Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-008 - DDS Alternative Community Services (ACS) Provider Manual Update Transmittal # 60

Current through Register Vol. 49, No. 6, June, 2024
Section II DDS
			 Alternative Community Services (ACS) Waiver
201.200
Organized Health Care Delivery
			 System Provider
The DDS Alternative Community Services (ACS) Waiver allows a
				provider who is licensed and certified as a DDS ACS case manager or a DDS ACS
				supportive living services provider to enroll in the Arkansas Medicaid Program
				as a DDS ACS organized health care delivery system (OHCDS) provider.
As long as the OHCDS provides at least one waiver service, an
				OHCDS provider may provide any other DDS ACS Waiver service via a sub-contract
				with an entity qualified to furnish the service.
The OHCDS provider furnishes the services as the individual's
				provider of choice as described in that individual's multi-agency plan of
				services (MAPS). The OHCDS provider must adhere to DDS ACS Waiver regulations
				as outlined in this provider manual. The OHCDS assumes all liability for
				services provided and/or performed by a sub-contracted entity.
I 210.000 PROGRAM COVERAGE
211.000
Scope
The Arkansas Medical Assistance Program (Medicaid) offers
				certain home and community based services as an alternative to
				institutionalization. These services are available for eligible individuals
				with a developmental disability who would otherwise require an intermediate
				care facility for the mentally retarded (ICF/MR) level of care. The home and
				community based services to be provided through this waiver are described
				herein as the DDS Alternative Community Services Waiver Renewal, hereafter
				referred to as DDS ACS Waiver.
As stated in the DDS ACS Waiver, "waiver services will not be
				furnished to persons while they are inpatients of a hospital, Nursing Facility
				(NF), or Intermediate Care Facility for the Mentally Retarded (ICF/MR) unless
				payment to the hospital, NF, or ICF/MR is being made through private pay or
				private insurance."
Services provided under this program are as follows:
A. ACS Supportive Living
B. Community Experiences
C. ACS Respite Care
D. ACS Non-Medical Transportation
E. ACS Waiver Coordination
F. Supported Employment
G. Adaptive Equipment
H. Environmental Modifications
I. ACS Specialized Medical Supplies
J. Supplemental Support Service
K. Case Management Services
L. Consultation Services
M. Crisis Intervention Services
N. Crisis Center
213.100
ACS Supportive Living
			 Exclusions
Only hired caregivers may be reimbursed for supportive living
				services provided.
Payments for supportive living services will not be made to the
				parent, stepparent or legal guardian of a person less than 18 years old.
Payments will not be made to a spouse.
The payments for these services exclude the costs of room and
				board, including general maintenance, upkeep or improvement to the individual's
				own home or that of his or her family.
Routine care and supervision for which payment will not be made
				are defined as those activities that are necessary to assure a person's well
				being but are not activities that directly relate to active treatment goals and
				objectives.
See section
				270.000 for billing
				information.
214.000
Community Experiences
Community experiences services are a flexible array of supports
				designed to allow individuals to gain experience and abilities that will
				prevent institutionalization. Through this broad base of learning
				opportunities, participants will identify, pursue and gain skills and abilities
				in activities that reflect their interests.
This model helps to improve community acceptance, employment
				opportunities and general well-being. The services are preventive, therapeutic,
				diagnostic and habilitative and will create an environment that will promote a
				person's optimal functioning.
The model also teaches developmental and living skills in the
				natural environment or clinic setting to ensure maximum learning and
				generalization. The services focus on enabling the person to attain or maintain
				his or her potential functional level and must be coordinated with any
				physical, occupational or speech therapies listed in the plan of care. These
				services reinforce skills or lessons taught in school, therapy or other
				settings.
When supports are provided in a clinic setting and the
				individual receives four or more hours of support, a noon meal is included in
				the service.
Services include activities and supports to accomplish
				individual goals or learning areas, including recreation and/or for specific
				training or leisure activities. To participate in community experiences
				activities, an individualized plan of treatment is required. Each activity is
				then adapted according to the participant's needs. Activities DDS may approve
				under this service include but are not limited to:
A. Community Based Time Management
B. Home Safety (sanitation, food handling,
			 laundry, chemical storage)
C.
