Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.12-022 - IndependentChoices provider manual amendments - INCHOICE-1-11 and State Plan Amendment #2012-009
Current through Register Vol. 49, No. 9, September, 2024
Section II IndependentChoices
The IndependentChoices program is a state plan service under 1915(j) of the Social Security Act. IndependentChoices is operated by the Division of Aging and Adult Services (DAAS). The program offers Medicaid-eligible individuals who are elderly and individuals with disabilities an opportunity to self-direct their personal assistant services.
IndependentChoices seeks to increase the opportunity for consumer direction and control for Medicaid beneficiaries receiving or needing personal assistant services. Personal Assistant services in IndependentChoices include state plan personal care for Medicaid beneficiaries and Adult Companion and Homemaker services for ElderChoices beneficiaries. IndependentChoices offers an allowance and counseling services in place of traditional agency-provided personal assistance services and items related to personal assistance needs.
The participant or designee is the employer and accepts the responsibility in directing the work of their employee to the degree necessary to meet their individual needs for assistance with activities of daily living and instrumental activities of daily living.
If the IC participant can make decisions regarding his or her care but does not feel comfortable reading and filling out forms or talking on the phone, he or she can appoint a Communications Manager. The Communications Manager can act as the participant's voice and complete and sign forms, but will not make decisions for the participant. The Communications Manager will not hire, train, supervise or fire the personal assistant for the IC participant.
If the participant needs someone to hire and supervise the personal assistant, make decisions about care and administer the cash expenditure plan as well as complete all forms, a Decision-Making Partner will be appointed.
IndependentChoices participants or their Decision-Making Partners must be able to assume the responsibilities of becoming an employer by hiring, training, supervising and firing if necessary their directly hired workers. In doing so the program participant accepts the risks, rights and responsibilities of directing their care and having their health care needs met.
The IndependentChoices program respects the employer authority of the participant who chooses to direct his or her care by hiring an employee who will be trained by the employer or Decision-Making Partner to provide assistance how, when, and where the employer or Decision-Making Partner determines will best meet the participant's individual needs. The Medicaid beneficiary assumes the risks, rights and responsibilities of having their health care needs met in doing so.
NOTE: The IndependentChoices Program follows the rules and regulations of the State Plan approved Personal Care Program, unless stated otherwise in this manual.
To be eligible for IndependentChoices, a participant must:
The Division of Aging and Adult Services is the point of entry for all enrollment activity for IndependentChoices. The program is limited based on an approved number through the Medicaid State Plan.
The individual or their designee will first call the IndependentChoices toll-free number at 888-682-0044 to speak with an IndependentChoices counselor. The counselor will provide information to the individual about the program and verify that the individual is currently enrolled in a Medicaid category that covers personal assistance services. If the individual is currently enrolled in an appropriate Medicaid category and has an assessed physical dependency need for "hands on" assistance with personal care needs, the counselor will enter the individual's information into a DAAS database. Based on the individual's county of residence, the IndependentChoices counselor will either continue working with the individual through the enrollment process, or refer the individual to the contracted counseling agency for the individual's area of the state. If the individual is not currently enrolled in an appropriate Medicaid category, the counselor will refer the individual to the DHS County Office for eligibility determination.
The counselor, nurse and fiscal agent will then work with the individual to complete the enrollment forms either by mail and telephone contact or by a face-to-face meeting. The individual will be provided with the "My IndependentChoices Handbook," which explains the individual's responsibilities regarding enrollment and continuing participation. The individual must complete the forms in the Enrollment Packet, which consists of the Participant Responsibilities and Agreement, the Backup Personal Assistant and the Authorization to Disclose Health Information. The participant must also complete the forms in the Employer Packet, which includes the Limited Power of Attorney, IRS and direct deposit forms related to being a household employer. Each personal assistant must complete the forms in the Employee Packet which include the standard tax withholding forms normally completed by an employee, the Employment Eligibility Verification Form (I-9), a Participant/Personal Assistant Agreement, Employment Application and a Provider Agreement. The packets each include step-by-step instructions on how to complete the forms. IndependentChoices staff will be available to the individual, Decision-Making Partner/Communications Manager and the personal assistant to help complete the forms and answer any questions.
