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: HOSPITAL SERVICES › Section 16.03.09.415 - OUTPATIENT HOSPITAL SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Outpatient Hospital
. The
				  Department will not pay more than the combined payments the provider is allowed
				  to receive from the participants and carriers or intermediaries for providing
				  comparable services under comparable circumstances under Medicare. For those
				  providers subject to cost settlement, outpatient hospital services identified
				  below that are not listed in the Department's fee schedules will be reimbursed
				  reasonable costs based on a year-end cost settlement. (3-17-22)
a. Maximum payment for hospital outpatient
				  diagnostic laboratory services will be limited to the Department's established
				  fee schedule. (3-17-22)
b. Maximum
				  payment for hospital outpatient partial care services will be limited to the
				  Department's established fee schedule. (3-17-22)
c. Hospital-based ambulance services will be
				  reimbursed at the lower of either the provider's actual charge for the service
				  or the maximum allowable charge for the service as established by the
				  Department in its pricing file. (3-17-22)
d. Hospital Outpatient Surgery. Those items
				  furnished by a hospital to an outpatient in connection with Ambulatory Surgical
				  Center must be surgical procedures covered by Idaho Medicaid. The aggregate
				  amount of payments for related facility services, furnished in a hospital on an
				  outpatient basis, is equal to the lesser of: (3-17-22)
i. The hospital's reasonable costs as reduced
				  by federal mandates for certain operating costs, capital costs, customary
				  hospital charges; or (3-17-22)
ii.
				  The blended payment amount that is based on hospital specific cost and charge
				  data and Medicaid rates paid to free-standing Ambulatory Surgical Centers
				  (ASC); or (3-17-22)
iii. The
				  blended rate of costs and the Department's fee schedule for ambulatory surgical
				  centers at the time of cost settlement; or (3-17-22)
iv. The blended rate for outpatient surgical
				  procedures is equal to the sum of forty-two percent (42%) of the hospital
				  specific amount and fifty-eight percent (58%) of the ASC amount.
				  (3-17-22)
e. Hospital
				  Outpatient Radiology Services include diagnostic and therapeutic radiology, CAT
				  scan procedures, magnetic resonance imaging, ultrasound and other imaging
				  services. The aggregate payment for hospital outpatient radiology services
				  furnished will be equal to the lesser of: (3-17-22)
i. The hospital's reasonable costs; or
				  (3-17-22)
ii. The hospital's
				  customary charges; or (3-17-22)
iii. The blended payment amount for hospital
				  outpatient radiology equal to the sum of forty-two percent (42%) of the
				  hospital specific amount and fifty-eight percent (58%) of the Department's fee
				  schedule amount. (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: HOSPITAL SERVICES › Section 16.03.09.422 - RECONSTRUCTIVE SURGERY: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Reconstruction or restorative procedures that may be
					 rendered with prior approval by the Department include procedures that restore
					 function of the affected or related body part(s). Approvable procedures include
					 breast reconstruction after mastectomy, or the repair of other injuries
					 resulting from physical trauma. (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: HOSPITAL SERVICES › Section 16.03.09.431 - SURGICAL PROCEDURES FOR WEIGHT LOSS: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
Surgery for the correction of obesity is covered when all
					 of the following conditions are met: (3-17-22)
01.
Participant Medical
				  Condition
. The participant must meet criteria for clinically severe
				  obesity with a Body Mass Index (BMI) equal to or greater than forty (40), or a
				  BMI equal to or greater than thirty-five (35) with comorbid conditions such as
				  type 2 diabetes, hypothyroidism, atherosclerotic cardiovascular disease, or
				  osteoarthritis of the lower extremities. The serious comorbid medical condition
				  must be documented by the primary physician who refers the patient for the
				  procedure, or a physician specializing in the participant's comorbid condition
				  who is not associated by clinic or other affiliation with the surgeons who will
				  perform the surgery. (3-17-22)
02.
Other Medical Condition Exists
. The obesity is caused by the
				  serious comorbid condition, or the obesity could aggravate the participant's
				  cardiac, respiratory or other systemic disease. (3-17-22)
03.
