ATTACHMENT 3.1-APage 1d
AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED
Revised: October 1, 2023
CATEGORICALLY NEEDY
2a. Outpatient Hospital Services (Continued) Non-Emergency Services
Outpatient hospital services other than those which qualify as emergency, outpatient surgical procedures and treatment, and therapy services are covered as non-emergency services.
Benefit Limit
Outpatient hospital services are limited to a total of twelve (12) visits a year. This yearly limit is based on the State Fiscal Year - July 1 through June 30. Outpatient hospital services include the following:
* non-emergency outpatient hospital and related physician and nurse practitioner services; and
* outpatient hospital therapy and treatment services and related physician and nurse practitioner services.
For services beyond the 12-visit limit, an extension of benefits will be provided if medically necessary. The following diagnoses are considered categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection; renal failure; opioid use disorder when the visit is part of a Medication Assisted Treatment Plan; and pregnancy. All other diagnoses are subject to prior authorization before benefits can be extended.
Outpatient hospital services are not benefit limited for recipients in the Child Health Services (EPSDT) Program.
2b. Rural Health Clinic Services5. Services of nurse midwives6. Visiting nurse services on a part-time or intermittent basis to home-bound patients (limited to areas in which there is a shortage of home health agencies). Rural health clinic ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the Rural health clinic offers such a service (e.g. dental, visual, etc.). The "other ambulatory services" that are provided by the Rural health clinic will count against the limit established in the plan for that service.
Medication Assisted Treatment visits do not count against the Rural Health Clinic encounter benefit limit when the visit is part of a Medication Assisted Treatment plan.
2c.Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by a FQHC in accordance with Section 4231 of the State Medicaid Manual (NCFA - Pub. 45-4). Federally qualified health center services are limited to sixteen (16) encounters per client, per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or older. The applicable benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, rural health clinic encounters, and advanced practice registered nurse services, or a combination of the seven. For federally qualified health center core services beyond the benefit limit, extensions will be available if medically necessary. Beneficiaries under age twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit limited.
FQHC hospital visits are limited to one (1) day of care for inpatient hospital covered days regardless of the number of hospital visits rendered. The hospital visits do not count against the FQHC encounter benefit limit.
Medication Assisted Treatment visits do not count against the FQHC encounter benefit limit when the visit is part of a Medication Assisted Treatment plan.
3. Other Laboratory and X-Ray Services Other professional and technical laboratory and radiological services are covered when ordered and provided under the direction of a physician or other licensed practitioner of the healing arts within the scope of his or her practice, as defined under 42 CFR 440.30 in an office or similar facility other than a hospital outpatient department or clinic.
Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY, July 1 - June 30), and radiology/other services benefits are separately limited to five hundred dollars ($500) per SFY. Radiology/other services include, but are not limited to, diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. The five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services benefit limit, do not apply to services provided to recipients under twenty-one (21) years of age enrolled in the Child Health Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program.
(1) The following diagnoses are specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services health benefit limits:(c) renal failure. The cost of related diagnostic laboratory services, and radiology/other services will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limits or the five hundred dollars ($500) per SFY radiology/other services health benefit limits.(2) Drug screening will be specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services health benefit limit when the diagnosis is for Opioid Use Disorder (OUD), and the screening is part of a Medication Assisted Treatment (MAT) plan. The cost of these screenings will not be included in the calculation of the recipient's five hundred dollars ($500) diagnostic laboratory services health benefit limit.(3) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory services benefit limit or the five hundred dollars ($500) per SFY radiology/other services health benefit limits. The cost of these procedures will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, or the recipient's five hundred dollars ($500) per SFY radiology/other services health benefit limits.(4) Portable X-Ray Services are subject to the five hundred dollars ($500) per SFY radiology/other services benefit limit. Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. Services may be provided to an eligible recipient in their place of residence upon the written order of the recipient's physician. Portable X-ray services are limited to the following: a. Skeletal films that involve arms and legs, pelvis, vertebral column, and skull;b. Chest films that do not involve the use of contrast media; andc. Abdominal films that do not involve the use of contrast media.(5) Two (2) chiropractic X-rays are covered per SFY. Chiropractic X-Ray Services are subject to the five hundred dollars ($500) benefit limit per SFY for radiology/other services. Extensions of the radiology/other services benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary.12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist a. Prescribed Drugs (1) Each recipient age twenty-one (21) or older may have up to six (6) prescriptions each month under the program. Family Planning, tobacco cessation, prescription drugs for opioid or alcohol use disorder as part of a Medication Assisted Treatment plan, EPSDT, high blood pressure, hypercholesterolemia blood modifiers, diabetes and respiratory illness inhaler prescriptions do not count against the prescription limit.(2) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.(3) The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid recipients, for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses - with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 C.F.R. § 423.104 (f)(1)(ii)(A) - to full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit - Part D. The following excluded drugs, set forth on the Arkansas Medicaid Pharmacy Vendor's Website, are covered:
