Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.18-019 - Provider-Led Arkansas Shared Savings Entity (PASSE) Program
Current through Register Vol. 49, No. 9, September, 2024
1915(i) State plan Home and Community-Based Services Administration and Operation
The state implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit
for elderly and disabled individuals as set forth below.
1. Services. (Specify the state's service title(s) for the HCBS defined under "Services " and listed in Attachment 4.19-B):
Supported Employment; Behavior Assistance; Adult Rehabilitation Day Treatment; Peer Support; Family Support Partners; Residential Community Reintegration; Respite; Mobile Crisis Intervention; Therapeutic Host Home; Recovery Support Partners (for Substance Abuse); Substance Abuse Detox (Observational); Pharmaceutical Counseling; Supportive Life Skills Development, Child and Youth Support; Partial Hospitalization, Supportive Housing; and Therapeutic Communities.
2. Concurrent Operation with Other Programs. (Indicate whether this benefit will operate concurrently with another Medicaid authority):
3. State Medicaid Agency (SMA) Line of Authority for Operating the State plan HCBS. Benefit-(Select one):
4. Distribution of State plan HCBS Operational and Administrative Functions.
[TICK] (By checking this box the state assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid Agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid Agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid Agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specify the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies):
(Check all agencies and/or entities that perform each function):
(Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function):
The PASSEs will assist with 4, 5, 6, and 8.
The contracted actuary will assist with 8.
The External Quality Review Organization (EQRO) that contracts with DMS will assist with 3,5, and 10.
(By checking the following boxes the State assures that):
5. [TICK] Conflict of Interest Standards. The state assures the independence of persons performing evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum, that persons performing these functions are not:
* related by blood or marriage to the individual, or any paid caregiver of the individual
* financially responsible for the individual
* empowered to make financial or health-related decisions on behalf of the individual
* providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the state, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. (If the state chooses this option, specify the conflict of interest protections the state will implement):
6. [TICK] Fair Hearings and Appeals. The state assures that individuals have opportunities for fair hearings and appeals in accordance with 42 CFR 431 Subpart E.
7. [TICK] No FFP for Room and Board. The state has methodology to prevent claims for Federal financial participation for room and board in State plan HCBS.
8. [TICK] Non-duplication of services. State plan HCBS will not be provided to an individual at the same time as another service that is the same in nature and scope regardless of source, including Federal, state, local, and private entities. For habilitation services, the state includes within the record of each individual an explanation that these services do not include special education and related services defined in the Individuals with Disabilities Education Improvement Act of 2004 that otherwise are available to the individual through a local education agency, or vocational rehabilitation services that otherwise are available to the individual through a program funded under §110 of the Rehabilitation Act of 1973.
Number Served
1. Projected Number of Unduplicated Individuals To Be Served Annually.
(Specify for year one. Years 2-5 optional):
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Annual Period |
From |
To |
Projected Number of Participants |
|
Year 1 |
Mar. 1,2019 |
Feb.29,2020 |
30,000 |
|
Year 2 |
Mar. 1, 2020 |
Feb. 28,2021 |
|
|
Year 3 |
Mar. 1,2021 |
Feb.28, 2022 |
|
|
Year 4 |
Mar. 1, 2022 |
Feb.28,2023 |
|
|
Year 5 |
Mar. 1, 2023 |
Feb.28,2024 |
2. [TICK] Annual Reporting. (By checking this box the state agrees to): annually report the actual number of unduplicated individuals served and the estimated number of individuals for the following year.
Financial Eligibility
1. [TICK] Medicaid Eligible. (By checking this box the state assures that): Individuals receiving State plan HCBS are included in an eligibility group that is covered under the State's Medicaid Plan and have income that does not exceed 150% of the Federal Poverty Line (FPL). (This election does not include the optional categorically needy eligibility group specified at §1902(a)(10)(A)(ii)(XXII) of the Social Security Act. States that want to adopt the § 1902(a)(10)(A)(ii)(XXII) eligibility category make the election in Attachment 2.2-A of the state Medicaid plan.)