			 Etiquette/Manners
D. Physical
			 Exercise
E. Literacy
F. Job Interviewing Skills
G. Interpersonal Skills
H. Sex Education
I. Self Care/Proper Attire
J. Budgeting
K. Diet/Nutrition
L. Verbal Communication Skills
M. Self Improvement
N. Mental Health Support Groups
O. Adapted Curriculum AA Groups
P. Understanding Medications (e.g., what
			 medication is used for, side effects, how to contact the physician or emergency
			 services, how to communicate with a physician, understanding various lab and
			 X-ray procedures, fear abatement, etc.)
Q. Disability Support Groups
See section
				270.000 for billing
				information.
223.000
Case Management Services
Case management services refer to a system of ongoing
				monitoring of the provision of services included in the waiver participant's
				multi-agency plan of service (MAPS). Case managers initiate and oversee the
				process of assessment of the individual's level of care and the review of MAPS
				at specified reassessment intervals.
Case management services include responsibility for locating,
				coordinating and monitoring:
A. All
			 proposed waiver services
B. Other
			 Medicaid State Plan services
C.
			 Needed medical, social, educational and other publicly funded services
			 regardless of the funding source
D.
			 Informal community supports needed by individuals and their families
The intent of case management services is to enable waiver
				participants to receive a full range of appropriate services in a planned,
				coordinated, efficient and effective manner.
Case management services consist of the following
				activities:
A. Arranging for the
			 provision of services and additional supports
B. Monitoring and reviewing participant
			 services
C. Facilitating crisis
			 intervention
D. Guidance and
			 support
E. Case planning
F. Needs assessment and referral for
			 resources
G. Follow-along to ensure
			 quality of care
H. Case reviews
			 that focus on the individual's progress in meeting goals and objectives
			 established through the case plan
I. Assuring the integrity of all case
			 management Medicaid waiver billing in that the service delivered must have
			 prior authorization and meet required waiver service definitions and must be
			 delivered before billing can occur
J. Assuring submission of timely (advance)
			 and comprehensive behavior and/or assessment reports, continued plans of care,
			 revisions as needs change and information and documents required for ICF/MR
			 level of care and waiver Medicaid eligibility determination
K. Arranging for access to advocacy services
			 as requested by consumer in the event that case management and direct service
			 are the same provider entry
Service gaps of thirty (30) consecutive days must be reported
				to the DDS Specialist assigned to the case with a copy of the report sent to
				the DDS Program Director. The report must include the reason for the gap and
				identify remedial action to be taken.
Case management services are optional for some level categories
				and are available at three service levels. They are:
A. Pervasive - Minimum of one personal visit
			 AND one other contact monthly
B.
			 Extensive - Minimum of one personal visit OR one other contact
			 monthly
C. Limited - Minimum of one
			 personal visit each quarter
The level is determined by the needs or options of the person
				receiving waiver services as defined in sections
				230.000 through
				230.300.
See section
				270.000 for billing
				information.
230.210
Service Levels
Coverage is provided within three service levels. Service
				levels are defined as pervasive, extensive and limited.
230.211
Pervasive Service Level
The pervasive service level is defined as needs that require
				constant supports provided across environments that are potentially life
				sustaining in nature. Supports are intrusive and long term and include a
				combination of any available waiver supports provided 24 hours a day, 7 days a
				week for 365 days a year with case management at the highest level (minimum of
				one personal visit and one other contact monthly). Sublevels are:
A. People who are adjudicated under Act 609;
			 are receiving Department of Health and Human Services (DHHS) Integrated
			 Supports; are civil commitments; are children in custody of the Division of
			 Children and Family Services (DCFS) and who are receiving services through the
			 Children's Adolescents Special Services Programs.
B. Human Development Center (HDC) residents
			 transitioning to community living.
C. Nursing facility residents transitioning
			 to community living.
