reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: DENTAL SERVICES › Section 16.03.09.803 - DENTAL SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Some covered dental services may be subject to limitations,
					 authorization from the Idaho Smiles contractor or benefit restrictions
					 according to the terms of its contract with the Department, in addition to
					 those specified in these rules. (3-17-22)
01.
Dental Coverage for
				  Children
. Children are covered for dental services that include
				  preventative screenings, problem-focused and comprehensive exams, diagnostic,
				  restorative, endodontic services (including root canals and crowns),
				  periodontics, prosthodontic, orthodontic treatments, dentures, and oral
				  surgery; (3-17-22)
02.
Dental Limitation for Children
. Orthodontics are limited to children who
				  meet Medicaid eligibility requirements and the Idaho Medicaid Handicapping
				  Malocclusion Index as determined by the State's contractor. (3-17-22)
03.
Dental Coverage for Adults
.
				  Adults are covered for dental services that include preventative screenings,
				  problem-focused and comprehensive exams, diagnostic, restorative, periodontics,
				  prosthodontic, dentures, oral surgery, and endodontic services with
				  limitations. (3-17-22)
04.
Dental Limitation for Adults
. Root canals and crowns are not covered.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: DENTAL SERVICES › Section 16.03.09.804 - DENTAL SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
Providers must enroll in the Idaho Smiles network with the
					 dental insurance contractor and meet both credentialing and quality assurance
					 guidelines of the contractor. (3-17-22)
01.
Administer Idaho Smiles
. The
				  contractor is responsible for administering the Idaho Smiles program, including
				  dental claims processing, payments to providers, customer service, eligibility
				  verification, and data reporting. (3-17-22)
02.
Authorization
. The
				  contractor is responsible for authorization of covered dental services that
				  require authorization prior to claim payment. (3-17-22)
03.
Grievances
. The contractor
				  is responsible for tracking and reporting all grievances to the State's
				  contract monitor. (3-17-22)
04.
Appeals
. Appeals are handled by a process between the contractor
				  and the Department as specified in IDAPA 16.05.03, "Contested Case Proceedings
				  and Declaratory Rulings," and in compliance with state and federal
				  requirements. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: DENTAL SERVICES › Section 16.03.09.805 - DENTAL SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Providers are credentialed by the contractor to ensure they
					 meet licensing requirements of the Idaho Board of Dentistry standards or the
					 applicable state in which services are provided. Providers' duties are based on
					 the contract requirements and are monitored and enforced by the contractor.
					 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: DENTAL SERVICES › Section 16.03.09.806 - DENTAL SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
The Idaho Smiles administrator reimburses dental providers
					 on a fee-for-service basis under a Department-approved fee schedule. The State
					 will collaborate with the contractor to establish rates that promote and ensure
					 adequate access to dental services. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: DENTAL SERVICES › Section 16.03.09.807 - DENTAL SERVICES: QUALITY ASSURANCE

Current through August 31, 2023
Providers are subject to the contractor's Quality Assurance
					 guidelines including monitoring for potential fraud, overutilization, or abuse
					 of Medicaid. The contractor is required to share such potential cases with the
					 Medicaid Fraud Unit as discovered. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.820 - RURAL HEALTH CLINIC (RHC) SERVICES

Current through August 31, 2023
A Rural Health Clinic is located in a rural area designated
					 as a physician shortage area, and is neither a rehabilitation agency nor does
					 it primarily provide for the care and treatment of mental diseases.
					 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.823 - RURAL HEALTH CLINIC (RHC) SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
RHC services are defined as follows: (3-17-22)
01.
Physician Services
.
				  Physician services; (3-17-22)
02.
Services and Supplies Incident to a Physician Service
. Services
				  and supplies incident to a physician service, which cannot be self
				  administered; (3-17-22)
03.
Physician Assistant Services
. Physician assistant services;
				  (3-17-22)
04.
Nurse
				  Practitioner or Clinical Nurse Specialist Services
. Nurse practitioner
				  or clinical nurse specialist services; (3-17-22)
05.
Clinical Psychologist
				  Services
. Clinical psychologist services; (3-17-22)
06.
Clinical Social Worker
				  Services
. Clinical social worker services; (3-17-22)
07.
Other Services and Supplies
.
				  Services and supplies incident to a nurse practitioner, physician's assistant,
				  clinical psychologist, or clinical social worker as would otherwise be covered
				  by a physician service; or (3-17-22)
08.
