Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.18-019 - Provider-Led Arkansas Shared Savings Entity (PASSE) Program

Current through Register Vol. 49, No. 6, June, 2024
1915(i) State plan Home and Community-Based Services
				Administration and Operation
The state implements the optional 1915(i) State plan Home and
				Community-Based Services (HCBS) benefit
for elderly and disabled individuals as set forth
				below.
1.
Services.
(Specify the state's service title(s) for the HCBS defined under
			 "Services " and listed in Attachment 4.19-B):
Supported Employment; Behavior Assistance; Adult Rehabilitation
				Day Treatment; Peer Support; Family Support Partners; Residential Community
				Reintegration; Respite; Mobile Crisis Intervention; Therapeutic Host Home;
				Recovery Support Partners (for Substance Abuse); Substance Abuse Detox
				(Observational); Pharmaceutical Counseling; Supportive Life Skills Development,
				Child and Youth Support; Partial Hospitalization, Supportive Housing; and
				Therapeutic Communities.
2.
Concurrent Operation with Other Programs.
(Indicate
			 whether this benefit will operate concurrently with another Medicaid
			 authority):
Click here
				to view image
3.
State Medicaid Agency (SMA) Line of Authority for Operating the State
			 plan HCBS. Benefit-
(Select one):
Click here
				to view image
4.
Distribution of State plan HCBS Operational and Administrative
			 Functions.
[TICK]
(By checking this box the state assures that):
When the Medicaid agency does not directly conduct an administrative
				function, it supervises the performance of the function and establishes and/or
				approves policies that affect the function. All functions not performed
				directly by the Medicaid Agency must be delegated in writing and monitored by
				the Medicaid Agency. When a function is performed by an agency/entity other
				than the Medicaid Agency, the agency/entity performing that function does not
				substitute its own judgment for that of the Medicaid Agency with respect to the
				application of policies, rules and regulations. Furthermore, the Medicaid
				Agency assures that it maintains accountability for the performance of any
				operational, contractual, or local regional entities. In the following table,
				specify the entity or entities that have responsibility for conducting each of
				the operational and administrative functions listed
(check each that
				applies):
(Check all agencies and/or entities that perform each
				function):
Click here
				to view image
Click here
				to view image
(Specify, as numbered above, the agencies/entities
				(other than the SMA) that perform each function):
The PASSEs will assist with 4, 5, 6, and 8.
The contracted actuary will assist with 8.
The External Quality Review Organization (EQRO) that contracts
				with DMS will assist with 3,5, and 10.
(By checking the following boxes the State assures
				that):
5.
[TICK] Conflict of Interest Standards.
The state assures the
			 independence of persons performing evaluations, assessments, and plans of care.
			 Written conflict of interest standards ensure, at a minimum, that persons
			 performing these functions are not:
* related by blood or marriage to the individual, or any paid
				caregiver of the individual
* financially responsible for the individual
* empowered to make financial or health-related decisions on
				behalf of the individual
* providers of State plan HCBS for the individual, or those who
				have interest in or are employed by a provider of State plan HCBS; except, at
				the option of the state, when providers are given responsibility to perform
				assessments and plans of care because such individuals are the only willing and
				qualified entity in a geographic area, and the state devises conflict of
				interest protections.
(If the state chooses this option, specify the
				conflict of interest protections the state will implement):
6.
[TICK] Fair Hearings and
			 Appeals.
The state assures that individuals have opportunities for fair
			 hearings and appeals in accordance with 42 CFR 431 Subpart E.
7.
[TICK] No FFP for Room and Board.
The state has methodology to prevent claims for Federal financial
			 participation for room and board in State plan HCBS.
8.
[TICK] Non-duplication of services.
State plan HCBS will not be provided to an individual at the same time
			 as another service that is the same in nature and scope regardless of source,
			 including Federal, state, local, and private entities. For habilitation
			 services, the state includes within the record of each individual an
			 explanation that these services do not include special education and related
			 services defined in the Individuals with Disabilities Education Improvement Act
			 of 2004 that otherwise are available to the individual through a local
			 education agency, or vocational rehabilitation services that otherwise are
			 available to the individual through a program funded under §110 of the
			 Rehabilitation Act of 1973.
Number Served
1.
Projected Number of Unduplicated
			 Individuals To Be Served Annually.
(Specify for year one. Years 2-5
				optional):
Annual Period
From
To
Projected Number of Participants
Year 1
Mar. 1,2019
Feb.29,2020
30,000
Year 2
Mar. 1, 2020
Feb. 28,2021
Year 3
Mar. 1,2021
Feb.28, 2022
Year 4
Mar. 1, 2022
Feb.28,2023
Year 5
Mar. 1, 2023
Feb.28,2024
2.
[TICK] Annual Reporting.
(By checking this box the state
			 agrees to):
annually report the actual number of unduplicated
			 individuals served and the estimated number of individuals for the following
			 year.
Financial Eligibility
1.
