Idaho ID

Idaho publishes general PA PROCESS forms alongside its per-class clinical criteria: (1) A Universal Form — generic PA for non-preferred meds / age overrides / quantity overrides (requires prior failed trials + justification + chart notes/labs); (2) Physician Administered Drugs — buy-and-bill/J-code PA capturing billing code, drug/dose/dx, prior trials; (3) Hospice — PA for drugs for hospice enrollees that fall OUTSIDE hospice palliative care (hospice dx, plan of care, hospice pharmacist review; up to 6 mo). These are submission-process artifacts, not drug-class coverage rules — captured here so the full Idaho PA picture is recorded.

Idaho Medicaid PA is FFS-dominant. The canonical PA criteria do NOT live as a single state PA portal; they are distributed across per-service-type Provider Guidelines PDFs on the Gainwell-operated provider portal idmedicaid.com (Provider Handbook page), each carrying medical-necessity/PA requirements for that service category, plus a General Information & Requirements handbook and per-service PA request forms. DHW (healthandwelfare.idaho.gov) is the policy authority and routes providers TO the Gainwell portal. The two previously pinned DHW URLs (pa_index, provider_manual) under /providers/medicaid-providers/* are now 404 (site restructured to /providers/idaho-medicaid-providers/...). BH is carved out to Optum Idaho (ASO, via magellanofidaho.com). Telligen historically a UM contractor but criteria publication is via the Gainwell Provider Guidelines, not a Telligen-branded portal. Pharmacy is state-administered (separate program page).

Last award: ?. Next due: 2029-12-31 (planned transition to comprehensive MCO 2030-01-01). Contracts extended through: {'magellan_ibhp': 'term ongoing from 2024-07-01', 'molina_duals': 'term active', 'uhc_duals': 'IMPlus 2025-06-01; MMCP 2026-01-01', 'mcna_dental': 'active', 'mtm_nemt': 'extended via option years from original 2018 award'}.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How ID requires PA Idaho Medicaid's prior authorization (PA) requirements are primarily managed through a fragmented system of Provider Guidelines distributed across PDF documents on the Gainwell-operated provider portal, `idmedicaid.com`. These guidelines cover specific service types and drugs, detailing medical necessity criteria and documentation requirements for providers to submit PA requests. For instance, therapy services like occupational, physical, and speech therapies require current evaluations, plans of care with goals, physician orders, and recent treatment notes. ## 2. How ID publishes and reports PA Idaho Medicaid publishes its PA criteria through Provider Guidelines available on the Gainwell-operated provider portal `idmedicaid.com`. These guidelines are distributed across multiple PDF documents, each addressing specific service types such as therapy services, durable medical equipment (DMEPOS), behavioral health/social services, transportation services, home and community-based services (HCBS)/long-term support services (LTSS), and hospital services. The portal also includes a Therapy PA Request Form for occupational, physical, and speech therapies. Reporting on PA decisions is not explicitly detailed in the source documents. ## 3. ID's CMS-0057-F and PA-reform compliance posture Idaho Medicaid's compliance with CMS-0057-F is only partially addressed in the source documents, via its distributed Provider Guidelines on `idmedicaid.com`. The lack of a single centralized PA criteria portal suggests potential gaps relative to CMS transparency/access expectations. The state has several 1115 waivers (including the Idaho Behavioral Health Transformation and a Family/Personal Care Services amendment) that may influence PA processes but are not fully detailed in the source documents. Idaho is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Idaho.) No WISeR participation should be inferred for ID. ## 4. How ID runs its own program Idaho Medicaid operates under a mixed model that includes fee-for-service (FFS) and managed care components. The state has carve-outs for pharmacy services, behavioral health, and long-term support services. Pharmacy services are administered through a FFS model with a preferred drug list managed by a pharmacy benefit manager (PBM). Behavioral health services are carved out to a single statewide prepaid inpatient health plan (PIHP), while long-term support services operate under an FFS model with duals integrated into managed care plans. The state's fiscal-agent history shows transitions from ACS-Inc to Conduent/Gainwell, indicating changes in the vendor managing Medicaid operations. Current contracts (per source documents) include Magellan IBHP, Molina Duals, UHC Duals, MCNA Dental, and MTM NEMT, with varying end dates extending through 2026. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Distributed PA Criteria**: A decentralized approach distributing criteria across multiple Provider Guidelines PDFs on the Gainwell portal. - **Specific Service Coverage**: Detailed guidelines for specific services (therapy, DMEPOS, behavioral health). - **1115 Waivers**: Idaho has several 1115 waivers that may influence PA processes but are not fully detailed in the findings. ### Missing/Uncertain: - **Centralized Portal**: Absence of a single centralized PA criteria portal raises questions about CMS-aligned transparency/access. - **Comprehensive MCO Transition**: A planned move toward comprehensive managed care (referenced as later-decade) may alter PA practices; details not provided. (Flag as unverified.) - **Behavioral Health Law Details**: BH carve-out to a single PIHP is noted, but governing statute/regulation is unspecified. - **Foster Care Program**: The MCO arrangement for foster care is unspecified.