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Covered Services
Some benefits, or services that Medicaid or ARKids First will pay for are explained here. Please keep in mind:
- Medicaid and ARKids First pay for a wide range of medical services, but not all services.
- Sometimes benefits change. If that happens, DHS will send you a letter before the change takes effect.
- If you need to know whether Medicaid pays for a service that you don't see listed below, call:
The Medical Assistance (Medicaid) Office
682-8501 in Little Rock or
1-800-482-5431 toll-free
- If you need to know whether ARKids First pays for a service that you don't see listed below, call:
ARKids First
1-888-474-8275
- Always have your Medicaid or ARKids First ID number with you when you call.
Many benefits have limits, especially for adults. Limits can be annual or monthly.
- An "annual benefit limit" means Medicaid or ARKids First will pay for only a certain number of services, or will pay a certain amount for services, from July 1 of one year to June 30 of the next. Each year on July 1, the count starts over.
- A "monthly benefit limit" means Medicaid or ARKids First will pay for a certain number of services or will pay a certain amount for services in a calendar month. The count starts over on the first day of each month.
To get some services, you will need an okay from your primary care physician (PCP). Your PCP's okay is called a "referral."
Ambulance Service (Emergency Only)
Ambulatory Surgical Center
Child Health Management Services (CHMS)
Chiropractor
Community Health Centers
Dental Care
Disability Services
Doctor's Services
Domiciliary Care (Room and Board for Out-of-Town Care)
Emergency Room Services
Federally Qualified Health Center (FQHC)
Hearing
Home Health Services
Hospice Care
Hospital Care
Immunizations
Lab Tests and X-Rays
Long-Term Care
Medical Equipment
Medical Supplies
Mental Health Services
Non-Emergency
Transportation (NET) Program
Nurse-Midwife (Certified)
Nursing Home Care
Nurse Practitioners
Personal Care
Podiatrist
Pregnancy Termination
Prescription Drugs
Rehabilitative Services
Rural Health
Clinic
Targeted Case Management
Therapy (Physical, Occupational, or Speech)
Tobacco Cessation
Program
Vision Care
Well-Child Care
Women's Health
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Ambulance Service (Emergency Only)
Ambulance service is emergency transportation that can be by emergency automobile, helicopter or airplane.
Medicaid and ARKids First will pay for ambulance service only in certain cases, and only when you need it to stay alive or to prevent serious damage to your health. Then Medicaid and ARKids First will pay for ambulance service:
- From the place of an emergency to a hospital emergency room if the patient is admitted.
- From a hospital to another hospital.
- From the patient's home to a hospital for admission.
- From a hospital to the person's home after the person is discharged from the hospital.
- From a nursing home to a hospital for admission.
- From a nursing home (after being discharged) to the person's home.
- From one nursing home to another nursing home, when the original nursing home has been decertified and the transportation is necessary.
Ambulatory Surgical Center
Ambulatory surgical centers provide surgeries that do not require an overnight hospital stay. Medicaid and ARKids First pay for covered surgeries in these centers. A referral from your PCP is usually required. If you have ARKids First-B, you will have to pay a co-payment.
Child Health Management Services (CHMS)
Medicaid or ARKids First-A: If a child under 21 is found to have a health problem or is not developing normally, Medicaid or ARKids First-A will pay for many different services. These can include medical, psychological, speech and language pathology, occupational therapy, physical therapy, behavioral therapy, and audiology. The purpose is to find out what's wrong and how to treat it, to keep it from getting worse and affecting the child's future. To receive these services, you will need to get your primary care doctor's okay, called a "referral."
ARKids First-B does not offer the CHMS program, but some of the same services are covered if needed. A PCP referral is required.
Chiropractor
A chiropractor is a doctor who can make adjustments in your spine to treat back pain and other problems. Medicaid and ARKids First cover chiropractic care. You will need a referral from your PCP. There is a limit to the number of visits Medicaid will pay for if you are 21 or older. If you have ARKids First-B, you will have to pay a co-payment for each visit.
