016.29.22 Ark. Code R. 017

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.29.22-017 - ARHOME, Workers with Disabilities, Transitional Medicaid Cost Sharing

Section I

124.000Beneficiary Aid Categories

A full list of client aid categories is available online. View or print the Client Aid Category list.

124.100Client Aid Categories with Limited Benefits

Most Medicaid categories provide the full range of Medicaid services as specified in the Arkansas Medicaid State Plan. However, certain categories offer a limited benefit package. These categories are discussed below. View or print the Client Aid Category list.

124.200Client Aid Categories with Additional Cost Sharing

Certain programs require additional cost sharing for Medicaid services. View or print the Client Aid Category list.

The forms of cost sharing in the Medicaid Program are co-payment and premiums. These programs are discussed in Sections 124.210 through 124.250.

Copayments may not exceed the amounts listed in the cost sharing schedules, as updated each January 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 5-cent increment.

A family's total annual out-of-pocket cost sharing cannot exceed five percent (5%) of the family's gross income.

124.220TEFRA

Eligibility category 49 covers children under age 19 who are eligible for Medicaid services as authorized by Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and amended by the Omnibus Budget Reduction Act. Children in category 49 receive the full range of Medicaid services. However, there are cost sharing requirements. Families will be charged a sliding scale monthly premium based on the income of the custodial parents. Custodial parents with incomes above 150 percent of the federal poverty level (FPL) and in excess of $25,000 annually will be subject to a sliding scale monthly premium. The monthly premium, described in the following chart, can only be assessed if the family income is in excess of one-hundred and fifty percent (150%) of the federal poverty level.

The premiums listed in the TEFRA Cost Share Schedule below represent family responsibility. They will not increase if a family has more than one TEFRA-eligible child. Co-payments are not charged for services to TEFRA children, and a family's total annual out-of-pocket cost sharing cannot exceed five percent (5%) of the family's gross income.

TEFRA Cost Share Schedule

Effective July 1, 2022

Family Income		Monthly Premiums
From	To	%	From	To
$0	$25,000	0%	$0	$0
$25,001	$50,000	1.00%	$20	$41
$50,001	$75,000	1.25%	$52	$78
$75,001	$100,000	1.50%	$93	$125
$100,001	$125,000	1.75%	$145	$182
$125,001	$150,000	2.00%	$208	$250
$150,001	$175,000	2.25%	$281	$328
$175,001	$200,000	2.50%	$364	$416
$200,001	No limit	2.75%	$458	$458

The maximum premium is $5,500 per year ($458 per month) for income levels of $200,001 and above.

124.230Workers with Disabilities

The Workers with Disabilities (WD) category is an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages sixteen (16) through sixty-four (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.

Co-payments are required for the following services:

Adult Medicaid Cost Share Schedule
Service	Copay
Office Visits and Outpatient Services
Physician visit (including PCP/specialist/audiologist/podiatrist visit, excluding preventive services and X-ray)	$4.70
Preventative Care/Screening/Immunizations/EPSDT	$0.00
Other Practitioner Office Visit (Nurse, Physician Assistant)	$4.70
Federally Qualified Health Center (FQHC)	$4.70
Rural Health Clinic	$4.70
Ambulatory Surgical Center	$4.70
Family planning services and supplies (including contraceptives)	$0.00
Chiropractor	$4.70
Acupuncture	Not covered
Pharmacy
Generics	$4.70
Preferred Brand Drugs	$4.70
Non-Preferred Brand Drugs	$9.40
Specialty Drugs (i.e., High-Cost)	$9.40
Testing and Imaging
X-rays and Diagnostic Imaging	$4.70
Imaging (CT/Pet Scans, MRIs)	$4.70
Laboratory Outpatient and Professional Services	$4.70
Allergy Testing	$4.70
Inpatient Services
All Inpatient Hospital Services (including MH/SUD)	$0.00
Emergency and Urgent Care
Emergency Room Services	$0.00
Non-Emergency Use of the Emergency Department	$9.40
Emergency Transportation/Ambulance	$0.00
Urgent Care Centers or Facilities	$4.70
Durable Medical Equipment
Durable Medical Equipment	$4.70
Prosthetic Devices	$4.70
Orthotic Appliances	$4.70
Mental and Behavioral Health and Substance Abuse
All Inpatient Hospital Services (including MH/SUD)	$0.00
Mental/Behavioral Health and SUD Outpatient Services	$4.70
Rehabilitation and Habilitation
Rehabilitative Occupational Therapy	$4.70
Rehabilitative Speech Therapy	$4.70
Rehabilitative Physical Therapy	$4.70
Outpatient Rehabilitation Services	$4.70
Habilitation Services	$4.70
Surgery
Inpatient Physician and Surgical Services	$0.00
Outpatient Surgery Physician/Surgical Services	$4.70
Treatments and Therapies
Chemotherapy	$4.70
Radiation	$4.70
Infertility Treatment	Not covered
Infusion Therapy	$4.70
Vision
Dental
Accidental Dental	$4.70
Women's Services
Delivery and all Inpatient services for maternity care	$0.00
Prenatal and postnatal care	$0.00
Other
Home health Care Services	$4.70
Hospice Services	$0.00
End Stage Renal Disease Services (Dialysis)	$0.00
Personal Care	Not covered

