SECTION II - PROVIDER-LED ARKANSAS SHARED SAVINGS ENTITY (PASSE) PROGRAM200.000 DEFINITIONSProvider-Led Arkansas Shared Savings Entity (PASSE)
A Risk Based Provider Organization (RBPO) in Arkansas that has enrolled in Medicaid and meets the following requirements:
A. Is 51% owned by participating providers; and B. Has the following Members or Owners:1. An Arkansas licensed or certified direct service provider of Developmental Disabilities (DD) services;2. An Arkansas licensed or certified direct service provider of Behavioral Health (BH) services;3. An Arkansas licensed hospital or hospital services organizations;4. An Arkansas licensed physician's practice; and5. A Pharmacist who is licensed by the Arkansas State Board of Pharmacy.Risk-based Provider Organization (RBPO)
An entity that is licensed by the Insurance Commissioner under Act 775 of 2017 and the risk-based provider organization rules.
Participating Provider
An organization or individual that is a member of or has an ownership interest in a PASSE and delivers healthcare services to beneficiaries attributed to a PASSE.
Direct Service Provider
An organization or individual that delivers healthcare services to beneficiaries attributed to a PASSE. Participating providers can be direct service providers.
The Act
Risk-based Provider Organization (RBPO)
Title XIX of the Social Security Act.
Enrollment
A RBPO's successful completion of all requirements to become a Medicaid PASSE provider.
Attribution
The method by which DHS assigns a beneficiary to a PASSE.
Transition
The movement of a beneficiary from one PASSE to another.
Abeyance
A temporary suspension of PASSE services, due to:
A. A temporary loss of Medicaid eligibility;B. Placement in a setting excluded from the PASSE; orC. Loss of contact with the beneficiary or guardian for more than forty-five (45) days.Closure
A determination by DHS that a beneficiary is no longer eligible to receive PASSE services.
Medical/Quality Management Committee
A committee developed by the PASSE to oversee Quality Assurance of PASSE services.
Referral Network
The Direct Service Providers that join the PASSE.
210.000 ATTRIBUTION, ENROLLMENT, TRANSITIONING AND CLOSURE211.000 PASSE Enrollment Eligibility To be eligible to enroll as a Provider-Led Arkansas Shared Savings Entity (PASSE) with Arkansas Medicaid, the entity must:
A. Be licensed by the Arkansas Insurance Department (AID) as a risk-based provider organization under Act 775 and the risk-based provider organization regulations issued by the Insurance Commissioner;B. Demonstrate a network adequate to ensure coverage of services as outlined in Section 230.000 of this manual;C. Have the ability to provide care coordination to attributed beneficiaries who have been identified by the Department of Human Services (DHS) as requiring Tier II and Tier III levels of BH and DD services beginning on October 1, 2017;D. Sign the Provider-Led Arkansas Shared Savings Entity (PASSE) Agreement to operate as a PASSE provider type and agree to adhere to all requirements of this Manual and any applicable federal regulations; andE. Successfully complete the Readiness Review outlined in Section 212.000 of this manual.212.000 Readiness Review The PASSE must provide the following items for review and approval by DHS:
B. Referral network directory,C. Composition of and by-laws for the Medical/Quality Management Committee,D. Key staff members and organizational charts,F. Proof of 24 hour a day 7 days a week access to care coordination,G. Proof of hiring and training an adequate number of care coordinators,H. Proof of the ability to manage and maintain Electronic Health Records,J. Beneficiary rights policies, andK. Proof of Referral Network adequacy according to Section 231.000.213.000 Beneficiary Attribution213.100 Attribution MethodologyA. DHS will attribute beneficiaries in a PASSE using a methodology based on the individual's relationship with Direct Service Providers who joined that PASSE's Referral Network. For existing Medicaid clients, DHS will examine the previous twelve (12) months of claims history to determine specialty service providers, primary care providers, pharmacists, and other providers used by the individual. Then, the individual will be attributed to a PASSE according to a methodology that will be weighted toward the individual's DD and BH specialty providers.B. A beneficiary will be attributed to a PASSE based upon their "relationship score" with Direct Service Providers. The relationship score is equal to the product of the visit points and the specialty points, plus the cost points. 