Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-003 - Personal Care Provider Manual Update #58 - Level I ALFs and Level II ALFs may enroll in the Arkansas Medicaid Personal Care Program

Current through Register Vol. 49, No. 6, June, 2024
Section II
Personal
			 Care
200.110
Class
			 A Home Health Agencies
The Division of Health Facility Services, Arkansas Department
				of Health, must license a Class A Home Health agency before the agency may
				apply to enroll as a personal care provider.
200.140
Assisted Living Facilities
A. There are three types of assisted
			 living facilities (ALFs). The three types are: Residential Care Facilities
			 (RCFs), Level I Assisted Living Facilities (Level I ALFs) and Level II Assisted
			 Living Facilities (Level II ALFs).
B. The Arkansas Office of Long Term Care
			 (OLTC) certifies, licenses and regulates certain institutions, including
			 ALFs.
C. Each ALF has a separate
			 license, regardless of which type it is and regardless of its location or
			 proprietorship.
D. Each ALF that
			 provides personal care for Medicaid beneficiaries and that desires Medicaid
			 reimbursement for those services must enroll separately in the Arkansas
			 Medicaid Personal Care Program, effective for dates of service on and after
			 March 1, 2005.
1. Some providers operate
			 multiple ALF facilities, sometimes on the same property or in the same complex
			 and sometimes in multiple locations.
a.
			 Effective for dates of service before March 1, 2005, Medicaid covers personal
			 care services provided by enrolled RCFs for residents of Level I ALFs and Level
			 II ALFs under the same proprietorship as the enrolled RCF.
b. Level I and Level II ALFs that are not
			 under the same proprietorship as a Medicaid-enrolled RCF may not contract for
			 Medicaid-covered personal care with an enrolled RCF owned by another
			 entity.
c. Except under the
			 conditions described in part a above, personal care in any assisted living
			 facility may be provided only by the facility itself, if it is enrolled in the
			 Arkansas Medicaid Personal Care Program, or by
1) A private care agency that is enrolled as
			 a Personal Care provider or
2) A
			 Class A or Class B home health agency that is enrolled as a Personal Care
			 provider.
2.
			 Several provider files may share the same Federal Employer Identification
			 Number (FEIN). For example: A corporate entity that has one FEIN owns an RCF
			 and a Level I ALF and enrolls them as Personal Care Program providers.
a. Each facility is assigned a unique
			 Arkansas Medicaid provider number.
b. Each facility's Arkansas Medicaid Personal
			 Care provider number is linked to its unique license number.
c. Each facility's Arkansas Medicaid Personal
			 Care provider number is linked to the corporate entity's single FEIN.
E. For dates of service
			 before March 1, 2005, RCFs are the only assisted living facilities that may
			 participate in the Personal Care Program.
F. Sections 200.141, 200.142 and 200.143
			 outline Arkansas Medicaid Personal Care Program participation requirements for
			 RCFs, Level I ALFs and Level II ALFs.
G. In addition to the Personal Care Program,
			 Level II ALFs may participate in the Living Choices Assisted Living Program.
1. Living Choices is a home- and
			 community-based program established for certain nursing home-eligible
			 individuals who, without a program like Living Choices, would not be able to
			 live in a dwelling of their own or would be able to do so only with great
			 difficulty and with significant risk to their health and safety.
2. Providers may obtain Living Choices
			 Program participation requirements by downloading the Living Choices Assisted
			 Living Provider Manual from the Arkansas Medicaid website,
			 www.medicaid.state.ar.us.
3. Living
			 Choices services are not covered for beneficiaries receiving services through
			 the Personal Care Program, and Personal Care Program services are not covered
			 for participants in the Living Choices Program.
200.141
Residential Care
			 Facilities
A residential care facility applying for enrollment as a
				personal care provider must be licensed as a residential care facility by the
				OLTC.
200.142
Level I
			 Assisted Living Facilities
A Level I ALF applying for enrollment as a personal care
				provider must be licensed as a Level I ALF by the OLTC.
200.143
Level II Assisted Living
			 Facilities
A Level II ALF applying for enrollment as a personal care
				provider must be licensed as a Level II ALF by the OLTC.
201.000
Provider Enrollment
A. Effective January 3, 2005, EDS assumed
			 provider enrollment functions for the Arkansas Medicaid Program.
