016.06.09 Ark. Code R. 045
The Arkansas Department of Human Services (DHS) was granted an 1115 Research and Demonstration waiver to implement IndependentChoices, a Cash and Counseling Demonstration and Evaluation Project in 1998. On April 1, 2008, the IndependentChoices program became a state plan service under 19150 of the Social Security Act. IndependentChoices is operated by the Division of Aging and Adult Services (DAAS). The program offers Medicaid-eligible aged and disabled individuals an opportunity to self-direct their personal assistant services.
The IndependentChoices program has been operational since 1998. Some of the results of evaluations performed by Mathematica Policy Research, Inc. specifically identified these results that may positively impact community services in Arkansas:
Operation of the IndependentChoices program as a state plan service will use the positive foundation established through lessons learned as an 1115 Research and Demonstration Waiver to continue to offer opportunities for improved life in the community.
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 Manger can act as the participant's voice and complete and sign forms, etc., 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 Medicaid beneficiary 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.
To be eligible for IndependentChoices, a participant must:
Individuals meeting participant eligibility requirements may enroll in the program. Personal contact will be made by telephone and in person to determine the individual's ability to understand the requirements for directing his or her own personal assistance services. Individuals who are not comfortable with this responsibility or who are determined to be unable to understand this responsibility will be asked to identify a Decision-Making Partner. Individuals who are unable to understand the risks, rights and responsibilities of managing personal assistance services with an allowance and who do not have anyone to serve as a Decision-Making Partner will be discouraged from participating in IndependentChoices.
If the individual has a mental or cognitive limitation that restricts him or her from voicing his or her preferences and self-directing his or her care, the individual will not be able to participate in IndependentChoices without a Decision-Making Partner. Individuals able to voice their preferences and self-direct their care, but having limitations that hinder their ability to keep up with the paperwork involved, such as signing timesheets, etc., may designate a Communications Manager to assist them. If they do not have a Communications Manager to designate, they may still participate, but will be followed with intensified counseling to give them the opportunity to self-direct. If at any time the individual's health and safety is jeopardized because of the inability to self-direct his or her care and there is no Decision-Making Partner available, the individual will be disenrolled from IndependentChoices.
A Decision-Making Partner will be required if the individual interested in participating has a court-appointed legal guardian, other appointed representative, i.e., power of attorney, or an established payee of income. A Decision-Making Partner will also be required for any potential enrollee or participant who is:
The enrollee, counseling staff, or a representative of the fiscal agency may request a Decision-Making Partner. A Decision-Making Partner may be a legal guardian, other legally appointed Decision-Making Partner, an income payee, family member, or friend. The Decision-Making Partner may not be paid for this service and may not be an employee of the participant. A Decision-Making Partner must be at least 18 years of age and demonstrate a strong personal commitment to the participant and be knowledgeable of the participant's preferences. The individual chosen as Decision-Making Partner must be willing and capable of complying with all program criteria and responsibilities. Each Decision-Making Partner will be required to complete and sign a Decision-Making Partner Screening Questionnaire (DAAS-IC-05) and Designation for Authorized Decision-Making Partner Form (DAAS-IC-05A).
The Division of Aging and Adult Services is the point of entry for all enrollment activity for IndependentChoices. The program will be limited to no more than 7,500 active participants at any given time.
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 is interested in participating in IndependentChoices, 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 "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 and IRS 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 1-9, 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 IndependentChoices RN will complete an assessment using the DMS-618, Personal Care Assessment and Service Plan, and/or Minimum Data Set-Home Care (MDS-HC) instrument. The assessment will determine how many hours of personal assistance services are needed by the participant. NOTE: For ElderChoices beneficiaries, the ElderChoices 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. If the IndependentChoices RN believes the beneficiary needs a different number of hours than what is stated on the ElderChoices plan of care, the IndependentChoices RN will discuss the need with the ElderChoices RN. The ElderChoices RN will make the final decision on the number of hours needed by the beneficiary. IndependentChoices staff will obtain physician authorization for the hours indicated on the ElderChoices Plan of Care.
After the in-home assessment, the IndependentChoices RN will complete the paperwork and send the information to the IndependentChoices counselor. The counselor will process all of the completed enrollment forms. The DMS-618 and/or MDS-HC Summary, which includes the cap triggers and the number of hours of services needed, will be sent to the participant's physician for authorization. State and IRS tax forms will be retained by 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 underage 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. 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 also determine when IndependentChoices services can begin. If the participant is currently receiving personal care through an agency, IndependentChoices will begin 7 days from the time DAAS sends a letter to the personal care agency informing the agency to stop services. If the client is not receiving agency personal care services, the start date will be the date the IndependentChoices RN completes the assessment if personal care is already being provided by the participant's personal assistant or the date the participant's personal assistant will begin working for the participant. 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.
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.
