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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.700 - INPATIENT BEHAVIORAL HEALTH SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Freestanding Psychiatric
				  Hospital
. A hospital, nursing facility, or other institution of sixteen
				  (16) beds or less that is primarily engaged in the diagnosis and treatment of
				  mental diseases. The hospital is not considered freestanding if it shares a
				  building or campus with another hospital, or is owned by another hospital.
				  (3-17-22)
02.
Hospital
				  Psychiatric Unit
. The psychiatric unit of a general hospital that
				  furnishes inpatient care and treatment services for mental illness under a
				  psychiatrist or other physician qualified to treat mental diseases.
				  (3-17-22)
03.
Institutions
				  for Mental Disease (IMD)
. A hospital, nursing facility or other
				  institution of seventeen (17) beds or more that is primarily engaged in
				  providing diagnosis, treatment, or care of persons with mental diseases,
				  including medical attention, nursing care, and related services. A specific
				  licensure is not necessary to meet this definition. This definition does not
				  apply to ICF/IIDs. (3-17-22)
04.
Substance Use Disorder
. A substance use disorder is evidenced by a
				  cluster of cognitive, behavioral, and physiological symptoms indicating that
				  the individual continues using a substance despite significant
				  substance-related problems. A diagnosis of a substance use disorder is based on
				  a pathological pattern of behaviors related to use of the substance and the
				  current DSM. (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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.701 - INPATIENT BEHAVIORAL HEALTH SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
01.
Inpatient Psychiatric Hospital
				  Services
. Participants are eligible who have a diagnosis from the
				  current DSM with substantial impairment in thought, mood, perception, or
				  behavior. A court-ordered admission or physician's emergency certificate alone
				  does not justify Medicaid reimbursement for these services. Medical necessity
				  must be demonstrated for admission or extended stay by meeting the severity of
				  illness and intensity of service criteria as found in Subsections
				  701.03 and
				  701.04 of this rule. Services
				  may be provided in: (3-17-22)
a. A
				  freestanding psychiatric hospital; (3-17-22)
b. A hospital psychiatric unit; and
				  (3-17-22)
c. Subject to federal
				  approval, an institution for 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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.702 - INPATIENT BEHAVIORAL HEALTH SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Initial Length of Stay
. An
				  initial length of stay, or a prior authorization requirement, will be
				  established by the Department, or its designee, in the Idaho Medicaid Provider
				  Handbook. Requirements for establishing length of stay will never be more
				  restrictive than requirements for non-behavioral health services in a general
				  hospital. (3-17-22)
02.
Extended Stay
. The Department, or its designee, will establish
				  authorization requirements in the Idaho Medicaid Provider Handbook. An
				  authorization is necessary when the appropriate care of the participant
				  indicates the need for inpatient days in excess of the initial length of stay
				  or previously approved extended stay. (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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.703 - INPATIENT BEHAVIORAL HEALTH SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Prior Authorization
. Some
				  services may require a prior authorization from the Department, or its
				  designee. The Department will set documentation requirements in the Idaho
				  Medicaid Provider Handbook to ensure quality of care and integrity of services.
				  Requests for prior authorization must include: (3-17-22)
a. Diagnosis; and (3-17-22)
b. Summary of present medical findings
				  including symptoms, complaints and complications indicating the need for
				  admission; and (3-17-22)
c. Medical
				  history; and (3-17-22)
d. Mental
				  and physical functional capacity; and (3-17-22)
e. Prognosis. (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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.704 - INPATIENT BEHAVIORAL HEALTH SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Provider Qualifications
.
				  Inpatient hospital psychiatric services must be provided under the direction of
				  a physician in a facility accredited by the Joint Commission on Accreditation
				  of Healthcare Organizations (JCAHO) and licensed by the state of Idaho or the
				  state in which they provide services. To provide services beyond emergency
				  medical screening and stabilization treatment, the hospital must have a
				  separate psychiatric unit with staff qualified to provide psychiatric services.
				  General hospitals licensed to provide services in their state, but are not
				  JCAHO certified, may not bill for psychiatric services beyond emergency
				  screening and stabilization. (3-17-22)
02.
Record Keeping
. A written
				  report of each evaluation and the plan of care must be entered into the
				  participant's record at the time of admission or if the participant is already
				  in the facility, immediately upon completion of the evaluation or plan.
				  (3-17-22)
03.
