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: PREVENTION SERVICES › Section 16.03.09.574 - CHIS: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
All CHIS identified on a participant's ACTP must be prior
					 authorized by the Department, or its contractor, and must be maintained in each
					 participant's file. The CHIS provider is responsible for documenting and
					 submitting the participant's ACTP to obtain prior authorization before
					 delivering any CHIS. (3-17-22)
01.
Prior Authorization Request
. The request must be submitted to the
				  Department, or its contractor, who will review and approve or deny prior
				  authorization requests and notify the provider and the parent or legal guardian
				  of the decision. Prior authorization is intended to help ensure the provision
				  of medically necessary services and will be approved according to the
				  timeframes established by the Department and as described in the Medicaid
				  Provider Handbook. (3-17-22)
a. Once the
				  initial request for prior authorization is submitted, CHIS may be delivered for
				  a maximum of twenty-four (24) total hours for up to thirty (30) calendar days
				  or until the prior authorization is approved. Initial prior authorization
				  requests must include: (3-17-22)
i. A
				  recommendation from a physician or other practitioner of the healing arts;
				  (3-17-22)
ii. The ACTP; and
				  (3-17-22)
iii. Implementation
				  plan(s). (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: PREVENTION SERVICES › Section 16.03.09.575 - CHIS: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
CHIS are delivered by individuals who meet or exceeds one
					 (1) of the qualifying criteria below in Subsections
					 575.01 through
					 575.07 of this rule, and are
					 employed by a certified DDA, or who meet the criteria as defined in Subsection
					 575.08 of this rule and is
					 enrolled as an independent CHIS provider. All providers of CHIS must meet the
					 continuing training requirements in Subsection
					 575.09 of this rule.
					 (3-17-22)
01.
Crisis
				  Intervention Technician
. A crisis intervention technician can deliver
				  crisis intervention directly with the eligible participant and must meet the
				  qualifications of a community- based supports staff as defined in IDAPA
				  16.03.10, "Medicaid Enhanced Plan Benefits," Section
				  526. The technician must be under
				  the supervision of a specialist or professional who is observing and reviewing
				  the direct crisis intervention services performed. Supervision must occur
				  monthly, or more often as necessary, to ensure the technician demonstrates the
				  necessary skills to correctly provide the crisis intervention service.
				  (3-17-22)
02.
Intervention
				  Technician
. An intervention technician can deliver habilitative skill
				  building, behavioral intervention, and crisis intervention. This is a
				  provisional position intended to allow an individual to gain the necessary
				  degree, competency, or experience needed to qualify as an intervention
				  specialist or higher. An intervention technician must be an employee of a DDA
				  and be under the supervision of a specialist or professional who is observing
				  and reviewing the direct services performed by the intervention technician.
				  Supervision must occur monthly, or more often as necessary, to ensure the
				  intervention technician demonstrates the necessary skills to correctly provide
				  the intervention. Provisional status is limited to a single eighteen (18)
				  successive month period. The qualifications for this type of provider can be
				  met by one (1) of the following: (3-17-22)
a.
				  An individual who is currently enrolled and is within twenty-four (24) semester
				  credits, or equivalent, to complete their bachelor's degree or higher from an
				  accredited institution in a human services field and working towards meeting
				  the experience and competency requirements; or (3-17-22)
b. An individual who holds a bachelor's
				  degree from an accredited institution in a human services field or has a
				  bachelor's degree and a minimum of twenty-four (24) semester credits, or
				  equivalent, in a human services field and working towards meeting the
				  experience and competency 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: PREVENTION SERVICES › Section 16.03.09.576 - CHIS: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Reimbursement
. The CHIS in Sections
				  570 through
				  577 of these rules are reimbursed
				  as defined in IDAPA 16.03.10, Medicaid Enhanced Plan Benefits," Section
				  038. (3-17-22)
02.
Claim Forms
. Provider
				  claims for payment must be submitted on claim forms provided or approved by the
				  Department. General billing instructions will be provided by the Department.
				  (3-17-22)
03.
Rates
.
				  The reimbursement rates calculated for CHIS include both services and mileage.
				  No separate charges for mileage will be paid by the Department for provider
				  transportation to and from the participant's home or other service delivery
				  location. (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: PREVENTION SERVICES › Section 16.03.09.577 - CHIS: QUALITY ASSURANCE

Current through August 31, 2023
The Department will establish performance criteria to meet
					 federal assurances that measure the outcomes and effectiveness of the CHIS.
