Spreadsheet: 000c9a81-1150-4cb6-a28f-963181b75ba9
Sheet: Full Version

PBP Section | Service Category Description | Supplemental Benefits | Required by State | Proposed HPMS Instructions -- All benefits entered as mandatory | [NAME] in HPMS Notes Filed and/or Pertinent Administrative Rule | Plan Questions are in this column and referenced in blue. | IDHW Responses
1A | Inpatient Hospital Acute | Additional Days | Required by State | Is the Benefit unlimited? Yes | Elective medical and surgical treatments (except family planning services and medically necessary cosmetic surgery), are excluded from payment unless prior approved by the Health Plan or its authorized agent. | Notes can only be used in specific cases, not to list excluded services, that are excluded by Medicare. | If a service is excluded, that exclusion is not required to be listed.  However, Health Plans may exclude services that are excluded by Medicare and Medicaid.
 |  |  |  | If No: Indicate Number of additional days per period: | Acupuncture, bio‐feedback therapy, and laetrile therapy are excluded from payment.                                                                                                                   Procedures, counseling, and testing for the inducement of fertility are excluded from payment.  Surgical procedures for the treatment of morbid obesity and panniculectomies are excluded unless prior approved by the Health Plan or its authorized agent.  IDAPA 16.03.09.400-406. | IDAPA references please confirm why the reference is listed -- do they pertain to the benefit only, or do they expect the plan to follow reimbursement, etc.  ? | Health Plans may reimburse network providers at no less than Medicaid rates, so the rule references may have relevance, at least in some cases, for reimbursement as well as benefits.
 |  |  |  | Coinsurance
 |  |  |  | Number of day intervals for Additional Days: Zero (no coinsurance per day) |  | Do you expect the authorization and referral instructions to be administered by the plan.  Plan expectation is to create their own PA and referral instructions? | The Health Plan may administer the authorization and referral instructions, whenever applicable.  The Health Plan may require prior authorization for services that Medicaid permits prior authorization for.  The Health Plan may have less stringent prior authorization criteria than Medicaid.  The Health Plan has flexibility re: how the PA process works.
 |  |  |  | [NAME] and intervals:
 |  |  |  | % Interval 1: / Begin Day Interval 1: / End Day Interval 1: |  | General:  CMS limits the type of notes that can be placed in the PBP -- i.e., explain min - maximum cost sharing. | Understood.
 |  |  |  | % Interval 2: / Begin Day Interval 2: / End Day Interval 2:
 |  |  |  | % Interval 3: / Begin Day Interval 3: / End Day Interval 3:
 |  |  |  | Copayment
 |  |  |  | Number of day intervals for Additional Days: Zero (no coinsurance per day)
 |  |  |  | Copayment amounts and intervals:
 |  |  |  | Amt Interval 1: / Begin Day Interval 1: / End Day Interval 1:
 |  |  |  | Amt Interval 2: / Begin Day Interval 2: / End Day Interval 2:
 |  |  |  | Amt Interval 3: / Begin Day Interval 3: / End Day Interval 3:
 |  |  |  | Authorization from:
 |  |  |  | Procedures generally accepted by the medical community and which are medically
 |  |  |  | necessary may not require prior approval.
 |  |  |  | Referral required? No
 |  | Non-Medicare Covered Stay | Required by State | Is the coinsurance structure the same as the [NAME] stay? No; no coinsurance. |  | A Non-Medicare covered stay is a stay that is not medically necessary and reasonable according to Medicare coverage guidelines, or is provided in a facility not certified by Medicare.  Please provided examples? | Correct, a non-Medicare covered stay that is not medically necessary and reasonable according the Medicare coverage guidelines.  Only a Medicare certified hospital, licensed by the state in which it operates, may enroll in the Idaho Medicaid program and can be paid for Medicaid services.
