Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.19-005 - ARKDS-4-18, Domiciliary Care-1-18, Section I-5-18, Section III-4-18, and State Plan Amendment #2019-001

Universal Citation: AR Admin Rules 016.06.19-005

Current through Register Vol. 49, No. 9, September, 2024

Section II ARKids First-B

221.200

Exclusions

Services Not Covered for ARKids First-B Beneficiaries:

Adult Developmental Day Treatment (ADDT)

Audiological Services; EXCEPTION, Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range. (View ICD codes.)

Child Health Services/Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Diapers, Underpads and Incontinence Supplies

Early Intervention Day Treatment (EIDT)

End Stage Renal Disease Services

Hearing Aids

Hospice

Hyperalimentation

Non-Emergency

Transportation

Nursing Facilities

Orthotic Appliances and Prosthetic Devices

Personal Care

Private Duty Nursing Services

Rehabilitation Therapy for Chemical Dependency

Rehabilitative Services for Children

Rehabilitative Services for Persons with Physical Disabilities (RSPD)

Targeted Case Management

Ventilator Services

Section I

103.200 Optional Services

Program

Coverage

Adult Behavioral Health Services for Community Independence

18 or older

Adult Developmental Day Treatment (ADDT)

Pre-School and Age 18 or Older

Ambulatory Surgical Center

All Ages

Audiological

Under Age 21

Certified Registered Nurse Anesthetist (CRNA)

All Ages

Chiropractic Services

All Ages

Dental Services

Under Age 21

Developmental Rehabilitation Services

Under Age 3

Durable Medical Equipment

All Ages

Early Intervention Day Treatment (EIDT)

Under Age 21

End-Stage Renal Disease (ESRD) Facility Services

All Ages

Hearing Aid Services

Under Age 21

Hospice

All Ages

Hyperalimentation

All Ages

IndependentChoices (Self-Directed Personal Assistance)

Age 18 or Older

Inpatient Psychiatric Services

Under Age 21

Intermediate Care Facility Services for Individuals with Intellectual Disabilities

All Ages

Medical Supplies

All Ages

Nursing Facility

Under Age 21

Occupational, Physical and Speech-Language Therapy

Under Age 21

Orthotic Appliances

All Ages

Outpatient Behavioral Health Services

All Ages

PACE (Program of All-Inclusive Care for the Elderly)

(*Participants must meet additional medical and non-medical criteria in addition to age eligibility.)

Age 55 or older*

Personal Care

All Ages

Podiatrist

All Ages

Portable X-Ray

All Ages

Prescription Drugs

All Ages

Private Duty Nursing Services (High Technology, Non-Ventilator Dependent, EPSDT Program)

Under Age 21

Private Duty Nursing Services (Non-Ventilator Dependent Beneficiaries Age 21 or Older)

Age 21 or Older

Private Duty Nursing Services (Ventilator-Dependent)

All Ages

Prosthetic Devices

All Ages

Rehabilitative Hospital and Extended Rehabilitative Hospital Services

All Ages

Rehabilitative Services for Persons with Physical Disabilities (RSPD)

Under Age 21

Rehabilitative Services for Youth and Children

Under Age 21

Respiratory Care

Under Age 21

School-Based Mental Health Services

Under Age 21

Targeted Case Management for Beneficiaries of DDS Children's Services (Title V Agency)

Under Age 21

Targeted Case Management for DDS Children's Services (Title V Agency) who are SSI Beneficiaries and TEFRA Waiver Participants

Under Age 16

Targeted Case Management for Beneficiaries Age 21 or Under with a Developmental Disability

Age 21 or Under

Targeted Case Management for Beneficiaries Age 22 or Older with a Developmental Disability

Age 22 or Older

Targeted Case Management for Beneficiaries in the Child Health Services (EPSDT) Program

Under Age 21

Targeted Case Management for Beneficiaries in the Division of Children and Family Services

Under Age 21

Targeted Case Management for Beneficiaries in the Division of Youth Services

Under Age 21

Targeted Case Management for Beneficiaries Age 60 or Older

Age 60 or Older

Targeted Case Management for Pregnant Women

Pregnant Women - All Ages

Ventilator Equipment

All Ages

Visual Care

All Ages

124.230 Working Disabled

The Working Disabled category is an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages 16 through 64, with a disability as defined by Supplemental Security Income (SSI) criteria and who meet the income and resource criteria may be eligible in this category.