Home Health Agency Shortage Area
				  Services
. Part-time or intermittent nursing care, and related medical
				  services to a home bound individual, when an RHC located in an area with a
				  shortage of home health agencies. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.826 - RURAL HEALTH CLINIC (RHC) SERVICES: REIMBURSEMENT METHODOLOGY

Current through August 31, 2023
01.
Payment
. Payment for
				  Federally Qualified Health Center and Rural Health Clinic services must be made
				  in accordance with Section
				  702 of the Medicare, Medicaid, and
				  SCHIP Benefits Improvement and Protection Act of 2000,
				  P.L.
				  106-554,
				  42USC Section
				  1396a(bb), Subsections (1)
				  through (4). (3-17-22)
02.
RHC Encounter
. An encounter, for RHC payment purposes, is a
				  face-to-face contact for the provision of a medical or mental service between a
				  clinic patient and a provider as specified in 823.01 through 823.06 of these
				  rules. (3-17-22)
a. Each contact with a
				  separate discipline of health professional (medical or mental) on the same day
				  at the same location is considered a separate encounter. (3-17-22)
b. Reimbursement for services is limited to
				  two (2) encounters per participant per day. (3-17-22)
c. As an exception to Subsection
				  826.02.a. of this rule, a
				  second encounter with the same professional on the same day may be reimbursed;
				  or (3-17-22)
d. As an exception to
				  Subsection 826.02.b. of this rule, an
				  additional encounter may be reimbursed, if the encounter is caused by an
				  illness or injury that occurs later in time than the first encounter and
				  requires additional diagnosis or treatment. (3-17-22)
e. A core service ordered by a health
				  professional who did not perform the service but was performed by support staff
				  is considered a single encounter. (3-17-22)
f. Multiple contacts with clinic staff of the
				  same discipline (medical, mental) on the same day related to the same illness
				  or injury are considered a single encounter. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.830 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Change in Intensity of Services of
				  an FQHC
. A change in the intensity of services of an FQHC means a change
				  in the quantity and complexity of services delivered that could change an
				  FQHC's total allowable cost per encounter. This does not include an expansion
				  or remodeling of an existing FQHC. This may include such things as the addition
				  of new services or the deletion of existing services. (3-17-22)
02.
Encounter
. An encounter, for
				  FQHC payment purposes, is a face-to-face contact for the provision of
				  medical/mental or dental services between a FQHC patient and a provider as
				  specified in Subsections
				  832.01 through
				  832.07 of these rules. For the
				  purposes of establishing encounter rates, the term "medical/mental" refers to a
				  single category of service. (3-17-22)
03.
Encounter Rate
. An encounter
				  rate can be of two (2) types, either medical/mental or dental; either of these
				  two (2) types can be either an interim rate or a finalized rate. An encounter
				  rate is the total amount of annual costs for the type of encounter divided by
				  the total number of encounters for that type of encounter for the FQHC's fiscal
				  year. (3-17-22)
a. Interim Encounter Rate. If
				  the FQHC is new and historical cost information is not available, the
				  Department sets the interim encounter rate using budgeted cost and encounter
				  information submitted by the provider. If the FQHC is not able to obtain its
				  financial budget information, the Department sets the interim encounter rate by
				  referring to encounter rates paid to other FQHCs in the same or adjacent
				  regional areas with similar caseloads. (3-17-22)
b. Finalized Encounter Rate. If the FQHC is
				  an existing facility and has at least twenty-four (24) consecutive months of
				  historical cost and encounter information, the Department uses the second full
				  twelve (12) month audited Medicare cost report to calculate a finalized
				  encounter rate. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.832 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
FQHC services are defined as follows: (3-17-22)
01.
Physician Services
.
				  Physician services; or (3-17-22)
02.
Incidental Services and Supplies to
				  Physician Services
. Services and supplies incidental to physician
				  services, including drugs and pharmaceuticals that cannot be self-administered;
				  or (3-17-22)
03.
Physician
				  Assistant Services
. Physician assistant services; or (3-17-22)
04.
Nurse Practitioner or Clinical
				  Nurse Specialist Services
. Nurse practitioner or clinical nurse
				  specialist services; or (3-17-22)
05.
Clinical Psychologist
				  Services
. Clinical psychologist services; or (3-17-22)
06.
Clinical Social Worker
				  Services
. Clinical social worker services; or (3-17-22)
07.