Utilization
				  Review (UR)
. The facility must have in effect a written utilization
				  review plan that provides for review of each participant's need for the
				  services that the hospital furnishes them. The UR plan must meet the
				  requirements under 42 CFR
				  456.201 through
				  456.245. (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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.705 - INPATIENT BEHAVIORAL HEALTH SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Failure to request a prior authorization, concurrent
					 review, or continued stay review in a timely manner will result in a
					 retrospective review being conducted by the Department. If the retrospective
					 review determines the stay is medically necessary, the Department will assess a
					 penalty to the hospital as specified in Subsection
					 705.02 of this rule. The
					 admitting physician will be assessed a penalty for failure to request a prior
					 authorization, concurrent review, or continued stay review in a timely manner
					 as specified in Subsection
					 705.03 of this rule. A physician
					 who provides hospital care but has no control over the admission, continued
					 stay, or discharge of the participant is not subject to this penalty.
					 (3-17-22)
01.
Payment
.
				  Reimbursement for the participant's admission and length of stay is subject to
				  prior authorization, concurrent review, continued stay review, or retrospective
				  review by the Department. The hospital and the participant's physician are
				  responsible for obtaining the required review. If such review identifies that
				  an admission or continued stay is not medically necessary, then no Medicaid
				  payment will be made. (3-17-22)
a. In
				  reimbursing for inpatient hospital psychiatric services the Department will pay
				  the lesser of customary charges or the established Medicaid semi-private rates
				  for inpatient hospital care in accordance with the rules set forth in IDAPA
				  16.03.10, "Medicaid Enhanced Plan Benefits." (3-17-22)
b. The cost of services that would be the
				  responsibility of the Department of Education for school age children cannot be
				  considered in the cost of inpatient psychiatric hospital 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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.706 - INPATIENT BEHAVIORAL HEALTH SERVICES: QUALITY ASSURANCE

Current through August 31, 2023
The policy, rules, and regulations to be followed must be
					 those cited in 42 CFR
					 456.480 through
					 42 CFR
					 456.482. (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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.708 - OUTPATIENT BEHAVIORAL HEALTH SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
All participants who are eligible for Medicaid Basic or
					 Enhanced Benchmark State Plan services, except for participants enrolled in the
					 Idaho Medicare-Medicaid Coordinated Plan (MMCP), are automatically enrolled in
					 the Idaho Behavioral Health Plan and may access behavioral health services that
					 are determined to be medically necessary. (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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.709 - OUTPATIENT BEHAVIORAL HEALTH SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Community-Based Outpatient
				  Behavioral Health Services
. The Community-Based Outpatient Behavioral
				  Health Services included in the Idaho Behavioral Health Plan (IBHP) or the
				  Idaho State Plan are covered services that evaluate the need for and provide
				  therapeutic and rehabilitative treatment to minimize symptoms of mental illness
				  and substance use disorders and restore independent functioning.
				  (7-1-23)T
02.
Prior
				  Authorization
. Some behavioral health services may require prior
				  authorization from the IBHP 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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.710 - OUTPATIENT BEHAVIORAL HEALTH SERVICES: PROVIDER QUALIFICATIONS

Current through August 31, 2023
The IBHP services are delivered by network providers who
					 are enrolled with the contractor and meet reimbursement, quality, and
					 utilization standards. All community-based outpatient behavioral health service
					 providers are subject to the limitations of practice imposed by state law,
					 federal regulations, and by the various state boards that regulate professional
					 competency requirements, and in accordance with applicable Department rules.
					 The contractor will enter into agreements with enrolled providers to provide
					 the services under the IBHP. These agreements will include the reimbursement
					 methodology agreed upon by the contractor and 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: BEHAVIORAL HEALTH SERVICES › Section 16.03.09.711 - OUTPATIENT BEHAVIORAL HEALTH SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
Providers must enroll in the IBHP with the contractor and
					 meet both the credentialing and quality assurance guidelines of the contractor.
					 (3-17-22)
01.
Administer
				  IBHP
. The contractor is responsible for administering the IBHP,
				  including: eligibility verification, management of behavioral health service
				  provision, behavioral health claims processing, payments to providers, data
				  reporting, utilization management, and customer service. (3-17-22)
02.
Authorization
. The
				  contractor is responsible for authorization of covered behavioral health
				  services that require authorization prior to claim payment. (3-17-22)
03.
