Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 29 - Division of Medical Services › Rule 016.29.23-004 - Medication Assisted Treatment (MAT) and Over the Counter (OTC) Updates

Current through Register Vol. 49, No. 6, June, 2024
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
				MEDICAL ASSISTANCE PROGRAM
STATE ARKANSAS
ATTACHMENT 3.1-A
Page 1d
AMOUNT, DURATION, AND SCOPE OF SERVICES
				PROVIDED
Revised: October 1, 2023
CATEGORICALLY NEEDY
2a. Outpatient Hospital Services (Continued)
Non-Emergency Services
Outpatient hospital services other than those which qualify as
				emergency, outpatient surgical procedures and treatment, and therapy services
				are covered as non-emergency services.
Benefit Limit
Outpatient hospital services are limited to a total of twelve
				(12) visits a year. This yearly limit is based on the State Fiscal Year - July
				1 through June 30. Outpatient hospital services include the following:
* non-emergency outpatient hospital and related physician and
				nurse practitioner services; and
* outpatient hospital therapy and treatment services and
				related physician and nurse practitioner services.
For services beyond the 12-visit limit, an extension of
				benefits will be provided if medically necessary. The following diagnoses are
				considered categorically medically necessary and do not require prior
				authorization for medical necessity: Malignant neoplasm; HIV infection; renal
				failure
;
opioid use disorder when the visit is part of a
				Medication Assisted Treatment Plan
;
and pregnancy. All other
				diagnoses are subject to prior authorization before benefits can be
				extended.
Outpatient hospital services are not benefit limited for
				recipients in the Child Health Services (EPSDT) Program.
2b. Rural Health Clinic Services
5. Services of nurse midwives
6. Visiting nurse services on a part-time or
			 intermittent basis to home-bound patients (limited to areas in which there is a
			 shortage of home health agencies).
Rural health clinic ambulatory services are defined as any
				other ambulatory service included in the Medicaid State Plan if the Rural
				health clinic offers such a service (e.g. dental, visual, etc.). The "other
				ambulatory services" that are provided by the Rural health clinic will count
				against the limit established in the plan for that service.
Medication Assisted Treatment visits do not count against the
				Rural Health Clinic encounter benefit limit when the visit is part of a
				Medication Assisted Treatment plan.
2c.
Federally qualified health
			 center (FQHC) services and other ambulatory services that are covered under the
			 plan and furnished by a FQHC in accordance with Section 4231 of the State
			 Medicaid Manual (NCFA - Pub.
			 45-4). Federally qualified health center services
			 are limited to sixteen (16) encounters per client
,
per State
			 Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or
			 older. The applicable benefit limit will be considered in conjunction with the
			 benefit limit established for physicians' services, medical services furnished
			 by a dentist, office medical services furnished by an optometrist, certified
			 nurse midwife services, rural health clinic encounters, and advanced practice
			 registered nurse services, or a combination of the seven.
For federally qualified health center core services beyond the
				benefit limit, extensions will be available if medically necessary.
				Beneficiaries under age twenty-one (21) in the Child Health Services (EPSDT)
				Program are not benefit limited.
FQHC hospital visits are limited to one (1) day of care for
				inpatient hospital covered days regardless of the number of hospital visits
				rendered. The hospital visits do not count against the FQHC encounter benefit
				limit.
Medication Assisted Treatment visits do not count against the
				FQHC encounter benefit limit when the visit is part of a Medication Assisted
				Treatment plan.
3.
			 Other Laboratory and X-Ray Services
Other
professional and technical laboratory and
				radiological services
are covered when ordered and provided under the
				direction of a physician or other licensed practitioner of the healing arts
				within the scope of his or her practice, as defined
under
				42 CFR
				440.30 in an office or similar facility other
				than a hospital outpatient department or clinic.
Diagnostic laboratory
s
ervices benefits are
				limited to five hundred dollars ($500) per State Fiscal Year (SFY
,
July 1 - June 30), and radiology/other services benefits are separately limited
				to five hundred dollars ($500) per SFY. Radiology/other services include, but
				are not limited to, diagnostic X-rays, ultrasounds, and electronic
				monitoring/machine tests, such as electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21)
				years of age or older will be provided through prior authorization, if
				medically necessary. The five hundred dollars ($500) per SFY diagnostic
				laboratory services benefit limit
,
and the five hundred dollars
				($500) per SFY radiology/other services benefit limit, do not apply to services
				provided to recipients under twenty-one (21) years of age enrolled in the Child
				Health Services
/
Early and Periodic Screening, Diagnostic and
				Treatment (EPSDT) Program.