 |  |  |  | If No (1): [NAME]
 |  |  |  | If No (2): Number of day intervals: Zero (no coinsurance per day)/One/Two/Three |  | [NAME] Yes (no copayment) ? | No copyament (which means it has the same structure as Medicare, which also had no copayment)
 |  |  |  | If No (3): [NAME] and intervals:
 |  |  |  | % Interval 1: / Begin Day Interval 1: / End Day Interval 1:
 |  |  |  | % Interval 2: / Begin Day Interval 2: / End Day Interval 2:
 |  |  |  | % Interval 3: / Begin Day Interval 3: / End Day Interval 3:
 |  |  |  | Is the copayment structure the same as the [NAME] stay? Yes (no copayment)
 |  |  |  | If No (1): Co‐payment amount for non‐Medicare stay
 |  |  |  | If No (2): Number of day intervals:
 |  |  |  | If No (3): :
 |  |  |  | Amt Interval 1: / Begin Day Interval 1: / End Day Interval 1:
 |  |  |  | Amt Interval 2: / Begin Day Interval 2: / End Day Interval 2:
 |  |  |  | Amt Interval 3: / Begin Day Interval 3: / End Day Interval 3:
 |  |  |  | Authorization from: Procedures generally accepted by the medical community and which are medically
 |  |  |  | necessary may not require prior approval.
 |  |  |  | Referral required? No
1B | Inpatient Hospital Psychiatric | Additional Days | Not Required |  | IDAPA 16.03.09.702-706 and 16.03.10.100-102 | IDAPA has a provision for 10 inpatient days.  Shouldn't these be listed as additional days over the 190 lifetime? | The 10 inpatient days per year is a Medicaid covered service limitation when Medicare does not pay, so this can occur after the 190 day lifetime limit for Medicare or when the lifetime limit is not reached, but Medicare does not cover the service.
 |  | Non-Medicare Covered Stay | Required by State | Is the Benefit unlimited?  Yes |  | Unlimited days - confirm non-Medicare criteria & is the authorization from PCP / referral required or can the plan select? | Medicaid criteria is listed in the IDAPA references.  Authorization from the PCP is required.
 |  |  |  | Copayment: None
 |  |  |  | Authorization from:  PCP
 |  |  |  | Referral required? Yes
2 | Skilled Nursing Facility | Additional Days beyond Medicare covered | Required | Is the Benefit unlimited? Yes | IDAPA 16.03.10.220‐296 | Unlimited days -- = one? | The days are unlimited.
 |  |  |  | If No: Indicate Number of additional days per period: |  | What is the Patient liability and intervals: ? | Patient liability for skilled nursing facility services is a monthly amount and will vary based on an individual's income.  IDHW will provide these amounts to Health Plans.  For purposes of the PBP, Health Plans should enter this as coinsurance with a maximum coinsurance amount of 100%.  In the notes, Health Plans should affirm that the cost sharing is a patient liability which will vary from person to person.
 |  | Non-Medicare Covered Stay | Required | Patient Liability |  | Authorization?  Medical Home | Yes, PA is initiated by a Medical Home, which includes a Primary Care Provider.
 |  |  |  | Number of day intervals for Additional Days: One
 |  |  |  | Patient liability % and intervals: Members in long‐term care facilities may be required to pay a monthly patient |  | Same note used  for Additional covered days -- is the patient cost share the same / different? | Same.
 |  |  |  | liability for the cost of the long‐term care services to the long‐term care facilities in accordance with IDAPA
 |  |  |  | 16.03.10.224 and 16.03.05.722‐726.
 |  |  |  | % Interval 1: / Begin Day Interval 1: / End Day Interval 1:
 |  |  |  | % Interval 2: / Begin Day Interval 2: / End Day Interval 2:
 |  |  |  | % Interval 3: / Begin Day Interval 3: / End Day Interval 3:
 |  |  |  | Copayment
 |  |  |  | Number of day intervals for Additional Days: Zero (no copayment per day)
 |  |  |  | Copayment amounts and intervals:
 |  |  |  | Amt Interval 1: / Begin Day Interval 1: / End Day Interval 1:
 |  |  |  | Amt Interval 2: / Begin Day Interval 2: / End Day Interval 2:
 |  |  |  | Amt Interval 3: / Begin Day Interval 3: / End Day Interval 3:
 |  |  |  | Authorization from: Prior authorization is initiated by the Medical Home
 |  |  |  | Referral required? Yes
6 | Home Health | Additional Hours of Care | Required | [NAME]: Yes | IDAPA 16.03.09.720-725 | Medicare has unlimited Home Health? | If Medicare covers a service to the same or greater extent as Medicaid, there are no additional Medicaid benefits required for that service.
