Current through Register Vol. 49, No. 9, September, 2024
SECTION II
- PROVIDER-LED ARKANSAS SHARED SAVINGS ENTITY (PASSE) PROGRAM
200.000
DEFINITIONS
Provider-Led Arkansas Shared Savings Entity
(PASSE)
A Risk Based Provider Organization (RBPO) in Arkansas that has
enrolled in Medicaid and meets the following requirements:
A. Is 51% owned by participating providers;
and
B. Has the following Members
or Owners:
1. An Arkansas licensed or
certified direct service provider of Developmental Disabilities (DD)
services;
2. An Arkansas licensed
or certified direct service provider of Behavioral Health (BH)
services;
3. An Arkansas licensed
hospital or hospital services organizations;
4. An Arkansas licensed physician's practice;
and
5. A Pharmacist who is licensed
by the Arkansas State Board of Pharmacy.
Risk-based Provider Organization
(RBPO)
An entity that is licensed by the Insurance Commissioner under
Act 775 of 2017 and the risk-based provider organization rules.
Participating Provider
An organization or individual that is a member of or has an
ownership interest in a PASSE and delivers healthcare services to beneficiaries
attributed to a PASSE.
Direct Service
Provider
An organization or individual that delivers healthcare services
to beneficiaries attributed to a PASSE. Participating providers can be direct
service providers.
The Act
Risk-based Provider Organization
(RBPO)
Title XIX of the Social Security Act.
Enrollment
A RBPO's successful completion of all requirements to become a
Medicaid PASSE provider.
Attribution
The method by which DHS assigns a beneficiary to a
PASSE.
Transition
The movement of a beneficiary from one PASSE to another.
Abeyance
A temporary suspension of PASSE services, due to:
A. A temporary loss of Medicaid
eligibility;
B. Placement in a
setting excluded from the PASSE; or
C. Loss of contact with the beneficiary or
guardian for more than forty-five (45) days.
Closure
A determination by DHS that a beneficiary is no longer eligible
to receive PASSE services.
Medical/Quality Management
Committee
A committee developed by the PASSE to oversee Quality Assurance
of PASSE services.
Referral Network
The Direct Service Providers that join the
PASSE.
210.000
ATTRIBUTION, ENROLLMENT, TRANSITIONING AND CLOSURE
211.000 PASSE Enrollment Eligibility
To be eligible to enroll as a Provider-Led Arkansas Shared
Savings Entity (PASSE) with Arkansas Medicaid, the entity must:
A. Be licensed by the Arkansas Insurance
Department (AID) as a risk-based provider organization under Act 775 and the
risk-based provider organization regulations issued by the Insurance
Commissioner;
B. Demonstrate a
network adequate to ensure coverage of services as outlined in Section 230.000
of this manual;
C. Have the ability
to provide care coordination to attributed beneficiaries who have been
identified by the Department of Human Services (DHS) as requiring Tier II and
Tier III levels of BH and DD services beginning on October 1, 2017;
D. Sign the Provider-Led Arkansas Shared
Savings Entity (PASSE) Agreement to operate as a PASSE provider type and agree
to adhere to all requirements of this Manual and any applicable federal
regulations; and
E. Successfully
complete the Readiness Review outlined in Section 212.000 of this
manual.
212.000
Readiness Review
The PASSE must provide the following items for review and
approval by DHS:
A. Beneficiary
handbook,
B. Referral network
directory,
C. Composition of and
by-laws for the Medical/Quality Management Committee,
D. Key staff members and organizational
charts,
E. Marketing
materials,
F. Proof of 24 hour a
day 7 days a week access to care coordination,
G. Proof of hiring and training an adequate
number of care coordinators,
H.
Proof of the ability to manage and maintain Electronic Health
Records,
I. Beneficiary
notices,
J. Beneficiary rights
policies, and
K. Proof of Referral
Network adequacy according to Section 231.000.