a. select agents when used for weight gainb. select agents when used for the symptomatic relief of cough and coldsc. select prescription vitamins and mineral products, except prenatal vitamins and fluorided. select nonprescription drugs(4) The State will reimburse only for the drugs of pharmaceutical manufacturers who have entered into and have in effect a rebate agreement in compliance with Section 1927 of the Social Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3), or 1927(d) apply. The State permits coverage of participating manufacturers' drugs, even though it may be using a formulary or other restrictions. Utilization controls will include prior authorization and may include drug utilization reviews. Any prior authorization program instituted after July 1, 1991 will provide for a 24-hour turnaround from receipt of the request for prior authorization. The prior authorization program also provides for at least a seventy-two (72) hour supply of drugs in emergency situations.ATTACHMENT 3.1-BState/Territory: ARKANSAS
AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S):
4d. Tobacco cessation counseling services for pregnant women [X] Provided [] No limitations [] With limitations*
e. Medication-Assisted Treatment for opioid use disorders when provided as part of a Medication Assisted Treatment plan [X] Provided [] No limitations [] With limitations*
5a. Physicians' services, whether furnished in the office, the patient's home, a hospital, a nursing facility, or elsewhere. [X] Provided [] No limitations [] With limitations*
b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). [X] Provided [] No limitations [] With limitations*
*Description provided on attachment.
2a. Outpatient Hospital Services (Continued) Non-Emergency Services
Outpatient hospital services other than those which qualify as emergency, outpatient surgical procedures and treatment, and therapy services are covered as non-emergency services.
Benefit Limit
Outpatient hospital services are limited to a total of twelve (12) visits a year. This yearly limit is based on the
State Fiscal Year - July 1 through June 30. Outpatient hospital services include the following:
* non-emergency outpatient hospital and related physician and nurse practitioner services; and
* outpatient hospital therapy and treatment services and related physician and nurse practitioner services.
For services beyond the 12-visit limit, an extension of benefits will be provided if medically necessary. The following diagnoses are considered categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection; renal failure; opioid use disorder when the visit is part of a Medication Assisted Treatment plan, and pregnancy. All other diagnoses are subject to prior authorization before benefits can be extended.
Outpatient hospital services are not benefit limited for recipients in the Child Health Services (EPSDT) Program.
2b. Rural Health Clinic Services5. Services of nurse midwives; and6. Visiting nurse services on a part-time or intermittent basis to home-bound patients (limited to areas in which there is a shortage of home health agencies). Rural health clinic ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the rural health clinic offers such a service (e.g. dental, visual, etc.). The "other ambulatory services" that are provided by the rural health clinic will count against the limit established in the plan for that service.
Medication Assisted Treatment visits do not count against the Rural Health Clinic encounter benefit limit when the diagnosis is for opioid use disorder and is part of a Medication Assisted Treatment plan.
2c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by a FQHC in accordance with Section 4231 of the State Medicaid Manual) NCFA - Pub. 45-4). Federally qualified health center services are limited to sixteen (16) encounters per client, per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or older. The applicable benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, rural health clinic encounters, and advanced practice registered nurse services, or a combination of the seven.
Benefit extensions will be available if medically necessary. Clients under age twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit limited.
FQHC hospital visits are limited to one (1) day of care for inpatient hospital covered days regardless of the number of hospital visits rendered. The hospital visits do not count against the FQHC encounter benefit limit.
Medication Assisted Treatment visits do not count against the FQHC encounter benefit limit when the diagnosis is for opioid use disorder and is part of a Medication Assisted Treatment plan.
3. Other Laboratory and X-Ray Services Other professional and technical laboratory and radiological services are covered when ordered and provided under the direction of a physician or other licensed practitioner of the healing arts within the scope of his or her practice, as defined under 42 CFR 440.30 in an office or similar facility other than a hospital outpatient department or clinic.
Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY, July 1-June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY. Radiology/other services include, but are not limited to, diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. The five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services benefit limit, do not apply to services provided to recipients under twenty-one (21) years of age enrolled in the Child Health Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program.