1. Visit Points - Using available databases, DHS will determine if there is an established relationship between the individual and providers based on whether an individual received at least one service from a provider in any month in the previous twelve (12) month period. Each provider that rendered a service to an individual in a month will be recognized for that month. There are no additional points for multiple visits within the same month. A visit must include direct contact with the individual to deliver a reimbursable service in that month and must not be incidental.2. Specialty Points - Weights will be assigned amongst provider classes to reflect the importance of specialty providers for this population. Provider Classes will be classified as follows:a. Provider class 5 i. Certified Behavioral Health Provider ii. Intermediate Care Facilities/DD/IDiii. Supportive Living Provider iv. Developmental Day Treatment Clinic Services (DDTCS) and successor programs v. Child Health Management Services (CHMS) and successor programs b. Provider class 4 i. Physician - Primary Care Physician iii. Federally Qualified Health Center (FQHC)iv. Person-Centered Medical Home (PCMH)c. Provider class 3 i. Physician - non-Primary Care Physicianiv. Inpatient Hospital Services including psychiatric stays for adultsd. Provider class 2 iii. Occupational therapistiv. Care Coordinator who is not otherwise a provider of direct servicese. Provider class 1 i. Durable Medical Equipment providerii. Personal Care provideriii. Home Health provider3. Cost Points - The cost of care is also an important consideration in determining the relationship between the individual and the provider. DHS will use all available Medicaid claims data that is fully adjudicated and refreshed on a quarterly basis.C. If a single provider accounts for at least fifty percent (50%) of both visits and spending for a beneficiary, the beneficiary will be attributed to that provider and assigned into the PASSE that providers has joined. If there is no majority provider, the beneficiary will be attributed to the PASSE with the highest relationship score that is greater than thirty-five percent (35%) of the total possible score.D. If there is no majority provider and no PASSE represents a total of 35% of the total possible relationship score, then DHS will review an additional twelve (12) months of claims data.E. When a tie-breaker is needed: for example when the majority provider is in more than one PASSE or when two PASSES have an equal relationship score, or no PASSE has a relationship score of greater than 35%, proportional assignment will be used. That is, the first member will be assigned to PASSE A, the next to PASSE B, the next to PASSE C, etc.213.200 Mandatory Beneficiary AttributionThe following beneficiaries must be attributed to a PASSE and undergo an Independent Assessment (lA):
A. Beneficiaries identified to meet Tier II or Tier III Level of Care as defined by DHS.B. For beneficiaries with BH service needs: 1. Tier II - At this level of need, services are provided in a counseling services setting but the level of need requires a broader array of services.2. Tier III - Eligibility for this level of need will be identified by additional criteria, which could lead to inpatient admission or residential placement.C. For beneficiaries with Developmental Disabilities (DD) service needs: 1. Tier II - The individual meets the institutional level of care criteria but does not currently require 24 hours-a-day of paid support and services to maintain his or her current placement.2. Tier III - The individual meets the institutional level of care criteria and does require 24 hours-a-day of paid support and services to maintain his or her current placement.213.300 Services Excluded from Attribution MethodologyThe following services are excluded from consideration when attributing a beneficiary to a PASSE:
A. Payment for Medicare covered services for individuals who are eligible for Medicare and Medicaid ("dual eligible");B. Services covered by private insurance and private payment;C. Costs of transplants reimbursed by Arkansas Medicaid;D. Emergency department visits reimbursed by Arkansas Medicaid; and.E. Psychiatric Residential Treatment Units or Center Placements reimbursed by Arkansas Medicaid.214.000 Transitioning to another PASSEA beneficiary may voluntarily transition from their attributed PASSE and choose another PASSE within ninety (90) days of initial attribution. A beneficiary will not be permitted to change their PASSE more than once within a twelve (12) month period, unless cause for transition, as described in 42 CFR 438.56, is met.
On the beneficiary's annual anniversary of attribution to a PASSE, the beneficiary will have the ability to transition to a different PASSE. If no action is taken by the beneficiary, they will remain attributed to their current PASSE and will not be permitted to change their PASSE, unless cause for transition, as described in 42 CFR 438.56, is met.