Community Health Centers
Community health centers are also called Federally Qualified Health Centers (FQHCs). You may choose one of these health centers as your PCP instead of choosing a doctor. Otherwise, you will need a referral from your PCP if you need to go to an FQHC. If you have ARKids First B, you will need to pay a co-payment.
Dental Care
Dental care is covered only for children with ARKids First or for people with regular Medicaid.
For children under age 21: Dental care is covered for children with ARKids First A and Medicaid. This includes orthodontic care such as braces, if needed for medical reasons. All orthodontic care must be approved by Medicaid before treatment. Children with ARKids First B can get some dental care, but not orthodontic care.
For adults: Medicaid will pay up to $500 a year for most dental care, from July 1 to June 30 or each year. This includes one office visit, one cleaning, one set of x-rays and one fluoride treatment. If your dentist says you need it, Medicaid will pay for
- simple tooth pulling
- surgical tooth pulling (if Medicaid approves it first)
- fillings
- one set of dentures (if Medicaid approves it first)
Fees to the Dental Lab for dentures and tooth-pulling do not count toward your $500 limit, but you can only get one set of dentures or partial dentures in your lifetime. It's up to you to make sure Medicaid will pay for other dental care if you need it.
ConnectCare services include Dental Coordinated Care. Dental care coordinators are available from 8 a.m. to 4:30 p.m. to help with:
- Dental information
- Finding a Medicaid dentist in your area
- Scheduling dental appointments
- Scheduling needed transportation (Medicaid and ARKids First A only)
- Reminding you of your dental appointment
- Rescheduling missed dental appointments
To find out more, 1-800-322-5580 (TDD: 1-800-285-1131).
Disability Services
Here are some services for people with disabilities. More options may be found under "Long-Term Care" or under "Rehabilitation".
TEFRA (Tax Equity and Fiscal Responsibility Act) Waiver Program
TEFRA provides Medicaid benefits and services to disabled children so they can be cared for at home rather than in a nursing home, hospital or other facility. To qualify, a child must:
- Be age 18 or younger
- Be eligible for care in a hospital, skilled nursing facility, ICF/MR facility or alternative home
- Live at home
If the parents or guardians have an annual gross income higher than $25,000, the family may pay a small fee for TEFRA services. The fee is based on income. If the family has other health insurance, they must keep it. TEFRA only covers certain services for disabled children.
To find out more about TEFRA, contact the DHS office in your county.
Developmental Day Treatment Clinic Services (DDTCS)
These are services provided by a licensed clinic to adults and children with developmental disabilities, such as autism or severe learning disabilities. The services may include identifying the disability and assessing how severe it is.
For more information, call Developmental Day Treatment Clinic Services at 501-682-8677.
Alternatives for Adults with Physical Disabilities (APD)
This program is for adults with physical disabilities who live in the community, not in a hospital or nursing home. These services are available to disabled people aged 21 through 64 who have a physical disability according to an SSI/SSA or DHS Medical Review Team (MRT). It is only for people who would need a nursing home if they did not have home and community-based services. A nurse or counselor assesses the person who needs services, and prepares a care plan. The care plan goes to the person's doctor for approval.
Services offered include:
- Environmental Accessibility Adaptations/Adaptive Equipment
(adapting the person's home and providing equipment to
help them) - Agency Attendant Care- Consumer-Directed
- Agency Attendant Care- Traditional and Consumer-Directed
- Case Management/Counseling Support
Call your county DHS office or call the Division of Aging and Adult Services at 1-800-981-4457.
DDS Alternative Community Services
These services are for people who have a developmental disability and need special care, no matter how old they are. The person must have cerebral palsy, epilepsy or autism, or have been declared mentally disabled before they turn 22. The care is provided in the person's home, in a foster home, or an apartment in a group home. A referral from a doctor may be required. To find out more or apply, call 501- 682-2277 for children. For adults call 501-682-8678 or 501-683-5687.
