Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 27 - Department of Medical Services
Rule 016.27.20-020 - ARChoices 1-20, LCAL 1-20, PERSCARE 3-20, ARChoices and Living Choices Waiver Amendments, and Medical Services Policy C-265, I-630, I-640, L-120
Current through Register Vol. 49, No. 9, September, 2024
Section II
ARChoices In Homecare Home and Community-Based 2176 Waiver
The ARChoices Program processes for beneficiary intake, assessment and service plan development include:
These indications notwithstanding, the final determination of Level of Care and functional eligibility is made by the OLTC.
For more information on ARIA, please see the ARIA Manual.
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.
O SERIOUS MENTAL ILLNESS OR DISORDER means schizophrenia, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; or other psychotic disorder. For further clarification, see 42 CFR § 483.100- 102, Subpart C -Preadmission Screening and Annual Resident Review (PASARR) of Individuals with Mental Illness and Intellectual Disability.
Prior to the expiration date of the provisional PCSP, the DHS 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 three hundred sixty-five (365) days from the date of the DHS RN's signature on form AAS-9503, the ARChoices PCSP. Once the renewal is either approved or denied by the DHS Division of County Operations the providers will be notified by the DHS 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.
Prior to the expiration of the three hundred sixty-five (365) days, financial and functional eligibility will be reviewed for renewal of the PCSP. Functional eligibility will be determined by an evaluation done by the DHS RN.
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 DHS RN or Case Manager. 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 DHS 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 Division of County Operations, providers must immediately report all changes in the beneficiary's status to the DHS RN.
The Targeted Case Manager is responsible for monitoring the beneficiary's status on a regular basis for changes in service need, referring the beneficiary for evaluation of any beneficiary complaints or change of condition to the DHS RN, or DHS RN Supervisor immediately upon learning of the change. The DHS RN will determine if a reassessment is necessary or if a change in condition warrants a change to the PCSP based upon the DHS RNs evaluation of the beneficiary.
Section II
Living Choices Assisted Living
The Living Choices Program processes for beneficiary intake, assessment, evaluation, and service plan development include:
These indications notwithstanding, the final determination of Level of Care and functional eligibility is made by the Office of Long Term Care (OLTC).
For more information on ARIA, please see the ARIA Provider Manual.
A prospective Living Choices beneficiary must require a nursing facility intermediate level of care.
The intermediate level of care determination is made by medical staff with the Department of Human Services (DHS), Office of Long Term Care. The determination is based on the assessment performed by the Independent Assessment Contractor RN, using standard criteria for functional eligibility 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 Living Choices services.
An evaluation is completed annually by the DHS RN to determine continued functional eligibility. Should a change of medical condition be present, a referral may be made to the Independent Assessment Contractor to complete a reassessment. The Office of Long Term Care re-determines level of care annually. The results of the level of care determination and the re-evaluation are documented on form DHS-704, Decision for Nursing Home Placement.
NOTE: While federal guidelines require level of care reevaluation at least annually, the Independent Assessment Contractor may reassess a beneficiary's level of care and/or need any time it is deemed appropriate by the DHS RN to ensure that a beneficiary is appropriately placed in the Living Choices Assisted Living Program and is receiving services suitable to his or her needs.
The implementation plan must be designed to ensure that services are:
NOTE: Each service included on the Living Choices plan of care must be justified by the DHS 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 DHS RN.
Living Choices services must be provided according to the beneficiary plan of care. Providers may bill only for services in the amount and frequency that is authorized in the plan of care. As detailed in the Medicaid Program provider contract, providers may bill only after services are provided.
NOTE: Plans of care are updated annually by the DHS RN and sent to the assisted living provider prior to the expiration of the current plan of care. However, the provider has the responsibility for monitoring the plan of care expiration date and ensuring that services are delivered according to a valid plan of care. At least thirty (30) and no more than forty-five (45) days before the expiration of each plan of care, the provider shall notify the DHS RN via email and copy the RN supervisor of the plan of care expiration date.