D. Individuals
			 who have compulsive behavior disorder that is life threatening and appropriate
			 care in a group setting would be a violation of the rights of others.
E. People who meet the pervasive service
			 level as defined in the waiver document and as determined eligible based on the
			 Inventory for Client and Agency Planning (ICAP) assessment process.
F. Procedures for requesting pervasive
			 service level:
1. To request Pervasive Service
			 Level, the Case Manager must submit the following items to the DDS Waiver
			 Specialist:
a. Documentation of any medical,
			 behavioral or other changes that would justify the need for pervasive service
			 level.
b. Copy of the current plan
			 of care.
c. Copy of the person's
			 case management notes for the past year if request is due to
			 behavior.
d. If the reason for
			 pervasive service level is in whole or in part due to behavior issues, a copy
			 of the most recent psychological information on behavioral intervention efforts
			 to include:
(1). A functional/behavior
			 analysis of inappropriate behavior including possible antecedents
(2). Description of inappropriate behaviors
			 and consequences
(3). Information
			 related to increases or decreases in inappropriate behavior including time
			 involved and frequency
(4). Positive
			 programming changes to include a description of the behaviors attempting to be
			 established to replace the inappropriate behavioral expression.
e. Copy of the computer generated
			 or signed narrative report for the ICAP results which includes:
(1). ICAP Domain scores (age scores and
			 standard scores)
(2). Information
			 on problem behaviors recorded in the ICAP
(3). ICAP Maladaptive Behavior Index
			 Scores
(4). ICAP Service
			 Score/Level
(5). The name and
			 relationship of respondent must be clearly noted. (6). The name and credentials
			 of the person administering and writing the report must be clearly
			 noted.
2. DDS
			 Waiver Staff will do the following things upon receipt of a request for
			 pervasive service level:
a. The Waiver
			 Specialist will check with DDS Licensure to see if any incident reports have
			 been filed related to the individual. If any incident reports have been filed a
			 copy will be obtained for the plan of care meeting.
b. The Waiver Manager will check the Incident
			 Reporting Information System (IRIS) to see if any reports have been filed
			 related to the individual. If any reports have been filed on IRIS, a summary
			 will be compiled for the plan of care meeting.
c. The Waiver Audit staff will check the
			 Medicaid Management Information System (MMIS) and all waiver prior
			 authorizations issued and payments for waiver services for the past
			 year.
3. If the request
			 packet is not complete, it will not be accepted. Retroactive approval will not
			 be granted on pervasive service level although emergency approval pending
			 receipt of required documents and determination may be obtained from the
			 Assistant Director of Adult and Waiver Services. Emergency requests may be made
			 via fax. For emergency requests, all the required documentation listed in this
			 rule must be submitted within two working days.
4. If the Plan of Care team cannot make a
			 decision on pervasive service level and needs additional information, they will
			 request assistance from the DDS Psychological team.
5. If assistance is requested from the DDS
			 Psychological Team, the DDS Psychological team will convene within five working
			 days following the Plan of Care meeting.
6. If the Plan of Care team requires
			 additional information due to information not being complete or based on review
			 of Incident Reports or IRIS, the time frame for approving of pervasive service
			 level will start over.
7. All
			 requests for pervasive service level will be reviewed at the weekly plan of
			 care meetings.
230.212
Extensive Service Level
The extensive service level is defined as needs that require
				daily supports in one or more of a work, home or community environment.
				Supports are less intrusive than supports that may be needed daily but less
				than 24 hours per day or 7 days a week. Supports are long-term and may require
				intermittent, short-term crisis intervention in response to episodic behavior
				needs.
Supports include habilitation, residential habilitation
				reinforcement and other assisted living waiver services based upon individual
				needs. Case management is available at a reduced level of minimally one visit
				or contact per month.
230.213
Limited Service Level
The limited service level is defined as supports that are
				anticipated to be for the foreseeable future. They are individually
				time-limited and may be intermittent in nature and are subject to re-evaluation
				every 12 months. This level of support requires that parental support, group
				settings and community assistance be available to the individual.
