Current through Register Vol. 49, No. 9, September, 2024
Section II
Federally Qualified Health
Center
212.220
Services
Furnished in Collaboration with a Physician Nurse practitioner services
are performed in collaboration with a physician or physicians.
A. Collaboration is a process in which a
nurse practitioner works with one (1) or more physicians to deliver health care
services within the scope of the practitioner's expertise, with medical
direction, and appropriate supervision as provided for in jointly developed
guidelines or other mechanisms as provided by State law.
B. The collaborating physician does not need
to be present with the nurse practitioner when the services are furnished or to
make an independent evaluation of each patient who is seen by the nurse
practitioner.
C. Medication
Assisted Treatment (MAT) for Opioid Use Disorders: Effective dates of service
on and after September 1, 2020, Medication Assisted Treatment for
Opioid Use Disorders is available to all qualifying Medicaid beneficiaries when
provided by providers who possess an X-DEA license on file with Arkansas
Medicaid Provider Enrollment for billing purposes. All rules and regulations
promulgated within the Physician's provider manual for provision of this
service must be followed.
220.000
Benefit Limits
A. Arkansas Medicaid beneficiaries aged
twenty-one (21) and older are limited to twelve (12) FQHC core service
encounters per state fiscal year (SFY, July 1 through June 30).
1. FQHC inpatient hospital visits do not
count against the FQHC encounter benefit limit. Medicaid covers only one (1)
FQHC inpatient hospital visit per Medicaid-covered inpatient day, for
beneficiaries of all ages.
2.
Obstetric and gynecologic procedures reported by CPT surgical procedure code do
not count against the FQHC encounter benefit limit.
3. Family planning surgeries and encounters
do not count against the FQHC encounter benefit limit.
4. Medication Assisted Treatment for Opioid
Use Disorder does not count against the FQHC encounter limit when it is the
primary diagnosis (View ICD Codes) and rendered by a MAT specialty
prescriber.
B. Medicaid
beneficiaries under the age of twenty-one (21) in the Child Health Services
(EPSDT) Program are not subject to an FQHC encounter benefit limit.
220.200
Extension of
Benefits
A. Extensions of family
planning benefits are not available.
B. Extensions of the FQHC core service
encounter benefit are automatic for the following diagnoses:
1. Malignant Neoplasm (View ICD
codes.)
2. HIV Infection and AIDS
(View ICD codes.)
3. Renal Failure
(View ICD codes.)
4. Opioid Use
Disorder when treated with MAT (View ICD codes).
262.430
Medication Assisted
Treatment
When billing an encounter for (MAT) the actual rendering
provider's NPI must be entered on the claim. If the billing provider's number
is used, the claim will deny.
272.501
Medication Assisted Treatment
and Opioid Use Disorder Treatment Drugs
Effective for dates of service on and after September 1,
2020, Medication Assisted Treatment for Opioid Use Disorders is
available to all qualifying Medicaid beneficiaries when provided by providers
who possess an X-DEA license on file with Arkansas Medicaid Provider Enrollment
for billing purposes. All rules and regulations promulgated within the
Physician's provider manual for provision of this service must be
followed.
Effective for dates of services on and after October 1,
2018, the following Healthcare Common Procedure Coding System Level II
(HCPCS) procedure codes are payable:
1.
J2315 - Injection,
naltrexone, depot form, 1 mg
2.
J0570 - Buprenorphine implant, 74.2 mg
3.
Q9991 - Injection,
buprenorphine extended-release (Sublocade), less than or equal to 100
mg
4.
Q9992 -
Injection, buprenorphine extended-release (Sublocade), greater than 100 mg
To access prior approval of these HCPCS procedure codes when
necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms
found at the DHS contracted Pharmacy vendor website.
252.448
Medication Assisted
Treatment and Opioid Use Disorder Treatment Drugs
Effective for dates of service on and after September 1,
2020, Medication Assisted Treatment for Opioid Use Disorders is
available to all qualifying Medicaid beneficiaries when provided by providers
who possess an X-DEA license on file with Arkansas Medicaid Provider Enrollment
for billing purposes. All rules and regulations promulgated within the
Physician's provider manual for provision of this service must be
followed.
Effective for dates of services on and after October 1,
2018, the following Healthcare Common Procedure Coding System Level II
(HCPCS) procedure codes are payable:
1.
J2315 - Injection,
naltrexone, depot form, 1 mg
2.
J0570 - Buprenorphine implant, 74.2 mg
3.
Q9991 - Injection,
buprenorphine extended-release (Sublocade), less than or equal to 100
mg
4.
Q9992 -
Injection, buprenorphine extended-release (Sublocade), greater than 100 mg
To access prior approval of these HCPCS procedure codes when
necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms
found at the DHS contracted Pharmacy vendor website.
211.200
Staff
Requirements
Each Outpatient Behavioral Health Services provider must ensure
that they employ staff which are able and available to provide appropriate and
adequate services offered by the provider. Behavioral Health staff members must
provide services only within the scope of their individual licensure. The
following chart lists the terminology used in this provider manual and explains
the licensure, certification, and supervision that are required for each
performing provider type.