 |  |  |  | If Yes: [NAME]: Home health visits are limited to one hundred (100) per recipient per calendar
 |  |  |  | year provided by any combination of
 |  |  |  | home health agency licensed nurse, home health aide, home health physical therapist, home health
 |  |  |  | occupational therapist, home health speech‐language pathologist, or licensed nurse.
 |  |  |  | If Yes: Max Coverage Periodicity: Yearly
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Coinsurance Minimum:
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Copayment Minimum:
 |  |  |  | If Yes (2): Copayment Maximum:
 |  |  |  | Authorization from:
 |  |  |  | Home health services are ordered by a physician.
 |  |  |  | Referral required? Yes
7B | Chiropractic Services | Routine Care | Required | Unlimited Benefit: No | Only treatment involving manipulation of the spine to correct a subluxation condition is covered. IDAPA 16.03.09.530‐532. | Are we required to collect a copay? | Because Medicaid does not offer more extensive chiropractic benefits than Medicare, no additional chiropractic benefits, beyond those which are covered by Medicare, need to be entered.
 |  |  |  | If No (1): Number of routine care visits: Six (6) |  | Medicare only covers manual manipulation of the spine.  Maximum benefit limit should not be required? | Because Medicaid does not offer more extensive chiropractic benefits than Medicare, no additional chiropractic benefits, beyond those which are covered by Medicare, need to be entered.
 |  |  |  | If No (2): Routine care periodicity: Yearly
 |  |  |  | [NAME]: Yes
 |  |  |  | If Yes (1): [NAME]: Six (6) office visits
 |  |  |  | If Yes (2): [NAME] Periodicity: Yearly
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): MOOP Amount:
 |  |  |  | If Yes (1): MOOP Periodicity:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Coinsurance Minimum:
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Deductible Amount:
 |  |  |  | [NAME]: Yes
 |  |  |  | If Yes (1): Copayment Minimum: $3.65 (see IDAPA 16.03.18.310‐330)
 |  |  |  | If Yes (2): [NAME]: $3.65 (see IDAPA 16.03.18.310‐330)
 |  |  |  | Authorization from:
 |  |  |  | None
 |  |  |  | Referral required? No
7C | Occupational Therapy Services | Non-Medicare Occup. Therapy Services | Not Required |  |  | Confirming no entry is necessary. | Medicaid does not require additional benefits beyond what is covered by Medicare for these services.
7I | Physical Therapy |  | Not Required |  | Although Medicaid does not supplement Medicare occupational therapy benefits, enrollees with developmental disabilities approved for 1915(i) and 1915(c) services have the following limitations: The combination of adult day care, developmental therapy and occupational therapy must not exceed thirty (30) hours per week; and therapy services (psychotherapy, physical therapy, occupational therapy and speech‐language pathology services) provided in combination with community supported employment services must not exceed forty (40) hours per week. |  | Because of changes to DD services, only the following limits need to be applied to OT in combination with other services:  OT, Adult day health and developmental therapy may not exceed 30 hours.  The reference that said "and therapy services (psychotherapy, physical therapy, occupational therapy, and speech-language pathology services) provided in combination with community supported employment services must not exceed forty (40) hours per week" no longer applies.
13C | Meal Benefit-Home Delivered Meals | Aged and Disabled Waiver Benefit for A&D Waiver Participants | Required | [NAME]: Yes | One (1) to two (2) meals per day may be provided to an Enrollee who: | PBP Entry is only allowing Max Benefit Coverage in $$$ not counting of meals. | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payment will be determined by IDHW and shared with Health Plans.
 |  |  |  | If Yes: [NAME]: 2 meals | [NAME] or owns a home; | Copayment Yes?  How do we subscribe.