213.000
Beneficiary
Attribution
213.100
Attribution MethodologyA. DHS will
attribute beneficiaries in a PASSE using a methodology based on the
individual's relationship with Direct Service Providers who joined that PASSE's
Referral Network. For existing Medicaid clients, DHS will examine the previous
twelve (12) months of claims history to determine specialty service providers,
primary care providers, pharmacists, and other providers used by the
individual. Then, the individual will be attributed to a PASSE according to a
methodology that will be weighted toward the individual's DD and BH specialty
providers.
B. A beneficiary will be
attributed to a PASSE based upon their "relationship score" with Direct Service
Providers. The relationship score is equal to the product of the visit points
and the specialty points, plus the cost points.
1. Visit Points - Using available databases,
DHS will determine if there is an established relationship between the
individual and providers based on whether an individual received at least one
service from a provider in any month in the previous twelve (12) month period.
Each provider that rendered a service to an individual in a month will be
recognized for that month. There are no additional points for multiple visits
within the same month. A visit must include direct contact with the individual
to deliver a reimbursable service in that month and must not be
incidental.
2. Specialty Points -
Weights will be assigned amongst provider classes to reflect the importance of
specialty providers for this population. Provider Classes will be classified as
follows:
a. Provider class 5
i. Certified Behavioral Health Provider
ii. Intermediate Care
Facilities/DD/ID
iii. Supportive
Living Provider iv. Developmental Day Treatment Clinic Services (DDTCS) and
successor programs
v. Child Health
Management Services (CHMS) and successor programs
b. Provider class 4
i. Physician - Primary Care Physician
ii. Pharmacy
iii. Federally Qualified Health Center
(FQHC)
iv. Person-Centered Medical
Home (PCMH)
c. Provider
class 3
i. Physician - non-Primary Care
Physician
ii. Nurse
Practitioners
iii. Outpatient
Clinic
iv. Inpatient Hospital
Services including psychiatric stays for adults
d. Provider class 2
i. Speech therapist
ii. Physical therapist
iii. Occupational therapist
iv. Care Coordinator who is not otherwise a
provider of direct services
e. Provider class 1
i. Durable Medical Equipment
provider
ii. Personal Care
provider
iii. Home Health
provider
3. Cost
Points - The cost of care is also an important consideration in determining the
relationship between the individual and the provider. DHS will use all
available Medicaid claims data that is fully adjudicated and refreshed on a
quarterly basis.
C. If a
single provider accounts for at least fifty percent (50%) of both visits and
spending for a beneficiary, the beneficiary will be attributed to that provider
and assigned into the PASSE that providers has joined. If there is no majority
provider, the beneficiary will be attributed to the PASSE with the highest
relationship score that is greater than thirty-five percent (35%) of the total
possible score.
D. If there is no
majority provider and no PASSE represents a total of 35% of the total possible
relationship score, then DHS will review an additional twelve (12) months of
claims data.
E. When a tie-breaker
is needed: for example when the majority provider is in more than one PASSE or
when two PASSES have an equal relationship score, or no PASSE has a
relationship score of greater than 35%, proportional assignment will be used.
That is, the first member will be assigned to PASSE A, the next to PASSE B, the
next to PASSE C, etc.
213.200
Mandatory Beneficiary
Attribution
The following beneficiaries must be attributed to a PASSE and
undergo an Independent Assessment (lA):
A. Beneficiaries identified to meet Tier II
or Tier III Level of Care as defined by DHS.
B. For beneficiaries with BH service needs:
1. Tier II - At this level of need, services
are provided in a counseling services setting but the level of need requires a
broader array of services.
2. Tier
III - Eligibility for this level of need will be identified by additional
criteria, which could lead to inpatient admission or residential
placement.
C. For
beneficiaries with Developmental Disabilities (DD) service needs:
1. Tier II - The individual meets the
institutional level of care criteria but does not currently require 24
hours-a-day of paid support and services to maintain his or her current
placement.
