Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.18-012 - Provider-Led Arkansas Shared Savings Entity (PASSE) 1-18 Part 1

Current through Register Vol. 49, No. 6, June, 2024
Section II
Provider-Led Arkansas Shared Savings Entity (PASSE) Program
200.000 DEFINITIONS
Adjusted Premium
				Revenue
Premium revenue as defined in
				42 CFR
				§
											438.8 minus the PASSE's Federal, State
				and local ' taxes, licensing and regulatory fees as defined in
				42 CFR
				§
											438.8.
Administrative Cost
				Ratio
Administrative Cost Percentage [
				42 CFR §
											438.116(a) and (b) ] is the
				total administrative expenses, divided by total payments received from State of
				Arkansas less premium tax.
Adverse Decision/Adverse
				Action
Any decision or action by the PASSE or DHS that adversely
				affects a Medicaid provider or beneficiary in regard to receipt of and payment
				for claims and services including but not limited to decisions or findings
				related to:
A. Appropriate level of
			 care or coding,
B. Medical
			 necessity,
C. Prior
			 authorization,
D. Concurrent
			 reviews.
E. Retrospective
			 reviews,
F. Least restrictive
			 setting,
G. Desk audits,
H. Field audits and onsite audits
I. Inspections, and
J. Payment amounts due to or from a
			 particular provider resulting from gain sharing, risk sharing, incentive
			 payments or another reimbursement mechanism or methodology.
Arkansas Department of Human Services
				(DHS)
The Arkansas Department of Human Services (DHS) is the
				designated single state agency with responsibilities to administer the Medicaid
				program.
Arkansas Insurance Department
				(AID)
The Arkansas Insurance Department (AID) has the responsibility
				to license PASSEs. Among its responsibilities, AID establishes bonding and
				reserve requirements for solvency.
Assignment
The process by which DHS assigns a newly eligible member among
				the active PASSEs. The individual will have 90 days from the date coverage
				begins to switch to a different PASSE. If the individual does not choose to
				switch to a different PASSE within this time, he/she will remain a member of
				that PASSE until the end of the coverage year.
Benefit Expenditure Report
				(BER)
The Benefit Expenditure Report documents how much was paid
				during the performance year by the PASSE, in the aggregate, to direct service
				providers for services provided to its members. A PASSE may choose to spend up
				to five percent (5%) of benefit expenditures on community investments.
				Community investments will be counted as benefit expenditures rather than
				administrative expenditures in calculating and reporting the medical loss
				ratio.
Care Coordination
Activities involving
a
collaborative
				patient-centered engagement of the individual and their caregiver in service
				referral, follow up, and service navigation. The care coordination process
				includes assessing, collaborating on care planning, medication management,
				treatment plan follow-through, service coordination, monitoring the patient
				adherence, and reevaluating the patient for medically necessary care and
				service. These activities focus on ensuring the individual's healthcare and
				support service needs are met; through effective provider and patient
				communication, information sharing, follow up, care transitions, and assurance
				of timely access to care that promotes quality, cost-effective outcomes.
Case Management
Services furnished to assist individuals in gaining access to
				needed medical, social, educational, and others services in accordance with
				42 CFR §
											440.169.
Centers for Medicare & Medicaid Services
				(CMS)
The Centers for Medicare & Medicaid Services (CMS) is the
				federal agency delegated by the Secretary of the US Department of Health and
				Human Services to administer the Medicaid program under Title XIX of the Social
				Security Act and thereby has federal oversight responsibilities for the state
				and the PASSES.
The state and the PASSES must meet the requirements of a
				Medicaid managed care organization as defined in 42 CFR § Part 438.
Claims Payment
A claims payment is a payment made in full or in part to a
				service provider for the provision of medically necessary treatment and
				services to an eligible beneficiary that is a PASSE member. Claims types
				include hospital inpatient, outpatient, professional payments, clinic,
				ancillary, pharmacy, support service, and other institutional payments.
Claims Payment
				Process
A claims payment process involves all the business and
				operational processes, claims management information systems, and banking
				processes that are necessary to receive, validate, adjudicate, audit, and
				reimburse providers for services provided to eligible beneficiary. These
				business and operational activities, processes, and systems are performed and
				managed by the PASSE organization to meet the claims payment standards of the
				State.