As part of the enrollment process, the DAAS RN will complete an assessment using the Home and Community Based Services (HCBS) Level of Care Assessment Tool. Through completing the assessment and using professional judgment, the DAAS RN will determine how many hours of personal assistance services are needed by the participant. Eligibility for personal care services is based on the same criteria as state plan personal care services. NOTE: For ElderChoices beneficiaries, the DAAS RN will determine the number of personal care, Adult Companion Services and Homemaker hours needed. The ElderChoices plan of care will reflect that the beneficiary chooses IndependentChoices as the provider. DAAS-HCBS staff will obtain physician authorization for persons not receiving either ElderChoices or Alternatives for Adults with Physical Disabilities waiver services.
After the in-home assessment, the DAAS RN will complete the paperwork and coordinate with the IndependentChoices counselor. The counselor will process all of the completed enrollment forms. The HCBS Level of Care Assessment Tool, which includes the cap triggers and the number of hours of services needed, will be sent to the participant's physician for authorization if the participant is not authorized for services through a waiver plan of care for ElderChoices or Alternatives for Adults with Physical Disabilities. State and IRS tax forms will be retained by the fiscal agent. Disbursement of funds to a participant or their employee will not occur until all required forms are accurately completed and in the possession of the fiscal agent.
Personal care assessments for participants aged 21 years or older and authorized by the participant's physician in excess of 14.75 hours per week will be forwarded by the participant's counselor to Utilization Review in the Division of Medical Services for approval. View or print Utilization Review contact information. For individuals under age 21, all personal care hours must be authorized through Medicaid's contracted Quality Improvement Organization (QIO), QSource of Arkansas. View or print QSource of Arkansas contact information.
IndependentChoices follows the rules and regulations found in the Arkansas Medicaid Personal Care Provider Manual in determining and authorizing personal care hours. The initial authorization for personal assistance services may not begin until the participant's primary care physician or an advanced practice nurse enrolled in the Arkansas Medicaid APN program seeing patients in an Arkansas Medicaid enrolled Rural Health Clinic or Federally Qualified Health Center signs and dates the Home and Community Based Services (HCBS) Level of Care Assessment Tool. For beneficiaries receiving services through the ElderChoices or Alternatives for Adults with Physical Disabilities waiver program, the APN or physician's signature is not required. The signature of the DAAS RN is sufficient to authorize personal care services. After the service plan is authorized, the actual day services begin is dependent upon all of the following conditions:
If the individual is not a recipient of ElderChoices or Alternatives for Adults with Physical Disabilities services, then continuation of personal assistance services requires reauthorization prior to the end of the current service plan end date.
When required for non-waiver beneficiaries, the earlier of the two following conditions will suffice for the face-to-face visit required sixty days prior to the begin date of the new service plan:
When the approval by Utilization Review is received, or the individual needs 14.75 hours or less per week, the IndependentChoices Counselor will contact the participant or Decision-Making Partner/Communications Manager to develop the cash expenditure plan. The participant and the counselor will determine when IndependentChoices services can begin, but may not commence prior to the date authorized by the physician. The participant is required to have a face-to-face visit with their physician within 60 days of the date that the physician signs the Assessment Tool or 60 days prior to the service plan begin date and each subsequent reassessment. At no time will services begin prior to the first day of the previous month unless authorized by the Division of Aging and Adult Services.
An individualized personal assistance service plan, signed and dated by the participant's personal physician constitutes the physician's personal assistant services authorization. All services must be prior approved through the service plan.
NOTE: An advanced practice nurse (APN) enrolled in the Arkansas Medicaid Program seeing patients in a Rural Health Clinic or Federally Qualified Health Center enrolled in the Arkansas Medicaid Program as an RHC or FQHC may sign the personal care service plan/order if practicing within an environment for which his/her certification applies and within the scope of his/her certification. No MD signature is required in addition to the APN's signature unless required by their license and/or certification.
The amount of the Cash Expenditure Plan (CEP) is determined by the assessment performed by the DAAS RN. The counselor and the participant or Decision-Making Partner will work together to develop the CEP, which may be updated and revised whenever a need arises. The CEP is intended to be a blueprint of how the monthly allowance may be spent to meet the needs identified in the service plan. The CEP may include ten percent of the amount of the participant's plan as a discretionary expenditure not to exceed $75.00. The discretionary expenditure is used to purchase personal hygiene items and does not require the participant to maintain receipts for the purchases. For reporting purposes, discretionary purchases will be self-declared by the participant and will be part of the quarterly reporting requirement performed by the fiscal agent.
