Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-023 - Transition of ARKids First-B Program

Current through Register Vol. 49, No. 6, June, 2024
200.110
ARKids First-A and ARKids
			 First-B
Medicaid-eligible children in the SOBRA eligibility category
				for pregnant women, infants and children (category 61 PW-PL) and newborn
				children born to Medicaid-eligible mothers (categories 52 and 63), are known as
				ARKids First-A beneficiaries. Un-insured, non Medicaid-eligible children that
				meet additional established eligibility requirements will have health coverage
				under ARKids First-B, a CHIP separate child health program. All ARKids First
				beneficiaries will receive a program identification card without indication of
				level of coverage (either ARKids First-A or ARKids First-B).
A Provider Electronic Solutions (PES) eligibility verification
				transaction response will indicate that the individual is either an ARKids
				First-A beneficiary or an ARKids First-B beneficiary. The response will also
				indicate that cost sharing may be required for ARKids First-B
				beneficiaries.
When a child presents as an ARKids First-A eligible
				beneficiary, the provider must refer to the regular Medicaid provider policy
				manuals. When an ARKids First-B eligible beneficiary is identified, the
				provider must refer to the ARKids First-B Provider Manual for determination of
				levels of coverage, as well as the associated Medicaid provider policy manuals
				for the services provided.
221.100
ARKids First-B Medical Care
			 Benefits
Listed below are the covered services for the ARKids First-B
				program. This chart also includes benefits, whether Prior Authorization or a
				Primary Care Physician (PCP) referral is required, and specifies the
				cost-sharing requirements.
Program Services
Benefit Coverage and
						  Restrictions
Prior
Authorization/ PCP Referral*
Co-payment/ Coinsurance/ Cost Sharing
						  Requirement**
Ambulance (Emergency Only)
Medical Necessity
None
$10 per trip
Ambulatory Surgical Center
Medical Necessity
PCP Referral
$10 per visit
Audiological Services (only Tympanometry, CPT procedure
						  code 92567, when the diagnosis is within the ICD range
(View ICD
						  codes.))
Medical Necessity
None
None
Certified Nurse-Midwife
Medical Necessity
PCP Referral
$10 per visit
Chiropractor
Medical Necessity
PCP Referral
$10 per visit
Dental Care
Routine dental care and orthodontia
						  services
None - PA for inter-periodic screens and orthodontia
						  services
$10 per visit
Durable Medical Equipment
Medical Necessity $500 per state fiscal year (July 1
						  through June 30) minus the coinsurance/cost-share. Covered items are listed in
						  Section 262.120
PCP Referral and Prescription
10% of Medicaid allowed amount per DME item
						  cost-share
Emergency Dept. Services
Emergency
Medical Necessity
None
$10 per visit
Non-Emergency
Medical Necessity
PCP Referral
$10 per visit
Assessment
Medical Necessity
None
$10 per visit
Family Planning
Medical Necessity
None
None
Federally Qualified Health Center (FQHC)
Medical Necessity
PCP Referral
$10 per visit
Home Health
Medical Necessity (10 visits per state fiscal year
						  (July 1 through June 30)
PCP Referral
$10 per visit
Hospital, Inpatient
Medical Necessity
PA on stays over 4 days if age 1 or over
10% of first inpatient day
Hospital, Outpatient
Medical Necessity
PCP referral
$10 per visit
Inpatient Psychiatric Hospital and Psychiatric
						  Residential Treatment Facility
Medical Necessity
PA & Certification of Need is required prior to
						  admittance
10% of first inpatient day
Immunizations
All per protocol
None
None
Laboratory & X-Ray
Medical Necessity
PCP Referral
$10 per visit
Medical Supplies
Medical Necessity Benefit of $125/mo. Covered supplies
						  listed in Section 262.110
PCP Prescriptions
PA required on supply amounts exceeding
						  $125/mo
None
Mental and Behavioral Health, Outpatient
Medical Necessity
PCP Referral PA on treatment services
$10 per visit
Nurse Practitioner
Medical Necessity
PCP Referral
$10 per visit
Physician
Medical Necessity
PCP referral to specialist and inpatient professional
						  services
$10 per visit
Podiatry
Medical Necessity
PCP Referral
$10 per visit
Prescription Drugs
Medical Necessity
Prescription
Up to $5 per prescription (Must use generic, if
						  available)***
Preventive Health Screenings
All per protocol
PCP Administration or PCP Referral
None
Rural Health Clinic
Medical Necessity
PCP Referral
$10 per visit
Speech Therapy
Medical Necessity
4 evaluation units (1 unit =30 min) per state fiscal
						  year
4 therapy units (1 unit=15 min) daily
PCP Referral
Authorization required on extended benefit of
						  services
$10 per visit
Occupational Therapy
Medical Necessity
4 evaluation units (1 unit = 30 min) per state fiscal
						  year
4 therapy units (1 unit = 15 min) daily
PCP Referral
Authorization required on extended benefit of
						  services
$10 per visit
Physical Therapy
Medical Necessity
4 evaluation units (1 unit = 30 min) per state fiscal
						  year
4 therapy units (1 unit = 15 min) daily
PCP Referral
Authorization required on extended benefit of
						  services
$10 per visit
Substance Abuse Treatment Services (SATS)
Medical Necessity
Psychiatrist or Physician Prescription (See Section
						  221.000 of SATS manual)
Prior Authorization required for all substance abuse
						  treatment services, except codes H0001 &T1007 when billed with no modifier.