Direct Service
				Provider
An organization or individual that delivers healthcare services
				to beneficiaries attributed to a PASSE. PASSE Equity Owners can be direct
				service providers.
Dlsenrollment
A determination by DHS that a member is no longer eligible to
				receive PASSE services.
Federal. State, and local taxes and licensing
				and regulatory fees
Federal, State, and local taxes and licensing and regulatory
				fees are as defined in
				42 CFR
				§
											438.8.
Flexible Supports
Flexible supports are a person-centered support developed for
				an individual need, and is generally provided on a case-by-case basis. These
				supports do not have to be pre-approved by DHS.
Fraud Prevention
				Activities
Fraud Prevention Activities are as defined in
				42 CFR
				§
											438.8
Incurred Claims
Incurred claims are as defined in
				42 CFR
				§
											438.8
Independent
				Assessment
An Independent Assessment (IA) is required prior to becoming a
				member of a PASSE. Not all Medicaid enrollees can be enrolled in a PASSE.
				Individuals must be in need of behavioral health or developmental disabilities
				services. An IA is conducted by qualified individual using an assessment
				instrument approved by DHS. Individuals who are assessed as meeting a Tier II
				or Tier III level of care condition will be assigned into an active PASSE and
				are required to obtain all non-excluded Medicaid services through the
				PASSE.
An individual who is assessed as meeting a Tier I level of care
				condition may voluntarily enroll in a PASSE as of July 1,2019 or later as
				specified by DHS.
The Tier is also used by DHS in the determination of the
				actuarially sound rates to be paid to a PASSE for that individual.
Medical/Qualitv Management
				Committee
A committee developed by the PASSE to oversee Quality Assurance
				and Quality Improvement activities of PASSE services.
Medical Loss Ratio
Each PASSE must report its Medical Loss Ratio (MLR) to AID and
				DHS. Calculation of the MLR is defined at
				42 CFR
				§
											438.8.
Member
A Medicaid beneficiary who is enrolled in a PASSE.
Network Provider
The provider who, under a contract with a PASSE or with its
				contractor/subcontractor, has agreed to provide Health Care Services to persons
				with an expectation of receiving payments directly or indirectly from the
				PASSE.
Open Enrollment
				Period
DHS will, on an annual basis, offer an open enrollment period
				for all current enrollees to choose a different PASSE for coverage beginning
				January 1 of the following year. If an individual does not make an active
				choice to switch PASSEs during the open enrollment period, that individual will
				remain a member of the same PASSE for the twelve (12) months of the new
				coverage year provided the individual is otherwise eligible.
Out-of-Network
				Provider
A provider who is enrolled in the Arkansas Medicaid program but
				who did not join the network of a particular PASSE. Payment to an
				out-of-network provider may differ from an in-network provider, but must comply
				with any applicable Arkansas Medicaid consent decree.
If an out-of-network provider renders a service to a PASSE
				member, it must do so in conformance with the rights of a Medicaid enrollee.
				These rights include that the provider accept the PASSE payment
for
services as payment in
full
and not bill
the
				individual.
PASSE Equity
				Partners
An organization or individual that is a member of or has an
				ownership interest in a PASSE and delivers healthcare services to members or is
				an administrator of healthcare services.
Person-Centered Service Plan
				(PCSP)
The total plan of care made in accordance with person centered
				service planning as described in 42 CFR
441.301 (c)(1
)
that
indicates the following:
A.
			 Services necessary for the member;
B. Any specific needs the member
			 has;
C. The member's strength and
			 needs; and,
D. A crisis plan for
			 the member.
Performing Provider
Individual who is the rendering provider of a particular
				service.
Premium Revenue
Premium revenue is as defined in
				42 CFR
				§
											438.8.
Provider-Led Arkansas Shared Savings Entity
				(PASSE)
A Risk Based Provider Organization (RBPO) in Arkansas that has
				enrolled in Medicaid and meets the following requirements:
A.
Is
51% owned by PASSE Equity
			 Partners;
and
B. Has
			 the following Members or Owners:
1. An
			 Arkansas licensed or certified direct service provider of Developmental
Disabilities (DD) services;
2. An Arkansas licensed or certified direct
			 service provider of Behavioral Health (BH) services;
3. An Arkansas licensed
hospital or
			 hospital services
organizations;
4. An Arkansas licensed physician's practice;
			 and
5. A Pharmacist who is licensed
			 by the Arkansas State Board of Pharmacy.