Complaints, Grievances, and
				  Appeals
. Complaints, grievances, and appeals are handled through a
				  process between the contractor and Department that is in compliance with state
				  and federal requirements. Participants must utilize the complaint, grievance,
				  and appeal process required by the contractor prior to initiating an
				  administrative appeal with 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: HOME HEALTH SERVICES › Section 16.03.09.720 - HOME HEALTH SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Aggregator
. System that collects provider EVV information from multiple
				  software platforms and standardizes the information in MMIS for EVV data
				  validation. (3-17-22)
02.
Claims Adjudication
. The process of determining Medicaid financial
				  responsibility for claims submitted to MMIS. (3-17-22)
03.
Electronic Visit Verification
				  (EVV)
. EVV is a software or device(s) that electronically captures
				  information verifying service delivery. (3-17-22)
04.
Home Health Plan of Care
. A
				  written description of home health services to be provided to a participant as
				  defined in IDAPA 16.03.07, "Home Health Agencies." (3-17-22)
05.
Home Health Services
. Home
				  health services and items include nursing services, home health aide services,
				  physical therapy, occupational therapy, speech-language pathology services,
				  audiology services, and medical supplies, equipment, and appliances provided
				  under a home health plan of care. (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: HOME HEALTH SERVICES › Section 16.03.09.722 - HOME HEALTH SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Settings
. Home health
				  services are covered in a participant's place of residence and any setting in
				  which normal life activities take place. Services are not covered when provided
				  in a: (3-17-22)
a. Hospital;
				  (3-17-22)
b. Nursing facility;
				  (3-17-22)
c. ICF/IID, unless such
				  services are not otherwise required to be provided by the ICF/IID; or
				  (3-17-22)
d. Any setting in which
				  Medicaid covers inpatient services, including room and board.
				  (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: HOME HEALTH SERVICES › Section 16.03.09.723 - HOME HEALTH SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Orders
. (3-17-22)
a. Home health services must be ordered by a
				  physician, or a licensed practitioner of the healing arts. Orders must include
				  the provider's National Provider Identifier (NPI), the services or items to be
				  provided, the frequency, and, where applicable, the expected duration of time
				  for which the home health services will be needed. Orders for medical supplies,
				  equipment, and appliances are detailed in Section
				  753 of these rules.
				  (7-1-23)T
b. Home health services
				  required for extended periods must be reordered at least every sixty (60) days
				  for services and annually for medical supplies, equipment, and appliances.
				  (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: HOME HEALTH SERVICES › Section 16.03.09.724 - ELECTRONIC VISIT VERIFICATION (EVV)

Current through August 31, 2023
Effective July 1, 2021, Home Health Agencies (HHAs) are
					 required to submit claims using a compliant EVV system as mandated by Section
					 12006 of the 21st Century Cures
					 Act for all services provided except for the provision of medical supplies and
					 equipment. Providers must: (3-17-22)
01.
Maintain System
. Maintain an
				  EVV system chosen by their agency that is certified as compliant with the MMIS
				  aggregator, as determined by the Department and/or the MMIS Contractor;
				  (3-17-22)
02.
Document
				  Consent
. Document and retain participant consent for use of electronic
				  verification methods; (3-17-22)
03.
Develop Policies and Procedures
. Develop and maintain policies and
				  procedures outlining agency implementation and use of EVV technology, including
				  strategies for safeguarding of participant information and privacy; and
				  (3-17-22)
04.
Submit EVV
				  Data
. Submit EVV data that captures these six (6) system-validated data
				  elements for services rendered: (3-17-22)
a.
				  Date of service; (3-17-22)
b, Time
				  the service begins and ends; (3-17-22)
c. Individual providing the service;
				  (3-17-22)
d. Participant receiving
				  the service; (3-17-22)
e. Billable
				  service performed; and (3-17-22)
f.
				  Location of service delivery. (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: HOME HEALTH SERVICES › Section 16.03.09.725 - HOME HEALTH SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
In order to participate as a Home Health Agency (HHA)
					 provider for Medicaid-eligible persons, the provider must be licensed as
					 required by the state, and be certified to participate in the Medicare Program.
					 Loss of either state license or Medicare Program certification is cause for
					 termination of Medicaid provider status. (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: HOME HEALTH SERVICES › Section 16.03.09.726 - HOME HEALTH SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Home Health Services
.