Psychiatric Evaluation
. The
				  participant must have a psychiatric evaluation to determine the stability of
				  personality at least ninety (90) days prior to the date a request for prior
				  authorization is submitted to Medicaid. (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: HOSPITAL SERVICES › Section 16.03.09.432 - SURGICAL PROCEDURES FOR WEIGHT LOSS: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Non-Surgical Treatment for
				  Obesity
. Services in connection with non-surgical treatment of obesity
				  are covered only when such services are an integral and necessary part of
				  treatment for another medical condition that is covered by Medicaid.
				  (3-17-22)
02.
Abdominoplasty
				  or Panniculectomy
. Abdominoplasty or panniculectomy is covered when
				  medically necessary, as defined in Section
				  011 of these rules, and when the
				  surgery is prior authorized by the Department. The request for prior
				  authorization must include the following documentation: (3-17-22)
a. Photographs of the front, side and
				  underside of the participant's abdomen; (3-17-22)
b. Treatment of any ulceration and skin
				  infections involving the panniculus; (3-17-22)
c. Failure of conservative treatment,
				  including weight loss; (3-17-22)
d.
				  That the panniculus severely inhibits the participant's walking;
				  (3-17-22)
e. That the participant
				  is unable to wear a garment to hold the panniculus up; and (3-17-22)
f. Other detrimental effects of the
				  panniculus on the participant's health such as severe arthritis in the lower
				  body. (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: HOSPITAL SERVICES › Section 16.03.09.433 - SURGICAL PROCEDURES FOR WEIGHT LOSS: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Medically Necessary
. The
				  Department must determine the surgery to be medically necessary, as defined in
				  Section 011 of these
				  rules. (3-17-22)
02.
Prior
				  Authorization
. The surgery must be prior authorized by the Department.
				  The Department will consider the guidelines of private and public payors,
				  evidence-based national standards of medical practice, and the medical
				  necessity of each participant's case when determining whether surgical
				  correction of obesity will be prior authorized. (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: HOSPITAL SERVICES › Section 16.03.09.434 - SURGICAL PROCEDURES FOR WEIGHT LOSS: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Physicians and hospitals must meet national medical
					 standards for weight loss surgery. (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: HOSPITAL SERVICES › Section 16.03.09.443 - INVESTIGATIONAL PROCEDURES OR TREATMENTS: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
The Department may consider Medicaid coverage for
					 investigational procedures or treatments on a case-by-case basis for
					 life-threatening medical illnesses when no other treatment options are
					 available. For these cases, a focused case review is completed by a
					 professional medical review organization to determine if an investigational
					 procedure would be beneficial to the participant. The Department will perform a
					 cost-benefit analysis on the procedure or treatment in question. The Department
					 will determine coverage based on this review and analysis. (3-17-22)
01.
Focused Case Review
. A
				  focused case review consists of assessment of the following: (3-17-22)
a. Health benefit to the participant of the
				  proposed procedure or treatment; (3-17-22)
b. Risk to the participant associated with
				  the proposed procedure or treatment; (3-17-22)
c. Result of standard treatment for the
				  participant's condition, including alternative treatments other than the
				  requested procedure or treatment; (3-17-22)
d. Specific inclusion or exclusion by
				  Medicare national coverage guidelines of the proposed procedure or treatment;
				  (3-17-22)
e. Phase of the clinical
				  trial of the proposed procedure or treatment; (3-17-22)
f. Guidance regarding the proposed procedure
				  or treatment by national organizations; (3-17-22)
g. Clinical data and peer-reviewed literature
				  pertaining to the proposed procedure or treatment; and (3-17-22)
h. Ethics Committee review, if appropriate.
				  (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: AMBULATORY SURGICAL CENTERS › Section 16.03.09.452 - AMBULATORY SURGICAL CENTER SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Those surgical procedures identified by the Medicare
					 program as appropriately and safely performed in an ASC will be reimbursed by
					 the Department. In addition, the Department may add surgical procedures to the
					 list developed by the Medicare program as required by
					 42 CFR
					 416.164 if the procedures meet the criteria
					 identified in 42 CFR
					 416.166. (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: AMBULATORY SURGICAL CENTERS › Section 16.03.09.454 - AMBULATORY SURGICAL CENTER SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Provider Approval
. The ASC
				  must be surveyed as required by
				  42 CFR
				  416.25 through
				  416.52 and be approved by the U.S.
				  Department of Health and Human Services for participation as a Medicare ASC
				  provider. (3-17-22)
02.