2. Tier III - The
individual meets the institutional level of care criteria and does require 24
hours-a-day of paid support and services to maintain his or her current
placement.
213.300
Services Excluded from
Attribution Methodology
The following services are excluded from consideration when
attributing a beneficiary to a PASSE:
A. Payment for Medicare covered services for
individuals who are eligible for Medicare and Medicaid ("dual
eligible");
B. Services covered by
private insurance and private payment;
C. Costs of transplants reimbursed by
Arkansas Medicaid;
D. Emergency
department visits reimbursed by Arkansas Medicaid; and.
E. Psychiatric Residential Treatment Units or
Center Placements reimbursed by Arkansas Medicaid.
214.000
Transitioning to another
PASSE
A beneficiary may voluntarily transition from their attributed
PASSE and choose another PASSE within ninety (90) days of initial attribution.
A beneficiary will not be permitted to change their PASSE more than once within
a twelve (12) month period, unless cause for transition, as described in
42
CFR 438.56, is met.
On the beneficiary's annual anniversary of attribution to a
PASSE, the beneficiary will have the ability to transition to a different
PASSE. If no action is taken by the beneficiary, they will remain attributed to
their current PASSE and will not be permitted to change their PASSE, unless
cause for transition, as described in
42
CFR 438.56, is met.
Cause for transition, as described in
42
CFR 438.56, is as follows:
A. The beneficiary moves out of the
state;
B. The PASSE for which the
beneficiary is attributed is sanctioned pursuant to section 152.000 of this
manual;
C. The PASSE does not,
because of moral or religious objections, cover the service the beneficiary
seeks; or
D. Other reasons,
including poor quality of care, lack of access to services covered under the
PASSE agreement, or lack of access to providers experienced in dealing with the
beneficiary's care needs.
Transition from a PASSE will be processed by DHS after receipt
of oral or written request. The effective date of an approved transition must
be no later than the first day of the second month following the month in which
the beneficiary request for transition was received. Failure by DHS to process
a timely transition request will result in an automatic approval of
request.
To request a transition, a beneficiary should contact:
Arkansas Department of Human Services, PASSE
Enrollment
Mailing Address
Little Rock, AR 72201
Phone: 501-XXX-XXXX
The PASSE cannot transition any attributed beneficiary.
DHS reserves the right to transition beneficiaries in
compliance with
42
CFR 438.56.
215.000
Closure
DHS reserves the right to close any beneficiary's PASSE service
after held in Abeyance fc (90) days.
220.000
BENEFICIARY
INFORMATION
221.000
General InformationA. The PASSE must
provide attributed beneficiaries information in a manner and format (at least
12-point font) that is easily understood and is readily accessible.
B. The PASSE must provide written materials
that are critical to obtaining services, including, at a minimum, provider
directories, beneficiary handbooks, appeal and grievance notices, and marketing
material.
C. All materials provided
by the PASSE must available in English and Spanish.
D. The PASSE must make available all
materials (or information) in alternative formats upon request, of the
beneficiary or potential beneficiary at no cost.
E. The PASSE must make available auxiliary
aids and services upon request of the potential beneficiary or beneficiary at
no cost.
F. The PASSE must notify
beneficiaries of their right to obtain information in alternative
formats.
222.000
Beneficiary Policy
The PASSE must have written policies addressing the
following:
A. The right to be treated
with respect and with due consideration for his or her dignity and
privacy.
B. The right to receive
information on available treatment options and alternatives, presented in an
appropriate format.
C. The right to
participate in decisions regarding his or her health care, including the right
to refuse treatment.
D. The right
to be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation.
E. The right to request and receive a copy of
his or her medical records, and to request that they be amended or
corrected.
F. The right to exercise
his or her rights without the PASSE treating the beneficiary
adversely.
G. The right to be
provided written notice of a change in the beneficiaries care coordination
provider within seven (7) calendar days.
H. The right to a beneficiary handbook and
referral network directory within a reasonable amount of time after
attribution.