				  Payment for home health services is limited to the services authorized in
				  Sections 720 through
				  722 of these rules and must not
				  exceed the lesser of reasonable cost as determined by Medicare or the Medicaid
				  percentile cap. (3-17-22)
a. The Medicaid
				  percentile cap is revised annually, effective at the beginning of each state
				  fiscal year. Revisions are made using the data from the most recent finalized
				  Medicare cost reports on hand thirty (30) days prior to the effective date.
				  (3-17-22)
b. Payment by the
				  Department for home health will include mileage as part of the cost of the
				  visit. (3-17-22)
c. Provider claims
				  for services requiring EVV will include the corresponding EVV data elements
				  listed in Subsection 724.04 of
				  these rules. Provider EVV data will be submitted to the state's aggregator
				  prior to billing claims. Claims corresponding to EVV data submissions are
				  subject to a quality review in accordance with Subsection
				  210.10 of these rules.
				  (3-17-22)
d. If a person is
				  eligible for Medicare, all services ordered by the physician or licensed
				  practitioner of the healing arts will be purchased by Medicare, except for the
				  deductible and co-insurance amounts that the Department will pay.
				  (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: THERAPY SERVICES › Section 16.03.09.730 - THERAPY SERVICES: DEFINITIONS

Current through August 31, 2023
For the purposes of these rules, the following terms are
					 used as defined below: (3-17-22)
01.
Duplicate Services
. Services are considered duplicate: (3-17-22)
a. When participants receive any combination
				  of physical therapy, occupational therapy, or speech-language pathology
				  services with treatments, evaluations, treatment plans, or goals that are not
				  separate and unique to each service provided; or (3-17-22)
b. When more than one (1) type of therapy is
				  provided at the same time. (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: THERAPY SERVICES › Section 16.03.09.731 - THERAPY SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
To be eligible for therapy services, a participant must be
					 eligible for Medicaid benefits and must have: (3-17-22)
01.
Order
. A physician or
				  licensed practitioner of the healing arts order for therapy services; and
				  (3-17-22)
02.
A Therapy
				  Evaluation Showing Need
. A therapy evaluation of the participant showing
				  a need for therapy due to a functional limitation, a loss or delay of skill, or
				  both; and (3-17-22)
03.
A
				  Therapy Evaluation Establishing Participant Benefit
. A therapy
				  evaluation establishing that the participant will benefit and demonstrate
				  progress as a result of the therapy 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: THERAPY SERVICES › Section 16.03.09.732 - THERAPY SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Therapy services are covered under these rules when
					 delivered by a therapy professional and provided by one (1) of the following
					 providers: outpatient hospitals, outpatient rehabilitation facilities,
					 comprehensive outpatient rehabilitative facilities, nursing facilities,
					 school-based services, independent practitioners, and home health agencies.
					 Therapy services provided by a home health agency under a home health plan of
					 care must meet the requirements under Sections
					 730 through
					 739 of these rules, and the
					 requirements under Sections
					 720 through
					 729 of these rules.
					 (7-1-23)T
01.
Service
				  Description: Occupational Therapy and Physical Therapy
. Modalities,
				  therapeutic procedures, tests, and measurements as described in the Idaho
				  Medicaid Provider Handbook are covered with the following limitations:
				  (3-17-22)
a. Any evaluation or re-evaluation
				  may only be performed by the therapist. Any changes in the participant's
				  condition not consistent with planned progress or treatment goals necessitate a
				  documented re-evaluation by the therapist before further treatment is carried
				  out. (3-17-22)
b. Any CPT procedure
				  code that falls under the heading of either, "Active Wound Care Management," or
				  "Tests and Measurements," requires the therapist to have direct, one-to-one
				  (1:1) patient contact. (3-17-22)
c.
				  The therapist may be reimbursed for the technical component of muscle testing,
				  joint range of motion, electromyography, or nerve velocity determinations as
				  described in the CPT Manual when ordered by a physician, nurse practitioner, or
				  PA. (7-1-23)T
d. Any assessment
				  provided under the heading "Orthotic Management and Prosthetic Management" must
				  be completed by the therapist. (3-17-22)
e. The services of occupational or physical
				  therapy assistants used when providing covered therapy benefits are included as
				  part of the covered service. These services are billed by the supervising
				  therapist. Therapy assistants may not provide evaluation services, or take
				  responsibility for the service. The therapist has full responsibility for the
				  service provided. (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: THERAPY SERVICES › Section 16.03.09.733 - THERAPY SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
The Department will pay for therapy services rendered by a
					 therapy professional if such services are ordered by a physician, nurse
					 practitioner, or PA as part of a plan of care. (7-1-23)T
01.