1. The Medicaid Provider Enrollment Unit is
			 automating, to the extent possible, provider enrollment tasks, including
			 provider file maintenance.
2. The
			 automated enrollment system includes provisions for obtaining and maintaining
			 required enrollment materials and documentation by means of mail, personal
			 contact and telephone contact.
3.
			 The new enrollment system includes procedures by which enrolled providers and
			 applicants for enrollment can easily query EDS regarding the status of their
			 file.
B. The assumption
			 of provider enrollment duties by EDS notwithstanding, the Arkansas Medicaid
			 Program and Medicaid providers retain certain responsibilities.
1. The Division of Medical Services (DMS)
			 retains ultimate authority to approve or disapprove provider applications and
			 Medicaid contracts.
2. Applicants
			 for Medicaid enrollment and enrolled Medicaid providers are ultimately
			 responsible for ensuring that all required documentation is on file with the
			 Medicaid Provider Enrollment Unit. Failure to provide required documentation on
			 request and within specified timeframes will result in denial of a provider
			 application or termination of a Medicaid contract.
a. Whenever verification of a provider's
			 licensure renewal is 30 days overdue, the Medicaid Management Information
			 System (MMIS) generates a letter to the provider requesting that the provider
			 forward a copy of the document within a specified timeframe.
b. Providers may inquire at any time
			 regarding the status of the documentation in their files by calling the
			 Medicaid Provider Enrollment Unit.
View or print Medicaid
			 Provider Enrollment Unit contact information.
201.100
Provider Enrollment Procedures
A. All applicants for enrollment as personal
			 care providers must complete and submit to the Medicaid Provider Enrollment
			 Unit a provider application (form DMS-652), a Medicaid contract (form DMS-653)
			 and a Request for Taxpayer Identification Number and Certification (Form W-9).
View or print form DMS-652, form DMS-653 and Form W-9. View
			 or print Medicaid Provider Enrollment Unit contact
			 information
.
B.
			 The Arkansas Medicaid Program must approve all Medicaid provider applications
			 and Medicaid contracts before enrolling providers. Persons and entities that
			 are excluded or debarred under any state or federal law, regulation, or rule
			 are not eligible to enroll, or to remain enrolled, as Medicaid
			 providers.
C. The Provider
			 Enrollment Unit reviews, for accuracy and completeness, provider applications,
			 Medicaid contracts and all other required documentation.
1. The Provider Enrollment Unit contacts
			 applicants to correct errors or omissions in the enrollment documents. Some
			 errors, such as failure to provide an original signature, necessitate returning
			 the documents to the applicant for correction.
2. When the provider application materials
			 are complete and correct and Arkansas Medicaid approves the application and
			 contract, the Provider Enrollment Unit assigns a provider number, establishes a
			 provider file and forwards to the provider written confirmation of the provider
			 number and the effective date of the provider's enrollment.
D. Sections 201.110 through
			 201.140 list the documentation required of each type of applicant for
			 enrollment as a provider in the Personal Care program.
201.110
Class A and Class B Home Health
			 Agencies
Class A and Class B Home Health Agencies must ensure that there
				is on file with the Medicaid Provider Enrollment Unit a copy of their current
				Class A or Class B license.
201.120
Private Care Agencies
A. Private care agencies must ensure that
			 there is on file with the Medicaid Provider Enrollment Unit a copy of their
			 current license from the Arkansas Department of Health.
B. Private care agencies must ensure that
			 there is on file with the Provider Enrollment Unit a copy of their current
			 license from the Arkansas Department of Labor.
C. Private care agencies must ensure that
			 there is on file with the Provider Enrollment Unit proof of liability insurance
			 coverage of not less than one million dollars ($1,000,000.000), covering their
			 employees and independent contractors while those individuals and entities are
			 engaged in providing covered Medicaid services.
D. Annually, private care agency providers
			 must ensure that there is on file with the Provider Enrollment Unit proof that
			 the agency's required liability insurance remains in force and has remained in
			 force at a level of coverage no less than the required minimum since the
			 provider's previous report.
201.130
Assisted Living Facilities
201.131
Residential
			 Care Facilities
A residential care facility applying for enrollment as a
				personal care provider must ensure that there is on file with the Medicaid
				Provider Enrollment Unit a copy of its current license from the Office of Long
				Term Care (OLTC).
