Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.15-021 - State Plan Amendments #2015-004 & 2015-007; Targeted Case Management 2-15; IndependentChoices 2-15; Personal Care 3-15; ARChoices-New-15 and ARChoices Waiver

A. Be located in the state of Arkansas|

B. Be licensed as a Class A or Class B Home Health Agency or Private Care Agency by the Arkansas Department of Health or a unit of state government or be a private or public incorporated agency whose stated purpose is to provide case management to the elderly or adults with physical disabilities;

C. Be able to demonstrate one year of experience in performing case management services| (Experience must be within the past 3 years);

D. Be able to demonstrate one year of experience in working specifically with individuals in the targeted group. (Experience must be within the past 3 years);

E. Have an administrative capacity to insure quality of services in accordance with state and federal requirements;

F. Have the financial management capacity and system that provides documentation of services and costs;

G. Have the capacity to document and maintain individual case records in accordance with state and federal requirements!

H. Be able to demonstrate that the provider has current liability coverage; and

I. Employ qualified case managers who must:

A. Experience developmental delays;

B. Have diagnosed physical or mental conditions with a high probability of resulting in a developmental delay;

C. Are determined at risk of having substantial developmental delay if early intervention services are not provided;

D. Are diagnosed with a developmental disability attributable to an intellectual disability, cerebral palsy, spina bifida, Down syndrome, epilepsy, autism or any other medical condition considered to be closely related to an intellectual disability because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with an intellectual disability or requires treatment and services similar to those required for such persons; and

E. Are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.

A. Experience developmental delays|

B. Have a diagnosed physical or mental condition with a high probability of resulting in developmental delay;

C. Are determined to be at risk of having substantial developmental delay if early intervention services are not provided; and

D. Are diagnosed as having a developmental disability which is attributable to an intellectual disability, cerebral palsy, spina bifida, Down syndrome, epilepsy, autism or any other medical condition considered closely related to an intellectual disability because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with an intellectual disability or requires treatment and services similar to those required for such persons.

A. Diagnosed as having a developmental disability of an intellectual disability, cerebral palsy, spina bifida, Down syndrome, epilepsy, autism or any other condition of a person found to be closely related to an intellectual disability because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with an intellectual disability or requires treatment and services similar to those required for such persons. (Refer to Section 203.000 for more information.)

B. Not receiving DDS ACS waiver services.

A. A plan of care developed by the DAAS RN for the ARChoices in Homecare (ARChoices) Program replaces any other plan of care. The ARChoices plan of care must include all appropriate ARChoices services and certain non-waiver services appropriate for the beneficiary.

B. If services are currently provided to an ARChoices client, the provider must report these services to the DAAS RN. Before beginning or revising services to an ARChoices client, the DAAS RN must be contacted to ensure that the plan of care is revised and approved. All changes in service or client circumstances must be reported to the DAAS RN immediately. Certain services provided to an ARChoices client that are not included in the plan of care may be subject to recoupment by the Medicaid Program.

C. An ARChoices plan of care may not be revised by anyone other than the DAAS RN. All services, regardless of the funding source, must be documented by the TCM provider in the beneficiary's TCM case file. Non-Medicaid funded services, such as food stamps, housing, etc., must be included in the overall TCM assessment and on the TCM service plan. These type services that are not required on the waiver plan of care may be implemented without prior approval by the DAAS RN.

D. If a temporary situation arises based on a filled position becoming temporarily vacant and the hiring of the position is in process, a case manager may exceed the maximum of 90 active cases for no more than 60 consecutive days. The maximum number of active cases during a temporary situation, as described above, may not exceed 110 Medicaid beneficiaries. If the TCM agency temporarily stops accepting referrals, written notification must be sent to the DAAS RN with an effective date. Once referrals are being accepted again, written notification must be sent to the DAAS RN with an effective date. This will ensure all TCM agencies are fairly represented and it will avoid unnecessary referrals, which would ultimately delay services being provided to the beneficiary.

A. The assessment of an eligible beneficiary to determine the need for any medical, educational, social and other services. Specific assessment activities include:

B. An assessment may be completed between annual assessments, if the TCM deems it necessary.

C. Service plan development builds on the information collected through the assessment phase and includes ensuring the active participation of the Medicaid-eligible beneficiary or their authorized representative. The goals and actions in the care plan must address medical, social, education, and other services needed by the Medicaid-eligible beneficiary. Service plans must:

D. The assessment and the service plan may be accomplished at the same time, during the same visit, or separately.

NOTE: Annual reassessments and service plan development are allowed, in fact, encouraged. This policy does not prohibit annual reassessments and service plan development. Reassessments may be conducted any time the case manager deems it appropriate, however, when reassessments are performed more frequently than annually, justification for conducting a full reassessment, rather than a monitoring visit, must be included in the documentation contained in the case record.

TCM service plans must be renewed, at least, annually.

A. Functions and processes that include contacting service providers selected by the beneficiary and negotiation for the delivery of services identified in the service plan. Contacts with the beneficiary and/or professionals, caregivers or other parties on behalf of the beneficiary may be a part of service management.

B. For beneficiaries participating in a DAAS HCBS waiver program, the transfer of information to the DAAS RN via the AAS-9511, AAS-9510, or other communication form is not a covered service.

See Section 262.100 for the appropriate procedure code.

A. The activities and contacts may be with the Medicaid-eligible beneficiary, family members, providers or other entities.

B. They may be as frequent as necessary, within established Medicaid maximum allowable limitations, to help determine such things as:

C. Monitoring is allowed through regular contacts with service providers at least every month to verify that appropriate services are provided in a manner that is in accordance with the service plan and assuring through contacts with the beneficiary, at least monthly, that the beneficiary continues to participate in the service plan and is satisfied with services.

D. Updating includes:

E. Non-Covered Services include:

F. Examples of case monitoring and service plan updating are shown below:

This same policy applies to any service where the case management agency is the same agency providing the in-home service.

G. A TCM provider is allowed to bill a monitoring contact when the monitoring is for the purpose of verifying the services included on the POC are sufficient based on the beneficiary's current condition. This is also true when the case manager is contacted by the beneficiary.

H. All requests from case managers to increase or decrease services or change service providers will be verified by the DHS RN and justified by the DHS RN prior to any changes being made to the waiver plan of care. This applies when the beneficiary is a participant in a home and community based waiver program.

See Section 262.100 for the appropriate procedure code and modifier.

240.010 Prior Authorization (PA) Required for Beneficiaries Under 21

Prior authorization (PA) is required and must be obtained before providing targeted case management services for Medicaid eligible beneficiaries under the age of 21.

241.000 Individuals Exempt from Prior Authorization (PA)

Prior authorization (PA) is not applicable for targeted case management (TCM) services for those beneficiaries who are twenty-one (21) years of age and older, who have been diagnosed with a developmental disability, nor for beneficiaries sixty (60) years of age and older, nor beneficiaries ages 21 and older or 65 and older who are participating in the ARChoices Program.

