Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 29 - Division of Medical Services › Rule 016.29.22-017 - ARHOME, Workers with Disabilities, Transitional Medicaid Cost Sharing

Current through Register Vol. 49, No. 6, June, 2024
Section I
124.000
Beneficiary Aid
			 Categories
A full list of client aid categories is available online.
View or print the Client Aid Category list
.
124.100
Client Aid Categories with
			 Limited Benefits
Most Medicaid categories provide the full range of Medicaid
				services as specified in the Arkansas Medicaid State Plan. However, certain
				categories offer a limited benefit package. These categories are discussed
				below.
View or print the Client Aid Category list
.
124.200
Client Aid
			 Categories with Additional Cost Sharing
Certain programs require additional cost sharing for Medicaid
				services.
View or print the Client Aid Category list.
The forms of cost sharing in the Medicaid Program are
				co-payment and premiums. These programs are discussed in Sections 124.210
				through 124.250.
Copayments may not exceed the amounts listed in the cost
				sharing schedules, as updated each January 1 by the percentage increase in the
				medical care component of the CPI-U for the period of September to September
				ending in the preceding calendar year and then rounded to the next higher
				5-cent increment.
A family's total annual out-of-pocket cost sharing cannot
				exceed five percent (5%) of the family's gross income.
124.220
TEFRA
Eligibility category 49 covers children under age 19 who are
				eligible for Medicaid services as authorized by Section 134 of the Tax Equity
				and Fiscal Responsibility Act of 1982 (TEFRA) and amended by the Omnibus Budget
				Reduction Act. Children in category 49 receive the full range of Medicaid
				services. However, there are cost sharing requirements. Families will be
				charged a sliding scale monthly premium based on the income of the custodial
				parents. Custodial parents with incomes above 150 percent of the federal
				poverty level (FPL) and in excess of $25,000 annually will be subject to a
				sliding scale monthly premium. The monthly premium, described in the following
				chart, can only be assessed if the family income is in excess of one-hundred
				and fifty percent (150%) of the federal poverty level.
The premiums listed in the TEFRA Cost Share Schedule below
				represent family responsibility. They will not increase if a family has more
				than one TEFRA-eligible child. Co-payments are not charged for services to
				TEFRA children, and a family's total annual out-of-pocket cost sharing cannot
				exceed five percent (5%) of the family's gross income.
TEFRA Cost Share Schedule
Effective July 1, 2022
Family Income
Monthly Premiums
From
To
%
From
To
$0
$25,000
0%
$0
$0
$25,001
$50,000
1.00%
$20
$41
$50,001
$75,000
1.25%
$52
$78
$75,001
$100,000
1.50%
$93
$125
$100,001
$125,000
1.75%
$145
$182
$125,001
$150,000
2.00%
$208
$250
$150,001
$175,000
2.25%
$281
$328
$175,001
$200,000
2.50%
$364
$416
$200,001
No limit
2.75%
$458
$458
The maximum premium is $5,500 per year ($458 per month) for
				income levels of $200,001 and above.
124.230
Workers with
			 Disabilities
The Workers with Disabilities (WD) category is an employment
				initiative designed to enable people with disabilities to gain employment
				without losing medical benefits. Individuals who are ages sixteen (16) through
				sixty-four (64), with a disability as defined by Supplemental Security Income
				(SSI) criteria and who meet the income and resource criteria may be eligible in
				this category.
Co-payments are required for the following services:
Adult Medicaid Cost Share
						  Schedule
Service
Copay
Office Visits and Outpatient
						  Services
Physician visit (including
						  PCP/specialist/audiologist/podiatrist visit, excluding preventive services and
						  X-ray)
$4.70
Preventative Care/Screening/Immunizations/EPSDT
$0.00
Other Practitioner Office Visit (Nurse, Physician
						  Assistant)
$4.70
Federally Qualified Health Center (FQHC)
$4.70
Rural Health Clinic
$4.70
Ambulatory Surgical Center
$4.70
Family planning services and supplies (including
						  contraceptives)
$0.00
Chiropractor
$4.70
Acupuncture
Not covered
Pharmacy
Generics
$4.70
Preferred Brand Drugs
$4.70
Non-Preferred Brand Drugs
$9.40
Specialty Drugs (i.e., High-Cost)
$9.40
Testing and Imaging
X-rays and Diagnostic Imaging
$4.70
Imaging (CT/Pet Scans, MRIs)
$4.70
Laboratory Outpatient and Professional Services
$4.70
Allergy Testing
$4.70
Inpatient Services
All Inpatient Hospital Services (including
						  MH/SUD)
$0.00
Emergency and Urgent Care
Emergency Room Services
$0.00
Non-Emergency Use of the Emergency Department
$9.40
Emergency Transportation/Ambulance
$0.00
Urgent Care Centers or Facilities
$4.70
Durable Medical Equipment
Durable Medical Equipment
$4.70
Prosthetic Devices
$4.70
Orthotic Appliances
$4.70
Mental and Behavioral Health and Substance
						  Abuse
All Inpatient Hospital Services (including
						  MH/SUD)
$0.00
Mental/Behavioral Health and SUD Outpatient
						  Services
$4.70
Rehabilitation and Habilitation
Rehabilitative Occupational Therapy
$4.70
Rehabilitative Speech Therapy
$4.70
Rehabilitative Physical Therapy
$4.70
Outpatient Rehabilitation Services
$4.70
Habilitation Services
$4.70
Surgery
Inpatient Physician and Surgical Services
$0.00
Outpatient Surgery Physician/Surgical Services
$4.70
Treatments and Therapies
Chemotherapy
$4.70
Radiation
$4.70
Infertility Treatment
Not covered
Infusion Therapy
$4.70
Vision
Dental
Accidental Dental
$4.70
Women's Services
Delivery and all Inpatient services for maternity
						  care
$0.00
Prenatal and postnatal care
$0.00
Other
Home health Care Services
$4.70
Hospice Services
$0.00
End Stage Renal Disease Services (Dialysis)
$0.00
Personal Care
Not covered
* Exception:
Cost sharing for nursing facility
				services is in the form of "patient liability" which generally requires that
				patients contribute most of their monthly income toward their nursing facility
				care. Therefore, WD clients (Aid Category 10) and Transitional Medicaid clients
				(Aid Category 25) who temporarily enter a nursing home and continue to meet WD
				or TM eligibility criteria will be exempt from the co-payments listed
				above.