* 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 clients (Aid Category 10) and Transitional Medicaid clients (Aid Category 25) who temporarily enter a nursing home and continue to meet WD or TM eligibility criteria will be exempt from the co-payments listed above.

124.240Transitional Medicaid Adult

The Transitional Medicaid program extends Medicaid coverage to families up to 185% of FPL that, due to earned income, lost eligibility for the Parents/Caretaker-Relative (PCR) Aid Category. The Transitional Medicaid program provides up to twelve (12) months of extended coverage after losing PCR eligibility.

Pertinent co-payment amounts for clients covered by Adult Transitional Medicaid are the same as those listed in Section 124.230.

124.250Arkansas Health and Opportunity for Me (ARHOME)

The ARHOME program operates as a demonstration waiver under Section 1115 of the Social Security Act. It provides premium assistance to allow clients eligible under Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act to enroll in qualified health plans. The ARHOME aid category covers adults ages 19-64 who earn up to 138% of the federal poverty level and are not eligible for Medicare. Under ARHOME, clients receive services either through a qualified health plan (QHP) or through three other benefit plans delivered through fee for service. Cost sharing applies only to ARHOME clients who are enrolled in a QHP or who are awaiting enrollment in a QHP (IABP benefit plan). ARHOME clients in a benefit plan based on their status as medically frail (FRAIL) or alternative benefit plan (ABP) will not be subject to any cost sharing.

ARHOME QHP Cost Share amounts for clients enrolled in a QHP are as follows:

ARHOME QHP Cost Share Schedule
Service	Copay
Office Visits and Outpatient Services
Physician visit (including PCP/specialist/audiologist/podiatrist visit, excluding preventive services and X-ray)	$4.70
Preventative Care/Screening/Immunizations/EPSDT	$0.00
Other Practitioner Office Visit (Nurse, Physician Assistant)	$4.70
Federally Qualified Health Center (FQHC)	$4.70
Rural Health Clinic	$4.70
Ambulatory Surgical Center	$4.70
Family planning services and supplies (including contraceptives)	$0.00
Chiropractor	$4.70
Acupuncture	Not covered
Nutritional Counseling	$4.70
Pharmacy
Generics	$4.70
Preferred Brand Drugs	$4.70
Non-Preferred Brand Drugs	$9.40
Specialty Drugs (i.e., High-Cost)	$9.40
Testing and Imaging
X-rays and Diagnostic Imaging	$4.70
Imaging (CT/Pet Scans, MRIs)	$4.70
Laboratory Outpatient and Professional Services	$4.70
Allergy Testing	$4.70
Inpatient Services
All Inpatient Hospital Services (including MH/SUD)	$0.00
Emergency and Urgent Care
Emergency Room Services	$0.00
Non-Emergency Use of the Emergency Department	$9.40
Emergency Transportation/Ambulance	$0.00
Urgent Care Centers or Facilities	$4.70
Durable Medical Equipment
Durable Medical Equipment	$4.70
Prosthetic Devices	$4.70
Orthotic Appliances	$4.70
Mental and Behavioral Health and Substance Abuse
All Inpatient Hospital Services (including MH/SUD)	$0.00
Mental/Behavioral Health and SUD Outpatient Services	$4.70
Rehabilitation and Habilitation
Rehabilitative Occupational Therapy	$4.70
Rehabilitative Speech Therapy	$4.70
Rehabilitative Physical Therapy	$4.70
Outpatient Rehabilitation Services	$4.70
Habilitation Services	$4.70
Surgery
Inpatient Physician and Surgical Services	$0.00
Outpatient Surgery Physician/Surgical Services	$4.70
Treatments and Therapies
Chemotherapy	$4.70
Radiation	$4.70
Infertility Treatment	Not covered
Infusion Therapy	$4.70
Vision
Routine Eye Exam	Not covered
Dental
Basic Dental Services	Not covered
Accidental Dental	$4.70
Orthodontia	Not covered
Women's Services
Delivery and all Inpatient services for maternity care	$0.00
Prenatal and postnatal care	$0.00
Other
Eyeglasses for Adults	Not covered
Diabetes Education	$0.00
Home Health Care Services	$4.70
Private-Duty Nursing	Not covered
Hospice Services	$0.00
End Stage Renal Disease Services (Dialysis)	$0.00
Personal Care	Not covered