[TICK] Medicaid Eligible.
(By checking this box the state assures that):
Individuals receiving State plan HCBS are included in an eligibility
			 group that is covered under the State's Medicaid Plan and have income that does
			 not exceed 150% of the Federal Poverty Line (FPL). (This election does not
			 include the optional categorically needy eligibility group specified at
			 §1902(a)(10)(A)(ii)(XXII) of the Social Security Act. States that want to
			 adopt the § 1902(a)(10)(A)(ii)(XXII) eligibility category make the
			 election in Attachment 2.2-A of the state Medicaid plan.)
2.
Medically Needy
(Select one):
Click here
				to view image
Evaluation/Reevaluation of
				Eligibility
1.
Responsibility for Performing Evaluations
/
Reevaluations.
Eligibility for the State plan HCBS benefit must be determined through
			 an independent evaluation of each individual). Independent
			 evaluations/reevaluations to determine whether applicants are eligible for the
			 State plan HCBS benefit are performed
{Select one):
Directly by the Medicaid agency
X
By Other
{specify State agency or entity under
						  contract with the State Medicaid agency):
Evaluations and re-evaluations are conducted by DHS's
						  third-party contractor who completes the independent assessment. Eligibility is
						  determined by DMS using the results of the independent assessment and the
						  individual's diagnoses.
i. .
2.
Qualifications of Individuals Performing Evaluation/Reevaluation.
The independent evaluation is performed by an agent that is independent
			 and qualified. There are qualifications (that are reasonably related to
			 performing evaluations) for the individual responsible for
			 evaluation/reevaluation of needs-based eligibility for State plan HCBS.
(Specify qualifications):
The assessor must have a Bachelor's Degree or be a registered
				nurse with one (1) year of experience with mental health populations.
3.
Process for Performing
			 Evaluation/Reevaluation.
Describe the process for evaluating whether
			 individuals meet the needs-based State plan HCBS eligibility criteria and any
			 instrument(s) used to make this determination. If the reevaluation process
			 differs from the evaluation process, describe the differences:
Individuals are referred for the independent assessment based
				upon their current diagnosis and utilization of services. Measurement is
				completed through an assessment of functional deficit through a face-to-face
				evaluation of the beneficiary, caregiver report and clinical record review. The
				assessment measures the beneficiary's behavior in psychosocial sub-domains and
				intervention domain that evaluates the level of intervention necessary to
				managed behaviors as well as required supports to maintain beneficiary in home
				and community settings. After completion of the independent assessment of
				functional need, DMS makes the final eligibility determination for all clients
				based on the results of the independent assessment and the individual's
				diagnosis contained in his or her medical record. Eligibility is re-evaluated
				on an annual basis.
4.
[TICK] Reevaluation Schedule.
(By checking this box the
			 state assures that):
Needs-based eligibility reevaluations are
			 conducted at least every twelve months.
5.
[TICK] Needs-based HCBS Eligibility
			 Criteria.
(By checking this box the state assures that):
Needs-based criteria are used to evaluate and reevaluate whether an
			 individual is eligible for State plan HCBS.
The criteria take into account the individual's support needs,
				and may include other risk factors:
(Specify the needs-based
				criteria):
After medical eligibility has been determined through
				diagnosis, the following needs-based criteria is used:
The individual must receive a minimum of a Tier 2 functional
				assessment for HCBS behavioral health services. To meet a Tier 2, the
				individual must have difficulties with certain behaviors that require a full
				array of nonresidential services to help with functioning in home and
				community-based settings and moving towards recovery, and is not a harm to his
				or herself or others. Behaviors assessed include manic, psychotic, aggressive,
				destructive, and other socially unacceptable behaviors.
Measurement is completed through an assessment of functional
				deficit through a face-to-face evaluation of the beneficiary, caregiver report
				and clinical record review. The assessment measures the beneficiary's behavior
				in psychosocial sub-domains and intervention domain that evaluates the level of
				intervention necessary to managed behaviors as well as required supports to
				maintain beneficiary in home and community settings.
1915(i) services must be appropriate to address the individuals
				identified functional deficits due to their behavioral health diagnosis.
6.
[TICK] Needs-based
			 Institutional and Waiver Criteria.
(By checking this box the
			 state assures that):
There are needs-based criteria for receipt of institutional
				services and participation in certain waivers that are more stringent than the
				criteria above for receipt of State plan HCBS. If the state has revised
				institutional level of care to reflect more stringent needs-based criteria,
				individuals receiving institutional services and participating in certain
				waivers on the date that more stringent criteria become effective are exempt
				from the new criteria until such time as they no longer require that level of
				care.
