Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 29 - Division of Medical Services
Rule 016.29.24-004 - Continuous Glucose Monitors and Diabetic Supplies Coverage

Universal Citation: AR Admin Rules 016.29.24-004

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

221.100 AR Kids First-B Medical Care Benefits

Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.

Program Services

Benefit Coverage and Restrictions

Prior Authorization/ PCP Referral*

Co-payment/ Coinsurance/ Cost Sharing Requirement**

Ambulance (Emergency Only)

Medical Necessity

None

$10 per trip

Ambulatory Surgical Center

Medical Necessity

PCP Referral

$10 per visit

Audiological Services (only Tympanometry, CPT procedure code****, when the diagnosis is within the ICD range (View ICD codes.))

Medical Necessity

None

None

Certified Nurse-Midwife

Medical Necessity

PCP Referral

$10 per visit

Chiropractor Dental Care

Medical Necessity

Routine dental care and orthodontia services

PCP Referral

None - PA for inter-periodic screens and orthodontia services

$10 per visit $10 per visit

Durable Medical Equipment

Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance/cost-share. Covered items are listed in Section 262.120

PCP Referral and Prescription

10% of Medicaid allowed amount per DME item cost-share

Emergency Dept. Services

Emergency

Non-Emergency

Assessment

Medical Necessity

Medical Necessity

Medical Necessity

None

PCP Referral

None

$10 per visit

$10 per visit

$10 per visit

Family Planning

Medical Necessity

None

None

Federally Qualified Health Center (FQHC)

Medical Necessity

PCP Referral

$10 per visit

Home Health

Medical Necessity (10 visits per state fiscal year (July 1 through June 30)

PCP Referral

$10 per visit

Hospital, Inpatient

Medical Necessity

PA on stays over 4 days if age 1 or over

10% of first inpatient day

Hospital, Outpatient

Medical Necessity

PCP referral

$10 per visit

Inpatient Psychiatric Hospital and Psychiatric Residential Treatment Facility

Medical Necessity

PA & Certification of Need is required prior to admittance

10% of first inpatient day

Immunizations

All per protocol

None

None

Laboratory & X-Ray

Medical Necessity

PCP Referral

$10 per visit

Medical Supplies

Medical Necessity Benefit of $125/mo. Covered supplies listed in Section 262.110

PCP Prescriptions

PA required on supply amounts exceeding $125/mo

PCP Referral PA on treatment services

PA Required (See Section 250.000 of the School-Based Mental Health provider manual.)

None

Mental and Behavioral Health, Outpatient

School-Based Mental Health

Medical Necessity

Medical Necessity

$10 per visit

$10 per visit

Nurse Practitioner

Medical Necessity

PCP Referral

$10 per visit

Physician

Medical Necessity

PCP referral to specialist and inpatient professional services

$10 per visit

Podiatry

Medical Necessity

PCP Referral

$10 per visit

Prenatal Care

Medical Necessity

None

None

Prescription Drugs Diabetic Supplies

Medical Necessity

Prescription

Up to $5 per prescription (Must use generic, if available)***

Preventive Health Screenings

All per protocol

PCP Administration or PCP Referral

None

Rural Health Clinic

Medical Necessity

PCP Referral

$10 per visit

Speech-Language Therapy

Medical Necessity

4 evaluation units (1 unit =30 min) per state fiscal year

4 therapy units (1 unit=15 min) daily

PCP Referral

Authorization required on extended benefit of services

$10 per visit

Occupational Therapy

Medical Necessity

2 evaluation units per state fiscal year

PCP Referral

Authorization required on extended benefit of services

$10 per visit

Physical Therapy

Medical Necessity

2 evaluation units per state fiscal year

PCP Referral

Authorization required on extended benefit of services

$10 per visit

Vision Care

Eye Exam

One (1) routine eye exam (refraction) every 12 months

None

$10 per visit

Eyeglasses

One (1) pair every 12 months

None

None

*Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.