134.000Exclusions from Cost Sharing Policy

The following populations are excluded from the client cost sharing requirement:

A. Individuals under twenty-one (21) years of age, except:

1. ARKids First-B clients (see the ARKids First-B manual for cost share and more information about this program).

B. Pregnant women.

C. Individuals who are American Indian or Native Alaskan

D. Individuals who are inpatients in a long-term care facility (nursing facility (NF) and intermediate care for individuals with intellectual disabilities (ICF/IID) facility) when, as a condition for receiving the institutional services, the individual is required to spend all but a minimal amount (for personal needs) of his or her income for medical care costs.

The fact that a client is a resident of a nursing facility does not on its own exclude the Medicaid services provided to the client from the cost sharing requirement. Unless a Medicaid client has been found eligible for long term care assistance through the Arkansas Medicaid Program, and Medicaid is making a vendor payment to the nursing facility (NF or ICF/IID) for the client, the client is not exempt from the cost sharing requirement.

E. Individuals who are enrolled in a Provider-led Arkansas Shared Savings Entity (PASSE).

F. Individuals receiving hospice care.

G. Individuals who are at or below 20% of the federal poverty level.

The following services are excluded from the client cost sharing requirement:

A. Emergency services - services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in:

1. Placing the patient's health in serious jeopardy,

2. Serious impairment to bodily functions, or

3. Serious dysfunction of any bodily organ or part.

B. Pregnancy-related services

C. Preventive services

D. Services for provider-preventable conditions

E. Family planning services and supplies.

The provider must maintain sufficient documentation in the client's medical record to substantiate any exemption from the client cost sharing requirement.

135.000Collection of Coinsurance/Co-payment 1-1-23

The method of collecting the coinsurance/co-payment amount from the client is the provider's responsibility. In cases of claim adjustments, the responsibility of refunding or collecting additional cost sharing (coinsurance or co-payment) from the client remains the provider's responsibility.

The provider may not deny services to a Medicaid client because of the individual's inability to pay the coinsurance or co-payment. However, the individual's inability to pay does not eliminate his or her liability for the coinsurance or co-payment charge.

The client's inability to pay the coinsurance or co-payment does not alter the Medicaid reimbursement for the claim. Unless the client or the service is exempt from cost sharing requirements as listed in Section 134.000, Medicaid reimbursement is made in accordance with the current reimbursement methodology and when applicable cost sharing amounts are deducted from the maximum allowable fee before payment.

Hospitals are required to comply with certain federal rules before assessing non-emergency copays. Hospitals are expected to comply with emergency room screening requirements, help locate alternate providers when screening determines the patient's need to be non-emergent, and inform clients of treatment options that have a lesser co-pay before the hospital and the state can charge the non-emergency use of the emergency room co-pay.

Hospitals must develop written policies and tracking mechanisms to identify how they comply with the requirement and produce data on member choice and expenditures. Policies and data must be available upon request of DHS and its designees.

The Medicaid cost-sharing amount for clients who use hospital emergency department services for non-emergency reasons can be found in the ARHOME QHP Cost Share Schedule for clients enrolled in a QHP or the Adult Medicaid Cost Share Schedule. (See Sections 124.230 and 124.250)

This cost-sharing amount will only apply to Medicaid clients who are subject to a copay. There will not be any cost-sharing required from clients who need emergency services or treatment.