262.100 Targeted Case Management Procedure Codes

The procedure code in this section must be billed either electronically or on paper with the proper modifier indicated. Prior authorization is required when billing for beneficiaries under age 21. There are benefit limits for TCM services for beneficiaries ages 21 and older. See Section 242.000 for prior authorization requirements and Section 220.000 for information about benefit limits.

The column labeled U21, 21+, and 60+ indicates that the procedure code or the procedure code along with a particular modifier must be used when billing for beneficiaries under age 21, for those ages 21 and older who have been diagnosed with a developmental disability, or for those ages 60 and older.

The following procedure codes and modifiers must be used to bill for targeted case management services:

*** (...) This symbol, along with text in parenthesis, indicates the Arkansas Medicaid description of the service.

A. A private care agency applying to enroll as a personal care provider must be licensed by the Arkansas Department of Health.

B. Private care agencies must hold current licensure from the Arkansas Department of Labor.

C. Private care agencies must be enrolled in the Arkansas Medicaid ARChoices Program.

D. Private care agencies must have liability insurance coverage of not less than one million dollars ($1,000,000.00) covering their employees and independent contractors while those individuals and entities are engaged in providing covered Medicaid services.

A. Personal care services are primarily based on the assessed physical dependency need for "hands-on" services with the following activities of daily living (ADL): eating, bathing, dressing, personal hygiene, toileting and ambulating. Hands-on assistance in at least one of these areas is required. This type of assistance is provided by a personal care aide based on a beneficiary's physical dependency needs (as opposed to purely housekeeping services). A plan of care is developed through the assessment process and is based on a beneficiary's dependency in at least one of the above-listed activities of daily living. While not a part of the eligibility criteria, the need for assistance with other tasks and lADLs (Instrumental Activities of Daily Living) are considered in the assessment. Both types of assistance are considered when determining the amount of overall personal care assistance authorized. Routines or lADLs include meal preparation, incidental housekeeping, laundry, medication assistance, etc. These tasks are also defined and described in this section of this provider manual.

B. The tasks the aide performs are similar to those that a nurse's aide would normally perform if the beneficiary were in a hospital or nursing facility.

C. Personal care services may be similar to or overlap some services that home health aides furnish.

D. Personal care services, as described in this manual, are furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for persons with intellectual disabilities, or institution for mental disease that are:

E. Personal care for Medicaid-eligible individuals under the age of 21 requires prior authorization. See Sections 240.000 through 246.000.

F. Only Class-A Home Health agencies, Class-B Home Health agencies and Private Care agencies may provide personal care in all State-approved locations. Residential care facilities, public schools, education service cooperatives and DDS facilities may provide personal care only within their own facilities. School districts and education service cooperatives may not provide personal care in the beneficiary's home unless the home is deemed a public school in accordance with the Arkansas Department of Education guidelines set forth in Section 213.520.

A. The Division of Medical Services (DMS), in some circumstances and for certain specified providers, requires exclusive use of form DMS-618 (View or print form DMS-618.) to satisfy particular Program documentation requirements.

B. The Division of Medical Services requires Residential Care Facility (RCF) Personal Care providers to use exclusively form DMS-618 and to comply with all rules applicable to RCFs regarding the use of form DMS-618.

C. For assessments completed on individuals participating in the IndependentChoices Program, the following applies:

For IndependentChoices participants, the DMS-618 is not required. Only the AR Path assessment will be used by the DAAS RN.

For IndependentChoices participants who are also active waiver participants in the ARChoices Program, the assessment tool used for waiver level of care determination and the waiver plan of care will suffice to support authorization for personal care services, if signed by the DAAS RN. Eligibility for personal care services is based on the same criteria as state plan personal care services. Services are effective the date of the DAAS RN's signature on the waiver assessment tool or the waiver plan of care, whichever is the latter of the two. Personal care services provided prior to that date are not eligible for Medicaid reimbursement. The waiver assessment tool and the waiver plan of care must include, at least, the information included on the DMS-618 that is utilized to support the medical necessity, eligibility and amount of personal care services provided through IndependentChoices or agency personal care services. This information is required in documentation whether or not an extension of benefits is requested. As with all required documentation, this information must be available in the participant's chart or electronic record and available for audit and Quality Management Strategy reviews.

A. Adult family home

B. Attendant care services

C. Home delivered meals

D. Personal emergency response system

E. Adult day services

F. Adult day health services

G. Respite care

H. Environmental accessibility/adaptations/adaptive equipment

ARChoices eligibility requires a determination of categorical eligibility, a determination of level of care, the development of a plan of care and a cost comparison to determine the cost-effectiveness of the plan of care. ARChoices requires notifying the beneficiary that he or she may freely choose between waiver services and institutional services.

Refer to the ARChoices provider manual for more detailed information.

A. Regular Medicaid cost sharing.

Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). They are designated in the system as "WD RegCO."

B. New cost sharing requirements.

Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as "WD NewCo".

The cost sharing amounts for the "WD NewCo" eligibles are listed in the chart below:

* Exception: Cost sharing for nursing facility services is in the form of "patient liability" which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above.

** Exception: This service is NOT covered for individuals within the Occupational, Physical and Speech Therapy Program for individuals ages 21 and older.

A. ARChoices waiver services

B. Anesthesia services, excluding outpatient pain management

C. Assessment (including the physician's assessment) in the emergency department of an acute care hospital to determine whether an emergency condition exists. The physician and facility assessment services do not require a PCP referral (if the Medicaid beneficiary is enrolled with a PCP)

D. Dental services

E. DDS Alternative Community Services (ACS) Waiver services

F. Developmental Day Treatment Clinic Services (DDTCS) core services

G. Disease control services for communicable diseases, including testing for and treating sexually transmitted diseases such as HIV/AIDS

H. Domiciliary care

I. Emergency services in an acute care hospital emergency department, including emergency physician services

J. Family Planning services

K. Gynecological care

L. Inpatient hospital admissions on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment

M. Mental health services, as follows:

N. Obstetric (antepartum, delivery and postpartum) services.

O. Nursing facility services and intermediate care facility for mentally retarded (ICF/MR) services

P. Ophthalmology services, including eye examinations, eyeglasses, and the treatment of diseases and conditions of the eye

Q. Optometry services

R. Pharmacy services

S. Physician services for inpatients in an acute care hospital. This includes:

T. Hospital non-emergency or outpatient clinic services on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment.

U. Physician visits (except consultations) in the outpatient departments of acute care hospitals:

V. Professional components of diagnostic laboratory, radiology and machine tests in the outpatient departments of acute care hospitals. Medicaid covers these services without a PCP referral only:

W. Targeted Case Management services provided by the Division of Youth Services or the Division of Children and Family Services under an inter-agency agreement with the Division of Medical Services

X. Transportation (emergency and non-emergency) to Medicaid-covered services

Y. Other services, such as sexual abuse examinations, when the Medicaid Program determines that restricting access to care would be detrimental to the patient's welfare or to program integrity, or would create unnecessary hardship.