Licensed Dentist and Dental
				  Hygienist Services
. Licensed dentist and dental hygienist services; or
				  (3-17-22)
08.
Incidental
				  Services and Supplies to Non-Physicians
. Services and supplies incident
				  to a nurse practitioner, physician's assistant, clinical psychologist, clinical
				  social worker, or dentist or dental hygienist services that would otherwise be
				  covered if furnished by or incident to physician services; or
				  (3-17-22)
09.
FQHC
				  Services
. In the case of an FQHC that is located in an area that has a
				  shortage of home health agencies, FQHC services are part-time or intermittent
				  nursing care and related medical services to a homebound individual; and
				  (3-17-22)
10.
Other Payable
				  Medical Assistance Ambulatory Services
. Other payable medical assistance
				  ambulatory services offered by the Idaho Medicaid program that the FQHC
				  undertakes to provide, including pneumococcal or immunization vaccine and its
				  administration. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.835 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) SERVICES: REIMBURSEMENT METHODOLOGY

Current through August 31, 2023
01.
Payment
. Payment for Federally Qualified Health Center and Rural Health
				  Clinic services must be made in accordance with Section
				  702 of the Medicare, Medicaid, and
				  SCHIP Benefits Improvement and Protection Act of 2000,
				  P.L.
				  106-554,
				  42 USC Section
				  1396a(bb), Subsections (1)
				  through (4). (3-17-22)
02.
FQHC Encounter Limitations and Exceptions
. FQHC encounters have
				  the following limitations and exceptions to these limitations as described in
				  Subsections 835.02.a. through 835.02.d. of
				  this rule: (3-17-22)
a. Each contact with a
				  separate discipline of health professional (medical/mental or dental), on the
				  same day at the same location, is considered a separate encounter. All contacts
				  with all practitioners within a disciplinary category (medical/mental or
				  dental) on the same day is one (1) encounter. (3-17-22)
b. Reimbursement for services is limited to
				  three (3) encounters per participant per day. (3-17-22)
c. As an exception to Subsection
				  835.02.a. of this rule, a
				  second encounter with the same professional on the same day may be reimbursed;
				  or (3-17-22)
d. As an exception to
				  Subsection 835.02.b. of this rule, an
				  additional encounter may be reimbursed, if the encounter is caused by an
				  illness or injury that occurs later in time than the first encounter and
				  requires additional diagnosis or treatment. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.836 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) SERVICES: RATE SETTING METHODOLOGY

Current through August 31, 2023
01.
Prospective Payment System
. (3-17-22)
a. For rate periods beginning on January 1,
				  2001, the Department will establish separate, finalized rates for
				  medical/mental encounters and for dental encounters. The Department will
				  prospectively set these finalized encounter rates using the FQHC's
				  medical/mental and dental encounter costs. (3-17-22)
b. Beginning in federal fiscal year 2002, and
				  for each federal fiscal year thereafter, the Department will pay each FQHC an
				  encounter rate equal to the amount paid in the previous federal fiscal year.
				  For the period starting with federal fiscal year 2002 and thereafter, the
				  Department will adjust the encounter rate for inflation using the Medicaid
				  Economic Index (MEI), as published by CMS. For both medical/mental encounters
				  and dental encounters, FQHCs are paid on a per encounter basis, with the
				  limitations and exceptions described under Subsection
				  835.02 of these rules.
				  (3-17-22)
c. If an out-of-state
				  FQHC becomes an Idaho Medicaid provider and provides less than one hundred
				  (100) Idaho Medicaid encounters or receives less than ten thousand dollars
				  ($10,000) in Idaho Medicaid payments in the first year after entering the
				  program, the Department will deem the FQHC a low utilization provider. The
				  finalized encounter rate for low utilization providers will be the same as the
				  interim encounter rate as defined in Subsection
				  836.02.a. of this rule. If
				  there is an increase in either the number of encounters or in the amount of
				  payments over any twelve (12) month Medicare cost report period, the Department
				  reserves the right to audit a low utilization provider's Medicare cost report
				  in order to set a new interim encounter rate as defined in Subsection
				  836.02.a. of this rule.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.842 - INDIAN HEALTH SERVICE (IHS) CLINIC SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Payment will be available to Indian Health Service (IHS)
					 clinics for any service provided within the conditions of the scope of care and
					 services described in Subsection
					 835.02 of these rules.
