Medicaid plans available
- Basic Plan– This plan provides health, prevention, and wellness benefits for adults who do nothave special health needs. This plan includes annual physicals, immunizations, most prescriptions, doctor and hospital visits, and more.
- Enhanced Plan– This plan is for individuals with disabilities or special health needs. This plan has all the benefits of the Basic Plan, plus additional benefits. Most of the time, individuals will need to be referred by a doctor to become eligible for the enhanced plan.
- Medicare-MedicaidCoordinated Plan–Designedfor people who are eligible and enrolled in both Medicare and Medicaid, (alsoknown as dual eligibles). This plan has all the benefits of the Enhanced Plan,plus allows people to enroll in a managed care plan to help coordinate Medicareand Medicaid benefits. There are many advantages to enrolling in managed care,one of the most valuable is access to a care coordinator who helpspeoplewith complex medical conditions to achieve better health.
To view more details about available health plans and find cost-sharing information please see below:
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What's covered
Medicaidwill pay for a number of services, such as:
- Annual physicals
- Counseling and mental health services
- Dental (dental services)
- Doctor visits
- Durable Medical Equipment
- Emergency Medical Transportation
- Home health care (doctor prescribed)
- Hospice care
- Immunizations
- Inpatient and outpatient hospital care
- Lab tests
- Medical equipment and supplies
- Medical transportation services
- Nurse midwife
- Pregnancy and family planning services
- Prescriptions
- Primary Care Case Management
- Prosthetics/orthotics
- Substance abuse treatment
- Smoking Cessation
- Vision (vision services)
- Weight loss
- X-rays
Preventative Health Assistance (PHA) Benefit
TheWeight Management benefit (WM) is designed to help eligibleparticipants and their families improve their lifestyle through:
- Physical fitness
- Balanced diet
- Personal health education
Qualifyingparticipants can earn up to $200 each year to help pay for services offered byPHA providers such as participation in theNational Diabetes Prevention Program, fees for a weight management program, a gymmembership, healthy lifestyle classes, or nutrition classes or services. Anyadditional fees are the participant’s responsibility.
WM Qualification Guidance:
- Participantsmust have full Basic or Enhanced Medicaid coverage to qualify.
- Participants must also meet the following criteria by age:
- Adults (21 orolder): a bodymass index (BMI) of 30 or higher or 18.5 or lower according to the CDCAdultBMI Calculator.
- Children (5 to 21 years old): abody mass index (BMI) that falls in either the overweight or the underweightcategory according to the CDCChildand Teen BMI Calculator.
- Participants onthe Home Care for Certain Disabled Children Program (Katie Beckett) andMedicare-Medicaid Coordinated Plan participants are not eligible for thesebenefits.
Steps to sign up for the PHA program
- Participantsinterested in the program should visit their primary care provider (PCP).
- ThePCP will initiate the process by printing and filling out their portion of thePHA Agreement Form.
- The participant is then responsiblefor filling out their section of the form.
- The participant takes the form totheWMproviderthey’ve chosen to receiveservices from for their signature. After all sections are complete, the form mustbe submitted to the PHA program for approval. The benefit will start on thedate of approval.
Non-Emergency Medical Transportation Services (NEMT)
Idaho Medicaid contracts with MTM(Medical TransportationManagement, Inc.)to manage a statewide network of transportation providersfor Idaho's NEMT services for Medicaid eligible participants who have no othermeans of transportation. The Idaho NEMT program covers transportation in-stateand out-of-state, to and from healthcare services covered under the Medicaid program.
Idaho rules for the NEMT program can be found atIDAPA 16.03.09.870 through 873.
MEMBER SERVICES
If you have a medical appointment but you do not have a car,cannot operate a car, or do not have a friend or family member who can takeyou, you can request transportation through MTM.
- If you have a vehicle to transport yourself or family members to their appointments, please contact MTM and ask about their mileage reimbursem*nt program.
- MTM will review your request and decide if Medicaid will pay for your transportation. MTM will review your request based on the least expensive transportation available and the closest available Medicaid provider for the service.
- If you have been referred for medical care outside your community, MTM may ask for a referral from your doctor before they will schedule your transportation.
- You need to call at least two (2) business days before your appointment.
You may reach MTM to request transportation by calling 1-877-503-1261,by visitingMTM's MedicaidTransportation website, or by usingMTM's Transport ServiceManagement Portal. Trips can be scheduled twenty-four (24) hours a day, seven (7) days a week.