201.132
Level I Assisted Living Facilities
A Level I Assisted Living Facility (ALF) applying to enroll as
				a personal care provider must ensure that there is on file with the Provider
				Enrollment Unit a copy of its current license from the OLTC.
201.133
Level II Assisted Living
			 Facilities
A Level II ALF applying to enroll as a personal care provider
				must ensure that there is on file with the Provider Enrollment Unit a copy of
				its current license from the OLTC.
201.140
Division of Developmental
			 Disabilities Services Community Providers
A Developmental Disabilities Services Community Provider
				facility applying for enrollment as a personal care provider must ensure that
				there is on file with the Provider Enrollment Unit a copy of its current
				license from the Arkansas Division of Developmental Disabilities
				Services.
202.000
Routine Services Providers and Limited Services Providers
202.100
Routine Services Providers
Routine services providers in the Arkansas Medicaid Personal
				Care Program are enrolled Medicaid providers who, in accordance with the
				regulations of the Arkansas Medicaid Program,
may provide medically necessary services to eligible and
				qualified individuals who choose to receive their services.
202.110
Personal Care Providers in
			 Arkansas
Enrolled Personal Care providers in Arkansas qualify as routine
				services providers. However, some personal care providers are limited to
				providing services only in certain places of service. See section
				213.000, part F.
202.200
Limited Services
			 Providers
Limited services providers are providers that are allowed to
				participate in Arkansas Medicaid only in order to provide emergency or prior
				authorized services.
202.201
Limited Services Providers and
			 Emergency Services
Personal care is not an emergency service, as emergency
				services are defined in title 42, Code of Federal Regulations (42 CFR), at
				§
										424.101. Therefore, personal care
				providers outside Arkansas do not qualify as limited services providers of
				emergency services.
202.202
Limited Services Providers and Prior Authorized Services
A. Services that are prior authorized to be
			 furnished by a limited services provider must always be medically necessary
			 and, in most cases, not available in Arkansas.
1. In the Personal Care Program, the
			 requirement that the service not be available in Arkansas may be waived when a
			 personal care client is temporarily out of the state.
a. See section
			 213.600 for policy guidelines
			 regarding personal care clients who temporarily change location and must
			 transfer their care to a local provider.
b. When the temporary location is in another
			 state, the Arkansas Medicaid Program may allow a personal care provider in that
			 state to enroll as a limited services provider to furnish the client's services
			 during the stay.
2.
			 Personal care for clients temporarily in another state requires prior
			 authorization.
3. Personal care for
			 clients temporarily in another state is subject to the additional regulations
			 in sections
			 213.600 and
			 213.610.
B. Send written requests for prior
			 authorization to the Division of Medical Services, Utilization Review Section.
View or print Division of Medical Services, Utilization
			 Review Section contact information
.
1. Upon notification of the prior
			 authorization, the provider may submit to the Medicaid Provider Enrollment Unit
			 the provider application (form DMS-652), Medicaid contract (form DMS-653) and a
			 Request for Taxpayer
			 I dentification Number and
			 Certification (Form W-9).
View or print form DMS-652, form
			 DMS-653 and Form W-9
.
View or print
			 Medicaid Provider Enrollment Unit contact
			 information
.
2.
			 Additionally, the provider must submit appropriate licensure, certification or
			 other documentation required by Arkansas Medicaid to establish that the
			 applicant is a qualified personal care provider.
C. Prior authorization does not guarantee
			 payment for the service.
1. The beneficiary
			 must be Medicaid eligible on the dates of service and must have available
			 benefits.
2. The provider must
			 follow the enrollment procedures in Sections I and
			 II and the billing procedures in
			 Sections II and
			 III of this manual.
D. Limited services providers must
			 submit paper claims directly to the Division of Medical Services, Utilization
			 Review Section.
View or print Division of Medical Services,
			 Utilization Review Section contact information
.
202.210
Personal Care
			 Providers Not Licensed in Arkansas
A.
			 Personal care providers licensed only in other states may not provide services
			 in Arkansas.
B. Providers that are
			 licensed in other states and that are not licensed in Arkansas may enroll in
			 Arkansas Medicaid as limited services providers only.