					 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.845 - INDIAN HEALTH SERVICE (IHS) CLINIC SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Payment Procedure
. Payment
				  for services other than prescribed drugs will be made on a per visit basis at a
				  rate not exceeding the outpatient visit rate established by the Federal Office
				  of Management and Budget as published annually in the Federal Register.
				  (3-17-22)
02.
Payment for
				  Prescribed Drugs
. Payment for prescribed drugs will be available as
				  described in Subsection
				  662.01 of these rules.
				  (3-17-22)
03.
Dispensing Fee
				  for Prescriptions
. The allowed dispensing fee used to compute maximum
				  payment for each prescription will be the midpoint dispensing fee of the range
				  of fees in effect at the date of service unless a higher fee is justified by a
				  pharmacy cost of operations report on file with the Department.
				  (3-17-22)
04.
Third Party
				  Liability Not Applicable
. The provisions of Section
				  215 of these rules are not
				  applicable to Indian health service clinics. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.851 - SCHOOL-BASED SERVICE: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
To be eligible for medical assistance reimbursement for
					 covered services, school districts and charter schools must ensure:
					 (3-17-22)
01.
Medicaid
				  Eligibility
. Eligible for Medicaid and the service for which the school
				  district or charter school is seeking reimbursement; (3-17-22)
02.
School Enrollment
. Enrolled
				  in an Idaho school district or charter school; (3-17-22)
03.
Age
. Twenty-one (21) years
				  of age or younger and the semester in which their twenty-first birthday falls
				  is not finished; (3-17-22)
04.
Educational Disability
. Identified as having an educational
				  disability under the Department of Education standards in IDAPA 08.02.03,
				  "Rules Governing Thoroughness." (3-17-22)
05.
Parental Consent
. Providers
				  must obtain a one-time parental consent to access public benefits or insurance
				  from a parent or legal guardian for school-based Medicaid reimbursement.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.852 - SCHOOL-BASED SERVICE: SERVICE-SPECIFIC PARTICIPANT ELIGIBILITY

Current through August 31, 2023
Skills Building/Community Based Rehabilitation Services
					 (CBRS). CHIS and Personal Care Services (PCS) have additional eligibility
					 requirements. (3-17-22)
01.
Skills Building/Community Based Rehabilitation Services (CBRS)
. To be
				  eligible for Skills Building/CBRS, the student must meet one (1) of the
				  following: (3-17-22)
a. A student who is a
				  child under eighteen (18) years of age must meet the Serious Emotional
				  Disturbance (SED) eligibility criteria for children in accordance with the
				  Children's Mental Health Services Act, Section
				  16-2403, Idaho Code. A child who
				  meets the criteria for SED must experience a substantial impairment in
				  functioning. The child's level and type of functional impairment must be
				  documented in the school record. A Department-approved assessment must be used
				  to obtain the child's initial functional impairment score. Subsequent scores
				  must be obtained at least annually in order to determine the child's change in
				  functioning that occurs as a result of mental health treatment.
				  (3-17-22)
b. A student who is
				  eighteen (18) years old or older must meet the criteria of Serious and
				  Persistent Mental Illness (SPMI). This requires that a student participant meet
				  the criteria for SMI, as described in
				  42 CFR
				  483.102(b)(1), have at least
				  one (1) additional functional impairment, and have a diagnosis under DSM-V, or
				  later edition, with one (1) of the following: Schizophrenia, Schizoaffective
				  Disorder, Bipolar I Disorder, Bipolar II Disorder, Major Depressive Disorder
				  Recurrent Severe, Delusional Disorder, or Borderline Personality Disorder. The
				  only Not Otherwise Specified (NOS) diagnosis included is Psychotic Disorder NOS
				  for a maximum of one hundred twenty (120) days without a conclusive diagnosis.