A. Be 18 years of age or older

B. Be eligible for Medicaid, as determined by the DHS Division of County Operations, in a category that covers personal care, or be eligible for Supplemental Security Income (SSI) through the Social Security Administration, or be eligible for ARChoices and determined in need of attendant care services or personal care by the DAAS Registered Nurse (RN).

C. Be receiving personal assistance services or be medically eligible to receive personal assistance services. Personal assistance services include state plan personal care and ARChoices attendant care services.

D. Not be living in a home or property owned, operated or controlled by a provider of services unless the provider is related by blood or marriage to the participant. This includes single family homes, group homes, adult family homes, congregate settings, a living situation sponsored or staffed by an agency provider, etc.

E. Be willing to participate in IndependentChoices and understand the rights, risks and responsibilities of managing his or her own care with an allowance; or, if unable to make decisions independently, have a willing representative decision-maker who understands the rights, risks and responsibilities of managing the care of the participant with an allowance.

A. DAAS issues a seven-day notice to discontinue service to any agency personal care, ARChoices provider currently providing services to the individual.

B. The date the beneficiary's worker is able to begin providing the necessary care. It can be no earlier than the date the physician authorized the service plan for the non-waiver eligible participant, if an agency provider is not providing the personal care services.

C. The fiscal agent is in possession of all required employer and employee documents.

If the beneficiary is not a recipient of ARChoices 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:

A. The beneficiary's primary care physician or eligible nurse practitioner (as described in this manual) signature on the HCBS Level of Care Assessment Tool attests that he or she has examined the patient within the past 60 days.

B. The beneficiary has a face-to-face visit with their primary care physician or eligible nurse practitioner 60 days prior to the service plan begin date.

When the approval by Utilization Review is received, or the beneficiary needs 14.75 hours or less per week, the IndependentChoices Counselor will contact the beneficiary or Decision-Making Partner/Communications Manager to develop the cash expenditure plan. The Medicaid beneficiary as the employer and the counselor will determine when IndependentChoices services can begin, but may not commence prior to the date authorized by the physician. The beneficiary 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.

A. Personal Assistance Services including personal care and attendant care services for ARChoices beneficiaries

B. Medical related transportation not provided through the Non-Emergency Transportation (NET) Waiver

C. Prescription Medication Not Covered by Insurance, Medicaid or Medicare Part D

D. Over-the-counter Drugs

E. Adaptive Equipment (Purchase or Rental)

F. Communication Devices

G. Discretionary Cash used to purchase personal hygiene items

H. Home Modifications

I. Emergency Food and Clothing

J. Safety Devices

K. Technology (Computers)

L. Environmental Equipment

M. Emergency Pest Control

N. Emergency Housing

O. Emergency Utilities

P. Education

Q. Service Animal Purchase and Maintenance

R. Other, with approval by the Division of Aging and Adult Services

A. The hospice provider is responsible for assessing the patient's hospice-related needs and developing the hospice plan of care to meet those needs, implementing all interventions described in the plan of care, and developing and maintaining a system of communication and integration to provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. The hospice provider coordinates the hospice aide with the services furnished under the Medicaid personal care program to ensure that patients receive all the services that they require. Coordination occurs through contact with beneficiaries or in home providers.

B. The hospice aide services are not meant to be a daily service, nor 24-hour daily services, and are not expected to fulfill the caregiver role for the patient. The hospice provider can use the services furnished by the Medicaid personal care program to the extent that the hospice would routinely use the services of a hospice patient's family in implementing a patient's plan of care. The hospice provider is only responsible for the hospice aide and attendant care services necessary for the treatment of the terminal condition.

C. Medicaid payments for personal care services provided to an individual also receiving hospice services, regardless of the payment source for hospice services, must be supported by documentation in the individual's personal care medical chart or the IndependentChoices Cash Expenditure Plan. Documentation must support the policy described above in this section of the Personal Care provider manual.

Extension of benefits for personal care for beneficiaries receiving both hospice services and personal care services will be considered based on the individual beneficiary's physical dependency needs. Requests for increased personal care hours will be reviewed for medical necessity; duplication of services will be adjusted accordingly.

NOTE: Based on audit findings, it is imperative that required documentation be recorded by the hospice provider and available in the hospice record. Documentation must substantiate all services provided. It is the hospice provider's responsibility to coordinate care and assure there is no duplication of services. While hospice care and personal care services are not mutually exclusive, documentation must support the inclusion of both services and the corresponding amounts on the care plan. To avoid duplication and to support hospice care in the home that provides the amount of services required to meet the needs of the beneficiary, the amount of personal care services needed beyond the care provided by the hospice agency must meet the criteria detailed in this section. Most often, if personal care services are in place prior to hospice services starting, the amount of personal care services will be reduced to avoid any duplication. If those services are not reduced or discontinued, documentation in the hospice and personal care records must explain the need for both and be supported by the policy in this section.

201.000 Arkansas Medicaid Certification Requirements for ARChoices

HCBS Waiver Program

All ARChoices Home and Community-Based Services (HCBS) Waiver providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:

ARChoices HCBS Waiver providers must be certified by the Division of Aging and Adult Services (DAAS) as having met all Centers for Medicare and Medicaid Services (CMS) approved provider criteria for the service(s) they wish to enroll to provide.

Certification by the Division of Aging and Adult Services does not guarantee enrollment in the Medicaid program.

All providers must maintain their provider files at the Hewlett Packard Enterprise Provider Enrollment Unit by submitting current certification, licensure, all DAAS-issued certification renewals and any other renewals affecting their status as a Medicaid-eligible provider, etc.

Copies of certifications and renewals required by DAAS must be maintained by DAAS to avoid loss of provider certification. These copies must be submitted to DAAS Provider Certification. View or print the Division of Aging and Adult Services Provider Certification contact information. Payment cannot be authorized for services provided beyond the certification period.

201.100 Providers of ARChoices HCBS Waiver Services in Bordering and Non-Bordering States

An ARChoices provider must be physically located in the State of Arkansas or physically located in a bordering state and serving a trade-area city. The trade-area cities are limited to Monroe and Shreveport, Louisiana; Clarksdale and Greenville, Mississippi; Poplar Bluff and Springfield, Missouri; Poteau and Sallisaw, Oklahoma; Memphis, Tennessee; and Texarkana, Texas.

All providers must be licensed and/or certified by their states' appropriate licensing/certifying authorities. Copies of all appropriate licenses and certifications must be submitted to DAAS for certification as a potential ARChoices provider.

Arkansas Medicaid does not provide ARChoices Waiver services in non-bordering states.

201.105 Provider Assurances

A. Adult Family Homes

B. Attendant Care Services

C. Home-Delivered Meals

D. Personal Emergency Response System

E. Adult Day Services

F. Adult Day Health Services

G. Respite Care

H. Environmental Accessibility Adaptations/Adaptive Equipment

These services are designed to maintain Medicaid eligible beneficiaries at home in order to preclude or postpone institutionalization of the individual.

In accordance with 42 CFR 441.301(b) (1) (ii) ARChoices services may not be provided to inpatients of nursing facilities, hospitals or other inpatient institutions except for inpatient respite services.