(1) The following diagnoses are specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services health benefit limits: (c) renal failure. The cost of related diagnostic laboratory services and radiology/other services will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit or the five hundred dollars ($500) per SFY radiology/other services health benefit limit.(2) Drug screening will be specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services health benefit limit when the diagnosis is for Opioid Use Disorder (OUD), and the screening is part of a Medication Assisted Treatment (MAT) plan. The cost of these screenings will not be included in the calculation of the recipient's five hundred dollars ($500) diagnostic laboratory or radiology/other services health benefit limits.(3) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory services benefit limit or five hundred dollars ($500) per SFY radiology/other services health benefit limit. The cost of these procedures will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit or the recipient's five hundred dollars ($500) per SFY radiology/other services health benefit limit.(4) Portable X-Ray Services are subject to the five hundred dollars ($500) per SFY X-ray services benefit limit. Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. Services may be provided to an eligible recipient in their residence upon the written order of the recipient's physician. Portable X-ray services are limited to the following: a. Skeletal films that involve arms and legs, pelvis, vertebral column, and skull;b. Chest films that do not involve the use of contrast media; andc. Abdominal films that do not involve the use of contrast media.(5) Two (2) chiropractic X-rays are covered per SFY. Chiropractic X-Ray Services are subject to the five hundred dollars ($500) benefit limit per SFY for radiology/other services. Extensions of the radiology/other services benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary.4a. Nursing Facility Services - Not Provided4c. Family Planning Services (1) Comprehensive family planning services are limited to an original examination and up to three (3) follow-up visits annually. This limit is based on the state fiscal year (July 1 through June 30).4d.(1) Face-to-Face Tobacco Cessation Counseling Services provided (by): (i)[X] By or under supervision of a physician;(ii) [X] By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; * or(iii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time) *Describe if there are any limits on who can provide these counseling services
Arkansas Medicaid does not limit who can provide these counseling services at this time so long as they meet (ii) and (iii).
**Any benefit package that consists of less than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12-month period (eight (8) per year) should be explained below.
(2) Face-to-Face Tobacco Cessation Counseling Services Benefit Package for Pregnant Women Provided: [x] No limitations [] With limitations*
*Any benefit package that consists of less than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12-month period (eight (8) per year) should be explained below.
4e. Prescription drugs for treatment of opioid use disorder a.Preferred prescription drugs (preferred on the PDL) used for treatment of opioid or alcohol use disorder require no prior authorization and do not count against the monthly prescription limits when prescribed as part of a Medication Assisted Treatment plan.12 Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist a. Prescribed Drugs (1) Each recipient age twenty-one (21) or older may have up to six (6) prescriptions each month under the program. Family Planning, tobacco cessation, prescription drugs for opioid or alcohol use disorder when part of a Medication Assisted Treatment plan, EPSDT, high blood pressure, hypercholesterolemia, blood modifiers, diabetes and respiratory illness inhaler prescriptions do not count against the prescription limit.(2) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.(3) The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid recipients, for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses - with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 C.F.R. § 423.104 (f)(1)(ii)(A) - to full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit - Part D. The following excluded drugs, set forth on the Arkansas Medicaid Pharmacy Vendor's Website, are covered:
a. select agents when used for weight gain:b. select agents when used for the symptomatic relief of cough and colds:c. select prescription vitamins and mineral products, except prenatal vitamins and fluoride:d. select nonprescription drugs:(4) The State will reimburse only for the drugs of pharmaceutical manufacturers who have entered into and have in effect a rebate agreement in compliance with Section 1927 of the Social Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3), or 1927(d) apply. The State permits coverage of participating manufacturers' drugs, even though it may be using a formulary or other restrictions. Utilization controls will include prior authorization and may include drug utilization reviews. Any prior authorization program instituted after July 1, 1991, will provide for a 24-hour turnaround from receipt of the request for prior authorization. The prior authorization program also provides for at least a 72-hour supply of drugs in emergency situations.ATTACHMENT 3.1-FPage 29
OMB No.:0938-933
Citation | Condition or Requirement |
| 1. Describe any additional circumstances of "cause" for disenrollment (if any). |
| K. Information requirements for beneficiaries |
| Place a check mark to affirm state compliance. |
1932(a)(5) CFR 438.50 42 CFR 438.10 | X The state assures that its state plan program complies with 42 CFR 42438.10(i) for information requirements specific to MCOs and PCCM programs operated under section 1932(a)(1)(A)(i) state plan amendments. (Place a check mark to affirm state compliance.) |
1932(a)(5)(D) 1905(t) | L. List all services that are excluded for each model (MCO & PCCM) |
| The following PCCM exempt services do not require PCP authorization: |
| Dental Services |
| Emergency hospital care |
| Developmental Disabilities Services Community and Employment |
| Support |
| Family Planning |
| Anesthesia |
| Alternative Waiver Programs |
| Adult Developmental Day Treatment Services 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 |
| Medication-Assisted Treatment Services for opioid use disorder when part of a |
| Medication Assisted Treatment plan |
| Mental health services as follows: |
| a. Psychiatry for services provided by a psychiatrist enrolled in Arkansas Medicaid and practice as an individual practitioner |
| b. Rehabilitative Services for Youth and Children |
| Nurse 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, delivery, and postpartum) services |
| Pharmacy |
| Physician Services for inpatients acute care |
| Transportation |
Supplement 1 to Attachment 3.1-B
Page 1
October 1, 2023
State of Arkansas
1905(a)(29) Medication Assisted Treatment (MAT)
Citation: 3.1(b)(1) Amount, Duration, and Scope of Services: Medically Needy (Continued)
1915(a)(29) __X___MAT as described and limited in Supplement 1 to Attachment 3.1-B.