Intermittent and time-limited supports are supports for primary
				caregiver relief, employment training, transitional supports, crisis behavior
				management and assisted living supports.
Case management for this Level I is a minimum of one visit per
				quarter. When case management is not chosen as a service component there must
				be a willing, responsible adult to assume all case management functions.
				Sublevels are:
Supported living arrangements: Provided for beneficiaries of
				DDS-funded supported living arrangements. General revenue must be available and
				in use for the existing service level with supporting general revenue to be
				used for the payment of Medicaid match in order for waiver conversion to occur.
				There are two categories of supported living arrangements:
A. Moderate supported living services level -
			 at least15 days of service per month inclusive of case management and
B. Minimal supported living services level -
			 at least10 days of service per month inclusive of case management.
230.223
Supportive Living
			 Arrangement Model
In the supported living arrangement model, care is provided in
				DDS-supported living arrangements, in supported living apartments, in home and
				in group homes up to (but not inclusive of) 15 beds.
Supported living, community experiences, respite, waiver
				coordination and non-medical transportation are available for one rate of
				reimbursement with at least one service component being provided on at least 15
				days each month for the moderate level or at least 10 days each month for the
				minimum level.
Under this model, the provider must deliver the service level
				needed regardless of minimum service provision requirements. Case management,
				crisis center and crisis intervention is available and payable in addition to
				the monthly rates.
Living arrangements include:
A. Existing group homes serving groups of no
			 more than 14 unrelated adults (age 18 and above) with developmental
			 disabilities in the residential setting.
B. Existing DDS licensed supportive living
			 apartments serving up to 4 unrelated adults (age 18 and above) with
			 developmental disabilities in each self-contained apartment unit up to the
			 total number of licensed units in the complex.
C. Adults served in their family home, in
			 their own home or in an integrated apartment complex or in an alternative
			 living setting with no more than 4 unrelated adults with developmental
			 disabilities in the home.
D.
			 Children served in their family home or in the home of an alternative family
			 with no more than 4 unrelated children with developmental disabilities in the
			 home.
Exception: Only those supportive living apartments and group
				homes licensed by the DDS prior to July 1, 1995, are approved to serve more
				than 4 adults. No expansions will be approved beyond the July 1, 1995, total
				capacity (waiver and non-waiver).
230.410
MAPS for All Category
			 Types
A. General Information
			 Identification information must include:
1.
			 Recipient's full name and address
2. Recipient's Medicaid number
3. Guardian with an address (when
			 applicable)
4. Individuals with
			 MR/DD residing in home of waiver recipient
5. Physician Level of Care
			 Certification/Prescription
6.
			 Names, titles and signatures of the multi-agency team members responsible for
			 the development of the recipient's multi-agency plan of service
			 (MAPS)
B. Budget Sheet,
			 Worksheets and Level of Care Information must include:
1. Identification of waiver
			 services
2. Services
			 provider
3. Total amount by
			 service
4. Total plan
			 amount
5. Beginning and ending date
			 for each service
6. Supported
			 Living Array worksheet listing units and total cost by service
7. Adaptive Equipment/Environmental
			 Modifications and Specialized Medical/Supplemental Support worksheets listing
			 units and total cost by service
8.
			 Level of Care sheet showing case management/waiver coordinator providers and
			 staff and level of care.
C. Narrative Justification Initial Plan of
			 Care and Continued Care Reviews
Justification must, at a minimum:
1. Identify progress or regression
2. Detail exceptional events such as major
			 illness, injury, loss of primary caregiver(s), loss of home, graduation,
			 awards, etc., that impacted service delivery and have a direct cause and effect
			 for future needs.
3. Specify
			 justification for requested services and identify consumer satisfaction
			 level.
230.420
MAPS
A. The MAPS for individual, group and
			 self-directed option categories must include proposed outcomes, immediate and
			 long term needs.
B. In addition to
			 the information detailed in Section 230.410, the following information must
			 also be included:
1. Identification of
			 individual outcomes expected
2.