					 Quality assurance activities will include the observation of service delivery
					 with participants, face-to-face visits to review program protocol, and review
					 of participant records maintained by the provider. All CHIS providers must
					 grant the Department immediate access to all information requested 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 for CHIS. The Department will visit providers to monitor
				  outcomes, assure treatment fidelity, and assure health and safety. The
				  Department will also gather information to assess family and participant
				  satisfaction with services. These findings may lead to quality improvement
				  activities to enhance provider processes and outcomes for the participant. If
				  problems are identified that impact health and safety or are not resolved
				  through quality improvement activities, implementation of a corrective action
				  process will occur. (3-17-22)
02.
Quality Improvement
. Quality improvement consists of the
				  Department working with the provider to resolve identified issues and enhance
				  services provided. Quality improvement activities may include any of the
				  following: (3-17-22)
a. Consultation;
				  (3-17-22)
b. Technical assistance
				  and recommendations; or (3-17-22)
c. A Corrective Action.
				  (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: PREVENTION SERVICES › Section 16.03.09.580 - CHILD WELLNESS SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Interperiodic Medical Screens
. Interperiodic medical screens are screens
				  that are done at intervals other than those identified in the American Academy
				  of Pediatrics periodicity schedule. (3-17-22)
02.
Periodic Medical Screens
.
				  Interperiodic medical screens are screens done at intervals identified in the
				  American Academy of Pediatrics periodicity schedule. (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: PREVENTION SERVICES › Section 16.03.09.581 - CHILD WELLNESS SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
Child Wellness Services are available to all participants
					 up to, and including, the month of their twenty-first (21st) 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: PREVENTION SERVICES › Section 16.03.09.582 - CHILD WELLNESS SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Periodic Medical Screens
.
				  Periodic medical screens are to be completed according to the American Academy
				  of Pediatrics periodicity schedule including blood lead tests at age twelve
				  (12) months and twenty-four (24) months. The medical screen must include a
				  blood lead test when the participant is age two (2) through age twenty-one (21)
				  and has not been previously tested. (3-17-22)
02.
Interperiodic Screens
.
				  Interperiodic screens will be performed when there are indications that it is
				  medically necessary to determine whether a child has a physical or mental
				  illness or condition that may require further assessment, diagnosis, or
				  treatment. Interperiodic screens may occur in children who have already been
				  diagnosed with an illness or condition, and there is indication that the
				  illness or condition may have become more severe or changed sufficiently, so
				  that the further examination is medically necessary (3-17-22)
03.
Developmental Screens
.
				  Developmental screening is considered part of every routine initial and
				  periodic examination. If the screening identifies a developmental problem, then
				  a developmental assessment will be ordered by the physician, certified nurse
				  midwife, PA, or NP and be conducted by qualified professionals.
				  (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: PREVENTION SERVICES › Section 16.03.09.584 - CHILD WELLNESS SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Interperiodic Medical
				  Screens
. Interperiod medical screens must be performed by a physician,
				  NP, or PA. (3-17-22)
02.
Periodic Medical Screens
. Periodic medical screens can be performed by a
				  physician, certified nurse midwife, PA, or NP. (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: PREVENTION SERVICES › Section 16.03.09.585 - EARLY INTERVENTION SERVICES

Current through August 31, 2023
Early Intervention Services for infants and toddlers
					 enrolled in Idaho Medicaid are provided by the Idaho Infant Toddler Program
					 (ITP). Early Intervention Services must be provided in accordance with the
					 Individuals with Disabilities Education Act (IDEA), Part C, and all Medicaid
					 regulations. (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: PREVENTION SERVICES › Section 16.03.09.586 - EARLY INTERVENTION SERVICES: PROGRAM REQUIREMENTS

Current through August 31, 2023
Idaho Medicaid and the ITP coordinate the delivery of Early
					 Intervention Services through an intra-agency agreement published on the
					 Department's website. Program requirements include: (3-17-22)
01.
Physician Recommendation
.
				  The ITP can bill for health-related services provided to eligible children when
				  the services are documented as medically necessary and provided under the
				  recommendation of a physician, certified nurse midwife, PA, or NP. ITP may not
				  seek reimbursement for services provided more than thirty (30) days prior to
				  the signed and dated physician recommendation. The recommendation is valid for
				  up to three hundred sixty-five (365) days. (3-17-22)
02.
Individualized Family Service Plan
				  (IFSP)
. The ITP may bill for Medicaid services covered by a current
				  IFSP. The plan must be developed by a multi-disciplinary team and be based on
				  the results of assessment(s). (3-17-22)
03.