Cause for transition, as described in 42 CFR 438.56, is as follows:
A. The beneficiary moves out of the state;B. The PASSE for which the beneficiary is attributed is sanctioned pursuant to section 152.000 of this manual;C. The PASSE does not, because of moral or religious objections, cover the service the beneficiary seeks; orD. Other reasons, including poor quality of care, lack of access to services covered under the PASSE agreement, or lack of access to providers experienced in dealing with the beneficiary's care needs. Transition from a PASSE will be processed by DHS after receipt of oral or written request. The effective date of an approved transition must be no later than the first day of the second month following the month in which the beneficiary request for transition was received. Failure by DHS to process a timely transition request will result in an automatic approval of request.
To request a transition, a beneficiary should contact:
Arkansas Department of Human Services, PASSE Enrollment
Mailing Address
Little Rock, AR 72201
Phone: 501-XXX-XXXX
The PASSE cannot transition any attributed beneficiary.
DHS reserves the right to transition beneficiaries in compliance with 42 CFR 438.56.
215.000 ClosureDHS reserves the right to close any beneficiary's PASSE service after held in Abeyance fc (90) days.
220.000 BENEFICIARY INFORMATION221.000 General InformationA. The PASSE must provide attributed beneficiaries information in a manner and format (at least 12-point font) that is easily understood and is readily accessible.B. The PASSE must provide written materials that are critical to obtaining services, including, at a minimum, provider directories, beneficiary handbooks, appeal and grievance notices, and marketing material.C. All materials provided by the PASSE must available in English and Spanish.D. The PASSE must make available all materials (or information) in alternative formats upon request, of the beneficiary or potential beneficiary at no cost.E. The PASSE must make available auxiliary aids and services upon request of the potential beneficiary or beneficiary at no cost.F. The PASSE must notify beneficiaries of their right to obtain information in alternative formats.222.000 Beneficiary Policy The PASSE must have written policies addressing the following:
A. The right to be treated with respect and with due consideration for his or her dignity and privacy.B. The right to receive information on available treatment options and alternatives, presented in an appropriate format.C. The right to participate in decisions regarding his or her health care, including the right to refuse treatment.D. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.E. The right to request and receive a copy of his or her medical records, and to request that they be amended or corrected.F. The right to exercise his or her rights without the PASSE treating the beneficiary adversely.G. The right to be provided written notice of a change in the beneficiaries care coordination provider within seven (7) calendar days.H. The right to a beneficiary handbook and referral network directory within a reasonable amount of time after attribution.223.000 Beneficiary HandbookA. The PASSE must provide each attributed beneficiary with a handbook that contains, at a minimum, the following:1. A description of care coordination that includes, at a minimum, the definition contained in Section 241.000 of this Manual.2. All information contained in the Section 222.000 of this Manual regarding beneficiary rights.3. The process of selecting and changing the beneficiary's PCP.4. The process for filing a grievance, including timeframes.5. How a beneficiary can exercise an advance directive.6. The toll-free telephone number the beneficiary can use to access care coordination and member support servicesB. The PASSE must provide notice of any significant change in the information specified in the beneficiary handbook, at least thirty (30) days before the intended effective date of the change.C. The PASSE will disseminate the beneficiary handbook as follows: 1. Mail a printed copy of the information to the mailing address on file for the beneficiary;2. Provide the information by email after obtaining the beneficiary's agreement to receive information by email;3. Post the information on its website and advise the beneficiary in paper or electronic form that the information is available on the Internet, including the applicable Internet address. The PASSE must ensure that beneficiaries with disabilities who cannot access this information online are provided auxiliary aids and services upon request at no cost; or,4. Provide the information by any other method that can reasonably be expected to result in the beneficiary receiving that information.224.000 Marketing MaterialsThe PASSE may only market to potential beneficiaries through its website or printed material distributed by DHS's choice counselors.
All marketing materials and activities must be approved by DHS in advance of use.
230.000 NETWORK REQUIREMENTS231.000 Referral Network RequirementsThe PASSE must have the ability to make arrangements with or referrals to a sufficient number of Direct Service Providers enrolled as Arkansas Medicaid providers to ensure that needed services can be furnished to beneficiaries promptly and without compromising the quality of care.