The first step in the process will be for hospital emergency departments to conduct an appropriate medical screening to determine whether the client needs emergency services.

If the screening determines that emergency services are needed, hospitals should tell the client what the cost-sharing amount will be for the emergency services provided in the emergency department ($0.00). Hospitals should then provide needed emergency services per their established protocols.

If the screening determines that emergency services are not needed, hospitals may provide non-emergency services in the emergency department. Before providing non-emergency services and imposing client cost sharing for such services, however, the hospital must:

* Tell the client what the cost-sharing amount will be for the non-emergency services provided in the emergency department,

* Give the client the option of paying for and receiving services in the emergency department, or

* Give the client the name and location of an alternate non-emergency services provider that can provide the needed services in a timely manner and at a lower cost than the hospital emergency department, and

* Refer the client to the alternate provider, who will then coordinate scheduling for treatment.

Beneficiary Aid Category List

Some categories provide a full range of benefits while others may offer limited benefits or may require cost sharing by a beneficiary. The following codes describe each level of coverage.

FR	full range
LB	limited benefits
AC	additional cost sharing
MNLB	medically needy limited benefits
QHP/IABP/MF	Qualified Health Plan/awaiting QHP assignment/medically frail

Category	Category Name	Description	Code
01	ARKIDS B	CHIP Separate Child Health Program	LB, AC
06	ARHOME	New Adult Expansion Group	QHP, AC lABP, AC MF, FR
10	WD	Workers with Disabilities	FR, AC
11	Assisted Individual -Aged	Assisted Living Facility- Individual is >= 65 years old	FR
11	ARChoices - Aged	ARChoices waiver -Individual is >= 65 years old	FR
13	SSI Aged Individual	SSI Medicaid	FR
14	SSI Aged Spouse	SSI Medicaid	FR
15	PACE	Program of All-inclusive Care for the Elderly (PACE)	FR
16	AA-EC Aged Individual	Medically Needy, Exceptional Category-Individual is >= 65 years old	MNLB
17	AA-SD - Aged	Medically Needy Spend Down- Individual is >= 65 years old	MNLB
18QMB	AA Aged Individual	Qualified Medicare Beneficiary (QMB)-Individual is >= 65 years old	LB
19	ARSeniors	ARSeniors	FR
20	PCR	Parent Caretaker Relative	FR
25	TM	Transitional Medicaid	FR, AC
26	AFDC Medically Needy-EC	AFDC Medically Needy Exceptional Category	MNLB
27	AFDC Medically Needy-SD	AFDC Medically Needy Spend Down	MNLB
31	Pickle	Disregard COLA Increase	FR
33	SSI Blind Individual	SSI Medicaid	FR
34	SSI Blind Spouse	SSI Medicaid	FR
35	SSI Blind Child	SSI Medicaid	FR
36	Blind Medically Needy-EC**	AABD Medically Needy - Individual is Blind as indicated on the Disability screen	MNLB
37	Blind Medically Needy-SD-	Aid to the Blind-Medically Needy Spend Down-Individual has disability type of blind	MNLB
38	Blind - QMB	Aid to the Blind-Qualified Medicare Beneficiary (QMB) - Individual is Blind as indicated on the Disability screen	LB
40	Nursing Facility - Aged	Nursing Facility - Individual age is >= 65 years old	FR
40	Nursing Facility - Blind	Nursing Facility- Individual is Blind as indicated on the Disability screen	FR
40	Nursing Facility - Disabled	Nursing Facility - Individual has a disability	FR
41	Disabled Widow/er Surviving Divorced Spouse	Widows/Widowers and Surviving Divorced Spouses with a Disability (COBRA 90)	FR
41	Assisted Living	Assisted Living Facility-Individual has a disability of any type	FR
41	ARChoices	ARChoices-Individual has disability type of physical or blind	FR
41	DAC	Disabled Adult Child	FR
41	Autism	Autism Waiver	FR
41	DDS	DDS Waiver	FR
41	Disregard (1984) Widow/Widow/er	Disabled Widower 50-59 (COBRA)	FR
41	Disregard SSA Disabled Widow/er	Disabled Widower 60-65 (OBRA 87)	FR