Qualified Staff
. ITP staff
				  qualifications must meet IDEA Part C requirements, and all Medicaid regulations
				  as specified in the intra-agency agreement. (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: PREVENTION SERVICES › Section 16.03.09.587 - EARLY INTERVENTION SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Medicaid will reimburse the Infant Toddler Program for
					 covered medically necessary services. (3-17-22)
01.
Fee Schedule
. Reimbursement
				  for Early Intervention Services will be based on the Idaho Medicaid Fee
				  Schedule for Early Intervention. (3-17-22)
02.
Payment Review
.
				  Reimbursement is subject to pre-payment and post-payment review in accordance
				  with Section
				  56-209h(3), Idaho
				  Code, and recoupment in accordance with IDAPA 16.05.07, "The Investigation and
				  Enforcement of Fraud, Abuse, and Misconduct." (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: PREVENTION SERVICES › Section 16.03.09.590 - ADULT PHYSICALS

Current through August 31, 2023
Adult preventive physical examinations are limited to one
					 (1) per year. (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: PREVENTION SERVICES › Section 16.03.09.602 - SCREENING MAMMOGRAPHIES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Screening Mammographies
.
				  Align with the "A" and "B" recommendations of the United States Preventative
				  Services Task force. (7-1-23)T
02.
Diagnostic Mammographies
. Are not subject to the limitations of
				  screening mammographies. Diagnostic mammographies are covered when a physician
				  or licensed practitioner of the healing arts orders the procedure for a
				  participant of any age. (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: PREVENTION SERVICES › Section 16.03.09.604 - SCREENING MAMMOGRAPHIES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Idaho Medicaid will cover screening or diagnostic
					 mammographies performed with mammography equipment by staff considered
					 certifiable or certified by the Bureau of Laboratories or the equivalent for
					 providers in other states. (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: PREVENTION SERVICES › Section 16.03.09.610 - CLINIC SERVICES: DIAGNOSTIC SCREENING CLINICS

Current through August 31, 2023
The Department will reimburse medical social service visits
					 to clinics that coordinate the treatment between physicians and other medical
					 professionals for participants which are diagnosed with cerebral palsy,
					 myelomeningitis or other neurological diseases and injuries with comparable
					 outcomes. (3-17-22)
01.
Multidisciplinary Assessments and Consultations
. The clinic must perform
				  on site multidisciplinary assessments and consultations with each participant
				  and responsible parent or guardian. Diagnostic and consultive services related
				  to the diagnosis and treatment of the participant will be provided by board
				  certified physician specialists in physical medicine, neurology and
				  orthopedics. (3-17-22)
02.
Billings
. No more than five (5) hours of medical social services per
				  participant may be billed by the specialty clinic each state fiscal year for
				  which the medical social worker monitors and arranges participant treatments
				  and provides medical information to providers who have agreed to coordinate the
				  care of their participant. (3-17-22)
03.
Services Performed
. Services
				  performed or arranged by the clinic will be subject to the amount, scope and
				  duration for each service as set forth elsewhere in this chapter.
				  (3-17-22)
04.
The
				  Clinic
. The clinic is established as a separate and distinct entity from
				  the hospital, physician or other provider practices. (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: PREVENTION SERVICES › Section 16.03.09.618 - HEALTH QUESTIONNAIRE

Current through August 31, 2023
The Health Questionnaire assesses the general health status
					 and health behaviors of a participant. The information collected is used to
					 provide customized health education to the participant. The Health
					 Questionnaire is administered at initial program entry and at periodic
					 intervals thereafter. Participant responses to the issues addressed in the
					 Health Questionnaire may identify a participant's interest in the Preventive
					 Health Assistance benefits described in Section
					 620 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: PREVENTION SERVICES › Section 16.03.09.620 - PREVENTIVE HEALTH ASSISTANCE (PHA): DEFINITIONS

Current through August 31, 2023
01.
Behavioral PHA
. Benefits available to a participant specifically
				  to support weight control. (3-17-22)
02.
Benefit Year
. A benefit year
				  is twelve (12) continuous months. A participant's PHA benefit year begins the
				  date their initial points are earned. (3-17-22)
03.
PHA Benefit
. A mechanism to
				  reward healthy behaviors and good health choices of a participant eligible for
				  preventive health assistance. (3-17-22)
04.