At a minimum, the PASSE must meet the following time and distance requirements:
A. Have the ability to make referrals for the following providers to all attributed beneficiaries which includes at least one (1) of the each of following provider types within sixty (60) minutes of normal transportation time or within sixty (60) miles, whichever is shorter, for all attributed beneficiaries: 5. Primary Care PhysicianB. At least one (1) substance abuse provider within one hundred and twenty (120) minutes of normal transportation time or within one hundred twenty (120) miles, whichever is shorter, for all attributed beneficiaries. The PASSE may request a variance of these standards in certain geographic areas of the state. DHS may grant a variance upon consideration of the number of providers of that type and the rural nature of the geographic area for which the variance is requested.
231.100 Referral Network DirectoryThe PASSE must create a Referral Network Directory that, at a minimum, does the following:
A. Provides the following information to beneficiaries for each Direct Service Provider that has joined its Referral Network: 1. Names, as well as any group affiliations.4. Website URLs, as appropriate.5. Specialties, as appropriate.B. Clearly explains that the Referral Network is a list of preferred providers only, and that the beneficiary may access services from any enrolled Medicaid provider until January 1, 2019.C. Updates at least monthly, with the updates posted on the PASSE website.240.000 CARE COORDINATION REQUIREMENTS241.000 Definition of Care CoordinationA. The PASSE must provide care coordination to each of its attributed beneficiaries. Care coordination means ensuring that specialty services are coordinated and appropriately delivered by specialty providers (BH and DD services, as appropriate). The PASSE must provide care coordinators who will work with the beneficiary's providers to ensure continuity of care across all services. Act 775 of the 2017 Arkansas Regular Session defined care coordination as including the following activities:1. Health education and coaching;2. Coordination with other healthcare providers for diagnostics, ambulatory care, and hospital services;3. Assistance with social determinants of health, such as access to healthy food and exercise;4. Promotion of activities focused on the health of a patient and their community, including without limitation outreach, quality improvement, and patient panel management; and5. Coordination of Community-based management of medication therapyB. The care coordinator employed by the PASSE is responsible for the total plan of care for each beneficiary assigned to him or her. The total plan of care is all services and plans related to the client. The total plan of care may include, but is not limited to, the following:1. Behavioral Health Treatment Plan;2. Person Centered Service Plan for Waiver Clients;3. Primary Care Physician Care Plan;4. Individualized Education Program;5. Individual Treatment Plans for developmental clients in day habilitation programs;8. Any existing Work Plan;9. Justice system-related plan;10. Child welfare plan; or11. Medication Management Plan The PASSE care coordinator is responsible for obtaining copies of all treatment and service plans related to an individual beneficiary and coordinating services between those plans. The goal is to prevent duplication of services, ensure timely access to all needed services, and identify any service gaps for the beneficiary, as well as provide any health education and health coaching identified by those plans. The PASSE care coordinator should also obtain the report from the beneficiaries IA.
C. The PASSE care coordinator will assume the responsibility of providing case management under the concurrent 1915(c) Home and Community Based Services Community and Employment Support (CES) Waiver for attributed beneficiaries who are Waiver participants, including: 1. Coordinating and arranging all CES waiver services and other state plan services;2. Identifying and accessing needed medical, social, educational and other publicly funded services (regardless of funding source);3. Identifying and accessing informal community supports needed by eligible participants and their families;4. Monitoring and reviewing services provided to the beneficiary to ensure all plan services are being provided and to ensure the health and safety of the participant;5. Facilitating crisis intervention;6. Providing guidance and support to meet generic needs;7. Conducting appropriate needs assessments and referral for resources;8. Monitoring services provided to ensure quality of care and case reviews which focus on the participants progress in meeting goals and objectives established on existing case plans;9. Providing assistance relative to obtaining waiver Medicaid eligibility and ICF/IID level of care eligibility determinations;10. Ensuring submission of timely (advanced) and comprehensive behavior and assessment reports, continued plans of care, revisions as needs change and information and documents required for ICF/IID level of care and waiver Medicaid eligibility determinations;11. Arranging for access to advocacy services as requested by participant;12. Providing assistance upon receipt of DDS or DHS notices or denials, including assistance with the reconsideration and appeal process. The PASSE must comply with Conflict Free Case Management rules.