The fiscal agent may establish and maintain a savings account for individuals who want to save part of the monthly allowance for a more expensive personal assistant service item. The item must be approved by the IndependentChoices counselor and be listed on the Cash Expenditure Plan. These funds may be saved to purchase more expensive personal assistant services items or services. All savings must be spent on appropriate items by the end of the participant's eligibility for IndependentChoices services or returned to the Arkansas Medicaid program within 45 days of disenrollment from IndependentChoices.
The DAAS RN will assure that a written work agreement DAAS-IC-20 is executed between the participant or Decision-Making Partner and the employee to clearly identify the tasks required on a daily basis to meet the participant's personal assistance needs. In addition to the Work Agreement, the fiscal agent is responsible for obtaining the Participant/Personal Assistant Agreement form DAAS-IC-17. The purpose of the DAAS-IC-17 is to state the agreements to which both the employer and the employee(s) are in agreement. The agreement is signed by both the participant or Decision-Making Partner and the employee.
The primary use of the monthly allowance is to purchase personal assistance services to meet the participant's personal assistance needs. Assistants will be recruited, interviewed, hired and managed by the Decision-Making Partner. Family members, other than those with legal responsibility to the participant may serve as personal assistants. A court appointed legal guardian, spouse, power of attorney or income payee may not serve as a Personal Assistant.
The participant's personal assistant performs the services identified on the DAAS-IC-20 Work Agreement under the agreed upon terms of the DAAS-IC-17 IndependentChoices Participant/Personal Assistant Agreement.
In-home services are designed to reduce or prevent inappropriate institutionalization by maintaining, strengthening or restoring an eligible participant's function in his or her own home. IndependentChoices allows ElderChoices participants the choice of self-directed Homemaker Services rather than receiving Homemaker services through a certified agency.
The DAAS RN will determine the number of hours of Homemaker Services needed by the participant as indicated on the ElderChoices Plan of Care. If the participant chooses to self-direct Homemaker Services, the DAAS RN will refer the participant to the IndependentChoices program by sending the plan of care to IndependentChoices, notating that IndependentChoices was selected.
Adult Companion Services is nonmedical care, supervision and socialization provided to an adult with a functional impairment who is an enrolled participant in the ElderChoices home and community-based waiver operated by the Division of Aging and Adult Services. Participants enrolled in ElderChoices and in need of Adult Companion Services may either receive Adult Companion Services through an agency or self-direct the services through IndependentChoices.
The DAAS RN will determine the number of hours of Adult Companion Services needed by the participant as indicated on the ElderChoices Plan of Care. If the participant chooses to self-direct Adult Companion Services, the DAAS RN will refer the participant to the IndependentChoices program by sending the plan of care to IndependentChoices notating that IndependentChoices was selected.
An IndependentChoices participant's allowance paid prospectively during hospitalization must be returned to the Medicaid Program. The day of admission and day of discharge are allowable days when the participant receives personal assistance services prior to admission or after discharge from the hospital. The participant is instructed to provide supporting hospital documentation to their counselor and Financial Management Services provider to support receipt of personal assistance services on the day of admission. The DAAS Financial Management Service will be responsible for calculating and collecting the refund.
When the participant voluntarily elects to discontinue participation in IndependentChoices, the counselor will discuss with the individual the reason for disenrollment and assist the individual in resolving any barriers or problems that may exist in preventing continuation. If the participant wishes to continue with the option to disenroll, the counselor will assist the participant by informing him or her of traditional agency personal care providers in the participant's area. The counselor will assist with the coordination of agency services to the degree requested by the participant.
IndependentChoices can continue until agency services are established or the participant may elect to use informal supports until agency services are established.
Parti cipants may be disenrolled for the following reasons:
Whenever a participant is involuntarily disenrolled, the IndependentChoices program will mail a notice to close the case. The notice will provide at least 10 days but no more than 30 days before IndependentChoices will be discontinued, depending on the situation. During the transition period, the counselor will work with the participant or Decision-Making Partner to provide services to help the individual transition to the most appropriate services available.
If the participant loses eligibility for personal assistance services, he or she may ask for an Administrative Reconsideration according to Section 161.200 of the Medicaid Provider Manual or may appeal the decision according to Medicaid Provider Manual policy 161.300 through 169.000.
An appeal may be filed by a participant or Decision-Making Partner based on actions or circumstances listed below:
Counselors for IndependentChoices will be employed or contracted by DAAS. Counselors must possess a Bachelor's degree in humanities, social science or a related field plus two years experience in social or community work pertaining to adults with chronic conditions and disabilities or a related field.
Other job related education and/or experience may be substituted for all or part of these basic requirements with approval of DAAS.