 |  |  |  | If Yes: Max Coverage Periodicity: Daily | [NAME] Is alone for significant parts of the day;
 |  |  |  | [NAME]: No | c. Has no caregiver for extended periods of time; and
 |  |  |  | If Yes: MOOP Amount: | d. Is unable to prepare a meal without assistance.
 |  |  |  | If Yes: MOOP Periodicity: | IDAPA 16.03.10.326.10
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Coinsurance Percentage:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Deductible Amount:
 |  |  |  | [NAME]: Yes
 |  |  |  | If Yes: Copayment Amount: Deductions are subtracted from countable income after exclusions to determine
 |  |  |  | the base amount subject to cost participation in the form co‐payments per IDAPA 16.03.18.
 |  |  |  | Authorization from:
 |  |  |  | Health Plan (based on determination in Uniform Assessment Instrument)
 |  |  |  | Referral required? Yes
13F | Specific Pregnancy Related Services | Specific Pregnancy Related Services | Required | [NAME]: Yes | IDAPA 16.03.09.890‐895 | Maximum Benefit Coverage?  Description in PBP not an option. | $2078.29 is the maximum possible benefit based on maximums (for all visits/services) of $55.08 for individual and family social services, $395.76 for nursing services, $53.30 for nutrition services, and $1,574.15 for maternity nursing visits.  However, this is merely a proxy/work-around.  Health Plans should include in the notes section a statement that indicates the actual benefit limitation is the number of visits for each sub-category, and that the dollar limitation is only listed as a proxy or work-around, in the notes section.
 |  |  |  | If Yes (1): [NAME]: Two (2) visits during covered period for each of the following: individual and
 |  |  |  | family social services, nursing services, and nutrition services; Nine (9) maternity nursing visits for maternity;
 |  |  |  | If Yes (2): [NAME] Periodicity: Covered period (after confirmation of pregnancy and extending through
 |  |  |  | the end of the month in which the sixtieth
 |  |  |  | day following delivery occurs.)
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): MOOP Amount:
 |  |  |  | If Yes (2): MOOP Periodicity:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Coinsurance Percentage:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Deductible Amount:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Copayment Amount:
 |  |  |  | Authorization from:
 |  |  |  | Physician, nurse practitioner or nurse midwife
 |  |  |  | Referral required? Yes
13H | Additional Other | Home and Community Based Services (i.e. Aged and Disabled Waiver services, which are specifically listed in 13C, 13D, 13E, and 13H) | Required | Max Benefit Coverage: Varies amongst the 18 HCBS Aged and Disabled waiver services. | IDAPA 16.03.10.320‐330 | Why would we list these services under multiple areas -- | The broad category of "Home and Community Based Services" does not need to be listed.  Only the specific A&D waiver services need to be listed as described elsewhere.
 |  |  |  | If Yes (1): [NAME]: [NAME] to the specific waiver services for individualized information. |  | [NAME] Yes?  How do we document cost sharing? | The broad category of "Home and Community Based Services" does not need to be listed.  Only the specific Aged and Disabled (A&D) waiver services need to be listed as described elsewhere.  For the fourteen (14) Aged and Disabled (A&D) Waiver service with co-pays (i.e. all A&D waiver services except for dental services, environmental accessibility adaptations, non-medical transportation, and specialized medical equipment and supplies, which do not have co-pays), Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  |  |  | If Yes (2): [NAME] Periodicity: Refer to the specific waiver services for individualized information. |  | Bundled Services? | Although some A&D waiver services were combined for purposes of saving space in the PBP, each A&D waiver service is distinct.
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Coinsurance Minimum:
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | [NAME]: Yes ‐ but only for adult day health, day habilitation, homemaker, residential habilitation,
 |  |  |  | respite, supported employment, attendant care, adult residential care, chore services, companion services,
 |  |  |  | consultation, home delivered meals, personal emergency response system, and skilled nursing services.
 |  |  |  | If Yes (1): Copayment Minimum: Deductions are subtracted from countable income after exclusions to
 |  |  |  | determine the base amount subject to cost participation in the form co‐payments per IDAPA 16.03.18.
 |  |  |  | If Yes (2): Copayment Maximum: Deductions are subtracted from countable income after exclusions to
 |  |  |  | determine the base amount subject to cost participation in the form co‐payments per IDAPA 16.03.18.
