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Asian-American girl, dancing and yellingWhat does ARKids pay?

The following tables summarize the benefits offered under
ARKids A and ARKids B.

ARKids A
(copayment not required)
Program Coverage Limits Prior
Authorization
Ambulance (emergency only) Medical necessity None
Ambulatory Surgical Center Medical necessity PCP referral
Chiropractor Medical necessity PCP referral
Dental Care (Orthodontia included) Medical necessity PA required for some procedures
Durable Medical Equipment Medical necessity PA required for some equipment
Emergency Room Services Medical necessity None
EPSDT Screens All per protocol PCP or ADH administered
Family Planning Family Planning services only None
Federally Qualified Health Center Medical necessity See Physician Service
Hearing Services Medical necessity PCP referral
Home Health Medical necessity PCP Rx required
Hospice Medical necessity Physician certification
Immunizations All per protocol PCP or ADHadministered
Inpatient Hospital Medical necessity PA for stays of more than 4 days
Inpatient Psychiatric and
Psychiatric Residential Treatment Facility
Services
Medical necessity PA required
Laboratory and X-Ray Medical necessity PCP referral
Medical Supplies Medical necessity PCP Rx required
Nurse Midwife Medical necessity None
Outpatient Mental and
Behavioral Health
Medical necessity PCP Rx required
Physician Services Medical necessity PCP referral to specialists.
Patient must use PCP for
access to all services,
including the professional
component of services rendered in inpatient
settings.
Psychology Services Medical necessity Physician Rx required
Podiatry Medical necessity PCP referral
Prescription Drugs Medical necessity Prescription (must use
generic and rebate mfg.
when available)
Rural Health Clinic Medical necessity See Physician Services
Therapy Services —
Speech, Occupational, and Physical
Medical necessity PCP referral and
prescription required
Transportation For Medicaid-covered
services only
None
Vision Care 1 eye exam and
1 pair of eyeglasses per 12 months
None

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ARKids B
(copayment required)
Program Coverage Limits Prior Authorization Copayment*
Ambulance(emergency only) Medical necessity None $10 per trip
Ambulatory Surgical Center Medical necessity PCP referral $10 per visit
Chiropractor Medical necessity PCP referral $10 per visit
Dental Care (Orthodontia included) Medical necessity Some restorative services $10 per visit
Durable Medical Equipment $500 per year PCP prescription plus referral 20% per DME
item
Emergency Room Services Medical necessity None $10 per visit
Family Planning Family Planning
services only
None None
Federally Qualified
Health Center
Medical necessity None $10 per visit
Home Health Medical necessity PCP referral (limited
to 10 visits per State
Fiscal Year)
$10 per visit
Immunizations All per protocol PCP or ADH administered None
Inpatient Hospital Medical necessity Prior approval for stays of more than 4 days 10% of first inpatient day
Inpatient Psychiatric
and Psychiatric Residential Treatment
Facility Services
Medical necessity Prior approval required 10% of first inpatient day
Laboratory and X-Ray Medical necessity PCP referral $10 per visit
Medical Supplies Medical necessity PCP prescriptions
(limited to $125 per
month, with extension based on medical necessity)
None
Nurse Midwife Medical necessity None $10 per visit
Outpatient Mental and Behavioral Health Medical necessity PCP referral $10 per visit
Physician Services Medical necessity PCP referral to specialists.
Patient must use PCP for
access to all services,
including the professional component of services rendered in
inpatient settings.
$10 per visit
Podiatry Medical necessity PCP referral $10 per visit
Prescription Drugs Medical necessity Prescription $5 per prescription
(must use generic and rebate mfg.
when available)
Preventive Health Screening All per protocol PCP or ADH administered None
Rural Health Clinic Medical necessity None $10 per visit
Therapy Services —
Speech, Occupational, and Physical
Medical necessity PCP referral $10 per visit
Vision Care 1 eye exam and 1 pair of eyeglasses per 12 months Routine exams and
diagnostic
$10 per visit

* Effective July 1, 2006, DHS will set an annual cap on cost-sharing (co-payments and coinsurance) for ARKids B families. The annual cost-sharing cap is 5% of the family’s annual gross (before taxes) income. For example, if a family of four (4) has annual gross income of $40,000.00: $40,000.00 x 5%=$2,000.00. Therefore, the family’s maximum amount of cost-sharing is $2,000.00 for the year.

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