Medicaid provides health coverage for children who meet certain eligibility criteria. There are several different Medicaid programs available to address specific circumstances and needs of children.
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Medicaid offers different programs to provide health coverage for children in Idaho:
- Children with income under 190 percent of the federal poverty level (FPL)
- Children with disabilities
- Children with behavioral health needs
If you or someone in your family needs healthcare, you should apply for Medicaid even if you are not sure you qualify. Some income and resources aren't counted when determining your eligibility. For example, owning your home might not prevent you from getting Medicaid.
Children with household income over 138 percent of FPL may qualify for the Children Health Insurance Plan (CHIP). See more information about CHIP under Medicaid programs.
- Basic Plan –If your child only needs health, prevention, and wellness benefits, this plan is for them. It includes annual physicals, well-child checkups, immunizations, most prescriptions, doctor and hospital visits, and more.
- Enhanced Plan – If your child has disabilities or special health needs, this is the plan has all the benefits of the basic plan, plus additional benefits. Most of the time, your child will need to be referred by a doctor to become eligible for the enhanced plan.
Medicaid and CHIP will pay for a number of services, such as prescriptions and dental care. While it is possible to have Medicaid and private health insurance, if your child has private health insurance, they won't qualify for CHIP.
- Annual physicals
- Children's Medicaid
- Counseling and mental health services
- Dental (dental services)
- Doctor visits
- Durable Medical Equipment
- Emergency Medical Transportation
- Early Periodic Screening, Diagnostic and Treatment (must be pre-authorized)
- Home health care (doctor prescribed)
- Immunizations
- Inpatient and outpatient hospital care
- Lab tests
- Medical equipment and supplies
- Medical transportation services
- Non-IV-E Foster Care/Adoption/Guardianship
- Otherwise Ineligible Non-Citizens (child or adult)
- Prescriptions
- Primary Care Case Management
- Prosthetics/orthotics
- Refugee Medical
- Substance Abuse Treatment
- Smoking Cessation
- Title IV-E Foster Care (includes ages up to 26)
- Vision (vision services)
- Weight loss
- X-rays
If your child is on the CHIP, the Children’s Wellness Benefit can provide you with an additional benefit for keeping your child up to date on well-child checks and immunizations. Each child current on their well-child checkups and immunizations is eligible to receive a $10 deduction for their monthly CHIP premiums.
Age to have a Well-Child CheckUP
Babies under 1 year old:
- 3 to 5 days old
- 1 week to 1 month
- 2 months
- 4 months
- 6 months
- 9 months
Toddlers 1-3 years old:
- 12 Months
- 15 Months
- 18 Months
- 24 Months
- 30 Months
Children 3-19 years old:
- Children ages 3-19 need a checkup once a year.
Please ask your doctor which immunizations your child needs and ask your doctor to enter the immunization record into IRIS, Idaho's Immunization Registry. If you don't have a doctor for your child, use the Find a Provider tool or call Healthy Connections at 888-528-5861.
The Weight Management benefit is designed to help eligible members and their families improve their lifestyle through:
- Physical fitness
- Balanced diet
- Personal health education
If you qualify, you can earn up to $200 each year to help pay for services offered by PHA providers such as participation in the National Diabetes Prevention Program, fees for a weight management program, a gym membership, healthy lifestyle classes, or nutrition classes or services. Any additional fees are your responsibility.
Weight management qualification guidance
- You must have full basic or enhanced Medicaid coverage to qualify.
- You must also meet the following criteria by age:
- Be an adult over 21 and have a body mass index of 30 or higher or 18.5 or lower according to the Centers for Disease Control and Prevention adult body mass index calculator..
- Be a child 5-21 and have a body mass index that falls in either the overweight or the underweight category according to the Centers for Disease Control and Prevention child and teen body mass index calculator.
- If you are on the Home Care for Certain Disabled Children Program (Katie Beckett) and Medicare-Medicaid Coordinated Plan you aren’t eligible for these benefits.
Steps to sign up for the PHA program
- If you’re interested in the program, visit your primary care provider (PCP).
- Your PCP will initiate the process by printing and filling out their portion of the Preventive Health Assistance Agreement Form.
- You then will need to fill out your section of the form.
- Take the form to the weight management provider you’ve chosen ad get their signature. After all sections are complete, the form must be submitted to the PHA program for approval. The benefit will start on the date of approval.
Idaho Medicaid contracts with Medical Transportation Management, Inc. (MTM.) to manage a statewide network of transportation providers for NEMT services for Medicaid eligible members who have no other means of transportation. The Idaho NEMT program covers transportation in-state and out-of-state, to and from healthcare services covered under the Medicaid program.
Idaho rules for the NEMT program can be found at IDAPA 16.03.09.870 through 873.
Member Services
If you have a medical appointment but you don’t have a car, can’t operate a car, or don’t have a friend or family member who can take you, 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 reimbursement 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 business days before your appointment.
You may reach MTM to request transportation by calling 877-503-1261, by visiting MTM's Medicaid Transportation website, or by using MTM's Transport Service Management Portal. Trips can be scheduled 24 hours a day, 7 days a week.
If you or someone you’re helping has questions about MTM, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 888-561-8747.
Appeals or Grievances
If you or someone you’re helping has questions about the grievance or appeal process, please call: 866-436-0457 or complete the MTM “contact us” on-line form. Information and personal contact information will be securely transmitted directly to MTM and will be kept confidential to the extent required by HIPAA.
If you have questions or feedback for the Medicaid NEMT responsible for overseeing the contract with MTM, you may complete our online feedback form, email the team at MedicaidTransport@dhw.idaho.gov, or call 800-296-0509.