				  In addition, the psychiatric disorder must be of sufficient severity to affect
				  the participant's functional skills negatively, causing a substantial
				  disturbance in role performance or coping skills in at least two (2) of the
				  areas listed below on either a continuous or intermittent basis, at least once
				  per year. The skill areas that are targeted must be consistent with the
				  participant's ability to engage and benefit from treatment. The detail of the
				  participant's level and type of functional impairment must be documented in the
				  medical record in the following areas: (3-17-22)
i. Vocational or educational;
				  (3-17-22)
ii Financial;
				  (3-17-22)
iii. Social relationships
				  or support; (3-17-22)
iv. Family;
				  (3-17-22)
v. Basic living skills;
				  (3-17-22)
vi. Housing;
				  (3-17-22)
vii. Community or legal;
				  or (3-17-22)
viii. Health or
				  medical. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.853 - SCHOOL-BASED SERVICE: COVERAGE AND LIMITATIONS

Current through August 31, 2023
The Department will pay school districts and charter
					 schools for covered rehabilitative and health-related services. Services
					 include medical or remedial services provided by school districts or other
					 cooperative service agencies, as defined in Section
					 33-317, Idaho Code.
					 (3-17-22)
01.
Excluded
				  Services
. The following services are excluded from Medicaid payments to
				  school-based programs: (3-17-22)
a. Vocational
				  Services. (3-17-22)
b. Educational
				  Services. Educational services (other than health-related services) or
				  education-based costs normally incurred to operate a school and provide an
				  education. Evaluations completed for educational services only cannot be
				  billed. (7-1-23)T
c. Recreational
				  Services. (3-17-22)
d. Payment for
				  school-related services will not be provided to students who are inpatients in
				  nursing homes or hospitals. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.854 - SCHOOL-BASED SERVICE: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
The following documentation must be maintained by the
					 provider and retained for a period of five (5) years: (3-17-22)
01.
Individualized Education Program
				  (IEP) and Other Service Plans
. School districts and charter schools may
				  bill for Medicaid services covered by a current Individualized Education
				  Program (IEP), transitional Individualized Family Service Plan (IFSP), or
				  Services Plan (SP) defined in the Idaho Special Education Manual on the State
				  Department of Education website for parentally placed private school students
				  with disabilities when designated funds are available for special education and
				  related services. The plan must be developed within the previous three hundred
				  sixty-five (365) days which indicates the need for one (1) or more
				  medically-necessary health-related service, and lists all the Medicaid
				  reimbursable services for which the school district or charter school is
				  requesting reimbursement. The IEP and transitional IFSP must include: (3-17-22)
a. Type, frequency, and duration of the
				  service(s) provided; (3-17-22)
b.
				  Title of the provider(s), including the direct care staff delivering services
				  under the supervision of the professional; (3-17-22)
c. Measurable goals, when goals are required
				  for the service; and (3-17-22)
d.
				  Specific place of service, if provided in a location other than school.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.855 - SCHOOL-BASED SERVICE: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Medicaid will only reimburse for services provided by
					 qualified staff. The following are the minimum qualifications for providers of
					 covered services: (3-17-22)
01.
Behavioral Intervention
. Must be provided by, or under the supervision
				  of, an intervention specialist or professional. Individuals providing
				  behavioral intervention must be one (1) of the following: (7-1-23)T
a. Intervention Paraprofessional. Provides
				  direct services. The specialist or professional must observe and review the
				  direct services performed by the paraprofessional monthly, or more often as
				  necessary, to ensure the paraprofessional demonstrates the necessary skills to
				  correctly provide the direct service. An intervention paraprofessional under
				  the direction of a qualified intervention specialist or professional must:
				  (7-1-23)T
i. Be at least eighteen (18) years
				  of age; (3-17-22)
ii. Demonstrate
				  the knowledge, have the skills needed to support the program to which they are
				  assigned; and (3-17-22)
iii. Meet
				  the paraprofessional requirements under IDAPA 08.02.02, "Rules Governing
				  Uniformity." (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: ESSENTIAL PROVIDERS › Section 16.03.09.857 - SCHOOL-BASED SERVICE: QUALITY ASSURANCE AND IMPROVEMENT

Current through August 31, 2023
The provider will grant the Department immediate access to
					 all information required to review compliance with these rules.
					 (3-17-22)
01.
Quality
				  Assurance
. Quality Assurance consists of reviews to assure compliance
				  with the Department's rules and regulations. If problems are identified during
				  the review, the provider must implement a corrective action plan within
				  forty-five (45) days after the results are received. The Department will work
				  with the school to answer questions and provide clear direction regarding the
				  corrective action plan. (3-17-22)
02.