There are two levels of cost sharing in this aid category, depending on the individual's income:

A. Regular Medicaid cost sharing.

Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). They are designated in the system as "WD RegCO."

B. New cost sharing requirements.

Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as "WD NewCo".

The cost sharing amounts for the "WD NewCo" eligibles are listed in the chart below:

Program Services

New Co-Payment*

Adult Developmental Day Treatment Services

$10 per day

ARChoices Waiver Services

None

Ambulance

$10 per trip

Ambulatory Surgical Center

$10 per visit

Audiological Services

$10 per visit

Augmentative Communication Devices

10% of the Medicaid maximum allowable amount

Chiropractor

$10 per visit

Dental

$10 per visit (no co-pay on EPSDT dental screens)

Diapers, Underpads and Incontinence Supplies

None

Durable Medical Equipment (DME)

20% of Medicaid maximum allowable amount per DME item

Early Intervention Day Treatment

$10 per day

Emergency Department: Emergency Services

$10 per visit

Emergency Department: Non-emergency Services

$10 per visit

End Stage Renal Disease Services

None

Early and Periodic Screening, Diagnosis and Treatment

None

Eyeglasses

None

Family Planning Services

None

Federally Qualified Health Center (FQHC)

$10 per visit

Hearing Aids (not covered for individuals ages 21 and over)

10% of Medicaid maximum allowable amount

Home Health Services

$10 per visit

Hospice

None

Hospital: Inpatient

25% of the hospital's Medicaid per diem for the first Medicaid-covered inpatient day

Hospital: Outpatient

$10 per visit

Hyperalimentation

10% of Medicaid maximum allowable amount

Immunizations

None

Laboratory and X-Ray

$10 per encounter, regardless of the number of services per encounter

Medical Supplies

None

Inpatient Psychiatric Services for Under Age 21

25% of the facility's Medicaid per diem for the first Medicaid-covered day

Outpatient Behavioral Health

$10 per visit

Nurse Practitioner

$10 per visit

Private Duty Nursing

$10 per visit

Certified Nurse Midwife

$10 per visit

Orthodontia (not covered for individuals ages 21 and older)

None

Orthotic Appliances

10% of Medicaid maximum allowable amount

Personal Care

None

Physician

$10 per visit

Podiatry

$10 per visit

Prescription Drugs

$10 for generic drugs; $15 for brand name

Prosthetic Devices

10% of Medicaid maximum allowable amount

Rehabilitation Services for Persons with Physical Disabilities (RSPD)

25% of the first covered day's Medicaid inpatient per diem

Rural Health Clinic

$10 per core service encounter

Targeted Case Management

10% of Medicaid maximum allowable rate per unit

Occupational Therapy (Age 21 and older have limited coverage**)

$10 per visit

Physical Therapy (Age 21 and older have limited coverage**)

$10 per visit

Speech-Language Therapy (Age 21 and older have limited coverage**)

$10 per visit

Transportation (non-emergency)

None

Ventilator Services

None

Visual Care

$10 per visit

* Exception: Cost sharing for nursing facility services is in the form of "patient liability" which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above.

** Exception: This service is NOT covered for individuals within the Occupational, Physical and Speech-Language Therapy Program for individuals ages 21 and older.

NOTE: Providers must consult the appropriate provider manual to determine coverage and benefits.

172.100 Services not Requiring a PCP Referral

The services listed in this section do not require a PCP referral.

A. Adult Developmental Day Treatment (ADDT) core services

B. ARChoices waiver services

C. Anesthesia services, excluding outpatient pain management

D. Assessment (including the physician's assessment) in the emergency department of an acute care hospital to determine whether an emergency condition exists. The physician and facility assessment services do not require a PCP referral (if the Medicaid beneficiary is enrolled with a PCP)

E. Chiropractic Services

F. Dental services

G. Developmental Disabilities Services Community and Employment Support

H. Disease control services for communicable diseases, including testing for and treating sexually transmitted diseases such as HIV/AIDS

I. Emergency services in an acute care hospital emergency department, including emergency physician services

J. Family Planning services

K. Gynecological care

L. Inpatient hospital admissions on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment

M. Mental health services, as follows:
1. Psychiatry for services provided by a psychiatrist enrolled in Arkansas Medicaid and practicing as an individual practitioner.

