Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.04-080 - State Plan Transmittal #2004-015 - Hospital Update #70 and Physician Update #91

Current through Register Vol. 49, No. 6, June, 2024
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
1. Inpatient Hospital Services
All inpatient admissions to an acute care/general hospital or
				rehabilitative hospital will be allowed up to four (4) days of service per
				admission when determined inpatient care is medically necessary. On the fifth
				day of hospitalization, if the physician determines the patient should not be
				discharged on the fifth day of hospitalization, the hospital may contact the
Quality Improvement
Organization (Arkansas Foundation for Medical
				Care, Inc.) and request an extension of inpatient days. The
Quality
				Improvement
Organization
(QIO)
will then determine
				medically necessary days. Calls for extension of days may be made at any point
				from the fourth day of stay through discharge. However the provider must accept
				the financial liability should the stay not meet the necessary medical criteria
				for inpatient services. Medically necessary inpatient days are available to
				individuals under age 1 without regard to the four day limit and extension
				procedures required under the plan. Additionally, effective for dates of
				service on or after November 1,2001, a benefit limit of 24 days per State
				Fiscal Year (July 1 through June 30) is imposed for recipients age 21 and
				older. No extensions will be authorized. The benefit limit does not apply to
				recipients under age 21 in the Child Health Services (EPSDT) Program.
Inpatient hospital services required for pancreas/kidney
				transplants,
liver/bowel transplants
and skin transplants for
				burns are covered for eligible Medicaid recipients in the Child Health Services
				(EPSDT) Program. Refer to Attachment 3.1-E, Pages 2,4 and 6.
2. Inpatient Hospital Services
All inpatient admissions to an acute care/general hospital or
				rehabilitative hospital will be allowed up to four (4) days of service per
				admission when determined inpatient care is medically necessary. On the fifth
				day of hospitalization, if the physician determines the patient should not be
				discharged on the fifth day of hospitalization, the hospital may contact the
Quality Improvement
Organization (Arkansas Foundation for Medical
				Care, Inc.) and request an extension of inpatient days. The
Quality
				Improvement
Organization
(QIO)
will then determine
				medically necessary days. Calls for extension of days may be made at any point
				from the fourth day of stay through discharge. However the provider must accept
				the financial liability should the stay not meet the necessary medical criteria
				for inpatient services. Medically necessary inpatient days are available to
				individuals under age 1 without regard to the four day limit and extension
				procedures required under the plan. Additionally, effective for dates of
				service on or after November 1,2001, a benefit limit of 24 days per State
				Fiscal Year (July 1 through June 30) is imposed for recipients age 21 and
				older. No extensions will be authorized. The benefit limit does not apply to
				recipients under age 21 in the Child Health Services (EPSDT) Program.
Inpatient hospital services required for pancreas/kidney
				transplants,
liver/bowel transplants
and skin transplants for
				burns are covered for eligible Medicaid recipients in the Child Health Services
				(EPSDT) Program. Refer to Attachment 3.1-E, Pages 2,4, and 6.
ATTACHMENT 3.1-E
State/Territory:
ARKANSAS
STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT SERVICES
The Arkansas Medicaid Program covers Corneal Transplants, Renal
				Transplants, Heart Transplants, Liver Transplants, Non-Experimental Bone Marrow
				Transplants and Lung Transplants for eligible Medicaid recipients of all ages.
				Pancreas/Kidney Transplants,
Liver/Bowel Transplants
and Skin
				Transplants for Burns are covered for eligible Medicaid recipients in the Child
				Health Services (EPSDT) Program.
Corneal Transplants
Corneal transplants require prior authorization. Medicaid will
				pay for hospitalization, physician services and follow-up care when associated
				with corneal transplants. Covered benefits include the acquisition and
				preservation of the organ from a cadaver donor. Corneal transplants are subject
				to the same inpatient hospital, outpatient and physician benefit limits as all
				other covered inpatient, outpatient and physician services.
Renal Transplants
Renal transplants require prior authorization. Benefits are
				provided for the following services related to renal transplantation:
! Hospitalization and physician services for the removal of
				the organ from the living donor.
! Harvesting of the organ for renal transplant from a cadaver
				donor is reimbursed through the hospital cost settlement process. !
				Transportation and preservation of the organ from a living or cadaver
				donor.
! Hospitalization and physician services for transplanting
				kidney into the receiver.
! Follow-up care.
Renal transplants are subject to the same inpatient hospital,
				outpatient and physician benefit limits as all other inpatient, outpatient and
				physician services for both donor and receiver.
TN No.________________ Approval Date________________ Effective
				Date__________________
Supersedes TN No._________________________
ATTACHMENT 3.1-E
STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT
				SERVICES
Heart Transplants
Heart transplants require prior authorization. Benefits are
				provided for the following services related to heart transplantation:
* Procurement (harvesting) of the organ from a cadaver donor.
				Cost will be included in the hospital charges.
* Hospitalization and physician services for transplanting the
				heart into the receiver.
* Post-operative care until discharged from the
				hospital.
Liver
and Liver/Bowel Transplants
Liver
and liver/bowel
transplants require prior
				authorization.