203.000
IndependentChoices Waiver;
			 Counseling and Fiscal Agent Enrollment
IndependentChoices is a Cash and Counseling Demonstration and
				Evaluation Project. IndependentChoices seeks to increase the opportunity for
				consumer direction and control for Medicaid recipients receiving or needing
				personal care by offering a cash allowance and counseling services in place of
				traditionally provided personal care.
A. The goal of the IndependentChoices Program
			 is to evaluate the efficiency and feasibility of a Medicaid personal care
			 program that offers consumer direction and control with a monthly cash
			 allowance.
B. As the single State
			 agency authorized to contract for Medicaid services, the Department of Human
			 Services (DHS) developed and received approval of a Section 1115 research and
			 demonstration waiver to provide IndependentChoices to adults (aged 18 and
			 older) with disabilities and the elderly (aged 65 and older).
			 IndependentChoices is administered by the Division of Aging and Adult Services
			 (DAAS).
C. The Division of Medical
			 Services contracts with counseling agencies to provide counseling and fiscal
			 services. The counseling and fiscal agent services agencies have been selected
			 through a Request for Proposal (RFP) process. One Counseling and Fiscal Agent
			 (CFA) has been selected for each of four regions.
1. Each CFA selected must submit a provider
			 application (form DMS-652), Medicaid contract (form DMS-653) and a Request for
			 Taxpayer Identification Number and Certification (Form W-9) to the Medicaid
			 Provider Enrollment Unit for enrollment as a Medicaid provider.
View or print form DMS-652, form DMS-653 and Form W-9. View
			 or print Medicaid Provider Enrollment Unit contact
			 information.
2.
			 Each CFA must ensure that the Provider Enrollment Unit has on file a letter
			 from DAAS verifying that the CFA has DAAS approval to enroll as a Medicaid
			 provider.
204.000
Record Requirements
A. Providers are required to keep the records
			 described in section
			 221.000 and, upon request, to
			 furnish the records to authorized representatives of the Arkansas Division of
			 Medical Services, the Medicaid Fraud Control Unit of the Arkansas Office of the
			 Attorney General and to representatives of the Secretary of Health and Human
			 Services.
B. All required records
			 must be kept for a period of five years from the ending date of service or
			 until all audit questions, appeal hearings, investigations or court cases are
			 resolved, whichever period is longer.
C. Furnishing records on request to
			 authorized individuals and agencies listed above in part A is a contractual
			 obligation of providers enrolled in the Medicaid Program. Sanctions will be
			 imposed for failure to furnish medical records upon request.
D. When the Medicaid Field Audit Unit of the
			 Division of Medical Services (DMS) conducts an audit of a provider's records,
			 all documentation must be made available to authorized DMS personnel at the
			 provider's place of business during normal business hours. When requested
			 records are stored off-site, the provider will be allowed up to three business
			 days to make them available to Field Audit staff.
E. If an audit determines that recoupment of
			 Medicaid payments is necessary, DMS will accept additional documentation for
			 only thirty days after the date of the notification of recoupment. Additional
			 documentation will not be accepted later.
213.500
Personal Care Service
			 Locations
A. Arkansas Medicaid covers
			 personal care in a client's home and, at the state's option, in another
			 location, for clients of all ages.
1. A
			 client's home is the client's residence, subject to the exclusions in part B,
			 below.
2. Service locations outside
			 the client's home must be included in the service plan. (If shopping or
			 assistance with shopping is included in the service plan, it is understood that
			 the actual activity occurs at a store. The place of service-for billing
			 purposes- remains the client's home.)
3. The client's assessment and service plan
			 must justify the medical necessity for personal care in a location other than
			 the client's residence. For example: A client's service plan includes
			 assistance with dressing. This particular client regularly (by PCP referral or
			 a physician's order) goes to a clinic or other site for a therapy, such as aqua
			 therapy, that involves changing clothes. If, at the therapy site, assistance
			 with dressing and/or changing is not included with the therapy service, the
			 personal care service plan may include an aide's assistance. However, in such a
			 situation, only the time the aide spends performing the service is
			 covered.
B. Medicaid
			 does not cover personal care services in the following locations:
1. A hospital,
2. A nursing facility,
3. An intermediate care facility for the
			 mentally retarded (ICF/MR) or
4. An
			 institution for mental diseases (IMD).