|
PROVIDER TYPE
|
LICENSES
|
STATE CERTIFICATION REQUIRED
|
SUPERVISION
|
|
Independently Licensed Clinicians -
Master's/Doctoral
|
Licensed Clinical Social Worker (LCSW)
Licensed Marital and Family Therapist (LMFT)
Licensed Psychologist (LP)
Licensed Psychological Examiner - Independent
(LPEI)
Licensed Professional Counselor (LPC)
|
Yes, must be certified to provide services
|
Not Required
|
|
Independently Licensed Clinicians - Parent/Caregiver
& Child (Dyadic treatment of Children age 0-47 months &
Parent/Caregiver) Provider
|
Licensed Clinical Social Worker (LCSW)
Licensed Marital and Family Therapist (LMFT)
Licensed Psychologist (LP)
Licensed Psychological Examiner - Independent
(LPEI)
Licensed Professional Counselor (LPC)
|
Yes, must be certified to provide services
|
Not Required
|
|
Non-independently Licensed Clinicians -
Master's/Doctoral
|
Licensed Master Social Worker (LMSW)
|
Yes, must be supervised by appropriate Independently
Licensed Clinician
|
Required
|
|
|
Licensed Associate Marital and Family Therapist
(LAMFT)
Licensed Associate Counselor (LAC)
Licensed Psychological Examiner (LPE)
Provisionally Licensed Psychologist (PLP)
|
|
|
|
Non-independently Licensed Clinicians -
Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months
& Parent/Caregiver) Provider
|
Licensed Master Social Worker (LMSW)
Licensed Associate Counselor (LAC)
Licensed Psychological Examiner (LPE)
Provisionally Licensed Psychologist (PLP)
|
Yes, must be supervised by appropriate Independently
Licensed Clinician and must be certified to provide services
|
Required
|
|
Advanced Practice Nurse (APN)
|
Adult Psychiatric Mental Health Clinical Nurse
Specialist
Child Psychiatric Mental Health Clinical Nurse
Specialist
Adult Psychiatric Mental Health APN
Family Psychiatric Mental Health APN
|
No, must be part of a certified agency or have a
Collaborative Agreement with a Physician
|
Collaborative Agreement with Physician Required
|
|
Physician
|
Doctor of Medicine (MD)
Doctor of Osteopathic Medicine (DO)
|
No, must provide proof of licensure
|
Not Required
|
The services of a medical records librarian are required. The
medical records librarian (or person performing the duties of the medical
records librarian) shall be responsible for ongoing quality controls, for
continuity of patient care, and patient traffic flow. The librarian shall
assure that records are maintained, completed and preserved; that required
indexes and registries are maintained, and that statistical reports are
prepared. This staff member will be personally responsible for ensuring that
information on enrolled patients is immediately retrievable, establishing a
central records index, and maintaining service records in such a manner as to
enable a constant monitoring of continuity of care.
When an Outpatient Behavioral Health Services provider files a
claim with Arkansas Medicaid, the staff member who actually performed the
service must be identified on the claim as the rendering provider. This action
is taken in compliance with the federal Improper Payments Information Act of
2002 (IPIA),
Public
Law 107-300, and the resulting Payment Error Rate
Measurement (PERM) program initiated by the Centers for Medicare and Medicaid
Services (CMS).
214.200
Medication Assisted Treatment and Opioid Use Disorder Treatment
Drugs
Effective for dates of service on and after September 1, 2020,
Medication Assisted Treatment for Opioid Use Disorders is available to all
qualifying Medicaid beneficiaries when provided by providers who possess an
X-DEA license on file with Arkansas Medicaid Provider Enrollment for billing
purposes. All rules and regulations promulgated within the Physician's provider
manual for provision of this service must be followed.
201.500
Providers of
Medication-Assisted Treatment (MAT) for Opioid Use Disorder
Providers of Medication-Assisted Treatment (MAT) for Opioid Use
Disorder must be licensed in Arkansas and have a current X-DEA identification
number on file with Arkansas Medicaid.
201.510
Providers of
Medication-Assisted Treatment (MAT) for Opioid Use Disorder in Arkansas and
Bordering States
Providers of MAT in Arkansas and the six (6) bordering states
(Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and Texas) may be
included as routine services providers if they meet all participation
requirements for enrollment in Arkansas Medicaid and requirements outlined in
Section 201.500.
Reimbursement may be available for MAT covered in the Arkansas
Medicaid Program when treating Opioid Use Disorders. Claims must be filed
according to the specifications in this manual. This includes assignment of ICD
and HCPCS codes for all services rendered.
201.520
Providers of
Medication-Assisted Treatment (MAT) for Opioid Use Disorder in States Not
Bordering Arkansas
A. Providers in
states not bordering Arkansas may enroll in the Arkansas Medicaid Program as
limited services providers only after they have provided services to an
Arkansas Medicaid eligible beneficiary and have a claim or claims to file with
Arkansas Medicaid.
To enroll, a non-bordering state provider must download an
Arkansas Medicaid application and contract from the Arkansas Medicaid website
and submit the application, contract, and claim to Arkansas Medicaid Provider
Enrollment. A provider number will be assigned upon approval of the provider
application and Medicaid contract. View or print the provider enrollment and
contract package (Application Packet). View or print Provider Enrollment Unit
contact information.
B.
Limited services providers remain enrolled for one (1) year.
1. If a limited services provider provides
services to another Arkansas Medicaid beneficiary during the year of enrollment
and bills Medicaid, the enrollment may continue for one (1) year past the most
recent claim's last date of service, if the enrollment file is kept
current.
2. During the enrollment
period, the provider may file any subsequent claims directly to the Medicaid
fiscal agent. Limited services providers are strongly encouraged to file
subsequent claims through the Arkansas Medicaid website because the front-end
processing of web-based claims ensures prompt adjudication and facilitates
reimbursement.
203.270
Physician's Role in Behavioral
Health Services
Medicaid covers behavioral health services when furnished by
qualified providers to eligible Medicaid beneficiaries. A primary care
physician referral is required for some behavioral health services.
For additional information about services that may not require
PCP referral, refer to Section 172.100 of this manual.
203.271
Medication-Assisted Treatment
Provider Role for Administering Opioid Use Disorder Services
SAMHSA defines Medication Assisted Treatment (MAT) as the use
of medications in combination with counseling and behavioral therapies for the
treatment of substance use disorders. A combination of medication and
behavioral therapies is effective in the treatment of substance use disorders
and can help some people to sustain recovery. This definition and other MAT
guidelines can be found at the SAMHSA website.