						  Codes H0001 & T1007 require prior authorization when billed with a modifier
						  (See Section 231.100 of SATS manual).
Prior Authorization required on extended benefit of
						  services (See Section 230.000 of SATS manual)
$10 per visit
Vision Care Eye Exam
One (1) routine eye exam (refraction) every 12
						  months
None
$10 per visit
Eyeglasses
One (1) pair every 12 months
None
None
"Refer to your Arkansas Medicaid specialty provider manual for
				prior authorization and PCP referral procedures.
"ARKids First-B beneficiary cost-sharing is capped at 5% of the
				family's gross annual income.
***ARKids First-B beneficiaries will pay a maximum of $5.00 per
				prescription. The beneficiary will pay the provider the amount of co-payment
				that the provider charges non-Medicaid purchasers up to $5.00 per
				prescription.
221.200
Exclusions
Services Not Covered for ARKids First-B
				Beneficiaries:
Audiological Services; EXCEPTION, Tympanometry, CPT procedure
				code
92567,
when the diagnosis is within the ICD range
(View ICD codes.)
.
Child Health Management Services (CHMS)
Child Health Services/Early and Periodic Screening, Diagnosis
				and Treatment (EPSDT)
Developmental Day Treatment Clinic Services (DDTCS)
Diapers, underpads and incontinence Supplies
Domiciliary Care
End Stage Renal Disease Services
Hearing aids
Hospice
Hyperalimentation
Non-Emergency transportation
Nursing facilities
Orthotic Appliances and Prosthetic Devices
Personal Care
Private Duty Nursing Services
Rehabilitation Therapy for Chemical Dependency
Rehabilitative Services for Children
Rehabilitative Services for Persons with Physical Disabilities
				(RSPD)
School-Based Mental Health Services
Targeted Case Management
Ventilator Services
222.300
Dental Services Benefit
Dental services benefits for ARKids First-B beneficiaries are
				one periodic dental exam, bite-wing x-rays, and prophylaxis/fluoride treatments
				every six (6) months plus one (1) day. Scalings are covered once per State
				Fiscal Year (SFY). Orthodontia services are also covered for ARKids First-B
				beneficiaries.
The procedure codes listed in Section 262.150 may be billed for
				the periodic dental exams, interperiodic dental exams and prophylaxis/fluoride,
				and orthodontia services for ARKids First-B beneficiaries.
Refer to Section II of the Medicaid Dental Provider Manual for
				a complete listing of covered dental and orthodontia services. Procedures for
				dental treatment services that are not listed as a payable service in the
				Medicaid Dental Provider Manual may be requested on individual treatment plans
				for prior authorization review. These individually requested procedures and
				dental and orthodontia treatment services are subject to determination of
				medical necessity, review and approval by the Division of Medical Services
				dental consultants.
222.600
Occupational, Physical and Speech Therapy Benefits
Occupational, physical and speech therapy services are
				available to beneficiaries in the ARKids First-B program and must be performed
				by a qualified, Medicaid participating Occupational, Physical or Speech
				Therapist. A referral for an occupational, physical or speech therapy
				evaluation and prescribed treatment must be made by the beneficiary's PCP or
				attending physician if exempt from the PCP program. All therapy services for
				ARKids First-B beneficiaries require referrals and prescriptions be made
				utilizing the "Occupational, Physical and Speech Therapy for Medicaid Eligible
				Recipients Under Age 21" form DMS-640.
View or print form
				DMS-640
Occupational, physical and speech therapy referrals and covered
				services are further defined in the Physicians and in the Occupational,
				Physical and Speech Therapy Provider Manuals. Physicians and therapists must
				refer to those manuals for additional rules and regulations that apply to
				occupational, physical or speech therapy services for ARKids First-B
				beneficiaries.
Arkansas Medicaid applies the following daily therapy benefits
				to occupational, physical and speech therapy services in this program:
A. Medicaid will reimburse up to four (4)
			 occupational, physical and speech therapy evaluation units (1 unit = 30
			 minutes) per state fiscal year (July 1 through June 30) without authorization.
			 Additional evaluation units will require an extended therapy request.
B. Medicaid will reimburse up to four (4)
			 occupational, physical and speech therapy units (1 unit = 15 minutes) daily,
			 without authorization. Additional therapy units will require an extended
			 therapy request.
C. All requests
			 for extended therapy services must comply with the guidelines located within
			 the Occupational, Physical and Speech Therapy Provider Manual.