Wellness PHA
. Benefits
				  available to a participant to support wellness. (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: PREVENTION SERVICES › Section 16.03.09.621 - PREVENTIVE HEALTH ASSISTANCE (PHA): PARTICIPANT ELIGIBILITY

Current through August 31, 2023
01.
Behavioral PHA
. The
				  participant must have a Health Questionnaire on file with the Department. The
				  Health Questionnaire is used to determine eligibility for a Behavioral PHA. The
				  participant must indicate on the Health Questionnaire that they want to change
				  a behavior related to weight management. The participant must meet one (1) of
				  the following criteria: (3-17-22)
a. For an
				  adult, a body mass index (BMI) of thirty (30) or higher or eighteen and
				  one-half (18 1/2) or lower. (3-17-22)
b. For a child, a body mass index (BMI) that
				  falls in either the overweight or the underweight category as calculated using
				  the Centers for Disease Control (CDC) Child and Teen BMI Calculator.
				  (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: PREVENTION SERVICES › Section 16.03.09.622 - PREVENTIVE HEALTH ASSISTANCE (PHA): COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Point System
. The PHA
				  benefit uses a point system to track points earned and used by a participant.
				  Each point equals one (1) dollar. (3-17-22)
a.
				  Maximum Benefit Points. (3-17-22)
i. The
				  maximum number of points that can be earned for a Behavioral PHA is two hundred
				  (200) points each benefit year. (3-17-22)
ii. The maximum number of points that can be
				  earned for a Wellness PHA benefit is one hundred twenty (120) points each
				  benefit year. (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: PREVENTION SERVICES › Section 16.03.09.623 - PREVENTIVE HEALTH ASSISTANCE (PHA): PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Behavioral PHA
. (3-17-22)
a. A PHA benefit will be established for each
				  participant who meets the eligibility criteria for Behavioral PHA. A
				  participant must complete a PHA Benefit Agreement Form prior to earning any
				  points. (3-17-22)
b. Each
				  participant who chooses to enroll in weight management must participate in a
				  physician approved or monitored weight management program. (3-17-22)
c. An initial one hundred (100) points are
				  earned when the agreement form is received by the Department and the benefit is
				  established. (3-17-22)
d. An
				  additional one hundred (100) points can be earned by a participant who
				  completes their program or reaches a chosen, defined goal. The vendor
				  monitoring the participant's progress must verify that the program was
				  completed or the goal was reached. (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: PREVENTION SERVICES › Section 16.03.09.624 - PREVENTIVE HEALTH ASSISTANCE (PHA): PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Provider Agreement
. A
				  behavioral PHA vendor must have a fully-executed provider agreement on file
				  with the Department prior to providing services or products.
				  (3-17-22)
02.
Prior
				  Authorization
. A behavioral PHA vendor must request prior authorization
				  from the Department for each product or service provided as a PHA benefit.
				  (3-17-22)
03.
Medications and
				  Pharmaceutical Supplies Vendor
. Each vendor must be a licensed pharmacy
				  and must meet the criteria in Section
				  664 of these rules for prescription
				  drug provider qualifications and duties. (3-17-22)
04.
Weight Management Program
				  Vendor
. Each vendor must: (3-17-22)
a.
				  Be established as a business that serves the general public;
				  (3-17-22)
b. Meet all state,
				  county, and local business licensing requirements: and (3-17-22)
c. Be able to provide a weight management
				  program as described in Section
				  622 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: PREVENTION SERVICES › Section 16.03.09.625 - PREVENTIVE HEALTH ASSISTANCE (PHA): PROVIDER REIMBURSEMENT

Current through August 31, 2023
With the prior agreement of the participant, the vendor may
					 bill the participant for the difference between the Department's reimbursement
					 and the vendor's usual and customary charge for Behavioral PHA products or
					 services 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: PREVENTION SERVICES › Section 16.03.09.626 - PREVENTIVE HEALTH ASSISTANCE (PHA): QUALITY ASSURANCE

Current through August 31, 2023
The Department will establish performance measurements to
					 evaluate the effectiveness of PHA. The performance measurements will be
					 reviewed at least annually and adjusted as necessary to provide quality
					 assurance. (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: PREVENTION SERVICES › Section 16.03.09.630 - NUTRITIONAL SERVICES: DEFINITIONS

Current through August 31, 2023
Nutritional services include intensive nutritional
					 education, counseling, and monitoring. (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: PREVENTION SERVICES › Section 16.03.09.632 - NUTRITIONAL SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Order
. The need for nutritional services must be discovered by
				  screening services and ordered by the physician or non-physician practitioner.
