Current through Register Vol. 49, No. 9, September, 2024
Section
II
Nurse Practitioner
214.210
Advanced Practice Registered
Nurse (APRN) Services Benefit Limits 7-1-22
A. For clients twenty-one (21) years of age
or older, APRN services provided in a physician office, an APRN office, a
patient's home, or nursing home are limited to sixteen (16) visits per state
fiscal year (SFY) (July 1 through June 30).
The following services are counted toward the Service Benefit
Limits established for the state fiscal year:
1. APRN services in the office, patient's
home, or nursing facility
2.
Physician services in the office, patient's home or nursing facility
3. Rural health clinic (RHC)
encounters
4. Medical services
furnished by a dentist
5. Medical
services furnished by an optometrist
6. Certified nurse-midwife services
7. Federally qualified health center (FQHC)
encounters
The established benefit limit does not apply to clients under
age twenty-one (21).
Global obstetric fees are not counted against the -visit limit.
Itemized obstetric office visits are not counted in the limit.
Extensions of the benefit limit will be considered for services
beyond the established benefit limit when documentation verifies medical
necessity. Refer to Section 214.900 of this manual for procedures for obtaining
extension of benefits.
225.000
Outpatient Hospital Benefit
Limit 7-1-22
Medicaid-eligible clients twenty-one (21) years or 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 (SFY/July 1 through June 30).
A. Outpatient hospital services include the
following:
1. Non-emergency professional
visits in the outpatient hospital and related physician, advanced practice
registered nurse (APRN), and physician assistant services.
2. Outpatient hospital therapy and treatment
services and related physician, APRN, and physician assistant
services.
B. Extension of
benefits will be considered for clients 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 OUD Codes.)
D.
When a Medicaid eligible client's primary diagnosis is one (1) of those listed
above and the Medicaid eligible client has exhausted the Medicaid established
benefit limit for outpatient hospital services and related physician, APRN, and
physician assistant services, the provider does not have to file for an
extension of the benefit limit.
E.
All outpatient hospital services for clients under age twenty-one (21) in the
Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) Program are not benefit limited.
F. Emergency and surgical physician services
provided in an outpatient hospital setting are not benefit
limited.
226.000
Physician Services Benefit Limit 7-1-22
Physician Program
A. For clients twenty-one (21) years of age
or older, services provided in a physician's office, advanced practice
registered nurse's (APRN) office, a patient's home, or nursing home are limited
to sixteen (16) visits per state fiscal year (July 1 through June 30).
Clients under twenty-one (21) years of age in the Child Health
Services/Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT)
Program are not subject to this benefit limit.
The following services are counted toward the service benefit
limits:
1. Services of physicians in
the office, client's home, or nursing facility.
2. Medical services provided by a
dentist.
3. Medical services
furnished by an optometrist.
4.
Certified nurse-midwife services.
5. APRN services in the office, client's
home, or nursing facility.
6. Rural
health clinic (RHC) encounters.
7.
Federally qualified health center (FQHC) encounters.
B. Extensions of this benefit are considered
when documentation verifies medical necessity. Refer to Sections 229.100
through 229.120 of the manual for procedures on obtaining extension of benefits
for Primary Care Provider (PCP) 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 OUD Codes.)
When a Medicaid client's primary diagnosis is one (1) of those
listed above and the client has exhausted the Medicaid established benefit for
physician, APRN, and physician assistant 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.
257.000
Tobacco Cessation Products and
Counseling Services 7-1-22
Tobacco cessation products either prescribed or initiated
through statewide pharmacist protocol are available without Prior Authorization
(PA) to eligible Medicaid clients. Additional information can be found on the
DHS Contracted
Pharmacy Vendor website or in the
Prescription
Drug Program Prior Authorization Criteria.
A. Providers may participate by prescribing
covered tobacco cessation products. Reimbursement for tobacco cessation
products is available for all prescription and over the counter (OTC) products
and subject to be within U.S. Food and Drug Administration prescribing
guidelines.