Quality Improvement
. The
				  Department may gather and utilize information from providers to evaluate
				  student satisfaction, outcomes monitoring, quality assurance, quality
				  improvement activities, and health and safety. These findings may lead to
				  quality improvement activities to improve provider processes and outcomes for
				  the students. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.861 - EMERGENCY TRANSPORTATION SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
Ambulance services are medically necessary when an
					 emergency condition exists. For purposes of reimbursement, an emergency
					 condition exists when a participant manifests acute symptoms or signs, or both,
					 which, by reasonable medical judgment of the Department, represent a condition
					 of sufficient severity such that the absence of immediate medical attention
					 could reasonably be expected to result in death, serious impairment of a bodily
					 function or major organ, or serious jeopardy to the overall health of the
					 participant. If such condition exists, and treatment is required at the
					 participant's location, or transport of the participant for treatment in
					 another location by ambulance is the only appropriate mode of travel, the
					 Department will review such claims and consider authorization for emergency
					 ambulance services. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.862 - EMERGENCY TRANSPORTATION SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Prior Authorization
.
				  Medically necessary ambulance services are reimbursable in emergency situations
				  or when prior authorization has been obtained from the Department.
				  (3-17-22)
02.
Local Transport
				  Only
. Only local transportation by ambulance is covered. In exceptional
				  situations where the ambulance transportation originates beyond the locality to
				  which the participant was transported, payment may be made for such services
				  only if the evidence clearly establishes that such institution is the nearest
				  one with appropriate facilities and the service is authorized by the
				  Department. (3-17-22)
03.
Air Ambulance Service
. In some areas, transportation by airplane or
				  helicopter may qualify as ambulance services. Air ambulance services are
				  covered only when: (3-17-22)
a. The point of
				  pickup is inaccessible by land vehicle; or (3-17-22)
b. Great distances or other obstacles are
				  involved in getting the participant to the nearest appropriate facility and
				  speedy admission is essential; and (3-17-22)
c. Air ambulance service will be covered
				  where the participant's condition and other circumstances necessitate the use
				  of this type of transportation; however, where land ambulance service will
				  suffice, payment will be based on the amount payable for land ambulance, or the
				  lowest cost. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.863 - EMERGENCY TRANSPORTATION SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Services Subject to Review
.
				  Ambulance services are subject to review by the Department prior to the service
				  being rendered, and on a retrospective basis. (3-17-22)
02.
Non-Emergency Transport Prior
				  Authorization Required
. If an emergency does not exist, prior written
				  authorization to transport by ambulance must be secured from the Department.
				  (3-17-22)
03.
Air
				  Ambulance
. Air ambulance services must be approved in advance by the
				  Department, except in emergency situations. Emergency air ambulance services
				  will be authorized by the Department on a retrospective basis.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.864 - EMERGENCY TRANSPORTATION SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Medically Necessary
. For
				  purposes of reimbursement, in non-emergency situations, the provider must
				  provide justification to the Department that travel by ambulance is medically
				  necessary due to the medical condition of the participant, and that any other
				  mode of travel would, by reasonable medical judgment of the Department, result
				  in death, serious impairment of a bodily function or major organ, or serious
				  jeopardy to the overall health of the participant. (3-17-22)
02.
Licensure Required
. All
				  Emergency Medical Services (EMS) Providers that provide services to Medicaid
				  participants in Idaho must hold a current license issued by the Emergency
				  Medical Services Bureau of the Department in accordance with IDAPA 16.01.03,
				  "Emergency Medical Services (EMS) Agency Licensing Requirements," and IDAPA
				  16.01.07, "Emergency Medical Services (EMS) Personnel Licensing Requirements."
				  Ambulances based outside the state of Idaho must hold a current license issued
				  by their states' EMS licensing authority when the transport is initiated
				  outside the state of Idaho. Payment will not be made to ambulances that do not
				  hold a current license. (3-17-22)
03.
Usual Charges
. Ambulance
				  services providers cannot charge Medicaid participants more than is charged to
				  the general public for the same service. (3-17-22)
04.
Air Ambulance
. The operator
				  of the air service must bill the air ambulance service rather than the hospital
				  or other facility receiving the participant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.870 - NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES: DEFINITIONS

Current through August 31, 2023
For the purposes of Sections
					 870 through
					 879 of these rules, the following
					 definitions apply. (3-17-22)
01.
Contracted Transportation Provider
. A non-emergency medical
				  transportation provider who is under contract with the transportation broker to
				  provide non-emergency medical transportation for Medicaid participants.
				  (3-17-22)
02.
Individual
				  Contracted Transportation Provider
. An individual who is under contract
				  with the transportation broker to provide non-emergency medical transportation
				  for a Medicaid participant in the provider's personal vehicle.
