Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-022 - IndependentChoices provider manual amendments - INCHOICE-1-11 and State Plan Amendment #2012-009

Current through Register Vol. 49, No. 6, June, 2024
Section II
IndependentChoices
200.100
IndependentChoices
The IndependentChoices program is a state plan service under
				1915(j) of the Social Security Act. IndependentChoices is operated by the
				Division of Aging and Adult Services (DAAS). The program offers
				Medicaid-eligible individuals who are elderly and individuals with disabilities
				an opportunity to self-direct their personal assistant services.
IndependentChoices seeks to increase the opportunity for
				consumer direction and control for Medicaid beneficiaries receiving or needing
				personal assistant services. Personal Assistant services in IndependentChoices
				include state plan personal care for Medicaid beneficiaries and Adult Companion
				and Homemaker services for ElderChoices beneficiaries. IndependentChoices
				offers an allowance and counseling services in place of traditional
				agency-provided personal assistance services and items related to personal
				assistance needs.
The participant or designee is the employer and accepts the
				responsibility in directing the work of their employee to the degree necessary
				to meet their individual needs for assistance with activities of daily living
				and instrumental activities of daily living.
If the IC participant can make decisions regarding his or her
				care but does not feel comfortable reading and filling out forms or talking on
				the phone, he or she can appoint a Communications Manager. The Communications
				Manager can act as the participant's voice and complete and sign forms, but
				will not make decisions for the participant. The Communications Manager will
				not hire, train, supervise or fire the personal assistant for the IC
				participant.
If the participant needs someone to hire and supervise the
				personal assistant, make decisions about care and administer the cash
				expenditure plan as well as complete all forms, a Decision-Making Partner will
				be appointed.
IndependentChoices participants or their Decision-Making
				Partners must be able to assume the responsibilities of becoming an employer by
				hiring, training, supervising and firing if necessary their directly hired
				workers. In doing so the program participant accepts the risks, rights and
				responsibilities of directing their care and having their health care needs
				met.
The IndependentChoices program respects the employer authority
				of the participant who chooses to direct his or her care by hiring an employee
				who will be trained by the employer or Decision-Making Partner to provide
				assistance how, when, and where the employer or Decision-Making Partner
				determines will best meet the participant's individual needs. The Medicaid
				beneficiary assumes the risks, rights and responsibilities of having their
				health care needs met in doing so.
NOTE: The IndependentChoices Program follows the rules
				and regulations of the State Plan approved Personal Care Program, unless stated
				otherwise in this manual.
200.200
Eligibility
To be eligible for IndependentChoices, a participant
				must:
A. Be 18 years of age or
			 older
B. Be eligible for Medicaid,
			 as determined by the DHS Division of County Operations, in a category that
			 covers personal care, or be eligible for Supplemental Security Income (SSI)
			 through the Social Security Administration, or be eligible for ElderChoices and
			 determined in need of Adult Companion services, Homemaker services or personal
			 care by the DAAS Registered Nurse (RN)
C. Be receiving personal assistance services
			 or be medically eligible to receive personal assistance services. Personal
			 assistance services include state plan personal care, ElderChoices adult
			 companion services and ElderChoices Homemaker services.
1.
Personal Care:
In determining
			 eligibility and level of need for personal care, IndependentChoices follows
			 policy found in the Arkansas Medicaid Personal Care Provider Manual.
2.
Adult Companion Services:
The
			 DAAS RN must determine and authorize adult companion services based on
			 ElderChoices policy.
3.
Homemaker Services:
The DAAS RN must determine and authorize
			 ElderChoices Homemaker services according to ElderChoices policy.
D. Not be living in a home or
			 property owned, operated or controlled by a provider of services unless the
			 provider is related by blood or marriage to the participant. This includes
			 single family homes, group homes, adult family homes, congregate settings, a
			 living situation sponsored or staffed by an agency provider, etc.
E. Be willing to participate in
			 IndependentChoices and understand the rights, risks and responsibilities of
			 managing his or her own care with an allowance; or, if unable to make decisions
			 independently, have a willing representative decision-maker who understands the
			 rights, risks and responsibilities of managing the care of the participant with
			 an allowance.
202.300
Enrollment
The Division of Aging and Adult Services is the point of entry
				for all enrollment activity for IndependentChoices. The program is limited
				based on an approved number through the Medicaid State Plan.
The individual or their designee will first call the
				IndependentChoices toll-free number at 888-682-0044 to speak with an
				IndependentChoices counselor. The counselor will provide information to the
				individual about the program and verify that the individual is currently
				enrolled in a Medicaid category that covers personal assistance services. If
				the individual is currently enrolled in an appropriate Medicaid category and
				has an assessed physical dependency need for "hands on" assistance with
				personal care needs, the counselor will enter the individual's information into
				a DAAS database. Based on the individual's county of residence, the
				IndependentChoices counselor will either continue working with the individual
				through the enrollment process, or refer the individual to the contracted
				counseling agency for the individual's area of the state. If the individual is
				not currently enrolled in an appropriate Medicaid category, the counselor will
				refer the individual to the DHS County Office for eligibility
				determination.
The counselor, nurse and fiscal agent will then work with the
				individual to complete the enrollment forms either by mail and telephone
				contact or by a face-to-face meeting. The individual will be provided with the
				"My IndependentChoices Handbook," which explains the individual's
				responsibilities regarding enrollment and continuing participation. The
				individual must complete the forms in the Enrollment Packet, which consists of
				the Participant Responsibilities and Agreement, the Backup Personal Assistant
				and the Authorization to Disclose Health Information. The participant must also
				complete the forms in the Employer Packet, which includes the Limited Power of
				Attorney, IRS and direct deposit forms related to being a household employer.
				Each personal assistant must complete the forms in the Employee Packet which
				include the standard tax withholding forms normally completed by an employee,
				the Employment Eligibility Verification Form (I-9), a Participant/Personal
				Assistant Agreement, Employment Application and a Provider Agreement. The
				packets each include step-by-step instructions on how to complete the forms.
				IndependentChoices staff will be available to the individual, Decision-Making
				Partner/Communications Manager and the personal assistant to help complete the
				forms and answer any questions.
As part of the enrollment process, the DAAS RN will complete an
				assessment using the Home and Community Based Services (HCBS) Level of Care
				Assessment Tool. Through completing the assessment and using professional
				judgment, the DAAS RN will determine how many hours of personal assistance
				services are needed by the participant. Eligibility for personal care services
				is based on the same criteria as state plan personal care services.
NOTE:
For ElderChoices beneficiaries, the DAAS RN will determine the number
				of personal care, Adult Companion Services and Homemaker hours needed. The
				ElderChoices plan of care will reflect that the beneficiary chooses
				IndependentChoices as the provider. DAAS-HCBS staff will obtain physician
				authorization for persons not receiving either ElderChoices or Alternatives for
				Adults with Physical Disabilities waiver services.
After the in-home assessment, the DAAS RN will complete the
				paperwork and coordinate with the IndependentChoices counselor. The counselor
				will process all of the completed enrollment forms. The HCBS Level of Care
				Assessment Tool, which includes the cap triggers and the number of hours of
				services needed, will be sent to the participant's physician for authorization
				if the participant is not authorized for services through a waiver plan of care
				for ElderChoices or Alternatives for Adults with Physical Disabilities. State
				and IRS tax forms will be retained by the fiscal agent. Disbursement of funds
				to a participant or their employee will not occur until all required forms are
				accurately completed and in the possession of the fiscal agent.