A. To qualify for the ARChoices Program, a person must be age 21 through 64 and who are determined to have a physical disability through the Social Security Administration or the DHS Medical Review Team (MRT) and require an intermediate level of care in a nursing facility, or be 65 years of age or older and require an intermediate level of care in a nursing facility. Persons determined to meet the skilled level of care, as determined by the Office of Long Term Care, are not eligible for the ARChoices Program.

The beneficiary intake and assessment process for the ARChoices Program includes a determination of categorical eligibility, financial eligibility, a nursing facility level of care determination, the development of a PCSP and the beneficiary's notification of his or her choice between home and community-based services and institutional services.

B. Applicants for participation in the program (or their representatives) must make application for services at the DHS office in the county of their residence. Medicaid eligibility is determined by the DHS County Office and is based on non-functional and functional criteria. Income and resources comprise the non-functional criteria. The individual must be an individual with a functional need.

C. To be determined an individual with a functional need; an individual must meet at least one of the following three criteria, as determined by a licensed medical professional:

D. No individual who is otherwise eligible for waiver services shall have his or her eligibility denied or terminated solely as the result of a disqualifying episodic medical condition that is temporary and expected to last no more than 21 days. However, that individual shall not receive waiver services or benefits when subject to a condition or change of condition that would render the individual ineligible if the condition or change in condition is expected to last more than 21 days.

E. Beneficiaries diagnosed with a serious mental illness or intellectual disability are not eligible for the ARChoices program unless they have medical needs unrelated to the diagnosis of mental illness or intellectual disability and meet the other qualifying criteria. A diagnosis of severe mental illness or intellectual disability must not bar eligibility for beneficiaries having medical needs unrelated to the diagnosis of serious mental illness or intellectual disability when they meet the other qualifying criteria.

F. Eligibility for the ARChoices Waiver program is determined as the latter of the date of application for the program or the date the PCSP is signed by the DAAS RN and beneficiary. (If a waiting list is implemented in order to remain in compliance with the waiver application as approved by CMS, the eligibility date determination will be based on the waiting list process.)

G. The ARChoices Waiver provides for the entrance of all eligible persons on a first-come, first-served basis, once beneficiaries meet all functional and financial eligibility requirements. However, the waiver dictates a maximum number of unduplicated beneficiaries who can be served in any waiver year. Once the maximum number of unduplicated beneficiaries is projected to be reached considering the number of active cases and the number of pending applications, a waiting list will be implemented for this program and the following process will apply:

212.100 Reserved

212.200 Level of Care Determination

To be determined eligible for the ARChoices Waiver, an applicant must require a nursing facility intermediate level of care. Registered Nurses employed by the Division of Aging and Adult Services (DAAS RNs) perform a comprehensive assessment of each applicant to determine his or her personal assistance and health care needs. The assessment tool is ArPath, the electronic interRAI home care instrument, which evaluates the individual's level of care need.

The intermediate level of care determination is based on the comprehensive assessment performed by the DAAS RN, using standard criteria for functional need in evaluating an individual's need for nursing home placement in the absence of community alternatives. The level of care determination, in accordance with nursing home admission criteria, must be completed and the individual deemed eligible for an intermediate level of care by a licensed medical professional prior to receiving ARChoices services.

The DAAS RN performs a comprehensive assessment at least annually. The results of the level of care determination and the reevaluation are documented on form DHS-704, Decision for Nursing Home Placement.

Providers may submit relevant medical, social and personal information concerning beneficiaries to the DAAS RN prior to reassessments. Providers may upload information to http://www.daas.ar.gov/provrequest.htmlso that it can be received immediately by the appropriate DAAS RN. It is up to providers to submit the information in a timely manner. DAAS RNs schedule reassessments 6 to 10 weeks ahead of the expiration date. To ensure that the DAAS RN receives the information prior to the reassessments, providers need to submit the information no later than 12 weeks prior to the expiration date of the PCSP. DAAS will not provide providers with any special alerts or reminders of the expiration date. It is up to the provider to keep track of this date and submit the information in a timely manner.

NOTE: While federal guidelines require level of care reassessment at least annually, DAAS may reassess a beneficiary's level of care and/or need any time it is deemed appropriate by the DAAS RN to ensure that a beneficiary is appropriately placed in the ARChoices program and is receiving services suitable to his or her needs.

212.300 Person-Centered Service Plan (PCSP)

212.305 Targeted Case Management Services (Non-Waiver Service)

Each ARChoices PCSP will include Targeted Case Management, unless refused by the waiver beneficiary. The Targeted Case Manager is responsible for monitoring the beneficiary's status on a regular basis for changes in their service need, referring the beneficiary for reassessment, if necessary, and reporting any beneficiary complaints and changes in status to the DAAS RN or Nurse Manager immediately upon learning of the change.

NOTE: As stated in this manual, the service provider and the ARChoices beneficiary must review and follow the signed authorized PCSP. Each service included on the ARChoices PCSP must be justified by the DAAS RN. This justification is based on medical necessity, the beneficiary's physical, mental and functional status, other support services available to the beneficiary and other factors deemed appropriate by the DAAS RN.

For ARChoices beneficiaries whose waiver PCSP includes TCM at the time the DAAS RN signs the PCSP, the ARChoices PCSP, signed by a DAAS RN, will serve as the authorization for TCM services for one year from the date of the DAAS RN's signature, as described above.

212.310 Provisional Person-Centered Service Plan (PCSP)

The ARChoices registered nurse (DAAS RN) may develop a provisional PCSP prior to establishment of Medicaid eligibility, based on information obtained during the in-home functional assessment, when recommending functional approval based on the nursing home criteria. The DAAS RN must discuss the provisional PCSP policy and have the approval of the applicant prior to completing and processing the provisional PCSP. The PCSP will be developed by the applicant and the DAAS RN and signed by the applicant or the applicant's representative and the DAAS RN.

The provisional PCSP will include all current PCSP information, except for the waiver eligibility date and the Medicaid beneficiary ID number.

The provisional PCSP will be mailed to the waiver applicant and each provider included on the PCSP. If the beneficiary and the provider accept the risk of ineligibility, the provider must begin services within an established time frame as determined by the Division of Aging and Adult Services (DAAS) and notify the DAAS RN, via Start Services form AAS-9510, that services have started. The DAAS RN will track the start of care dates and give the applicant options when services are not started.

The provisional PCSP will expire 60 days from the date signed by the applicant and the DAAS RN. A PCSP that has been approved with a Medicaid number and waiver eligibility date must be in place no later than the expiration date of the provisional PCSP.

212.311 Denied Eligibility Application

NOTE: If waiver services were provided and the applicant dies prior to approval of the application, waiver eligibility will begin (if all other eligibility requirements are met) on the date waiver service(s) began and end on the date of death.

212.312 Comprehensive Person-Centered Service Plan (PCSP)

Prior to the expiration date of the provisional PCSP, the DAAS RN will send the comprehensive PCSP to the waiver beneficiary and all providers included on the PCSP. The comprehensive PCSP will replace the provisional PCSP. The comprehensive PCSP will include the Medicaid beneficiary ID number, the waiver eligibility date established according to policy and the comprehensive PCSP expiration date.