Only providers who have met the requirements of Section 201.500
may prescribe medication required for the treatment of opioid use disorder for
Arkansas Medicaid beneficiaries in conjunction with coordinating all follow-up
and referrals for counseling and other services. This program applies only to
prescribers of FDA-approved drugs for treatment of Opioid Use Disorder and will
not be reimbursed for the practice of pain management.
225.000
Outpatient Hospital Benefit
Limit
Medicaid-eligible beneficiaries age twenty-one (21) and older
are limited to a total of twelve (12) outpatient hospital visits a year. This
benefit limit includes outpatient hospital services provided in an acute care,
general, or a rehabilitative hospital. This yearly limit is based on the State
Fiscal Year (July 1 through June 30).
A. Outpatient hospital services include the
following:
1. Non-emergency professional
visits in the outpatient hospital and related physician services.
2. Outpatient hospital therapy and treatment
services and related physician services.
B. Extension of benefits will be considered
for patients based on medical necessity.
C. The Arkansas Medicaid Program
automatically extends the outpatient hospital visit benefit for certain primary
diagnoses. Those diagnoses are:
1. Malignant
neoplasm (View ICD Codes.)
2. HIV
infection and AIDS (View ICD Codes.)
3. Renal failure (View ICD Codes.)
4. Pregnancy (View ICD Codes.)
5. Opioid Use Disorder when treated with MAT
(View ICD Codes.)
D.
When a Medicaid eligible beneficiary's primary diagnosis is one (1) of those
listed above and the Medicaid eligible beneficiary has exhausted the Medicaid
established benefit limit for outpatient hospital services and related
physician services, the provider does not have to file for an extension of the
benefit limit.
E. All outpatient
hospital services for beneficiaries under age twenty-one (21) in the Child
Health Services (EPSDT) Program are not benefit limited.
F. Emergency and surgical physician services
provided in an outpatient hospital setting are not benefit limited.
225.100
Laboratory and X-Ray
Services
The Medicaid Program's laboratory and X-ray services benefit
limits apply to outpatient laboratory services, radiology services, and machine
tests (such as electrocardiograms).
A.
Medicaid has established a maximum paid amount (benefit limitation) of $500 per
state fiscal year (July 1 through June 30) for beneficiaries aged twenty-one
(21) and older, for outpatient laboratory and machine tests and outpatient
radiology.
1. There is no lab and X-ray
benefit limit for beneficiaries under age twenty-one (21).
2. There is no benefit limit on professional
components of laboratory, X-ray, and machine tests for hospital
inpatients.
3. There is no benefit
limit on laboratory services related to family planning. See Section 292.552
for the family planning-related clinical laboratory procedures exempt from
benefit limits.
4. There is no
benefit limit on laboratory, X-ray, and machine-test services performed as
emergency services.
B.
Extension-of-benefit requests are considered for medically necessary services.
1. The claims processing system automatically
overrides benefit limitations for services supported by the following
diagnoses:
a. Malignant neoplasm (View ICD
Codes.)
b. HIV infection and AIDS
(View ICD Codes.)
c. Renal failure
(View ICD Codes.)
d. Pregnancy
(View ICD Codes.)
e. Opioid Use
Disorder when treated with MAT (View ICD Codes.) Designated lab tests will be
automatically overridden when the diagnosis is Opioid Use Disorder. (View Lab
and Screening Codes.)
2.
Benefits may be extended for other conditions for documented reasons of medical
necessity. Providers may request extensions of benefits according to
instructions in Section 229.100 of this manual.
C. Magnetic resonance imaging (MRI) is exempt
from the $500 outpatient laboratory and X-ray annual benefit limit. Medical
necessity for each MRI must be documented in the beneficiary's medical
record.
D. Cardiac catheterization
procedures are exempt from the $500 annual benefit limit for outpatient
laboratory and X-ray. Medical necessity for each procedure must be documented
in the beneficiary's medical record.
226.000
Physician Services Benefit
Limit
A. Physician services in a
physician's office, patient's home, or nursing home for beneficiaries aged
twenty-one (21) or older are limited to twelve (12) visits per state fiscal
year (July 1 through June 30). Beneficiaries under age twenty-one (21) in the
Child Health Services (EPSDT) Program are not subject to this benefit limit.
The following services are counted toward the twelve (12)
visits per state fiscal year limit established for the Physician
Program:
1. Physician services in the
office, patient's home, or nursing facility.
2. Rural health clinic (RHC)
encounters.
3. Medical services
provided by a dentist.
4. Medical
services furnished by an optometrist.
5. Certified nurse-midwife
services.
6. Advanced nurse
practitioner services.
B. Extensions of this benefit are considered
when documentation verifies medical necessity. Refer to Sections 229.100
through 229.120 of this manual for procedures on obtaining extension of
benefits for physician services.
C.
The Arkansas Medicaid Program exempts the following diagnoses from the
extension of benefit requirements when the diagnosis is entered as the primary
diagnosis:
1. Malignant neoplasm (View ICD
Codes.).
2. HIV infection or AIDS
(View ICD Codes.).
3. Renal failure
(View ICD Codes.).
4. Pregnancy*
(View ICD Codes.).
5. Opioid Use
Disorder when treated with MAT (View ICD Codes.)
When a Medicaid beneficiary's primary diagnosis is one (1) of
those listed above and the beneficiary has exhausted the Medicaid established
benefit for physician services, outpatient hospital services, or laboratory and
X-ray services, a request for extension of benefits is not required.
*OB ultrasounds and fetal non-stress tests are not exempt from
Extension of Benefits. See Section 292.673 for additional coverage
information.
230.000
Medication-Assisted Treatment
for Opioid Use Disorder
A. MAT is
covered for eligible Medicaid beneficiaries who have an Opioid Use Disorder
when diagnosis and clinical impression is determined in the terminology of
ICD.
B. Providers are required to
follow SAMHSA guidelines for the full provision of MAT.
