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.
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 are not 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 – This plan provides health, prevention, and wellness benefits for children who do not have special health needs. This plan includes annual physicals, well-child checkups, 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.
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, children who have private health insurance cannot qualify for CHIP.
- Annual physicals
- 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)
- Inpatient and outpatient hospital care
- Lab tests
- Medical equipment and supplies
- Medical transportation services
- Primary Care Case Management
- Substance Abuse Treatment
- Smoking Cessation
- Vision (vision services)
- Weight loss
The Children’s Wellness Benefit provides parents with children on the Children's Health Insurance Program (CHIP) an additional benefit for keeping their children up to date on well-child checks and immunizations. Every 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 the Healthy Connections Unit at 888-528-5861.
The Weight Management benefit (WM) is designed to help eligible participants and their families improve their lifestyle through:
- Physical fitness
- Balanced diet
- Personal health education
Qualifying participants 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 the participant’s responsibility.
WM qualification guidance:
- Participants must have full Basic or Enhanced Medicaid coverage to qualify.
- Participants must also meet the following criteria by age:
- Children (5 to 21 years old): a body mass index (BMI) that falls in either the overweight or the underweight category according to the CDC Child and Teen BMI Calculator.
- Participants on the Home Care for Certain Disabled Children Program (Katie Beckett) and Medicare-Medicaid Coordinated Plan participants are not eligible for these benefits.
Steps to sign up for the PHA program
- Participants interested in the program should visit their Primary Care Provider (PCP).
- The PCP will initiate the process by printing and filling out their portion of the PHA Agreement Form.
- The participant is then responsible for filling out their section of the form.
- The participant takes the form to the WM provider they have chosen to receive services from for 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 MTM (Medical Transportation Management, Inc) to manage a statewide network of transportation providers for Idaho's NEMT services for Medicaid-eligible participants who have no other means of transportation. The Idaho NEMT program covers transportation in-state and out-of-state and to and from healthcare services when those services are covered under the Medicaid program.
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 take you to your apppointment, 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 48 hours 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. Routine trips can be scheduled Monday through Friday from 8 a.m. to 6 p.m.
Appeals or Grievances: If you or someone you are 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 Team 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.
Appeals and Fair Hearings
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
Accrediting Entity: Utilization Review Accreditation Commission (URAC)
Accreditation Level:, Dental Plan, 7.4 Accreditation Program