Personal care assessments for participants aged 21 years or
				older and authorized by the participant's physician in excess of 14.75 hours
				per week will be forwarded by the participant's counselor to Utilization Review
				in the Division of Medical Services for approval.
View or
				print Utilization Review contact information.
For
				individuals under age 21, all personal care hours must be authorized through
				Medicaid's contracted Quality Improvement Organization (QIO), QSource of
				Arkansas.
View or print QSource of Arkansas contact
				information.
IndependentChoices follows the rules and regulations found in
				the Arkansas Medicaid Personal Care Provider Manual in determining and
				authorizing personal care hours. The initial authorization for personal
				assistance services may not begin until the participant's primary care
				physician or an advanced practice nurse enrolled in the Arkansas Medicaid APN
				program seeing patients in an Arkansas Medicaid enrolled Rural Health Clinic or
				Federally Qualified Health Center signs and dates the Home and Community Based
				Services (HCBS) Level of Care Assessment Tool. For beneficiaries receiving
				services through the ElderChoices or Alternatives for Adults with Physical
				Disabilities waiver program, the APN or physician's signature is not required.
				The signature of the DAAS RN is sufficient to authorize personal care services.
				After the service plan is authorized, the actual day services begin is
				dependent upon all of the following conditions:
A. DAAS issues a seven-day notice to
			 discontinue service to any agency personal care, adult companion services or
			 homemaker provider currently providing services to the individual.
B. The date the participant's worker is able
			 to begin providing the necessary care. It can be no earlier than the date the
			 physician authorized the service plan for the non-waiver eligible participant,
			 if an agency provider is not providing the personal care services.
C. The fiscal agent is in possession of all
			 required employer and employee documents.
If the individual is not a recipient of ElderChoices or
				Alternatives for Adults with Physical Disabilities services, then continuation
				of personal assistance services requires reauthorization prior to the end of
				the current service plan end date.
When required for non-waiver beneficiaries, the earlier of the
				two following conditions will suffice for the face-to-face visit required sixty
				days prior to the begin date of the new service plan:
A. The participant's primary care physician
			 or eligible nurse practitioner (as described in this manual) signature on the
			 HCBS Level of Care Assessment Tool attests that he or she has examined the
			 patient within the past 60 days.
B.
			 The participant has a face-to-face visit with their primary care physician or
			 eligible nurse practitioner 60 days prior to the service plan begin date.
When the approval by Utilization Review is received, or the
				individual needs 14.75 hours or less per week, the IndependentChoices Counselor
				will contact the participant or Decision-Making Partner/Communications Manager
				to develop the cash expenditure plan. The participant and the counselor will
				determine when IndependentChoices services can begin, but may not commence
				prior to the date authorized by the physician. The participant is required to
				have a face-to-face visit with their physician within 60 days of the date that
				the physician signs the Assessment Tool or 60 days prior to the service plan
				begin date and each subsequent reassessment. At no time will services begin
				prior to the first day of the previous month unless authorized by the Division
				of Aging and Adult Services.
202.500
Personal Assistance Services
			 Plan
An individualized personal assistance service plan, signed and
				dated by the participant's personal physician constitutes the physician's
				personal assistant services authorization. All services must be prior approved
				through the service plan.
NOTE: An advanced practice nurse (APN) enrolled in the
				Arkansas Medicaid Program seeing patients in a Rural Health Clinic or Federally
				Qualified Health Center enrolled in the Arkansas Medicaid Program as an RHC or
				FQHC may sign the personal care service plan/order if practicing within an
				environment for which his/her certification applies and within the scope of
				his/her certification. No MD signature is required in addition to the APN's
				signature unless required by their license and/or certification.
202.600
Cash
			 Expenditure Plan
The amount of the Cash Expenditure Plan (CEP) is determined by
				the assessment performed by the DAAS RN. The counselor and the participant or
				Decision-Making Partner will work together to develop the CEP, which may be
				updated and revised whenever a need arises. The CEP is intended to be a
				blueprint of how the monthly allowance may be spent to meet the needs
				identified in the service plan. The CEP may include ten percent of the amount
				of the participant's plan as a discretionary expenditure not to exceed $75.00.
				The discretionary expenditure is used to purchase personal hygiene items and
				does not require the participant to maintain receipts for the purchases. For
				reporting purposes, discretionary purchases will be self-declared by the
				participant and will be part of the quarterly reporting requirement performed
				by the fiscal agent.
202.700
Savings Accounts
The fiscal agent may establish and maintain a savings account
				for individuals who want to save part of the monthly allowance for a more
				expensive personal assistant service item. The item must be approved by the
				IndependentChoices counselor and be listed on the Cash Expenditure Plan. These
				funds may be saved to purchase more expensive personal assistant services items
				or services. All savings must be spent on appropriate items by the end of the
				participant's eligibility for IndependentChoices services or returned to the
				Arkansas Medicaid program within 45 days of disenrollment from
				IndependentChoices.
202.800
Work Agreement and Participant/Personal Assistant Agreements
The DAAS RN will assure that a written work agreement
				DAAS-IC-20 is executed between the participant or Decision-Making Partner and
				the employee to clearly identify the tasks required on a daily basis to meet
				the participant's personal assistance needs. In addition to the Work Agreement,
				the fiscal agent is responsible for obtaining the Participant/Personal
				Assistant Agreement form DAAS-IC-17. The purpose of the DAAS-IC-17 is to state
				the agreements to which both the employer and the employee(s) are in agreement.
				The agreement is signed by both the participant or Decision-Making Partner and
				the employee.
220.200
Personal Assistance Services
The primary use of the monthly allowance is to purchase
				personal assistance services to meet the participant's personal assistance
				needs. Assistants will be recruited, interviewed, hired and managed by the
				Decision-Making Partner. Family members, other than those with legal
				responsibility to the participant may serve as personal assistants. A court
				appointed legal guardian, spouse, power of attorney or income payee may not
				serve as a Personal Assistant.
The participant's personal assistant performs the services
				identified on the DAAS-IC-20 Work Agreement under the agreed upon terms of the
				DAAS-IC-17 IndependentChoices Participant/Personal Assistant Agreement.
220.300
Homemaker Services
In-home services are designed to reduce or prevent
				inappropriate institutionalization by maintaining, strengthening or restoring
				an eligible participant's function in his or her own home. IndependentChoices
				allows ElderChoices participants the choice of self-directed Homemaker Services
				rather than receiving Homemaker services through a certified agency.
The DAAS RN will determine the number of hours of Homemaker
				Services needed by the participant as indicated on the ElderChoices Plan of
				Care. If the participant chooses to self-direct Homemaker Services, the DAAS RN
				will refer the participant to the IndependentChoices program by sending the
				plan of care to IndependentChoices, notating that IndependentChoices was
				selected.
220.400
Adult Companion Services
Adult Companion Services is nonmedical care, supervision and
				socialization provided to an adult with a functional impairment who is an
				enrolled participant in the ElderChoices home and community-based waiver
				operated by the Division of Aging and Adult Services. Participants enrolled in
				ElderChoices and in need of Adult Companion Services may either receive Adult
				Companion Services through an agency or self-direct the services through
				IndependentChoices.
The DAAS RN will determine the number of hours of Adult
				Companion Services needed by the participant as indicated on the ElderChoices
				Plan of Care. If the participant chooses to self-direct Adult Companion
				Services, the DAAS RN will refer the participant to the IndependentChoices
				program by sending the plan of care to IndependentChoices notating that
				IndependentChoices was selected.