C. Providers are encouraged to use
telemedicine services when in-person treatment is not readily
accessible.
D. In accordance with
SAMHSA guidelines, MAT requires at a minimum:
a.
Initial evaluation and diagnosis of
Opioid Use Disorder, including:
i.
Drug screening tests to accompany proper medication prescribing for MAT.
Buprenorphine mono-therapy is typically reserved only for pregnant women and
those with a documented anaphylactic reaction to other MAT medications like
Buprenorphine/Naloxone combinations.
ii. Lab screening tests for communicable
diseases, as appropriate based on the patient's history.
iii. Use of all necessary consent forms for
treatment and HIPAA compliant communication.
iv. Execution of a Treatment Agreement or
Contract such as SAMHSA's sample treatment agreement found under Tip 63 on the
SAMHSA website: https://www.samhsa.gov/search_results?k=Opioid+Use+Disorder.
Providers may develop their own agreement or contract as long as it contains
all elements listed within SAMHSA's sample agreement.
v. Development of a Person-Centered Treatment
Plan.
vi. Referral for independent
clinical counseling or documented plan for integrated follow-up visit including
counseling.
vii. Identification of
a MAT team member to function as the case manager to offer support
services.
b.
Continuing Treatment (first year):
i. Regular outreach to the patient to
determine need for assistance in accessing resources, providing information on
available programs and supports in the community, and referrals as needed to
other practitioners.
ii. At least
one (1) follow-up MAT office visit per month for medication and treatment
management.
iii. Drug testing in
conjunction with each monthly visit.
iv. At least one (1) independent clinical
counseling visit or documented plan for integrated follow-up visit including
counseling per month.
c.
Maintenance Treatment (subsequent years)
i. Regular outreach to the patient to
determine need for assistance in accessing resources, providing information on
available programs and supports in the community, and referrals as needed to
other practitioners.
ii. At least
one (1) follow-up MAT office visit quarterly for medication and treatment
management.
iii. Drug testing in
conjunction with each quarterly visit.
iv. At least one (1) independent clinical
counseling visit or documented plan for integrated follow-up visit including
counseling at an amount and duration medically necessary for continued
recovery.
230.100
Compliance with SAMHSA
Guidelines
Arkansas Medicaid or its designated authority will periodically
review claims for MAT to ensure provider compliance with minimum requirements
set forth in this manual and with the SAMHSA guidelines that are current as of
the date of services. Failure to comply with minimum requirements for the
program may result in recoupment or other sanctions outlined in Section I of
the Arkansas Medicaid Provider Manual.
MAT providers are expected to adhere to the SAMHSA guidelines
when providing MAT. We understand MAT providers may not be able to control all
elements of treatment when referred and provided by other practitioners.
However, to ensure the effectiveness of the program, the MAT provider is
responsible for case management and adjusting the treatment plan for the
beneficiary's maximum progress. Documentation regarding how the MAT provider is
monitoring and addressing non-compliance will be reviewed. For example, when a
client routinely misses office visits or referred counseling appointments or is
otherwise not following the MAT program, the client should be appropriately
tapered off medication if necessary. In the patient/prescriber agreement, the
provider would set out those expectations in accordance with SAMHSA guidelines.
If counseling or other components of treatment are being referred, those
providers' records are also subject to post payment review and recoupment for
services not documented as compliant with SAMHSA guidelines.
263.000
Prescription Drug Prior
Authorization
Prescription drugs are available for reimbursement under the
Arkansas Medicaid Program when prescribed by a provider with prescriptive
authority. Certain prescription drugs may require prior authorization. It is
the responsibility of the prescriber to request and obtain the prior
authorization. Refer to the DHS contracted Pharmacy vendor's website for the
following information:
A. Prescription
drugs requiring prior authorization.
B. Criteria for drugs requiring prior
authorization.
C. Forms to be
completed for prior authorization.
D. Procedures required of the prescriber to
request and obtain prior authorization.
E. Effective for dates of services on and
after
October 1, 2018, the following Healthcare Common Procedure
Coding System Level II (HCPCS) procedure codes are payable:
1.
J2315 - Injection,
naltrexone, depot form, 1 mg
2.
J0570 - Buprenorphine implant, 74.2 mg
3.
Q9991 - Injection,
buprenorphine extended-release (Sublocade), less than or equal to 100
mg
4.
Q9992 -
Injection, buprenorphine extended-release (Sublocade), greater than 100 mg To
access prior approval of these HCPCS procedure codes when necessary, reference
the Pharmacy Memorandums, Criteria Documents and forms found at the DHS
contracted Pharmacy vendor's website.
263.100
Coverage of Oral Drugs Used for
Opioid Use Treatment
Effective for claims with dates of service on or after
January 1, 2020, coverage of preferred oral prescription drugs
(preferred on the PDL) for opioid use disorder and tobacco cessation are
available without prior authorization to eligible Medicaid beneficiaries.
Products for other use disorders may still require PA. Additional criteria can
be found at the DHS contracted Pharmacy vendor's website.
Coverage and Limitations
A. Reimbursement for preferred oral drugs is
available with a valid prescription and compliance with the guidelines issued
by the Substance Abuse and Mental Health Services Administration (SAMHSA) for
eligible Medicaid beneficiaries. Additional SAMHSA information is available at
https://www.samhsa.gov/.
B. Prescription drugs for treatment of opioid
use disorder will not count against the monthly prescription benefit limit and
are not subject to co-pay.
C.
Injectable products will require a prior authorization. The criteria can be
found at the DHS contracted Pharmacy vendor's website.
D. FDA dosing and prescribing limitations
apply.
272.600
Medication Assisted Treatment for Opioid Use Disorder
Parti cipating MAT providers must bill all components related
to MAT guidelines, including but not limited to office visits, lab screening
and testing, and required counseling if not referred to another
provider.