				  (3-17-22)
03.
Non-Emergency
				  Medical Transportation
. Non-emergency medical transportation is
				  transportation that is: (3-17-22)
a. Not of an
				  emergency nature; and (3-17-22)
b.
				  Required for a Medicaid participant to access medically necessary services
				  covered by Medicaid when the participant's own transportation resources, family
				  transportation resources, or community transportation resources do not allow
				  the participant to reach those services. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.871 - NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES: DUTIES OF THE TRANSPORTATION BROKER

Current through August 31, 2023
The transportation broker under contract with the
					 Department is required to: (3-17-22)
01.
Coordinate and Manage
.
				  Coordinate and manage all non-emergency medical transportation services for
				  Medicaid participants statewide. (3-17-22)
02.
Contract With Transportation
				  Providers
. Contract with transportation providers throughout the state
				  to provide non-emergency medical transportation services for Medicaid
				  participants. (3-17-22)
03.
Call Center
. Operate a call center to receive and review non-emergency
				  medical transportation for Medicaid participants meeting the requirements in
				  Section 872 of these
				  rules. (3-17-22)
04.
Authorize Non-Emergency Medical Transportation Services
. Authorize
				  non-emergency medical transportation services for Medicaid participants
				  requesting transportation and who meet the requirements in Section
				  872 of these rules.
				  (3-17-22)
05.
Reimburse
				  Contracted Transportation Providers
. Reimburse contracted transportation
				  providers for non-emergency medical transportation services meeting the
				  requirements in Section
				  872 of these rules.
				  (3-17-22)
06.
Safe and
				  Professional Transportation
. Assure that contracted transportation
				  providers deliver non-emergency medical transportation services in a safe and
				  professional manner. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.872 - NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Non-Emergency Medical
				  Transportation Services
. The transportation broker will reimburse
				  contracted transportation providers for non-emergency medical transportation
				  services under the following conditions: (3-17-22)
a. The travel is essential to get to or from
				  a medically necessary Medicaid covered service; (3-17-22)
b. The mode of transportation is the least
				  costly that is appropriate for the medical needs of the participant;
				  (3-17-22)
c. The transportation is
				  to the nearest medical provider appropriate to perform the needed services, and
				  transportation is by the most direct route practicable; (3-17-22)
d. Other modes of transportation, including
				  personal vehicle, assistance by family, friends, and charitable organizations,
				  are unavailable or impractical under the circumstances; (3-17-22)
e. The travel is authorized and scheduled by
				  the transportation broker; and (3-17-22)
f. The contracted transportation provider is
				  in compliance with the terms of its contract with the transportation broker.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.873 - NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES: REIMBURSEMENT METHODOLOGY

Current through August 31, 2023
The Department will reimburse the NEMT services broker a
					 fixed, actuarially sound amount per member per month based on the cost of
					 efficiently delivered, timely, and safe non-emergency medical transportation
					 for eligible Idaho Medicaid participants and the cost for efficient
					 administration of the brokerage program. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: EPSDT SERVICES › Section 16.03.09.880 - EARLY PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES: DEFINITION

Current through August 31, 2023
Medically necessary services for eligible Medicaid
					 participants under the age of twenty-one (21) are health care, diagnostic
					 services, treatment, and other measures described in Section
					 1905(a)  of the
					 Social Security Act (SSA) necessary to correct or ameliorate defects, physical
					 and mental illness, and conditions discovered by the screening services as
					 defined in Section 1905(r)
					  of the SSA, whether or not such services are
					 covered under the State Plan. Services must be considered safe, effective, and
					 meet acceptable standards of medical practice. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: EPSDT SERVICES › Section 16.03.09.881 - EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
EPSDT services are available to child participants from
					 birth through the month of their twenty-first birthday. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: EPSDT SERVICES › Section 16.03.09.882 - EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Additional Services
. Any service required as a result of an EPSDT screen
				  and which is currently covered under the scope of the Idaho Medicaid program
				  will not be subject to the existing amount, scope, and duration, but will be
				  subject to the authorization requirements of those rules. (3-17-22)
02.
Medically Necessary
. The
				  need for additional services must be documented by the attending physician as
				  medically necessary. (3-17-22)
03.