First Connections Program
All children grow and develop differently. Some children have delays in development and need special care. The First Connections Program is for these children, from birth to age 3, and their families. The program works with each family to find and coordinate services to help the child learn, and to help the family care for the child. To find out more, call 1-800-642-8258.
Doctor's Services
If you are 21 or older, there is a limit to the number of doctor visits that Medicaid will pay for each year. If you need to see the doctor more often, your doctor might be able to get an extension.
If you need to see a different doctor for specialized care, you will need a referral from your PCP.
If you have ARKids First-B, you will have to pay a co-payment for each doctor visit.
Domiciliary Care (Room and Board for Out-of-Town Care)
Domiciliary care is room and board for people who have to be away from home while they are getting medical treatment. Medicaid and ARKids First-A will pay for room and board when you live too far away to drive back and forth every day. There is no limit to the number of days you can stay while you are being treated. Medicaid will also pay for a ride from your home to the place you will stay. The domiciliary care provider will give you a ride to the clinic or medical center where you will be treated.
ARKids First-B does not cover domiciliary care.
Emergency Room Services
You should seek emergency care if you have a good reason to believe that your life or health or your child's life or health is in serious danger. (This includes your unborn baby if you are pregnant.) Medicaid and ARKids First cover emergency care only in a medical emergency. You do not need a referral from your PCP. If you have ARKids First-B, you will have to pay a co-payment. Remember, if you use the emergency room when you know your problem isn't an emergency, you might have to pay the bill. To find out more, see "What to do in an emergency".
Federally Qualified Health Center (FQHC)
FQHCs are sometimes called "community health centers." You may choose one of these health centers as your PCP instead of choosing a doctor. Otherwise, you will need a referral from your PCP if you need to go to an FQHC. If you have ARKids First-B, you will need to pay a co-payment.
Hearing
Arkansas Medicaid covers hearing tests and hearing aids for children under age 21 who are enrolled in the Child Health Services (EPSDT) Program. The services must be prescribed by a doctor. Licensed audiologists (hearing specialists) may provide hearing tests. If a child needs a hearing aid, he or she gets three follow-up visits to the hearing aid dealer to make sure the hearing aid is working properly. Hearing aids are not covered under ARKids First B.
Home Health Services
Medicaid and ARKids First will pay for some services to be provided in your home by a home health care worker or nurse but only if a doctor says the home care services are needed.
Medicaid will only pay if home care is needed for medical reasons. Your doctor will decide what level of care you need. In some cases, Medicaid needs to approve the services ahead of time. Medicaid has limits on what it will pay for some home services and supplies.
Hospice Care
Hospice services are for people who are very sick and will not live much longer. Instead of trying to make a person well, hospice care just makes a person as comfortable as possible. Hospice care is usually provided in the patient's home, or sometimes in a hospital or nursing home. Medicaid and ARKids First-A will pay for hospice services, but ARKids First-B will not.
Hospital Care
Medicaid and ARKids First pay for most hospital care, whether you have to stay in the hospital overnight (inpatient care) or can go home the same day you are treated (outpatient care).
- Inpatient Care: Medicaid and ARKids First will pay for hospital care that is needed for your health. The hospital might need to get Medicaid's approval first. For adults age 21 and older, Medicaid will pay for a limited number of days of inpatient hospital care. There is no limit for children younger than 21. You will have to pay a co-pay if you are 18 or older, or have ARKids First-B. The amount of the co-pay depends on the first day's hospital bill. Also, ARKids First-B will not pay for inpatient care for mental health.
- Outpatient Care: Medicaid and ARKids First will pay for most outpatient hospital care, but you may have to pay some charges. Also, there is a limit on the number of visits for adults aged 21 and older. Families with ARKids First-B will have to pay a co-payment.
Immunizations
Immunizations are shots to keep you or your child from getting dangerous diseases. Medicaid and ARKids First cover these shots at certain ages. You can get these shots from your PCP or from the Arkansas Department of Health in your area. For more information about childhood immunizations, see Well-child care.