When a MAT provider meets all conditions outlined within
Section 230.000 within the same day, an inclusive payment method may be
available for billing the required services (with the exception of lab
testing).
When proper treatment according to these guidelines cannot be
accomplished within the same day or must encompass referrals for counseling,
each provider must bill separately for the actual services he or she provided
according to regular fee-for-service billing rules. See Section 292.920 for
special billing procedures.
292.920
Medication Assisted Treatment
(MAT) for Opioid Use Disorder
There are two (2) methods of billing for MAT.
1. Method 1- Inclusive Rate a. The inclusive
method of billing shall be used when all SAMHSA guideline services as set forth
at a minimum in Section 230.000 are provided on the same date of service by the
same billing group who has at least one (1) performing provider with an X-DEA
number on file with Arkansas Medicaid.
i. For
new patients, the provider group shall use HCPCS code H0001, modifier X2 and
list an Opioid Use Disorder ICD-10 code as primary. The performing provider
must be enrolled as a MAT provider and the claim will pay a single rate for all
services (Office Visit, counseling, case management, medication
induction/maintenance, etc). Drug and lab testing/screening will continue to be
billed separately, using an X2 modifier with the proper code for the test or
screen.
ii. For established
patients requiring continuing follow-up MAT treatment, the provider group shall
use HCPCS code H0001, modifiers U8, X2, and list an Opioid Use Disorder ICD-10
code as primary. The performing provider must be enrolled as a MAT provider and
the claim will pay a single rate for all follow-up services as indicated on the
treatment plan and set forth at a minimum in Section 230.000 (Office Visit,
counseling and medication induction/maintenance, etc). Drug and lab
testing/screening will continue to be billed separately, using an X2 modifier
with the proper code for the test or screen.
iii. For established patients requiring
maintenance follow-up MAT treatment, the provider group shall use HCPCS code
H0001, modifiers U8, X4, and list an Opioid Use Disorder ICD-10 code as
primary. The performing provider must be enrolled as a MAT provider and the
claim will pay a single rate for all follow-up services as indicated on the
treatment plan and set forth at a minimum in Section 230.000 (Office Visit,
counseling and medication induction/maintenance, etc). Drug and lab
testing/screening will continue to be billed separately, using an X4 modifier
with the proper code for the test or screen.
iv. The specific HCPCS code and modifiers
found in the following link are required for billing the inclusive rate. View
or print the procedure codes and modifiers for MAT services.
2. Method 2 - Regular
Fee-for-Service Rates a. The regular Fee-for-Service method of billing shall be
used when all SAMHSA guideline services as set forth at a minimum in Section
230.000 cannot be provided on the same date of service, or cannot be provided
by the same billing group who has the MAT specialized performing provider;
therefore, causing some SAMHSA guideline services to be referred elsewhere.
i. For new patients, the MAT provider shall
use the appropriate E & M (office visit) code, add modifier X2, and list an
Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper
Lab and Urine Screening codes plus the additional X2 modifier for the
screenings required.
ii. For
established patients requiring continuing treatment, the MAT provider shall use
the appropriate E & M (office visit) code, add modifier X2, and list an
Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper
Lab and Urine Screening codes plus the additional X2 modifier for the
screenings required.
iii. For
established patients requiring maintenance treatment, the MAT provider shall
use the appropriate E & M (office visit) code, add modifier X4, and list an
Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper
Lab and Urine Screening codes plus the additional X4 modifier for the
screenings required.
Allowable ICD-10 codes for Opioid Use Disorder may be found
here: (SEE OUD CODES)
Allowable lab and screening codes may be found here: (SEE LAB
CODES)
Providers utilizing telemedicine, regardless of Method, shall
adhere to telemedicine rules listed in Sections 105.190 and 305.000 in addition
to those above. The provider at the distance site shall use both the GT
modifier and the X2 or X4 modifier on the service claim.
211.100
Rural
Health Clinic Core Services
Rural Health Clinic core services are as follows:
A. Professional services that are performed
by a physician at the clinic or are performed away from the clinic by a
physician whose agreement with the clinic provides that he or she will be paid
by the clinic for such services;
B.
Services and supplies furnished "incident to" a physician's professional
services;
C. Services provided by
non-physician, services of physician assistants, nurse practitioners, nurse
midwives, and specialized nurse practitioners when the provider is legally:
1. employed by, or receiving compensation
from a rural health clinic;
2.
under the medical supervision of a physician;
3. acting in accordance with any medical
orders for the care and treatment of a patient prepared by a physician;
and
4. acting within their scope of
practice by providing services they are legally permitted to perform by the
state in which the service is provided if the services would be covered if
furnished by a physician;
D. Services and supplies that are furnished
as an incident to professional services furnished by a nurse practitioner,
physician assistant, nurse midwife, or other specialized nurse
practitioner;
E. Visiting nurse
services on a part-time or intermittent basis to home-bound patients in areas
in which there is a shortage of home health agencies.
Note: For purposes of visiting nurse care, a home-bound
patient is one who is permanently or temporarily confined to his or her place
of residence because of a medical or health condition. Institutions, such as a
hospital or nursing care facility, are not considered a patient's
residence.
Note: A patient's place of residence is where he or she
lives, unless he or she is in an institution such as a nursing facility,
hospital, or intermediate care facility for individuals with intellectual
disabilities (ICF/IID); and
F. Effective for dates of service on and
after September 1, 2020, Medication Assisted Treatment (MAT) for
Opioid Use Disorders is available to all qualifying Medicaid beneficiaries when
provided by providers who possess an X-DEA license on file with Arkansas
Medicaid Provider Enrollment for billing purposes. All rules and regulations
promulgated within the Physician's provider manual for provision of this
service must be followed.
218.100
RHC Encounter Benefit
Limits
A. There is no RHC encounter
benefit limit for Medicaid beneficiaries under the age of twenty-one (21) in
the Child Health Services (EPSDT) Program.