The comprehensive PCSP expiration date will be 365 days from the date of the DAAS RN's signature on form AAS-9503, the ARChoices PCSP. Once the application is either approved or denied by the DHS county office, the providers will be notified by the DAAS RN. The notification for the approval will be in writing via a PCSP that includes the waiver eligibility date and Medicaid ID number. The notification for a denial will be via a form AAS-9511 reflecting the date of denial.

212.313 ARChoices Applicants Leaving an Institution

The policy regarding retroactive eligibility applies to applicants entering the waiver program from the community and to applicants entering the program from an institution. The same process and the same policy determining the waiver eligibility date will apply to applications of each type.

212.314 Optional Participation

Neither waiver providers nor waiver applicants are required to begin or receive services prior to an eligibility determination by the Division of County Operations. When services are started based on the receipt of a provisional PCSP, it is the responsibility of each provider to explain the process and financial liability to the applicant and/or representative prior to beginning services. The decision to begin services prior to an eligibility determination must be a joint decision between the provider and the applicant, both of whom must understand the financial liability of the applicant if eligibility is not established.

212.320 Authorization Of The ARChoices Person-Centered Service Plan

(PCSP) with Personal Care Services

The following applies to individuals receiving both personal care services and ARChoices services.

NOTE: For ARChoices participants who have chosen to receive their personal care services through the IndependentChoices Program, the ARChoices PCSP, signed by a DAAS RN, will serve as the authorization for personal care services for one year from the date of the DAAS RN's signature, as described above.

212.322 Revisions when the Person-Centered Service Plan (PCSP) Contains Personal Care Services

Requested changes to the personal care services included on the ARChoices PCSP may originate with the personal care RN or the DAAS RN, based on the recipient's circumstances. Unless requested by an IndependentChoices beneficiary, the individual or agency requesting revisions to the Personal Care services on the ARChoices PCSP is responsible for securing any required signatures authorizing the change prior to the ARChoices PCSP being revised. The DAAS RN will obtain electronic signatures for dates of service on or after January 1, 2013.

If revised by the DAAS RN, a copy of the revised ARChoices PCSP and a Start of Care Form (AAS-9510) will be mailed to the personal care provider within 10 working days after being revised. If authorization is secured by the Personal Care agency, a copy of the revised personal care order, signed by the physician, must be sent to the DAAS RN prior to implementing any revisions. Once received, the ARChoices PCSP will be revised accordingly within 10 days of its receipt. If any problems are encountered with implementing the requested revisions, the DAAS RN will contact the personal care provider to discuss possible alternatives. These discussions and the final decision regarding the requested revisions must be documented in the nurse narrative. The final decision rests with the DAAS RN.

212.323 Medicaid Audit Requirements

When the Medicaid Program, as authorized by the ARChoices PCSP, reimburses for personal care services, all Medicaid audits will be performed based on that authorization. Therefore, all documentation by the personal care provider must tie services rendered to authorized services as reflected on the ARChoices PCSP.

212.324 Personal Care/Hospice Policy Clarification

Medicaid beneficiaries are allowed to receive Medicaid personal care services, in addition to hospice aide services, if the personal care services are unrelated to the terminal condition or the hospice provider is using the personal care services to supplement the hospice aide and homemaker services.

212.400 Temporary Absences from the Home

Once an ARChoices eligibility application has been approved, waiver services must be provided in a home and community-based services setting for eligibility to continue. Unless stated otherwise below, the county Department of Human Services (DHS) office must be notified immediately by the DAAS RN when waiver services are discontinued and action will be initiated by the DHS county office to close the waiver case. Providers will be notified by the DAAS RN.

212.500 Reporting Changes in Beneficiary's Status

Because the provider has more frequent contact with the beneficiary, many times the provider becomes aware of changes in the beneficiary's status sooner than the DAAS RN, Case Manager, or DHS county office. It is the provider's responsibility to report these changes immediately so proper action may be taken. Providers must complete the Waiver Provider Communication - Change of Participant Status Form (AAS-9511) and send it to the DAAS RN. A copy must be retained in the provider's beneficiary case record. Regardless of whether the change may result in action by the DHS county office, providers must immediately report all changes in the beneficiary's status to the DAAS RN.

The Case Manager is responsible for monitoring the beneficiary's status on a regular basis for changes in service need, referring the beneficiary for reassessment if necessary and reporting any beneficiary complaints and changes in status to the DAAS RN, or DAAS RN Supervisor immediately upon learning of the change.

212.600 Relatives Providing ARChoices Services

All ARChoices services, except for Adult Family Homes, may be provided by a beneficiary's relative, unless stated otherwise in this manual. No Adult Family Home provider, employee or family member of the provider may be related to the Adult Family Home waiver beneficiary.

For the purposes of this section, a relative or family member shall be defined as all persons related to the beneficiary by virtue of blood, marriage, or adoption. The following is applicable for all waiver services:

Under no circumstances may Medicaid payment be made for any waiver service rendered by the waiver beneficiary's:

213.100 Adult Family Homes

Adult Family Homes services are personal care and supportive services (e.g., attendant care, transportation and medication oversight (to the extent permitted under State Law)), provided in a certified private home by a principal care provider who lives in the home.

Payment for Adult Family Home services is not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. Payment for Adult Family Home services does not include payments made, directly or indirectly, to members of the beneficiary's immediate family.

Adult Family Home services provide a family living environment for adults who are functionally impaired and who, due to the severity of their functional impairments, are considered to be at imminent risk of death or serious bodily harm and, as a consequence, are not capable of fully independent living.

The number of beneficiaries served by an Adult Family Home may not exceed three (3) and beneficiaries must be unrelated to the adult family home provider. "Unrelated" is defined as any person who is not related to the provider by virtue of blood, marriage, or adoption. Other than the Adult Family Home provider, immediate family members or caregivers residing in the adult family home with the waiver beneficiary are prohibited from receiving Medicaid reimbursement for direct provision of any ARChoices services.

Adult Family Home services shall be included in the PCSP only when it is necessary to prevent the permanent institutionalization of a beneficiary as determined by the DAAS RN. The Adult Family Home provider is responsible for meeting the needs of the waiver beneficiary, as defined by this waiver service description, 24 hours/day, 7 days/week.

Adult Family Homes add a dimension of family living to the provision of supportive services and personal care services such as:

213.110 Adult Family Homes Certification Requirements

Enrollment as an ARChoices Adult Family Homes provider requires certification by the Department of Human Services, Division of Aging and Adult Services (DAAS), as an Adult

Family Home. Adult Family Homes providers must complete an application packet, including Medicaid Provider forms; be tested over designated training materials and achieve a passing score and submit the home for inspection by designated DAAS staff. If substitute caregivers are identified, these beneficiaries must meet the same training and testing requirements as the Adult Family Homes provider. In addition, drug screens and background checks are required for the provider, substitute care givers and provider family members residing in the home and who are over the age of sixteen. Providers must recertify with DAAS annually. This requires submission of a renewal application packet and home inspection, as well as documentation of at least twelve hours of related training activities.