 |  |  |  | Authorization from:
 |  |  |  | Health Plan (based on determination in Uniform Assessment Instrument)
 |  |  |  | Referral required? Yes
 | Additional Other | Personal Care Services | Required | [NAME]: Yes | IDAPA 16.03.10.300-308 | [NAME] are not a PBP option | Personal care services are reimbursed at a rate of $15.72/hr.  Sixteen hours per week translates to $251.52/week for Personal Care Services, and this amount should be entered as the maximum plan benefit coverage amount.  However, this is merely a proxy/work-around.  Health Plans should include in the notes section a statement that indicates the actual benefit limitation is sixteen hours per week, and that the dollar limitation is only listed as a proxy or work-around, in the notes section.
 |  |  |  | If Yes: [NAME]: 16 hours
 |  |  |  | If Yes: Max Coverage Periodicity: Weekly
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Coinsurance Minimum:
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Copayment Minimum:
 |  |  |  | If Yes (2): Copayment Maximum:
 |  |  |  | Authorization from: A registered nurse must determine a need for Personal Care Services through the Uniform
 |  |  |  | Assessment Instrument.
 |  |  |  | Referral required? Yes
 |  | Self-Directed personal Assistance Services | Required | Various Limits and Cost Sharing | Various IDAPA | How do we document the cost sharing? | Nothing should be entered in this category.  Self-direction may apply to the personal care services and the following A&D waiver services: attendant care, homemaker, chore, companion, consultation and skilled nursing services.  However, those services will be entered elsewhere in the PBP.
 |  | Services in an | Required |  |  | How do we document the limits?
 |  | Intermediate Care
 |  | Facility for Persons
 |  | with Intellectual
 |  | Disabilities (ICF/ID)
 |  | Targeted Case | Required
 |  | Management for
 |  | Persons with
 |  | Developmental
 |  | Disabilities and/or
 |  | Serious and
 |  | Persistent Mental
 |  | Illness, and Primary Care Case Management
 |  | Other 1: Adult Day |  |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Health ‐ A&D Waiver
 |  | benefit for A&D
 |  | Waiver participants
 |  | Other 2: Day | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Habilitation ‐ A&D
 |  | Waiver benefit for
 |  | A&D Waiver
 |  | participants
 |  | Other 3: Homemaker | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Care, Attendant Care,
 |  | and Respite ‐ A&D
 |  | Waiver benefit for
 |  | A&D Waiver
 |  | participants
 |  | Other 4: Residential | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Habilitation ‐ A&D
 |  | Waiver benefit for
 |  | A&D Waiver
 |  | participants
 |  | Other 5: Supported | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Employment ‐ A&D
 |  | Waiver benefit for
 |  | A&D Waiver
 |  | participants
 |  | Other 6: Adult | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Residential Care ‐
 |  | A&D Waiver benefit
 |  | for A&D Waiver
 |  | participants
 |  | Other 7: Chore | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Service and
 |  | Companion Services ‐
 |  | A&D Waiver benefits
 |  | for A&D Waiver
 |  | participants
 |  | Other 8: Consultation | Required |  |  |  | Health Plans should list the minimum co-payment as 0% and the maximum co-payment as 100%.  Health Plans should add a note indicating that co-payments will vary from person to person, and that the amount of the possible co-payments will be determined by IDHW and shared with Health Plans.
 |  | Services ‐ A&D
 |  | Waiver benefit for
 |  | A&D Waiver
 |  | participants
 |  | Other 13: Community‐Based | Required | [NAME]: No | IDAPA rules are under development | What should we address? | Health Plans should affirm that there is no benefit limitation for these services.
