016.06.18 Ark. Code R. 012
Adjusted Premium Revenue
Premium revenue as defined in 42 CFR § 438.8 minus the PASSE's Federal, State and local ' taxes, licensing and regulatory fees as defined in 42 CFR § 438.8.
Administrative Cost Ratio
Administrative Cost Percentage [ 42 CFR § 438.116(a) and (b)] is the total administrative expenses, divided by total payments received from State of Arkansas less premium tax.
Adverse Decision/Adverse Action
Any decision or action by the PASSE or DHS that adversely affects a Medicaid provider or beneficiary in regard to receipt of and payment for claims and services including but not limited to decisions or findings related to:
Arkansas Department of Human Services (DHS)
The Arkansas Department of Human Services (DHS) is the designated single state agency with responsibilities to administer the Medicaid program.
Arkansas Insurance Department (AID)
The Arkansas Insurance Department (AID) has the responsibility to license PASSEs. Among its responsibilities, AID establishes bonding and reserve requirements for solvency.
Assignment
The process by which DHS assigns a newly eligible member among the active PASSEs. The individual will have 90 days from the date coverage begins to switch to a different PASSE. If the individual does not choose to switch to a different PASSE within this time, he/she will remain a member of that PASSE until the end of the coverage year.
Benefit Expenditure Report (BER)
The Benefit Expenditure Report documents how much was paid during the performance year by the PASSE, in the aggregate, to direct service providers for services provided to its members. A PASSE may choose to spend up to five percent (5%) of benefit expenditures on community investments. Community investments will be counted as benefit expenditures rather than administrative expenditures in calculating and reporting the medical loss ratio.
Care Coordination
Activities involving a collaborative patient-centered engagement of the individual and their caregiver in service referral, follow up, and service navigation. The care coordination process includes assessing, collaborating on care planning, medication management, treatment plan follow-through, service coordination, monitoring the patient adherence, and reevaluating the patient for medically necessary care and service. These activities focus on ensuring the individual's healthcare and support service needs are met; through effective provider and patient communication, information sharing, follow up, care transitions, and assurance of timely access to care that promotes quality, cost-effective outcomes.
Case Management
Services furnished to assist individuals in gaining access to needed medical, social, educational, and others services in accordance with 42 CFR § 440.169.
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) is the federal agency delegated by the Secretary of the US Department of Health and Human Services to administer the Medicaid program under Title XIX of the Social Security Act and thereby has federal oversight responsibilities for the state and the PASSES.
The state and the PASSES must meet the requirements of a Medicaid managed care organization as defined in 42 CFR § Part 438.
Claims Payment
A claims payment is a payment made in full or in part to a service provider for the provision of medically necessary treatment and services to an eligible beneficiary that is a PASSE member. Claims types include hospital inpatient, outpatient, professional payments, clinic, ancillary, pharmacy, support service, and other institutional payments.
Claims Payment Process
A claims payment process involves all the business and operational processes, claims management information systems, and banking processes that are necessary to receive, validate, adjudicate, audit, and reimburse providers for services provided to eligible beneficiary. These business and operational activities, processes, and systems are performed and managed by the PASSE organization to meet the claims payment standards of the State.
Direct Service Provider
An organization or individual that delivers healthcare services to beneficiaries attributed to a PASSE. PASSE Equity Owners can be direct service providers.
Dlsenrollment
A determination by DHS that a member is no longer eligible to receive PASSE services.
Federal. State, and local taxes and licensing and regulatory fees
Federal, State, and local taxes and licensing and regulatory fees are as defined in 42 CFR § 438.8.
Flexible Supports
Flexible supports are a person-centered support developed for an individual need, and is generally provided on a case-by-case basis. These supports do not have to be pre-approved by DHS.