(Complete chart below to summarize the needs-based criteria for
				State Plan HCBS and corresponding more-stringent criteria for each of the
				following institutions):
State plan HCBS needs-based eligibility
						  criteria
NF (& NF
LOC**
waivers)
ICF/IID (& ICF/IID LOC
waivers)
Applicable Hospital* (& Hospital LOC
						  waivers)
The individual must receive a minimum of a Tier 2
						  functional assessment for HCBS behavioral health services. To meet a Tier 2,
						  the individual must have difficulties with certain behaviors that require a
						  full array of nonresidential services to help with functioning in home and
						  community-based settings and moving towards recovery, and is not a harm to his
						  or herself or others. Behaviors assessed include manic, psychotic, aggressive,
						  destructive, and other socially unacceptable behaviors.
1915(i) services must be appropriate to address the
						  individuals identified functional deficits due to their behavioral health
						  diagnosis.
Must meet at least one of the following three criteria
						  as determined by a licensed medical professional:
1. The individual is unable to perform either of the
						  following: A. At least one (1) of the three (3) activities of daily living
						  (ADLs) of transferring/locomotion, eating or toileting without extensive
						  assistance from or total dependence upon another person; or,
B. At least two (2) of the three (3) activities of
						  daily living (ADLs) of transferring/locomotion, eating or toileting without
						  limited assistance from another person; or,
2. The individual has a primary or secondary diagnosis
						  of Alzheimer's disease or related dementia and is cognitively impaired so as to
						  require substantial supervision from another individual because he or she
						  engages in
1) Diagnosis of developmental disability that
						  originated prior to age of 22;
2) The disability has continued or is expected to
						  continue indefinitely; and
3) The disability constitutes a substantial handicap to
						  the person's ability to function without appropriate support services,
						  including but not limited to, daily living and social activities, medical
						  services, physical therapy, speech therapy, occupational therapy, job training
						  and employment.
Must also be in need of and able to benefit from active
						  treatment and unable to access appropriate services in a less restrictive
						  setting.
Individuals must be assessed a Tier 2 or Tier
						  3
There must be a written certification of need (CON)
						  that states that an individual is or was in need of inpatient psychiatric
						  services. The certification must be made at the time of admission, or if an
						  individual applies for Medicaid while in the facility, the certification must
						  be made before Medicaid authorizes payment.
Tests and evaluations used to certify need cannot be
						  more than one (1) year old. All histories and information used to certify need
						  must have been compiled within the year prior to the CON.
In compliance with
						  42 CFR
						  441.152, the facility-based and independent
						  CON teams must certify that:
A. Ambulatory care resources available in the community
						  do not meet
inappropriate behaviors which pose serious health or
						  safety hazards to himself or others; or,
3. The individual has a diagnosed medical condition
						  which requires monitoring or assessment at least once a day by a licensed
						  medical professional and the condition, if untreated, would be
						  life-threatening.
4. No individual who is otherwise eligible for waiver
						  services shall have his or her eligibility denied or terminated solely as the
						  result of a disqualifying episodic medical condition or disqualifying episodic
						  change of medical condition which is temporary and expected to last no more
						  than twenty-one (21) days. However, that individual shall not receive waiver
						  services or benefits when subject to a condition or change of condition which
						  would render the individual ineligible if expected to last more than twenty-one
						  (21) days.
to receive services in the CES Waiver or an
						  ICF/IID.
the treatment needs of the beneficiary;
B. Proper treatment of the beneficiary's psychiatric
						  condition requires inpatient services under the direction of a physician
						  and
C. The services can be reasonably expected to prevent
						  further regression or to improve the beneficiary's condition so that the
						  services will no longer be needed.
Specifically, a physician must make a medical necessity
						  determination that services must be provided in a hospital setting because the
						  client is a danger to his or herself or other, and cannot safely remain in the
						  community setting.
*Long Term Care/Chronic Care Hospital **LOC= level of
				care
7.
[TICK] Target
			 Group(s).
The state elects to target this 1915(i) State plan HCBS
			 benefit to a specific population based on age, disability, diagnosis, and/or
			 eligibility group. With this election, the state will operate this program for
			 a period of 5 years. At least 90 days prior to the end of this 5-year period,
			 the state may request CMS renewal of this benefit for additional 5-year terms
			 in accordance with 1915(i)(7)(C) and
			 42
			 CFR 441.710(e)(2).
{Specify targetgroup(s)):
Targeted to individuals with a behavioral health diagnosis, who
				are age four and older.
[] Option for Phase-in of Services and Eligibility.
If the state elects to target this 1915(i) State plan HCBS benefit, it
				may limit the enrollment of individuals or the provision of services to
				enrolled individuals in accordance with 1915(i)(7)(B)(ii)and
				42
				CFR 441.745(a)(2)(h) based
				upon criteria described in a phase- in plan, subject to CMS approval. At a
				minimum, the phase-in plan must describe:
(1) the criteria used to limit enrollment or
			 service delivery;
(2) the rationale
			 for phasing-in services and/or eligibility; and
(3) timelines and benchmarks to ensure that
			 the benefit is available statewide to all eligible individuals within the
			 initial 5-year approval.
(Specify the phase-in plan) :
(By checking the following box the State assures
				that):