The current contract requires IndependentChoices counseling providers to perform the following:
Supplement 4 to Attachment 3.1-A
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State: ARKANSAS 1915(j) Self-Directed Personal Assistance Services
Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation.
The State determines eligibility for Self-Directed Personal Assistance Services:
The State elects to have the following included as Self-Directed Personal Assistance Services:
ElderChoices - Adult Companion Services ElderChoices - Homemaker Services
PAS under section 1915(j) as that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services.
The State will provide the following safeguards to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional service delivery models.
When the participant voluntarily elects to discontinue participation in IndependentChoices, the counselor will discuss with the individual the reason for disenrollment and assist the individual in resolving any barriers or problems that may exist in preventing continuation. If the participant wishes to continue with the option to disenroll, the counselor will assist by informing the participant of traditional agency personal care providers in the participant's area. The counselor will assist with the coordination of agency services to the degree requested by the participant.
IndependentChoices can continue until agency services are established or the participant may elect to use informal supports until agency services are established.
The timeframes discussed under involuntary disenrollment do not apply to voluntary disenrollment. The request of the participant will be honored whether they ask to be disenrolled immediately or at anytime in the future. The counselor will coordinate the participant's wishes to the degree requested by the participant. This may include self-advocation by the participant and asking the counselor to coordinate agency services with the participant's preferred provider. In some instances the participant may wish to forego agency personal assistance services and choose to rely on family or friends. If the participant requests that the counselor coordinate the agency services the counselor will ascertain when services can be started. The counselor will then close the IndependentChoices case the day before agency services begin. Regardless of the situation, the State will assure that there will not be an interruption in delivering necessary services unless it is the preference of the participant to depend on informal supports.
Parti cipants may be disenrolled for the following reasons:
Should an unapproved expenditure or oversight occur a second time, the participant/ representative will be notified that their IndependentChoices case is being closed and the participant is being returned to traditional personal care. Program Integrity is informed of situations as required. The State will assure interruption of services will not occur while the participant is transitioning from IndependentChoices to traditional services.
When a participant is involuntarily disenrolled, a notice of intent to close the IndependentChoices case will be mailed to the participant. The notice will allow a minimum of 10 days but no more than 30 days before IndependentChoices enrollment will be discontinued, depending on the situation. During the transition period, the counselor will work with the participant/representative to assure services are provided to help the individual transition to the most appropriate personal care services available.
Any additional restrictions on participant living arrangements, other than homes or property owned, operated or controlled by a provider of services, not related by blood or marriage to the participant are noted below.
There are no additional restrictions on living arrangements.
State Plan; or
o At the request of the participant for any reason; or o When the State or its contracted entities observes the participant lacks the necessary skills to meet employer and budget authority.
The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider's influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence.
Not applicable. The state will not allow entities who provide other Medicaid State Plan services to be responsible for developing the self-directed service plan.
The State's quality assurance and improvement plan is described below, including:
Many activities evaluate the overall performance of the IndependentChoices program such as:
* The IndependentChoices program uses a database to track a wide array of data, and uses all of the data it stores . Data entry drives end user functionality through form and e-mail generation, field calculation, data cross-referencing, and notices and reports. The reporting capabilities can help to monitor every element of operations such as: case particulars, work reports and management and operational tools. Use of the database supports discovery, remediation, and quality improvements.
* Using a DMS approved assessment tool to determine the resources in time required to provide care in the home.
* Reports received from Financial Management Services provider received on a quarterly basis used by counselors to determine why underutilization of the Cash Expenditure Plan occurs and how underutilization can be resolved.
All individual facets of the program work in a continuum to identify, remediate and improve the quality of services and the satisfaction of program participants while improving the overall performance of the program. Each phase of the program is described, detailing how assurances are met through the Arkansas Quality Assurance and Improvement Plan described below.
Monitoring and Oversight
The Division of Medical Services (DMS) retains responsibility for the administration and oversight of all Medicaid programs. The Division of Aging and Adult Services (DAAS) is the operating agency for the IndependentChoices program and responsible for the day-to-day operations. Both Divisions are part of the Arkansas Department of Human Services. DAAS will be responsible for executing the Quality Assurance and Improvement Plan with monitoring and oversight by DMS.