Fraud Prevention Activities
Fraud Prevention Activities are as defined in 42 CFR § 438.8
Incurred Claims
Incurred claims are as defined in 42 CFR § 438.8
Independent Assessment
An Independent Assessment (IA) is required prior to becoming a member of a PASSE. Not all Medicaid enrollees can be enrolled in a PASSE. Individuals must be in need of behavioral health or developmental disabilities services. An IA is conducted by qualified individual using an assessment instrument approved by DHS. Individuals who are assessed as meeting a Tier II or Tier III level of care condition will be assigned into an active PASSE and are required to obtain all non-excluded Medicaid services through the PASSE.
An individual who is assessed as meeting a Tier I level of care condition may voluntarily enroll in a PASSE as of July 1,2019 or later as specified by DHS.
The Tier is also used by DHS in the determination of the actuarially sound rates to be paid to a PASSE for that individual.
Medical/Qualitv Management Committee
A committee developed by the PASSE to oversee Quality Assurance and Quality Improvement activities of PASSE services.
Medical Loss Ratio
Each PASSE must report its Medical Loss Ratio (MLR) to AID and DHS. Calculation of the MLR is defined at 42 CFR § 438.8.
Member
A Medicaid beneficiary who is enrolled in a PASSE.
Network Provider
The provider who, under a contract with a PASSE or with its contractor/subcontractor, has agreed to provide Health Care Services to persons with an expectation of receiving payments directly or indirectly from the PASSE.
Open Enrollment Period
DHS will, on an annual basis, offer an open enrollment period for all current enrollees to choose a different PASSE for coverage beginning January 1 of the following year. If an individual does not make an active choice to switch PASSEs during the open enrollment period, that individual will remain a member of the same PASSE for the twelve (12) months of the new coverage year provided the individual is otherwise eligible.
Out-of-Network Provider
A provider who is enrolled in the Arkansas Medicaid program but who did not join the network of a particular PASSE. Payment to an out-of-network provider may differ from an in-network provider, but must comply with any applicable Arkansas Medicaid consent decree.
If an out-of-network provider renders a service to a PASSE member, it must do so in conformance with the rights of a Medicaid enrollee. These rights include that the provider accept the PASSE payment for services as payment in full and not bill the individual.
PASSE Equity Partners
An organization or individual that is a member of or has an ownership interest in a PASSE and delivers healthcare services to members or is an administrator of healthcare services.
Person-Centered Service Plan (PCSP)
The total plan of care made in accordance with person centered service planning as described in 42 CFR 441.301 (c)(1) that indicates the following:
Individual who is the rendering provider of a particular service. Premium Revenue
Premium revenue is as defined in 42 CFR § 438.8.
Provider-Led Arkansas Shared Savings Entity (PASSE)
A Risk Based Provider Organization (RBPO) in Arkansas that has enrolled in Medicaid and meets the following requirements:
Among other things, each PASSE must be licensed by AID, enrolled as a Medicaid provider, and enter into an annual PASSE agreement with DHS.
Provider Network
The group of direct service providers that are contracted to provide services to members of a PASSE.
Quality Improvement
Activities that improve healthcare quality as defined in 42 CFR § 438.8. These activities must be designed to:
Risk-Based Comprehensive Global Payment
Risk-based comprehensive global payment is a capitated payment that is made in monthly prorated payment to the PASSE for each assigned PASSE member. Only a licensed Risk-Based Provider Organization/ Provider-Led Arkansas Shared Savings Entity (PASSE) in good standing in the State of Arkansas is eligible to receive a global payment under the program. Comprehensive means that the PASSE is at financial risk and obligated to pay for medically necessary inpatient hospital, outpatient, institutional, professional services, pharmacy, ancillary, long term care services and supports, and any other covered service, not exclusive or carved out, for members as specified in the scope of services identified in the State plan section 1905(a).
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.
Service Encounter
A standardized record of a health care-related service, procedure, treatment, or therapy rendered by a licensed provider or providers to a PASSE member. There are two types of service encounters, paid claim encounter and non-paid encounters that were performed but are not reimbursable.
Telemedicine
The use of electronic information and communication technology to deliver healthcare services, including without limitation the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient. It included store-and-forward technology and remote patient monitoring.