Lab Tests and X-Rays
Medicaid and ARKids First pay for lab tests and X-rays if your doctor says you need them. You will need a referral from your PCP if you need to go somewhere else for tests or X-rays. If you have ARKids First-B, you will have to pay a co-payment. If you're 21 or older, there are yearly limits on the number of some tests and X-rays that Medicaid will cover, and on the amount Medicaid will pay for others. Your doctor can ask for an extension on the number of X-rays covered if medically necessary.
Long-Term Care
When most people talk about long-term care, they mean nursing home care. But nursing home care is only one kind of long-term care. Here are some other kinds of long-term care. More options may be found under "Disability Services" or under "Personal Care".
Program of All-Inclusive Care for the Elderly (PACE)
PACE is a program for people 55 and older who have been certified by the state to need nursing home care. PACE allows them to live as independently as they can. PACE provides all needed services to those enrolled in the program, in all health care settings, 24 hours a day, every day of the year.
Nursing Home Care
Medicaid pays for nursing home care in a Medicaid-certified nursing home. For Medicaid to pay for nursing home care, a doctor must recommend it. You (or someone who can represent you) will need to apply for nursing home care in the DHS office in the county where the nursing home is located. If you are in a nursing home, you do not have to pay copayments for medical care or prescription drugs. ARKids First B does not cover nursing home care.
LivingChoices Assisted Living
LivingChoices assisted living is a Medicaid program that pays for apartment-style housing for people who need some extra care and supervision. It's for people who are at risk of being placed in a nursing home or who already live in a nursing home and want more independence. Housing and care is provided by specially licensed assisted living facilities. The housing is designed to keep residents safe and comfortable. Staff members take care of the residents, but try to let them make most of their own decisions. To qualify for LivingChoices assisted living, a person must:
- be aged 65 or older OR
- be aged 21 or older and declared disabled by Social Security/SSI or the DHS Medical Review Team
- meet income and asset limits (make less than a certain amount of money and own less than a certain amount)
- meet requirements for nursing home admission at the "intermediate" level of care
- have a medical need and receive one or more of the services provided
ElderChoices
ElderChoices provides services to people aged 65 years or older who need special care to live at home or in the community instead of in a nursing home. If the person needs a more skilled level of care, they won't qualify. A nurse or counselor assesses the person and prepares a care plan. Then the person's doctor must approve the care plan.
Medical Equipment
Equipment such as wheelchairs, oxygen tanks, and hospital beds that you use at home is called "durable medical equipment." Medicaid and ARKids First will pay for some durable medical equipment. You will need a prescription and a referral from your PCP.
- ARKids First-A and Medicaid for Children Under 21: Your doctor will need to get approval from Medicaid before you get certain equipment.
- ARKids First-B: ARKids First-B will pay up to a limited amount each year for durable medical equipment. You will have to pay a percentage of the cost, plus any costs after Medicaid has paid its limit.
- Medicaid: If you are 21 or older, Medicaid will only pay for certain kinds of equipment. You will need a prescription from your PCP.
Medical Supplies
Medical supplies are items you need for your health that might only be used once and then thrown away. Medicaid and ARKids First pay for some medical supplies. You will need a prescription from your PCP. There is a limit on what Medicaid or ARKids First will pay for supplies each month.
Mental Health Services
Medicaid will pay for special care for people with mental health problems. Mental health services that Medicaid will pay for include:
Licensed Mental Health Practitioner Services
These are visits with a mental health worker who is licensed to provide certain types of care. Medicaid will pay with a referral from a doctor. In some cases, Medicaid will need to approve the services in advance. This is called "prior authorization." The doctor or mental health worker should handle getting the services approved.
School-Based Mental Health Services (SBMH)
The School-Based Mental Health Services Program provides mental health services to children under age 21 who are in school and who have a mental health problem. Medicaid will pay for these services if:
- The child has a referral from a doctor. The referral must be renewed every six months.
- Care is provided by a mental health worker who works for the
school or under a contract with the school - A mental health exam shows the child needs these services
- The services are part of a treatment plan
- The services are provided at a public school, or at the child's
home if the child is enrolled in the public school system but
attends school at home.