DAAS will provide DMS with a monthly report comparing status of current data to previous year data. Examples included in the report may include but are not limited to the following:
* Enrollment activities
* Extension of Benefits results
* Status of pending applications
* Status of active case load
* Parti cipants who also receive home and community based services (HCBS)
* Medicaid Cost for IndependentChoices including participant-directed cost for HCBS services
* Detailed information for cost data for the most current month including cost of participant's budget and support services.
* Year in Progress count of participants, contact notes, home visits, new enrollments for the current month, year to date and accumulative prior year experiences.
Lines of communication between the two Divisions are established and utilized to discuss additional needs and concerns that either Division may have.
The IndependentChoices database is designed in such a way that discovery and remediation go hand in hand; not only for the counselors, nurses and contractors, but also for management staff. By design, the efficiency of the database enhances the counselor's ability to provide good customer service and not be overly burdened with paper work.
Examples on the following pages may include but are not limited to:
The database quantifies:
* referrals received during the month,
* persons disenrolling,
* Extensions of Benefits requested.
The database identifies:
* reasons for disenrolling from the program,
* IndependentChoices participants who also receive HCBS waiver services,
* the HCBS RN assigned to the participant ,
* the participant's physician,
* physician's fax number,
* date next reassessment due.
The database tracks and creates exception reports when standards are not met and quantifies results. Some examples of the reports are :
* time between the date of referral, the nurse's home visit, and receipt of the assessment from the HCBS RN,
* time between receiving the assessment, sending the assessment to the physician and receiving the authorization from the physician,
* time between the referral and the actual enrollment
* number of home visits made by HCBS RN's within a timeframe.
Each active and pending record contained within the database only includes data fields that are used in reporting. Each participant record may include the following:
* representative information, if applicable,
* parti cipant's employee,
* parti cipant's back-up worker,
* directions to the participant's home,
* nurse tracking,
* counselor tracking,
* contact notes,
* HCBS ElderChoices (EC) service plan for persons receiving both ElderChoices and IndependentChoices.
These data elements will assist the counselors and nurses in performing their duties by allowing timely management and monitoring of each participant's case . The HCBS service plan is used to determine if an extension of benefits is warranted, as all community resources are considered when requesting an extension of benefits. The database allows nurses, counselors or contractors to set health risk indicators identifying program participants who may require more frequent monitoring.
The data allows nurses and counselors to run reports from their case load. Automated highlights on specific data elements draw the nurse or counselor's attention to areas that require special attention. Highlighted data fields represent the following:
* assessment performed by the nurse but not received by DAAS,
* counselor's request for authorization by a physician not received after four or more days,
* date enrollment forms sent to a potential enrollee but not returned.
Reports are available to management to monitor quality of services provided to program participants and performance of staff. The reports identify program strengths and weaknesses or individual areas of concern. Reports compare data elements over periods of time to measure progress of corrective actions. As issues are identified they are addressed with appropriate staff to determine a new course of action through issuing new policy, enacting new procedures, clarifying an existing policy or procedure, or developing additional training. Identified issues continue to be monitored to determine if the corrective action is resolving the concern and is achieving the expected outcomes.
These reports allow flexibility to generate data based on any specified period of time, by a nurse, counselor, contractor or by management. Reporting frequencies range from daily, monthly, or annually. Policy dictates a maximum period of time for completion of specific tasks with the focus on completing necessary tasks that allow the program participant to direct and meet their own health care needs.
Reporting is used to identify and remediate problems, improve program operation and to evaluate staff performance.
The database stores contact notes documenting IndependentChoices staff and contractors communication with program participants. Policy requires each contact note to be entered into the participant's record to enhance the ability of management to address concerns expressed by the participant, a legislator, the Governor's Office, etc., with a quick review of the contact notes.
Examples of data elements found in the nurse tracking database portion may include, but is not limited to these data elements describing some of the following characteristics:
* MDS-HC RUG category
* principal diagnosis,
* secondary diagnoses,
* parti cipant well cared for,
* strong informal supports,
* no concerns noted,
* need for frequent counselor contact.
Contact notes may include the following:
* person initiating the call,
* person receiving the call,
* date and time of call,
* subject of contact
* description of communication,
* complaint indicator
* whom complaint is directed toward
* date of complaint resolution
Nurses are supported by the Nurse Case Load Report that quantifies the active and pending caseload for each nurse by describing the following:
* by county, the number of active and pending clients with or without home and community-based services and those with extension of benefits,
* data is also displayed in the aggregate by nurse per assigned counties.