231.300
Hospitalization
An IndependentChoices participant's allowance paid
				prospectively during hospitalization must be returned to the Medicaid Program.
				The day of admission and day of discharge are allowable days when the
				participant receives personal assistance services prior to admission or after
				discharge from the hospital. The participant is instructed to provide
				supporting hospital documentation to their counselor and Financial Management
				Services provider to support receipt of personal assistance services on the day
				of admission. The DAAS Financial Management Service will be responsible for
				calculating and collecting the refund.
231.500
Voluntary Disenrollment
When the participant voluntarily elects to discontinue
				participation in IndependentChoices, the counselor will discuss with the
				individual the reason for disenrollment and assist the individual in resolving
				any barriers or problems that may exist in preventing continuation. If the
				participant wishes to continue with the option to disenroll, the counselor will
				assist the participant by informing him or her of traditional agency personal
				care providers in the participant's area. The counselor will assist with the
				coordination of agency services to the degree requested by the
				participant.
IndependentChoices can continue until agency services are
				established or the participant may elect to use informal supports until agency
				services are established.
231.600
Involuntary Disenrollment
Parti cipants may be disenrolled for the following
				reasons:
A.
Health, Safety and
			 Well-being
: At any time that DAAS determines that the health, safety
			 and well-being of the participant is compromised by continued participation in
			 the IndependentChoices Program, the participant may be returned to the
			 traditional personal care program.
B.
Change in Condition
: Should
			 the participant's cognitive ability to direct his or her own care diminish to a
			 point where he or she can no longer direct his or her own care and there is no
			 Decision-Making Partner available to direct the care, the IndependentChoices
			 case will be closed. The counselor will assist the participant with a referral
			 to traditional services.
C.
Misuse of Allowance
: Should a participant or the Decision-Making
			 Partner who is performing all of their payroll functions (and not using the
			 fiscal agent) use the allowance to purchase items unrelated to personal care
			 needs, fail to pay the salary of an assistant, misrepresent payment of an
			 assistant's salary, or fail to pay related state and federal payroll taxes, the
			 participant or Decision-Making Partner will receive a warning notice that such
			 exceptions to the conditions of participation are not allowed. The participant
			 will be permitted to remain on the program, but will be assigned to the fiscal
			 intermediary, who will provide maximum bookkeeping services. The participant or
			 Decision-Making Partner will be notified that further failure to follow the
			 expenditure plan could result in disenrollment. Should an unapproved
			 expenditure or oversight occur a second time, the participant or
			 Decision-Making Partner will be notified that the IndependentChoices case is
			 being closed and they are being returned to traditional personal assistance
			 services. Program Integrity is informed of situations as required. The
			 counselor will assist the participant with transition to traditional services.
			 The preceding rules are also applicable to participants using the fiscal
			 agent.
D.
Underutilization of
			 Allowance
: The fiscal agent is responsible for monitoring the use of
			 the Medicaid funds received on behalf of the participant. If the participant is
			 underutilizing the allowance and not using it according to the cash expenditure
			 plan, the fiscal agent will inform the counseling entities through quarterly
			 reports and monthly reports on request. The counselor will discuss problems
			 that are occurring with the participant and their support network. The
			 counselor will continue to monitor the participant's use of their allowance
			 through both review of reports and personal contact with the participant. If
			 underutilization continues to occur, future discussions will focus on what is
			 in the best interest of the participant in meeting their ADL's even if the best
			 solution is a return to agency services. Unused funds are returned to the
			 Arkansas Medicaid program within 45 days after disenrollment. Funds accrued in
			 the absence of a savings plan will be returned to Medicaid within a
			 twelve-month filing deadline. Involuntary disenrollment may be considered if
			 the participant has been hospitalized for more than 30 days and a discharge
			 date is unknown to the participant or Decision-Making Partner. Participants
			 with approval by their physician for an out-of-state visit may be involuntarily
			 disenrolled if their stay extends past the approval period authorized by their
			 physician. The participant is required to provide a copy of the physician's
			 authorizations to their counselor for monitoring purposes.
E.
Failure to Assume Employer
			 Authority
: Failure to Assume Employer Authority occurs when a
			 participant fails to fulfill the role of employer and does not respond to
			 counseling support. Disenrollment will not occur without guidance and
			 counseling by the counselor or by the fiscal intermediary. When this occurs,
			 the counselor will coordinate agency personal care services to the degree
			 requested by the participant. The participant may wish to self-advocate from a
			 list provided by the counselor, ask the counselor to coordinate or may simply
			 wish to receive personal assistance services informally. The participant's
			 wishes will be respected.
Whenever a participant is involuntarily disenrolled, the
				IndependentChoices program will mail a notice to close the case. The notice
				will provide at least 10 days but no more than 30 days before
				IndependentChoices will be discontinued, depending on the situation. During the
				transition period, the counselor will work with the participant or
				Decision-Making Partner to provide services to help the individual transition
				to the most appropriate services available.
250.200
Reason for Appeal
If the participant loses eligibility for personal assistance
				services, he or she may ask for an Administrative Reconsideration according to
				Section 161.200 of the Medicaid Provider Manual or may appeal the decision
				according to Medicaid Provider Manual policy 161.300 through 169.000.
An appeal may be filed by a participant or Decision-Making
				Partner based on actions or circumstances listed below:
A. Dissatisfaction with action taken by an
			 IndependentChoices Counselor or Fiscal Agent
B. Involuntary case terminations including
			 but not limited to:
1. Loss of Medicaid
			 eligibility
2.
			 Institutionalization
3.
			 Dissatisfaction with number of personal care hours
4. Health, safety or well being of
			 participant is compromised
5.
			 Duplication of services
6.
			 IndependentChoices case closure based on noncompliance with program
			 requirements
C. Loss of
			 Medicaid eligibility will result in the closure of the case. Any appeal made by
			 the participant must be filed with the Office of Appeals and Hearings according
			 to Medicaid Provider Manual Policy 161.300 through 169.000.
D. Request for personal care hours above
			 14.75 denied by Utilization Review (UR) in the Division of Medical Services.
			 Appeals must be filed with the Office of Appeals and Hearings according to
			 Medicaid Provider Manual Policy 161.300 through 169.000.
E. Requests for personal care hours for
			 beneficiaries under age 21 denied by Medicaid's contracted QIO may be filed for
			 reconsideration. Reconsideration requests must be made in writing to QSource of
			 Arkansas and must include additional documentation to substantiate the medical
			 necessity of the requested services.
View or print QSource of
			 Arkansas contact information.
If the decision is reversed
			 during the reconsideration review, an approval is forwarded to all relevant
			 parties specifying the approved units and services. If the denial is upheld,
			 the QIO issues a written notification of the decision to all relevant parties.
			 Any further appeal on this action must be filed with the Office of Appeals and
			 Hearings according to Medicaid Provider Manual Policy 161.300 through
			 169.000.
260.430
Counselors
Counselors for IndependentChoices will be employed or
				contracted by DAAS. Counselors must possess a Bachelor's degree in humanities,
				social science or a related field plus two years experience in social or
				community work pertaining to adults with chronic conditions and disabilities or
				a related field.
Other job related education and/or experience may be
				substituted for all or part of these basic requirements with approval of
				DAAS.
The current contract requires IndependentChoices counseling
				providers to perform the following:
A.
			 Enrollment of new participants
B.
