016.29.23 Ark. Code R. 004 - Medication Assisted Treatment (MAT) and Over the Counter (OTC) Updates
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM
STATE ARKANSAS
Page 1d
AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED
Revised: October 1, 2023
CATEGORICALLY NEEDY
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 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.
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 part of a Medication Assisted Treatment plan.
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 part of a Medication Assisted Treatment plan.
Other professional and technical laboratory and radiological 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 under 42 CFR 440.30 in an office or similar facility other than a hospital outpatient department or clinic.
Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY, July 1 - June 30), and radiology/other services benefits are separately limited to five hundred dollars ($500) per SFY. Radiology/other services include, but are not limited to, diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. The five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services benefit limit, do not apply to services provided to recipients under twenty-one (21) years of age enrolled in the Child Health Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program.
The following excluded drugs, set forth on the Arkansas Medicaid Pharmacy Vendor's Website, are covered:
Revision: HCFA-PM-93-5 October 1, 2023
Page 2a
State/Territory: ARKANSAS
AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S):
[X] Provided [] No limitations [] With limitations*
[X] Provided [] No limitations [] With limitations*
[X] Provided [] No limitations [] With limitations*
[X] Provided [] No limitations [] With limitations*
*Description provided on attachment.
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 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.
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 part of a Medication Assisted Treatment plan.
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 part of a Medication Assisted Treatment plan.
Other professional and technical laboratory and radiological 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 under 42 CFR 440.30 in an office or similar facility other than a hospital outpatient department or clinic.
Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY, July 1-June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY. Radiology/other services include, but are not limited to, diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. The five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services benefit limit, do not apply to services provided to recipients under twenty-one (21) years of age enrolled in the Child Health Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program.
*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.
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.
The following excluded drugs, set forth on the Arkansas Medicaid Pharmacy Vendor's Website, are covered:
CMS-PM-10120
Date: January 1, 2014
Revised: October 1, 2023
Page 29
OMB No.:0938-933
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Citation |
Condition or Requirement |
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1. Describe any additional circumstances of "cause" for disenrollment (if any). |
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K. Information requirements for beneficiaries |
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Place a check mark to affirm state compliance. |
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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.) |
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1932(a)(5)(D) 1905(t) |
L. List all services that are excluded for each model (MCO & PCCM) |
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The following PCCM exempt services do not require PCP authorization: |
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Dental Services |
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Emergency hospital care |
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Developmental Disabilities Services Community and Employment |
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Support |
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Family Planning |
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Anesthesia |
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Alternative Waiver Programs |
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Adult Developmental Day Treatment Services Core Services only |
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Disease Control Services for Communicable Diseases |
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ARChoices waiver services |
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Gynecological care |
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Inpatient Hospital admissions on the effective date of PCP enrollment or on the day |
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after the effective date of PCP enrollment |
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Medication-Assisted Treatment Services for opioid use disorder when part of a |
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Medication Assisted Treatment plan |
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Mental health services as follows: |
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a. Psychiatry for services provided by a psychiatrist enrolled in Arkansas Medicaid and practice as an individual practitioner |
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b. Rehabilitative Services for Youth and Children |
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Nurse Midwife services |
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ICF/IID Services |
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Nursing Facility services |
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Hospital non-emergency or outpatient clinic services on the effective date of PCP |
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enrollment or on the day after the effective date of PCP enrollment. |
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Ophthalmology and Optometry services |
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Obstetric (antepartum, delivery, and postpartum) services |
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Pharmacy |
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Physician Services for inpatients acute care |
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Transportation |
Supplement 1 to Attachment 3.1-B
Page 1
October 1, 2023
State of Arkansas
1905(a)(29) Medication Assisted Treatment (MAT)
Citation: 3.1(b)(1) Amount, Duration, and Scope of Services: Medically Needy (Continued)
1915(a)(29) __X___MAT as described and limited in Supplement 1 to Attachment 3.1-B.
ATTACHMENT 3.1 -B identifies the medical and remedial services provided to the medically needy.
MAT is covered under the Medicaid state plan for all Medicaid clients who meet the medical necessity criteria for receipt of the service for the period beginning October 1, 2020, and ending September 30, 2025.
The state covers the following counseling services and behavioral health therapies as part of MAT.
MAT is covered exclusively under section 1905(a)(29) for the period of 10/01/2020 through 9/30/2025.
Services available:
Physicians and Nurse Practitioners must be Arkansas Licensed.
Physician Assistants must have a legal agreement to practice under an Arkansas Licensed Physician per Arkansas statute.
Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must possess a current and valid Arkansas license.
__X___ The state has drug utilization controls in place. (Check each of the following that apply)
_______ Generic first policy
___X__ Preferred drug lists
_______ Clinical criteria
___X__ Quantity limits
_______ The state does not have drug utilization controls in place.
Describe the state's limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT.