B. Counseling by the
prescriber is required to obtain initial Prior Authorization (PA) coverage of
the products. Counseling consists of reviewing the Public Health Service (PHS)
guideline-based checklist with the client. The prescriber must retain the
counseling checklist in the client records for audit. View or print the
Arkansas Be Well Referral Form.
C.
Counseling procedures do not count against the visit limits allowed per State
Fiscal Year (SFY/July 1 to June 30), but they are limited to no more than two
(2) 15 minute units and two (2) thirty minute units for a maximum allowable of
four (4) units per SFY.
D.
Counseling sessions can be billed in addition to an office visit or Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT) visit. These sessions do
not require a Primary Care Provider (PCP) referral.
E. If the client is under eighteen (18) years
of age, and the parent or legal guardian smokes, the parent or legal guardian
can be counseled as well, and the visit billed under the minor client's
Medicaid number. The provider cannot prescribe medications for the parent or
legal guardian under the minor client's Medicaid number. A parent or legal
guardian session will count towards the four (4) counseling sessions limit
described in Section C above.
F.
Additional prescription benefits will be allowed per month for tobacco
cessation products and will not be counted against the monthly prescription
benefit limit. Tobacco cessation products are not subject to co-pay.
G. Arkansas Medicaid will provide coverage of
prescription and over the counter (OTC) smoking/tobacco cessation covered
outpatient drugs for pregnant women as recommended in "Treating Tobacco Use and
Dependence - 2008 Update: A Clinical Practice Guideline" published by the
Public Health Service in May 2008 or any subsequent modification of such
guideline.
H. Refer to Section
292.900 for procedure codes and billing instructions.
292.740
Psychotherapy 7-1-22
The psychotherapy procedures covered under the Physician
Program are allowed as a covered service when provided by the physician or when
provided by a qualified practitioner who by State licensure is authorized to
provide psychotherapy services.
Psychotherapy services must be provided by a physician or
qualified practitioner rendering psychotherapy in the physician's office, the
hospital, or the nursing home. Psychotherapy codes cannot be billed in
conjunction with an office visit, a hospital visit or inpatient psychiatric
facility visit and cannot be billed when services are performed in an
outpatient behavioral health facility. Only one (1) psychotherapy visit per day
is allowed in the physician's office, the hospital, or nursing home.
Psychotherapy Services provided by a psychiatrist will count against the twelve
(12) visits per State Fiscal Year service benefit limit. Record Review is not
covered.
171.100
PCP-Qualified Physicians, Advanced Practice Nurse Practitioners, and
Single-Entity Providers 7-1-22 A.
Primary Care Provider (PCP)-qualified physicians are those whose sole or
primary specialty is
1. Family
practice
2. General
practice
3. Internal
medicine
4. Pediatrics and
adolescent medicine
5. Obstetrics
and gynecology
B.
Obstetricians and gynecologists may choose whether to be PCPs.
C. Physicians with multiple specialties may
elect to enroll as PCPs if a secondary or tertiary specialty in their Medicaid
provider file is listed in part A above.
D. All other PCP-qualified physicians and
clinics must enroll as PCPs, except for those who certify in writing that they
are employed exclusively by a University of Arkansas Medical School (UAMS)
Regional Program, a federally qualified health center (FQHC), a Medical College
Physicians Group, or a hospital (i.e., they are "hospitalists", and they
practice exclusively in a hospital).
E. Advanced practice registered nurses (APRN)
licensed by the Arkansas State Board of Nursing may choose to enroll as
PCPs.
F. PCP-qualified clinics and
health centers (single-entity PCPs) are
1.
UAMS Regional Programs
2.
FQHCs
3. The family practice and
internal medicine clinics at the University of Arkansas for Medical
Sciences
171.630
Advanced Practice Registered
Nurses and Physician Assistants in Rural Health Clinics (RHCs) 7-1-22
Advanced practice registered nurses (APRN) may function as
Primary Care Providers at the performing provider level.