ATTACHMENT 3.1 -B identifies the medical and remedial services provided to the medically needy.
i. General Assurance MAT is covered under the Medicaid state plan for all Medicaid clients who meet the medical necessity criteria for receipt of the service for the period beginning October 1, 2020, and ending September 30, 2025.
ii. Assurances a. The state assures coverage of Naltrexone, Buprenorphine, and Methadone and all of the forms of these drugs for MAT that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).b. The state assures that Methadone for MAT is provided by Opioid Treatment Programs that meet the requirements in 42 C.F.R. Part 8.c. The state assures coverage for all formulations of MAT drugs and biologicals for opioid use disorder (OUD) that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).iii. Service Package The state covers the following counseling services and behavioral health therapies as part of MAT.
a) Please set forth each service and components of each service (if applicable), along with a description of each service and component service. MAT is covered exclusively under section 1905(a)(29) for the period of 10/01/2020 through 9/30/2025.
Services available:
1. Individual Behavioral Health Counseling2. Group Behavioral Health Counseling3. Marital/Family Behavioral Health Counseling that involves the participation of a non-Medicaid eligible is for the direct benefit of the client. The service must actively involve the client in the sense of being tailored to the client's individual needs. There may be times when, based on clinical judgment, the client is not present during the delivery of the service, but remains the focus of the service.b) Please include each practitioner and provider entity that furnishes each service and component service.1. Physicians, Physician Assistants and Nurse Practitioners may provide counseling and behavioral health therapies.2. Licensed Behavioral Health Practitioners: Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), Licensed Marital and Family Therapists (LMFT). This group's role is to provide the behavioral and substance use disorder counseling required.c) Please include a brief summary of the qualifications for each practitioner or provider entity that the state requires. Include any licensure, certification, registration, education, experience, training and supervisory arrangements that the state requires. Physicians and Nurse Practitioners must be Arkansas Licensed.
Physician Assistants must have a legal agreement to practice under an Arkansas Licensed Physician per Arkansas statute.
Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must possess a current and valid Arkansas license.
iv. Utilization Controls __X___ The state has drug utilization controls in place. (Check each of the following that apply)
_______ Generic first policy
___X__ Preferred drug lists
_______ Clinical criteria
___X__ Quantity limits
_______ The state does not have drug utilization controls in place.
v. Limitations Describe the state's limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT.
MAT drugs and biologicals are limited based on the FDA indication and manufacturers' prescribing guidelines. Some medications are also subject to status on the Preferred Drug List (PDL).
The preferred (PDL) agents for MAT therapy do not require a PA.
The Arkansas Medicaid Pharmacy program removed the prior authorization for preferred Buprenorphine products on 1/1/2020, due to Arkansas State Law from Act 964 which prohibits a prior authorization for Medication Assisted Treatment of Opioid Use Disorder. The removal of prior authorization was for MAT treatment according to SAMHSA guidelines. In addition, on 1/22/2021, per section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), for all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262) to be covered, Arkansas instructed the pharmacy vendor to bypass the non-rebate-participation, repackaged indicator, inner indicator, and prioritize coverage of all the pharmacy MAT products.
PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing section 1006(b) of the SUPPORT for Patients and Communities Act (P.L. 115-271) enacted on October 24, 2018. Section 1006(b) requires state Medicaid plans to provide coverage of Medication-Assisted Treatment (MAT) for all Medicaid enrollees as a mandatory Medicaid state plan benefit for the period beginning October 1, 2020, and ending September 30, 2025. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 # 60). Public burden for all of the collection of information requirements under this control number is estimated to take about 80 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C 4-26-05, Baltimore, Maryland 21244-1850.
Supplement 5 to Attachment 3.1-A
Page 1
October 1, 2023
State of ARKANSAS
1905(a)(29) Medication-Assisted Treatment (MAT)
Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)
1905(a)(29) ___X__MAT as described and limited in Supplement __5__ to Attachment 3.1-A.
ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy.
i. General Assurance MAT is covered under the Medicaid state plan for all Medicaid clients who meet the medical necessity criteria for receipt of the service for the period beginning October 1, 2020 and ending September 30, 2025.
ii. Assurances a. The state assures coverage of Naltrexone, Buprenorphine, and Methadone, all of the forms of these drugs for MAT that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).b. The state assures that Methadone for MAT is provided by Opioid Treatment Programs that meet the requirements in 42 C.F.R. Part 8.c. The state assures coverage for all formulations of MAT drugs and biologicals for opioid use disorder (OUD)that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).iii. Service Package The state covers the following counseling services and behavioral health therapies as part of MAT.
a) Please set forth each service and components of each service (if applicable), along with a description of each service and component service. MAT is covered exclusively under section 1905(a)(29) for the period of 10/01/2020 through 9/30/2025.
Services available:
1. Individual Behavioral Health Counseling2. Group Behavioral Health Counseling3. Marital/Family Behavioral Health Counseling that involves the participation of a non-Medicaid eligible is for the direct benefit of the client. The service must actively involve the client in the sense of being tailored to the client's individual needs. There may be times when, based on clinical judgment, the client is not present during the delivery of the service, but remains the focus of the service.b) Please include each practitioner and provider entity that furnishes each service and component service.1. Physicians, Physician Assistants, and Nurse Practitioners may provide counseling and behavioral health therapies.2. Licensed Behavioral Health Practitioners: Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), Licensed Marital and Family Therapists (LMFT), This group's role is to provide the behavioral and substance use disorder counseling requiredc) Please include a brief summary of the qualifications for each practitioner or provider entity that the state requires. Include any licensure, certification, registration, education, experience, training, and supervisory arrangements that the state requires. Physicians and Nurse Practitioners must be Arkansas Licensed.
Physician Assistants must have a legal agreement to practice under an Arkansas Licensed Physician per Arkansas statute.
Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must possess a current and valid Arkansas license.
iv. Utilization Controls __X___ The state has drug utilization controls in place. (Check each of the following that apply)
_______ Generic first policy
___X__ Preferred drug lists
_______ Clinical criteria
___X__ Quantity limits
_______ The state does not have drug utilization controls in place.
v. Limitations Describe the state's limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT.
MAT drugs and biologicals are limited based on the FDA indication and manufacturers' prescribing guidelines. Some medications are also subject to status on the Preferred Drug List (PDL). The preferred (PDL) agents for MAT therapy do not require a Prior Authorization.
The Arkansas Medicaid Pharmacy program removed the prior authorization for preferred Buprenorphine products on 1/1/2020, due to Arkansas State Law from Act 964 which prohibits a prior authorization for Medication Assisted Treatment of Opioid Use Disorder. The removal of prior authorization was for MAT treatment according to SAMHSA guidelines. In addition, on 1/22/2021, per section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), for all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262) to be covered, Arkansas instructed the pharmacy vendor to bypass the non-rebate-participation, repackaged indicator, inner indicator, and prioritize coverage of all the pharmacy MAT products.
1905(a)(29) Medication-Assisted Treatment (MAT)
Amount, Duration, and Scope of Medical and Remedial Care Services Provided to the Categorically Needy (continued)
PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing section 1006(b) of the SUPPORT for Patients and Communities Act (P.L. 115-271) enacted on October 24, 2018. Section 1006(b) requires state Medicaid plans to provide coverage of Medication-Assisted Treatment (MAT) for all Medicaid enrollees as a mandatory Medicaid state plan benefit for the period beginning October 1, 2020, and ending September 30, 2025. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 # 60). Public burden for all of the collection of information requirements under this control number is estimated to take about 80 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C 4-26-05, Baltimore, Maryland 21244-1850.
Section II214.200Medication Assisted Treatment and Opioid Use Disorder or Alcohol Use Disorder Treatment DrugsMedication Assisted Treatment for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.
212.220Services Furnished in Collaboration with a PhysicianNurse practitioner services are performed in collaboration with a physician or physicians.