Services are not compensable unless there is a valid and current care plan in effect on the date of service.
REVISIONS TO A BENEFICIARY PLAN OF CARE MAY ONLY BE MADE BY THE DHS RN.
NOTE: All revisions to the plan of care must be authorized by the DHS RN. A revised plan of care will be sent to each appropriate provider. Regardless of when services are provided, unless the provider and the service are authorized on a Living Choices plan of care, services are considered non-covered and do not qualify for Medicaid reimbursement. Medicaid expenditures paid for services not authorized on the Living Choices plan of care are subject to recoupment.
NOTE: No provisional plans of care will be developed if the waiting list process is in effect.
The assisted living provider RN must evaluate each Living Choices Program beneficiary at least every three (3) months, more often if necessary. The assisted living provider RN must alert the DHS RN to any indication that a beneficiary's direct care services needs are changing or have changed, so that the DHS RN can reevaluate the individual.
Each Living Choices beneficiary will be evaluated at least annually by a DHS RN. The DHS RN evaluates the resident to determine whether a nursing home intermediate level of care is still appropriate and whether the plan of care should continue unchanged or be revised. Evaluations and subsequent plan of care revisions must be made within fourteen (14) days of any significant change in the beneficiary's status.
Section II
Personal Care
The DHS RN is responsible for developing an ARChoices Person-Centered Service Plan (PCSP) that includes both waiver and non-waiver services. Once developed, the PCSP is signed by the DHS RN authorizing the services listed.
The signed ARChoices PCSP will suffice as the "Personal Care Authorization" for services required in the Personal Care Program. The personal care individualized service plan, developed by the Personal Care provider, is still required.
The ARChoices PCSP is effective for one (1) year from the date of the beneficiary's most recent assessment, reassessment, or evaluation. The authorization for personal care services, when included on the ARChoices PCSP, will be for one (1) year from the date of the beneficiary's most recent assessment, reassessment, or evaluation unless revised by the DHS RN or the personal care individualized service plan needs to be revised, whichever occurs first.
NOTE: For ARChoices beneficiaries who receive personal care through traditional agency services or have chosen to receive their personal care services through the Independent Choices Program, the ARChoices PCSP, signed by a DHS RN, will serve as the authorization for personal care services for one year from the date of the beneficiary's most recent assessment, reassessment, or evaluation as described above.
The responsibility of developing a personal care individualized service plan is not placed with the DHS RN. The personal care provider is still required to complete a service plan, as described in the Arkansas Medicaid Personal Care Provider Manual.
The Arkansas Medicaid Program waives no other Personal Care Program requirements with regard to personal care individualized service plan authorizations obtained by DHS RNs.
Appendix A: Waiver Administration and Operation
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix C: Participant Services
Appendix C: Participant Services
C-1/C-3: Service Specification
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Appendix C: Participant Services
C-1/C-3: Service Specification
Appendix C: Participant Services
Appendix C: Participant Services
Quality Improvement: Qualified Providers
Appendix C: Participant Services
Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'
Appendix C: Participant Services
Appendix C: Participant Services
Appendix D: Participant-Centered Planning and Service Delivery
Appendix D: Participant-Centered Planning and Service Delivery
Appendix E: Participant Direction of Services
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix F: Participant Rights
Appendix F-1: Opportunity to Request a Fair Hearing
The state provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals:
Procedures for Offering Opportunity to Request a Fair Hearing. Describe how the individual (or his/her legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and notices referenced in the description are available to CMS upon request through the operating or Medicaid agency.
