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

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