124.240
Transitional Medicaid Adult
The Transitional Medicaid program extends Medicaid coverage to
				families up to 185% of FPL that, due to earned income, lost eligibility for the
				Parents/Caretaker-Relative (PCR) Aid Category. The Transitional Medicaid
				program provides up to twelve (12) months of extended coverage after losing PCR
				eligibility.
Pertinent co-payment amounts for clients covered by Adult
				Transitional Medicaid are the same as those listed in Section 124.230.
124.250
Arkansas Health and
			 Opportunity for Me (ARHOME)
The ARHOME program operates as a demonstration waiver under
				Section 1115 of the Social Security Act. It provides premium assistance to
				allow clients eligible under Section 1902(a)(10)(A)(i)(VIII) of the Social
				Security Act to enroll in qualified health plans. The ARHOME aid category
				covers adults ages 19-64 who earn up to 138% of the federal poverty level and
				are not eligible for Medicare. Under ARHOME, clients receive services either
				through a qualified health plan (QHP) or through three other benefit plans
				delivered through fee for service. Cost sharing applies only to ARHOME clients
				who are enrolled in a QHP or who are awaiting enrollment in a QHP (IABP benefit
				plan). ARHOME clients in a benefit plan based on their status as medically
				frail (FRAIL) or alternative benefit plan (ABP) will not be subject to any cost
				sharing.
ARHOME QHP Cost Share amounts for clients enrolled in a QHP are
				as follows:
ARHOME QHP Cost Share
						  Schedule
Service
Copay
Office Visits and Outpatient
						  Services
Physician visit (including
						  PCP/specialist/audiologist/podiatrist visit, excluding preventive services and
						  X-ray)
$4.70
Preventative Care/Screening/Immunizations/EPSDT
$0.00
Other Practitioner Office Visit (Nurse, Physician
						  Assistant)
$4.70
Federally Qualified Health Center (FQHC)
$4.70
Rural Health Clinic
$4.70
Ambulatory Surgical Center
$4.70
Family planning services and supplies (including
						  contraceptives)
$0.00
Chiropractor
$4.70
Acupuncture
Not covered
Nutritional Counseling
$4.70
Pharmacy
Generics
$4.70
Preferred Brand Drugs
$4.70
Non-Preferred Brand Drugs
$9.40
Specialty Drugs (i.e., High-Cost)
$9.40
Testing and Imaging
X-rays and Diagnostic Imaging
$4.70
Imaging (CT/Pet Scans, MRIs)
$4.70
Laboratory Outpatient and Professional Services
$4.70
Allergy Testing
$4.70
Inpatient Services
All Inpatient Hospital Services (including
						  MH/SUD)
$0.00
Emergency and Urgent Care
Emergency Room Services
$0.00
Non-Emergency Use of the Emergency Department
$9.40
Emergency Transportation/Ambulance
$0.00
Urgent Care Centers or Facilities
$4.70
Durable Medical Equipment
Durable Medical Equipment
$4.70
Prosthetic Devices
$4.70
Orthotic Appliances
$4.70
Mental and Behavioral Health and Substance
						  Abuse
All Inpatient Hospital Services (including
						  MH/SUD)
$0.00
Mental/Behavioral Health and SUD Outpatient
						  Services
$4.70
Rehabilitation and Habilitation
Rehabilitative Occupational Therapy
$4.70
Rehabilitative Speech Therapy
$4.70
Rehabilitative Physical Therapy
$4.70
Outpatient Rehabilitation Services
$4.70
Habilitation Services
$4.70
Surgery
Inpatient Physician and Surgical Services
$0.00
Outpatient Surgery Physician/Surgical Services
$4.70
Treatments and Therapies
Chemotherapy
$4.70
Radiation
$4.70
Infertility Treatment
Not covered
Infusion Therapy
$4.70
Vision
Routine Eye Exam
Not covered
Dental
Basic Dental Services
Not covered
Accidental Dental
$4.70
Orthodontia
Not covered
Women's Services
Delivery and all Inpatient services for maternity
						  care
$0.00
Prenatal and postnatal care
$0.00
Other
Eyeglasses for Adults
Not covered
Diabetes Education
$0.00
Home Health Care Services
$4.70
Private-Duty Nursing
Not covered
Hospice Services
$0.00
End Stage Renal Disease Services (Dialysis)
$0.00
Personal Care
Not covered