Appendix F: Participant-Rights
Appendix F-2: Additional Dispute Resolution Process
Appendix F: Participant-Rights
Appendix F-3: State Grievance/Complaint System
Appendix G: Participant Safeguards
Appendix G-1: Response to Critical Events or Incidents
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3)
Appendix G: Participant Safeguards
Appendix G-3: Medication Management and Administration (1 of 2)
Appendix H: Quality Improvement Strategy (1 of 3)
Under §1915(c) of the Social Security Act and 42 CFR § 441.302, the approval of an HCBS waiver requires that CMS determine that the state has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the state specifies how it has designed the waiver's critical processes, structures and operational features in order to meet these assurances.
* Quality Improvement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement.
CMS recognizes that a state's waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver's relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the state is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.
It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.
Quality Improvement Strategy: Minimum Components
The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).
In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I), a state spells out:
* The evidence based discovery activities that will be conducted for each of the six major waiver assurances; and
* The remediation activities followed to correct individual problems identified in the implementation of each of the assurances.
In Appendix H of the application, a state describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.
If the state's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the state plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.
When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid state plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the state must be able to stratify information that is related to each approved waiver program. Unless the state has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the state must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.
Appendix H: Quality Improvement Strategy (2 of 3)
Appendix H: Quality Improvement Strategy (3 of 3)
Appendix I: Financial Accountability
I-1: Financial Integrity and Accountability
Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (1 of 3)
Appendix I: Financial Accountability
I-3: Payment (1 of 7)
Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (1 of 3)
Appendix I: Financial Accountability
I-5: Exclusion of Medicaid Payment for Room and Board
Appendix I: Financial Accountability
I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)
Appendix J: Cost Neutrality Demonstration
J-1: Composite Overview and Demonstration of Cost-Neutrality Formula
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (1 of 9)
Appendix A: Waiver Administration and Operation
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix B: Participant Access and Eligibility
Appendix C: Participant Services
Appendix C: Participant Services
C-1/C-3: Service Specification
Appendix C: Participant Services
Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'
Appendix C: Participant Services
Appendix C: Participant Services
Appendix D: Participant-Centered Planning and Service Delivery.
Appendix D: Participant-Centered Planning and Service Delivery
Appendix E: Participant Direction of Services
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix F: Participant Rights
Appendix F-1: Opportunity to Request a Fair Hearing
The state provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals:
Procedures for Offering Opportunity to Request a Fair Hearing. Describe how the individual (or his/her legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and notices referenced in the description are available to CMS upon request through the operating or Medicaid agency.
Appeals are the responsibility of the Department of Human Services Appeals and Hearings section. Waiver applicants are advised on the DCO-707 (Notice of Action) or the system-generated Notice of Action by the County Office of their right to request a fair hearing when adverse action is taken to deny, suspend or terminate eligibility for Living Choices. The notice is issued by the LTSS caseworker, and explains the participant's right to a fair hearing, how to file for a hearing and the participant's right to representation. Notices of adverse actions and the opportunity to request a fair hearing are kept in the participant's case record. Applicants must make their request for an appeal no later than 30 days from the date on the DCO-707.
The DCO-707 Notice of Action is kept in the participant's county office case record. If the DCO-707 is a request for information only, the form may be discarded when all the needed information is received. If the information requested is not received, the form may be discarded five years from the month of origin. Otherwise, the DCO-700 will be retained for five years from the date of last approval, closure or denial.
Participants also have the right to appeal if they disagree with a revision to their service plan, which reduces or terminates services, while their eligibility remains active. Information regarding hearings and appeals is included with the participant's service plan. The DHS Appeals and Hearings section is also responsible for these types of appeals. Requests for appeals must be received by the DHS Appeals and Hearings section no later than 30 days from the business day following the postmark on the envelope with the service plan that contains a revision which the participant wishes to appeal.
Living Choices participants have the option of continuing Medicaid eligibility and services during the appeal process. They are informed of their options when notified by the DHS county office of the pending adverse action. If the findings of the appeal are not in the participant's favor, and the participant has elected the continuation of benefits, the participant is liable for payment to the provider. If Medicaid has paid the provider, DHS will consider the services that were provided during the period of ineligibility a Medicaid overpayment and will seek reimbursement from the participant.