B. A benefit limit of twelve (12) visits per
state fiscal year (SFY), July 1 through June 30, has been established for
beneficiaries aged twenty-one (21) and older. The following services are
counted toward the twelve (12) visits per SFY benefit limit:
1. Physician visits in the office, patient's
home, or nursing facility;
2.
Certified nurse-midwife visits;
3.
RHC encounters;
4. Medical services
provided by a dentist;
5. Medical
services provided by an optometrist; and
6. Advanced nurse practitioner services.
Global obstetric fees are not counted against the 12-visit
limit. Itemized obstetric office visits are counted in the limit.
The established benefit limit does not apply to individuals
receiving Medication Assisted Treatment for Opioid Use Disorder when it is the
primary diagnosis and rendered by a qualified X-DEA waivered provider. (View
ICD Codes).
Extensions of the benefit limit will be considered for services
beyond the established benefit limit when documentation verifies medical
necessity. Refer to Section 218.310 of this manual for procedures for obtaining
extension of benefits.
252.400
Special Billing
Procedures
252.401
Upper Respiratory Infection - Acute Pharyngitis
A Rural Health Center (RHC) must submit a claim that includes
CPT code 87430, 87650, 87651, 87802, or 87880 in the Upper Respiratory
Infection (URI)-Acute Pharyngitis episode if a strep test is performed when
prescribing an antibiotic for beneficiaries. This allows DMS to determine if
the Principle Accountable Provider (PAP) met or exceeded the quality threshold
in order to qualify for a full positive supplemental payment for the
URI-Pharyngitis episode.
252.402
Medication Assisted
Treatment
When billing a claim for MAT the actual attending provider's
NPI must be entered on the claim.
211.105
Coverage of Medication Assisted
Treatment and Opioid Use Disorder Treatment Drugs
Effective for claims with dates of service on or after
January 1, 2020, coverage of preferred oral prescription drugs
(preferred on the PDL) for opioid use disorder are available without prior
authorization to eligible Medicaid beneficiaries. Products for other use
disorders may still require PA. Additional criteria can be found at the DHS
contracted Pharmacy vendor's website.
Coverage and Limitations
A. Reimbursement for preferred oral drugs is
available with a valid prescription and compliance with the guidelines issued
by the Substance Abuse and Mental Health Services Administration (SAMHSA) for
eligible Medicaid beneficiaries. Additional SAMHSA information is available at
https://www.samhsa.gov/.
B. Oral prescription drugs will not count
against the monthly prescription benefit limit and are not subject to co-pay
when used for a primary diagnosis of opioid use disorder.
C. Injectable opioid use disorder treatment
drugs will require a prior authorization. The criteria can be found at the DHS
contracted Pharmacy vendor's website.
D. FDA dosing and prescribing limitations
apply.
213.100
Monthly Prescription Limits
A. Each
prescription for all Medicaid-eligible beneficiaries may be filled for up to a
maximum 31 day supply. Maintenance medications for chronic illnesses must be
prescribed and dispensed in quantities sufficient (not to exceed the maximum
31-day supply per prescription) to effect optimum economy in dispensing. For
drugs that are specially packaged for therapy exceeding thirty-one (31) days,
the days' supply limit (other than thirty-one (31)), as approved by the Agency,
will be allowed for claims processing. Contact the Pharmacy Help Desk to
inquire about specific days' supply limits on specially packaged dosage units.
View or print the contact information for the DHS contracted
Pharmacy vendor.
B. Each
Medicaid-eligible beneficiary age twenty-one (21) years and older is limited to
three (3) Medicaid-paid prescriptions per calendar month.
Each prescription filled counts toward the monthly prescription
limit except for the following:
1.
Family planning items. This includes, but is not limited to, birth control
pills, contraceptive foams, contraceptive sponges, suppositories, jellies,
prophylactics, and diaphragms.
2.
Prescriptions for Medicaid-eligible long-term care facility residents.
(Prescriptions must be for Medicaid-covered drugs.)
3. Prescriptions for Medicaid-eligible
beneficiaries under age twenty-one (21) in the Child Health Services/Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) Program. (Prescriptions
must be for Medicaid-covered drugs.)
4. Prescriptions for opioid use disorder
treatment when used according to SAMHSA guidelines.
5. Prescriptions for tobacco cessation
products.
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. Medication Assisted
Treatment for Opioid Use Disorder when rendered by an X-DEA waivered
practitioner
3. 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, including direct patient care (initial
and subsequent evaluation and management services, surgery, etc.), and 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,
which do require PCP referral) in the outpatient departments of acute care
hospitals but only if the Medicaid beneficiary is enrolled with a PCP and the
services are within applicable benefit limitations;
V. Professional components of diagnostic
laboratory, radiology, and machine tests in the outpatient departments of acute
care hospitals, but only if the Medicaid beneficiary is enrolled with a PCP and
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; and
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.
ATTACHMENT 3.1-A
AMOUNT, DURATION, AND SCOPE OF SERVICES
PROVIDED
2.a.
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 rendered by
an X-DEA waivered provider as 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.
2.b. Rural Health Clinic Services
5. Services of physician
assistants, nurse practitioners, nurse midwives, and specialized nurse
practitioners;
6. Services and
supplies furnished as an incident to a nurse practitioner's or physician
assistant's services; and
7.
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 rendered by
an X-DEA waivered provider as part of a Medication Assisted Treatment
plan.
2.c.
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).
Effective for claims with dates of service on or after July 1,
1995, federally qualified health center (FQHC) services are limited to twelve
(12) encounters per beneficiary, per State Fiscal Year (July 1 through June 30)
for beneficiaries age twenty-one (21) and older. For federally
qualified health center core services beyond the 12-visit limit, extensions
will be provided 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 rendered by an X-DEA
waivered provider as part of a Medication Assisted Treatment
plan.