41	Disregard SSA Disabled Widow/e	OBRA 90	FR
43	SSI Disabled Individual	SSI Medicaid	FR
44	SSI Disabled Spouse	SSI Medicaid	FR
45	SSI Disabled Child	SSI Medicaid	FR
46	Disabled Medically Needy - EC	AABD Medically Needy - Individual has disability of any type other than blind	MNLB
47	Disabled Medically Needy - SD	AABD Medically Needy Spenddown - Individual has any other disability type other than Blind	MNLB
48	Disabled QMB	Qualified Medicare Beneficiary (QMB) -Individual has any other disability type other than Blind	LB
49	TEFRA	TEFRA Waiver for Disabled Child	FR, AC
52		Newborn	FR
56 U-18 EC	Newborn	Under Age 18 Medically Needy Exceptional Category	MNLB
57	U-18 Medically Needy - SD	AFDC U18 Medically Needy Spend Down	MNLB
58	Qualifying Individual (QI-1)	Qualifying Individual-1 (Medicaid pays only the Medicare premium)	LB
61	ARKids A	ARKids A	FR
61	Unborn	Pregnant Women - Unborn Child (No family planning benefits allowed)	LB
65	Pregnant Women - Full	Pregnant Women - Full	FR
66	Pregnant Women Medically Needy - EC	AFDC Pregnant Women Medically Needy	MNLB
67	Pregnant Women Medically Needy - SD	AFDC Pregnant Women Medically Needy Spend Down	MNLB
68	Qualified Disabled and Working individual (QDWI)	Qualified Disabled and Working individual (QDWI) - (Medicaid pays only the Medicare Part A premium)	LB
76	AFDC UP Medically Needy - EC	Unemployed Parent Medically Needy	MNLB
77	AFDC UP Medically Needy Spenddown	Unemployed Parent Medically Needy Spend Down	MNLB
81	RMA	Refugee Resettlement	FR
87	RMA Spenddown	Refugee Resettlement- Medically Needy Spend Down	MNLB
88	SLMB	Specified Low Income Qualified Medicare Beneficiary (SLMB) (Medicaid pays only the Medicare premium)	LB
91	Foster Care Non-IV-E	Non IV-E Foster Care - User selection based on Child in Placement screen	FR
92	Foster Care IV-E	IV-E Foster Care - User selection based on Child in Placement screen	FR
92	Foster Care ICPC IV-E	ICPC IV-E Foster Care - User selection based on Child in Placement screen	FR
93	Former Foster Care	Former Foster Care Up to Age 26	FR
94	Adoption	Non- IV-E- User selection based on Child in Placement screen	FR
94	Adoption	ICAMA Non- IV-E- User selection based on Child in Placement screen	FR
94	Adoption	IV-E- User selection based on Child in Placement screen	FR
94	Adoption	ICAMA IV-E- User selection based on Child in Placement screen	FR
95	Guardianship (GAP)	Guardianship Non-IV-E - User selection based on Child in Placement screen	FR
95	Guardianship (GAP)	Guardianship IV-E- User selection based on Child in Placement screen	FR
96	Foster Care Exceptional Category	Foster Care Medically Needy Exceptional Category - Individual fails Foster Care Non-IVE Income Test and is eligible for FC EC	MNLB
97 FC-SD	Foster Care Spend Down	Foster Care Medically Needy Spend Down-Individual fails FC EC Income Test/or Income Test of any other higher category and has medical bills to be eligible on spenddown	MNLB

Section II

213.200Coverage and Limitations of the Adult Program

A. One visual examination and one pair of glasses are available to eligible Medicaid clients every twelve (12) months.

1. If repairs are needed, the eyeglasses must have been originally purchased through the Arkansas Medicaid Program for repairs to be made.

2. All repairs will be made by the optical laboratory.

B. Lens replacement as medically necessary with prior authorization

C. Lens power for single vision must be a minimum of:

1. +1.00 OR -0.75 sphere

2. -0.75 axis 90 or 0.75 axis 180 cylinder or at any axis

D. Tinted lenses, photogray lenses or sunglasses are limited to post-operative cataract or albino patients

E. Bifocals for presbyopia must have a power of +1.00 and any changes in bifocals must be in increments of at least +0.50

F. Bifocal lenses are limited to:

1. D-28 and

2. Kryptok

G. For clients who are eligible for both Medicare and Medicaid, see Section I for coinsurance and deductible information.