An Adult Family Home, for the purpose of the ARChoices Program, does not include any house, institution, hotel or other similar living situation that supplies room and board only, room only, or board only.

As a condition of certification, each Adult Family Homes provider shall execute with and provide to each beneficiary an admission agreement specifying services to be provided, the beneficiary's cost for room and board, conditions and rules governing the beneficiary and grounds for termination of residency. Each Adult Family Homes provider will also be required to develop and maintain written program policies. Program policies must include and comply with the HCBS Settings rules found in section 201.000.

NOTE: The Adult Family Home provider's ElderChoices certification will be valid as an ARChoices Adult Family Home provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.

NOTE: At the next annual certification, the Adult Family Home provider must have policies in place that include and comply with the HCBS Settings rules found in section 201.000.

213.210 Attendant Care Services

Attendant Care services are designed to reduce or prevent inappropriate institutionalization by maintaining, strengthening or restoring an eligible beneficiary's functioning in his or her own home or elsewhere in the community where the beneficiary engages in activities, including work-related activities.

Attendant care services consists of assistance with activities of daily living (ADLs), instrumental activities of daily living (lADLs) and health-related tasks through hands-on assistance, supervision and/ or cueing.

Hands-on assistance, supervision and/or cueing are defined as:

Activities of daily living include:

Instrumental activities of daily living include:

213.230 Attendant Care Services Certification Requirements

The following requirements must be met prior to certification by the Division of Aging and Adult Services (DAAS) by providers of attendant care services. The provider must:

213.240 Environmental Accessibility Adaptations/Adaptive Equipment

Environmental Accessibility Adaptations/Adaptive Equipment services enable the individual to increase, maintain and/or improve his or her functional capacity to perform daily life tasks that would not be possible otherwise. Environmental Accessibility Adaptations/Adaptive Equipment is physical adaptations to the home that are necessary to ensure the health, welfare and safety of the beneficiary, to function with greater independence in the home and preclude or postpone institutionalization. Adaptive equipment also enables the Alternatives beneficiary to increase, maintain and/or improve his/her functional capacity to perform daily life tasks that would not be possible otherwise and perceive, control or communicate with the environment in which he or she lives.

Excluded are adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, air conditioning and others. Adaptations which add to the total square footage of the home are excluded from this benefit. All services must be in accordance with applicable state or local building codes. All dwellings that receive adaptations must be in good repair and have the appearance of sound structure.

Permanent fixtures are not allowed on rented or leased properties.

213.250 Benefit Limit - Environmental Accessibility Adaptations/Adaptive

213.260 Examples of Acceptable Environmental Accessibility

Adaptations/Adaptive Equipment

Acceptable environmental accessibility adaptations/adaptive equipment must be necessary for the welfare of the beneficiary and may include, but are not limited to:

213.270 Examples of Unacceptable Environmental Accessibility

Adaptations/Adaptive Equipment

Unacceptable environmental accessibility adaptations/adaptive equipment to the home include, but are not limited to:

213.280 Provider Qualifications Environmental Accessibility Adaptations/Adaptive Equipment

Individuals or businesses seeking certification by the Division of Aging and Adult Services and enrollment as Medicaid providers of environmental accessibility adaptations/adaptive equipment services must meet the following criteria:

NOTE: All environmental modifications requiring electrical or plumbing work must be completed by a licensed professional. If a contractor subcontracts with an electrician or plumber, the contractor must submit a copy of the subcontractor's license with the claim form.

213.290 Environmental Modifications/Adaptive Equipment

Prior to payment for this service, the waiver beneficiary is required to secure 3 separate itemized bids for the same service. The bids are reviewed by the DAAS RN or designee prior to submission for Medicaid payment. If only two bids can be secured due to a shortage of qualified providers in the service area, documentation attesting to the attempt to secure bids and the shortage of providers must be provided.

Each claim must be signed by the provider, the waiver beneficiary and DAAS RN, or designee. A statement of satisfaction form must be signed by the waiver beneficiary prior to any claim being submitted.

Note: The Environmental Modification provider's AAPD certification will be valid as an ARChoices Environmental Modification provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under AAPD.

213.310 Hot Home-Delivered Meals

Hot Home-Delivered Meals provide one meal per day with a nutritional content equal to 33 1/3 percent of the Dietary Reference Intakes established by the Food and Nutrition Board of the National Academy of Sciences. The meals must comply with the Dietary Guidelines for Americans and with the DAAS Nutrition Services Program Policy Number 206.

Hot Home-Delivered Meal services provide one daily nutritious meal to eligible beneficiaries who are homebound. Homebound is defined as a person with normal inability to leave home without assistance (physical or mental) from another person; a person who is frail, homebound by reason of illness or incapacitating disability or otherwise isolated; or for whom leaving home requires considerable and taxing effort by the individual and absences from the home are infrequent, relatively short in duration or are attributable to the need to receive medical treatment.

Additionally, the beneficiary must:

213.311 Hot Home-Delivered Meal Provider Certification Requirements

To be certified by the Division of Aging and Adult Services (DAAS) as a provider of Hot Home-Delivered Meal services, a provider must:

NOTE: This requirement DOES NOT apply to those ARChoices beneficiaries whose ARChoices PCSP includes attendant care services or personal care services at least three (3) times per week.

Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.

Hot Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.

NOTE: The Home-Delivered Meals provider's ElderChoices certification will be valid as an ARChoices Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.

213.320 Frozen Home-Delivered Meals

Frozen Home-Delivered Meals service provides one meal per day with a nutritional content equal to 33 1/3 percent of the Dietary Reference Intakes established by the Food and Nutrition Board of the National Academy of Sciences. The meals must comply with the Dietary Guidelines for Americans and with DAAS Nutrition Services Program Policy Number 206.

The goal of the Frozen Home-Delivered Meals service is to supplement, not replace, the Hot Home-Delivered Meal service by providing one daily nutritious meal to homebound persons at risk of being institutionalized who:

NOTE: While the individual has freedom of choice regarding this service, it is the responsibility of the DAAS RN developing the PCSP to ensure the appropriateness of the service. A hot meal delivered daily remains the food service of choice, when available. Therefore, a frozen meal must be approved by the DAAS RN. The service must be included on the PCSP. If the individual responsible for developing the PCSP does not think the frozen meals are appropriate for the individual, other options will be considered. Those options include removing the Home-Delivered Meal service rather than authorizing a frozen meal.

It is the certified provider's responsibility to deliver the meals regardless if they are hot or frozen. Meals may not be left on the doorstep. The meals cannot be mailed to the individual via United States Postal Service or delivered by paid carrier such as Fed Ex or UPS.

213.321 Beneficiary Requirements for Frozen Home-Delivered Meals

The beneficiary must:

213.322 Reserved

213.323 Frozen Home-Delivered Meal Provider Certification Requirements

In order to become approved providers of frozen meals, providers must meet all applicable requirements of DAAS Nutrition Services Program Policy Number 206.

