division of Youth Services | Under Age 21 |
Targeted Case Management for Beneficiaries Age 60 or Older | Age 60 or Older |
Targeted Case Management for Pregnant Women | Pregnant Women - All Ages |
Ventilator Equipment | All Ages |
Visual Care | All Ages |
The Working Disabled category is an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages 16 through 64, with a disability as defined by Supplemental Security Income (SSI) criteria and who meet the income and resource criteria may be eligible in this category.
There are two levels of cost sharing in this aid category, depending on the individual's income:
Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). They are designated in the system as "WD RegCO."
Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as "WD NewCo".
The cost sharing amounts for the "WD NewCo" eligibles are listed in the chart below:
Program Services | New Co-Payment* |
Adult Developmental Day Treatment Services | $10 per day |
ARChoices Waiver Services | None |
Ambulance | $10 per trip |
Ambulatory Surgical Center | $10 per visit |
Audiological Services | $10 per visit |
Augmentative Communication Devices | 10% of the Medicaid maximum allowable amount |
Chiropractor | $10 per visit |
Dental | $10 per visit (no co-pay on EPSDT dental screens) |
Diapers, Underpads and Incontinence Supplies | None |
Durable Medical Equipment (DME) | 20% of Medicaid maximum allowable amount per DME item |
Early Intervention Day Treatment | $10 per day |
Emergency Department: Emergency Services | $10 per visit |
Emergency Department: Non-emergency Services | $10 per visit |
End Stage Renal Disease Services | None |
Early and Periodic Screening, Diagnosis and Treatment | None |
Eyeglasses | None |
Family Planning Services | None |
Federally Qualified Health Center (FQHC) | $10 per visit |
Hearing Aids (not covered for individuals ages 21 and over) | 10% of Medicaid maximum allowable amount |
Home Health Services | $10 per visit |
Hospice | None |
Hospital: Inpatient | 25% of the hospital's Medicaid per diem for the first Medicaid-covered inpatient day |
Hospital: Outpatient | $10 per visit |
Hyperalimentation | 10% of Medicaid maximum allowable amount |
Immunizations | None |
Laboratory and X-Ray | $10 per encounter, regardless of the number of services per encounter |
Medical Supplies | None |
Inpatient Psychiatric Services for Under Age 21 | 25% of the facility's Medicaid per diem for the first Medicaid-covered day |
Outpatient Behavioral Health | $10 per visit |
Nurse Practitioner | $10 per visit |
Private Duty Nursing | $10 per visit |
Certified Nurse Midwife | $10 per visit |
Orthodontia (not covered for individuals ages 21 and older) | None |
Orthotic Appliances | 10% of Medicaid maximum allowable amount |
Personal Care | None |
Physician | $10 per visit |
Podiatry | $10 per visit |
Prescription Drugs | $10 for generic drugs; $15 for brand name |
Prosthetic Devices | 10% of Medicaid maximum allowable amount |
Rehabilitation Services for Persons with Physical Disabilities (RSPD) | 25% of the first covered day's Medicaid inpatient per diem |
Rural Health Clinic | $10 per core service encounter |
Targeted Case Management | 10% of Medicaid maximum allowable rate per unit |
Occupational Therapy (Age 21 and older have limited coverage**) | $10 per visit |
Physical Therapy (Age 21 and older have limited coverage**) | $10 per visit |
Speech-Language Therapy (Age 21 and older have limited coverage**) | $10 per visit |
Transportation (non-emergency) | None |
Ventilator Services | None |
Visual Care | $10 per visit |
* Exception: Cost sharing for nursing facility services is in the form of "patient liability" which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above.
** Exception: This service is NOT covered for individuals within the Occupational, Physical and Speech-Language Therapy Program for individuals ages 21 and older.
NOTE: Providers must consult the appropriate provider manual to determine coverage and benefits.
The services listed in this section do not require a PCP referral.
The following provider types accept Medicare-Medicaid Crossovers: Ambulatory Surgical Center, Chiropractic, Clinics, Dental, Family Planning, Federally Qualified Health Center, Health Department, Hearing Services, Hemodialysis, Home Health, Hospital, Hyperalimentation, Independent Laboratory, Independent Radiology, Inpatient Psychiatric Services for Under Age 21, Nurse Practitioner, Nursing Home, Occupational, Physical and Speech-Language Therapy Services, Physician, Podiatrist, Prosthetics, Rehabilitation Center, Rural Health Clinic Services, Transportation, Ventilator Equipment and Visual Care.
Claim filing procedures for these provider types are in Sections 332.100 through 332.300.
Attachment 2.6-A
There will be a co-payment for Medicaid-covered services, as listed below, for WD eligibles, whose gross income is equal to greater than 100% of the Federal Poverty Level.