A. Collaboration is a process in which a nurse practitioner works with one (1) or more physicians to deliver health care services within the scope of the practitioner's expertise, with medical direction, and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as provided by State law.B. The collaborating physician does not need to be present with the nurse practitioner when the services are furnished or to make an independent evaluation of each patient who is seen by the nurse practitioner.C. Medication Assisted Treatment (MAT) for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.220.000Benefit LimitsA. Arkansas Medicaid clients aged twenty-one (21) and older are limited to sixteen (16) FQHC core service encounters per state fiscal year (SFY, July 1 through June 30). The following services are counted toward the sixteen (16) encounters per SFY benefit limit:
1. Federally Qualified Health Center (FQHC) encounters;2. Physician visits in the office, patient's home, or nursing facility;3. Certified nurse-midwife visits;5. Medical services provided by a dentist;6. Medical services provided by an optometrist; and7. Advanced practice registered nurse services in the office, patient's home, or nursing facility.B. The following services are not counted toward the sixteen (16) encounters per SFY benefit limit: 1. FQHC inpatient hospital visits do not count against the FQHC encounter benefit limit. Medicaid covers only one (1) FQHC inpatient hospital visit per Medicaid-covered inpatient day, for clients of all ages.2. Obstetric and gynecologic procedures reported by CPT surgical procedure code do not count against the FQHC encounter benefit limit.3. Family planning surgeries and encounters do not count against the FQHC encounter benefit limit.4. Medication Assisted Treatment for Opioid Use Disorder does not count against the FQHC encounter limit when it is the primary diagnosis (View ICD OUD Codes).C. Medicaid clients under the age of twenty-one (21) in the Child Health Services (EPSDT) Program are not subject to an FQHC encounter benefit limit.272.501Medication Assisted Treatment and Opioid or Alcohol Use Disorder Treatment DrugsMedication Assisted Treatment for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.
Effective for dates of services on and after October 1, 2023, the following Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes are payable:
View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.
To access prior approval of these HCPCS procedure codes when necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms found at the DHS contracted Pharmacy vendor website.
252.448Medication Assisted Treatment and Opioid or Alcohol Use Disorder Treatment DrugsMedication Assisted Treatment for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.
Effective for dates of services on and after October 1, 2023, the following Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes are payable:
View or print the procedure codes for Nurse Practitioner services.
To access prior approval of these HCPCS procedure codes when necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms found at the DHS contracted Pharmacy vendor website.
211.105Coverage of Medication Assisted Treatment and Opioid Use Disorder or Alcohol Use Disorder Treatment DrugsCoverage of preferred prescription drugs (preferred on the PDL) for opioid or alcohol use disorder are available without prior authorization to eligible Medicaid beneficiaries. Products for other use disorders may still require PA. Additional criteria can be found at the DHS contracted Pharmacy vendor's website.
Coverage and Limitations
A. Reimbursement for preferred drugs is available with a valid prescription when prescribed according to FDA approved label.B. Prescription drugs will not count against the monthly prescription benefit limit and are not subject to co-pay when used for a primary diagnosis of opioid or alcohol use disorder.C. FDA dosing and prescribing limitations apply.212.000ExclusionsA. Products manufactured by non-rebating pharmaceutical companies.B. Effective January 1, 2006, the Medicaid agency will not cover any drug covered by Medicare Part D for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.C. The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid beneficiaries under § 1927 (d) of the Social Security Act, for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses; with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 CFR § 423.104 (f)(1)(ii) (A), to full-benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit - Part D. The following excluded drugs are set forth on the DHS Contracted Pharmacy Vendor website.
1. Select agents when used for weight gain2. Select agents when used for the symptomatic relief of cough and colds3. Select prescription vitamins and mineral products, except prenatal vitamins and fluoride4. Select nonprescription drugsD. Medical accessories are not covered under the Arkansas Medicaid Pharmacy Program. Typical examples of medical accessories are atomizers, nebulizers, hot water bottles, fountain syringes, ice bags and caps, urinals, bedpans, glucose monitoring devices and supplies, cotton, gauze and bandages, wheelchairs, crutches, braces, supports, diapers, and nutritional products.213.100Monthly Prescription LimitsA. Each prescription for all Medicaid-eligible clients may be filled for up to a maximum thirty-one-day supply. Maintenance medications for chronic illnesses must be prescribed and dispensed in quantities sufficient (not to exceed the maximum thirty-one-day supply per prescription) to effect optimum economy in dispensing. For drugs that are specially packaged for therapy exceeding thirty-one (31) days, the days' supply limit (other than thirty-one (31)), as approved by the agency, will be allowed for claims processing. Contact the Pharmacy Help Desk to inquire about specific days' supply limits on specially packaged dosage units. View or print the contact information for the DHS contracted Pharmacy vendor.
B. Each Medicaid-eligible client twenty-one (21) years of age and older is limited to six (6) Medicaid-paid prescriptions per calendar month. Each prescription filled counts toward the monthly prescription limit except for the following:
1. Family planning items. Including without limitation, birth control pills, contraceptive foams, contraceptive sponges, suppositories, jellies, prophylactics, and diaphragms;2. Prescriptions for Medicaid-eligible long-term care facility residents(must be for Medicaid-covered drugs);3. Prescriptions for Medicaid-eligible clients under twenty-one (21) years of age in the Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. (must be for Medicaid-covered drugs);4. Prescriptions for opioid or alcohol use disorder treatment;5. Prescriptions for tobacco cessation products;6. Prescriptions for the treatment of high blood pressure;7. Prescriptions for the treatment of hypercholesterolemia;8. Blood modifier medications;9. Prescriptions for the treatment of diabetes; and10. Inhalers to treat respiratory illness.C. Living Choices Assisted Living Program clients are eligible for up to nine (9) medically necessary prescriptions per month.D. After the client has received the maximum monthly benefit or the maximum monthly extended benefit, they will be responsible for paying for their own medications for the remainder of the month.201.500Providers of Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use DisorderProviders of Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use Disorder must be licensed in Arkansas and be enrolled with Arkansas Medicaid.