Nurses use a DMS approved assessment tool to define the participant's medical needs relative to the amount of resources required to care for the person in the home. The DMS approved assessment tool is similar to the MDS assessment performed in nursing homes but is specifically designed for the community environment. The assessment results in a Resource Utilization Group (RUG) with an ADL Index defining the degree of functional impairment. These results help define the population served in addition to using a scientifically scaled and validated assessment instrument. The use of this assessment helps to more clearly describe the medical complexities of program participants as they strive to remain in the community and avoid institutionalization.
Monitoring occurs in various other ways such as:
* Underutilization of the allowance could be the first indication that a participant may be experiencing difficulty directing their own care. It could indicate the beginning of a decline in cognitive function, impairing the participant's ability to direct their care, a need for a representative or decision making partner ; a loss of worker; or it may be nothing more than not submitting the timesheets in a timely manner. Each counselor works with his or her participants to determine the cause of the underutilization. The counselor and participant work together to resolve the problem with the counselor providing further assistance, as needed, or by the participant meeting his or her responsibilities as an employer. The counselor follows-up with additional calls to the participant and monitors future underutilization reports for reoccurrences.
* Site visits to the contractors are made at a minimum bi-annually and more often if needed. The purpose of the site visit may be to provide an in-service, address concerns, or to evaluate performance. If during an evaluation deficiencies are noted, DAAS may provide additional in-services, require an acceptable corrective action plan, monitor the corrective action plan, withhold payment or terminate the contract.
Parti cipant Feedback
The DAAS and its counseling and fiscal contractors support and encourage participant communication by provision of a toll-free number. Participants may pose questions and voice concerns using the toll-free number. Incoming calls from participants and outgoing calls from counselors or contractors are entered into the participant's individual electronic record. If the communication is an expressed complaint the counselor follows DAAS required reporting procedures for documenting and resolving the complaint. Resolutions may include policy or procedural changes. Monitoring will continue to determine if the change has any impact or if the problem needs additional review.
A DHS appeal process is available for decisions made concerning Medicaid eligibility or extension of benefits. An internal appeal process is available for participants when they
are in disagreement with the number of hours recommended by the HCBS RN, involuntary disenrollment or if they have disagreements with their counselor or fiscal agent . The purpose of the internal appeal is to allow the participant a voice in the decision and a way to mediate any misunderstandings between the participant and the IndependentChoices program. Additional supporting information may be shared during this time. DAAS will issue a letter to the participant within five days from the date the internal appeal is conducted . Most disagreements are resolved prior to a participant initiating a request for a fair hearing and appeal. A formal Medicaid Fair Hearing is available when services are reduced, suspended, eliminated, or upon loss of Medicaid eligibility.
Information and Assistance
Brochures are available for marketing purposes and are provided to any of the 75 county offices upon request.
Each participant receives a program handbook to convey program guidelines and expectations. Examples of i nformation provided may include any of the following and is subject to additions and deletions as needs arise :
* Overview of the IndependentChoices program
* Overview of support services
* Use of a representative (Decision-Making Partner) or Communications Manager
* Eligibility
* Parti cipant rights
* Parti cipant responsibilities
* Personal assistance services
* Other Medicaid services
* Medicaid waiver services
* Expectations from counselor, nurse, bookkeeper
* Parti cipant's enrollment duties
* Confidentiality
* When participant-direction begins
* Case Expenditure Plan
* Record Keeping
* Payroll
* Timesheets
* Hiring, training, conflict resolution, and termination of personal assistant
* Adult protective services
* Support services monitoring
* Reassessments
* Appeal rights
Parti cipants may also receive in-home visits, newsletters, questionnaires, and contact by phone to support participants wishing to direct their own care.
Parti cipants can speak with their counselor or the fiscal intermediary from 8:00 a.m. until 4:30 p.m., Monday through Friday, except for legal holidays or during inclement weather . After hours the participant may leave a message; the counselor will return the call within one working day. Complaints are entered by the receiving party whether that is the counselor or the fiscal intermediary.
A packet of communication forms is provided to each participant to report a change, to revoke and/or change disclosure of information and to appeal adverse decisions. The counselor may also verbally take information related to changes in address or phone number.
Health and Welfare
Each participant must have an individual back-up plan to handle situations when the participant's primary employee is unavailable. The participant identifies a person who is willing to assume the tasks of the primary employee. The participant determines the risk involved and how the risk is mitigated based on their own individual needs. Inquiry of the use of the back-up plan occurs during phone communication with the participant. Reports from the IndependentChoices database can identify any program participant without a back-up personal attendant and if there is a conflict regarding a representative serving as a paid back-up personal attendant. The counselor initiates communications with the participant to begin remediation.