Cancellation
. Grounds for cancellation of the provider agreement
				  include: (3-17-22)
a. The loss of Medicare
				  program approval; or (3-17-22)
b.
				  Identification of any condition that threatens the health or safety of patients
				  by the Department's Bureau of Facility Standards. (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: AMBULATORY SURGICAL CENTERS › Section 16.03.09.455 - AMBULATORY SURGICAL CENTER SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Payment Methodology
. ASC
				  services reimbursement is designed to pay for use of facilities and supplies
				  necessary to safely care for the patient. Such services are reimbursed as
				  follows: (3-17-22)
a. ASC service payments
				  represent reimbursement for the costs of goods and services recognized by the
				  Medicare program under 42 CFR, Part 416 . Payment will be determined by the
				  Department. Any surgical procedure covered by the Department, but which is not
				  covered by Medicare will have a reimbursement rate established by the
				  Department. (7-1-23)T
b. ASC
				  services include the following: (3-17-22)
i.
				  Nursing, technician, and related services; (3-17-22)
ii. Use of ASC facilities;
				  (3-17-22)
iii. Drugs, biologicals,
				  surgical dressings, supplies, splints, casts, and appliances and equipment
				  directly related to the provision of surgical procedures; (3-17-22)
iv. Diagnostic or therapeutic services or
				  items directly related to the provision of a surgical procedure;
				  (3-17-22)
v. Administration,
				  recordkeeping, and housekeeping items and services; and (7-1-23)T
vi. Materials for anesthesia.
				  (3-17-22)
c. ASC services
				  do not include the following services: (3-17-22)
i. Physician services; (3-17-22)
ii. Laboratory services, x-ray or diagnostic
				  procedures (other than those directly related to the performance of the
				  surgical procedure); (3-17-22)
iii.
				  Prosthetic and orthotic devices; (3-17-22)
iv. Ambulance services; (3-17-22)
v. DME typically used in the participant's
				  place of residence, but may be suitable for use in any setting in which normal
				  life activities take place, other than a hospital, nursing facility, or
				  ICF/IID; and (7-1-23)T
vi. Any
				  other service not specified in Subsection
				  455.01.b. of this rule.
				  (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: PHYSICIAN SERVICES AND ABORTION PROCEDURES › Section 16.03.09.500 - PHYSICIAN SERVICES

Current through August 31, 2023
Physician services include the treatment of medical and
					 surgical conditions by doctors of medicine or osteopathy subject to the
					 limitations of practice imposed by state law, and to the restrictions and
					 exclusions of coverage contained in Section
					 390 and Section
					 502 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: PHYSICIAN SERVICES AND ABORTION PROCEDURES › Section 16.03.09.502 - PHYSICIAN SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Sterilization Procedures
. Restrictions pertaining to payment for
				  sterilization procedures are contained in Sections
				  680 through
				  686 of these rules.
				  (3-17-22)
02.
Abortions
. Restrictions governing payment for abortions are contained in
				  Sections 511 through
				  514 of these rules.
				  (3-17-22)
03.
Tonometry
. Payment for tonometry is limited to one (1) examination
				  for individuals over the age of forty (40) years during any twelve (12) month
				  period (in addition to tonometry as a component of examination to determine
				  visual acuity). In the event examination to determine visual acuity is not
				  done, two (2) tonometry examinations per twelve (12) month period are allowed
				  for participants over the age of forty (40). This limitation does not apply to
				  participants receiving continuing treatment for glaucoma. (3-17-22)
04.
Physical Therapy Services
.
				  Payment for physical therapy services performed in the physician's office is
				  limited to those services that are described and supported by the diagnosis.
				  (3-17-22)
05.
Injectable
				  Vitamins
. Payment for allowable injectable vitamins will be allowed when
				  supported by the diagnosis. Injectable vitamin therapy is limited to Vitamin
				  B12 (and analogues), Vitamin K (and analogues), folic acid, and mixtures
				  consisting of Vitamin B12, folic acid, and iron salts in any combination.
				  (3-17-22)
06.