2. Rehabilitative Services for Youth and Children (RSYC) Program.

N. Obstetric (antepartum, delivery and postpartum) services.
1. Only obstetric-gynecologic services are exempt from the PCP referral requirement.

2. The obstetrician or the PCP may order home health care for antepartum or postpartum complications.

3. The PCP must perform non-obstetric, non-gynecologic medical services for a pregnant woman or refer her to an appropriate provider.

O. Nursing facility services and intermediate care facility for individuals with intellectual disabilities (ICF/IID) services

P. Ophthalmology services, including eye examinations, eyeglasses, and the treatment of diseases and conditions of the eye

Q. Optometry services

R. Pharmacy services

S. Physician services for inpatients in an acute care hospital. This includes:
1. Direct patient care (initial and subsequent evaluation and management services, surgery, etc.), and

2. Indirect care (pathology, interpretation of X-rays, etc.)

T. Hospital non-emergency or outpatient clinic services on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment.

U. Physician visits (except consultations) in the outpatient departments of acute care hospitals:
1. Medicaid will cover these services without a PCP referral only if the Medicaid beneficiary is enrolled with a PCP and the services are within applicable benefit limitations.

2. Consultations require PCP referral.

V. Professional components of diagnostic laboratory, radiology and machine tests in the outpatient departments of acute care hospitals. Medicaid covers these services without a PCP referral only:
1. If the Medicaid beneficiary is enrolled with a PCP and

2. The services are within applicable benefit limitations.

W. Targeted Case Management services provided by the Division of Youth Services or the Division of Children and Family Services under an inter-agency agreement with the Division of Medical Services

X. Transportation (emergency and non-emergency) to Medicaid-covered services

Y. Other services, such as sexual abuse examinations, when the Medicaid Program determines that restricting access to care would be detrimental to the patient's welfare or to program integrity, or would create unnecessary hardship.

Section III

332.000 Patients With Joint Medicare-Medicaid Coverage

The following provider types accept Medicare-Medicaid Crossovers: Ambulatory Surgical Center, Chiropractic, Clinics, Dental, Family Planning, Federally Qualified Health Center, Health Department, Hearing Services, Hemodialysis, Home Health, Hospital, Hyperalimentation, Independent Laboratory, Independent Radiology, Inpatient Psychiatric Services for Under Age 21, Nurse Practitioner, Nursing Home, Occupational, Physical and Speech-Language Therapy Services, Physician, Podiatrist, Prosthetics, Rehabilitation Center, Rural Health Clinic Services, Transportation, Ventilator Equipment and Visual Care.

Claim filing procedures for these provider types are in Sections 332.100 through 332.300.

Attachment 2.6-A

There will be a co-payment for Medicaid-covered services, as listed below, for WD eligibles, whose gross income is equal to greater than 100% of the Federal Poverty Level.

PROGRAM SERVICES

"New" COPAYMENT

Adult Developmental Day Treatment

$10 per day

Ambulance

$10 per trip

Ambulatory Surgical Center

$10 per visit

Audiology Services

$10 per visit

Augmentative Communication Devices

10% of the Medicaid maximum allowable amount

Chiropractor

$10 per visit

Dental (very limited benefits for individuals age 21 and over)

$10 per visit (no co-pay on EPSDT dental screens)

Diapers, Underpads and Incontinence Supplies

None

Durable Medical Equipment (DME)

20% of Medicaid maximum allowable amount per DME item

Early Intervention Day Treatment (not covered for age 21 and over)

$10 per day

Emergency Department Services: Emergency Services

Non-emergency

$10 per visit $10 per visit

End Stage Renal Disease Services

None

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (not available for individuals over age 21)

None

Eyeglasses

None

Family Planning Services

None

Federally Qualified Health Center (FQHC)

$10 per visit

Hearing Aids (not covered for individuals age 21 and over)

10% of Medicaid maximum allowable amount

Home Health Services

$10 per visit

Hospice

None

Hospital: Inpatient

Outpatient

25% of 1st inpatient day (Medicaid per diem) $10 per visit

Hyperalimentation

10% of Medicaid maximum allowable amount

Immunizations

None

Laboratory and X-Ray

$10 per visit

Medical Supplies

None

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

ATTACHMENT 3.1-A

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary.
a. Transportation
(4) Volunteer Transportation