3. Other Laboratory and
X-Ray Services
Other medically necessary laboratory and X-ray
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 by State law in the
practitioner's office or outpatient hospital setting or by a certified
independent laboratory which meets the requirements for participation in Title
XVIII. Services are limited to five hundred dollars ($500) per State
Fiscal Year (July 1 - June 30), unless specifically exempt from the
limit. Extensions of the benefit limit for recipients age
twenty-one (21) or older will be provided through prior authorization, if
medically necessary. The five hundred dollars ($500) per State Fiscal Year
benefit limit does not apply to services provided to recipients under age
twenty-one (21) enrolled in the Child Health Services (EPSDT)
Program.
(1) The following
diagnoses are specifically exempt from the five hundred dollars ($500)
per State Fiscal Year laboratory and X-ray services health benefit
limit: Malignant neoplasm; HIV infection; and renal failure. The
cost of related laboratory and X-ray services will not be included in the
calculation of the recipient's five hundred dollars ($500) laboratory and X-ray
services health benefit limit. Drug screening will be specifically exempt from
the five hundred dollars ($500) per State Fiscal Year laboratory and X-ray
services health benefit limit when the diagnosis is for opioid use disorder and
the screening is ordered by an X-DEA waivered provider as part of a Medication
Assisted Treatment plan. The cost of these screenings will not be included in
the calculation of the recipient's five hundred dollars ($500) laboratory and
X-ray services health benefit limit.
(2) Magnetic Resonance Imaging (MRI) and
Cardiac Catheterization procedures are specifically exempt from the five
hundred dollars ($500) per State Fiscal Year laboratory and X-ray services
health benefit limit. The cost of these procedures will not be included in the
calculation of the recipient's five hundred dollars ($500) laboratory and X-ray
services health benefit limit.
(3) Portable X-Ray Services are
subject
to the five hundred dollars ($500) benefit limit. Extensions of the benefit
limit for recipients age twenty-one (21) or older will be provided through
prior authorization, if medically necessary. Services may be provided to an
eligible recipient in his or her place of residence upon the written order of
the recipient's physician. Services are limited to the following:
a. Skeletal films which involve
arms and legs, pelvis, vertebral column, and skull;
b.
Chest films which do not
involve the use of contrast media; and
c.
Abdominal films which do not
involve the use of contrast media.
(4)
Two (2) chiropractic X-rays are
covered per state fiscal year. Chiropractic X-Ray Services are subject to the
five hundred dollars ($500) benefit limit. Extensions of the benefit limit for
recipients age twenty-one (21) 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. The first three (3) prescriptions do not require prior
authorization. The three (3) additional prescriptions must be prior authorized.
Family Planning, tobacco cessation , oral prescription drugs for opioid
use disorder prescribed by an X-DEA waivered provider as part of a Medication
Assisted Treatment plan, and EPSDT 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:
Androgenic Agents;
b. select agents
when used for the symptomatic relief of cough and colds: Antitussives;
Antitussive-Decongestants; and Antitussive-Expectorants;
c. select prescription vitamins and mineral
products, except prenatal vitamins and fluoride:
B12; Folic Acid; and Vitamin K;
d. select nonprescription drugs:
Antiarthritics; Antibacterials and Antiseptics; Antitussives;
Antitussives-Expectorants; Analgesics; Antipyretics; Antacids; Antihistamines;
Antihistamine-Decongestants; Antiemetic/Vertigo Agents; Gastrointestinal
Agents; Hematinics; Laxatives; Opthalmic Agents; Sympathomimetics; Topical
Antibiotics; Topical Antifungals; Topical Antiparasitics; and Vaginal
Antifungals; and
e.
non-prescription products for smoking cessation.
(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.
ATTACHMENT 3.1-B
AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED
MEDICALLY NEEDY GROUP(S):
Click here
to view image
2.a.
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 rendered by an X-DEA
waivered provider as 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.
2.b.
Rural
Health Clinic Services
5. Services of physician assistants, nurse
practitioners; nurse midwives; and specialized nurse practitioners;
6. Services and supplies furnished as an
incident to a nurse practitioner's or physician assistant's services;
and
7. 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 diagnosis is for
opioid use disorder and is rendered by an X-DEA waivered provider as part of a
Medication Assisted Treatment plan.
2.c.
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).
Effective for claims with dates of service on or after July 1,
1995, federally qualified health center (FQHC) services are limited to twelve
(12) encounters per beneficiary, per State Fiscal Year (July 1 through June 30)
for beneficiaries age twenty-one (21) and older. For federally
qualified health center core services beyond the 12-visit limit, extensions
will be provided 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 diagnosis is for opioid use disorder
and is rendered by an X-DEA waivered provider as part of a Medication Assisted
Treatment plan.
3. Other
Laboratory and X-Ray Services
Other medically necessary laboratory and X-ray
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 by State law in the
practitioner's office or outpatient hospital setting or by a certified
independent laboratory which meets the requirements for participation in Title
XVIII. Services are limited to five hundred dollars ($500)
per State Fiscal Year (July 1-June 30), unless specifically exempt
from the limit. Extensions of the benefit limit for recipients age
twenty-one (21) or older will be provided
through prior authorization, if medically necessary. The
five hundred dollars ($500) per State Fiscal Year benefit limit does not apply
to services provided to recipients under age twenty-one (21) enrolled in the
Child Health Services (EPSDT) Program.
The following diagnoses are specifically exempt from the
five hundred dollars ($500) per State Fiscal Year laboratory and X-ray services
health benefit limit: Malignant neoplasm; HIV infection; and renal failure. The
cost of related laboratory and X-ray services will not be included in the
calculation of the recipient's five hundred dollars ($500) laboratory and X-ray
services health benefit limit.