 |  | Outpatient Behavioral Health |  | If Yes (1): [NAME]:
 |  | Services (Community‐Based |  | If Yes (2): [NAME] Periodicity:
 |  | Outpatient Behavioral Health |  | [NAME]: No
 |  | Services; Screening, Evaluation |  | If Yes (1): Coinsurance Minimum:
 |  | and Diagnostic Assessments; |  | If Yes (2): [NAME]:
 |  | Treatment Planning; |  | [NAME]: No
 |  | Psychological and |  | If Yes (1): Copayment Minimum:
 |  | Neuropsychological Testing; |  | If Yes (2): Copayment Maximum:
 |  | Psychotherapy (Individual, |  | Authorization from:
 |  | Group, and Family); |  | Registered nurse or licensed practical or vocational nurse
 |  | Pharmacologic Management; |  | Referral required? Yes
 |  | Partial Care Treatment;
 |  | Behavioral Health Nursing; Drug
 |  | Screening; Community‐Based
 |  | Rehabilitation and Substance Use
 |  | Disorder Treatment Services)
14 C | Supplemental/Education / Wellness Program | Prevention and Health Assistance Benefits | Required | [NAME]: Yes | PHA benefits will be available when individuals complete specified activities in preparation for addressing the targeted health condition.  These activities include discussing the condition with their primary care provider, participating in an applicable support group, and completing basic educational material related to the condition.  IDADPA 16.03.09.620‐626 | Is the plan handling this program?  PBP Entry location? | The plan is handling the Behavioral PHA program and should enter it in 14c.  The plan is NOT responsible for the Wellness PHA program, as that program is only available to children.
 |  |  |  | If Yes (1): [NAME]: $200 (= 200 "points") for Behavioral preventive health assistance (PHA) and |  | Enhanced Disease Mgt.? | The PHA program is not considered to be enhanced disease management.
 |  |  |  | $120 (=120 points) for Wellness PHA, per IDAPA 16.03.09.622
 |  |  |  | If Yes (2): [NAME] Periodicity: Yearly
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): [NAME]:
 |  |  |  | If Yes (2): [NAME] Periodicity:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Coinsurance Amount:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes: Deductible Amount:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Copayment Amount:
 |  |  |  | Authorization from:
 |  |  |  | The reimbursable products and services of each vendor must be prior approved by the Health Plan.
 |  |  |  | Referral required? Yes
17A | Vision | Routine Eye Exams | Required | Unlimited Benefit: No | Will pay participating physicians and optometrists for medically necessary eye examinations when the participant has a chronic condition that may damage the eye, or when there is an acute condition that, if left untreated, may cause permanent or chronic damage to the eye.  IDAPA 16.03.09.781‐785 | Medicare Covered Service already. | If Medicare covers a service to the same or greater extent as Medicaid, there are no additional Medicaid benefits required for that service.
 |  |  |  | If No (1): Number of visits: One (1)
 |  |  |  | If No (2): Periodicity: Medically necessary eye examinations are available when the participant has a chronic
 |  |  |  | condition that may damage the eye, or when there is an acute condition that, if left untreated, may cause
 |  |  |  | permanent or chronic damage to the eye.
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Applies to: In‐network services only / Both in‐network and out‐of‐network
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | If Yes (3): [NAME] Periodicity:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Coinsurance Minimum:
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Copayment Minimum:
 |  |  |  | If Yes (2): Copayment Maximum:
 |  |  |  | Authorization from:
 |  |  |  | Health Plan
 |  |  |  | Referral required? No
18A | Hearing Exams | Routine Hearing Exams (Audiology Services) | Required | Is the Benefit unlimited? No | IDAPA 16.03.09 740-745 | Medicare covered service already. | If Medicare covers a service to the same or greater extent as Medicaid, there are no additional Medicaid benefits required for that service.
 |  |  |  | If No (1): Indicate Number: One (1)
 |  |  |  | If No (2): Select Periodicity: Diagnostic screening services are available when necessary to obtain a differential
 |  |  |  | diagnosis.
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Applies: In‐network services only / Both in‐network and out‐of‐network
 |  |  |  | If Yes (2): Amount:
 |  |  |  | If Yes (3): Periodicity:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Coinsurance Minimum:
 |  |  |  | If Yes (2): [NAME]:
 |  |  |  | [NAME]: No
 |  |  |  | If Yes (1): Copayment Minimum:
 |  |  |  | If Yes (2): Copayment Maximum:
 |  |  |  | Authorization from: Physician or midlevel practitioner
 |  |  |  | Referral required? Yes