Volunteer carriers are reimbursed for providing transportation to recipients to medical services provided the carriers are registered by the Arkansas Department of Human Services and Medical Services and the medical services are part of the case plan. A General Relief check is issued by local Human Services staff for payment of Medicaid transportation if a licensed carrier is not available. These services may be billed once per day, per recipient for a maximum of 300 miles per day. The benefit limit does not apply to EPSDT recipients.

b. Services of Christian Science Nurses - Not Provided.

c. Care and services provided in Christian Science sanitoria - Not Provided.

ATTACHMENT 3.1-B

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary.
a. Transportation
(4) Volunteer Transportation

Volunteer carriers are reimbursed for providing transportation to recipients to medical services provided the carriers are registered by the Arkansas Department of Human Services and Medical Services and the medical services are part of the case plan. A General Relief check is issued by local Human Services staff for payment of Medicaid transportation if a licensed carrier is not available. These services may be billed once per day, per recipient for a maximum of 300 miles per day. The benefit limit does not apply to EPSDT recipients.

b. Services of Christian Science Nurses - Not Provided.

c. Care and services provided in Christian Science sanitoria - Not Provided.

d. Nursing facility services provided for patients under 21 years of age - Not Provided.

e. Emergency Hospital Services

Limited to immediate treatment and removal of patient to a qualifying hospital as soon as patient's condition warrants.

ATTACHMENT 3.1-F

4. Describe any additional circumstances of "cause" for disenrollment (if any).
K. Information requirements for beneficiaries

Place a check mark to affirm state compliance.

X The state assures that its state plan program is in compliance with 42 CFR 42 438.10(i) for information requirements specific to MCOs and PCCM programs 42 operated under section 1932(a)(1)(A)(i) state plan amendments. (Place a check mark to affirm state compliance.)

L. List all services that are excluded for each model (MCO & PCCM)

The following PCCM exempt services do not require PCP authorization:

Developmental Disabilities Services Community and Employment Support

Family Planning Anesthesia

Alternative Waiver Programs

Adult Developmental Day Treatment Core Services only

Disease Control Services for Communicable Diseases

ARChoices waiver services

Gynecological care

Inpatient Hospital admissions on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment

Mental health services as follows:

Dental Services

Emergency hospital care

a. Psychiatry for services provided by a psychiatrist enrolled in Arkansas Medicaid and practice as an individual practitioner

b. Rehabilitative Services for Youth and Children Nurse

Midwife services

ICF/IID Services

Nursing Facility services

Hospital non-emergency or outpatient clinic services on the effective date of PCP

enrollment or on the day after the effective date of PCP enrollment.

Ophthalmology and Optometry services

Obstetric (antepartum, deliver and postpartum) services

Pharmacy

Physician Services for inpatients acute care.

Transportation

ATTACHMENT 4.19-B

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary.
a. Transportation
(4) Non-Emergency
(b) Non-Public Transportation

Effective for dates of service on or after December 1, 2001, Non-Public Transportation Services reimbursement is based on the lesser charges or the Title XIX maximum allowable. The Title XIX maximum is based on the Internal Revenue Service (IRS) reimbursement for private mileage in a business setting, plus an additional allowance for the cost of the driver. The standard mileage private reimbursement is compliant to the 1997 Standard Federal Tax Report, paragraph #8540.011. The calculation of the additional allowance for the cost of the driver is based on the minimum wage per hour, plus 28% of salaries (minimum wage) for fringe benefits, plus a fixed allowance of $2.11 for the provider's overhead and billings, divided by 30 (average number of miles per trip). The average number of miles was determined by utilizing data from SFY 1996 and dividing the number of miles per trip by the number of trips made.

The State Agency will negotiate with the affected provider group representatives should recipients access become an issue.

(5) Volunteer Transportation: Amount of payment is agreed on by County Human Services Office and the Carrier. Medicaid reimburses the County Human Services Office for the agreed amount.

The rate of reimbursement equals the amount of travel reimbursement per mile for a state employee. Medicaid reimbursement will not be made for services provided free of charge.

Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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