Corneal
				  Transplants and Kidney Transplants
. Corneal transplants and kidney
				  transplants are covered by the Medical Assistance 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: PHYSICIAN SERVICES AND ABORTION PROCEDURES › Section 16.03.09.504 - PHYSICIAN SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Misrepresentation of
				  Services
. Any representation that a service provided by a nurse
				  practitioner, nurse midwife, physical therapist, physician assistant,
				  psychologist, social worker, or other nonphysician professional as a physician
				  service is prohibited. (3-17-22)
02.
Locum Tenens Claims and Reciprocal
				  Billing
. (3-17-22)
a. In reimbursement
				  for Locum Tenens/reciprocal billing, the patient's regular physician may submit
				  the claim and receive payment for covered physician services (including
				  emergency visits and related services) provided by a Locum Tenens physician who
				  is not an employee of the regular physician if: (3-17-22)
i. The regular physician is unavailable to
				  provide the visit services. (3-17-22)
ii. The Medicaid patient has arranged for or
				  seeks to receive services from the regular physician. (3-17-22)
iii. The regular physician pays the Locum
				  Tenens for their services on a per diem or similar fee-for-time basis.
				  (3-17-22)
iv. The substitute
				  physician does not provide the visit services to Medicaid patients over a
				  continuous period of longer than ninety (90) days for Locum Tenens and over a
				  continuous period of fourteen (14) days for reciprocal billing.
				  (3-17-22)
v. The regular physician
				  identifies the services as substitute physician services meeting the
				  requirements of this rule by appending modifier-Q6 (service furnished by a
				  Locum Tenens physician) to the procedure code or Q5 (services furnished by a
				  substitute physician under reciprocal billing arrangements).
				  (3-17-22)
vi. The regular physician
				  must keep on file a record of each service provided by the substitute physician
				  associated with the substitute physician's UPIN, and make this record available
				  to the department upon request. (3-17-22)
vii. The claim identifies, in a manner
				  specified by the Department, the physician who furnished the 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: PHYSICIAN SERVICES AND ABORTION PROCEDURES › Section 16.03.09.505 - PHYSICIAN SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Physician Penalties for Late QIO Review
. Medicaid will assess the
				  physician a penalty for failure to request a preadmission review from the
				  Department, for procedures and diagnosis listed on the select list in the
				  Department's Physician Provider Handbook and the QIO Idaho Medicaid Provider
				  Manual. If a retrospective review determines the procedure was medically
				  necessary, and the physician was late in obtaining a preadmission review the
				  Department will assess a penalty according to Subsection
				  505.02 of this rule. The penalty
				  will be assessed after payment for physician services has occurred.
				  (3-17-22)
02.
Physician
				  Penalty Schedule
. (3-17-22)
a. A
				  request for preadmission QIO review that is one (1) day late will result in a
				  penalty of fifty dollars ($50). (3-17-22)
b. A request for preadmission QIO review that
				  is two (2) days late will result in a penalty of one hundred dollars ($100).
				  (3-17-22)
c. A request for
				  preadmission QIO review that is three (3) days late will result in a penalty of
				  one hundred and fifty dollars ($150). (3-17-22)
d. A request for preadmission QIO review that
				  is four (4) days late will result in a penalty of two hundred dollars ($200).
				  (3-17-22)
e. A request for
				  preadmission QIO review that is five (5) days late or later will result in a
				  penalty of two hundred and fifty dollars ($250). (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: PHYSICIAN SERVICES AND ABORTION PROCEDURES › Section 16.03.09.511 - ABORTION PROCEDURES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
The Department will fund abortions under circumstances
					 where the abortion is necessary to save the life of the woman, or in cases of
					 rape or incest as determined by the courts, or, where no court determination
					 has been made, if reported to a law enforcement agency or child protective
					 services. (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: PHYSICIAN SERVICES AND ABORTION PROCEDURES › Section 16.03.09.514 - ABORTION PROCEDURES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Required Documentation in the Case
				  of Rape or Incest
. In the case of rape or incest, the following
				  documentation must be provided to the Department: (3-17-22)
a. A copy of the court determination of rape
				  or incest; or (3-17-22)
b. Where no
				  court determination has been made, documentation that the rape or incest was
				  reported to a law enforcement agency or child protective services; or
				  (7-1-23)T
c. Where the rape or
				  incest was not reported to a law enforcement agency or child protective
				  services, a physician must certify in writing their professional opinion that
				  the woman was unable due to her health, to file a report. The certification
				  must contain the name and address of the woman. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.522 - NON-PHYSICIAN PRACTITIONER SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
The Medicaid Program will pay for services provided by
					 non-physician practitioners (NPPs), as defined in these rules and in accordance
					 with the provisions found under Sections
					 523 through
					 525 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: OTHER PRACTITIONER SERVICES › Section 16.03.09.524 - NON-PHYSICIAN PRACTITIONER SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Identification of Services
.