Inpatient Psychiatric Services for Under Age 21
Sometimes people with mental illnesses need to stay at a hospital or mental health center. Medicaid will pay for this only for children under age 21, and only with a doctor's referral. Medicaid must approve these services in advance, except in an emergency. (This is called "Prior Authorization.") The patient will also need a "certificate of need" in order for Medicaid to pay. The doctor who refers the patient should provide this.
Non-Emergency Transportation (NET) Program
If you have Medicaid or ARKids First-A, the NET Program can give you a ride to and from your doctor appointments and other Medicaid-covered services. There is no charge but you must follow the NET guidelines. ARKids First-B does not cover non-emergency transportation. To find out more, see "Getting to the Doctor: NET."
Nurse-Midwife (Certified)
A certified nurse-midwife is trained to deliver babies in a hospital, birthing center or clinic, or in a patient's home, and to care for a woman while she is pregnant and just after she has a baby. Medicaid and ARKids First pay for certified nurse-midwife services. If you have ARKids First-B, you will have to pay a co-payment for each visit.
Nursing Home Care
See "Long-Term Care". ARKids First-B does not cover nursing home care.
Nurse Practitioners
Nurse practitioners are nurses with special training. They are not doctors, but they can do some of the things a doctor can do. They can treat many illesses and injuries, and can prescribe medicine. They can do check-ups and help catch problems while they are easier to treat. Medicaid will pay for a certain number of visits with a nurse practitioner. Sometimes, a doctor's referral might be needed. If you have ARKids B, you might need to pay a co-pay.
Personal Care
Medicaid will cover personal care, if a doctor says it is needed. These services are for people who need help with everyday tasks such as bathing, getting dressed, going to the bathroom, preparing meals and eating. Personal care is usually provided in the person's home, by a worker who is trained to help people with these tasks — but not a nurse or a doctor.
IndependentChoices is another option for people who need personal care. It's only for people who are 65 and older, or who are at least 18 and have a disability. This program provides counseling and training to help people care for themselves. People who qualify also receive a cash allowance so they can hire their own assistant or pay for items or services related to their personal care. A nurse provides information about the program and answers questions. To find out more, call 1-888-682-0044.
Podiatrist
A podiatrist is a doctor who specializes in problems of the feet. You will need a referral from your PCP to see a podiatrist. If you have ARKids First-B, you will have to pay a co-payment for each visit. If you are 21 or older, there is a limit to the number of visits Medicaid will pay for. Medicaid and ARKids First will pay for surgery by a podiatrist. If you need to stay in the hospital for the surgery, your podiatrist may have to get approval from Medicaid beforehand.
Pregnancy Termination
Abortions are not covered unless medically necessary and approved by Medicaid before-hand.
Prescription Drugs
Medicaid and ARKids First cover most prescription drugs. The pharmacist has to give you a generic drug when one is available. If you want a brand-name drug, you will have to pay for it. For some drugs, your doctor will need to call Medicaid for approval. If you are 21 or older, there is a limit on the number of prescription drugs Medicaid will pay for each month. Birth control pills and other family planning prescriptions do not count toward the monthly limit. People in nursing homes do not have monthly limits or co-payments on their prescription drugs.
If you have ARKids First-B, or you're 18 or older with Medicaid, you will have to pay a co-payment.
Rehabilitative Services
Medicaid will pay for some rehabilitative services — also called rehab — for people with certain illnesses or injuries. Rehabilitation services help a person learn how to take care of themselves. Rehab services that Medicaid will pay for include:
Rehabilitative Services for Persons with Physical Disabilities (RSPD)
Medicaid pays for rehabilitation services for children under age 21 with physical disabilities, if the services are recommended by a doctor or other licensed medical worker. To qualify for RSPD services, the child must have had a severe brain injury, or a spinal cord disorder or injury. (Spinal cord disorders or injuries are only eligible for rehab services in a state-operated extended rehabilitative hospital.)