Licensed registered nurse practitioners (RNP) or licensed
physician assistants (PA) employed by a Medicaid-enrolled rural health clinic
(RHC) provider may not function as Primary Care Provider (PCP) substitutes, but
they may provide primary care for a PCP's enrollees, with certain
restrictions.
A. The PCP affiliated
with the RHC must issue a standing referral, authorizing primary care services
to be furnished
1. To the PCP's client
enrollees
2. By registered nurse
practitioners and physician assistants
3. In or on behalf of the RHC
B. Registered nurse practioners
and physician assistants (PA) may not make referrals for medical services
except for pharmacy services per established protocol.
C. The PCP must maintain a supervisory
relationship with the registered nurse practitioners and physician assistants
(PA).
218.100
RHC
Encounter Benefit Limits 7-1-22 A.
Medicaid clients under the age of twenty-one (21) in the Child Health Services
(EPSDT) Program do not have a rural health clinic RHC encounter benefit
limit.
B. A benefit limit of
sixteen (16) encounters per state fiscal year (SFY), July 1 through June 30,
has been established for clients twenty-one (21) years or older. The following
services are counted toward the per SFY encounter benefit limit:
1. Provider visits in the office, client'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;
6. Advanced practice registered nurse (APRN)
services in the office, client's home, or nursing facility; and
7. Federally qualified health center (FQHC)
encounters.
Global obstetric fees are not counted against the service
encounter limit. Itemized obstetric office visits are not 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 OUD 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.
218.300
Extension of Benefits 7-1-22
RHC encounters count toward the service benefit limits per
state fiscal year. Arkansas Medicaid considers, upon written request, extending
the RHC benefit for reasons of medical necessity.
A. Extensions of family planning benefits are
not available.
B. Extensions of the
RHC core service encounter benefit are automatic for certain diagnoses. The
following diagnoses do not require a benefit extension request.
1. Malignant neoplasm (View ICD
codes.)
2. HIV infection and AIDS
(View ICD codes.)
3. Renal failure
(View ICD codes.)
220.000
Benefit Limits 7-1-22
A. Arkansas Medicaid clients aged twenty-one
(21) and older are limited to sixteen (16) FQHC core service encounters per
state fiscal year (SFY, July 1 through June 30).
The following services are counted toward the sixteen (16)
encounters per SFY benefit limit:
1.
Federally Qualified Health Center (FQHC) encounters;
2. Physician visits in the office, patient's
home, or nursing facility;
3.
Certified nurse-midwife visits;
4.
RHC encounters;
5. Medical services
provided by a dentist;
6. Medical
services provided by an optometrist; and
7. Advanced practice registered nurse
services in the office, patient's home, or nursing facility.
B. The following services are not
counted toward the sixteen (16) encounters per SFY benefit limit:
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 clients
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 OUD Codes) and rendered by a MAT specialty
prescriber.
C. Medicaid
clients under the age of twenty-one (21) in the Child Health Services (EPSDT)
Program are not subject to an FQHC encounter benefit limit.
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES
PROVIDED
July 1, 2022
CATEGORICALLY NEEDY
2.
b. Rural
Health Clinic Services
Rural health clinic services are limited to sixteen (16)
encounters a year for clients twenty-one (21) years
of age and older. This yearly limit is based on the State Fiscal Year
(July I through June 30). The benefit limit will be considered in conjunction
with the benefit limit established for physicians' services, medical services
furnished by a dentist, office medical services furnished by an optometrist,
certified nurse midwife services, federally qualified health center
encounters, and advanced practice registered nurse services, or a
combination of the seven.
Extensions of the benefit limit will be
available if medically necessary. Certain services,
specified in the appropriate provider manual, are not counted toward the limit.
Clients under age twenty-one (21) in the Child
Health Services (EPSDT) Program are not benefit limited.