Participants have the right to appeal if they were not provided a choice in institutional care or waiver services, or a choice of providers.
The assisted living facility and the Department of Human Services county office inform the participant of their potential payment liability if a participant has been denied eligibility for the program and if an appeal of a denial is not in the participant's favor.
During the person centered service plan development process, the DHS RN explains these rights to the participant, family member or representative. Signatures on the service plan verify that the choice between waiver services or institutional care was exercised. Also, during this process, participants choose a provider from a list provided by the DHS RN. Choices of provider are documented on the Freedom of Choice form, and the participant signs the list of providers showing that the choice was made. During the development of the person centered service plan, if no change in provider is requested, the provider list is not signed by the participant.
Appendix F: Participant-Rights
Appendix F-2: Additional Dispute Resolution Process
Appendix F: Participant-Rights
Appendix F-3: State Grievance/Complaint System
Appendix G: Participant Safeguards
Appendix G-1: Response to Critical Events or Incidents
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3)
Appendix G: Participant Safeguards
Appendix G-3: Medication Management and Administration (1 of 2)
Appendix H: Quality Improvement Strategy (1 of 3)
Under §1915(c) of the Social Security Act and 42 CFR § 441.302, the approval of an HCBS waiver requires that CMS determine that the state has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the state specifies how it has designed the waiver's critical processes, structures and operational features in order to meet these assurances.
* Quality I mprovement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement.
CMS recognizes that a state's waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver's relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the state is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.
It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.
Quality Improvement Strategy: Minimum Components
The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).
In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I), a state spells out:
* The evidence based discovery activities that will be conducted for each of the six major waiver assurances; and
* The remediation activities followed to correct individual problems identified in the implementation of each of the assurances.
In Appendix H of the application, a state describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.
If the state's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the state plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.
When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid state plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the state must be able to stratify information that is related to each approved waiver program. Unless the state has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the state must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.
Appendix H: Quality Improvement Strategy (2 of 3)
Appendix H: Quality Improvement Strategy (3 of 3)
Appendix I: Financial Accountability
I-1: Financial Integrity and Accountability
Financial Integrity. Describe the methods that are employed to ensure the integrity of payments that have been made for waiver services, including:
Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (1 of 3)
Appendix I: Financial Accountability I-3: Payment (2 of 7)
Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (1 of 3)
Appendix I: Financial Accountability
I-5: Exclusion of Medicaid Payment for Room and Board
Appendix I: Financial Accountability
I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (2 of 5)
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (3 of 5)
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (4 of 5)
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (5 of 5)
Appendix J: Cost Neutrality Demonstration
J-1: Composite Overview and Demonstration of Cost-Neutrality Formula
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (1 of 9)
Medical Services Policy Manual, Section C
MS Manual 01/01/21
Participants may voluntarily disenroll from the PACE program at any time for any reason.
Participants may be involuntarily disenrolled due to:
The PACE Organization may appeal an adverse decision to the Division of Aging, Adult and Behavioral Health Services (DAABHS). If a timely appeal is received on or before the effective date of the action, the petitioner's case will remain open and benefits will continue until the hearing decision. If the petitioner wishes not to continue benefits until the hearing decision, they must opt out.
Medical Services Policy Manual, Section I
MS Manual 01/01/21
Recipients will be advised to report any changes in the amount of household income or resources.
If at any time the Division of Aging, Adult and Behavioral Health Services (DAABHS) or Division of Provider Services and Quality Assurance (DPSQA) Office of Long Term Care (OLTC) determines that cost effectiveness is not met, that the client no longer meets the requirements for Intermediate Level of Care, or that the client is no longer receiving Waiver services, the County Office will be notified, and the Waiver case will be closed. If the Waiver case is closed for any reason, the eligibility worker will determine if the client is eligible for any other Medicaid category. If eligible in another category, the recipient can be certified in that category without requiring a new application.
