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Overview

Idaho operates three managed care programs:

  • Idaho Behavioral Health Plan (IBHP): on September 1, 2013, Idaho Medicaid implemented the Idaho Behavioral Health Plan (IBHP).  United Behavioral Health (dba Optum Idaho) was selected to administer the plan using a managed care approach. This plan is used for outpatient behavioral health services (such as mental health counseling or substance use disorder services).
  • Idaho Smiles: Dental services are administered through Idaho Smiles as of July 1, 2011.  MCNA Dental is entity that currently administers the Idaho Smiles program for all individuals enrolled in Idaho’s Medicaid and SCHIP programs.
  • Medical Transportation Management, Inc. (MTM): Idaho Medicaid has also contracted with Medical Transportation Management, Inc. (MTM), as its non-emergency medical transportation (NEMT) broker.

All claims for Idaho Medicaid are paid on a fee-for-service basis with the exception of Mental Health, Dental, and NEMT, which are covered by the MCOs noted above.

 

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Coverage

Idaho Medicaid and SCHIP will pay for the following services on behalf of Medicaid eligible individuals:

  • Annual physicals
  • Counselling and mental health services
  • Dental care
  • Doctor visits
  • Durable Medical Equipment
  • Emergency Medical Transportation
  • EPSDT Services for children under the age of 21 (must be prior authorized)
  • Home health care (Doctor prescribed)
  • Outpatient Hospital
  • Podiatry
  • Inpatient Facility
  • Ambulatory Surgery Center
  • Vision
  • Ambulance services
  • Behavioral Health: inpatient facility, outpatient facility, psychological testing
  • Diagnostic Surgery
  • Diagnostic Lab/Pathology
  • Emergency Room
  • Prescriptions
  • Primary Care Case Management
  • Prosthetics/orthotics
  • Substance Abuse Treatment
  • Smoking Cessation
  • Vision Services
  • Weight loss
  • X-rays

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Data Considerations

HMS does not receive Managed Care Organization (MCO) encounter data under its contract with the Idaho Department of Health and Welfare, as the MCO is responsible for coordination of benefits and recovery.

HMS does not receive dental claims for individuals enrolled in Idaho’s Medicaid and SCHIP programs.  While there are four (4) dental claims noted in the 2019 data set for Idaho, it should be assumed that these were billed and paid in error.

The data set for Idaho represents the full FFS claim data universe HMS receives under its contract with the Idaho Department of Health and Welfare with the exception of services covered by the MCOs in Idaho.

 

 

Sources

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