Rural health clinic core services are defined as
follows:
1. Physicians' services,
advanced practice registered nurse's services, and physician
assistant services when properly supervised;
2. Services and supplies furnished as an
incident to professional services;
Services and supplies "incident to" the professional services
of physicians, physician assistants or advanced practice
registered nurses are those which are commonly furnished in
connection with these professional services, are generally furnished in the
rural health center office, and are ordinarily rendered without
charge or included in the clinic's bills; e.g., laboratory services, ordinary
medications and other services and supplies used in patient primary care
services.
3. Clinical
psychologist services;
4. Clinical
social worker services;
5. Services
of nurse midwives
6. 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).
Federally qualified health center services are
limited to sixteen (16) encounters per client, per
State Fiscal Year (July 1 through June 30) for clients twenty-one
(21) years or older. The applicable benefit limit will be considered in
conjunction with the benefit limit established for physicians' services,
medical services furnished by a dentist, office medical services furnished by
an optometrist, certified nurse midwife services, rural health clinic
encounters, and advanced practice registered nurse services, or a combination
of the seven.
For federally qualified health center core services beyond the
benefit limit, extensions will be available 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.
4.
c. Family Planning Services
(1) Comprehensive family planning services
are limited to an original examination and up to three 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: [X] No limitations [] 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:
5.
a. Physicians' services, whether furnished in
the office, the
client's home, a hospital, a skilled nursing
facility, or elsewhere
(1)
For clients
twenty-one (21) years of age or older, services provided in a physician's
office, a patient's home, a nursing home, or elsewhere are limited to sixteen
(16) visits per state fiscal year (SFY) (July 1 through June 30).
(a)
Benefit Limit Details
The benefit limit will be considered in conjunction with
the benefit limit established for rural health clinic, federally qualified
health center, medical services furnished by a dentist, office medical services
furnished by an optometrist, certified nurse midwife services and advanced
practice registered nurse or a combination of the seven. Clients under age
twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit
limited.
(b)
Extension of Benefits
For physicians' services, medical services provided by a
dentist, office medical services furnished by an optometrist, certified nurse
midwife services, advanced practice registered nurse, or rural
health clinic core services beyond the benefit limit, extensions will be
available if medically necessary.
(i) The following diagnoses are considered
categorically medically necessary and are exempt from benefit extension
requirements: Malignant neoplasm; HIV infection and renal failure.
(ii) Additionally, physicians' visits for
pregnancy in the outpatient hospital are exempt from benefit extension
requirements.
(c)
Special Exceptions(i) Each
attending physician/dentist is limited to billing one day of care for inpatient
hospital covered days regardless of the number of hospital visits
rendered.
(ii) Surgical procedures
which are generally considered to be elective require a
prior authorization from the Utilization Review
Section.
(iii) Desensitization
injections - Refer to Attachment 3.1-A, Item 4.b. (12).
(iv) Organ transplants are covered as
described in Attachment 3.1-E.
6. Medical care and any other type
of remedial care recognized under State law, furnished by licensed
practitioners within the scope of their practice as defined by State law.
b. Optometrists' Services
(2) One eye exam every twelve (12) months for
eligible client under 21 years of age in the Child Health Services
(EPSDT) Program. Extensions of the benefit limit will be available
if medically necessary for clients in the Child Health Services
(EPSDT) Program.
(3) Office medical
services provided by an optometrist are limited to twelve (12) visits per State
Fiscal Year (July 1 through June 30) for
clients twenty-one
(21
) years or older.
The benefit limit will be in conjunction with the benefit limit
established for physicians' services, medical services furnished by a dentist,
rural health clinic services, Federally Qualified Health Center
services, certified nurse midwife services, and advanced practice
registered nurses, or a combination of the
seven. For services beyond the benefit limit,
extensions will be available if medically necessary. Certain
services, specified in the appropriate provider manual, are not counted toward
the limit.
c.
Chiropractors' Services
(1) Services are
limited to licensed chiropractors meeting minimum standards promulgated by the
Secretary of HHS under Title XVIII.
(2) Services are limited to treatment by
means of manual manipulation of the spine which the chiropractor is legally
authorized by the State to perform.