To be certified by DAAS as a provider of Home-Delivered Meal services, a meal provider must:

NOTE: The milk must be delivered to the beneficiary at least seven (7) days prior to its expiration date.

NOTE: Changes in service delivery must receive prior approval by the DAAS RN who is responsible for the individual's PCSP. Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.

213.330 Limitations on Home-Delivered Meals

One unit of service equals one meal. The maximum number of Home-Delivered Meals eligible for Medicaid reimbursement per month equals 31 meals. This includes hot, frozen or a combination of the two. There is no separate benefit limit for frozen meals.

The maximum number of emergency meals per SFY is four (4).

Frozen Home-Delivered Meals may be provided daily to eligible beneficiaries. A maximum of seven (7) meals may be delivered at one time.

Home-Delivered Meal providers may deliver more than seven meals at one time, if:

Home-Delivered Meal providers delivering frozen meals may deliver 14 at one time if the DAAS RN enters 14 meals delivery approved in the comments section of the HDM entry on the PCSP. If this statement is not on the PCSP, or if any of the other factors above are not in place, the meal providers cannot deliver more than seven (7) meals at one time.

An ARChoices individual may not be provided with a Hot or Frozen Home-Delivered Meal on any day during which the individual receives more than five (5) hours of in-home or facility-based Respite care or more than five (5) hours of Adult Day Services or Adult Day Health Services. (Licensure mandates that providers of these services provide a meal or meals; therefore, a Home-Delivered Meal on these dates is a duplicative service and prohibited under waiver guidelines.)

NOTE: Medicaid reimbursement for Home-Delivered Meals is not allowed on the same day to beneficiaries who are also attending Adult Day Services, Adult Day Health Services, or facility-based Respite care for more than five (5) hours. When applying this policy, the time of day the beneficiary receives day services or respite services is also a factor. Whether there is duplication of services will be determined by comparing the time of day during which services occur.

When considering whether a Home-Delivered Meal is billable for an individual receiving Adult Day Services, Adult Day Health Services or facility-based Respite services, on a specific date of service, the following must be applied:

If an ARChoices beneficiary is receiving Adult Day Services, Adult Day Health Services or facility-based Respite at any time between the hours of 11:00 a.m. and 1:30 p.m. and the noon meal is routinely served to others at the facility during this timeframe, the noon meal must also be served to this individual. A Home-Delivered meal is not allowable on the same date of service. This is true regardless of the total number of Adult Day Services, Adult Day Health Services, or Respite hours provided.

213.340 Combination of Hot and Frozen Home-Delivered Meals

In instances where the ARChoices beneficiary wishes to receive a combination of hot and frozen meals, the DAAS RN shall evaluate the beneficiary's situation based on the criteria set forth in Section 213.320, Frozen Home-Delivered Meals. If the criteria are met, the DAAS RN may prescribe on the PCSP a combination of hot and frozen meals to be delivered.

213.350 Emergency Meals

Beneficiaries may receive up to four (4) emergency meals per state fiscal year. The meals must:

213.400 Personal Emergency Response System

The Personal Emergency Response System (PERS) is an in-home, 24-hour electric support system with two-way verbal and electronic communication with an emergency control center. PERS enables an elderly, infirm or homebound individual to secure immediate help in the event of a physical, emotional or environmental emergency.

PERS is specifically designed for high-risk beneficiaries whose needs have been carefully determined based on their level of medical vulnerability, functional impairment and social isolation. PERS is not intended to be a universal benefit. The DAAS RN must verify that the individual is capable, both physically and mentally, of operating the PERS unit.

PERS must be included in the beneficiary's written ARChoices PCSP.

PERS providers must contact each beneficiary at least once per month to test the system's operation. The provider shall maintain a log of test calls that includes the date and time of the test, specific test results, corrective actions and outcomes.

A log of all beneficiary calls received must be maintained by the emergency response center. The log must reflect the date, time and nature of the call and the response initiated by the center. All calls must be documented in the beneficiary's record. See Section 214.000 for other documentation requirements.

One (1) unit of service equals one (1) day. PERS is limited to a maximum of thirty-one (31) units per month.

The installation of PERS will be allowed once per lifetime or period of eligibility. Claims submitted for the installation of PERS should use procedure code S5160. Procedure code S5160 may be billed for ARChoices beneficiaries who are accessing PERS services for their first time or for the current period of re-eligibility for ARChoices Waiver Services. In the event of extenuating circumstances that result in the need for reinstallation, the provider may contact the Division of Aging and Adult Services for extension of the benefit.

View or print Division of Aging and Adult Services contact information.

213.410 Personal Emergency Response System Certification Requirements

To be certified by the Division of Aging and Adult Services (DAAS) as a provider of personal emergency response services, a provider must:

213.500 Adult Day Services

Adult day services facilities are licensed by the Office of Long-Term Care (OLTC) to provide care and supervision to meet the needs of four (4) or more functionally impaired adults for periods of less than 24 hours but more than two (2) hours per day, in a place other than the beneficiaries' own homes.

When provided according to the beneficiary's written ARChoices PCSP, ARChoices beneficiaries may receive adult day services for two (2) or more hours per day (8 units), not to exceed ten (10) hours per day (40 units), when the services are prescribed by the beneficiary's attending physician and provided according to the beneficiary's written PCSP. Adult day services of less than two (2) hours per day (8 units) are not reimbursable by Medicaid. Adult day services may be utilized up to fifty (50) hours per week (200 units), not to exceed two hundred thirty (230) hours per month (920 units). One (1) unit of service equals 15 minutes.

As required, beneficiaries who are present in the facility for more than five (5) hours a day (20 units, procedure code S5100) must be served a nutritious meal that equals one-third of the Recommended Daily Allowance. Therefore, ARChoices beneficiaries are not eligible to receive a home-delivered meal on the same day they receive more than five (5) hours (20 units) of adult day services. Additionally, beneficiaries who attend an adult day service for more than five (5) hours (20 units) are not eligible to receive attendant care services on the same date of service unless authorized by the DAAS RN.

213.510 Adult Day Services Certification Requirements

To be certified by the Division of Aging and Adult Services (DAAS) as a provider of adult day services in Arkansas, a provider must be a person, corporation, partnership, association or organization licensed by the Arkansas Department of Human Services, Office of Long-Term Care as a long-term adult day care facility. Providers in the designated trade area cities in states that border Arkansas must be licensed and/or certified by the appropriate state agency as an Adult Day Care Facility.

In order to be certified by DAAS, Adult Day Services providers must meet the HCBS Settings rules found in section 201.000.

Adult Day Services providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Adult Day Care license at all times.

In order to be recertified by DAAS, Adult Day Services providers must meet the HCBS Settings rules found in section 201.000.

Providers are required to submit copy of renewed license to DAAS.

213.600 Adult Day Health Services (ADHS)

Adult day health services facilities are licensed to provide a continuing, organized program of rehabilitative, therapeutic and supportive health services, social services and activities to beneficiaries who are functionally impaired and who, due to the severity of their functional impairment, are not capable of fully independent living.

