Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-029 - ARKids First B Update Transmittal #33

Current through Register Vol. 49, No. 6, June, 2024
221.100
ARKids First-B Medical Care
			 Benefits
Program Services
Coverage Limits on Benefit
Prior
Authorization/ PCP Referral
Co-payment/ Coinsurance
Ambulance (Emergency Only)
Medical Necessity
None
$10 per trip
Ambulatory Surgical Center
Medical Necessity
PCP Referral
$10 per visit
Certified Nurse-Midwife
Medical Necessity
PCP Referral
$10 per visit
Chiropractor
Medical Necessity
PCP Referral
$10 per visit
Dental Care (No Orthodontia)
Routine dental care
None
$10 per visit
Durable Medical Equipment
Medical Necessity $500 per state fiscal year (July 1
						  through June 30) minus the coinsurance
PCP Referral and Prescription
20% of Medicaid allowed amount per DME item
Emergency Dept. Ser
vices
Emergency
Medical Necessity
None
$10 per visit
Non-Emergency
Medical Necessity
PCP Referral
$10 per visit
Assessment
Medical Necessity
None
$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
20% of first inpatient day
Hospital, Outpatient
Medical Necessity
PCP referral
$10 per visit
Immunizations
All per protocol
PCP or
Administered by ADH
None
Laboratory & X-Ray
Medical Necessity
PCP Referral
$10 per visit
Medical Supplies
Medical Necessity Limited to $125/mo unless benefit
						  extension is approved
PCP Prescriptions
None
Mental and Behavioral Health, Outpatient
Medical Necessity
PCP Referral PA on treatment services
$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
Medical Necessity
Prescription
$5 per prescription (Must use generic and rebate
						  manufacturer, 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 Therapy
Medical Necessity
PCP Referral
$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 provider manual for prior
				authorization and PCP referral procedures.
ARKids First-B participant cost-sharing is capped at 5% of the
				family's gross annual income.
224.000
Cost Sharing
Co-payment or coinsurance will apply to all ARKids First-B
				Waiver services, with the exception of immunizations, preventive health
				screenings, family planning, prenatal care, eyeglasses and medical supplies.
				Co-payments orcoinsurancel range from $5.00 per prescription to 20% of the
				first day's hospital Medicaid per diem.
Effective July 1, 2006, ARKids First-B families will have an
				annual cumulative cost-sharing maximum of 5% of their gross family income; the
				annual period is July 1 through June 30 (state fiscal year (SFY). The ARKids
				First-B participant's annual cumulative cost-sharing maximum will be
				recalculated and the cumulative cost sharing counter will be reset to zero on
				July 1 each year.
The cost sharing provision will require providers to check and
				be alert to certain details about the ARKids First-B participants cost sharing
				obligation in order for this process to work smoothly. The following is a list
				of guidelines for providers:
1. On the
			 day service is delivered to the ARKids First-B participant, the provider should
			 access the eligibility verification system to determine if the ARKids First-B
			 participant has current ARKids First-B coverage and whether or not the ARKids
			 First-B participant has met their cumulative cost sharing maximum.
2. The provider should check the remittance
			 advice received with the claim submitted on the ARKids First-B participant
			 which will contain an explanation stating that the ARKids First-B participant
			 has met their cost sharing cap.
3.
			 It is strongly urged that providers submit their claims as quickly as possible
			 to EDS for payment so that the amount of the ARKids First-B participant's
			 co-payment can be posted to their cost share file and the amount is added to
			 the accrual.