H. Plastic or polycarbonate lenses only are covered under the Arkansas Medicaid Program.

I. Low vision aids are covered on a prior authorization basis.

J. Adult diabetics are eligible (with prior authorization) to receive a second pair of eyeglasses within the twelve (12) month period if their prescription changes more than one diopter.

K. One visual prosthetic device every twenty-four (24) months from the last date of service

L. Eye prosthesis and polishing services are covered with a prior authorization.

M. Trifocals are covered if medically necessary with a prior authorization.

N. Progressive lenses are covered if medically necessary with a prior authorization.

O. Contact lenses are covered if medically necessary with a prior authorization. Please refer to Section 212.000 for contact lens guidelines.

213.300Exclusions in the Adult Program

A. The Medicaid Program will not reimburse for replacement glasses, with the exception of post-cataract patients, which will require prior authorization.

B. Lenses may not be purchased separately from the frames. If the client desires frames other than the frames approved by Medicaid, he or she will be responsible for the lenses also. Medicaid will reimburse the provider for the examination in these situations.

C. Medicaid will not pay the prescription service charges in situations where the patient buys the eyeglasses.

D. Medicaid does not cover charges incurred due to errors made by doctors or optical laboratories.

E. Tinted lenses for cosmetics purposes are not covered.

F. Glass lenses are NOT covered by Medicaid.

214.200Coverage and Limitations of the Under Age 21 Program

A. One examination and one pair of glasses are available to eligible Medicaid beneficiaries every twelve (12) months.

1. If repairs are needed, the eyeglasses must have been originally purchased through the Arkansas Medicaid Program in order for repairs to be made.

2. If the glasses are lost or broken beyond repair within the twelve (12)-month benefit limit period, one additional pair will be available through the optical laboratory. After the first replacement pair, any additional pair will require prior authorization..

3. All replacements will be made by the optical laboratory and the doctor's office may make repairs only when necessary.

4. Only ARKids First-B beneficiaries will be assessed a ten-dollar ($10.00) co-pay. All co-pays will be applied to examination codes rather than to tests or procedures.

B. Prescriptive and acuity minimums must be met before glasses will be furnished. Glasses should be prescribed only if the following conditions apply:

1. The strength of the prescribed lens (for the poorer eye) should be a minimum of -.75D + 1.00D spherical or a minimum of .75 cylindrical or the unaided visual acuity of the poorer eye should be worse than 20/30 at a distance.

2. Reading glasses may be furnished based on the merits of the individual case. The doctor should indicate why such corrections are necessary. All such requests will be reviewed on a prior approval basis.

C. Plastic or polycarbonate lenses only are covered under the Arkansas Medicaid Program.

D. When the prescription has met the prescriptive and acuity minimum qualifications, Medicaid will purchase eyeglasses through a negotiated contract with an optical laboratory.

E. The eyeglasses will be forwarded to the doctor's office where he or she will be required to verify the prescription and fit or adjust them to the patient's needs.

F. Eye prosthesis and polishing services require a prior authorization.

G. Contact lenses are covered if medically necessary with a prior authorization. Please refer to Section 212.000 for contact lens guidelines.

H. Eyeglasses for children diagnosed as having the following diagnoses must have a surgical evaluation in conjunction with supplying eyeglasses.

1. Ptosis (droopy lid)

2. Congenital cataracts

3. Exotropia or vertical tropia

4. Children between the ages of twelve (12) and twenty-one (21) exhibiting exotropia

I. Prior authorized orthoptic and/or pleoptic training may be performed only in the office of a licensed optometrist or ophthalmologist for Medicaid eligible children ages twenty (20) and under and for CHIP eligible children ages eighteen (18) and under.

1. The initial prior authorization request must include objective and subjective measurements and tests used to indicate diagnosis.

2. The initial prior authorization approved for this treatment will consist of sixteen (16) treatments in a twelve (12)-month period with no more than one treatment per seven (7) calendar days.

3. An extension of benefits may be requested for medical necessity.

4. Requests for extension of benefits must include the initial objective and subjective measures with diagnosis along with subjective and objective measures after the initial sixteen (16) treatments are completed to show progress and the need for, or benefit of, further treatment.

5. For a list of diagnoses that are covered for orthoptic and/or pleoptic training (View ICD Codes.).

J. Prior authorized sensorimotor examination may be performed only in the office of a licensed optometrist or ophthalmologist for Medicaid eligible children ages twenty (20) and under and for CHIP eligible children ages eighteen (18) and under who have received a covered diagnosis based on specific observed and documented symptoms.