If the ARChoices Waiver client loses eligibility for one month only, the case may remain open with an overpayment submitted for the month of ineligibility. When the County has advance knowledge of ineligibility in a future month (e.g., land rent paid annually), procedures at MS E-410 will be followed, advance notice given, and the case adjusted.
If the Waiver client will be ineligible for more than one month, the case will be closed and a new application will be required.
A Waiver client may appeal an adverse decision made on his/her case as outlined in MS L 100-173 of the Medical Services Policy manual. If a timely appeal is received on or before the effective date of the action, the petitioner's case will remain open and benefits will continue until the hearing decision. If the petitioner wishes not to continue benefits until the hearing decision, they must opt out.
MS Manual 01/01/21
ALF Waiver recipients will be advised to report any changes in income or resources to the DHS County Office. If at any time the Division of Aging, Adult and Behavioral Health Services (DAABHS) or the Office of Long Term Care determines that cost effectiveness is not met or that the client no longer meets the requirements for an Intermediate Level of Care, the County Office will be notified and the ALF case will be closed. If the case is closed for any reason, the eligibility worker will determine if the client is eligible in any other Medicaid category. If eligible in another category, the recipient can be certified in that category without requiring a new application.
If the ALF Waiver client loses eligibility for one month only, the case may remain open with an overpayment submitted for the month of ineligibility. When the County has advance knowledge of ineligibility in a future month, procedures at MS E-410 will be followed, advance notice given, and the case adjusted at the appropriate time.
If the ALF recipient will be ineligible for more than one month, the case will be closed and a new application will be required to reopen.
An ALF Waiver recipient may appeal an adverse decision made on his/her case as outlined in MS Section L. If a timely appeal is received on or before the effective date of the action, the petitioner's case will remain open and benefits will continue until the hearing decision. If the petitioner wishes not to continue benefits until the hearing decision, they must opt out.
MS Manual 01/01/2021
In cases where an adverse action is taken against a beneficiary who qualifies for an institutional level of care (e.g. ARChoices, Living Choices, TEFRA, Autism, PACE, CES/DD, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) and LTC/nursing home), if a timely appeal is received on or before the effective date of the action, the petitioner's case will remain open and benefits will continue until the hearing decision. If the petitioner wishes not to continue benefits pending the hearing decision, they must opt out.
In all other cases, if a petitioner files an appeal for a hearing within the ten (10) day notice period, or five (5) days in the case of probable fraud, the case will remain open at the petitioner's request until the hearing decision. Otherwise, benefits will NOT continue.
At the conclusion of the hearing, the hearing official will decide whether the case should be closed or services reduced prior to the rendering of the hearing decision. The criteria for determining whether adverse action is taken prior to the rendering of the hearing decision will be based on whether or not a fact or judgment situation exists. If it is determined that the sole issue is one of state or federal law or policy, the proposed action will be taken.
Examples of issues of fact:
* Verified earned or unearned income which caused net income to be in excess of the maximum income limitations.
* Protest of Agency Policy-The recipient agrees that his income or resources exceed the limitation but feels that the policy imposing these limitations is unreasonable.
If the sole issue is one of judgment relating to a state or federal law or policy, no adverse action is taken prior to the hearing decision.
Examples of judgment are:
* Disability in MRT cases.
* Value of real or personal property.
The petitioner will be advised at the beginning of the hearing that a decision will be made at the conclusion of the hearing regarding whether the benefits will be reduced or terminated prior to the rendering of the hearing decision. If the decision by the hearing official is to reduce or terminate benefits, a Notice of Action will be prepared by DCO and mailed for immediate action. This Notice is not an additional appealable adverse action as it is simply an affirmation of the agency's original action.
If a subsequent change in the petitioner's open case occurs that results in adverse action while the hearing decision is pending and the petitioner does not timely appeal that new adverse action, the change will occur on the date specified in the notice.