				  The required services must be covered under the legal scope of practice as
				  identified by the appropriate State rules of the NPP. (3-17-22)
02.
Deliverance of Services
. The
				  services must be delivered under physician supervision, if required by state
				  regulations where the service is provided. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.525 - NON-PHYSICIAN PRACTITIONER SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Billing of Services
. Billing
				  for the services must be as provided by the NPP and not represented as a
				  physician service. (3-17-22)
02.
Payments Made Directly to CRNA
. Payments under the fee schedule
				  must be made directly to the CRNA under the individual provider number assigned
				  to the CRNA. Rural hospitals that qualify for a Medicare exception and employ
				  or contract CRNAs may be reimbursed on a reasonable cost basis.
				  (3-17-22)
03.
Reimbursement
				  Limits
. The Department will reimburse for each service to be delivered
				  by the NP, NM, CNS, PA, or RPh as either the billed charge or reimbursement
				  limit established by the Department, whichever is less. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.530 - CHIROPRACTIC SERVICES: DEFINITIONS

Current through August 31, 2023
Subluxation is partial or incomplete dislocation of the
					 spine. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.532 - CHIROPRACTIC SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Only treatment involving manipulation of the spine to
					 correct a subluxation condition is covered. The Department will pay for a total
					 of six (6) manipulation visits during any calendar year for remedial care by a
					 chiropractor. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.534 - CHIROPRACTIC SERVICES: PROVIDER QUALIFICATIONS

Current through August 31, 2023
A person who is qualified to provide chiropractic services
					 is licensed according to the regulations in the state where the services are
					 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: OTHER PRACTITIONER SERVICES › Section 16.03.09.540 - PODIATRIST SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Acute
				  Foot Conditions
. An acute foot condition, for the purpose of this
				  provision, means any condition that hinders normal function, threatens the
				  individual, or complicates any disease. (3-17-22)
02.
Chronic Foot Diseases
.
				  Chronic foot diseases, for the purpose of this provision, include: (3-17-22)
a. Diabetes melitus; (3-17-22)
b. Peripheral neuropathy involving the feet;
				  (3-17-22)
c. Chronic
				  thrombophlebitis; and (3-17-22)
d.
				  Peripheral vascular disease; (3-17-22)
e. Other chronic conditions that require
				  regular podiatric care for the purpose of preventing recurrent wounds, pressure
				  ulcers, or amputation; or (3-17-22)
f. Other conditions that have the potential
				  to seriously or irreversibly compromise overall health.
				  (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.541 - PODIATRIST SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
Participants eligible for podiatrist services are:
					 (3-17-22)
01.
Participants Who
				  Have a Chronic Disease
. Participants who have a chronic disease where
				  the evidence-based guidelines recommend regular foot care. (3-17-22)
02.
Participants with an Acute
				  Condition
. Participants with an acute condition that, if left untreated,
				  may cause an adverse outcome to the participant's health. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.542 - PODIATRIST SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
Coverage for podiatrist services is limited to:
					 (3-17-22)
01.
Services Defined
				  in Chronic Care Guidelines
. Acute and preventive foot care services
				  defined in chronic care guidelines; and (3-17-22)
02.
Treatment of Acute
				  Conditions
. Treatment of acute conditions that if left untreated will
				  result in chronic damage to the participant's foot. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.544 - PODIATRIST SERVICES: PROVIDER QUALIFICATIONS

Current through August 31, 2023
A qualified podiatrist is licensed by the Board of Podiatry
					 in the Idaho Board of Occupational Licensing, or licensed according to the
					 regulations in the state where the services are 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: OTHER PRACTITIONER SERVICES › Section 16.03.09.546 - LICENSED MIDWIFE (LM) SERVICES

Current through August 31, 2023
The Department will reimburse licensed midwives for
					 maternal and newborn services performed within the scope of their practice.