1. Responsibility for Performing Evaluations / Reevaluations. Eligibility for the State plan HCBS benefit must be determined through an independent evaluation of each individual). Independent evaluations/reevaluations to determine whether applicants are eligible for the State plan HCBS benefit are performed {Select one):
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Directly by the Medicaid agency |
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X |
By Other {specify State agency or entity under contract with the State Medicaid agency): Evaluations and re-evaluations are conducted by DHS's third-party contractor who completes the independent assessment. Eligibility is determined by DMS using the results of the independent assessment and the individual's diagnoses. i.. |
2. Qualifications of Individuals Performing Evaluation/Reevaluation. The independent evaluation is performed by an agent that is independent and qualified. There are qualifications (that are reasonably related to performing evaluations) for the individual responsible for evaluation/reevaluation of needs-based eligibility for State plan HCBS. (Specify qualifications):
The assessor must have a Bachelor's Degree or be a registered nurse with one (1) year of experience with mental health populations.
3. Process for Performing Evaluation/Reevaluation. Describe the process for evaluating whether individuals meet the needs-based State plan HCBS eligibility criteria and any instrument(s) used to make this determination. If the reevaluation process differs from the evaluation process, describe the differences:
Individuals are referred for the independent assessment based upon their current diagnosis and utilization of services. Measurement is completed through an assessment of functional deficit through a face-to-face evaluation of the beneficiary, caregiver report and clinical record review. The assessment measures the beneficiary's behavior in psychosocial sub-domains and intervention domain that evaluates the level of intervention necessary to managed behaviors as well as required supports to maintain beneficiary in home and community settings. After completion of the independent assessment of functional need, DMS makes the final eligibility determination for all clients based on the results of the independent assessment and the individual's diagnosis contained in his or her medical record. Eligibility is re-evaluated on an annual basis.
4. [TICK] Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility reevaluations are conducted at least every twelve months.
5. [TICK] Needs-based HCBS Eligibility Criteria. (By checking this box the state assures that): Needs-based criteria are used to evaluate and reevaluate whether an individual is eligible for State plan HCBS.
The criteria take into account the individual's support needs, and may include other risk factors: (Specify the needs-based criteria):
After medical eligibility has been determined through diagnosis, the following needs-based criteria is used:
The individual must receive a minimum of a Tier 2 functional assessment for HCBS behavioral health services. To meet a Tier 2, the individual must have difficulties with certain behaviors that require a full array of nonresidential services to help with functioning in home and community-based settings and moving towards recovery, and is not a harm to his or herself or others. Behaviors assessed include manic, psychotic, aggressive, destructive, and other socially unacceptable behaviors.
Measurement is completed through an assessment of functional deficit through a face-to-face evaluation of the beneficiary, caregiver report and clinical record review. The assessment measures the beneficiary's behavior in psychosocial sub-domains and intervention domain that evaluates the level of intervention necessary to managed behaviors as well as required supports to maintain beneficiary in home and community settings.
1915(i) services must be appropriate to address the individuals identified functional deficits due to their behavioral health diagnosis.