Rehabilitative Services for Persons with Mental Illness (RSPMI)
Medicaid will pay for rehab for people with mental illnesses in some cases, to help them fit in or just to help them feel better. The care must be provided by a certified RSPMI provider. Medicaid must approve these services before they are provided, or Medicaid will not pay. The RSPMI provider should handle getting Medicaid's approval. A referral from a primary care provider (PCP) may be required for children under age 21. If the person needs more than eight hours of care within a 24-hour period, the doctor or other provider will need to apply for an "extension of benefits" for the patient.
Rehabilitative Services for Youth and Children (RSYC)
Medicaid will pay for rehab services for children under age 21 who are in the Child Health Services (EPSDT) Program and in the custody or care of the Arkansas Division of Youth Services (DYS). These services are for children who have been abused or neglected, to help them deal with any psychological or emotional problems they may have.
Rehabilitative Hospital
Medicaid will pay for rehab services to be provided in a hospital if needed for a medical reason.
Rural Health Clinic
Rural health clinics offer many services in areas where there are not a lot of doctors' offices. If you're 21 or older, there is a limit to the number of visits Medicaid will pay for each year. The medical director of a rural health clinic can be named as a PCP (Primary Care Physician).
Targeted Case Management
Targeted case managers help patients find and get the medical services they need. A doctor must prescribe targeted case management. You might be able to get this service if you:
- are younger than 21 and were referred as a result of a well-child check-up.
- have ARKids First-A or regular Medicaid. ARKids First-B does not cover targeted case management.
- have a developmental disability.
- are age 60 or older.
- are pregnant.
Therapy (Physical, Occupational, or Speech)
Medicaid and ARKids First-A will pay for physical, occupational, or speech therapy for patients who are younger than 21. A doctor's prescription and referral are required.
ARKids First-B will pay for speech therapy with a doctor's referral. ARKids First-B will not pay for physical or occupational therapy.
Tobacco Cessation Program
This program helps people stop smoking or using tobacco. It can include counseling from your doctor and products or medicine to help fight the urge to use tobacco, such as patches, gum or pills. To find out more, talk to your doctor or call Arkansas Medicaid at 1-800-482-5431.
Vision Care
Medicaid and ARKids First will pay for a limited number of eye exams and eyeglasses. Adults aged 21 and older will have to pay a co-payment. For children under 21, Medicaid and ARKids First will pay for medically necessary replacement or repair of eyeglasses when Medicaid approves ahead of time. No referral is needed for vision care.
Well-Child Care
Well-child care includes shots to prevent diseases like measles, polio, and whooping cough and regular check-ups to make sure the child is developing normally.
Both ARKids First-A (Medicaid) and ARKids First-B cover well-child care, but they call it different things. To find out when your child needs to see the doctor for a well-child check up, call your doctor.
ARKids First-A and Medicaid: If your child has ARKids First-A or regular Medicaid, well child care is also called "EPSDT." EPSDT stands for Early and Periodic Screening, Diagnosis and Treatment. Medicaid has a special program, called the Child Health Services Program, to provide well-child care for people younger than 21. Even mothers and fathers who are younger than 21 can be a part of the Child Health Services Program. If you or your child are younger than 21, tell your DHS caseworker you want child health services. DHS will help you find a PCP or other provider. DHS will help you get a ride to the doctor if needed. To find out more about getting a ride, see "Getting to the Doctor: NET".
ARKids First-B: If your child has ARKids First-B, well child visits are called "preventive health screenings." These regular doctor visits are covered. You will not have to pay a co-pay for these visits.
Women's Health
Medicaid and ARKids First will pay for pelvic exams, pap tests, and mammograms for all ages. You can go to your PCP for these services, or you can go to a gynecologist (a women's health specialist). No referral is needed for these services. If you're 21 or older, there are yearly limits on the number of doctor visits Medicaid will pay for each year. If you have ARKids First-B, you may have to pay a co-payment. Medicaid will also pay for family planning for women who are able to have children. These services can include:
- physical exams
- lab work
- birth control
- information about preventing HIV and other sexually transmitted diseases
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