					 This section of rule does not include non-physician practitioner services
					 provided by a nurse midwife (NM) which are described in Sections
					 522 through
					 525 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: OTHER PRACTITIONER SERVICES › Section 16.03.09.547 - LM SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Licensed
				  Midwife
. An individual who holds a current license issued by the Idaho
				  Board of Midwifery. (3-17-22)
02.
Board of Midwifery
. The Idaho Board of Midwifery is located within
				  the Idaho Bureau of Occupational Licensing and is the licensing authority for
				  LM providers. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.548 - LM SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
A participant is eligible for LM services if the
					 participant is pregnant, in the six (6) week postpartum period, or is a newborn
					 up to six (6) weeks old. (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.549 - LM SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Maternity and Newborn - Coverage
. Antepartem, intrapartum, and up
				  to six (6) weeks of postpartum maternity and newborn care are covered.
				  (3-17-22)
02.
Maternity and
				  Newborn - Limitations
. Maternal or newborn services provided after the
				  sixth postpartum week are not covered. (7-1-23)T
03.
Medication - Coverage and
				  Limitations
. LM providers may administer medication and bill Medicaid if
				  the medication is a Medicaid-covered service, and is also listed in the LM
				  formulary under IDAPA 24.26.01, "Rules of the Idaho Board of Midwifery."
				  (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.550 - LM SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Each LM provider must: (3-17-22)
01.
Licensed
. Have a current
				  license as a LM from the Idaho Board of Midwifery or be licensed according to
				  the regulations in the state where the services are provided.
				  (3-17-22)
02.
Scope of
				  Practice
. Provide only those services that are within the scope of
				  practice under IDAPA 24.26.01, "Rules of the Idaho Board of Midwifery."
				  (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.551 - LM SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Reimbursement for LM services will be the lesser of the
					 billed amount, or eighty-five percent (85%) of the Department's physician fee
					 schedule, The physician fee schedule is available from the Central Office for
					 the Division of Medicaid, see online at: http://www.idmedicaid.com.
					 (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: OTHER PRACTITIONER SERVICES › Section 16.03.09.552 - LM SERVICES: PROVIDER QUALITY ASSURANCE ACTIVITIES

Current through August 31, 2023
Each Licensed Midwife (LM) provider must: (3-17-22)
01.
Informed Consent Form
				  Required
. Keep a signed copy of the participant's informed consent in
				  the participant's record. (3-17-22)
02.
Compliance with Board of Midwifery
				  Requirements
. Adhere to all regulations listed in IDAPA 24.26.01, "Rules
				  of the Idaho Board of Midwifery." (3-17-22)
03.
Department Access to Practice
				  Data
. Make all practice data submitted to the Board of Midwifery
				  according to the provisions in IDAPA 24.26.01, "Rules of the Idaho Board of
				  Midwifery," immediately available to the Department 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: OTHER PRACTITIONER SERVICES › Section 16.03.09.554 - OPTOMETRIST SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Optometrist services are provided to the extent specified
					 in the individual provider agreements entered into under the provisions of
					 Section 205 of these
					 rules. (3-17-22)
01.
Payment
				  Availability
. Payment for services included in Sections
				  780 through
				  786 of these rules is available to
				  all licensed optometrists. (3-17-22)
02.
Provider Qualifications
.
				  Optometrists who have certification or licensure according to the regulations
				  in the state where the services are provided, qualify for provider agreements
				  allowing payment for the diagnosis and treatment of injury or disease of the
				  eye to the extent allowed under Section
				  54-1501, Idaho Code, and to the
				  extent payment is available to physicians as defined in 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: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.561 - HEALTHY CONNECTIONS: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
01.
Primary Care Case Management Enrollment
. Each participant in Idaho
				  Medicaid is enrolled in Healthy Connections, unless the participant is granted
				  an exemption by the Department described in Subsections
				  561.02.a. through 561.02.h. of
				  this rule. Each participant must choose a PCP within the Healthy Connections
				  program. If a participant fails to choose a PCP, one will be assigned to the
				  participant by the Department. Participants of the same family may choose
				  different Healthy Connections providers. (3-17-22)
02.