D. The PASSE care coordinator will also be responsible for assisting the beneficiary with moving between service settings, for example with the move from the residential treatment setting to community based care.E. Care coordination services must be available to attributed beneficiaries 24 hours a day through a hotline or web-based application.F. If a beneficiary has already been assigned to or selected a PCP or PCMH, that PCP or PCMH will be responsible for coordinating the beneficiary's medical care. If the beneficiary does not have a PCP selected, the PASSE care coordinator must assist the beneficiary with selecting a PCP or provide a referral to a PCP.G. A PASSE care coordinator cannot have more than 50 beneficiaries on its caseload at any one time.H. The PASSE care coordinator must make a monthly face-to-face contact with each beneficiary assigned.I. If the beneficiary is seen in an emergency room or urgent care clinic or is admitted to an acute inpatient psychiatric facility, the care coordinator must follow up with the beneficiary within seven (7) days of discharge from the facility. The follow up visit is to ensure that all discharge instructions are being followed and any follow-up appointments have been scheduled.J. The PASSE care coordinator will assist the beneficiary in remaining in the most appropriate and least restrictive setting for that beneficiary.242.000 Care Coordinator QualificationsAn individual must meet the following qualifications to provide care coordination to PASSE beneficiaries:
A. Be a Registered Nurse (R.N.), a physician, or have a bachelor's degree in a social science or health-related field; or
Have at least one (1) year of experience working with developmentally or intellectually disabled clients or behavioral health clients;
AND;
C. Successfully complete a background check, that includes a criminal background and child and adult maltreatment registry check;D. Successfully pass an initial drug screen prior to providing care coordination and working directly with clients;E. Successfully pass an annual drug screen to continue to be allowed to provide care coordination; andF. Cannot be excluded or debarred under any state or federal law, regulation or rule or not eligible or prohibited to enroll as a Medicaid provider.243.000 PaymentsA. Care Coordination Payment. - For each attributed beneficiary, the PASSE will be paid a per-member, per-month fee for care coordination, unless Beneficiary's PASSE service is in abeyance.B.Foundation Payment. - In lieu of the care coordination fee, the PASSE will receive a onetime foundation payment upon the beneficiary's initial attribution to the PASSE.1. The foundation payment is non-transferable. It may only be paid to one PASSE for each beneficiary and will not continue past December 31, 2018.2. The purpose of the foundation payment is to assist the PASSE with providing the initial care coordination contact and services. The payment may be used to conduct initial assessments of the beneficiary and to begin collecting the required health information from existing providers.250.000 METRICS, ACCOUNTABILITY, REPORTS, AND QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI)251.000 Quality MetricsIn order to continue to receive the full Care Coordination PMPM for attributed beneficiaries, the PASSE must meet the following standards:
A. The caseloads assigned to each Care Coordinator must be no more than 50 beneficiaries. 1. The PASSE must provide quarterly reports to DHS that detail the monthly caseload for each Care Coordinator employed.2. The target is 100% of the Care Coordinators will have a caseload of no more than 50 beneficiaries.B. Care Coordinators must make monthly face-to-face contacts with beneficiaries within their caseload assignment. After the initial in person face-to-face contact, ongoing face-to-face contact can be accomplished utilizing video conferencing. If a face-to-face contact is not made, the care coordinator must have documented at least three (3) attempts to make face-to-face contact at the beneficiary's place of residence during that month. These three attempts must be at least 24 hours apart.1. The PASSE must provide quarterly reports to DHS that contain encounter data for the monthly contacts with beneficiaries within their caseload assignment.2. The target is that 100% of care coordinators will make monthly face-to-face contacts with all beneficiaries assigned to their caseload.C. Care Coordinators must initiate contact within 15 days of attribution to a PASSE. 1. The PASSE must provide quarterly reports to DHS that contains data indicating initial contact time frame with beneficiaries who are attributed to the PASSE.2. The target is that care coordinators will initiate contact within 15 days in 75% of all cases assigned to their caseload.D. Care Coordinators must follow-up with beneficiaries who have visited an Emergency Room or an urgent care clinic or been discharged from an inpatient psychiatric unit within seven (7) business days of discharge. 