201.510 Providers of Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use Disorder in Arkansas and Bordering StatesProviders of MAT in Arkansas and the six (6) bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and Texas) may be included as routine services providers if they meet all participation requirements for enrollment in Arkansas Medicaid and requirements outlined in Section 201.500.
Reimbursement may be available for MAT covered in the Arkansas Medicaid Program when treating Opioid or Alcohol Use Disorders. Claims must be filed according to the specifications in this manual. This includes assignment of ICD and HCPCS codes for all services rendered.
201.520Providers of Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use Disorder in States Not Bordering ArkansasA. Providers in states not bordering Arkansas may enroll in the Arkansas Medicaid Program as limited services providers only after they have provided services to an Arkansas Medicaid eligible beneficiary and have a claim or claims to file with Arkansas Medicaid. To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract, and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon approval of the provider application and Medicaid contract. View or print the provider enrollment and contract package (Application Packet). View or print Provider Enrollment Unit contact information.
B. Limited services providers remain enrolled for one (1) year. 1. If a limited services provider provides services to another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one (1) year past the most recent claim's last date of service, if the enrollment file is kept current.2. During the enrollment period, the provider may file any subsequent claims directly to the Medicaid fiscal agent. Limited services providers are strongly encouraged to file subsequent claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.203.271Medication-Assisted Treatment Provider Role for Administering Opioid or Alcohol Use Disorder ServicesSAMHSA defines Medication Assisted Treatment (MAT) as the use of medications in combination with counseling and behavioral therapies for the treatment of substance use disorders. A combination of medication and behavioral therapies is effective in the treatment of substance use disorders and can help some people to sustain recovery. This definition and other MAT guidelines can be found at the SAMHSA website.
Only providers who have met the requirements of Section 201.500 may prescribe medication required for the treatment of Opioid or Alcohol Use Disorder for Arkansas Medicaid beneficiaries in conjunction with coordinating all follow-up and referrals for counseling and other services. This program applies only to prescribers of FDA-approved drugs for treatment of Opioid or Alcohol Use Disorder and will not be reimbursed for the practice of pain management.
263.100 Coverage of Drugs Used for Opioid or Alcohol Use TreatmentCoverage of preferred prescription drugs (preferred on the PDL) for opioid or alcohol use disorder and tobacco cessation are available without prior authorization to eligible Medicaid beneficiaries. Products for other use disorders may still require PA. Additional criteria can be found at the DHS contracted Pharmacy vendor's website.
Coverage and Limitations
A. Reimbursement for preferred drugs is available with a valid prescription when prescribed according to FDA approved label.B. Prescription drugs for treatment of opioid or alcohol use disorder will not count against the monthly prescription benefit limit and are not subject to co-pay.C. FDA dosing and prescribing limitations apply.292.920Medication Assisted Treatment (MAT) for Opioid Use DisorderThere are two (2) methods of billing for MAT.