			 Develop and implement participant directed budget
C. Coordinate with Financial Management
			 Services (FMS) provider and DMS
D.
			 Orientation to IndependentChoices and the concept of consumer
			 direction
E. Skills training on how
			 to recruit, interview, hire, evaluate, manage or dismiss assistants
F. Consumer-directed counseling support
			 services
G. Monitor
			 IndependentChoices participants/Decision-Making Partners H. Monitor over and
			 under expenditures of the Cash Expenditure Plan I. Provide quarterly reports to
			 DAAS
J. Use RN's to assess
			 functional need for personal care
K. Provide all State and Federal forms
			 necessary for the enrolled participant to act as a "Household Employer" to the
			 fiscal provider
L. Inform DAAS of
			 participant's begin and end dates and results of RN's assessment
Supplement 4 to Attachment 3.1-A
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ARKANSAS
1915(j)
				Self-Directed Personal Assistance Services
Notwithstanding anything else in this State Plan provision, the
				coverage will be subject to such other requirements that are promulgated by CMS
				through interpretive issuance or final regulation.
i. Eligibility
The State determines eligibility for Self-Directed Personal
				Assistance Services:
A.
X
In the same manner as eligibility is determined for
			 traditional State Plan personal care services, described in Item 24 of the
			 Medicaid State Plan.
B.
X
In the same manner as eligibility is determined for
			 services provided through a 1915(c) Home and Community-Based Services
			 Waiver.
ii. Service
			 Package
The State elects to have the following included as
				Self-Directed Personal Assistance Services:
A.
X
State Plan
			 Personal Care and Related Services, to be self-directed by individuals eligible
			 under the State Plan.
B.
X
Services included in the following Section 1915(c)
			 Home and Community-Based Services waiver(s) to be self-directed by individuals
			 eligible under the waiver(s). The State assures that all services in the
			 impacted waiver(s) will continue to be provided regardless of service delivery
			 model. Please list waiver names and services to be included.
ElderChoices - Adult Companion Services ElderChoices -
				Homemaker Services
iii. Payment Methodology
A. The State will use the same payment
			 methodology for individuals self-directing their
PAS under section 1915(j)
as
that approved for
				State plan personal care services or for section 1915(c) Home and
				Community-Based waiver services.
B.
X
The State will
			 use a different reimbursement methodology for individuals self-directing their
			 PAS under section 1915(j) than that approved for State plan personal care
			 services or for section 1915(c) Home and Community-Based waiver services.
			 Amended Attachment 4.19-B page(s) are attached.
iv. Use of Cash
A.
X
The State
			 elects to disburse cash prospectively to participants self-directing personal
			 assistance services. The State assures that all Internal Revenue Service (IRS)
			 requirements regarding payroll/tax filing functions will be followed, including
			 when participants perform the payroll/tax filing functions
			 themselves.
B. The State elects not
			 to disburse cash prospectively to participants self-directing personal
			 assistance services.
v.
			 Voluntary Disenrollment
The State will provide the following safeguards to ensure
				continuity of services and assure participant health and welfare during the
				period of transition between self-directed and traditional service delivery
				models.
When the participant voluntarily elects to discontinue
				participation in IndependentChoices, the counselor will discuss with the
				individual the reason for disenrollment and assist the individual in resolving
				any barriers or problems that may exist in preventing continuation. If the
				participant wishes to continue with the option to disenroll, the counselor will
				assist by informing
the participant
of traditional agency personal
				care providers in the participant's area.
The counselor will assist with
				the coordination of agency services to the degree requested by the
				participant.
IndependentChoices can continue until agency services are
				established or the participant may elect to use informal supports until agency
				services are established.
The timeframes discussed under involuntary disenrollment do not
				apply to voluntary disenrollment. The request of the participant will be
				honored whether they ask to be disenrolled immediately or at anytime in the
				future.
The counselor will coordinate the participant's wishes to the
				degree requested by the participant. This may include self-advocation by the
				participant and asking the counselor to coordinate agency services with the
				participant's preferred provider. In some instances the participant may wish to
				forego agency personal assistance services and choose to rely on family or
				friends. If the participant requests that the counselor coordinate the agency
				services the counselor will ascertain
when services can be started. The
				counselor will then
close the
IndependentChoices
case
the day before agency services begin. Regardless of the situation, the State
				will assure that there will not be an interruption in delivering necessary
				services
unless it is the preference of the participant to depend on
				informal supports
.
vi. Involuntary Disenrollment
A. The circumstances under which a
			 participant may be involuntarily disenrolled from self-directing personal
			 assistance services, and returned to traditional service delivery model are
			 noted below.
Parti cipants may be disenrolled for the following
				reasons:
1. Health and
			 Welfare: Any time DAAS feels the health and welfare of the participant is
			 compromised by continued participation in the IndependentChoices Program, the
			 participant may be returned to the traditional personal care program. Prior to
			 this point the counselor has worked with the participant offering suggestions,
			 identifying or changing representatives or employees to better meet the needs
			 of the consumer, making in-home visits as needed by APS or
HCBS
RNs,
and
working to resolve these concerns. If no resolution is
			 available, meeting the participant's health and well-being needs is of most
			 importance; including referral back to the traditional model.
2. Change in Condition: Should the
			 participant's
cognitive
ability to direct his/her own care
			 diminish to a point where the participant can no longer self-direct and there
			 is no responsible representative available to direct the care
the
			 counselor will seek out sources of support.
If no resources are
			 available, the IndependentChoices case will be closed.
The participant
			 will be informed of the pending closure by letter. The letter will include a
			 list of traditional personal care agencies serving the participant's area. If
			 the participant is also a 1915(c) waiver recipient, an e-mail will be auto
			 generated to the HCBS RN or targeted case manager. The e-mail to the HCBS RN or
			 targeted case manager is auto generated and populated with the appropriate
			 names once a closure date is entered in the database. The e-mail will inform
			 the HCBS RN or targeted case manager of the pending closure of the
			 IndependentChoices case necessitating a change in the HCBS service plan. Within
			 five days of sending the letter the counselor will follow up with the
			 participant to determine which agency the participant may wish to choose. The
			 counselor will coordinate the referral with the agency provider. However, if
			 the participant declines agency services, the counselor will respect the choice
			 made by the participant. The participant may choose to have their needs met by
			 informal caregivers.
3.
			 Misuse of Allowance: A notice will be issued should the participant or the
			 representative who manages their cash allowance:
1) fail to pay related state and federal
			 payroll taxes;
2) use the allowance
			 to purchase items unrelated to personal care needs;
3) fail to pay the salary of a personal
			 assistant; or
4) misrepresent
			 payment of a personal assistant's salary. The counselor will discuss the
			 violations with the participant and allow the participant to take corrective
			 action including restitution if applicable. The participant will be permitted
			 to remain in the program, but will be assigned to the fiscal intermediary, who
			 will provide maximum bookkeeping support and services. The participant or
			 representative will be notified that further failure to follow the expenditure
			 plan
will
result in disenrollment and a report filed with
Program Integrity when
applicable.
Should an unapproved expenditure or oversight occur a second
				time, the participant/ representative will be notified that their
				IndependentChoices case is being closed and the participant is being returned
				to traditional personal care.
Program Integrity
is informed of
				situations as required. The State will assure interruption of services will not
				occur while the participant is transitioning from IndependentChoices to
				traditional services.