(3) Effective for dates of service on or
after July 1, 1996, chiropractic services will be limited to twelve (12) visits
per State Fiscal Year (July 1 through June 30) for eligible Medicaid
clients twenty-one (21) years or older. Services provided to
clients under age twenty-one (21) in the
Child Health Services (EPSDT) Program are not benefit limited.
(4)
Effective for dates of service on
or after January 1, 2018, chiropractic services do not
require a referral by the client's primary care
provider (PCP).
d. Advanced
Practice Registered
Nurses
(APRN)
For clients twenty-one (21) years of age or older,
services provided in an advanced practice registered nurse's office, a
patient's home, or nursing home are limited to sixteen (16) visits per state
fiscal year (July 1 through June 30).
The benefit limit will be in conjunction with the benefit limit
established for physicians' services, rural health
clinic, medical services furnished by a dentist, office
medical services furnished by an optometrist, certified nurse midwife
services and federally qualified health center, or a combination
of the seven. For services beyond the established
benefit limit, extensions will be available if medically
necessary. Certain services, specified in the appropriate provider manual, are
not counted toward the limit. Clients in the Child Health Services
(EPSDT) Program are not benefit limited.
Rural health clinic services are limited to sixteen
(16) visits a year for clients twenty-one (21) years
or older. This yearly limit is based on the State Fiscal Year (July I
through June 30). Rural health clinic
encounters will be considered in conjunction with the benefit
limit established for physician services, medical services furnished by a
dentist, office medical services furnished by an optometrist, certified nurse
midwife services, federally qualified health center encounters, and
advanced practice registered nurse services, or a combination of the seven.
Benefit limit extensions will be available if medically
necessary. Certain services, specified in the appropriate provider
manual, are not counted toward the service limit. Clients under age
twenty-one (21) in the Child Health Services (EPSDT)
Program are not benefit limited.
Rural health clinic core services are defined as
follows:
1. Physicians' services,
advanced practice registered nurses' services, and services
of physician assistants when provided under proper
supervision;
2. Services and
supplies furnished as an incident to professional services;
Services and supplies "incident to" the professional services
of physicians, physician assistants, or advanced practice
registered nurses, are those which are commonly furnished
in connection with these professional services, are generally furnished in the
rural health clinic office, and are ordinarily rendered without
charge or included in the clinic's bills; e.g., laboratory services, ordinary
medications and other services and supplies used in patient primary care
services.
3. Clinical
psychologist services;
4. Clinical
social worker services;
5. Services
of nurse midwives; and
6. 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).
Federally qualified health center services are
limited to sixteen (16) encounters per client, per
State Fiscal Year (July 1 through June 30) for clients twenty-one
(21) years or older. The applicable benefit limit will be
considered in conjunction with the benefit limit established for physicians'
services, medical services furnished by a dentist, office medical services
furnished by an optometrist, certified nurse midwife services, rural health
clinic encounters, and advanced practice registered nurse services, or a
combination of the seven.
Benefit extensions will be available
if medically necessary. Clients 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.
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
Arkansas Medicaid does not limit who can provide these
counseling services at this time so long as they meet (ii) and
(iii).
**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.
(2) Face-to-Face Tobacco Cessation Counseling
Services Benefit Package for Pregnant Women
Provided: [x] No limitations [] 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.
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
For clients twenty-one (21) years of age or older,
services provided in a physician's office, a patient's home, or nursing home or
elsewhere are limited to sixteen (16) visits per state fiscal year (July 1
through June 30).
The benefit limit will be in conjunction with the benefit
limit established for advance practice registered nurse services, rural health
clinic, medical services furnished by a dentist, office medical services
furnished by an optometrist, certified nurse midwife services, and federally
qualified health center, or a combination of the seven.
For services beyond the established visit limit,
extensions will be available if medically necessary. Clients in the Child
Health Services (EPSDT) Program are not benefit limited.