Orders
. (3-17-22)
a. All therapy must be ordered by a
				  physician, nurse practitioner, or PA. (7-1-23)T
b. If services are required for extended
				  periods, they must be reordered as necessary, but at least every ninety (90)
				  days for all participants with the following exceptions: (7-1-23)T
i. Therapy provided by home health agencies
				  must be included in the home health plan of care and be reordered at least
				  every sixty (60) days. (3-17-22)
ii. Therapy for individuals with long-term
				  medical conditions, as documented by physician, nurse practitioner, or PA, must
				  be reordered at least every three hundred sixty-five (365) days.
				  (7-1-23)T
c. Therapy
				  services provided under a home health plan of care must comply with the order
				  requirements in Section
				  723 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: THERAPY SERVICES › Section 16.03.09.734 - THERAPY SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
The following providers are qualified to provide therapy
					 services as Medicaid providers. (3-17-22)
01.
Occupational Therapist,
				  Licensed
. A person licensed to conduct occupational therapy assessment
				  and therapy according to the regulations in the state where the services are
				  provided. (3-17-22)
02.
Physical Therapist, Licensed
. A person licensed to conduct physical
				  therapy assessments and therapy according to the regulations in the state where
				  the services are provided. (3-17-22)
03.
Speech-Language Pathologist,
				  Licensed
. A person licensed to conduct speech-language assessments and
				  therapy according to the regulations in the state where the services are
				  provided who possesses a certificate of clinical competence in speech-language
				  pathology from the American Speech, Language, and Hearing Association (ASHA) or
				  who will be eligible for certification within one (1) year of employment.
				  (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: THERAPY SERVICES › Section 16.03.09.735 - THERAPY SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Payment for Therapy Services
. The payment for therapy includes the
				  use of therapeutic equipment to provide the modality or therapy. No additional
				  charge may be made to either the Medicaid program or the participant for the
				  use of such equipment. (3-17-22)
02.
Payment Procedures
. Payment
				  procedures are as follows: (3-17-22)
a.
				  Therapy provided by home health agencies will be paid at a per visit rate as
				  described in Section 725 of these
				  rules and in accordance with IDAPA 16.03.07, "Home Health Agencies."
				  (3-17-22)
b. Therapists enrolled
				  with Medicaid as independent practitioners and licensed by the appropriate
				  state licensing board will be reimbursed on a fee-for-service basis. Only those
				  independent practitioners who have been enrolled as Medicaid providers can bill
				  the Department directly for their services. A therapy assistant cannot bill
				  Medicaid directly. The maximum fee will be based upon the Department's fee
				  schedule, available from the central office for the Division of Medicaid.
				  (3-17-22)
c. Therapy rendered
				  on-site to hospital inpatients or outpatients will be paid at a rate not to
				  exceed the payment determined as reasonable cost using Title XVIII (Medicare)
				  standards and principles. (3-17-22)
d. Payment for therapy services rendered to
				  participants in long-term care facilities is included in the facility
				  reimbursement as described in IDAPA 16.03.10, "Medicaid Enhanced Plan
				  Benefits." (3-17-22)
e. Payment for
				  therapy services rendered to participants in school-based services is described
				  in Section 855 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: THERAPY SERVICES › Section 16.03.09.736 - THERAPY SERVICES: QUALITY ASSURANCE ACTIVITIES

Current through August 31, 2023
01.
Unreimbursable Services and Penalties
. Therapy services that are
				  not medically necessary or that are not specifically covered by these rules are
				  not reimbursable, and if paid are subject to recoupment and penalties under
				  IDAPA 16.05.07, "The Investigation and Enforcement of Fraud, Abuse, and
				  Misconduct." (3-17-22)
02.
Therapist Conditions and Requirements
. The therapist is required to
				  formulate all therapy interventions in accordance with the applicable licensure
				  rules in IDAPA 24.06.01, "Rules for the Licensure of Occupational Therapists
				  and Occupational Therapy Assistants," or IDAPA 24.13.01, "Rules Governing the
				  Physical Therapy Licensure Board," or IDAPA 24.23.01, "Rules of the Speech and
				  Hearing Services Licensure Board," as well as the applicable association's
				  professional Code of Ethics and Standards supporting best practice.
				  (3-17-22)
03.