**AR Kids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.

***AR Kids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription. For billing information to include Continuous Glucose Monitors (CGM), CGM supplies, patch or tubeless insulin pumps, blood glucose monitors (BGMs), and glucose testing supplies see the DHS contracted Pharmacy Vendor's website.

****View or print the procedure codes for ARKids First-B procedures and services.

242.150 Home Health Medical Supplies

The following Health Care Procedural Coding System (HCPCS) codes must be used when billing the Arkansas Medicaid Program for medical supplies. Providers must use the current HCPCS Book for code descriptions.

View or print the procedure codes for Home Health services.

Listed below are medical supplies that require special billing or need prior authorization. These items are listed with the HCPCS codes and require modifiers. The asterisk denotes these items and the required modifiers.

A. *Home Blood Glucose Supplies - Available to all beneficiaries

B. **Gradient Compression Stocking (Jobst Stocking), All Ages

The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. Before supplying the items, the Jobst stocking must be prior authorized by AFMC. View or print form DMS-679A and instructions for completion.Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose with edema, or a venous stasis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stocking and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy.

Code must be manually priced.

Code requires a prior authorization (PA). See Section 221.000.

Code requires prior authorization (PA); see Section 221.000. Code is manually priced and is covered for beneficiaries ages 0-20 years of age.

C. ***Food Thickeners, All Ages

Food thickeners, including "Thick-it", "Simple Thick", "Thick and Easy" and "Thick and Clear" are not subjected to the medical supply benefit limit.

The modifier NU must be used with the code found in this section and when food thickeners are administered enterally, the modifier "BA" must be used in conjunction with the code.

When food thickeners are billed, total units are to be calculated to the nearest full ounce. Partial units may be rounded up. When a date span is billed, the product cannot be billed until the end date of the span has elapsed.

The maximum number of units allowed for food thickeners is 16 units per date of service.

The following HCPCS codes usage must match the Arkansas Medicaid code description and use of modifier(s).

212.000 Exclusions

A. Products manufactured by non-rebating pharmaceutical companies.

B. Effective January 1, 2006, the Medicaid agency will not cover any drug covered by Medicare Part D for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

C. The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid beneficiaries under § 1927(d) of the Social Security Act, 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 CFR § 423.104(f)(1)(ii)(A), to full-benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit - Part D.

The following excluded drugs are set forth on the DHS Contracted Pharmacy Vendor website.

1. Select agents when used for weight gain

2. Select agents when used for the symptomatic relief of cough and colds

3. Select prescription vitamins and mineral products, except prenatal vitamins and fluoride

4. Select nonprescription drugs

D. Medical accessories are not covered under the Arkansas Medicaid Pharmacy Program. Typical examples of medical accessories are atomizers, nebulizers, hot water bottles, fountain syringes, ice bags and caps, urinals, bedpans, cotton, gauze and bandages, wheelchairs, crutches, braces, supports, diapers, and nutritional products.

216.100 Medical Supplies for Long-Term Care Facility Residents

A pharmacy often supplies items that are not covered under the Arkansas Medicaid Program to Medicaid eligibles in a long-term care facility. Under the cost-related reimbursement system in which long-term care (LTC) facilities are reimbursed, many of these items are the financial responsibility of the facility; therefore, the patient or the patient's family should not be billed for these items. The facility must furnish the following items to Medicaid beneficiaries:

A. First aid supplies (e.g., small bandages, merthiolate, mercurochrome, hydrogen peroxide, ointments for minor cuts and abrasions);

B. Dietary supplies (e.g., salt and sugar substitutes, supplemental feedings, equipment for preparing and dispensing tube feedings);

C. Items normally stocked by the facility in gross supply and distributed in small quantities (e.g., alcohol, hydrogen peroxide, applicators, cotton balls, tongue depressors);

D. All over-the-counter drugs and glucose monitors and supplies;

E. Enemas and douches-including equipment and solution (also disposables);

F. Catheters;

G. Special dressings (e.g., gauze, 4-by-4s, ABD pads, surgical and micropore tape, telfa gauze, ace bandages);

H. Colostomy drainage bags and

I. Equipment required for simple tests such as clinitest, acetest and dextrostix.

216.101 Medical Supplies Covered as a Pharmacy Benefit

The pharmacy National Council for Prescription Drug Program (NCPDP) benefit for the Arkansas Medicaid pharmacy program covers continuous glucose monitors (CGMs) and other diabetic supplies. This coverage would include CGMs and supplies, patch type insulin pumps and supplies, and blood glucose monitors (BGMs) and supplies.