			 Review date
3. List of medical and
			 other services, including waiver and non-waiver services necessary to obtain
			 expected outcomes.
4. Service
			 barriers
C. Product and
			 service cost effectiveness certification statement, with supporting
			 documentation, certifying that products, goods and services to be purchased
			 meet applicable codes and standards and are cost competitive for comparable
			 quality.
ACS Waiver Program services require prior authorization by the
				Division of Developmental Disabilities Services.
In the absence of prior
				authorization, reimbursement will be denied and will not be approved
				retroactively.
251.000
Approval Authority
For the purpose of plan of care and service approvals, DDS, a
				Division under the umbrella of the Department of Health and Human Services, is
				the Medicaid authority.
A. The DDS
			 prior authorization process requires that all annual plans of care projected to
			 cost over $50,000.00 must have approval by DDS Plan of Care Review authority.
			 This cost threshold is subject to reduction by DDS.
B. Plans of care projected to cost under
			 $50,000.00 will be subject to a more local level approval process.
C. All waiver services must be needed to
			 prevent institutionalization.
D.
			 All persons receiving medications must also receive appropriate support in the
			 management of medication(s). The use of psychotropic medications will require
			 the development, implementation and monitoring of a written medication
			 management plan.
E. Service
			 requests that will supplant Department of Education responsibilities WILL NOT
			 be approved.
F. All plan of care
			 reviews are subject to review by a qualified physician and random audit
			 scrutiny. In addition, the following activities will occur:
1. Review of provider standards and actions
			 that provide for the assurance of a person's health and welfare
2. Monitoring of compliance with standards
			 for any state licensure or certification requirement for persons furnishing
			 services provided under this waiver
3. Assurance that the requirements are met on
			 the date that services are furnished
4. Quality assurance reviews by DDS staff to
			 include announced and unannounced quarterly on-site visits
5. Random review equal to a percent as
			 prescribed by DDS Licensure/Certification policy
G. All service requests are subject to review
			 by DDS and may necessitate the gathering and submission of additional
			 justification, information and clarification before prior approval is made. In
			 this event, it is the primary responsibility of the case management provider,
			 with cooperation from the procurement source, to satisfy the request(s) within
			 the prescribed time frames.
H. It
			 is the responsibility of the case management services provider with cooperation
			 from the direct services providers to ensure that all requests for services are
			 submitted in a timely manner to allow for DDS prior authorization
			 activities.
I. Initially, an
			 individual receives up to three months of DDS ACS Waiver Services based on a
			 DDS pre-approved interim plan of care. The pre-approved interim plan of care
			 will include case management and waiver coordination.
1. At any time during the initial three
			 months, the providers will complete the multi-agency planning process and
			 submit a detailed plan of care that identifies all needed, medically necessary
			 services for the remainder of the annual plan of care year. Once approval is
			 obtained, the additional services may be implemented.
2. ACS Waiver Services will not be reimbursed
			 for any date of service that occurs prior to the date the individual's plan of
			 care is approved or the date the individual is determined ICF/MR level of care
			 and is deemed Medicaid/waiver eligible, whichever date is last.
3. All changes of service or service level
			 revisions that occur within an approved annual plan of care must also have
			 prior approval and there will be no reimbursement for any services not
			 prior-approved.
J.
			 Emergency approvals may be obtained via telephone, facsimile or e-mail, with
			 retroactive reimbursement permitted as long as the notice of emergency, with
			 request for service change, is received by DDS within 24 hours from the time
			 the emergency situation was known. All electronically transmitted requests for
			 emergency services must be followed with written notification and requests must
			 be supported with documented proof of emergency.
262.000
Rate Appeal Process
A provider may request reconsideration of a program decision by
				writing to the Assistant Director, Division of Medical Services. This request
				must be received within 20 calendar days following the application of policy
				and/or procedure or the notification of the provider of its rate. Upon receipt
				of the request for review, the Assistant Director will determine the need for a
				program and/or provider conference and will contact the provider to arrange a
				conference if needed. Regardless of the program decision, the provider will be
				afforded the opportunity for a
conference, if he or she wishes, for a full explanation of the
				factors involved and the Program decision. Following review, the Assistant
				Director will notify the provider of the action to be taken by the division
				within 20 calendar days of receipt of the request for review or the date of the
				program and/or provider conference.