Documentation
. (3-17-22)
a. The
				  provider must maintain financial and other records in sufficient detail to
				  allow the Department to audit them as described in Section
				  305 of these rules.
				  (3-17-22)
b. The following
				  documentation must be maintained in the files of the provider: (3-17-22)
i. Physician, nurse practitioner, or
				  physician assistant orders for therapy services; (3-17-22)
ii. Therapy plans of care; and
				  (3-17-22)
iii. Progress or other
				  notes documenting each assessment, each therapy session, and results of tests
				  and measurements related to therapy services. (3-17-22)
c. The provider must grant the Department
				  immediate access to all information required to review compliance with these
				  rules, as required in Section
				  330 of these rules. The absence of
				  such documentation is cause for recoupment of Medicaid payment.
				  (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: AUDIOLOGY SERVICES › Section 16.03.09.740 - AUDIOLOGY SERVICES

Current through August 31, 2023
Audiology services are diagnostic, screening, preventive,
					 or corrective services provided by an audiologist. These services must be
					 provided in accordance with Title 54, Chapter 29, Idaho Code, and require the
					 order of a physician, nurse practitioner, or physician assistant. Audiology
					 services do not include equipment needed by the patient such as communication
					 devices or environmental controls. (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: AUDIOLOGY SERVICES › Section 16.03.09.741 - AUDIOLOGY SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
01.
All Participants
. All participants are eligible to receive
				  diagnostic screening services necessary to obtain a differential diagnosis.
				  (3-17-22)
02.
Participants
				  Under the Age of 21
. Participants under the age of twenty-one (21) are
				  eligible for all services listed in Section
				  742 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: AUDIOLOGY SERVICES › Section 16.03.09.742 - AUDIOLOGY SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
All audiology services must be ordered by a physician or
					 non-physician practitioner. The Department will pay for routine audiometric
					 examination and testing once in each calendar year, and audiometric services
					 and supplies in accordance with the following guidelines and limitations:
					 (3-17-22)
01.
Non-Implantable
				  Hearing Aids
. When there is a documented hearing loss that meets the
				  criteria of the Idaho Medicaid Provider Handbook, the Department will cover the
				  purchase of non-implantable hearing aids for participants under the age of
				  twenty-one (21) with the following requirements and limitations: (3-17-22)
a. Covered services included with the
				  purchase of the hearing aid include proper fitting and refitting of the ear
				  mold or aid, or both, during the first year, instructions related to the aid's
				  use, and extended insurance coverage for two (2) years. (3-17-22)
b. The following services may be covered in
				  addition to the purchase of the hearing aid for participants under the age of
				  twenty-one (21): batteries purchased on a monthly basis, follow-up testing,
				  necessary repairs resulting from normal use after the second year, and the
				  refitting of the hearing aid or additional ear molds. (3-17-22)
c. Lost, misplaced, stolen or destroyed
				  hearing aids are the responsibility of the participant. The Department has no
				  responsibility for the replacement of any hearing aid. In addition, the
				  Department has no responsibility for the repair of hearing aids that have been
				  damaged as a result of neglect, abuse or use of the aid in a manner for which
				  it was not intended. (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: AUDIOLOGY SERVICES › Section 16.03.09.743 - AUDIOLOGY SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Audiology Examinations
. Basic audiometric testing by licensed
				  audiologists or licensed physicians will be covered without prior approval.
				  (3-17-22)
02.
Additional
				  Testing
. Any hearing testing beyond the basic comprehensive audiometry
				  and impedance testing must be ordered in writing before the testing is done and
				  kept on file by the provider. (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: AUDIOLOGY SERVICES › Section 16.03.09.744 - AUDIOLOGY SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
The following are qualified to provide audiology services
					 as Medicaid providers: (3-17-22)
01.
Audiologist, Licensed
. A person licensed to conduct hearing
				  assessment and therapy, according to the regulations in the state where the
				  services are provided, who meets the requirements of
				  42 CFR
				  440.110(c)(3).
				  (3-17-22)
02.