				  (3-17-22)
02.
Medically
				  Necessary
. The services must 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: PREVENTION SERVICES › Section 16.03.09.634 - NUTRITIONAL SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Nutritional services must be performed by a registered
					 dietician or an individual who has a baccalaureate degree from a U.S.
					 regionally accredited college or university and has met the academic and
					 professional requirements in dietetics as approved by the American Dietetic
					 Association. (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: PREVENTION SERVICES › Section 16.03.09.635 - NUTRITIONAL SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Payment for nutritional services is made at a rate
					 established 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: PREVENTION SERVICES › Section 16.03.09.640 - DIABETES EDUCATION AND TRAINING SERVICES: DEFINITIONS

Current through August 31, 2023
A Certified Diabetes Educator is a state-licensed health
					 professional who is certified by the Certification Board for Diabetes Care and
					 Education or the Association of Diabetes Care and Education Specialists
					 (ADCES). (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: PREVENTION SERVICES › Section 16.03.09.641 - DIABETES EDUCATION AND TRAINING SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
The medical necessity for diabetes education and training
					 are evidenced by the following: (3-17-22)
01.
Participants with Diabetes
.
				  Are eligible for a Diabetes Management Program when: (7-1-23)T
a. A recent diagnosis of diabetes within
				  ninety (90) days of enrollment with no history of prior diabetes education; or
				  (7-1-23)T
b. Uncontrolled diabetes
				  manifested by two (2) or more fasting blood sugar of greater than one hundred
				  forty milligrams per decaliter (140 mg/dL), hemoglobin A1c greater than eight
				  percent (8%), or random blood sugar greater than one hundred eighty milligrams
				  per decaliter (180 mg/dL), in addition to the manifestations; or
				  (7-1-23)T
c. Recent manifestations
				  from poor diabetes control including neuropathy, retinopathy, recurrent
				  hypoglycemia, repeated infections, or nonhealing wounds.
				  (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: PREVENTION SERVICES › Section 16.03.09.642 - DIABETES EDUCATION AND TRAINING SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Concurrent Diagnosis
. Only
				  training and education services that are reasonable and necessary will be
				  covered. Covered professional and educational services will address each
				  participant's medical needs through scheduled outpatient group or individual
				  training or counseling concerning diet and nutrition, exercise, medications,
				  home glucose monitoring, insulin administration, foot care, or the effects of
				  other current illnesses and complications. (7-1-23)T
02.
No Substitutions
. The
				  physician may not use the formally structured program, or a Certified Diabetes
				  Educator, as a substitute for basic diabetic care and instruction the physician
				  must furnish to the participant, which includes the disease process and
				  pathophysiology of diabetes mellitus, and dosage administration of oral
				  hypoglycemic agents. (3-17-22)
03.
Services Limited
. Diabetes education and training services will be
				  limited to twenty-four (24) hours of group sessions and twelve (12) hours of
				  individual counseling every five (5) calendar years. (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: PREVENTION SERVICES › Section 16.03.09.643 - DIABETES EDUCATION AND TRAINING SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
To receive diabetes counseling, the participant must have a
					 written order from the primary care provider who referred the participant to
					 the 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: PREVENTION SERVICES › Section 16.03.09.644 - DIABETES EDUCATION AND TRAINING SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Outpatient diabetes education and training services will be
					 covered under one (1) of the following conditions: (7-1-23)T
01.
Diabetes Management Program
.
				  The education and training services are provided through a diabetes management
				  program recognized as meeting the program standards of the American Diabetes
				  Association or Association of Diabetes Care and Education Specialists by a
				  certified diabetic educator. (7-1-23)T
02.
The National Diabetes Prevention
				  Program
. The provider meets the requirements for the program.
				  (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: PREVENTION SERVICES › Section 16.03.09.645 - DIABETES EDUCATION AND TRAINING SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Diabetes education and training services will be reimbursed
					 according to the Department's established 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: LABORATORY AND RADIOLOGY SERVICES › Section 16.03.09.650 - LABORATORY AND RADIOLOGY SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Independent Laboratory
. A laboratory that is not located in a
				  physician's office, and receives specimens from a source other than another
				  laboratory. A physician is not an independent laboratory. (3-17-22)
02.
Laboratory or Clinical
				  Laboratory
. A facility for the biological, microbiological, serological,
				  chemical, immunohematological, hematological, biophysical, cytological,
				  pathological, or other examinations of material derived from the human body for
				  the purpose of providing information for the diagnosis, prevention, or
				  treatment of any disease, or the impairment or assessment of human health.
