Idaho Administrative Code
Title IDAPA 16 - Health and Welfare, Department of
Rule 16.03.18 - MEDICAID COST-SHARING
Section 16.03.18.320 - MEDICAID OUTPATIENT SERVICES SUBJECT TO COPAYMENTS

Universal Citation: ID Admin Code 16.03.18.320

Current through August 31, 2023

Medicaid participants are responsible for making copayments for the outpatient services described in Subsections 320.01 through 320.10 of this rule, unless exempted. The amount of the copayment is provided in Section 310 of these rules. (3-15-22)

01. Accessing Hospital Emergency Department for Non-Emergency Medical Conditions. A participant who seeks care at a hospital emergency department for services that do not meet the definition of an emergency medical condition as defined in IDAPA 16.03.09, "Medicaid Basic Plan Benefits," may be required to pay a copayment to the provider. A participant who must access a hospital emergency department in order to receive routine services for their medical condition is exempt from this provision. (3-15-22)

02. Accessing Emergency Transportation Services for Non-Emergency Medical Conditions. A participant who accesses emergency transportation services for a condition that is determined by the Department to be a non-emergency medical condition may be required to pay a copayment to the provider of the service. (3-15-22)

03. Chiropractic Services. Those services for spinal manipulation performed by a chiropractor. (3-15-22)

04. Occupational Therapy. (3-15-22)

05. Optometric Services. Those services performed by a optometrist that fall into the "General Ophthalmological Services" category of Current Procedural Terminology (CPT). (3-15-22)

06. Outpatient Hospital Services. Any of the services included in Subsections 320.03 through 320.05 and Subsections 320.07 through 320.10 of this rule performed in an outpatient hospital setting. Services performed in a Hospital Emergency Department are excluded, except as provided for in Subsection 320.01 of this rule. (3-15-22)

07. Physical Therapy. (3-15-22)

08. Podiatry Services. Services provided by a podiatrist during an office visit. (3-15-22)

09. Physician Office Visit. Each physician office visit, unless: (3-15-22)

a. The visit is for a preventive wellness exam, immunizations, or family planning: (3-15-22)

b. The visit is for urgent care provided at a clinic billing as an urgent care facility. (3-15-22)

10. Speech Therapy. (3-15-22)

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