4. Underutilization of Allowance: The fiscal
			 intermediary is responsible for monitoring the use of Medicaid funds received
			 on behalf of the participant. If the participant is underutilizing the
			 allowance and not using the allowance according to their cash expenditure plan,
			 the fiscal intermediary will inform the counseling entities through
quarterly
report
s and monthly reports upon request
.
			 The counselor will discuss
problems that are occurring
with the
			 participant and their support network. Together the parties will
resolve
			 the underutilization
. The counselor will continue to monitor the
			 participant's use of their allowance through both reviewing of reports and
			 personal contact with the participant. If
a pattern of
underutilization continues to occur, future discussions will focus on what is
			 in the best interest of the participant in meeting their ADLs even if the best
			 solution is a return to agency services.
Unused funds are returned to the
			 Arkansas Medicaid program within 45 days after disenrollment. Funds accrued in
			 the absence of a savings plan
will be returned to the Arkansas Medicaid
			 program
within a twelve month filing deadline
. Exceptions to
			 involuntary disenrollment may be considered if the participant has been
			 hospitalized for an extended period of time or has had a brief visit out of
			 state with approval by the participant's physician. Person-centered planning
			 allows the flexibility of decision making based on individual needs that best
			 meet the needs of the participant.
5.
Failure to Assume Employer
			 Authority: Failure to Assume Employer Authority occurs when a participant fails
			 to fulfill the role of employer and does not respond to counseling support.
			 Participants who fail in their employer responsibilities but do not have a
			 representative will be given the opportunity to select a representative who can
			 assume employer responsibilities on behalf of the participant. Disenrollment
			 will not occur without guidance and counseling by the counselor or by the
			 fiscal intermediary. When this occurs, the counselor will coordinate agency
			 personal care services to the degree requested by the participant. The
			 participant may wish to self-advocate from a list provided by the counselor,
			 ask the counselor to coordinate, or may simply wish to receive personal
			 assistance services informally. The participant's wishes will be
			 respected.
B. The State will provide
			 the following safeguards to ensure continuity of services and assure
			 participant health, safety and welfare during the period of transition between
			 self-directed and traditional service delivery models.
When a participant is involuntarily disenrolled
, a notice
				of intent to close
the IndependentChoices
case will be mailed
to the participant. The notice will allow a minimum of 10 days but no
				more than 30 days before IndependentChoices
enrollment
will be
				discontinued, depending on the situation. During the transition period, the
				counselor will work with the participant/representative to
assure
				services are provided
to help the individual transition to the most
				appropriate
personal care
services available.
vii. Participant Living
			 Arrangement
Any additional restrictions on participant living arrangements,
				other than homes or property owned, operated or controlled by a provider of
				services, not related by blood or marriage to the participant are noted
				below.
There are no additional restrictions on living
				arrangements.
viii.
			 Geographic Limitations and Comparability
A.
X
The State elects to provide self-directed personal
			 assistance services on a statewide basis.
B. The State elects to provide self-directed
			 personal assistance services on a targeted geographic basis. Please describe:
			 _______________________________
C.
			 ____ The State elects to provide self-directed personal assistance services to
			 all eligible populations.
D.
X
The State elects to provide self-directed personal
			 assistance services to targeted populations. Please describe:
Age
			 18 and older.
E. ____
			 The State elects to provide self-directed personal assistance services to an
			 unlimited number of participants.
F.
X
The State
			 elects to provide self-directed personal assistance services to
7500
participants, at any given time.
ix. Assurances
A. The State assures that there are
			 traditional services, comparable in amount, duration and scope, to
			 self-directed personal assistance services.
B. The State assures that there are necessary
			 safeguards in place to protect the health and welfare of individuals provided
			 services under this State Plan Option, and to assure financial accountability
			 for funds expended for self-directed personal assistance services.
C. The State assures that an evaluation will
			 be performed of participants' need for personal assistance services for
			 individuals who meet the following requirements:
i. Are entitled to medical assistance for
			 personal care services under the Medicaid
State Plan; or
ii. Are entitled to and are receiving home
			 and community-based services under a Section 1915 (c) waiver; or
iii. May require self-directed personal
			 assistance services; or iv. May be eligible for self-directed personal
			 assistance services.
D.
			 The State assures that individuals are informed of all options for receiving
			 self-directed and/or traditional State Plan personal care services or personal
			 assistance services provided under a Section 1915(c) waiver, including
			 information about self-direction opportunities that is sufficient to inform
			 decision-making about the election of self-direction and provided on a timely
			 basis to individuals or their representatives.
E. The State assures that individuals will be
			 provided with a support system meeting the following criteria:
i. Appropriately assesses and counsels
			 individuals prior to enrollment;
ii. Provides appropriate counseling,
			 information, training and assistance to ensure that participants are able to
			 manage their services and budgets;
iii. Offers additional counseling,
			 information, training or assistance, including financial management services:
o At the request of the participant for any reason; or o When
				the State
or its contracted entities observes
the participant
lacks the necessary skills to meet employer and budget authority
.
x.
			 Service Plan
The State has the following safeguards in place, to permit
				entities providing other Medicaid State Plan services to be responsible for
				developing the self-directed personal assistance services service plan, to
				assure that the service provider's influence on the planning process is fully
				disclosed to the participant and that procedures are in place to mitigate that
				influence.
Not applicable. The state will not allow entities who provide
				other Medicaid State Plan services to be responsible for developing the
				self-directed service plan.
xi. Quality Assurance and Improvement Plan
The State's quality assurance and improvement plan is described
				below, including:
i. How it will
			 conduct activities of discovery, remediation and quality improvement in order
			 to ascertain whether the program meets assurances, corrects shortcomings, and
			 pursues opportunities for improvement; and
ii. The system performance measures, outcome
			 measures and satisfaction measures that the State will monitor and evaluate.
Many
activities evaluate the overall performance
				of the IndependentChoices program such as:
*
The IndependentChoices program uses a database to track
				a wide array of data, and uses all of the data it stores
.
Data
				entry drives end user functionality through form and e-mail generation, field
				calculation, data cross-referencing, and notices and reports. The reporting
				capabilities can help to monitor every element of operations such as: case
				particulars, work reports and management and operational tools. Use of the
				database supports discovery, remediation, and quality improvements.
* Using a
DMS approved
assessment
tool
to determine the resources in time required to provide care in the
				home.
* Reports received from Financial Management Services provider
received on a quarterly basis used
by counselors to
determine why
underutilization of the Cash Expenditure Plan
occurs and how underutilization can be resolved
.
All individual facets of the program work in a continuum to
				identify, remediate and improve
the quality of services and
the
				satisfaction of program participants while improving the overall performance of
				the program. Each phase of the program is described, detailing how assurances
				are met through the Arkansas Quality Assurance and Improvement Plan described
				below.
Monitoring and Oversight
The Division of Medical Services (DMS) retains responsibility
				for the administration and oversight of all Medicaid programs. The Division of
				Aging and Adult Services (DAAS) is the operating agency for the
				IndependentChoices program and responsible for the day-to-day operations. Both
				Divisions are part of the Arkansas Department of Human Services. DAAS will be
				responsible for executing the Quality Assurance and Improvement Plan with
				monitoring and oversight by DMS.
DAAS will provide DMS with a
monthly
report
comparing status of current data to previous year data. Examples
				included in the report may include but are not limited to
the
				following:
* Enrollment activities
* Extension of Benefits results
* Status of pending applications
* Status of active case load
* Parti
cipants who also receive home and community based
				services (HCBS)
* Medicaid Cost for IndependentChoices
including
				participant-directed cost for HCBS services
*
Detailed information for cost data for the most current
				month including cost of participant's budget and support
				services.
