016.06.11 Ark. Code R. 009

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.11-009 - ARKids-B-2-11 and Section I-1-11

SUBJECT: Provider Manual Update Transmittal #ARKids-2-11

REMOVE	INSERT
Section	Date	Section	Date
221.100	6-1-10	221.100	7-1-11
222.200	4-1-09	222.200	7-1-11
224.000	6-1-10	224.000	7-1-11
224.210	2-1-10	224.210	7-1-11
224.220	2-1-10	224.220	7-1-11

Explanation of Updates

Sections 211.100, 222.200, 224.000, 224.210, 224.220 are updated to reflect cost share amount changes from 20% to 10% for DME items and hospital first inpatient day.

The paper version of this update transmittal includes revised pages that may be filed in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes have already been incorporated.

If you have questions regarding this transmittal, please contact the HP Enterprise Services Provider Assistance Center at 1-800-457 -4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-0593 (Local); 1-800-482 -5850, extension 2-0593 (Toll-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).

Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

___________________________________________________

Eugene I. Gessow, Director

Section II

ARKids First-B

221.100ARKids 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
Certified Nurse-Midwife	Medical Necessity	PCP Referral	$10 per visit
Chiropractor	Medical Necessity	PCP Referral	$10 per visit
Dental Care (No Orthodontia)	Routine dental care	None - PA for inter-periodic screens	$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. Ser Emergency Non-Emergency Assessment	vices 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
Immunizations	All per protocol	PCP or Administered by ADH	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	None
Mental and Behavioral Health, Outpatient	Medical Necessity	PCP Referral PA on treatment services	$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	Medical Necessity	Prescription	Up to $5 per prescription (Must use generic and rebate manufacturer, 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 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
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.

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

^***ARKids 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.

222.200Durable Medical Equipment (DME) Benefit

Durable Medical Equipment (DME) benefit for ARKids First-B beneficiaries is $500.00 per state fiscal year (July 1 through June 30). There is a 10% co-insurance per item. DME may be billed by providers enrolled in the Prosthetics Program.

Refer to Section 262.120 of this manual for a listing of DME items covered by the ARKids First-B Program.

224.000Cost Sharing

Co-payment or coinsurance applies to all ARKids First-B services, with the exception of immunizations, preventive health screenings, family planning, prenatal care, eyeglasses and medical supplies. Co-payments or coinsurances range from up to $5.00 per prescription to 10% of the first day's hospital Medicaid per diem.

ARKids First-B families have an annual cumulative cost sharing maximum of 5% of their annual gross family income. The annual period is July 1 through June 30 SFY (state fiscal year). The ARKids First-B beneficiary's annual cumulative cost sharing maximum will be recalculated and the cumulative cost sharing counter reset to zero on July 1 each year.

The cost sharing provision will require providers to check and be alert to certain details about the ARKids First-B beneficiary's cost sharing obligation for this process to work smoothly. The following is a list of guidelines for providers:

1. On the day service is delivered to the ARKids First-B beneficiary, the provider must access the eligibility verification system to determine if the ARKids First-B beneficiary has current ARKids First-B coverage and whether or not the ARKids First-B beneficiary has met the family's cumulative cost sharing maximum.

2. The provider must check the remittance advice received with the claim submitted on the ARKids First-B beneficiary, which will contain an explanation stating that the ARKids First-B beneficiary has met their cost sharing cap.

3. It is strongly urged that providers submit their claims as quickly as possible to HP Enterprise Services for payment so that the amount of the ARKids First-B beneficiary's co-payment can be posted to their cost share file and the amount added to the accrual.

224.210Durable Medical Equipment Co-insurance

Durable Medical Equipment (DME) will require a co-insurance amount equal to 10% of the Medicaid allowed amount per item.

224.220Inpatient Hospital Co-insurance

The co-insurance charge per inpatient hospital admission for ARKids First-B beneficiaries is10% of the hospital's Medicaid per diem, applied on the first covered day. For example:

An ARKids First-B beneficiary is an inpatient for four (4) days in a hospital with an Arkansas Medicaid per diem of $500.00. When the hospital files a claim for four (4) days, ARKids First-B will pay $1950.00; the beneficiary will pay $50.00.

Four (4 days) times $500.00 (the hospital per diem) = $2000.00 (hospital allowed amount).

Ten percent (10% ARKids First-B co-insurance rate) of $500.00 = $50.00 co-insurance.

Two thousand dollars ($2000.00 hospital allowed amount) minus $50.00 (co-insurance) = $1950.00 (ARKids First-B payment).

The ARKids First-B beneficiary is responsible for paying a co-insurance amount equal to 10% of the per diem for one (1) day, which is $50.00 in the above example.

SUBJECT: Provider Manual Update Transmittal #SecI-1-11

REMOVE	INSERT
Section	Date	Section	Date
133.200	6-1-08	133.200	7-1-11

Explanation of Updates

Section 133.200 is updated to reflect the coinsurance charge per inpatient admission for ARKids First-B participants has changed from 20% to 10% of the hospital's Medicaid per diem.

Thank you for your participation in the Arkansas Medicaid Program.

___________________________________________________

Eugene I. Gessow, Director

133.200Inpatient Hospital Coinsurance Charge to ARKids First-B

Beneficiaries

For inpatient admissions, the coinsurance charge per admission for ARKids First-B participants is 10% of the hospital's Medicaid per diem, applied on the first covered day.

Example:

An ARKids First-B beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1950.00 and the beneficiary will pay $50.00 (10% Medicaid coinsurance rate).

1. Four (4 days) times $500.00 (the hospital per diem) = $2000.00 (hospital allowed amount).

2. Ten percent (10% Medicaid coinsurance rate) of $500.00 = $50.00 coinsurance.

3. Two thousand dollars ($2000.00 hospital allowed amount) minus $50.00 (coinsurance) = $1950.00 (Medicaid payment).

016.06.11 Ark. Code R. 009

7/14/2011