C. All individuals residing in locations
			 listed above in part B are ineligible for Medicaid-covered personal
			 care.
D. Individuals who are
			 inpatients or residents of the facilities and institutions listed in part B are
			 not eligible for Medicaid-covered personal care services in any
			 location.
213.510
Personal Care in Division of Developmental Disabilities Services (DDS)
			 Community Provider Facilities
A.
			 Medically necessary personal care is covered in a DDS community provider
			 facility.
B. Medicaid Program
			 requirements are the same as for personal care services delivered in a client's
			 home.
C. Personal Care Program
			 requirements are in addition to conditions imposed by other publicly funded
			 programs, including Medicaid programs, through which the client receives
			 services.
D. Individuals enrolled
			 in DDS community provider facilities may receive a number of services in
			 accordance with an Individualized Plan (IP), an Individualized Family Services
			 Plan (IFSP) or an Individualized Habilitation Plan (IHP).
1. None of these plans may supersede or
			 substitute for the personal care service plan.
2. The Personal Care Program requires a
			 distinct and separate assessment and service plan.
215.360
Service
			 Plan Requirements for Multiple Providers
A. A client may have two personal care
			 providers at a single location if the secondary provider furnishes services
			 during hours in which the primary provider does not operate or does not have an
			 available personal care aide, such as on weekends or at night.
B. Each provider must develop an
			 individualized service plan.
1. The providers
			 should cooperate in the development of the service plans.
2. Authorization of both service plans must
			 be by the same physician.
219.000
Beneficiary Due Process
219.100
Appealing an
			 Adverse Decision
A. When DMS denies
			 coverage of personal care services or denies a benefit extension request for
			 personal care, the client may appeal the denial and request a fair
			 hearing.
B. An appeal request must
			 be in writing and must be received by the Appeals and Hearings Section of the
			 Department of Human Services (DHS) within 30 days of the date on the letter
			 from DMS explaining the denial.
View or print the Department
			 of Human Services, Appeals and Hearings Section contact
			 information
.
219.200
Requesting Continuation of
			 Services Pending the Outcome of an Appeal
A. A beneficiary may request that services be
			 continued pending the outcome of an appeal.
1. Appeals that include a request to continue
			 services must be received by the DHS Appeals and Hearing Section within 10 days
			 of the date on the DMS denial letter.
2. When such requests are made and timely
			 received by the Appeals and Hearings Section, DMS will authorize the services
			 and notify the provider and beneficiary.
3. The provider will be reimbursed for
			 services furnished under these circumstances and for which the provider
			 correctly bills Medicaid.
B. If the beneficiary loses the appeal, DMS
			 will take action to recover from the beneficiary Medicaid's payments for the
			 services that were provided pending the outcome of the appeal.
220.113
Service Logging by
			 Electronic Media
A. Personal care aides
			 may log the times that they begin and end services, as well as the services
			 themselves, by electronic media, such as telephony.
B. Electronic signatures, as permitted under
			 Arkansas law and as defined in Section
			 IV of this manual, are allowed in
			 the Personal Care Program.
C. All
			 Arkansas Medicaid documentation requirements must be met, regardless of
			 documentation media.
262.110
Place of Service Codes for
			 Paper and Electronic Claims
Place of Service
Paper Claims
Electronic Claims
Client's Home
*
4
12
DDS Community Provider Facility
**
5
99
Public School
***
S
03
Other Locations
****
0 (zero)
99
*
The client's home is the client's residence,
				subject to the exclusions in section
				213.500, part B. For example, if
				a client lives in a residential care facility (RCF) or an assisted living
				facility (ALF), then the RCF or ALF is the client's home and is so indicated on
				an electronic claim by place of service code 12.
**
A Division of Developmental Disabilities
				Services Community Provider Facility, for clients under age 21 whose
				instruction is not the responsibility of the client's school district or for
				clients aged 21 and older.
NOTE: There is no HIPAA-approved place of
				service code for a developmental disabilities clinic or habilitation facility.
				Providers must use place of service code 99-"Other Place of Service" for this
				designation.
***
Personal Care services provided by a school
				district or education service cooperative require place of service code S and
				type of service code S on paper claims. See section
				213.520 for a full explanation of
				the "public school" place of service.
****
Not
a public
				school