*
Year in Progress count of participants, contact notes,
				home visits, new enrollments for the current month, year to date and
				accumulative prior year experiences.
Lines of communication between the two Divisions are
				established and utilized to discuss additional needs and concerns that either
				Division may have.
The IndependentChoices database is designed in such a way that
				discovery and remediation go hand in hand; not only for the counselors, nurses
				and contractors, but also for management staff. By design, the efficiency of
				the database enhances the counselor's ability to provide good customer service
				and not be overly burdened with paper work.
Examples on the following pages may include but are not
				limited to:
The database quantifies:
* referrals received during the month,
* persons disenrolling,
* Extensions of Benefits requested.
The database identifies:
* reasons for disenrolling from the program,
* IndependentChoices participants who also receive HCBS waiver
				services,
* the
HCBS
RN
assigned to the
				participant
,
* the participant's physician,
* physician's fax number,
* date next reassessment
due
.
The database
tracks and creates exception reports when
				standards are not met and quantifies results. Some examples of the reports
				are
:
* time between the date of referral, the nurse's home visit,
				and receipt of the assessment from the
HCBS
RN,
* time between receiving the assessment, sending the assessment
				to the physician and receiving the authorization from the physician,
* time between the referral and the actual enrollment
*
number of home visits made by HCBS RN's within a
				timeframe
.
Each active and pending record contained within the database
				only includes data fields that are used in reporting. Each participant record
				may include the following:
* representative information, if applicable,
* parti cipant's employee,
* parti cipant's back-up worker,
* directions to the participant's home,
* nurse tracking,
* counselor tracking,
* contact notes,
*
HCBS ElderChoices (EC) service plan for persons
				receiving both ElderChoices and IndependentChoices
.
These data elements will assist the counselors and nurses in
				performing their duties by allowing timely management and monitoring of each
				participant's
case
. The HCBS service plan is used
to
				determine
if an extension of benefits is warranted, as all community
				resources are considered when requesting an extension of benefits. The database
				allows nurses, counselors or contractors to set health risk indicators
				identifying program participants who may require more frequent
				monitoring.
The data allow
s
nurses and counselors to run
				reports from their case load. Automated highlights on specific data elements
				draw the nurse or counselor's attention to areas that require special
				attention. Highlighted data fields represent the following:
* assessment performed by the nurse but not received by
				DAAS,
* counselor's request for authorization by a physician not
				received after four or more days,
* date enrollment forms sent to a potential enrollee but not
				returned.
Reports are available to management to monitor quality of
				services provided to program participants and performance of staff. The reports
				identify program strengths and weaknesses or individual areas of concern.
				Reports compare data elements over periods of time to measure progress of
				corrective actions. As issues are identified they are addressed with
				appropriate staff to determine a new course of action through issuing new
				policy, enacting new procedures, clarifying an existing policy or procedure, or
				developing additional training. Identified issues continue to be monitored to
				determine if the corrective action is resolving the concern and is achieving
				the expected outcomes.
These reports allow flexibility to generate
data
based on any specified period of time, by a nurse, counselor, contractor or by
				management. Reporting frequencies range from daily, monthly, or annually.
				Policy dictates a maximum period of time for completion of specific tasks with
				the focus
on completing
necessary tasks that allow the program
				participant to direct and meet their own health care needs.
Reporting is used to identify and remediate problems, improve
				program operation and
to evaluate
staff performance.
The database stores
contact notes documenting
IndependentChoices staff and contractors communication with program
				participants. Policy requires each contact note to be entered into the
				participant's record to enhance the ability of management to address concerns
				expressed by the participant, a legislator, the Governor's Office, etc., with a
				quick review of the contact notes.
Examples of data elements found in the
nurse
				tracking database portion
may
include,
but is not limited to
				these
data elements describing some of the following
				characteristics:
* MDS-HC RUG category
* principal diagnosis,
* secondary diagnoses,
* parti cipant well cared for,
* strong informal supports,
* no concerns noted,
* need for frequent counselor contact.
Contact notes
may
include the following:
* person initiating the call,
* person receiving the call,
* date and time of call,
* subject of contact
* description of communication,
* complaint indicator
* whom complaint is directed toward
*
date of complaint resolution
Nurses are supported by the
Nurse Case Load Report
that
quantifies the active and pending caseload for each nurse by
				describing the following:
* by county, the number of active and pending clients with or
				without home and community-based services and those with extension of
				benefits,
* data is also displayed in the aggregate by nurse per assigned
				counties.
Nurses use
a DMS approved
assessment
tool
to define the participant's medical needs relative to the amount of
				resources required to care for the person in the home. The
DMS approved
				assessment tool
is similar to the MDS assessment performed in nursing
				homes but is specifically designed for the community environment. The
				assessment results in a Resource Utilization Group (RUG) with an ADL Index
				defining the degree of functional impairment. These results help define the
				population served in addition to using a scientifically scaled and validated
				assessment instrument. The use of this assessment helps to more clearly
				describe the medical complexities of program participants as they strive to
				remain in the community and avoid institutionalization.
Monitoring occurs in various other ways such as:
* Underutilization of the allowance could be the first
				indication that a participant may be experiencing difficulty directing their
				own care. It could indicate the beginning of a decline in cognitive function,
				impairing the participant's ability to direct
their care
, a need
				for a representative
or
decision mak
ing partner
; a
				loss of worker; or it may be nothing more than not submitting the timesheets in
				a timely manner. Each counselor works with his or her participants to determine
				the cause of the underutilization. The counselor and participant work together
				to resolve the problem with the counselor providing further assistance, as
				needed, or by the participant meeting his or her responsibilities as an
				employer. The counselor follows-up with additional calls to the participant and
				monitors future underutilization reports for reoccurrences.
* Site visits to the contractors are made at a minimum
				bi-annually and more often if needed. The purpose of the site visit may be to
				provide an in-service, address concerns, or to evaluate performance. If during
				an evaluation deficiencies are noted, DAAS may provide additional in-services,
				require an acceptable corrective action plan, monitor the corrective action
				plan, withhold payment or terminate the contract.
Parti
cipant Feedback
The DAAS and its counseling and fiscal contractors support and
				encourage participant communication by provision of a
toll-free
				number
. Participants
may
pose questions and voice
				concerns using the toll-free number. Incoming calls from participants and
				outgoing calls from counselors or contractors
are
entered into the
				participant's individual electronic record. If the communication is an
				expressed complaint the
counselor follows DAAS required reporting
				procedures for documenting and resolving the complaint. Resolutions
may
				include policy or procedural changes. Monitoring will continue to determine if
				the change has any impact or if the problem needs additional review.
A DHS appeal process is available for decisions made concerning
				Medicaid eligibility or extension of benefits. An internal appeal process is
				available for participants when they
are in disagreement with the number of hours recommended
				by the HCBS RN, involuntary disenrollment or if they have disagreements with
				their counselor or fiscal agent
. The purpose of the internal appeal is
				to allow the participant a voice in the decision and a way to mediate any
				misunderstandings between the participant and the IndependentChoices program.
				Additional supporting information may be shared during this time. DAAS will
				issue
a letter to the participant
within five days from the date
				the
internal appeal is conducted
. Most disagreements are resolved
				prior to a participant initiating a
request for a fair hearing and
appeal. A formal Medicaid Fair Hearing is available when services are reduced,
				suspended, eliminated
, or upon loss of Medicaid eligibility
.
