Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

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Products and Devices

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Idaho (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes			Limited to procedures safely performed in ambulatory setting, as approved by CMS, facilities must be certified	Fee for service	CN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			Public Health Clinics must be state-contracted, Enhanced Plan - 45 hours psych therapy/year at Mental Health Clinics whether public or private, Basic Plan - 26 hours psych therapy/year at Mental Health Clinics whether public or private	Fee for service	CN
Federally Qualified Health Center Services
Yes				Prospective cost based rate/visit	CN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes		Elective surgery admissions		Cost based payment	CN
Outpatient Hospital Services
Yes	$3/non-emergency visit in ER	Specified services	6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers	Fee for service using hospital cost as upper limit	CN
Rehabilitation Services: Mental Health and Substance Abuse
Yes			Psychosocial rehab 10 hours/week, substance abuse therapy 12 individual sessions/ week and 24 group sessions/week	Fee for service	CN
Rural Health Clinic Services
Yes				Prospective cost based rate/visit	CN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service at 85% of physician fee	CN
Chiropractor Services
Yes			24 visits/year, x-rays not covered	Fee for service	CN
Dental Services
Yes		Specified services	Limited to preventive and restorative services	Fee for service for Enhanced Plan, capitated payment for Basic Plan	CN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes		Specified services	Limited to preventative and restorative services	Fee for service	CN
Nurse Midwife Services
Yes				Fee for service at 85% of physician fee	CN
Nurse Practitioner Services
Yes				Fee for service at 85% of physician fee	CN
Optometrist Services
Yes			1 refractive exam/year	Fee for service	CN
Physician Services
Yes			1 wellness exam/year	Fee for service	CN
Podiatrist Services
Yes			Routine foot care and other specified services not covered	Fee for service	CN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes		Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs		AWP-12%, plus $4.94 dispensing fee, $5.54 dispensing fee if unit dose	CN
Physical Therapy and Other Services
Occupational Therapy Services
Yes			25 home or ambulatory visits/year included in limits for other specified practitioners	Fee for service	CN
Physical Therapy Services
Yes		Treatment plan	25 home or ambulatory visits/year included in limits for other specified practitioners	Fee for service	CN
Services for Speech, Hearing and Language Disorders
Yes			1 audiological testing and evaluation/year, 40 sessions speech therapy/year	Fee for service	CN
Products and Devices
Dentures
Yes			1 full upper and/or lower denture or 1 partial denture/5 years	Fee for service for Enhanced Plan, capitated payment for Basic Plan	CN
Eyeglasses
Yes			1 pair eyeglass frames/4 years, minimum diopter correction required for initial and replacement eyeglass lenses; replacement not covered for lost or broken eyeglasses	Products provided by state's volume purchase contractor, dispensing provider paid fee for service	CN
Hearing Aids
Yes			1 hearing aid/lifetime with 2 year warranty, repair after 2 years and refitting after 4 years	Fee for service	CN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items,		Fee for service	CN
Prosthetic and Orthotic Devices
Yes		Yes		Fee for service	CN
Transportation Services
Ambulance Services
Yes	$3/trip if determined an inappropriate use, except for tribal members	Non-emergency transports		Fee for service	CN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN
Other Services
Diagnostic, Screening and Preventive Services
Yes			1 preventive physical exam/year	Fee for service	CN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes				Fee for service, and using Medicare payment ceilings for lab services	CN
Targeted Case Management
Yes		Yes	Services limited to Enhanced Plan, quantity and frequency limits vary by group served	Fee for service	CN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services limited to Enhanced Plan and Medicare/Medicaid Coordinated Plan and for the following populations: 2, 4 & 8 - See both state-specific FN and service-specific FN	Fee for service or capitated payment	CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		100 nursing, home health aide and therapy visits/year; oxygen and related equipment covered for specified conditions	Fee for service	CN
Hospice Care
Yes		Services limited to Enhanced Plan and tMedicare/Medicaid Coordinatd Plan - See state-specific FN	Prospective rates based on Medicare methodology	CN
Personal Care Services
Yes	Yes	Services limited to Enhanced Plan and Medicare/Medicaid Coordinated Plan, 16 hours/week	Hourly rates based on nursing facility and ICF/MR wages, rates vary for independent providers and agencies	CN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		Hosp leave days not covered, 3 therapeutic leave days/home visit up to 15 days/year, facility must have fewer than 5 or 5% of its licensed beds vacant to be paid	Prospective cost based per diem with limits, leave days paid at 75% of facility's rate	CN
Inpatient Psychiatric Services, under age 21
Yes		Leave days not covered	Cost based payment	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Services limited to Enhanced Plan and Medicare/Medicaid Coordinatd Plan, hosp leave days not covered, 14 therapeutic leave days covered per home visit up to 36 days/year - See state-specific FN	Prospective cost based per diem with limits, leave days paid at 75% of facility's rate	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes	Admission	Services limited to Enhanced Plan and Medicare/Medicaid Coordinated Plan, hosp leave days not covered, 3 therapeutic leave days per home visit covered up to 15 days/year - See state-specific FN	Prospective per diem with limits, leave days paid at 75% of allowable costs	CN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State was one of the first to receive approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act of 2005. Idaho has implemented its Medicaid Basic Plan with services designed for healthy children and adults; this plan does not include long-term care, organ transplants or intensive mental health treatment. The Medicaid Enhanced Plan provides services designed for beneficiaries with more complex healthcare needs such as the elderly and disabled and includes long-term care in the institutional and community settings, organ transplants and intensive mental health treatment.