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

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.

*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.

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.

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:

Durable Medical Equipment (DME) will require a co-insurance amount equal to 10% of the Medicaid allowed amount per item.

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

Explanation of Updates

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

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).