				  (3-17-22)
03.
Proficiency
				  Testing
. Evaluation of a laboratory's ability to perform laboratory
				  procedures within acceptable limits of accuracy through analysis of unknown
				  specimens distributed at periodic intervals. (3-17-22)
04.
Quality-Control
. A
				  day-to-day analysis of reference materials to ensure reproducibility and
				  accuracy of laboratory results, and includes an acceptable system to assure
				  proper functioning of instruments, equipment and reagents. (3-17-22)
05.
Reference Laboratory
. A
				  laboratory that only accepts specimens from other laboratories.
				  (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: LABORATORY AND RADIOLOGY SERVICES › Section 16.03.09.653 - LABORATORY AND RADIOLOGY SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Medical Necessity Criteria
.
				  Services must meet the definition of Medical Necessity in Section
				  011 of these rules as detailed in
				  the Idaho Medicaid Provider Handbook. (3-17-22)
02.
Prior Authorization of
				  Services
. The Department may require prior authorization of any
				  laboratory or radiology service as detailed in the Idaho Medicaid Provider
				  Handbook. (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: LABORATORY AND RADIOLOGY SERVICES › Section 16.03.09.654 - LABORATORY AND RADIOLOGY SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Laboratory and Radiology
				  Requirements
. Providers of laboratory and radiology services must be
				  eligible for Medicare certification for these services. (3-17-22)
02.
Use of Reference
				  Laboratories
. Laboratories using reference laboratories must ensure that
				  all requirements of Sections
				  650 through
				  659 of these rules are met by the
				  reference laboratory. (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: LABORATORY AND RADIOLOGY SERVICES › Section 16.03.09.655 - LABORATORY AND RADIOLOGY SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Provider of Service
. Payment
				  for laboratory tests can only be made to the actual provider of that service.
				  An exception to the preceding is made in the case of: (3-17-22)
a. An independent laboratory that can bill
				  for a reference laboratory; (3-17-22)
b. A transplant facility that can bill for
				  histocompatibility testing; and (3-17-22)
c. Healthcare professionals acting within the
				  licensure and scope of their practice to comply with IDAPA 16.02.12, "Newborn
				  Screening." (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: LABORATORY AND RADIOLOGY SERVICES › Section 16.03.09.656 - LABORATORY AND RADIOLOGY SERVICES: QUALITY ASSURANCE

Current through August 31, 2023
Laboratories, as a condition of payment, must maintain a
					 quality-control program, including proficiency testing consistent with federal
					 requirements, as detailed in the Idaho Medicaid Provider Handbook. The
					 laboratory must provide the results of proficiency testing to the Department or
					 their Quality Improvement Organization vendor upon request. (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: PRESCRIPTION DRUGS › Section 16.03.09.661 - PRESCRIPTION DRUGS: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
01.
Obtaining a Prescription Drug
. To obtain a prescription drug, a Medicaid
				  participant or authorized agent must present the participant's Medicaid
				  identification card to a participating pharmacy together with a prescription
				  from a licensed prescriber. (3-17-22)
02.
Tamper-Resistant Prescription
				  Requirements
. Any written, non-electronic prescription for a Medicaid
				  participant must be written on a tamper-resistant prescription form. The paper
				  on which the prescription is written must have: (3-17-22)
a. One (1) or more industry-recognized
				  features designed to prevent unauthorized copying of a completed or blank
				  prescription form; (3-17-22)
b. One
				  (1) or more industry-recognized features designed to prevent the erasure or
				  modification of information written on the prescription by the prescriber;
				  (3-17-22)
c. One (1) or more
				  industry-recognized features designed to prevent the use of counterfeit
				  prescription forms. (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: PRESCRIPTION DRUGS › Section 16.03.09.662 - PRESCRIPTION DRUGS: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
General Drug Coverage
. The Department will pay for those prescription
				  drugs not excluded by Subsections
				  662.06 and
				  662.07 of this rule that are
				  legally obtainable by the order of a licensed prescriber whose licensing allows
				  for the prescribing of prescription drugs or legend drugs, as defined under
				  Section 54-1705, Idaho Code, and which are
				  deemed medically necessary as defined in Section
				  011 of these rules.
				  (3-17-22)
02.