Exemption from
				  Participation
. An exemption from participation in Healthy Connections
				  may be granted on a individual basis by the Department for a participant who:
				  (3-17-22)
a. Is unable to access a Healthy
				  Connections provider within a distance of thirty (30) miles, or within thirty
				  (30) minutes to obtain primary care services; (3-17-22)
b. Has an eligibility period that is less
				  than three (3) months; (3-17-22)
c.
				  Has an eligibility period that is only retroactive; (3-17-22)
d. Is eligible only as a Qualified Medicare
				  Beneficiary; (3-17-22)
e. Has an
				  existing relationship with a primary care physician or clinic who is not
				  participating in Healthy Connections; (3-17-22)
f. Is enrolled in the Medicare/Medicaid
				  Coordinated Plan; (3-17-22)
g.
				  Resides in a nursing facility or an ICF/IID; or (3-17-22)
h. Resides in a county where there are not an
				  adequate number of providers to deliver primary care case management 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: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.562 - HEALTHY CONNECTIONS: PRIMARY CARE SERVICES

Current through August 31, 2023
01.
Eligible Services
. Participants enrolled with a primary care
				  provider (PCP) are eligible to receive: (3-17-22)
a. Basic care management and care
				  coordination; (3-17-22)
b. Timely
				  access to routine primary care; (3-17-22)
c. A patient-centered health care decision
				  making process; (3-17-22)
d.
				  Twenty-four (24) hour, seven (7) days per week access to an on-call medical
				  professional; and (3-17-22)
e.
				  Referral to other medically necessary services as specified in Section
				  210 of these rules, based on the
				  clinical judgment of their primary care 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: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.563 - HEALTHY CONNECTIONS: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Changes to Requirements
. The Department will provide sixty (60)
				  day notice of any substantive and significant changes to requirements for
				  referrals, primary care provider reimbursement, as specified in Section
				  565 of these rules, or provider
				  duties on its website and provider portal. The Department will provide a method
				  to allow providers to provide input and comment on proposed changes.
				  (3-17-22)
02.
Problem
				  Resolution
. (3-17-22)
a. To help assure
				  the success of Healthy Connections, the Department provides a mechanism for
				  timely and personal attention to problems and complaints related to the
				  program. (3-17-22)
b. To facilitate
				  problem resolution, the Department will have a designated representative who
				  will receive and attempt to resolve all complaints and problems related to the
				  program and function as a liaison between participants and providers. It is
				  anticipated that most problems and complaints will be resolved informally at
				  this level. (3-17-22)
c. A
				  participant or a provider may register a complaint or notify the Department of
				  a problem related to Healthy Connections either in writing, electronically, or
				  by telephone to the designated representative. The designated representative
				  will attempt to resolve conflicts and disputes whenever possible and refer the
				  complainant to alternative forums where appropriate. (3-17-22)
d. If a participant or provider is not
				  satisfied with the resolution of a problem or complaint addressed by the
				  designated representative, they may file a formal grievance in writing to the
				  representative. The manager of the managed care program may, where appropriate,
				  refer the matter to a review committee designated by the Department to address
				  issues such as quality of care or medical necessity. However, such decisions
				  are not binding on the Department. The Department will respond in writing to
				  grievances within thirty (30) days of receipt. (3-17-22)
e. Decisions in response to grievances may be
				  appealed. Appeals are governed by the requirements of IDAPA 16.05.03,
				  "Contested Case Proceedings and Declaratory Rulings," and must be filed
				  according to the provisions of that chapter. (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: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.564 - HEALTHY CONNECTIONS: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Primary Care Providers
.
				  Primary care services may be provided by enrolled physicians, physician
				  assistants, advanced practice registered nurses, and by care teams under those
				  providers' direction. (3-17-22)
02.
Provider Duties
. All Healthy Connections providers are responsible
				  for delivering the services listed in Section
				  562 of these rules.
				  (3-17-22)
03.
Additional
				  Services
. Healthy Connections providers may also elect to provide
				  specific additional sets of patient-centered medical home services in exchange
				  for increased reimbursement as described in Section
				  565 of these rules. The definition
				  and provision of additional patient-centered medical home services are subject
				  to specific requirements as defined by the Department and described in the
				  Idaho Medicaid Provider Handbook and individual provider agreements with the
				  Department. Additional services may include: (3-17-22)
a. Connection to the Idaho Health Data
				  Exchange; (3-17-22)
b. Maintaining
				  third-party patient-centered medical home recognition or certification;
				  (3-17-22)
c. Expanded patient
				  access to services; (3-17-22)
d.