223.000
Beneficiary Handbook
A. The PASSE must provide
each attributed beneficiary with a handbook that contains, at a minimum, the
following:
1. A description of care
coordination that includes, at a minimum, the definition contained in Section
241.000 of this Manual.
2. All
information contained in the Section 222.000 of this Manual regarding
beneficiary rights.
3. The process
of selecting and changing the beneficiary's PCP.
4. The process for filing a grievance,
including timeframes.
5. How a
beneficiary can exercise an advance directive.
6. The toll-free telephone number the
beneficiary can use to access care coordination and member support
services
B. The PASSE
must provide notice of any significant change in the information specified in
the beneficiary handbook, at least thirty (30) days before the intended
effective date of the change.
C.
The PASSE will disseminate the beneficiary handbook as follows:
1. Mail a printed copy of the information to
the mailing address on file for the beneficiary;
2. Provide the information by email after
obtaining the beneficiary's agreement to receive information by
email;
3. Post the information on
its website and advise the beneficiary in paper or electronic form that the
information is available on the Internet, including the applicable Internet
address. The PASSE must ensure that beneficiaries with disabilities who cannot
access this information online are provided auxiliary aids and services upon
request at no cost; or,
4. Provide
the information by any other method that can reasonably be expected to result
in the beneficiary receiving that information.
224.000
Marketing Materials
The PASSE may only market to potential beneficiaries through
its website or printed material distributed by DHS's choice counselors.
All marketing materials and activities must be approved by DHS
in advance of use.
230.000
NETWORK REQUIREMENTS
231.000
Referral Network
Requirements
The PASSE must have the ability to make arrangements with or
referrals to a sufficient number of Direct Service Providers enrolled as
Arkansas Medicaid providers to ensure that needed services can be furnished to
beneficiaries promptly and without compromising the quality of care.
At a minimum, the PASSE must meet the following time and
distance requirements:
A. Have the
ability to make referrals for the following providers to all attributed
beneficiaries which includes at least one (1) of the each of following provider
types within sixty (60) minutes of normal transportation time or within sixty
(60) miles, whichever is shorter, for all attributed beneficiaries:
1. Hospital
2. DD provider
3. BH provider
4. Pharmacy
5. Primary Care Physician
B. At least one (1) substance
abuse provider within one hundred and twenty (120) minutes of normal
transportation time or within one hundred twenty (120) miles, whichever is
shorter, for all attributed beneficiaries.
The PASSE may request a variance of these standards in certain
geographic areas of the state. DHS may grant a variance upon consideration of
the number of providers of that type and the rural nature of the geographic
area for which the variance is requested.
231.100
Referral Network
Directory
The PASSE must create a Referral Network Directory that, at a
minimum, does the following:
A.
Provides the following information to beneficiaries for each Direct Service
Provider that has joined its Referral Network:
1. Names, as well as any group
affiliations.
2. Street
addresses.
3. Telephone
numbers.
4. Website URLs, as
appropriate.
5. Specialties, as
appropriate.
B. Clearly
explains that the Referral Network is a list of preferred providers only, and
that the beneficiary may access services from any enrolled Medicaid provider
until January 1, 2019.
C. Updates
at least monthly, with the updates posted on the PASSE website.
240.000
CARE COORDINATION
REQUIREMENTS
241.000
Definition of Care CoordinationA. The
PASSE must provide care coordination to each of its attributed beneficiaries.
Care coordination means ensuring that specialty services are coordinated and
appropriately delivered by specialty providers (BH and DD services, as
appropriate). The PASSE must provide care coordinators who will work with the
beneficiary's providers to ensure continuity of care across all services. Act
775 of the 2017 Arkansas Regular Session defined care coordination as including
the following activities:
1. Health education
and coaching;
2. Coordination with
other healthcare providers for diagnostics, ambulatory care, and hospital
services;
3. Assistance with social
determinants of health, such as access to healthy food and exercise;
4. Promotion of activities focused on the
health of a patient and their community, including without limitation outreach,
quality improvement, and patient panel management; and
5. Coordination of Community-based management
of medication therapy
B.