6. [TICK] Needs-based Institutional and Waiver Criteria. (By checking this box the state assures that):
There are needs-based criteria for receipt of institutional services and participation in certain waivers that are more stringent than the criteria above for receipt of State plan HCBS. If the state has revised institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional services and participating in certain waivers on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer require that level of care. (Complete chart below to summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions):
|
State plan HCBS needs-based eligibility criteria |
NF (& NF LOC** waivers) |
ICF/IID (& ICF/IID LOC waivers) |
Applicable Hospital* (& Hospital LOC waivers) |
|
The individual must receive a minimum of a Tier 2 functional assessment for HCBS behavioral health services. To meet a Tier 2, the individual must have difficulties with certain behaviors that require a full array of nonresidential services to help with functioning in home and community-based settings and moving towards recovery, and is not a harm to his or herself or others. Behaviors assessed include manic, psychotic, aggressive, destructive, and other socially unacceptable behaviors. 1915(i) services must be appropriate to address the individuals identified functional deficits due to their behavioral health diagnosis. |
Must meet at least one of the following three criteria as determined by a licensed medical professional: 1. The individual is unable to perform either of the following: A. At least one (1) of the three (3) activities of daily living (ADLs) of transferring/locomotion, eating or toileting without extensive assistance from or total dependence upon another person; or, B. At least two (2) of the three (3) activities of daily living (ADLs) of transferring/locomotion, eating or toileting without limited assistance from another person; or, 2. The individual has a primary or secondary diagnosis of Alzheimer's disease or related dementia and is cognitively impaired so as to require substantial supervision from another individual because he or she engages in |
1) Diagnosis of developmental disability that originated prior to age of 22; 2) The disability has continued or is expected to continue indefinitely; and 3) The disability constitutes a substantial handicap to the person's ability to function without appropriate support services, including but not limited to, daily living and social activities, medical services, physical therapy, speech therapy, occupational therapy, job training and employment. Must also be in need of and able to benefit from active treatment and unable to access appropriate services in a less restrictive setting. Individuals must be assessed a Tier 2 or Tier 3 |
There must be a written certification of need (CON) that states that an individual is or was in need of inpatient psychiatric services. The certification must be made at the time of admission, or if an individual applies for Medicaid while in the facility, the certification must be made before Medicaid authorizes payment. Tests and evaluations used to certify need cannot be more than one (1) year old. All histories and information used to certify need must have been compiled within the year prior to the CON. In compliance with 42 CFR 441.152, the facility-based and independent CON teams must certify that: A. Ambulatory care resources available in the community do not meet |
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inappropriate behaviors which pose serious health or safety hazards to himself or others; or, 3. The individual has a diagnosed medical condition which requires monitoring or assessment at least once a day by a licensed medical professional and the condition, if untreated, would be life-threatening. 4. 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 or disqualifying episodic change of medical condition which is temporary and expected to last no more than twenty-one (21) days. However, that individual shall not receive waiver services or benefits when subject to a condition or change of condition which would render the individual ineligible if expected to last more than twenty-one (21) days. |
to receive services in the CES Waiver or an ICF/IID. |
the treatment needs of the beneficiary; B. Proper treatment of the beneficiary's psychiatric condition requires inpatient services under the direction of a physician and C. The services can be reasonably expected to prevent further regression or to improve the beneficiary's condition so that the services will no longer be needed. Specifically, a physician must make a medical necessity determination that services must be provided in a hospital setting because the client is a danger to his or herself or other, and cannot safely remain in the community setting. |
*Long Term Care/Chronic Care Hospital **LOC= level of care
7. [TICK] Target Group(s). The state elects to target this 1915(i) State plan HCBS benefit to a specific population based on age, disability, diagnosis, and/or eligibility group. With this election, the state will operate this program for a period of 5 years. At least 90 days prior to the end of this 5-year period, the state may request CMS renewal of this benefit for additional 5-year terms in accordance with 1915(i)(7)(C) and 42 CFR 441.710(e)(2). {Specify targetgroup(s)):
Targeted to individuals with a behavioral health diagnosis, who are age four and older.
[] Option for Phase-in of Services and Eligibility. If the state elects to target this 1915(i) State plan HCBS benefit, it may limit the enrollment of individuals or the provision of services to enrolled individuals in accordance with 1915(i)(7)(B)(ii)and 42 CFR 441.745(a)(2)(h) based upon criteria described in a phase- in plan, subject to CMS approval. At a minimum, the phase-in plan must describe:
(Specify the phase-in plan) :
(By checking the following box the State assures that):
8. SAdjustment Authority. The state will notify CMS and the public at least 60 days before exercising the option to modify needs-based eligibility criteria in accord with 1915(i)(l)(D)(ii).
9. [TICK] Reasonable Indication of Need for Services. In order for an individual to be determined to need the 1915(i) State plan HCBS benefit, an individual must require:
|
i |
Minimum number of services. The minimum number of 1915(i) State plan services (one or more) that an individual must require in order to be determined to need the 1915(i) State plan HCBS benefit is: One. |
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ii. |
Frequency of services. The state requires (select one): |
|
X |
The provision of 1915(i) services at least monthly |
|
Monthly monitoring of the individual when services are furnished on a less than monthly basis If the state also requires a minimum frequency for the provision of 1915(i) services other than monthly (e.g., quarterly), specify the frequency: |
Home and Community-Based Settings
(By checking the following box the State assures that):
10. [TICK]Home and Community-Based Settings. The State plan HCBS benefit will be furnished to individuals who reside and receive HCBS in their home or in the community, not in an institution.