PROGRAM SERVICES | "New" COPAYMENT |
Adult Developmental Day Treatment | $10 per day |
Ambulance | $10 per trip |
Ambulatory Surgical Center | $10 per visit |
Audiology Services | $10 per visit |
Augmentative Communication Devices | 10% of the Medicaid maximum allowable amount |
Chiropractor | $10 per visit |
Dental (very limited benefits for individuals age 21 and over) | $10 per visit (no co-pay on EPSDT dental screens) |
Diapers, Underpads and Incontinence Supplies | None |
Durable Medical Equipment (DME) | 20% of Medicaid maximum allowable amount per DME item |
Early Intervention Day Treatment (not covered for age 21 and over) | $10 per day |
Emergency Department Services: Emergency Services Non-emergency | $10 per visit $10 per visit |
End Stage Renal Disease Services | None |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (not available for individuals over age 21) | None |
Eyeglasses | None |
Family Planning Services | None |
Federally Qualified Health Center (FQHC) | $10 per visit |
Hearing Aids (not covered for individuals age 21 and over) | 10% of Medicaid maximum allowable amount |
Home Health Services | $10 per visit |
Hospice | None |
Hospital: Inpatient Outpatient | 25% of 1st inpatient day (Medicaid per diem) $10 per visit |
Hyperalimentation | 10% of Medicaid maximum allowable amount |
Immunizations | None |
Laboratory and X-Ray | $10 per visit |
Medical Supplies | None |
AMOUNT, DURATION AND SCOPE OFSERVICES PROVIDED
CATEGORICALLY NEEDY
ATTACHMENT 3.1-A
Volunteer carriers are reimbursed for providing transportation to recipients to medical services provided the carriers are registered by the Arkansas Department of Human Services and Medical Services and the medical services are part of the case plan. A General Relief check is issued by local Human Services staff for payment of Medicaid transportation if a licensed carrier is not available. These services may be billed once per day, per recipient for a maximum of 300 miles per day. The benefit limit does not apply to EPSDT recipients.
ATTACHMENT 3.1-B
Volunteer carriers are reimbursed for providing transportation to recipients to medical services provided the carriers are registered by the Arkansas Department of Human Services and Medical Services and the medical services are part of the case plan. A General Relief check is issued by local Human Services staff for payment of Medicaid transportation if a licensed carrier is not available. These services may be billed once per day, per recipient for a maximum of 300 miles per day. The benefit limit does not apply to EPSDT recipients.
Limited to immediate treatment and removal of patient to a qualifying hospital as soon as patient's condition warrants.
ATTACHMENT 3.1-F
Place a check mark to affirm state compliance.
X The state assures that its state plan program is in compliance with 42 CFR 42 438.10(i) for information requirements specific to MCOs and PCCM programs 42 operated under section 1932(a)(1)(A)(i) state plan amendments. (Place a check mark to affirm state compliance.)
The following PCCM exempt services do not require PCP authorization:
Developmental Disabilities Services Community and Employment Support
Family Planning Anesthesia
Alternative Waiver Programs
Adult Developmental Day Treatment Core Services only
Disease Control Services for Communicable Diseases
ARChoices waiver services
Gynecological care
Inpatient Hospital admissions on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment
Mental health services as follows:
Dental Services
Emergency hospital care
Midwife services
ICF/IID Services
Nursing Facility services
Hospital non-emergency or outpatient clinic services on the effective date of PCP
enrollment or on the day after the effective date of PCP enrollment.
Ophthalmology and Optometry services
Obstetric (antepartum, deliver and postpartum) services
Pharmacy
Physician Services for inpatients acute care.
Transportation
ATTACHMENT 4.19-B
Effective for dates of service on or after December 1, 2001, Non-Public Transportation Services reimbursement is based on the lesser charges or the Title XIX maximum allowable. The Title XIX maximum is based on the Internal Revenue Service (IRS) reimbursement for private mileage in a business setting, plus an additional allowance for the cost of the driver. The standard mileage private reimbursement is compliant to the 1997 Standard Federal Tax Report, paragraph #8540.011. The calculation of the additional allowance for the cost of the driver is based on the minimum wage per hour, plus 28% of salaries (minimum wage) for fringe benefits, plus a fixed allowance of $2.11 for the provider's overhead and billings, divided by 30 (average number of miles per trip). The average number of miles was determined by utilizing data from SFY 1996 and dividing the number of miles per trip by the number of trips made.
The State Agency will negotiate with the affected provider group representatives should recipients access become an issue.
The rate of reimbursement equals the amount of travel reimbursement per mile for a state employee. Medicaid reimbursement will not be made for services provided free of charge.
016.06.19 Ark. Code R. 005