The care coordinator employed by the PASSE is responsible for the total plan of
care for each beneficiary assigned to him or her. The total plan of care is all
services and plans related to the client. The total plan of care may include,
but is not limited to, the following:
1.
Behavioral Health Treatment Plan;
2. Person Centered Service Plan for Waiver
Clients;
3. Primary Care Physician
Care Plan;
4. Individualized
Education Program;
5. Individual
Treatment Plans for developmental clients in day habilitation
programs;
6. Nutrition
Plan;
7. Housing Plan;
8. Any existing Work Plan;
9. Justice system-related plan;
10. Child welfare plan; or
11. Medication Management Plan
The PASSE care coordinator is responsible for obtaining copies
of all treatment and service plans related to an individual beneficiary and
coordinating services between those plans. The goal is to prevent duplication
of services, ensure timely access to all needed services, and identify any
service gaps for the beneficiary, as well as provide any health education and
health coaching identified by those plans. The PASSE care coordinator should
also obtain the report from the beneficiaries IA.
C. The PASSE care coordinator will assume the
responsibility of providing case management under the concurrent 1915(c) Home
and Community Based Services Community and Employment Support (CES) Waiver for
attributed beneficiaries who are Waiver participants, including:
1. Coordinating and arranging all CES waiver
services and other state plan services;
2. Identifying and accessing needed medical,
social, educational and other publicly funded services (regardless of funding
source);
3. Identifying and
accessing informal community supports needed by eligible participants and their
families;
4. Monitoring and
reviewing services provided to the beneficiary to ensure all plan services are
being provided and to ensure the health and safety of the
participant;
5. Facilitating crisis
intervention;
6. Providing guidance
and support to meet generic needs;
7. Conducting appropriate needs assessments
and referral for resources;
8.
Monitoring services provided to ensure quality of care and case reviews which
focus on the participants progress in meeting goals and objectives established
on existing case plans;
9.
Providing assistance relative to obtaining waiver Medicaid eligibility and
ICF/IID level of care eligibility determinations;
10. Ensuring submission of timely (advanced)
and comprehensive behavior and assessment reports, continued plans of care,
revisions as needs change and information and documents required for ICF/IID
level of care and waiver Medicaid eligibility determinations;
11. Arranging for access to advocacy services
as requested by participant;
12.
Providing assistance upon receipt of DDS or DHS notices or denials, including
assistance with the reconsideration and appeal process.
The PASSE must comply with Conflict Free Case Management
rules.
D. The
PASSE care coordinator will also be responsible for assisting the beneficiary
with moving between service settings, for example with the move from the
residential treatment setting to community based care.
E. Care coordination services must be
available to attributed beneficiaries 24 hours a day through a hotline or
web-based application.
F. If a
beneficiary has already been assigned to or selected a PCP or PCMH, that PCP or
PCMH will be responsible for coordinating the beneficiary's medical care. If
the beneficiary does not have a PCP selected, the PASSE care coordinator must
assist the beneficiary with selecting a PCP or provide a referral to a
PCP.
G. A PASSE care coordinator
cannot have more than 50 beneficiaries on its caseload at any one
time.
H. The PASSE care coordinator
must make a monthly face-to-face contact with each beneficiary
assigned.
I. If the beneficiary is
seen in an emergency room or urgent care clinic or is admitted to an acute
inpatient psychiatric facility, the care coordinator must follow up with the
beneficiary within seven (7) days of discharge from the facility. The follow up
visit is to ensure that all discharge instructions are being followed and any
follow-up appointments have been scheduled.
J. The PASSE care coordinator will assist the
beneficiary in remaining in the most appropriate and least restrictive setting
for that beneficiary.