Speech-Language Pathologist, Licensed
. A person licensed to conduct
				  speech-language assessment and therapy according to the regulations in the
				  state where the services are provided, who possesses a certificate of clinical
				  competence in speech-language pathology from the American Speech, Language and
				  Hearing Association (ASHA) or who will be eligible for certification within one
				  (1) year of employment. (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: AUDIOLOGY SERVICES › Section 16.03.09.745 - AUDIOLOGY SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Payment Procedures
. The following procedures must be followed when
				  billing the Department: (3-17-22)
a. The
				  Department will only pay the hearing aid provider for an eligible Medicaid
				  participant if a properly completed claim is submitted to the Department within
				  the one (1) year billing limitation. (3-17-22)
b. Payment will be based upon the
				  Department's fee schedule in accordance with Section
				  230 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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.751 - DURABLE MEDICAL EQUIPMENT AND SUPPLIES: PARTICIPANT RESPONSIBILITY

Current through August 31, 2023
The participant has a responsibility to reasonably protect
					 and preserve equipment issued to them. Replacement of medical equipment or
					 supplies that are lost, damaged or broken due to participant misuse or abuse
					 are the responsibility of 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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.752 - DURABLE MEDICAL EQUIPMENT AND SUPPLIES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
The Department will purchase or rent, when medically
					 necessary, reasonable and cost-effective, durable medical equipment (DME) and
					 medical supplies that are suitable for use in any setting in which normal life
					 activities take place. Medical supplies, equipment, and appliances provided by
					 a home health agency under a home health plan of care must meet the
					 requirements found in Sections
					 750 through
					 779 of these rules and the
					 requirements found in Sections
					 720 through
					 729 of these rules.
					 (3-17-22)
01.
Medical Necessity
				  Criteria -- Equipment and Supplies
. Department standards for medical
				  necessity are those national standards set by Centers for Medicare and Medicaid
				  Services (CMS) in the CMS/ Medicare DME coverage manual. Exceptions to Medicare
				  coverage are described in the Idaho Medicaid Provider Handbook available at:
				  www.idmedicaid.com. Items for convenience, comfort, or cosmetic reasons are not
				  covered. (3-17-22)
02.
Prior
				  Authorization -- Equipment and Supplies
. (3-17-22)
a. The Department will specify in the Idaho
				  Medicaid Provider Handbook, which durable medical equipment and medical
				  supplies require prior authorization by the Department. (3-17-22)
b. Each request for prior authorization must
				  include all medical necessity documentation required under Section
				  753 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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.753 - DURABLE MEDICAL EQUIPMENT AND SUPPLIES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Orders
. (3-17-22)
a. All medical supplies, equipment, and
				  appliances must be ordered by a physician or non-physician practitioner acting
				  within the scope of their licensure. Such orders must meet the requirements in
				  the CMS/Medicare DME coverage manual. (7-1-23)T
b. If medical equipment and supplies are
				  required for extended periods, these must be reordered as necessary, but at
				  least annually, for all participants. (7-1-23)T
c. The following information to support the
				  medical necessity of the item(s) must be included in the order and accompany
				  all requests for prior authorization, or be kept on file with the DME provider
				  for items that do not require prior authorization: (3-17-22)
i. The participant's medical diagnosis,
				  including current information on the medical condition that requires the use of
				  the supplies or medical equipment, or both; (3-17-22)
ii. An estimate of the time period that the
				  medical equipment or supply item will be necessary and frequency of use. As
				  needed (PRN) orders must include the conditions for use and the expected
				  frequency; (3-17-22)
iii. For
				  medical equipment, a full description of the equipment needed. All
				  modifications or attachments to the basic equipment must be supported;
				  (3-17-22)
iv. For medical supplies,
				  the type and quantity of supplies necessary must be identified; and
				  (3-17-22)
v. Documentation of the
				  participant's medical necessity for the item, that meets coverage criteria.
