Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.11-027 - Amendment to ARKids-B - 1115 Demonstration Waiver

Current through Register Vol. 49, No. 6, June, 2024
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
20% 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
20% of first inpatient day
Hospital, Outpatient
Medical Necessity
PCP referral
$10 per visit
Immunizations
All per protocol
PCPor
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
All per protocol
PCP Administration
None
Screenings
or PCP Referral
Rural Health Clinic
Medical Necessity
PCP Referral
$10 per visit
Speech Therapy
Medical Necessity
PCP Referral
$10 per visit
4 evaluation units (1 unit =30 min) per state fiscal
						  year
Authorization required on extended benefit
						  of
4 therapy units (1 unit=15 min) daily
services
Substance Abuse Treatment Services (SATS)
Medical Necessity i
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
$10 per visit
i
extended benefit of services (See Section
						  230.000 of SATS
						  manual)
Vision Care
Eye Exam
One (1) routine eye exam (refraction) every 12
						  months
None
$10 per visit
Eyeglasses
One (1) pair every 12
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.
222.900
Substance Abuse Treatment Services
Substance Abuse Treatment Services procedure codes may be
				billed by Medicaid enrolled Substance Abuse Treatment Services providers for
				ARKids First-B beneficiaries. Refer to Section
				II of the Substance Abuse
				Treatment Services provider manual for service definitions, information
				regarding reimbursement, prior authorization and extension of benefits and
				other information.
Title XXI Allotment Neutrality Budget Template
			 for Section 1115 Demonstrations
ATTACHMENT B
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Note: A Federal Fiscal Year (FFY) is October 1 through
				September 30.
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