242.000
Care Coordinator
Qualifications
An individual must meet the following qualifications to provide
care coordination to PASSE beneficiaries:
A. Be a Registered Nurse (R.N.), a physician,
or have a bachelor's degree in a social science or health-related field;
or
Have at least one (1) year of experience working with
developmentally or intellectually disabled clients or behavioral health
clients;
AND;
C.
Successfully complete a background check, that includes a criminal background
and child and adult maltreatment registry check;
D. Successfully pass an initial drug screen
prior to providing care coordination and working directly with
clients;
E. Successfully pass an
annual drug screen to continue to be allowed to provide care coordination;
and
F. Cannot be excluded or
debarred under any state or federal law, regulation or rule or not eligible or
prohibited to enroll as a Medicaid provider.
243.000
Payments
A.
Care Coordination Payment. -
For each attributed beneficiary, the PASSE will be paid a per-member, per-month
fee for care coordination, unless Beneficiary's PASSE service is in
abeyance.
B.
Foundation
Payment. - In lieu of the care coordination fee, the PASSE will receive
a onetime foundation payment upon the beneficiary's initial attribution to the
PASSE.
1. The foundation payment is
non-transferable. It may only be paid to one PASSE for each beneficiary and
will not continue past December 31, 2018.
2. The purpose of the foundation payment is
to assist the PASSE with providing the initial care coordination contact and
services. The payment may be used to conduct initial assessments of the
beneficiary and to begin collecting the required health information from
existing providers.
250.000
METRICS, ACCOUNTABILITY,
REPORTS, AND QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT
(QAPI)
251.000
Quality Metrics
In order to continue to receive the full Care Coordination PMPM
for attributed beneficiaries, the PASSE must meet the following
standards:
A. The caseloads assigned
to each Care Coordinator must be no more than 50 beneficiaries.
1. The PASSE must provide quarterly reports
to DHS that detail the monthly caseload for each Care Coordinator
employed.
2. The target is 100% of
the Care Coordinators will have a caseload of no more than 50
beneficiaries.
B. Care
Coordinators must make monthly face-to-face contacts with beneficiaries within
their caseload assignment. After the initial in person face-to-face contact,
ongoing face-to-face contact can be accomplished utilizing video conferencing.
If a face-to-face contact is not made, the care coordinator must have
documented at least three (3) attempts to make face-to-face contact at the
beneficiary's place of residence during that month. These three attempts must
be at least 24 hours apart.
1. The PASSE must
provide quarterly reports to DHS that contain encounter data for the monthly
contacts with beneficiaries within their caseload assignment.
2. The target is that 100% of care
coordinators will make monthly face-to-face contacts with all beneficiaries
assigned to their caseload.
C. Care Coordinators must initiate contact
within 15 days of attribution to a PASSE.
1.
The PASSE must provide quarterly reports to DHS that contains data indicating
initial contact time frame with beneficiaries who are attributed to the
PASSE.
2. The target is that care
coordinators will initiate contact within 15 days in 75% of all cases assigned
to their caseload.
D.
Care Coordinators must follow-up with beneficiaries who have visited an
Emergency Room or an urgent care clinic or been discharged from an inpatient
psychiatric unit within seven (7) business days of discharge.
1. The PASSE must provide quarterly reports
to DHS indicating follow-up for these beneficiaries.
2. The target is that care coordinators will
conduct follow up within seven days in 50% of the cases where a beneficiary
goes to an Emergency Room, an urgent care clinic, or has been discharged from
an inpatient psychiatric unit.
E. Care Coordinators are responsible for
assisting the beneficiary with selecting a PCP or provide a referral to a PCP.
1. The PASSE must provide quarterly reports
to DHS indicating the number of beneficiaries that have been referred to and
have been assigned a PCP.
2. The
PASSE must provide quarterly reports to DHS on PCP appointment attendance rates
for attributed beneficiaries.
3.
The target is that care coordinators will assist beneficiaries in obtaining a
PCP in 100% of their assigned cases.