Preferred Drug
				  List (PDL)
. (3-17-22)
a. The PDL
				  identifies the preferred drugs and non-preferred drugs within a therapeutic
				  class designated by the Department and reviewed by the Idaho Medicaid Pharmacy
				  and Therapeutics Committee. (3-17-22)
b. A brand name drug may be designated as a
				  preferred drug by the Department if the net cost of the brand name drug after
				  consideration of all rebates is less than the cost of the generic equivalent.
				  (3-17-22)
c. The Director of the
				  Department makes final decisions regarding the designated preferred or
				  non-preferred status of drugs based on therapeutic recommendations from the
				  Pharmacy and Therapeutics Committee and cost analysis from the Idaho Medicaid
				  Pharmacy Program. (3-17-22)
d.
				  Drugs in a drug class on the Medicaid PDL may require therapeutic prior
				  authorization regardless of preferred or non-preferred designation.
				  (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: PRESCRIPTION DRUGS › Section 16.03.09.663 - PRESCRIPTION DRUGS: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
In accordance with Section
					 1927(d)(1)(A)  of
					 the Social Security Act, the Idaho Medicaid Pharmacy Program may subject any
					 covered outpatient drug to prior authorization. (3-17-22)
01.
Drugs Requiring Prior
				  Authorization
. No payment for drugs requiring prior authorization will
				  be issued until the prior authorization request has been reviewed and approved
				  by the Department. (3-17-22)
02.
Prior Authorization Criteria
. Criteria for prior authorization for
				  individual drugs and drug classes will be determined by the Department, and
				  will include: (3-17-22)
a. Food and Drug
				  Administration (FDA) indications and labeling, including dosage guidelines.
				  (3-17-22)
b. Compendia of drug
				  information recognized by the Centers for Medicare and Medicaid Services (CMS),
				  including: (3-17-22)
i. American Hospital
				  Formulary Service-Drug Information; (3-17-22)
ii. United States Pharmacopeia-Drug
				  Information, or its successor publications; and (3-17-22)
iii. The DrugDex Information System.
				  (3-17-22)
c.
				  Evidence-based, peer-reviewed, published medical literature, including:
				  (3-17-22)
i. Systematic reviews;
				  (3-17-22)
ii. Randomized controlled
				  trials; and (3-17-22)
iii.
				  Meta-analysis studies. (3-17-22)
d. Guidelines and case-controlled studies may
				  be considered where systematic reviews, randomized controlled trials and
				  meta-analysis studies do not exist. (3-17-22)
e. The requested drug's preferred drug
				  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: PRESCRIPTION DRUGS › Section 16.03.09.664 - PRESCRIPTION DRUGS: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Payment for Covered Drugs
.
				  Payment will be made, as provided in Section
				  665 of these rules, only to
				  pharmacies registered with the Department as a provider for the specific
				  location where the service was performed. An out of the state pharmacy shipping
				  or mailing a prescription into Idaho must have a valid mail order license
				  issued by the Idaho Board of Pharmacy and be properly enrolled as a Medicaid
				  provider. (3-17-22)
02.
Dispensing Procedures
. The following protocol must be followed for
				  proper prescription filling. (3-17-22)
a.
				  Prescription Drug Refills. Refills of prescription drugs must be authorized by
				  the prescriber on the original or new prescription order on file and each
				  refill must be recorded on the prescription or logbook, or computer print-out,
				  or on the participant's medication profile. (3-17-22)
b. Automatic Refills. (3-17-22)
i. Automatic refills are not allowed for
				  Idaho Medicaid participants. A request specific to each medication is required.
				  (3-17-22)
ii. All prescription
				  refills must be initiated by a request from the participant, the prescriber, or
				  another person, such as a family member, acting as an agent of the participant.
				  (3-17-22)
iii. Authorization for
				  each prescription refill must be received prior to the beginning of the filling
				  process by the pharmacy. (3-17-22)
c. Dispensing Prescription Drugs.
				  Prescriptions must be dispensed according to: (3-17-22)
i.
												21 CFR Section
				  1300, et seq.; (3-17-22)
ii. Title 54, Chapter 17, and Title 37,
				  Chapters 1, 27, and 32, Idaho Code; (3-17-22)
iii. IDAPA 27.01.03, "Rules Governing
				  Pharmacy Practice"; and (3-17-22)
iv. Sections
				  660 through
				  666 of these rules.
				  (3-17-22)
d. Prescriptions
				  on File. Prescriptions must be maintained on file in pharmacies in such a
				  manner that they are available for immediate review by the Department upon
				  written request. (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: PRESCRIPTION DRUGS › Section 16.03.09.666 - PRESCRIPTION DRUGS: QUALITY ASSURANCE

Current through August 31, 2023
01.