{Explain how residential and non-residential settings in this SPA comply with Federal home and community-based settings requirements at 42 CFR 441.710(a)(l)-(2) and associated CMS guidance. Include a description of the settings where individuals will reside and where individuals will receive HCBS, and how these settings meet the Federal home and community-based settings requirements, at the time of submission and in the future):
(Note: In the Quality Improvement Strategy (QIS) portion of this SPA, the state will be prompted to include how the state Medicaid agency will monitor to ensure that all settings meet federal home and community-based settings requirements, at the time of this submission and ongoing.)
This State Plan Amendment, along with the concurrent 1915(b) PASSE Waiver and 1915(c) Community and Employment Supports Waiver, will be subject to the HCBS Settings requirements.
The 1915(i) service settings are fully compliant with the home and community-based settings rule or are covered under the statewide transition plan under another authority where they have been in operation before March of 2014.
The state assures that this State Plan amendment or renewal will be subject to any provisions or requirements included in the state's most recent and/or approved home and community-based settings Statewide Transition Plan. The state will implement any CMCS required changes by the end of the transition period as outlined in the home and community-based settings Statewide Transition Plan."
Person-Centered Planning & Service Delivery
(By checking the following boxes the state assures that):
1. [TICK] There is an independent assessment of individuals determined to be eligible for the State plan HCBS benefit. The assessment meets federal requirements at 42 CFR § 441.720.
2.[TICK] Based on the independent assessment, there is a person-centered service plan for each individual determined to be eligible for the State plan HCBS benefit. The person-centered service plan is developed using a person-centered service planning process in accordance with 42 CFR § 441.725(a), and the written person-centered service plan meets federal requirements at 42 CFR § 441.725(b).
3. [TICK] The person-centered service plan is reviewed, and revised upon reassessment of functional need as required under 42 CFR § 441.720, at least every 12 months, when the individual's circumstances or needs change significantly, and at the request of the individual.
4. Responsibility for Face-to-Face Assessment of an Individual's Support Needs and Capabilities.
There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with need for HCBS. (Specify qualifications):
The assessor must have a Bachelor's Degree or be a registered nurse with one (1) year of experience with mental health populations.
5. Responsibility for Development of Person-Centered Service Plan. There are qualifications (that are reasonably related to developing service plans) for persons responsible for the development of the individualized, person-centered service plan. (Specify qualifications):
The Provider Led Arkansas Shared Savings Entity (PASSE) Care coordinator is responsible for providing care coordination to all clients receiving State plan HCBS services, including development of the PCSP. The care coordination service is offered through the 1915(b) Waiver. These care coordinators must meet the following qualifications:
1. Be a registered nurse, a physician or have a bachelor's degree in a social science or a health-related field; or
2. Have at least one (1) year experience working with developmentally or intellectually disabled clients or behavioral health clients.
6. Supporting the Participant in Development of Person-Centered Service Plan. Supports and information are made available to the participant (and/or the additional parties specified, as appropriate) to direct and be actively engaged in the person-centered service plan development process. (Specify:
From the time an individual makes contact with DHS Beneficiary Support regarding receiving HCBS state plan services, DHS informs the individual and their caregivers of their right to make choices about many aspects of the services available to them and their right to advocate for themselves or have a representative advocate on their behalf. It is the responsibility of everyone at DHS, the PASSE who receives attribution and provides care coordination, and the services providers to make sure that the PASSE member is aware of and is able to exercise their rights and to ensure that the member and their caregivers are able to make choices regarding their services.
Immediately following enrollment in a PASSE, the PASSE care coordinator must develop an interim service plan (ISP) for member. If the member was already enrolled in a program that required PCSPs,
then that PCSP may be the ISP for the member. The ISP may be effective for up to 60 days, pending completion of the full PCSP.
