In Idaho:
  • There were a total of 230,725 beneficiaries enrolled in Idaho Medicaid as of July 2011, 100% of whom were enrolled in Healthy Connections, Idaho’s mandatory Primary Care Case Management Program. Physical Medicaid services are delivered through Healthy Connections.
  • While inpatient and outpatient behavioral health services have been covered under Healthy Connections, on September 1, 2013 the state implemented the Idaho Behavioral Health Plan. Under the plan, outpatient behavioral health services are offered through a capitated behavioral health organization, Optum Idaho.
  • Idaho provides dental benefits and transportation through Prepaid Ambulatory Health Plans. Dental services are offered through a program called Idaho Smiles, which is administered by a partnership between Blue Cross of Idaho and DentaQuest.
  • Idaho provides basic EPSDT services to children on a fee-for-service basis and delivers behavioral health services through its EPSDT Service Coordination (ESC) program and home and community-based services through its Children’s Developmental Disabilities Services Program. Idaho also has an approved Section 2703 Health Home State Plan Amendment to provide Health Home services to Medicaid participants with chronic conditions.
As of 2013, 198,551 individuals were eligible for EPSDT through Idaho’s Medicaid program. According to CMS data from 2013, Idaho achieved an EPSDT screening ratio of 56% and a participation ratio of 52%. 108,613 children received dental services of any kind, with 100,789 receiving preventive dental services.

Last updated May 2014


Medical Necessity
According to regulations in Idaho,
“A service is medically necessary if:   
  • It is reasonably calculated to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functionally significant deformity or malfunction; and   
  • There is no other equally effective course of treatment available or suitable for the participant requesting the service which is more conservative or substantially less costly.   
  • Medical services must be of a quality that meets professionally-recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality. Those records must be made available to the Department upon request.”
Idaho requires prior authorization for the following list of services:
  • Transportation through AMR for non-emergency medical services.
  • Some medical equipment and supplies.
  • Home and Community-Based Waiver Services.
  • Some inpatient and outpatient hospitalizations or medical procedures.
  • Some vision services.
  • Some dental services.
  • Personal care services.
  • Private duty nursing.
  • Physical, occupational, and speech therapy – beyond service limits.
  • Some medicines and most brand name drugs when generics are available.
  • Developmental disability agency services.
Initiatives to Improve Access
Reporting & Data Collection
Idaho Medicaid has reporting requirements for two of its initiatives: the Idaho Medical Home Collaborative multi-payer pilot and its ACA Section 2703 State Plan Amendment. Practices participating in the Medical Home Collaborative must achieve National Committee for Quality Assurance (NCQA) PCMH recognition and report on measures in three categories: clinical measures, including chronic disease outcome measures and preventive measures; practice transformation; and patient and provider/staff satisfaction.
Idaho Medicaid is using claims and chart-based process and outcome measures as endorsed by the National Quality Forum to track progress on six goals for the state’s health home program. Two of these are specific to children:
  • Improve care for asthma among adults and children.
  • Increase preventive care for children.
Behavioral Health
One of the qualifying Medicaid populations for Idaho’s ACA Section 2703 State Plan Amendment is pediatric patients with serious and persistent mental illness or serious emotional disturbance. Additionally, Idaho has the EPSDT Service Coordination Program (ESC) to help children with at least one of the following: a developmental delay or disability, special healthcare needs, or a severe emotional disorder. The ESC Service Coordinators help families with children who have special needs find and coordinate services their children need, such as health, educational, early intervention, advocacy and social services.
Idaho also offers Case Management services through its Children’s Developmental Disabilities Services Program. Services offered through this program include:
  • Respite
  • Habilitative supports
  • Family education
  • Habilitative intervention and evaluation
  • Family training
  • Therapeutic consultation
  • Interdisciplinary training
  • Crisis intervention and supports
Behavioral health services that exceed what is offered through the Idaho Medicaid state plan and are deemed medically necessary are delivered through Optum Idaho, a managed care contractor.
Support to Providers and Families
Support to Providers
Idaho Medicaid maintains a page for providers that includes links to forms, including the EPSDT Request for Additional Services. The provider page also has information on school-based services.
Support to Families
The Children’s Developmental Disabilities Services Program has an option that allows for Family-Directed Services. This option allows parents to choose, design, and direct services outside of the traditional menu of services within set parameters. It also allows families to hire (or act as) a support broker to develop and manage services. Additionally, a Fiscal Employer Agent is brought in to assist with and handle financial considerations. The ESC program also provides a number of services to assist families. These include:
  • Educating the family about the Infant Toddler Program (ITP – Early Intervention services for children birth to three)
  • Explaining the evaluation process
  • Explaining the family’s role as a participant on the multidisciplinary team
  • Explaining and reviewing the procedural safeguards
  • Providing support and resource information on service options
  • Facilitating the initial Individual Family Service Plan (IFSP)
  • Assisting the family with the selection of an ongoing service coordinator.
Idaho also has a 2-1-1 CareLine to provide statewide community information and referral service. 
Care coordination across settings, including referral and transition management is considered a “critical element” for the practices participating in the Idaho Medical Home Collaborative. Additionally, Idaho’s Section 2703 State Plan Amendment states that health home providers, “identify and lead the team based care coordination approach between the clinic and specialist so the whole person’s care is taken into account in both chronic disease and mental health treatment.” Finally a key role of the EPSDT Service Coordinators in the ESC Program is coordination of services such as health, educational, early intervention, advocacy and social services.
All children in Idaho Medicaid are eligible to be enrolled in Idaho Smiles, a managed care program administered by BlueCross of Idaho and DentaQuest.