Pharmacy
				  And Therapeutics Committee (P&T Committee)
. (3-17-22)
a. Membership. The P&T Committee is
				  appointed by the Director and is composed of practicing pharmacists, physicians
				  and other licensed health care professionals with authority to prescribe
				  medications. (3-17-22)
b. Function.
				  The P&T Committee has the following responsibilities for the prior
				  authorization of drugs under Section
				  663 of these rules: (3-17-22)
i. To serve in evaluational, educational and
				  advisory capacities to the Idaho Medicaid Pharmacy Program specific to the
				  prior authorization of drugs. (3-17-22)
ii. To review evidence-based clinical and
				  pharmacy economic data and recommend to the Department preferred and
				  non-preferred drugs in classes designated for the Idaho Medicaid Preferred Drug
				  List. (3-17-22)
iii. To recommend
				  to the Department the classes of medications to be reviewed through
				  evidence-based evaluation. (3-17-22)
iv. To review drug utilization outcome
				  studies and intervention reports from the Drug Utilization Review Board as part
				  of the process of reviewing and developing recommendations to the Department.
				  (3-17-22)
c. Meetings. The
				  P&T Committee meetings will be open to the public and a portion of each
				  meeting will be set aside to hear and review public comment. The P&T
				  Committee may adjourn to executive session to consider the following: (3-17-22)
i. Relative cost information for prescription
				  drugs that could be used by representatives of pharmaceutical manufacturers or
				  other people to derive the proprietary information of other pharmaceutical
				  manufacturers; or (3-17-22)
ii.
				  Participant-specific or provider-specific information.
				  (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: FAMILY PLANNING › Section 16.03.09.681 - FAMILY PLANNING SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
01.
Sterilization Procedures -- General
				  Restrictions
. The following restrictions govern payment for
				  sterilization procedures for eligible persons. (3-17-22)
a. No sterilization procedures will be paid
				  on behalf of a participant who is not at least twenty-one (21) years of age at
				  the time they sign the informed consent. (3-17-22)
b. No sterilization procedures will be paid
				  on behalf of any participant who is twenty-one (21) years of age or over and
				  who is incapable of giving informed consent. (3-17-22)
c. Each participant must voluntarily sign the
				  properly completed "Consent Form" HW 0034, or its equivalent, in the presence
				  of the person obtaining consent in accordance with Section
				  683 of these rules.
				  (3-17-22)
d. Each participant must
				  sign the "Consent Form" at least thirty (30) days but not more than one hundred
				  eighty (180) days, prior to the sterilization procedures. Exceptions to these
				  time requirements are described under Subsection
				  682.03 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: FAMILY PLANNING › Section 16.03.09.682 - FAMILY PLANNING SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Family planning includes counseling and medical services
					 prescribed or performed by an independent licensed physician, or a qualified
					 certified nurse practitioner or physician's assistant. Specific items covered
					 are diagnosis, treatment, contraceptive supplies, related counseling, and
					 restricted sterilization. (3-17-22)
01.
Contraceptive Supplies
.
				  (3-17-22)
a. Contraceptive supplies include
				  condoms, foams, creams and jellies, prescription diaphragms, intrauterine
				  devices, or oral contraceptives. (3-17-22)
b. Contraceptives requiring a prescription
				  are payable subject to Section
				  662 of these rules.
				  (3-17-22)
c. Payment for oral
				  contraceptives is limited to purchase of a three (3) month supply.
				  (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: FAMILY PLANNING › Section 16.03.09.683 - FAMILY PLANNING SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Sterilization Consent Form
				  Requirements
. Informed consent exists when a properly completed "Consent
				  Form" HW 0034, or its equivalent, is submitted to the Department together with
				  the physician's claim for the sterilization. (3-17-22)
a. The consent form must be signed and dated
				  by: (3-17-22)
i. The participant to be
				  sterilized; and (3-17-22)
ii. The
				  interpreter, if one (1) is provided; and (3-17-22)
iii. The individual who obtains the consent;
				  and (3-17-22)
iv. The physician who
				  will perform the sterilization procedure. (3-17-22)
v. If the individual obtaining the consent
				  and the physician who will perform the sterilization procedure are the same
				  person, that person must sign both statements on the consent form.
				  (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: FAMILY PLANNING › Section 16.03.09.685 - FAMILY PLANNING SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Payment to providers of family planning services for
					 contraceptive supplies is limited to estimated acquisition cost.
					 (3-17-22)