(1) The following diagnoses are considered
categorically medically necessary and are exempt from benefit extension
requirements: Malignant neoplasm; HIV infection and renal failure.
(2) Physicians' visits for pregnancy in the
outpatient hospital are exempt from benefit extension requirements.
(3) Each attending physician or
dentist is limited to billing one day of care for inpatient hospital covered
days regardless of the number of hospital visits rendered.
(4) Surgical procedures which are generally
considered to be elective require prior authorization from the Utilization
Review Section.
(5) Desensitization
injections - Refer to Attachment 3.1-A, Item 4.b. (12).
(6) Organ transplants are covered as
described in Attachment 3.1-E.
(7)
Consultations, including interactive consultations (telemedicine),
are limited to two (2) per recipient per year in a physician's office,
advanced practice registered nurse's office, patient's home,
hospital, or nursing home. This yearly limit is based on the State Fiscal Year
(July 1 through June 30). This limit is in addition to the yearly limit
described in Item 5.(1). Extensions of the benefit limit will be
available if medically necessary.
(8) Abortions are covered when the life of
the mother would be endangered if the fetus were carried to term or for victims
of rape or incest. The circumstances must be certified in writing by the
woman's attending physician. Prior authorization is required.
5.b. Medical and surgical services
furnished by a dentist (in accordance with Section 1905 (a)(5)(B) of the Act).
Medical services furnished by a dentist are limited to twelve
(12) visits per State Fiscal Year (July 1 through June 30) for clients
twenty-one (21) years or older.
6. Medical care and any other type of
remedial care recognized under State law, furnished by licensed practitioners
within the scope of their practice as defined by State law.
b. Optometrists' Services
(2) One eye exam every twelve (12) months for
eligible clients under twenty-one (21) years of age
in the Child Health Services (EPSDT) Program. Extensions of the benefit limit
will be available if medically necessary for clients
in the Child Health Services (EPSDT) Program.
(3) Office medical services provided by an
optometrist are limited to twelve (12) visits per State Fiscal Year (July 1
through June 30) for clients twenty-one (21) years or over. The
benefit limit will be in conjunction with the benefit limit established for
physicians' services, medical services furnished by a dentist, rural health
clinic services, federally qualified health center, certified
nurse midwife, and services provided by an advanced practice
registered nurse, or a combination of the seven. For
services beyond the twelve (12) visit limit, extensions will be provided if
medically necessary. Certain services, specified in the appropriate provider
manual, are not counted toward the sixteen (16) visit limit.
Beneficiaries in the Child Health Services (EPSDT) Program are not benefit
limited.
c.
Chiropractors' Services
(1) Services are
limited to licensed chiropractors meeting minimum standards promulgated by the
Secretary of HHS under Title XVIII.
(2) Services are limited to treatment by
means of manual manipulation of the spine which the chiropractor is legally
authorized by the State to perform.
(3) Effective for dates of service on or
after July 1, 1996, chiropractic services will be limited to twelve (12) visits
per State Fiscal Year (July 1 through June 30) for eligible Medicaid recipients
age 21 and older. Services provided to recipients under age 21 in the Child
Health Services (EPSDT) Program are not benefit limited.
(4)
Effective for dates of service on
or after January 1, 2018, chiropractic services do not
require a referral by the beneficiary's primary care physician
(PCP).
d. Advanced
Practice Registered Nurses
For clients twenty-one (21) years of age or older,
services provided in an advanced practice registered nurse's office, a
patient's home, or nursing home are limited to sixteen (16) visits per state
fiscal year (July 1 through June 30).
The benefit limit will be in conjunction with the benefit
limit established for physicians' services, rural health clinic, medical
services furnished by a dentist, office medical services furnished by an
optometrist, certified nurse midwife services, and federally qualified health
center or a combination of the seven. For services beyond the established
limit, extensions will be available if medically necessary. Certain services,
specified in the appropriate provider manual, are not counted toward the limit.
Clients in the Child Health Services (EPSDT) Program are not benefit
limited.