The following activities will not be considered a reportable encounter when delivered to a member of the PASSE:
The Act
Title XIX of the Social Security Act.
Transition
The movement of a member from one PASSE to another, either by choice or for cause as defined in section 213.000 of this manual.
Value-based Payments
Payments made by a PASSE to its providers to promote efficiency and effectiveness of services, improve quality of care, improve patient experience and access to care, and promote most appropriate utilization in the most appropriate setting. Such payments may be made as part of a PASSE's Quality Assessment and Performance Improvement (QAPI) strategy.
Virtual and Home Visit Provider Services
Virtual services are telemedicine, telehealth, e-consulting, and provider home visits that are part of a patient care treatment plan and are provided at the individual's home or in a community setting. These services are provided using mobile secure telecommunication devices, electronic monitoring equipment, and include clinical provider care, behavioral health therapies, speech, occupational and physical therapy services, and treatment provided to an individual at their residence. Virtual provider services may use various evidence-based and innovative independence at-home strategies. They may include the provision of on-going care management, remote telehealth monitoring and consultation, face to face or through the use secure web-based communication and mobile telemonitoring technologies to remotely monitor and evaluate the patient's functional and health status. Virtual and telehealth services are provided in lieu of providing the same services at a practice site or provided at the individual's place of residence. Therefore, these services must have patient consent, be documented in the patient integrated medical records, and submitted as a claims or encounter from a contracted provider as medically necessary service. The provision of virtual care can include an interdisciplinary care team or be provided by individual clinical service provider.
The purpose of the Arkansas PASSE program, pursuant to Title XIX of the Social Security Act (The Act) and Arkansas Act 775, is to organize and manage the delivery of services for certain Medicaid beneficiaries who have complex behavioral health and intellectual and developmental disabilities service needs. The federal statutory and regulatory requirements that govern the PASSE Program are described in 42 CFR § 438 . Under these authorities, DHS shall enter into a comprehensive PASSE Provider Agreement with eligible entities on an annual basis.
The scope of the PASSE program covered in this manual defines the services, standards and requirements of the PASSE organization. The PASSE organization is responsible for the provision of comprehensive medically necessary services to eligible beneficiaries who are enrolled (assigned) to the PASSE. In addition to medically necessary care and treatment services, the PASSE is responsible for:
INCORPORATION BY REFERENCE
The program descriptions, definitions, requirements, policies, procedures and standards presented in this PASSE manual are hereby incorporated by reference into the PASSE Provider Agreement.
The Centers for Medicare & Medicaid Services (CMS) must review and approve the PASSE Provider agreement. The proposed final PASSE Provider Agreement must be submitted in the form and manner established by CMS. The proposed final PASSE Provider Agreement must be submitted to CMS for review no later than 90 days prior to the effective date of the contract.
The PASSE Provider Agreement must comply with 42 CFR § 438.3. The PASSE Provider Agreement includes:
Actuarially sound capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the PASSE for the time period and the population covered under the terms of the contract, and such capitation rates are developed in accordance with the requirements in paragraph (b) of 42 CFR § 438.4.
Capitation rates for PASSEs must be reviewed and approved by CMS as actuarially sound. To be approved by CMS, capitation rates must:
DHS must adhere to the Rate Development Standards as specified in 42 CFR § 438.5.
Special contract provisions that are related to payment, if applicable, must comply with 42 CFR § 438.6.
States must submit to CMS for review and approval, all PASSE rate certifications concurrent with the review and approval process for contracts as specified in §438.3(a). Requirements for rate certification are contained in 42 CFR § 438.7.
Medical Loss Ratio (MLR) refers to the proportion of total per member per month capitation payments that is spent on clinical services and for quality improvement. Pursuant to 42 CFR 438.8, each PASSE must report MLR to DHS and must attest to the accuracy of the calculation of MLR.
Each PASSE must calculate their MLR based upon premium revenue, incurred claims, expenditures for activities that improve health care quality, fraud prevention activities, and Federal, State, and local taxes and licensing and regulatory fees on a quarterly and annual financial report to DHS.