1. Method 1- Inclusive Rate a. The inclusive method of billing shall be used when all SAMHSA guideline services as set forth at a minimum in Section 230.000 are provided on the same date of service by the same billing group. i. For new patients, the provider group shall use HCPCS code, modifier X2 and list an Opioid Use Disorder ICD-10 code as primary. The performing provider must be enrolled as a MAT provider and the claim will pay a single rate for all services (Office Visit, counseling, case management, medication induction/maintenance, etc). Drug and lab testing/screening will continue to be billed separately, using an X2 modifier with the proper code for the test or screen.ii. For established patients requiring continuing follow-up MAT treatment, the provider group shall use HCPCS code, modifiers U8, X2, and list an Opioid Use Disorder ICD-10 code as primary. The performing provider must be enrolled as a MAT provider and the claim will pay a single rate for all follow-up services as indicated on the treatment plan and set forth at a minimum in Section 230.000 (Office Visit, counseling and medication induction/maintenance, etc). Drug and lab testing/screening will continue to be billed separately, using an X2 modifier with the proper code for the test or screen.iii. For established patients requiring maintenance follow-up MAT treatment, the provider group shall use HCPCS code, modifiers U8, X4, and list an Opioid Use Disorder ICD-10 code as primary. The performing provider must be enrolled as a MAT provider and the claim will pay a single rate for all follow-up services as indicated on the treatment plan and set forth at a minimum in Section 230.000 (Office Visit, counseling and medication induction/maintenance, etc). Drug and lab testing/screening will continue to be billed separately, using an X4 modifier with the proper code for the test or screen.iv. The specific HCPCS code and modifiers found in the following link are required for billing the inclusive rate. View or print the procedure codes and modifiers for MAT services.2. Method 2 - Regular Fee-for-Service Ratesa. The regular Fee-for-Service method of billing shall be used when all SAMHSA guideline services as set forth at a minimum in Section 230.000 cannot be provided on the same date of service, or cannot be provided by the same billing group who has the MAT specialized performing provider; therefore, causing some SAMHSA guideline services to be referred elsewhere. i. For new patients, the MAT provider shall use the appropriate E & M (office visit) code, add modifier X2, and list an Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper Lab and Urine Screening codes plus the additional X2 modifier for the screenings required.ii. For established patients requiring continuing treatment, the MAT provider shall use the appropriate E & M (office visit) code, add modifier X2, and list an Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper Lab and Urine Screening codes plus the additional X2 modifier for the screenings required.iii. For established patients requiring maintenance treatment, the MAT provider shall use the appropriate E & M (office visit) code, add modifier X4, and list an Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper Lab and Urine Screening codes plus the additional X4 modifier for the screenings required. Allowable ICD-10 codes for Opioid Use Disorder may be found here: (View ICD OUD Codes.)
Allowable lab and screening codes may be found here: (View Lab and Screening Codes.)
Providers utilizing telemedicine, regardless of Method, shall adhere to telemedicine rules listed in Sections 105.190 and 305.000 in addition to those above. The provider at the distance site shall use both the GT modifier and the X2 or X4 modifier on the service claim.
211.100Rural Health Clinic Core ServicesRural Health Clinic core services are as follows:
A. Professional services that are performed by a physician at the clinic or are performed away from the clinic by a physician whose agreement with the clinic provides that he or she will be paid by the clinic for such services;B. Services and supplies furnished "incident to" a physician's professional services;C. Services provided by non-physician, services of physician assistants, nurse practitioners, nurse midwives, and specialized nurse practitioners when the provider is legally: 1. employed by, or receiving compensation from a rural health clinic;2. under the medical supervision of a physician;3. acting in accordance with any medical orders for the care and treatment of a patient prepared by a physician; and4. acting within their scope of practice by providing services they are legally permitted to perform by the state in which the service is provided if the services would be covered if furnished by a physician;D. Services and supplies that are furnished as an incident to professional services furnished by a nurse practitioner, physician assistant, nurse midwife, or other specialized nurse practitioner;E. Visiting nurse services on a part-time or intermittent basis to home-bound patients in areas in which there is a shortage of home health agencies. Note: For purposes of visiting nurse care, a home-bound patient is one who is permanently or temporarily confined to his or her place of residence because of a medical or health condition. Institutions, such as a hospital or nursing care facility, are not considered a patient's residence.
Note: A patient's place of residence is where he or she lives, unless he or she is in an institution such as a nursing facility, hospital, or intermediate care facility for individuals with intellectual disabilities (ICF/IID); and
F. Medication Assisted Treatment (MAT) for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.218.100RHC Encounter Benefit LimitsA. Medicaid clients under the age of twenty-one (21) in the Child Health Services (EPSDT) Program do not have a rural health clinic RHC encounter benefit limit.B. A benefit limit of sixteen (16) encounters per state fiscal year (SFY), July 1 through June 30, has been established for clients twenty-one (21) years or older. The following services are counted toward the per SFY encounter benefit limit:1. Provider visits in the office, client's home, or nursing facility;2. Certified nurse-midwife visits;4. Medical services provided by a dentist;5. Medical services provided by an optometrist;6. Advanced practice registered nurse (APRN) services in the office, client's home, or nursing facility; and7. Federally qualified health center (FQHC) encounters. Global obstetric fees are not counted against the service encounter limit. Itemized obstetric office visits are not counted in the limit.
The established benefit limit does not apply to individuals receiving Medication Assisted Treatment for Opioid Use Disorder when it is the primary diagnosis (View ICD OUD Codes).
Extensions of the benefit limit will be considered for services beyond the established benefit limit when documentation verifies medical necessity. Refer to Section 218.310 of this manual for procedures for obtaining extension of benefits.
RULES SUBMITTED FOR REPEAL
Rule #1: PUB 85: Differential Response: A Family-Centered Approach to Strengthen and Support Families
Rule #2: PUB 357: Child Maltreatment Investigation Determination Guide