				  Provision of an evidence-based primary care service model that enables improved
				  patient health outcomes; (3-17-22)
e. Reporting clinical data to the Department
				  to allow for assessment of provider abilities and impact of their services on
				  patient health outcomes; (3-17-22)
f. Coordination of transitions of care
				  between health care settings; (3-17-22)
g. Integration of behavioral health services;
				  and (3-17-22)
h. Other indicators
				  of improved patient health outcomes associated with primary care provider
				  abilities. (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: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.565 - HEALTHY CONNECTIONS: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Capitated Payments
. Healthy Connections providers are compensated
				  for their patient care services on a per participant per month basis.
				  (3-17-22)
02.
Capitated
				  Payment Amounts
. Capitated payment amounts are determined by the
				  Department and reflect the complexity of the patient's health combined with the
				  provider's ability to impact patient health outcomes. This monthly payment to a
				  provider is based on the number of participants assigned to the provider on the
				  first day of each month. (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: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.566 - HEALTHY CONNECTIONS: QUALITY ASSURANCE

Current through August 31, 2023
The Department will establish performance measurements to
					 evaluate the effectiveness of the primary care case management programs. 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 16.03.09.570 - CHILDREN'S HABILITATION INTERVENTION SERVICES (CHIS)

Current through August 31, 2023
CHIS are medically necessary, evidence-informed or
					 evidence-based therapeutic techniques based on applied behavior analysis
					 principles used to result in positive outcomes. These intervention services are
					 delivered directly to Medicaid-eligible participants with identified
					 developmental limitations that impact the participant's functional skills and
					 behaviors across an array of developmental domains. Case Management is an
					 available option to assist participants accessing CHIS by the Department as
					 described in the 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: PREVENTION SERVICES › Section 16.03.09.571 - CHIS: DEFINITIONS

Current through August 31, 2023
01.
Annual
. Every three hundred sixty-five (365), days except during a
				  leap year which equals three hundred sixty-six (366) days. (3-17-22)
02.
Aversive Intervention
. Uses
				  unpleasant physical or sensory stimuli in an attempt to reduce undesired
				  behavior. The stimuli usually cannot be avoided, is pain inducing, or both.
				  (3-17-22)
03.
Community
. Natural, integrated environments outside the participant's
				  home, outside of DDA center-based settings, or at school outside of school
				  hours. (3-17-22)
04.
Developmental Disabilities Agency (DDA)
. A DDA is an agency that is:
				  (3-17-22)
a. A type of developmental
				  disabilities facility, as defined in Section
				  39-4604, Idaho Code, that is
				  non-residential and provides services on an outpatient basis;
				  (3-17-22)
b. Certified by the
				  Department to provide services to participants with developmental disabilities;
				  and (3-17-22)
c. A business entity,
				  open for business to the general public. (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 16.03.09.572 - CHIS: ELIGIBILITY REQUIREMENTS

Current through August 31, 2023
01.
Medicaid
				  Eligibility
. Participants must be eligible for Medicaid and the service
				  for which the CHIS provider is seeking reimbursement. (3-17-22)
02.
Age of Participants
. CHIS
				  are available to participants from birth through the month of their
				  twenty-first birthday. (3-17-22)
03.
Eligibility Determination
.
				  Participants eligible to receive CHIS must have a demonstrated functional need
				  or a combination of functional and behavioral needs that require intervention
				  services; or requires intervention to correct or ameliorate their condition in
				  accordance with Section
				  880 of these rules. A functional or
				  behavioral need is determined by the Department approved screening tool when a
				  deficit is identified in three (3) or more of the following areas: self-care,
				  receptive and expressive language, learning, mobility, self-direction, capacity
				  for independent living, economic self-sufficiency, or maladaptive behavior. A
				  deficit is defined as one-point-five (1.5) or more standard deviations below
				  the mean for functional areas or above the mean for maladaptive behavior.
				  (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 16.03.09.573 - CHIS: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Excluded
				  for Medicaid Payment
. (7-1-23)T
i.
				  Vocational services; (3-17-22)
ii.
				  Educational services; and (3-17-22)
iii. Recreational services.
				  (3-17-22)