A. Medicaid beneficiaries are eligible for diabetic supplies processed as a pharmacy claim submission by pharmacies or DME providers and the provider (DME or pharmacy) will be reimbursed at the Wholesale Acquisition Cost (WAC) plus the applicable professional dispensing fee.

B. Traditional insulin pumps requiring tubing and cannula type supplies will remain processed as a medical benefit.

C. Beneficiaries with Medicare Part B benefits will continue to be serviced under the Durable Medical Equipment (DME) program.

D. For coverage details concerning prior authorization requirements and preferred product list see the DHS Pharmacy Vendor's websitefor specific information.

212.206 Home Blood Glucose Monitor and Supplies, All Ages

A. Effective 4/1/2024, Medicaid beneficiaries are eligible for diabetic and blood sugar testing supplies processed as a pharmacy claim submission by pharmacies or DME providers. Home blood sugar meters and supplies (strips, lancets, calibration solution, etc.) are available without a prior authorization. See the DHS Pharmacy Vendor's website for specific information for coverage details.

B. Beneficiaries with Medicare Part B benefits continue to be serviced under the durable medical equipment (DME) program.

212.207 Insulin Pump and Supplies, All Ages

Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages. Effective 4/1/2024, patch or tubeless insulin pumps are processed as a pharmacy claim submission by pharmacies or DME providers while traditional insulin pumps requiring tubing and cannula type supplies remain processed as a medical claim. Beneficiaries with Medicare Part B benefits continue to be serviced for all of their needs under the DME program.

Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service.

Insulin is covered through the prescription drug program.

The following criteria will be utilized in evaluating the need for the insulin pump:

A. Insulin-dependent diabetes that is difficult to control.

B. Fluctuation in blood sugars causing both high and low blood sugars in a patient on at least three (3), if not four (4), injections per day.

C. Beneficiary's motivation level in controlling diabetes and willingness to do frequent blood glucose monitoring.

D. Beneficiary's ability to learn how to use the pump effectively. This will have to be evaluated and documented by a professional with experience in the use of the pump.

E. Determination of the beneficiary's suitability to use the pump should be made by a diabetes specialist or endocrinologist.

F. Beneficiaries not included in one (1) of these categories will be considered on an individual basis.

Prior authorization requests for traditional insulin pumps and supplies (cannula, tubing) must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to DHS or its designated vendor.

View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.

When submitting prior authorization requests for the patch or tubeless insulin pumps see the DHS Pharmacy Vendor's website for specific information for coverage details.

A. Effective 4/1/2024, continuous glucose monitors (CGMs) are processed as a pharmacy claim submission by pharmacies or DME providers. Beneficiaries must meet the following criteria for coverage:
1. Either:
a. A presence of type 1 diabetes or any other type of diabetes with the use of insulin; or

b. A presence of type 1 diabetes or any other type of diabetes with evidence of Level 2 or Level 3 hypoglycemia; or

c. Diagnosis of glycogen storage disease type 1a; or

d. Use of an insulin pump; and

2. Regular follow-up with a healthcare provider at a minimum every six (6) months to assess for ongoing benefit.

3. See the DHS Pharmacy Vendor's website for specific information for coverage details.

B. Definition. As used in this section, "continuous glucose monitor" means an instrument or device, including repair and replacement parts, that:
1. Is designed and offered for the purpose of aiding an individual with diabetes;

2. Automatically estimates blood glucose levels, also called blood sugar, throughout the day and night;

3. Is generally not useful to an individual who has not been diagnosed with diabetes.

Beneficiaries with Medicare Part B benefits continue to be serviced under the DME program.

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