Counseling and fiscal entities will work closely together to provide information necessary for each entity to perform their duties. Frequent and thorough communication facilitates this good working relationship.
The database assists in addressing health and welfare concerns by allowing monitoring and management of each individual file by:
* identifying a participant's representative, employee, physician, back-up worker, directions to the home, results of the nurse's assessment, and updates by the counselor assisting the participant in the IndependentChoices program, and;
* documenting all communications with the program participants.
Financial Accountability
DAAS assures that payments are made to Medicaid eligible participants by:
* accessing Medicaid eligibility data prior to enrolling a person into IndependentChoices to assure eligibility for Medicaid and the IndependentChoices program;
* IndependentChoices program logic implemented by the Arkansas Medicaid fiscal intermediary interfaces with the Medicaid Management Information System (MMIS) to edit against creation of an allowance for any participant who is no longer Medicaid eligible or is institutionalized;
* DAAS maintains the MMIS eligibility file for IndependentChoices. The Arkansas fiscal intermediary reads the MMIS eligibility file to create claims for the IndependentChoices program. DAAS queries on a weekly basis the Medicaid data warehouse to identify persons who are deceased, entered a nursing home, or have lost Medicaid eligibility. Once identified, the IndependentChoices eligibility segment is closed by an IndependentChoices counselor on a weekly basis . Through contact with the participant or participant's family or representative this information is obtained prior to the update of the MMIS;
* DAAS also queries the Medicaid data warehouse to identify IndependentChoices participants who have had an acute hospitalization. Once identified, DAAS informs the program participant, FMS provider and the counseling entity by letter that the participant's allowance paid prospectively during the hospitalization must be returned to the Medicaid program. The day of admission and day of discharge are allowable days ;
* preventing duplication of agency and consumer-directed services by informing agency provider by fax seven days in advance the date the participant will begin directing their own personal care services.
Qualified Providers
IndependentChoices counseling and fiscal providers assist program participants in all phases of program participation. Some of the examples of the work by these providers may include but is not limited to any of the work activities below :
* enrollment of new participants;
* develop and implement participant-directed budget;
* coordinate with FMS provider and DAAS;
* orientation to IndependentChoices and the philosophy of participant direction ;
* offer skills training to the degree desired by the participant on how to recruit, interview, hire, evaluate, manage or dismiss assistants;
* parti cipant -directed counseling support services;
* monitoring IndependentChoices participants/representatives;
* monitor over and under expenditures of Cash Expenditure Plan;
* provide quarterly reports to DAAS;
* manage the individual budget on behalf of the participant;
* process payroll and support payment for other qualified services and supports;
* report and pay state and federal income taxes, FICA, Medicare, and state and federal unemployment taxes;
* verify citizenship status of workers;
* serve as the fiscal agent of the participant per IRS rules;
* issues reports to DAAS;
* communicate with counselors on budget changes;
* inform participants of their individual budget balance.
DAAS is responsible for the following activities:
* monitor the counseling and fiscal providers to ensure compliance with the spirit of participant -direction and that appropriate counseling, fiscal and programmatic procedures are maintained;
* serve as the liaison between counseling agency, fiscal provider, Medicaid Management Information System (MMIS), and the Arkansas Medicaid fiscal intermediary;
* monitor the process to reimburse the counseling agency and fiscal provider for services provided to program participants.
Quality assurance measures previously discussed, assist DAAS in discovery and remediation to assure high standards in the offering and management of the participant-directed personal care program. The IndependentChoices program establishes, as its foundation, a person-centered approach that guides not only DAAS, but counseling and fiscal providers as well.
The HCBS RN or the counselor is the catalyst for identifying potential risks. In-home visits by either party help to identify risks involved in the current home environment as well as potential risks involved with self-direction. The counselor or the HCBS RN can identify risks that may be environmental in nature such as throw rugs, uneven floors, etc. or the DMS approved assessment tool may identify potential risks such as not receiving a flu vaccine, etc. Based on the HCBS RN's observation and the DMS approved assessment tool, the HCBS RN after receiving notification from the counselor will discuss the potential risks identified with the individual. If the HCBS RN determines that a representative is needed, the RN will inform the counselor.
When the HCBS RN determines that a person is in need of a representative, the nurse will inform the counselor, and the counselor will work with the participant to determine if there is someone who knows the participant's likes, dislikes and preferences and is willing to accept the responsibilities to represent the participant in the IndependentChoices program.