If you or someone you are helping has questions about MTM, youhave the right to get help and information in your language at no cost. To talkto an interpreter, call 1-888-561-8747.
Appeals or Grievances:If youor someone you are helping has questions about thegrievance or appeal process,please call: 1-866-436-0457 or completetheMTM “contact us” on-line form. Information and personal contact information willbe securely transmitted directly to MTM and will be kept confidential to theextent required by HIPAA.
Ifyou have questions or feedback for the Medicaid NEMT Team responsible for overseeing the contract with MTM, you may complete ouronline feedback form, email the team atMedicaidTransport@dhw.idaho.gov, or call 1-800-296-0509.
EXTERNAL RESOURCES
Medicaid Transportation Services - Visit MTM
Find non-emergency medical transportation for Medicaid participants.
Appeals and Fair Hearings
Medicaid Appeals and Fair Hearings
If you disagree with a decision from the Department about the benefits you receive, you can appeal that decision. See the library for more information.
Medicaid Appeal Information Library
Estate recovery process
Medicaid estate recovery is the process through which each state recovers the costs of medical services it has paid from the estate of the person who received those services. The Medicaid estate recovery program impacts two groups of people receiving Medicaid benefits:
- Anyone over the age of 55 who has received Medicaid assistance, and
- Anyone who is permanently institutionalized and has received Medicaid assistance, regardless of age.
The estate recovery program may collect money from the estate of a deceased Medicaid recipient as repayment for any medical care services that were provided to the recipient and paid for by Medicaid, while the recipient was over 55 years of age, or permanently institutionalized, regardless of age.
Medical care includes a wide range of services, including nursing home and community based in-home care services. It also includes any hospital and prescription drug services the participant received while in a nursing home, or while receiving in-home care. Medical care also includes capitation payments to Medicaid-contracted health insurance companies or medical providers administering a defined package of benefits. The federal government directs states to pursue Medicaid estate recovery for these services.
Federal law recognizes that the needs of certain relatives can take precedence over the state’s interest in recovering assets from the deceased. For this reason, states are not allowed to pursue Medicaid estate recovery under the following circ*mstances:
- During the lifetime of the surviving spouse, regardless of where he or she lives.
- From a surviving child who is under age 21 years or is blind or permanently disabled (based on Social Security criteria), regardless of where he or she lives.
Idaho Medicaid Estate Recovery will exempt all property, whether held in trust or not, if the property is owned by an American Indian or Alaskan Native (AI/AN) and located within the boundaries of a tribal reservation.
As individual circ*mstances vary, and for more information, please call the Estate Recovery Office at 866-849-3843 or email FinancialRecovery@dhw.idaho.gov
Estate Recovery Brochures
English and Spanish Estate Recovery Brochures
To see frequently asked questions about estate recovery, see our online brochures library for both English and Spanish versions of this document.
Brochures
Other services from Medicaid partners
External resources
Services provided by Optum Idaho. If you have questions regarding these services, please contact us: 855-202-0973.
External resources
Provided by MCNA Dental through the Idaho Smiles program. If you have questions regarding these services, please contact us: 855-233-6262.
external resources
Find non-emergency medical transportation for Medicaid participants.
Other healthcare assistance services
Medicaid for Children
Medicaid programs designed for children are available. Learn more to see if your child(ren) may be eligible for CHIP or Children's Medicaid.
Visit Medicaid for Children
Rules
External Resources
Office of Administration Rules
View the Idaho rules regarding the administration of Medicaid in Idaho.
View Administration Rules
External Resources
Learn more about Social Security benefits, such as Medicare and retirement benefits, by visiting the Social Security Administration website.
Managed Care Health Plan Accreditation Information
United Behavioral Health dba Optum
Program: Idaho Behavioral Health Plan
Accreditation Status: Accredited (10/15/2021-10/17/2023)
Accrediting Entity: National Committee for Quality Assurance (NCQA)
Accreditation Level: Accredited
MCNA Insurance Company
Program: Dental Plan
Accreditation Status: Full Accreditation
Accredited (12/01/2020-12/01/2023)
Accrediting Entity: Utilization Review Accreditation Commission (URAC)
Accreditation Level:, Dental Plan, 7.4 Accreditation Program
Certificate