(1) The
			 following diagnoses are specifically exempt from the five hundred dollars
			 ($500) per SFY diagnostic laboratory services benefit limit
,
and
			 the five hundred dollars ($500) per SFY radiology/other services health benefit
			 limit
s:
(a) Malignant
			 neoplasm;
(b) HIV infection;
			 and
(c) renal failure. The cost of
			 related diagnostic laboratory services, and radiology/other services will not
			 be included in the calculation of the recipient's five hundred dollars ($500)
			 per SFY diagnostic laboratory services benefit limits or the five hundred
			 dollars ($500) per SFY radiology/other services health benefit
			 limits.
(2) Drug
			 screening will be specifically exempt from the five hundred dollars ($500) per
			 SFY diagnostic laboratory services health benefit limit when the diagnosis is
			 for Opioid Use Disorder (OUD)
,
and the screening is part of a
			 Medication Assisted Treatment
(
MAT
)
plan. The cost of
			 these screenings will not be included in the calculation of the recipient's
			 five hundred dollars ($500) diagnostic laboratory services health benefit
			 limit.
(3) Magnetic Resonance
			 Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt
			 from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory
			 services benefit limit or the five hundred dollars ($500) per SFY
			 radiology/other services health benefit limits. The cost of these procedures
			 will not be included in the calculation of the recipient's five hundred dollars
			 ($500) per SFY diagnostic laboratory services benefit limit, or the recipient's
			 five hundred dollars ($500) per SFY radiology/other services health benefit
			 limits.
(4) Portable X-Ray Services
			 are subject to the five hundred dollars ($500) per SFY radiology/other services
			 benefit limit. Extensions of the benefit limit for recipients twenty-one (21)
			 years of age or older will be provided through prior authorization, if
			 medically necessary. Services may be provided to an eligible recipient in their
			 place of residence upon the written order of the recipient's physician.
			 Portable X-ray
s
ervices are limited to the following:
a. Skeletal films that involve arms and legs,
			 pelvis, vertebral column, and skull;
b. Chest films that do not involve the use of
			 contrast media; and
c. Abdominal
			 films that do not involve the use of contrast media.
(5) Two (2) chiropractic X-rays are covered
			 per
S
FY. Chiropractic X-Ray Services are subject to the five
			 hundred dollars ($500) benefit limit per SFY for radiology/other services.
			 Extensions of the radiology/other services benefit limit for recipients
			 twenty-one (21) years of age or older will be provided through prior
			 authorization, if medically necessary.
12. Prescribed drugs, dentures, and
			 prosthetic devices; and eyeglasses prescribed by a physician skilled in
			 diseases of the eye or by an optometrist a. Prescribed Drugs
(1) Each recipient age twenty-one (21) or
			 older may have up to six (6) prescriptions each month under the program. Family
			 Planning, tobacco cessation
,
prescription drugs for opioid
or alcohol
use disorder as part of a Medication Assisted Treatment
			 plan, EPSDT, high blood pressure
, hypercholesterolemia
blood
			 modifiers, diabetes and respiratory illness inhaler prescriptions do not count
			 against the prescription limit.
(2)
			 Effective January 1, 2006, the Medicaid agency will not cover any Part D drug
			 for full-benefit dual eligible individuals who are entitled to receive Medicare
			 benefits under Part A or Part B.
(3) The Medicaid agency provides coverage, to
			 the same extent that it provides coverage for all Medicaid recipients, for the
			 following excluded or otherwise restricted drugs or classes of drugs, or their
			 medical uses - with the exception of those covered by Part D plans as
			 supplemental benefits through enhanced alternative coverage as provided in
			 42 C.F.R. §
											423.104 (f)(1)(ii)(A) - to
			 full benefit dual eligible beneficiaries under the Medicare Prescription Drug
			 Benefit - Part D.
The following excluded drugs, set forth on the Arkansas
				Medicaid Pharmacy Vendor's Website, are covered:
a. select agents when used for weight
			 gain
b. select agents when used for
			 the symptomatic relief of cough and colds
c. select prescription vitamins and mineral
			 products, except prenatal vitamins and fluoride
d. select nonprescription drugs
(4) The State will reimburse only
			 for the drugs of pharmaceutical manufacturers who have entered into and have in
			 effect a rebate agreement in compliance with Section 1927 of the Social
			 Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3), or
			 1927(d) apply. The State permits coverage of participating manufacturers'
			 drugs, even though it may be using a formulary or other restrictions.
			 Utilization controls will include prior authorization and may include drug
			 utilization reviews. Any prior authorization program instituted after July 1,
			 1991 will provide for a 24-hour turnaround from receipt of the request for
			 prior authorization. The prior authorization program also provides for at least
			 a seventy-two (72) hour supply of drugs in emergency
			 situations.