(1)
Drug screening will be specifically
exempt from the five hundred dollars ($500) per State Fiscal Year laboratory
and X-ray services health benefit limit when the diagnosis is for opioid use
disorder and the screening is ordered by an X-DEA waivered provider as part of
a Medication Assisted Treatment plan. The cost of these screenings will not be
included in the calculation of the recipient's five hundred dollars ($500)
laboratory and X-ray services health benefit limit.
(2)
Magnetic Resonance Imaging (MRI)
and Cardiac Catheterization procedures are specifically exempt from the five
hundred dollars ($500) per State Fiscal Year outpatient laboratory and X-ray
services health benefit limit. The cost of these procedures will not be
included in the calculation of the recipient's five hundred dollars ($500)
laboratory and X-ray services health benefit limit.
(3)
Portable X-Ray Services are subject
to the five hundred dollars ($500) benefit limit. Extensions of the benefit
limit for recipients age twenty-one (21) or older will be provided through
prior authorization, if medically necessary. Services may be provided to an
eligible recipient in his or her place of residence upon the written order of
the recipient's physician. Services are limited to the following:
a.
Skeletal films which involve arms
and legs, pelvis, vertebral column, and skull;
b.
Chest films which do not involve the
use of contrast media; and
c.
Abdominal films which do not involve
the use of contrast media.
(4)
Two (2) chiropractic X-rays are
covered per state fiscal year. Chiropractic X-Ray Services are subject to the
five hundred dollars ($500) benefit limit. Extensions of the benefit limit for
recipients age twenty-one (21) or older will be provided through prior
authorization, if medically necessary.
4.a. Nursing Facility Services - Not Provided
4.c. Family Planning Services
(1) Comprehensive family planning services
are limited to an original examination and up to three (3) follow-up visits
annually. This limit is based on the state fiscal year (July 1 through June
30).
4.d.
(1) Face-to-Face Tobacco Cessation Counseling
Services provided (by):
[X] (i) By or under
supervision of a physician;
[X]
(ii) By any other health care professional who is
legally authorized to furnish such services under State law and who is
authorized to provide Medicaid coverable services other than
tobacco cessation services; * or
(iii) Any other health care professional
legally authorized to provide tobacco cessation services under State law
and who is specifically
designated by the
Secretary in regulations. (None are designated at this time)
*describe if there are any limits on who can provide these
counseling services
(2) Face-to-Face Tobacco Cessation Counseling
Services Benefit Package for Pregnant Women
Provided: No limitations [X] With limitations*
*Any benefit package that consists of less
than four (4) counseling sessions per quit attempt, with a minimum of
two (2) quit attempts per 12-month period (eight (8) per year) should be
explained below.
Please describe any limitations:
Face-to-face tobacco cessation counseling services are
limited to no more than two (2) 15-minute units and two (2) 30-minute units for
a maximum allowable of four (4) units per state fiscal
year.
4.e.
Prescription drugs for treatment
of opioid use disorder
a.
Oral
preferred prescription drugs (preferred on the PDL) used for treatment of
opioid use disorder require no prior authorization and do not count against the
monthly prescription limits when prescribed by an X-DEA waivered provider as
part of a Medication Assisted Treatment plan.
5.a.
Physicians' services, whether furnished in the office, the recipient's home, a
hospital, a skilled nursing facility, or elsewhere (1) Physicians' services in
a physician's office, patient's home, or nursing home are limited to twelve
(12) visits per State Fiscal Year (July 1 through June 30) for recipients age
twenty-one (21) and older.
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. The first three (3) prescriptions do not require prior
authorization. The three (3) additional prescriptions must be prior authorized.
Family Planning, tobacco cessation, oral prescription drugs for opioid
use disorder when prescribed by an X-DEA waivered provider as part of a
Medication Assisted Treatment plan, and EPSDT 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:
Androgenic Agents;
b. select agents when used for the
symptomatic relief of cough and colds:
Antitussives; Antitussive-Decongestants; and
Antitussive-Expectorants;
c. select prescription vitamins and mineral
products, except prenatal vitamins and fluoride:
B 12; Folic Acid; and Vitamin K;
d. select nonprescription drugs:
Antiarthritics; Antibacterials and Antiseptics; Antitussives;
Antitussives-Expectorants; Analgesics; Antipyretics; Antacids; Antihistamines;
Antihistamine-Decongestants; Antiemetic/Vertigo Agents; Gastrointestinal
Agents; Hematinics; Laxatives; Opthalmic Agents; Sympathomimetics; Topical
Antibiotics; Topical Antifungals; Topical Antiparasitics; and Vaginal
Antifungals; and
e. non-prescription products for smoking
cessation.
(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 72-hour supply of drugs in emergency situations.
Citation Condition or Requirement
1. Describe any additional circumstances of
"cause" for disenrollment (if any).
K.
Information requirements for
beneficiaries
Place a check mark to affirm state compliance.
1932(a)(5)CFR 438.50
42 CFR
438.10
X The state assures that its state
plan program complies with 42 CFR 42 438.10(i)
for information requirements specific to MCOs and PCCM programs operated under
section 1932(a)(1)(A)(i) state plan amendments. (Place a check mark to affirm
state compliance.)
1932(a)(5)(D) 1905(t).
L
List all services that are
excluded for each model (MCO & PCCM)
The following PCCM exempt services do not require PCP
authorization:
Dental Services
Emergency hospital care
Developmental Disabilities Services Community and
Employment
Support
Family Planning
Anesthesia
Alternative Waiver Programs
Adult Developmental Day Treatment Services Core Services
only
Disease Control Services for Communicable Diseases
ARChoices waiver services
Gynecological care
I npatient Hospital admissions on the effective date of PCP
enrollment or on the day after the effective date of PCP enrollment
Medication-Assisted Treatment Services for opioid use
disorder when rendered by X-DEA waivered provider as part of a Medication
Assisted Treatment plan
Mental health services as follows:
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, delivery, and postpartum)
services
Pharmacy
Physician Services for inpatients acute care
Transportation