Prior Authorization
. Any service requested, that is covered under
				  Title XIX or Title XXI of the Social Security Act, that is not identified in
				  these rules specifically as a Medicaid-covered service will require prior
				  authorization prior to payment for that service. (3-17-22)
04.
Services Not Covered
. The
				  Department will not cover services for cosmetic, convenience, or comfort
				  reasons. (3-17-22)
05.
Hearing Aids Under EPSDT
. (3-17-22)
a.
				  When binaural aids are requested they will be authorized if documented to the
				  Department's satisfaction, that the child's ability to learn would be severely
				  restricted. (3-17-22)
b. When
				  replacement hearing aids are requested, they may be authorized if the
				  requirements in Subsections
				  742.01.a., 742.01.b., and
				  742.03 are met. (3-17-22)
c. The
				  Department will purchase additional ear molds after the initial six (6) months
				  to one (1) year period if medically necessary. Requests in excess of every six
				  (6) months will require prior authorization and documentation of medical need
				  from either the attending physician or audiologist.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: SPECIFIC PREGNANCY-RELATED SERVICES › Section 16.03.09.890 - PREGNANCY-RELATED SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Individual and Family Social Services
. Services directed at helping a
				  participant to overcome social or behavioral problems that may adversely affect
				  the outcome of the pregnancy. (3-17-22)
02.
Maternity Nursing Visit
.
				  Office visits by a licensed registered nurse, acting within the limits of the
				  Nurses Practices Act, for the purpose of checking the progress of the
				  pregnancy. (3-17-22)
03.
Nursing Services
. Home visits by a licensed registered nurse to assess
				  the participant's living situation and provide appropriate education and
				  referral during the covered period. (3-17-22)
04.
Nutritional Services
.
				  Nutritional services are described in Sections
				  630 through
				  635 of these rules.
				  (3-17-22)
05.
Risk Reduction
				  Follow-Up
. Services to assist the participant in obtaining medical,
				  educational, social and other services necessary to assure a positive pregnancy
				  outcome. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: SPECIFIC PREGNANCY-RELATED SERVICES › Section 16.03.09.892 - PREGNANCY-RELATED SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
When ordered by the participant's attending physician or
					 licensed practitioner of the healing arts, payment of the following services is
					 available after confirmation of pregnancy and extending through the end of the
					 month in which the sixtieth day following delivery occurs. (3-17-22)
01.
Individual and Family Social
				  Services
. Limited to two (2) visits during the covered period.
				  (3-17-22)
02.
Maternity
				  Nursing Visit
. These services are only available to women unable to
				  obtain a physician or licensed practitioner of the healing arts to provide
				  prenatal care. This service is to end immediately when a primary physician is
				  found. A maximum of nine (9) visits can be authorized. (7-1-23)T
03.
Nursing Services
. Limited to
				  two (2) visits during the covered period. (3-17-22)
04.
Nutrition Services
. As
				  described in Sections
				  630 through
				  632 of these rules.
				  (7-1-23)T
05.
Qualified
				  Provider Risk Assessment and Plan of Care
. When prior authorized by the
				  Department, payment is made for qualified provider services in completion of a
				  standard risk assessment and plan of care for women unable to obtain a primary
				  care physician, nurse practitioner, or nurse midwife for the provision of
				  antepartum care. (3-17-22)
06.
Risk Reduction Follow-Up
. (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: SPECIFIC PREGNANCY-RELATED SERVICES › Section 16.03.09.893 - PREGNANCY-RELATED SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
Pregnancy-related services described in Sections
					 890 through
					 892 of these rules must be prior
					 authorized by the Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: SPECIFIC PREGNANCY-RELATED SERVICES › Section 16.03.09.894 - PREGNANCY-RELATED SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Services must be: (3-17-22)
01.
Risk Reduction Follow-Up
.
				  Provided by a licensed social worker, RN, nurse midwife, physician, NP, or PA
				  either in independent practice or as employees of entities that have current
				  provider agreements with the Department. (7-1-23)T
02.
Individual and Family Social
				  Services
. Provided by a licensed social worker qualified to provide
				  individual counseling (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: SPECIFIC PREGNANCY-RELATED SERVICES › Section 16.03.09.895 - PREGNANCY-RELATED SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Rates
. Rate of payment for pregnancy-related services is
				  established under the provisions of Section
				  230 of these rules.
				  (3-17-22)
02.
Risk Reduction
				  Followup Services
. A single payment will be made for each month of
				  service provided. (3-17-22)