Liver/Bowel transplants are covered for eligible Medicaid
				recipients in the Child Health Services (EPSDT) Program.
Benefits are
				provided for the following services related to liver
and liver/bowel
transplantation:
* Hospitalization and physician services for the removal of the
				organ from a living donor.
* Procurement (harvesting) of the organ from a cadaver donor.
				Cost will be included in the hospital charges.
* Hospitalization and physician services for transplanting the
				liver
and liver/bowel
into the receiver.
* Post-operative care until discharged from the
				hospital.
Heart, Liver
and Liver/Bowel
Transplants are not
				subject to the established benefit limits for inpatient hospital services
				described elsewhere in the State Plan. Services excluded from the inpatient
				benefit limit are those services provided from the date of the transplant
				procedure to the date of discharge. The recipient may not be billed for
				Medicaid covered charges in excess of the State's reimbursement.
ATTACHMENT 4.19-A
1. Inpatient Hospital Services
The State has in place a public process, which complies with
				the requirements of Section 1902(a)(13)(A) of the Social Security Act.
In accordance with Section 1902(s) of the Social Security Act,
				we do not impose dollar limits on any inpatient hospital services for children
				under age one (or children that are hospitalized on their first birthday). This
				includes the $675.00 upper payment limit, the TEFRA rate of increase limit, the
				customary charge upper limit or the $150,000
bone marrow
transplant limit. This applies to all inpatient hospitals.
Effective for claims with dates of service on or after July 1,
				1991, all acute care hospitals with the exception of Pediatric Hospitals,
				Arkansas State Operated Teaching Hospitals, Rehabilitative Hospitals, Inpatient
				Psychiatric Hospitals and Out-of-State Hospitals, will be reimbursed based on
				reasonable costs with interim per diem rates and year-end cost settlements,
				with an upper limit of $584.00 per day.
Effective for claims with dates of service on or after April
				1,1996, all acute care hospitals with the exception of Pediatric Hospitals,
				Arkansas State Operated Teaching Hospitals, Rehabilitative Hospitals, Inpatient
				Psychiatric Hospitals and Out-Of-state Hospitals will be reimbursed based on
				reasonable cost with interim per diem rates and year-end cost settlements, with
				an upper limit of $675.00 per day. The upper limit was established taking the
				90th percentile of the cost based per diems using their 1994 year end cost
				reports. This does not include the hospitals listed above as exceptions.
Effective for claims with dates of service on or after January
				1, 1997, the upper limit of $675.00 per day will be applied to Arkansas State
				Operated Teaching Hospitals. The upper payment limit will apply to allowable
				costs; except GME payments will not be subject to the upper limit. Effective
				for cost reporting periods ending on or after June 30, 2000, the upper limit of
				$675.00 per day will no longer be applied to Arkansas State Operated Teaching
				Hospitals.
Arkansas Medicaid will use the lesser of cost or charges to
				establish cost settlements. If the lesser of cost or charges exceed the upper
				limit payment times total hospital Medicaid days, then the upper limit payment
				times the total hospital Medicaid days will be used to calculate the cost
				settlement. Effective for dates of service on or after July 1, 1991 thru March
				31, 1996, the upper limit payment
Direct medical education costs, including graduate medical
				education costs, are reimbursed based on Medicare reasonable cost rules in
				effect prior to the effective date of the September 29, 1989 rule.
TRANSPLANT SERVICES
A.
In-State Acute Care/General Hospitals, All Bordering City Hospitals and
			 All Out-of-State
Hospitals
1.
Corneal, Renal and
			 Pancreas/Kidney Transplants
Inpatient hospital services required for corneal, renal and
				pancreas/kidney transplants are reimbursed in the same manner as other
				inpatient hospital services.
2.
Bone Marrow
			 Transplants
Interim reimbursement for bone marrow transplants will be 80%
				of billed charges, subject to subsequent review to determine that only covered
				charges are reimbursed. Reimbursement will not exceed $150,000. Reimbursement
				includes all medical services relating to the transplant procedure from the
				date of admission for the bone marrow transplant procedure to the date of
				discharge. Both the hospital and physician claims will be manually priced
				simultaneously. If the combined total exceeds the $150,000 maximum,
				reimbursement for each provider type will be decreased by an equal percentage
				resulting in an amount which does not exceed the maximum dollar limit.
3.
Other Covered
			 Transplants
Hospital services (does not include organ acquisition)
				relating to other covered transplant procedures (does not include corneal,
				renal, pancreas/kidney and bone marrow) are reimbursed at 45% of submitted
				charges. Reimbursement includes all allowable medical services relating to the
				covered transplant from the date of the transplant procedure to the date of
				discharge. Transplant hospitalization days in excess of transplant length of
				stay averages must be approved through medical review. Transplant length of
				stay averages by each transplant type will be determined from the most current
				written Medicare National Coverage Decisions.
Inpatient hospital days prior to the transplant date will
				be reimbursed in accordance with the applicable State Plan methodology for the
				hospital type in which the transplant is performed.
Readmissions to the same hospital due to complications
				arising from the original transplant are reimbursed the same as the original
				transplant service at 45% of submitted charges. All excess length of stay
				approval requirements also apply.