Information and Assistance
Brochures are available for marketing purposes and
are
provided
to any of
the 75 county offices
upon
				request
.
Each participant receives a program
handbook
to
				convey program guidelines and expectations.
Examples of i
nformation provided
may include any of
the following
and is
				subject to additions and deletions as needs arise
:
*
Overview of the IndependentChoices
				program
*
Overview of support services
*
Use of a representative (Decision-Making Partner) or
				Communications Manager
*
Eligibility
* Parti
cipant rights
* Parti
cipant responsibilities
*
Personal assistance services
*
Other Medicaid services
*
Medicaid waiver services
*
Expectations from counselor, nurse, bookkeeper
* Parti
cipant's enrollment duties
*
Confidentiality
*
When participant-direction begins
*
Case Expenditure Plan
*
Record Keeping
*
Payroll
*
Timesheets
*
Hiring, training, conflict resolution, and termination
				of personal assistant
*
Adult protective services
*
Support services monitoring
*
Reassessments
*
Appeal rights
Parti
cipants may also receive in-home visits,
				newsletters, questionnaires, and contact by phone to support participants
				wishing to direct their own care.
Parti cipants can speak with their counselor or the fiscal
				intermediary from 8:00 a.m. until 4:30 p.m., Monday through Friday, except for
				legal holidays
or during inclement weather
. After hours the
				participant may leave a message; the counselor will return the call within one
				working day. Complaints are entered by the receiving party whether that is the
				counselor or the fiscal intermediary.
A packet of communication forms is provided to each participant
				to report a change, to revoke and/or change disclosure of information and to
				appeal adverse decisions.
The counselor may also verbally take
				information related to changes in address or phone number.
Health and Welfare
Each participant must have an individual back-up plan
to
				handle situations when the participant's primary employee is unavailable. The
				participant identifies a person who is willing to assume the tasks of the
				primary employee. The participant determines the risk involved and how the risk
				is mitigated based on their own individual needs.
Inquiry of the use of
				the back-up plan occurs during
phone communication with the participant.
Reports from the IndependentChoices database can identify any program
				participant without a back-up personal attendant and if there is a conflict
regarding
a representative serving as a paid back-up personal
				attendant. The counselor initiates communications with the participant to begin
				remediation.
Counseling and fiscal entities will work closely together to
				provide information necessary for each entity to perform their duties. Frequent
				and
thorough
communication facilitates this good working
				relationship.
The database assists in addressing health and welfare concerns
				by allowing monitoring and management of each individual file by:
* identifying
a
participant's representative,
employee
, physician, back-up worker, directions to the home,
				results of the nurse's assessment, and updates by the counselor assisting the
				participant in the IndependentChoices program, and;
* documenting all communications with the program
				participants.
Financial Accountability
DAAS
assures that payments are made to Medicaid
				eligible participants by:
* accessing Medicaid eligibility data prior to enrolling a
				person into IndependentChoices to assure eligibility for Medicaid and the
				IndependentChoices program;
* IndependentChoices program logic implemented by
the
Arkansas Medicaid fiscal intermediary interfaces with the Medicaid
				Management Information System (MMIS) to edit against creation of an allowance
				for any participant who is no longer Medicaid eligible or is
				institutionalized;
* DAAS maintains the MMIS eligibility file for
				IndependentChoices.
The Arkansas fiscal intermediary
reads
the MMIS eligibility file
to create claims for the
				IndependentChoices program. DAAS queries on a weekly basis the Medicaid data
				warehouse to identify persons who are deceased, entered a nursing home, or have
				lost Medicaid eligibility. Once identified, the IndependentChoices eligibility
				segment is closed by an IndependentChoices counselor
on a weekly
				basis
. Through contact with the participant or participant's family or
				representative this information is obtained prior to the update of the
				MMIS;
* DAAS also queries the Medicaid data warehouse to identify
				IndependentChoices participants who have had an acute hospitalization. Once
				identified, DAAS informs the program participant, FMS provider and the
				counseling entity by letter that the participant's allowance paid prospectively
during the
hospitalization must be returned to the Medicaid
				program.
The day of admission and day of discharge are allowable
				days
;
* prevent
ing
duplication of agency and
				consumer-directed services by informing agency provider by fax seven days in
				advance the date the participant will begin directing their own personal care
				services.
Qualified Providers
IndependentChoices counseling and fiscal providers
assist
				program participants in all phases of program participation. Some of the
				examples of the work by these providers may include but is not limited to any
				of the work activities below
:
* enrollment of new participants;
*
develop and implement participant-directed
				budget;
*
coordinate with FMS provider and DAAS;
* orientation to IndependentChoices and the
philosophy of
				participant direction
;
*
offer
skills training
to the degree
				desired by the participant
on how to recruit, interview, hire, evaluate,
				manage or dismiss assistants;
* parti cipant
-directed counseling support
				services;
* monitoring IndependentChoices
				participants/representatives;
*
monitor over and under expenditures of Cash Expenditure
				Plan;
* provide quarterly reports to DAAS;
*
manage the individual budget on behalf of the
				participant;
*
process payroll and support payment for other qualified
				services and supports;
*
report and pay state and federal income taxes, FICA,
				Medicare, and state and federal unemployment taxes;
*
verify citizenship status of workers;
*
serve as the fiscal agent of the participant per IRS
				rules;
*
issues reports to DAAS;
*
communicate with counselors on budget changes;
*
inform participants of their individual budget
				balance.
DAAS is responsible for the following activities:
* monitor the counseling and fiscal providers to ensure
				compliance with the spirit of
participant
-direction and that
				appropriate counseling, fiscal and programmatic procedures are
				maintained;
* serve as the liaison between counseling agency, fiscal
				provider, Medicaid Management Information System (MMIS), and the Arkansas
				Medicaid fiscal intermediary;
* monitor the process to reimburse the counseling agency and
				fiscal provider for services provided to program participants.
Quality assurance measures previously discussed, assist DAAS in
				discovery and remediation to assure high standards in the offering and
				management of the participant-directed personal care program. The
				IndependentChoices program establishes, as its foundation, a person-centered
				approach that guides not only DAAS, but counseling and fiscal providers as
				well.
xii. Risk
			 Management
A. The risk assessment methods
			 used to identify potential risks to participants are described below:
The
HCBS
RN
or the counselor
is the
				catalyst for identifying potential risks.
In-home visits by either party
				help to identify
risks involved in the current home environment as well
				as potential risks involved with self-direction. The
counselor or the
				HCBS
RN can identify risks that may be environmental in nature such as
				throw rugs, uneven floors, etc. or the
DMS approved assessment
				tool
may identify potential risks such as not receiving a flu vaccine,
				etc. Based on the
HCBS
RN's observation and the
DMS approved
				assessment tool,
the
HCBS RN after receiving notification from
				the counselor
will discuss the potential risks identified with the
				individual.
If the HCBS RN determines that a representative is needed,
				the RN will inform the counselor.
When the HCBS RN determines that a person is in need of a
				representative, the nurse will inform the counselor, and the counselor will
				work with the participant to determine if there is someone who knows the
				participant's likes, dislikes and preferences and is willing to accept the
				responsibilities to represent the participant in the IndependentChoices
				program.
xii. Risk Management
The counselor is responsible for working with the
				participant to determine who can serve as the representative. The counselor
				will then work with the representative to teach, educate and work with the
				proposed representative so that the representative is fully aware of the
				responsibilities they are accepting in representing a person in a
				participant-directed program.