				  (3-17-22)
vi. Additional
				  information may be requested by the Department for specific equipment or
				  supplies. (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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.756 - DURABLE MEDICAL EQUIPMENT AND SUPPLIES: QUALITY ASSURANCE

Current through August 31, 2023
The use or provision of DME/medical supply items to an
					 individual other than the participant for which such items were ordered is
					 prohibited. The provision of DME/medical supply items that is not supported by
					 required medical necessity documentation is prohibited and subject to
					 recoupment. Violators are subject to penalties for program fraud or abuse, or
					 both, that will be enforced by the Department. The Department has no obligation
					 to repair or replace any piece of durable medical equipment that has been
					 damaged, defaced, lost, or destroyed as a result of neglect, abuse, or misuse
					 of the equipment. Participants suspected of the same will be reported to the
					 Surveillance and Utilization Review (SUR/S) committee. (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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.771 - PROSTHETIC AND ORTHOTIC SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
The Medical Assistance Program will purchase or repair, or
					 both, medically necessary prosthetic and orthotic devices and related services
					 that artificially replace a missing portion of the body or support a weak or
					 deformed portion of the body within the limitations established 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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.772 - PROSTHETIC AND ORTHOTIC SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Program Requirements
. The
				  following program requirements will be applicable for all prosthetic and
				  orthotic devices or services purchased by the Department: (3-17-22)
a. A temporary lower limb prosthesis will be
				  purchased when documented by the attending physician or non-physician
				  practitioner that it is in the best interest of the participant's
				  rehabilitation to have a temporary lower limb prosthesis prior to a permanent
				  limb prosthesis. A new permanent limb prosthesis will only be requested after
				  the residual limb size is considered stable; (3-17-22)
b. A request for a replacement prosthesis or
				  orthotic device must be justified to be the least costly alternative as opposed
				  to repairing or modifying the current prosthesis or orthotic device;
				  (3-17-22)
c. All prosthetic and
				  orthotic devices that require fitting must be provided by a Podiatrist, or an
				  individual who is certified or registered by the American Board for
				  Certification in Orthotics, Prosthetics & Pedorthics (ABC) or the Board of
				  Certification/Accreditation (BOC); (4-6-23)
d. All equipment that is purchased must be
				  new at the time of purchase. Modification to existing prosthetic or orthotic
				  equipment, or both, will be covered by the Department; (3-17-22)
e. Prosthetic limbs purchased by the
				  Department must be guaranteed to fit properly for three (3) months from the
				  date of service; therefore, any modifications, adjustments, or replacements
				  within the three (3) months are the responsibility of the provider that
				  supplied the item at no additional cost to the Department or the participant;
				  and (3-17-22)
f. Not more than
				  ninety (90) days may elapse between the time of the order and the
				  preauthorization request is presented to the Department for consideration.
				  (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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.773 - PROSTHETIC AND ORTHOTIC SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
Prosthetic and orthotic devices and services will be paid
					 for only if prescribed by a physician or non-physician practitioner. The
					 following information must be included in the order and kept on file by the
					 provider: (3-17-22)
01.
Full
				  Description of the Services Requested
. (3-17-22)
02.
Number of Months the Equipment Will
				  Be Needed and the Participant's Prognosis
. (3-17-22)
03.
Participant's Medical Diagnosis and
				  Condition
. The participant's medical diagnosis and the condition that
				  requires the use of the prosthetic or orthotic services, or both, supplies,
				  equipment or modifications, or both; and (3-17-22)
04.
Modifications to the Prosthetic or
				  Orthotic Device
. All modifications must be supported by the attending
				  physician's description on the prescription. (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: DURABLE MEDICAL EQUIPMENT AND SUPPLIES › Section 16.03.09.775 - PROSTHETIC AND ORTHOTIC SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
The Department will reimburse according to Section
					 230 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: VISION SERVICES › Section 16.03.09.785 - VISION SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
All eyeglass frames and lenses provided to Medicaid
					 participants and paid for by the Medicaid Program will be purchased from the
					 supplier designated 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: DENTAL SERVICES › Section 16.03.09.800 - DENTAL SERVICES: SELECTIVE CONTRACT FOR DENTAL COVERAGE

Current through August 31, 2023
All participants eligible for Medicaid dental benefits are
					 covered under a selective contract for a dental insurance program called Idaho
					 Smiles at
http://www.healthandwelfare.idaho.gov/Medical/Medicaid/MedicalCare/DentalServices/tabid/696/Default.aspx
.
					 (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 16.03.09.801 - DENTAL SERVICES: DEFINITIONS

Current through August 31, 2023
For the purposes of dental services covered in Sections
					 800 through
					 807 of these rules, the following
					 definitions apply: (3-17-22)
01.
Adult
. A person who is past the month of their twenty-first
				  birthday. (3-17-22)
02.
Child
. A person from birth through the month of their twenty-first
				  birthday. (3-17-22)
03.
Idaho
				  Smiles
. A dental insurance program provided to eligible Medicaid
				  participants through a selective contract between the Department and a dental
				  insurance carrier. (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 16.03.09.802 - DENTAL SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
Children and adults eligible for Medicaid are eligible for
					 Idaho Smiles dental benefits described in Section
					 803 of these rules.
					 (3-17-22)