1. Benefit limit of one (1) sensorimotor examination in a twelve (12) month period.

2. An extension of benefits may be requested for medical necessity.

3. For a list of diagnoses that are covered for sensorimotor examination (View ICD Codes.).

K. Prior authorized developmental testing may be performed only in the office of a licensed optometrist or ophthalmologist for Medicaid eligible children ages twenty (20) and under and for CHIP eligible children ages eighteen (18) and under who have received a covered diagnosis based on specific observed and documented symptoms.

1. Benefit limit of one (1) developmental testing in a twelve (12) month period.

2. An extension of benefits may be requested for medical necessity.

3. For a list of diagnoses that are covered for developmental testing (View ICD Codes). View or print the procedure codes for Vision services.

MEDICAL SERVICES POLICY MANUAL, SECTION A

A-100General Program Information

The Health Care Program (Medicaid) is a Federal-State Program designed to meet the financial expense of medical services for eligible individuals in Arkansas. The Department of Human Services (DHS), Divisions of County Operations (DCO) and Medical Services have the responsibility for administration of the Health Care Program. The purpose of Medical Services is to provide medical assistance to low income individuals and families and to insure proper utilization of such services. DCO will accept all applications, verification documents, and make eligibility determinations.

Benefits for the Arkansas Medicaid and ARKids Programs include:

* Emergency Services;

* Home Health and Hospice;

* Hospitalization;

* Long Term Care;

* Physician Services;

* Prescription Drugs; and

* Transportation-(Refer to Appendix B for a description of Transportation Services).

Generally, there is no limit on benefits to individuals under twenty-one (21) years of age who are enrolled in the Child Health Services Program (EPSDT). There may be benefit limits to individuals over twenty-one (21) years of age.

The Adult Expansion Group coverage for most individuals will be provided through a private insurance plan, this is, a Qualified Health Plan (QHP). QHP coverage will include:

* Outpatient Services;

* Emergency Services;

* Hospitalization;

* Maternity and Newborn Care;

* Mental Health and Substance Abuse;

* Prescription Drugs;

* Rehabilitative and Habilitative Services;

* Laboratory Services;

* Preventive and Wellness Services and Chronic Disease Management; and

* Pediatric Services, including Dental and Vision Care;

Exception: Individuals eligible for the Adult Expansion Group who have health care needs that make coverage through a QHP impractical, or overly complex, or who would undermine continuity or effectiveness of care, will not enroll in a private QHP plan but will remain in Health Care.

A-110Cost Sharing Coinsurance/Copayment

Health Care Programs could include out-of-pocket spending (cost sharing) on covered services that follow 42 CFR § 447.50. Examples of cost sharing can include: coinsurance, co-payments, premiums, and prescription costs.

The coinsurance and copayment policy does not apply to the following recipients and/or services:

1.I ndividuals under twenty-one (21) years of age receiving coverage through ARKids A or Newborn;

2. Pregnant women;

3. Family Planning services and supplies;

4. Individuals receiving Medically Frail or Alternative Benefit Plan (ABP);

5. Emergency services;

6. Services that are considered preventative or provider-preventable diseases;

7. Health Maintenance Organization (HMO) enrollees;

8. Services provided to individuals receiving hospice care;

9. PASSE enrollees;

10. American Indian/ Alaska Natives; and

11. Individuals that are at or below twenty (20) percent of the FPL.

A-115Cost Sharing for Workers with Disabilities

Recipients of Medicaid for Workers with Disabilities (WD) with gross income up to one hundred and fifty percent (150%) of the FPL for their family size will be subject to paying Health Care co-pays. Recipients with income greater than one hundred and fifty percent (150%) of the FPL will be assessed for co-payments up to twenty percent (20%) of Health Care maximum allowable, up to ten dollars ($10) per visit.

NOTE: Transitional Medicaid will follow the same cost share guidelines as Workers with Disabilities.

A-163Child Health Services Program (EPSDT)

The Child Health Services Program (EPSDT) is a program designed to provide early and periodic screening, diagnosis, and treatment services.

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016.29.22 Ark. Code R. 017

Adopted by Arkansas Register Volume 48, Number 08, Effective 8/10/2023