Among other things, each PASSE must be licensed by AID,
				enrolled as a Medicaid provider, and
enter into an annual
PASSE
				agreement
with
DHS.
Provider Network
The group of direct service providers that are contracted to
				provide services to members of a PASSE.
Quality
				Improvement
Activities that improve healthcare quality as defined in
				42 CFR
				§
											438.8. These activities must be
				designed to:
A. Improve health
			 quality;
B. Meet specified quality
			 performance measures;
C. Increase
			 the likelihood of desired health outcomes in ways that are capable of being
			 objectively measured and or producing verifiable results and
			 achievements;
D. Be directed toward
			 individual members incurred for the benefit of specified segments of members or
			 provide health improvements to the population beyond those enrolled in coverage
			 as long as no additional costs are incurred due to the non-members;
			 and
E. Be grounded in
			 evidence-based medicine, widely accepted best clinical practice, or criteria
			 issued by recognized professional medical associations, accreditation bodies,
			 government agencies or other nationally recognized health care quality
			 organizations.
Risk-Based Comprehensive Global
				Payment
Risk-based comprehensive global payment is a capitated payment
				that is made in monthly prorated payment to the PASSE for each assigned PASSE
				member. Only a licensed Risk-Based Provider Organization/ Provider-Led Arkansas
				Shared Savings Entity (PASSE) in good standing in the State of Arkansas is
				eligible to receive a global payment under the program. Comprehensive means
				that the PASSE is at financial risk and obligated to pay for medically
				necessary inpatient hospital, outpatient, institutional, professional services,
				pharmacy, ancillary, long term care services and supports, and any other
				covered service, not exclusive or carved out, for members as specified in the
				scope of services identified in the State plan section 1905(a).
Risk-based Provider Organization
				(RBPO)
An entity that is licensed by the Insurance Commissioner under
				Act 775 of 2017 and the risk-based provider organization rules.
Service Encounter
A standardized record of a health care-related service,
				procedure, treatment, or therapy rendered by a licensed provider or providers
				to a PASSE member. There are two types of service encounters, paid claim
				encounter and non-paid encounters that were performed but are not
				reimbursable.
Telemedicine
The use of electronic information and communication technology
				to deliver healthcare services, including without limitation the assessment,
				diagnosis, consultation, treatment, education, care management, and
				self-management of a patient. It included store-and-forward technology and
				remote patient monitoring.
The following activities will not be considered a reportable
				encounter when delivered to a member of the PASSE:
A. Audio-only communication, including
			 without-limitation, interactive audio;
B. A facsimile machine;
C. Text messaging; or
D. Electronic mail systems.
The Act
Title XIX of the Social Security Act.
Transition
The movement of a member from one PASSE to another, either by
				choice or for cause as defined in section 213.000 of this manual.
Value-based
				Payments
Payments made by a PASSE to its providers to promote efficiency
				and effectiveness of services, improve quality of care, improve patient
				experience and access to care, and promote most appropriate utilization in the
				most appropriate setting. Such payments may be made as part of a PASSE's
				Quality Assessment and Performance Improvement (QAPI) strategy.
Virtual and Home Visit Provider
				Services
Virtual services are telemedicine, telehealth, e-consulting,
				and provider home visits that are part of a patient care treatment plan and are
				provided at the individual's home or in a community setting. These services are
				provided using mobile secure telecommunication devices, electronic monitoring
				equipment, and include clinical provider care, behavioral health therapies,
				speech, occupational and physical therapy services, and treatment provided to
				an individual at their residence. Virtual provider services may use various
				evidence-based and innovative independence at-home strategies. They may include
				the provision of on-going care management, remote telehealth monitoring and
				consultation, face to face or through the use secure web-based communication
				and mobile telemonitoring technologies to remotely monitor and evaluate the
				patient's functional and health status. Virtual and telehealth services are
				provided in lieu of providing the same services at a practice site or provided
				at the individual's place of residence. Therefore, these services must have
				patient consent, be documented in the patient integrated medical records, and
				submitted as a claims or encounter from a contracted provider as medically
				necessary service. The provision of virtual care can include an
				interdisciplinary care team or be provided by individual clinical service
				provider.