When the provider disagrees with the decision made by the
				Assistant Director of the Division of Medical Services, the provider may appeal
				the question to a standing Rate Review Panel established by the Director of the
				Division of Medical Services. The rate review panel will include one member of
				the Division of Medical Services, a representative of the provider association
				and a member of the Department of Health and Human Services (DHHS) management
				staff, who will serve as chairperson.
The request for review by the rate review panel must be
				postmarked within 15 calendar days following the notification of the initial
				decision by the Assistant Director of the Division of Medical Services. The
				rate review panel will meet to consider the question(s) within 15 calendar days
				after receipt of a request for such appeal. The panel will hear the questions
				and a recommendation will be submitted to the Director of the Division of
				Medical Services.
272.100
DDS ACS Waiver Procedure Codes
The following procedure codes and any associated modifier(s)
				must be billed for DDS ACS Waiver Services. Prior authorization is required for
				all services.
Procedure Code
M1
M2
PA
Description
Unit of Service
POS for
Paper
Claims
POS for
Electronic
Claims
A0080
Y
ACS Non-Medical Transportation
1 Year
0
99
H2016
Y
ACS Supportive Living (Individual)
1 Year
4, 0
12, 99
H2016
UB
Y
ACS Supportive Living (Group)
1 Year
4, 0
12, 99
H20231
Y
Supported Employment
15 Minutes
0
99
S5151
Y
ACS Respite Care
1 Year
4, 0
12, 99
T2020
Y
Community Experiences
1 Year
4, 0
12, 99
T2020
UA
Y
Supplemental Support Services
1 Year
4, 0
12, 99
T2022
Y
Case Management Services
1 Month
4, 0
12, 99
T2024
Y
ACS Waiver Coordination
1 Year
4, 0
12, 99
T20252
Y
Consultation Services
1 Hour
4, 0
12, 99
T20283
Y
ACS Specialized Medical Supplies
1 Year
4, 0
12, 99
T2034
Y
Crisis Center
1 Year
0, 4
99, 12
T20344
U1
UA
Y
ACS Crisis Intervention Services
1 Hour
0, 4
99, 12
1 Individuals are
			 limited to a maximum of 32 units (8 hours) of supported employment services per
			 date of service.
A breakdown of the supported employment units of service
				includes:
One unit = 15 minutes to 21 minutes Two units = 22 minutes to
				37 minutes Three units = 38 minutes to 52 minutes Four units = 53 minutes to 67
				minutes
2 Beneficiaries may
			 receive twenty-five (25) hours of ACS consultation services per waiver-eligible
			 year.
3 Reimbursement cannot exceed
			 $300 per month.
4 Crisis
			 intervention services may require a maximum of 24 hours of service during any
			 one day.
The following list contains the procedure codes used for ACS
				physical adaptations. Physical adaptations have a benefit limit of $7500 per
				year.
Procedure Code
M1
M2
PA
Description
POS for
Paper
Claims
POS for
Electronic
Claims
K0108
Y
***(ACS environmental modifications) Other
						  accessories
4
12
S5160
Y
***(Adaptive equipment, personal emergency response
						  system [PERS], installation and testing) Emergency response system;
						  installation and testing
4
12
S5161
Y
***(Adaptive equipment, personal emergency response
						  system [PERS], service fee, per month, excludes installation and testing)
						  Emergency response system; service fee, per month (excludes installation and
						  testing)
4
12
S5162
Y
***(Adaptive equipment, personal emergency response
						  system [PERS], purchase only) Emergency response system; purchase only
4
12
S5165
U1
Y
***(ACS adaptive equipment) Home modifications, per
						  service
4
12
[GREATER THAN]&(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the
				product.
Refer to section
				272.200 for definitions of the
				place of service codes listed above.