1. The PASSE must provide quarterly reports to DHS indicating follow-up for these beneficiaries.2. The target is that care coordinators will conduct follow up within seven days in 50% of the cases where a beneficiary goes to an Emergency Room, an urgent care clinic, or has been discharged from an inpatient psychiatric unit.E. Care Coordinators are responsible for assisting the beneficiary with selecting a PCP or provide a referral to a PCP. 1. The PASSE must provide quarterly reports to DHS indicating the number of beneficiaries that have been referred to and have been assigned a PCP.2. The PASSE must provide quarterly reports to DHS on PCP appointment attendance rates for attributed beneficiaries.3. The target is that care coordinators will assist beneficiaries in obtaining a PCP in 100% of their assigned cases.252.000 Failure to Meet Quality MetricsIf the PASSE fails to meet 2 of the 5 quality metrics for care coordination, DHS may take action to correct the failure or impose penalties on the PASSE. DHS's actions may include, but are not limited to:
A. Require the PASSE submit a Corrective Action Plan (CAP) to address proposed activities to improve adherence to quality metrics;B. Suspend, withhold, recoup, or recover payments, or any combination thereof, made to the PASSE;C. Terminate the PASSE from participation as a PASSE Medicaid Provider type;D. Suspend the PASSE's participation in the Medicaid Program;E. Cancel or shorten the PASSE's existing provider agreement; orF. Impose any sanction identified in § 152.000 of the Medicaid Provider Manual.253.000 Reporting Requirements and the Quality Assurance PerformanceImprovement (QAPI) Program
A. Pursuant to Act 775 of the 2017 Arkansas General Session, the PASSE is responsible for reporting to DHS on a quarterly basis, the following:1. Care Coordination encounter Data;2. Unique Identifiers of beneficiaries;3. Geographic and demographic information of beneficiaries; and4. Satisfaction scores from the PASSE administered beneficiary satisfaction survey.B. The PASSE must also implement and carry out a Quality Assurance and Performance Improvement (QAPI) program for care coordination. The QAPI must include, at a minimum: 1. Collection of and reporting on the quality metrics required by Section 251.000 of the Manual; and2. Mechanisms to detect both underutilization and overutilization of services.C. All reports submitted must include an attestation by the CEO or CFG of the PASSE (or their designee) that the information submitted is accurate, truthful and complete.D. The PASSE must retain all reports and data submitted, as well as all other records regarding the provision of care coordination for a minimum of ten (10) years from the final date of the contract period or the date of completion of an audit, whichever is later. 254.000 DHS Review of OutcomesPursuant to Act 775 of the 2017 Arkansas General Session, DHS will utilize data submitted from the PASSE to measure the performance of the following:
C. Efficiencies achieved; andD. Quality measures, which include:1. Reduction in unnecessary hospital emergency department utilization;2. Adherence to prescribed medication regimens;3. Reduction in avoidable hospitalizations for ambulatory-sensitive conditions; and4. Reduction in hospital readmissions.260.000 GRIEVANCES, APPEAL RIGHTS, SANCTIONS, AND THE CONSUMER ADVISORY COUNCIL261.000 GrievancesThe PASSE must have an internal grievance process to address beneficiary concerns and complaints. This grievance process must:
A. Allow the beneficiary 45 days from the date of the action to file the grievance;B. Be completed and resolved within 30 days of the filing date; andC. Result in written notice of the resolution being sent to the beneficiary. This notice must include the beneficiary's right to appeal to the State. The PASSE must submit a grievance log with their quarterly report.
262.000 Appeal RightsWhen the Division of Medical Services (DMS) denies PASSE eligibility or takes an adverse action against a PASSE or beneficiary, the PASSE or beneficiary may request a fair hearing to appeal the adverse action.
To do so, the beneficiary or provider must follow the procedures laid out in the Medicaid Provider Manual, Sections 160.000 & 190.000.
263.000 SanctionsDHS may impose the following sanctions, as well as those listed in Section 252.000 of this Manual:
A. Grant beneficiaries the right to transfer without cause;B. Suspend attribution into the PASSE;C. Appoint temporary management to the PASSE; and,D. Impose civil penalties as allowed by state and federal law.264.000 Consumer Advisory CouncilThe PASSE must have and maintain a consumer advisory council consisting of at least one (1) consumer of DD services, one (1) consumer of BH services, and one (1) consumer of substance abuse treatment services.