House Bill 260, passed by the 2011 Idaho Legislature, directs the Department to limit physical, occupational, and speech therapy services covered by Medicaid so they align with annual Medicare caps.
For dates of service on or after January 1, 2012, the Department will limit therapy services to:
- $1,870 per calendar year for speech language pathologist (speech therapy) services and physical therapy services combined.
- $1,870 per calendar year for occupational therapy services.
These limitations apply to therapy services delivered through independent therapy providers and outpatient hospital therapy providers. Information about how many therapy services a participant has used will be available in eligibility information online at www.idmedicaid.com, telephonically by dialing 1 (866) 686-4272, or electronically through a 270/271 transaction.
Medicaid will allow additional medically necessary services beyond these caps. In order to receive payment for services in excess of the cap, providers must submit the following supporting documentation:
- Physician’s order for therapy services (this is not a Healthy Connections Referral)
- Plan of Care
- Current progress notes
Each calendar year the participant reaches the therapy limitation cap, the provider must provide the Department the above required documentation.
Please fax these documents to 1 (877) 314-8779 at least one business day prior to submitting a claim for any services beyond the caps. You may also mail documentation to Idaho Medicaid, Medical Care Unit, P O Box 83720, Boise, ID 83720-0009.
To certify that any services provided beyond these limits are medically necessary, therapy providers must bill them in conjunction with a KX modifier on their claim form. Medicaid will deny claims for services beyond the cap that are not billed with a KX modifier or when the provider has not submitted current supporting documentation. Services that are not medically necessary, that do not require the skills of a professional therapist, or that are not supported by appropriate documentation will also be denied.
Detailed information about required documentation and the processes for submitting claims for services in excess of these caps will be available in updated provider handbooks at www.idmedicaid.com. You can also contact the Division of Medicaid at (208) 364-1897 with questions about this change.
Thank you for participating in the Idaho Medicaid Program.