The amount of the Cash Expenditure Plan (CEP) is determined by the assessment performed by the IndependentChoices 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 a ten percent discretionary expenditure per the amount of the participant's plan but may not exceed $75.00. The discretionary expenditure is used to purchase personal hygiene items and does not require the participant to maintain receipts for the purchase. 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. However, if the participant has a Decision-Making Partner, the Decision-Making Partner must account for 100% of the allowance with appropriate documentation
The IndependentChoices counselor will assure that a written work agreement DAAS-IC-17 is executed between the participant or Decision-Making Partner and each of his/her employees. The purpose of the agreement is to clearly identify the tasks to be performed by the participant's employee. The participant as the employer will detail the tasks to be performed within each work day. Both the participant/Decision-Making Partner and the assistant will retain a copy of the agreement for their records.
Naming a back-up worker is required for participation in IndependentChoices. The counselor will assist the participant or Decision-Making Partner in developing a back-up plan to outline how the participant's needs will be met should the assistant be absent from the home for any reason. The back-up plan must identify caregivers, either formal or informal, who will provide back-up personal attendant services.
The cash allowance allows the program participant to purchase those services that help the program participant receive assistance at times of the day that best meet his or her individual preferences. The allowance also supports the purchase of goods and services that lessen the need for human assistance while increasing the participant's ability to maintain independence in the community.
Primarily the allowance is used to pay the participant's employee's salary. The list of services listed below was developed by the IndependentChoices Advisory Committee comprised of representatives from Area Agencies on Aging, Department of Health, Spinal Cord Commission and advocates. Not all of these services are widely used, but the availability of these services on an individual basis has impacted the quality of life of individual program participants.
Following is a list of possible uses of the cash allowance:
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 or spouse may not serve as a Personal Assistant.
After an assistant is selected, the participant/ Decision-Making Partner, in consultation with the IndependentChoices counselor, will identify the exact tasks to be completed by the assistant and a Work Agreement will be completed and signed by all parties involved.
Medicaid beneficiaries who have elected hospice care under Title XVIII (Medicare) or Title XIX (Medicaid) and who have not revoked the election are not eligible to participate in IndependentChoices.
Hospice services include a personal care component. Therefore, Personal Care services and IndependentChoices participation are duplicative as the per diem for Hospice services includes the provision of personal care services. ElderChoices participants receiving only Adult Companion or Homemaker Services may be eligible for Hospice if Hospice is included in the ElderChoices plan of care and the participant otherwise meets all criteria and requirements of the Hospice program.
Homemaker services provide basic upkeep and management of the home and household assistance, such as:
Simple household tasks may include, but are not limited to, washing windows, cleaning ceiling fans and light fixtures, cleaning the refrigerator and washing inside walls.
Medically oriented personal care tasks are not included as part of this service.
Homemaker services must be provided according to the client's written plan of care.
The ElderChoices 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 ElderChoices RN will refer the participant to the IndependentChoices program by sending the plan of care to the IC RN, notating that IC was selected.
Benefits are limited by the amount of the participant's allowance. Each individual participant has a maximum allowance based on his or her individual service plan. The Division of Aging and Adult Services will authorize the allowance through an eligibility screen on the MMIS. Payment is made prospectively by the Medicaid fiscal intermediary. The participant's allowance will be issued monthly directly from the Medicaid fiscal intermediary to the IndependentChoices fiscal agent as long as the individual remains Medicaid eligible and the individual is not receiving hospice or nursing facility services. The IndependentChoices fiscal agent will disburse the cash allowance in accordance with the approved cash expenditure plan and timesheets completed by the participant or Decision-Making Partner and signed by the personal attendant twice monthly in equal intervals.
If at any time the IndependentChoices nurse determines that personal assistance services are not necessary for an IndependentChoices participant, the participant's IndependentChoices case will be closed after a 10-day notice and DAAS staff terminate the eligibility.
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.
It is the responsibility of the participant or Decision-Making Partner and personal attendant to report changes to the IndependentChoices counselor immediately so that proper action can be taken. Participants or Decision-Making Partners may complete the IndependentChoices change form DAAS-IC-09 and send it to the IndependentChoices counselor. The copy is retained in the participant's case record. Whether or not the change results in any action, participants/Decision-Making Partners must report all changes in the participant's status to the IndependentChoices counselor.
If the participant loses eligibility for personal assistance services, he or she may ask for an Informal 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:
Personal attendants will complete their timesheets and obtain the authorizing signature of the participant. The timesheet will be submitted to the fiscal agent twice monthly for time worked from the first of the month to the 15th of the month, and for the 16th to the end of the month. The fiscal agent will disburse the payroll checks on the 23rd of the month for the first half of the month and on the 8th of the month for time worked from the 16th to the end of the previous month.
The IndependentChoices participant is the employer of record, and as such, hires a Personal Assistant who meets these requirements:
Counselors for IndependentChoices will be employed or contracted by DAAS. Counselors must possess a Bachelors 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:
016.06.09 Ark. Code R. 045