Adult day health services programs provide rehabilitative and health services directed toward meeting the health restoration and maintenance needs of the beneficiary that cannot be provided by adult day care programs. Adult day health services are appropriate only for beneficiaries whose facility-developed care plans specify one or more of the following health services:

213.610 Adult Day Health Services (ADHS) Provider Certification Requirements

To be certified by the Division of Aging and Adult Services (DAAS) as a provider of adult day health services in Arkansas, a provider must be a person, corporation, partnership, association or organization licensed by Arkansas Department of Human Services, Office of Long-term Care as a long-term adult day health care facility. Providers in the designated trade area cities in states that border Arkansas must be licensed and/or certified by the appropriate state agency as an Adult Day Health Care Facility.

In order to be certified by DAAS, Adult Day Health Services providers must meet the HCBS Settings rules found in section 201.000.

Adult Day Health Services providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Adult Day Health Care license at all times. In order to be recertified, Adult Day Health Services providers must meet the HCBS Settings rules found in section 201.000.

Providers are required to submit copy of renewed license to DAAS.

NOTE: Adult day services and adult day health services are not allowed on the same date of service.

NOTE: The Adult Day Health Services ElderChoices provider's certification will be valid as an ARChoices Adult Day Health Services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.

213.700 Respite Care

Respite care services provide temporary relief to persons providing long-term care for beneficiaries in their homes. Respite care may be provided outside of the beneficiary's home to meet an emergency need or to schedule relief periods in accordance with the regular caregiver's need for temporary relief from continuous care giving. If there is no primary caregiver, respite care services will not be deemed appropriate and subsequently will not be prescribed by the beneficiary's physician.

In the event the in-home medical assessment performed by the DAAS RN substantiates a need for respite care services, the service will be prescribed as needed, via the beneficiary's PCSP, not to exceed an hourly maximum. The DAAS RN will establish the service limitation based on the beneficiary's medical need, other services included on the PCSP and support services available to the beneficiary. Respite care services must be provided according to the beneficiary's written PCSP.

An individual living in the home with the beneficiary is prohibited from serving as a Respite Services provider for the beneficiary.

213.710 In-Home Respite Care

In-home respite care may be provided by licensed personal care or home health agencies. Reimbursement will be made for direct care rendered according to the beneficiary's PCSP by trained respite workers employed and supervised by certified in-home respite providers.

Providers rendering respite care services in the beneficiary's home must bill procedure code S5150. One (1) unit of service for procedure code S5150 equals 15 minutes.

Eligible beneficiaries may receive up to 24 hours (96 units) of in-home respite care per date of service. For the state fiscal year (SFY), July 1 through June 30 each year, eligible beneficiaries may receive up to 1200 hours (4800 units) of In-Home Respite Care, or Facility-Based Respite Care or a combination of the two services.

When respite care is provided, the provision of or payment for other duplicate services under the waiver is prohibited. When a respite care provider is in the home to provide respite care services, the provider is responsible for all other in-home ARChoices services included on the beneficiary's PCSP. For example, if attendant care services and/or home-delivered meals are included on the PCSP, the respite provider must provide these services while in the home. No other ARChoices service, other than PERS, may be reimbursed for the same time period.

213.711 Facility-Based Respite Care

Facility-based respite care may be provided outside the beneficiary's home on a short- or long-term basis by certified adult family homes, residential care facilities, nursing facilities, adult day care facilities, adult day health care facilities, Level I and Level II Assisted Living Facilities and hospitals.

Facility-based providers rendering services for eight (8) hours or less per date of service must bill S5135 for short-term, facility-based respite care. One (1) unit of service for procedure code S5135 equals 15 minutes. Eligible beneficiaries may receive up to 8 hours (32 units) of short-term, facility-based respite care per date of service.

Facility-based providers rendering services for more than 8 hours/day must bill T1005 for long-term, facility-based respite care. One (1) unit of service for procedure code T1005 equals 15 minutes. A beneficiary may receive up to 24 hours (96 units) of service per date of service if the provider bills procedure code T1005.

Facility-based respite care services include short-term and long-term respite care services and can include any combination of billing codes S5135 or T1005. A single provider may provide both long-term and short-term facility-based respite care services for a particular beneficiary.

Eligible beneficiaries may receive up to 1200 hours (4800 units) per SFY of Facility-Based Respite Care- or In-Home Respite Care, or a combination of the two. Adult Family Home beneficiaries are limited to 600 hours (2400 units) of long-term facility-based respite per state fiscal year.

Beneficiaries receiving long-term, facility-based respite care services may receive only ARChoices PERS services concurrently.

Please refer to the NOTE found in Section 213.500 regarding Home-Delivered Meals and facility-based respite services.

213.712 In-Home Respite Care Certification Requirements

To be certified by the Division of Aging and Adult Services (DAAS) as a provider of in-home respite care services, a provider must:

213.713 Facility-Based Respite Care Certification Requirements

To be certified by the Division of Aging and Adult Services as a provider of facility-based respite care services, a provider must be licensed in their state as one or more of the following:

A. A copy of the beneficiary's PCSP

B. A brief description of the specific service(s) provided

C. The signature and title of the individual rendering the service(s)

D. The date and actual time the service(s) was rendered

A provider's failure to maintain sufficient documentation to support his or her billing practices may result in recoupment of Medicaid payment.

No documentation for ARChoices services, as with all Medicaid services, may be made in pencil.

A. Person Centered Service Plan - AAS-9503

B. Start Services - AAS-9510

C. Beneficiary Change of Status - AAS-9511

Providers may request form AAS-9511 by writing to the Division of Aging and Adult Services. View or print the Division of Aging and Adult Services contact information.

Forms AAS-9503 and AAS-9510 will be mailed to the provider by the DAAS RN.

Instructions for completion and retention are included with each form. If there are questions regarding any ARChoices form, providers may contact the DAAS RN in your area.

251.000 Method of Reimbursement

The reimbursement rates for ARChoices services will be according to the lesser of the billed amount or the Title XIX (Medicaid) maximum for each procedure.

251.010 Fee Schedules

Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://www.medicaid.state.ar.usunder the provider manual section. The fees represent the fee-for-service reimbursement methodology.

Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.

Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.

252.000 Rate Appeal Process

A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.

If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff who will serve as chairman.

The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.

261.000 Introduction to Billing

ARChoices providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.

Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.

262.000 CMS-1500 Billing Procedures

262.100 HCPCS Procedure Codes

The following procedure codes must be billed for ARChoices Services. Electronic and paper claims now require the same National Place of Service code.

262.210 Place of Service Codes

262.300 Billing Instructions - Paper Only

Hewlett Packard Enterprise offers providers several options for electronic billing. Therefore, claims submitted on paper are lower priority and are paid once a month. The only claims exempt from this rule are those that require attachments or manual pricing.

262.310 Completion of CMS-1500 Claim Form

262.400 Special Billing Procedures

Not applicable to this program.

Application for a §1915(c) Home and Community-Based

Services Waiver

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