The counselor is responsible for working with the participant to determine who can serve as the representative. The counselor will then work with the representative to teach, educate and work with the proposed representative so that the representative is fully aware of the responsibilities they are accepting in representing a person in a participant-directed program.
If the HCBS RN arrives and the participant is experiencing cognitive impairment and no informal supports are present, the participant will be discouraged from enrolling unless an informal support system can be identified, including someone to act as a representative decision maker. Participation in IndependentChoices requires the participant or their representative to be assertive in their role as employer and accept the risks, rights and responsibilities of directing their own care. If a representative is unavailable and the potential enrollee is incapable of performing these tasks without health and safety risks the person will not be enrolled. Blatant health and welfare concerns will not be compromised if solutions cannot be identified and enacted.
In addition to the HCBS RN's involvement there is communication with other agency providers providing home and community based services, with all parties having a vested interest in the health and welfare of the participant. This communication assists the operating agency to respond to any voiced concern with self-directed care.
The Participant Responsibilities and Agreement Form, which details all the requirements of self-direction, identifies areas where the individual may not be able to meet their responsibilities.
Every opportunity is afforded a participant to direct their own care, but the participant must accept and assume employer responsibility. Counseling support is available to help the participant, but ultimately it is the determination of the participant to succeed that determines whether participant direction will be a successful program for them. The IndependentChoices program requires a participant to make good decisions in order to assure that their personal assistance needs are met. The program allows the use of a Communications Manager for persons who have difficulty with written or oral communication. The Communications Manager acts as the voice of the participant but does not make decisions for the participant. Nor does the Communications Manager hire, train, supervise, or fire the participant's employee.
When a participant needs a representative the program allows for appointment of a Decision-Making Partner (DMP) who is willing to act and assume the employer role for the participant. The counselor is the person responsible for working with the participant or the participant's family in the appointment of either a Communications Manager or a Decision-Making Partner. Each time a DMP is appointed the enrollment requirements and process is similar to a new participant enrollment. The DMP must be at least 18 years of age and able and willing to meet the following requirements:
* Possess knowledge of the participant's preferences
* Be willing to meet and uphold all program requirements
* Be willing to sign tax form and verify timesheets,
* Show a strong personal commitment to the participant
* Visit the participant at least weekly
* Uphold all duties without influence by the personal assistant or paid back-up worker
* Obtain approval from the participant and a consensus from other family members of the participant to serve as the DMP
* Be willing to submit to a criminal background check
* Be available to discuss the program hours
Whether a participant appoints a Communications Manager or Decision-Making Partner, there are specific forms that must be completed.
If at any time DAAS learns that the participant's personal attendant is not providing the care agreed upon, the counselor will contact the participant/representative to ascertain the ability of the participant/representative to fulfill the role of employer. This discussion is to seek what types of assistance or support the participant or representative may need. A review of recurring instances of noncompliance could be reason for involuntary disenrollment.
When persons affiliated with the IndependentChoices program suspect abuse or neglect causing potential for health and safety risk to the participant by the representative, family members, personal attendant, or others, the participant will be referred to Adult Protective Services.
The service plan is a result of the assessment and will list any risks identified in the assessment and identify cautionary measures in relation to personal assistance needs with ADLs and IADLs. The service plan will identify any other risks identified through observation that were not identified through the assessment or risks identified by the participant, representative or interested parties through a participant-centered approach. The HCBS RN makes the counselor aware of these concerns requiring a plan or actions needed to mitigate the risks and who is responsible for each action. The service plan requires the signature of the participant/ representative.
HCBS RN's and counselors are trained to apply a participant-centered approach in developing all plans with the participant. Participants are always encouraged to invite friends and family members who have a personal commitment to the participant but are not acting as an employee to be present in all meetings or communications between the participant and nurse or counselor. Identified risks will be discussed with the participant/representative and interested parties to determine a plan to mitigate the risk. The counselor facilitates and guides the discussion and identifies concerns with any discussed approaches to mitigation of risk.
If the participant has been diagnosed with a mental or cognitive impairment such as mental retardation, dementia, Alzheimer's Disease, etc., the participant or family members close to the participant will be required to choose a representative in order to participate or continue to participate in IndependentChoices. If the participant is cognitively impaired and cannot fulfill the role of employer and has no family members who are knowledgeable of the participant's likes, dislikes and preferences they will no longer be able to direct their own care.