252.000
Failure to Meet Quality
Metrics
If the PASSE fails to meet 2 of the 5 quality metrics for care
coordination, DHS may take action to correct the failure or impose penalties on
the PASSE. DHS's actions may include, but are not limited to:
A. Require the PASSE submit a Corrective
Action Plan (CAP) to address proposed activities to improve adherence to
quality metrics;
B. Suspend,
withhold, recoup, or recover payments, or any combination thereof, made to the
PASSE;
C. Terminate the PASSE from
participation as a PASSE Medicaid Provider type;
D. Suspend the PASSE's participation in the
Medicaid Program;
E. Cancel or
shorten the PASSE's existing provider agreement; or
F. Impose any sanction identified in §
152.000 of the Medicaid Provider Manual.
253.000
Reporting Requirements and the
Quality Assurance Performance
Improvement (QAPI) Program
A. Pursuant to Act 775 of the 2017 Arkansas
General Session, the PASSE is responsible for reporting to DHS on a quarterly
basis, the following:
1. Care Coordination
encounter Data;
2. Unique
Identifiers of beneficiaries;
3.
Geographic and demographic information of beneficiaries; and
4. Satisfaction scores from the PASSE
administered beneficiary satisfaction survey.
B. The PASSE must also implement and carry
out a Quality Assurance and Performance Improvement (QAPI) program for care
coordination. The QAPI must include, at a minimum:
1. Collection of and reporting on the quality
metrics required by Section 251.000 of the Manual; and
2. Mechanisms to detect both underutilization
and overutilization of services.
C. All reports submitted must include an
attestation by the CEO or CFG of the PASSE (or their designee) that the
information submitted is accurate, truthful and complete.
D. The PASSE must retain all reports and data
submitted, as well as all other records regarding the provision of care
coordination for a minimum of ten (10) years from the final date of the
contract period or the date of completion of an audit, whichever is later.
254.000
DHS Review
of Outcomes
Pursuant to Act 775 of the 2017 Arkansas General Session, DHS
will utilize data submitted from the PASSE to measure the performance of the
following:
A. Delivery of
services;
B. Patient
outcomes;
C. Efficiencies achieved;
and
D. Quality measures, which
include:
1. Reduction in unnecessary hospital
emergency department utilization;
2. Adherence to prescribed medication
regimens;
3. Reduction in avoidable
hospitalizations for ambulatory-sensitive conditions; and
4. Reduction in hospital
readmissions.
260.000
GRIEVANCES, APPEAL RIGHTS,
SANCTIONS, AND THE CONSUMER ADVISORY COUNCIL
261.000
Grievances
The PASSE must have an internal grievance process to address
beneficiary concerns and complaints. This grievance process must:
A. Allow the beneficiary 45 days from the
date of the action to file the grievance;
B. Be completed and resolved within 30 days
of the filing date; and
C. Result
in written notice of the resolution being sent to the beneficiary. This notice
must include the beneficiary's right to appeal to the State.
The PASSE must submit a grievance log with their quarterly
report.
262.000
Appeal Rights
When the Division of Medical Services (DMS) denies PASSE
eligibility or takes an adverse action against a PASSE or beneficiary, the
PASSE or beneficiary may request a fair hearing to appeal the adverse
action.
To do so, the beneficiary or provider must follow the
procedures laid out in the Medicaid Provider Manual, Sections 160.000 &
190.000.
263.000
Sanctions
DHS may impose the following sanctions, as well as those listed
in Section 252.000 of this Manual:
A.
Grant beneficiaries the right to transfer without cause;
B. Suspend attribution into the
PASSE;
C. Appoint temporary
management to the PASSE; and,
D.
Impose civil penalties as allowed by state and federal law.
264.000
Consumer Advisory
Council
The PASSE must have and maintain a consumer advisory council
consisting of at least one (1) consumer of DD services, one (1) consumer of BH
services, and one (1) consumer of substance abuse treatment
services.