MAT drugs and biologicals are limited based on the FDA indication and manufacturers' prescribing guidelines. Some medications are also subject to status on the Preferred Drug List (PDL).
The preferred (PDL) agents for MAT therapy do not require a PA.
The Arkansas Medicaid Pharmacy program removed the prior authorization for preferred Buprenorphine products on 1/1/2020, due to Arkansas State Law from Act 964 which prohibits a prior authorization for Medication Assisted Treatment of Opioid Use Disorder. The removal of prior authorization was for MAT treatment according to SAMHSA guidelines. In addition, on 1/22/2021, per section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), for all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262) to be covered, Arkansas instructed the pharmacy vendor to bypass the non-rebate-participation, repackaged indicator, inner indicator, and prioritize coverage of all the pharmacy MAT products.
PRA Disclosure Statement - This information is being collected
to assist the Centers for Medicare & Medicaid Services in implementing
section 1006(b) of the SUPPORT for Patients and Communities Act (P.L.
Supplement 5 to Attachment 3.1-A
Page 1
October 1, 2023
State of ARKANSAS
1905(a)(29) Medication-Assisted Treatment (MAT)
Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)
1905(a)(29) ___X__MAT as described and limited in Supplement __5__ to Attachment 3.1-A.
ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy.
MAT is covered under the Medicaid state plan for all Medicaid clients who meet the medical necessity criteria for receipt of the service for the period beginning October 1, 2020 and ending September 30, 2025.
The state covers the following counseling services and behavioral health therapies as part of MAT.
MAT is covered exclusively under section 1905(a)(29) for the period of 10/01/2020 through 9/30/2025.
Services available:
Physicians and Nurse Practitioners must be Arkansas Licensed.
Physician Assistants must have a legal agreement to practice under an Arkansas Licensed Physician per Arkansas statute.
Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must possess a current and valid Arkansas license.
__X___ The state has drug utilization controls in place. (Check each of the following that apply)
_______ Generic first policy
___X__ Preferred drug lists
_______ Clinical criteria
___X__ Quantity limits
_______ The state does not have drug utilization controls in place.
Describe the state's limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT.
MAT drugs and biologicals are limited based on the FDA indication and manufacturers' prescribing guidelines. Some medications are also subject to status on the Preferred Drug List (PDL). The preferred (PDL) agents for MAT therapy do not require a Prior Authorization.
The Arkansas Medicaid Pharmacy program removed the prior authorization for preferred Buprenorphine products on 1/1/2020, due to Arkansas State Law from Act 964 which prohibits a prior authorization for Medication Assisted Treatment of Opioid Use Disorder. The removal of prior authorization was for MAT treatment according to SAMHSA guidelines. In addition, on 1/22/2021, per section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), for all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262) to be covered, Arkansas instructed the pharmacy vendor to bypass the non-rebate-participation, repackaged indicator, inner indicator, and prioritize coverage of all the pharmacy MAT products.
1905(a)(29) Medication-Assisted Treatment (MAT)
Amount, Duration, and Scope of Medical and Remedial Care Services Provided to the Categorically Needy (continued)
PRA Disclosure Statement - This information is being collected
to assist the Centers for Medicare & Medicaid Services in implementing
section 1006(b) of the SUPPORT for Patients and Communities Act (P.L.
The services listed in this section do not require a PCP referral:
Medication Assisted Treatment for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.
Nurse practitioner services are performed in collaboration with a physician or physicians.
The following services are counted toward the sixteen (16) encounters per SFY benefit limit:
Medication Assisted Treatment for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. 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, 2023, the following Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes are payable:
View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.
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.
Medication Assisted Treatment for Opioid or Alcohol Use Disorders is available to all qualifying Medicaid beneficiaries. 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, 2023, the following Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes are payable:
View or print the procedure codes for Nurse Practitioner services.
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.
Coverage of preferred prescription drugs (preferred on the PDL) for opioid or alcohol 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
The following excluded drugs are set forth on the DHS Contracted Pharmacy Vendor website.
View or print the contact information for the DHS contracted Pharmacy vendor.
Each prescription filled counts toward the monthly prescription limit except for the following:
Providers of Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use Disorder must be licensed in Arkansas and be enrolled with Arkansas Medicaid.
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 or Alcohol 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.
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.
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 or Alcohol 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 or Alcohol Use Disorder and will not be reimbursed for the practice of pain management.
Coverage of preferred prescription drugs (preferred on the PDL) for opioid or alcohol 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
There are two (2) methods of billing for MAT.
Allowable ICD-10 codes for Opioid Use Disorder may be found here: (View ICD OUD Codes.)
Allowable lab and screening codes may be found here: (View Lab and Screening 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.
Rural Health Clinic core services are as follows:
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
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 (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.
RULES SUBMITTED FOR REPEAL
Rule #1: PUB 85: Differential Response: A Family-Centered Approach to Strengthen and Support Families
Rule #2: PUB 357: Child Maltreatment Investigation Determination Guide
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.