The PASSE's care coordinator is responsible for scheduling and coordinating the PCSP development meeting. As part of this responsibility the care coordinator must ensure that anyone the member wishes to be present is invited. Typically, the development team will consist of the member and their caregivers, the care coordinator, service providers, professionals who have conducted assessments or evaluations, and friends and persons who support the member. The care coordinator must ensure that the member does not object to the presence of any participants to the PCSP development meeting. If the member or the caregiver would like a party to be present, the care coordinator is responsible for inviting that individual to attend.
During the PCSP development meeting, everyone in attendance is responsible for supporting and encouraging the member to express their wants and desires and to incorporate them into the PCSP when possible. The care coordinator is responsible for managing and resolving any disagreements which arise during the PCSP development meeting.
After enrollment, and prior to the PCSP development meeting, the care coordinator must conduct a health questionnaire with the member. The care coordinator must also secure any other information that may be needed to develop the PCSP, including, but not limited to:
The PCSP development team must utilize the results of the independent assessment, the health questionnaire, and any other assessment information gathered. The PCSP must include the member's goals, needs (behavioral, developmental, and health needs), and preferences. All needed services must be noted in the PCSP and the care coordinator is responsible for coordinating and monitoring the implementation of the PCSP.
The PCSP must be developed within 60 days of enrollment into the PASSE. At a minimum, the PCSP must be updated annually.
7. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the 1915(i) services in the person-centered service plan):
Before a member can access HCBS state plan services, they must be enrolled in a PASSE under the 1915(b) Provider Led Shared Savings Entities Waiver. The PASSE is responsible for providing all needed services to all enrolled members and may limit a member's choice of providers based on its provider network. The provider network must meet minimum adequacy standards set forth in the 1915(b) Waiver, the PASSE Provider Manual, and the PASSE provider agreement.
The member has 90 days after initial enrollment to change their assigned PASSE. Once a year, there is a 30-day open enrollment period, in which the member may change their PASSE for any reason. At any time during the year, a member may change their PASSE for cause, as defined in 42 CFR 438.56.
The State has a Beneficiary Support Office to assist the member in changing PASSE's, including informing the member of their rights regarding choosing another PASSE and how to access information on each PASSE's provider network. The Beneficiary Support Office will begin reaching out to a beneficiary once it is determined he or she meets the qualifications to be enrolled in a PASSE.
8. Process for Making Person-Centered Service Plan Subject to the Approval of the Medicaid Agency.
(Describe the process by which the person-centered service plan is made subject to the approval of the Medicaid agency):
DMS or the External Quality Review Organization (EQRO) arranges for a specified number of service plans to be reviewed annually, using the sampling guide, "A Practical Guide for Quality Management in Home and Community-Based Waiver Programs," developed by Human Services Research Institute and the Medstat Group for CMS in 2006. A systematic random sampling of the active case population is drawn whereby every "nth" name in the population is selected for inclusion in the sample. The sample size is based on a 95% confidence interval with a margin of error of+/- 8%. An online calculator is used to determine the appropriate sample size for the Waiver population. To determine the "nth" integer, the sample is divided by the population. Names are drawn until the sample size is reached.
DMS or the EQRO then requires the PASSE to submit the PCSP for all individuals in the sample. DMS or the EQRO conducts a retrospective review of provided PCSPs based on identified program, financial, and administrative elements critical to quality assurance. DMS or the EQRO reviews the plans to ensure they have been developed in accordance with applicable policies and procedures, that plans ensure the health and welfare of the member, and for financial and utilization components. DMS or the EQRO communicates findings from the review to the PASSE for remediation. Systemic findings may necessitate a change in policy or procedures. A pattern of non-compliance from one PASSE may result in sanctions to that PASSE under the PASSE Provider Manual and Provider Agreement.
9. Maintenance of Person-Centered Service Plan Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR § 74.53 . Service plans are maintained by the following (check each that applies):
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Medicaid Agency |
Operating Agency |
Case Manager |
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X |
Other (Specify): The PASSE |
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