016.29.24 Ark. Code R. 004
Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.
Program Services | Benefit Coverage and Restrictions | Prior Authorization/ PCP Referral* | Co-payment/ Coinsurance/ Cost Sharing Requirement** |
Ambulance (Emergency Only) | Medical Necessity | None | $10 per trip |
Ambulatory Surgical Center | Medical Necessity | PCP Referral | $10 per visit |
Audiological Services (only Tympanometry, CPT procedure code****, when the diagnosis is within the ICD range (View ICD codes.)) | Medical Necessity | None | None |
Certified Nurse-Midwife | Medical Necessity | PCP Referral | $10 per visit |
Chiropractor Dental Care | Medical Necessity Routine dental care and orthodontia services | PCP Referral None - PA for inter-periodic screens and orthodontia services | $10 per visit $10 per visit |
Durable Medical Equipment | Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance/cost-share. Covered items are listed in Section 262.120 | PCP Referral and Prescription | 10% of Medicaid allowed amount per DME item cost-share |
Emergency Dept. Services Emergency Non-Emergency Assessment | Medical Necessity Medical Necessity Medical Necessity | None PCP Referral None | $10 per visit $10 per visit $10 per visit |
Family Planning | Medical Necessity | None | None |
Federally Qualified Health Center (FQHC) | Medical Necessity | PCP Referral | $10 per visit |
Home Health | Medical Necessity (10 visits per state fiscal year (July 1 through June 30) | PCP Referral | $10 per visit |
Hospital, Inpatient | Medical Necessity | PA on stays over 4 days if age 1 or over | 10% of first inpatient day |
Hospital, Outpatient | Medical Necessity | PCP referral | $10 per visit |
Inpatient Psychiatric Hospital and Psychiatric Residential Treatment Facility | Medical Necessity | PA & Certification of Need is required prior to admittance | 10% of first inpatient day |
Immunizations | All per protocol | None | None |
Laboratory & X-Ray | Medical Necessity | PCP Referral | $10 per visit |
Medical Supplies | Medical Necessity Benefit of $125/mo. Covered supplies listed in Section 262.110 | PCP Prescriptions PA required on supply amounts exceeding $125/mo PCP Referral PA on treatment services PA Required (See Section 250.000 of the School-Based Mental Health provider manual.) | None |
Mental and Behavioral Health, Outpatient School-Based Mental Health | Medical Necessity Medical Necessity | $10 per visit $10 per visit | |
Nurse Practitioner | Medical Necessity | PCP Referral | $10 per visit |
Physician | Medical Necessity | PCP referral to specialist and inpatient professional services | $10 per visit |
Podiatry | Medical Necessity | PCP Referral | $10 per visit |
Prenatal Care | Medical Necessity | None | None |
Prescription Drugs Diabetic Supplies | Medical Necessity | Prescription | Up to $5 per prescription (Must use generic, if available)*** |
Preventive Health Screenings | All per protocol | PCP Administration or PCP Referral | None |
Rural Health Clinic | Medical Necessity | PCP Referral | $10 per visit |
Speech-Language Therapy | Medical Necessity 4 evaluation units (1 unit =30 min) per state fiscal year 4 therapy units (1 unit=15 min) daily | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Occupational Therapy | Medical Necessity 2 evaluation units per state fiscal year | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Physical Therapy | Medical Necessity 2 evaluation units per state fiscal year | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Vision Care Eye Exam | One (1) routine eye exam (refraction) every 12 months | None | $10 per visit |
Eyeglasses | One (1) pair every 12 months | None | None |
*Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.
**AR Kids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.
***AR Kids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription. For billing information to include Continuous Glucose Monitors (CGM), CGM supplies, patch or tubeless insulin pumps, blood glucose monitors (BGMs), and glucose testing supplies see the DHS contracted Pharmacy Vendor's website.
****View or print the procedure codes for ARKids First-B procedures and services.
The following Health Care Procedural Coding System (HCPCS) codes must be used when billing the Arkansas Medicaid Program for medical supplies. Providers must use the current HCPCS Book for code descriptions.
View or print the procedure codes for Home Health services.
Listed below are medical supplies that require special billing or need prior authorization. These items are listed with the HCPCS codes and require modifiers. The asterisk denotes these items and the required modifiers.
The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. Before supplying the items, the Jobst stocking must be prior authorized by AFMC. View or print form DMS-679A and instructions for completion.Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose with edema, or a venous stasis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stocking and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy.
Code must be manually priced.
Code requires a prior authorization (PA). See Section 221.000.
Code requires prior authorization (PA); see Section 221.000. Code is manually priced and is covered for beneficiaries ages 0-20 years of age.
Food thickeners, including "Thick-it", "Simple Thick", "Thick and Easy" and "Thick and Clear" are not subjected to the medical supply benefit limit.
The modifier NU must be used with the code found in this section and when food thickeners are administered enterally, the modifier "BA" must be used in conjunction with the code.
When food thickeners are billed, total units are to be calculated to the nearest full ounce. Partial units may be rounded up. When a date span is billed, the product cannot be billed until the end date of the span has elapsed.
The maximum number of units allowed for food thickeners is 16 units per date of service.
The following HCPCS codes usage must match the Arkansas Medicaid code description and use of modifier(s).
The following excluded drugs are set forth on the DHS Contracted Pharmacy Vendor website.
A pharmacy often supplies items that are not covered under the Arkansas Medicaid Program to Medicaid eligibles in a long-term care facility. Under the cost-related reimbursement system in which long-term care (LTC) facilities are reimbursed, many of these items are the financial responsibility of the facility; therefore, the patient or the patient's family should not be billed for these items. The facility must furnish the following items to Medicaid beneficiaries:
The pharmacy National Council for Prescription Drug Program (NCPDP) benefit for the Arkansas Medicaid pharmacy program covers continuous glucose monitors (CGMs) and other diabetic supplies. This coverage would include CGMs and supplies, patch type insulin pumps and supplies, and blood glucose monitors (BGMs) and supplies.
Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages. Effective 4/1/2024, patch or tubeless insulin pumps are processed as a pharmacy claim submission by pharmacies or DME providers while traditional insulin pumps requiring tubing and cannula type supplies remain processed as a medical claim. Beneficiaries with Medicare Part B benefits continue to be serviced for all of their needs under the DME program.
Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service.
Insulin is covered through the prescription drug program.
The following criteria will be utilized in evaluating the need for the insulin pump:
Prior authorization requests for traditional insulin pumps and supplies (cannula, tubing) must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to DHS or its designated vendor.
View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.
When submitting prior authorization requests for the patch or tubeless insulin pumps see the DHS Pharmacy Vendor's website for specific information for coverage details.
Beneficiaries with Medicare Part B benefits continue to be serviced under the DME program.
016.29.24 Ark. Code R. 004