If the
HCBS
RN arrives and the participant is
				experiencing cognitive impairment and no informal supports are present, the
				participant will be discouraged from enrolling unless an informal support
				system can be identified, including someone to act as a representative decision
				maker. Participation in IndependentChoices requires
the
participant
or their representative to
be assertive
in their
				role as employer
and accept the risks, rights and responsibilities of
				directing their
own
care. If
a representative is unavailable
				and
the potential enrollee is incapable of performing these tasks
				without health and safety risks the person will not be enrolled. Blatant health
				and welfare concerns will not be compromised if solutions cannot be identified
				and enacted.
In addition to the
HCBS
RN's involvement there is
				communication with other agency providers providing home and community based
				services, with all parties having a vested interest in the health and welfare
				of the participant. This communication
assists
the operating
				agency
to
respond to any voiced concern with self-directed
				care.
The Participant Responsibilities and Agreement Form, which
				details all the requirements of self-direction, identif
ies
areas
				where the individual may not be able to meet their responsibilities.
B. The tools or instruments used to mitigate
			 identified risks are described below.
Every opportunity is afforded a participant to direct
				their own care, but the participant must accept and assume employer
				responsibility. Counseling support is available to help the participant, but
				ultimately it is the determination of the participant to succeed that
				determines whether participant direction will be a successful program for them.
				The IndependentChoices program requires a participant to make good decisions in
				order to assure that their personal assistance needs are met. The program
				allows the use of a Communications Manager for persons who have difficulty with
				written or oral communication. The Communications Manager acts as the voice of
				the participant but does not make decisions for the participant. Nor does the
				Communications Manager hire, train, supervise, or fire the participant's
				employee.
When a participant needs a representative the program
				allows for appointment of a Decision-Making Partner (DMP) who is willing to act
				and assume the employer role for the participant. The counselor is the person
				responsible for working with the participant or the participant's family in the
				appointment of either a Communications Manager or a Decision-Making Partner.
				Each time a DMP is appointed the enrollment requirements and process is similar
				to a new participant enrollment. The DMP must be at least 18 years of age and
				able and willing to meet the following requirements:
*
Possess knowledge of the participant's
				preferences
*
Be willing to meet and uphold all program
				requirements
*
Be willing to sign tax form and verify
				timesheets,
*
Show a strong personal commitment to the
				participant
*
Visit the participant at least weekly
*
Uphold all duties without influence by the personal
				assistant or paid back-up worker
*
Obtain approval from the participant and a consensus
				from other family members of the participant to serve as the DMP
*
Be willing to submit to a criminal background
				check
*
Be available to discuss the program hours
Whether a participant appoints a Communications Manager
				or Decision-Making Partner, there are specific forms that must be
				completed.
If at any time DAAS learns that the participant's personal
				attendant is not providing the care agreed upon, the counselor will contact the
				participant/representative
to ascertain the ability of the
				participant/representative to fulfill the role of employer. This discussion is
				to seek what types of assistance or support the participant or representative
				may need. A review of recurring instances of noncompliance could be reason for
				involuntary disenrollment.
When persons affiliated with the
IndependentChoices
program
suspect abuse or neglect
causing
				potential for health and safety risk to the participant
by the
				representative, family members, personal attendant, or others, the participant
				will be referred to Adult Protective Services.
C. The State's process for ensuring that each
			 service plan reflects the risks that an individual is willing and able to
			 assume, and the plan for how identified risks will be mitigated, is described
			 below
.
The service plan is a result of the
assessment
and
				will list
any
risks identified in the assessment
and
				identify
cautionary measures in relation to personal assistance needs
				with ADLs and IADLs. The service plan will
identify
any other
				risks identified through observation that
were
not identified
				through the
assessment
or risks identified by the participant,
				representative or interested parties through a participant-centered approach.
				The
HCBS RN makes the counselor aware of these concerns requiring
				a
plan or actions needed to mitigate the risks and who is responsible
				for each action. The service plan requires the signature of the participant/
				representative.
D. The
			 State's process for ensuring that the risk management plan is the result of
			 discussion and negotiation among the persons designated by the State to develop
			 the service plan, the participant, the participant's representative, if any,
			 and others from whom the participant may seek guidance, is described below.
HCBS RN's
and counselors are trained to apply a
				participant-centered approach in developing all plans with the participant.
				Participants are always encouraged to invite friends and family members who
				have a personal commitment to the participant
but are not acting as an
				employee
to be present in all meetings
or communications
between the participant and nurse or counselor. Identified risks will be
				discussed with the participant/representative and interested parties to
				determine a plan to mitigate the risk. The counselor facilitate
s
and guide
s
the discussion and identif
ies
concerns
				with any discussed approaches to mitigation of risk.
xiii. Qualifications of Providers of Personal
			 Assistance
A. ____ The State elects to permit
			 participants to hire legally liable relatives, as paid providers of the
			 personal assistance services identified in the service plan and
			 budget.
B.
X
The State elects not to permit participants to hire
			 legally liable relatives, as paid providers of the personal assistance services
			 identified in the service plan and budget.
xiv. Use of Representative
A.
X
The State
			 elects to permit participants to appoint a representative to direct the
			 provision of self-directed personal assistance services on their behalf.
i.
X
The State
			 elects to include, as a type of representative, a State-mandated
			 representative. Please indicate the criteria to be applied.
If the participant has been diagnosed with a mental or
				cognitive impair
ment
such as mental retardation, dementia,
				Alzheimer
's Disease
, etc., the participant
or family
				members close to the participant
will be required to choose a
				representative in order to participate or continue to participate in
				IndependentChoices.
If the participant is cognitively impaired and cannot
				fulfill the role of employer and has no family members who are knowledgeable of
				the participant's likes, dislikes and preferences they will no longer be able
				to direct their own care.
B. ____ The State elects not to permit
			 participants to appoint a representative to direct the provision of
			 self-directed personal assistance services on their behalf.
xv. Permissible Purchases
a.
X
The State
			 elects to permit participants to use their service budgets to pay for items
			 that increase a participant's independence or substitute for a participant's
			 dependence on human assistance.
b.
			 The State elects not to permit participants to use their service budgets to pay
			 for items that increase a participant's independence or substitute for a
			 participant's dependence on human assistance.
xvi. Financial Management Services
A.
X
The State
			 elects to employ a Financial Management Entity to provide financial management
			 services to participants self-directing personal assistance services, with the
			 exception of those participants utilizing the cash option and performing those
			 functions themselves.
i. ____ The State
			 elects to provide financial management services through a reporting or subagent
			 through its fiscal intermediary in accordance with Section 3504 of the IRS Code
			 and Revenue Procedure 80-4 and Notice 2003-70; or
ii.
X
The State
			 elects to provide financial management services through vendor organizations
			 that have the capabilities to perform the required tasks in accordance with
			 Section 3504 of the IRS Code and Revenue Procedure 70-6. (When private entities
			 furnish financial management services, the procurement method must meet the
			 requirements set forth in Federal regulations
			 45 CFR Section
			 74.40- Section
			 74.48.)
iii. ____ The State elects to provide
			 financial management services using "agency with choice" organizations that
			 have the capabilities to perform the required tasks in accordance with the
			 principles of self-direction and with Federal and State Medicaid
			 rules.
B. _____ The
			 State elects to directly perform financial management services on behalf of
			 participants self-directing personal assistance services, with the exception of
			 those participants utilizing the cash option and performing those functions
			 themselves.