Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.11-009 - ARKids-B-2-11 and Section I-1-11

Current through Register Vol. 49, No. 6, June, 2024
SUBJECT: Provider Manual Update Transmittal
				#ARKids-2-11
REMOVE
INSERT
Section
Date
Section
Date
221.100
6-1-10
221.100
7-1-11
222.200
4-1-09
222.200
7-1-11
224.000
6-1-10
224.000
7-1-11
224.210
2-1-10
224.210
7-1-11
224.220
2-1-10
224.220
7-1-11
Explanation of Updates
Sections 211.100, 222.200, 224.000, 224.210, 224.220 are
				updated to reflect cost share amount changes from 20% to 10% for DME items and
				hospital first inpatient day.
The paper version of this update transmittal includes revised
				pages that may be filed in your provider manual. See Section I for instructions
				on updating the paper version of the manual. For electronic versions, these
				changes have already been incorporated.
If you have questions regarding this transmittal, please
				contact the HP Enterprise Services Provider Assistance Center at 1-800-457
				-4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501)
				376-2211.
If you need this material in an alternative format, such as
				large print, please contact our Americans with Disabilities Act Coordinator at
				501-682-0593 (Local); 1-800-482 -5850, extension 2-0593 (Toll-Free) or to
				obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY
				Hearing Impaired).
Arkansas Medicaid provider manuals (including update
				transmittals), official notices and remittance advice (RA) messages are
				available for downloading from the Arkansas Medicaid website:
				www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid
				Program.
___________________________________________________
Eugene I. Gessow, Director
Section
			 II
ARKids First-B
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
Certified Nurse-Midwife
Medical Necessity
PCP Referral
$10 per visit
Chiropractor
Medical Necessity
PCP Referral
$10 per visit
Dental Care (No Orthodontia)
Routine dental care
None - PA for inter-periodic screens
$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. Ser Emergency Non-Emergency
						  Assessment
vices Medical Necessity Medical Necessity Medical
						  Necessity
None
PCP Referral
None
$10 per visit $10 per visit $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
Immunizations
All per protocol
PCP or
Administered by ADH
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
Prenatal Care
Medical Necessity
None
None
Prescription Drugs
Medical Necessity
Prescription
Up to $5 per prescription (Must use generic and rebate
						  manufacturer, 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
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.
222.200
Durable Medical Equipment (DME)
			 Benefit
Durable Medical Equipment (DME) benefit for ARKids First-B
				beneficiaries is $500.00 per state fiscal year (July 1 through June 30). There
				is a 10% co-insurance per item. DME may be billed by providers enrolled in the
				Prosthetics Program.
Refer to Section 262.120 of this manual for a listing of DME
				items covered by the ARKids First-B Program.
224.000
Cost Sharing
Co-payment or coinsurance applies to all ARKids First-B
				services, with the exception of immunizations, preventive health screenings,
				family planning, prenatal care, eyeglasses and medical supplies. Co-payments or
				coinsurances range from up to $5.00 per prescription to 10% of the first day's
				hospital Medicaid per diem.
ARKids First-B families have an annual cumulative cost sharing
				maximum of 5% of their annual gross family income. The annual period is July 1
				through June 30 SFY (state fiscal year). The ARKids First-B beneficiary's
				annual cumulative cost sharing maximum will be recalculated and the cumulative
				cost sharing counter reset to zero on July 1 each year.
The cost sharing provision will require providers to check and
				be alert to certain details about the ARKids First-B beneficiary's cost sharing
				obligation for this process to work smoothly. The following is a list of
				guidelines for providers:
1. On the
			 day service is delivered to the ARKids First-B beneficiary, the provider must
			 access the eligibility verification system to determine if the ARKids First-B
			 beneficiary has current ARKids First-B coverage and whether or not the ARKids
			 First-B beneficiary has met the family's cumulative cost sharing
			 maximum.
2. The provider must check
			 the remittance advice received with the claim submitted on the ARKids First-B
			 beneficiary, which will contain an explanation stating that the ARKids First-B
			 beneficiary has met their cost sharing cap.
3. It is strongly urged that providers submit
			 their claims as quickly as possible to HP Enterprise Services for payment so
			 that the amount of the ARKids First-B beneficiary's co-payment can be posted to
			 their cost share file and the amount added to the accrual.
224.210
Durable Medical Equipment
			 Co-insurance
Durable Medical Equipment (DME) will require a co-insurance
				amount equal to 10% of the Medicaid allowed amount per item.
224.220
Inpatient Hospital Co-insurance
The co-insurance charge per inpatient hospital admission for
				ARKids First-B beneficiaries is10% of the hospital's Medicaid per diem, applied
				on the first covered day. For example:
An ARKids First-B beneficiary is an inpatient for four (4) days
				in a hospital with an Arkansas Medicaid per diem of $500.00. When the hospital
				files a claim for four (4) days, ARKids First-B will pay $1950.00; the
				beneficiary will pay $50.00.
Four (4 days) times $500.00 (the hospital per diem) = $2000.00
				(hospital allowed amount).
Ten percent (10% ARKids First-B co-insurance rate) of $500.00 =
				$50.00 co-insurance.
Two thousand dollars ($2000.00 hospital allowed amount) minus
				$50.00 (co-insurance) = $1950.00 (ARKids First-B payment).
The ARKids First-B beneficiary is responsible for paying a
				co-insurance amount equal to 10% of the per diem for one (1) day, which is
				$50.00 in the above example.
SUBJECT: Provider Manual Update Transmittal
				#SecI-1-11
REMOVE
INSERT
Section
Date
Section
Date
133.200
6-1-08
133.200
7-1-11
Explanation of Updates
Section 133.200 is updated
			 to reflect the coinsurance charge per inpatient admission for ARKids First-B
			 participants has changed from 20% to 10
%
of the hospital's
			 Medicaid per diem.
The paper version of this update transmittal includes revised
				pages that may be filed in your provider manual. See Section I for instructions
				on updating the paper version of the manual. For electronic versions, these
				changes have already been incorporated.
If you have questions regarding this transmittal, please
				contact the HP Enterprise Services Provider Assistance Center at 1-800-457
				-4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501)
				376-2211.
If you need this material in an alternative format, such as
				large print, please contact our Americans with Disabilities Act Coordinator at
				501-682-0593 (Local); 1-800-482 -5850, extension 2-0593 (Toll-Free) or to
				obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY
				Hearing I mpaired).
Arkansas Medicaid provider manuals (including update
				transmittals), official notices and remittance advice (RA) messages are
				available for downloading from the Arkansas Medicaid website:
				www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid
				Program.
___________________________________________________
Eugene
				I. Gessow,
				Director
133.200
Inpatient Hospital Coinsurance Charge to ARKids First-B
Beneficiaries
For inpatient admissions, the coinsurance charge per admission
				for ARKids First-B participants is 10
%
of the hospital's Medicaid
				per diem, applied on the first covered day.
Example:
An ARKids First-B beneficiary is an inpatient for 4 days in a
				hospital whose Arkansas Medicaid per diem is $500.00. When the hospital files a
				claim for 4 days, Medicaid will pay $1950.00 and the beneficiary will pay
				$50.00 (10% Medicaid coinsurance rate).
1. Four (4 days) times $500.00 (the hospital
			 per diem) = $2000.00 (hospital allowed amount).
2. Ten percent (10% Medicaid coinsurance
			 rate) of $500.00 = $50.00 coinsurance.
3. Two thousand dollars ($2000.00 hospital
			 allowed amount) minus $50.00 (coinsurance) = $1950.00 (Medicaid
			 payment).