Any retroactive changes to capitation rates after the contract year end will need to be incorporated in the MLR calculation. If the retroactive capitation rate adjustment occurs after the MLR report has been submitted to DHS, a new report incorporating the change will be required to be submitted within 30 days of the capitation rate adjustment payment.
MLR reporting requirements are specified in the PASSE Provider Agreement.
The PASSE may not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. In all contracts with network providers, the PASSE must comply with the requirements specified in 42 CFR § 438.214.
The above paragraph may not be construed to preclude the PASSE from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to members.
The PASSE must comply with all state insurance laws including the Patient Protection Act ("any willing provider").
The PASSE program operates under a waiver granted under section 1915(b) of the Act.
To be eligible to participate as a Provider-Led Arkansas Shared Savings Entity (PASSE) with Arkansas Medicaid, the entity must:
The PASSE is required to ensure that a member has access to all services covered under the Medicaid state plan, as well as under Section 1915(i) and DDS Community and Employment Supports (CES) waiver services, including therapy services and services through the Early Periodic Screening Diagnosis and Treatment (EPSDT) program for children.
The PASSE must comply with Sections 1902(a){43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and Federal regulations at 42 CFR § Part 441 Subpart B that require EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services.
The PASSE cannot provide an incentive, monetary or otherwise, to Provider for withholding medically necessary services. With the exception of flexible services, all services provided to PASSE members must be medically necessary for each member. The PASSE must ensure that services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished.
The PASSE may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition of the enrollee. The PASSE may place appropriate limits on a service for utilization control, provided the services furnished can reasonably achieve their purpose.
The PASSE is responsible for the provision of services (except as excluded below) as described in each specific programmatic Medicaid Manual located at
https://medicaid.mmis.arkansas.gov/Provider/Docs/Docs.aspx. All services described in Section II of the manuals must be made accessible to PASSE members if medically necessary.
In lieu of services are services that are provided in lieu of a covered benefit. These services are not part of the PASSE covered benefit, but because of special circumstances, it is deemed more cost effective to provide a non-covered service in lieu of more expensive institutional care which is covered under the PASSE program. The PASSE must determine that an "In Lieu of Service" will reduce cost and avoid institution placement or enhance the PASSE member's ability to transition from institutional or residential care. The cost of the service is claimable as a medical expense. The benefit to the PASSE is that provision of an "In Lieu of Service should reduce medical expenditures for institutional care. For example, if providing a mobile phone or paying for a WIFI connection allows the PASSE avoid skill nursing days by monitoring a member's health and vitals remotely, the cost of the mobile phone service or WIFI service would be an in lieu of service expense.
The PASSE must use the most current version of the Arkansas Preferred Drug List (https://arkansas.mageHanrx.com/provider/documents/). which is subject to periodic changes. The PASSE must use the Medicaid PDL developed by DHS or its Agent and may not develop and use its own PDL.
Any prior authorization program for covered outpatient drugs must comply with the requirements defined under Section 1927 of the Social Security Act.
The PASSE Provider Agreement requires that:
The PASSE must provide a detailed description of its drug utilization review program activities to the State on an annual basis as described in the PASSE Provider Agreement.
If the PASSEs do not include a covered outpatient drug that is otherwise covered by the state plan, access to the off-formulary covered outpatient drug must be aligned with the prior authorization requirements as defined under Section 1927 of the Social Security Act.
Fee For Service
PASSES must demonstrate prescription drug coverage for outpatient and physician-administered drugs that is not less than the amount, duration, and scope as described by Medicaid Fee-For-Service (FFS). AH PASSEs will be required to guarantee access to Medicaid Fee-for-Service Covered Outpatient Drugs.
PASSEs must guarantee access to inpatient drugs at least at the level consistent with Medicaid FFS.
The global capitation payment made to a PASSE covers the costs of services, administration, and care coordination of members assigned to the PASSE in accordance with 42 CFR § 438.2. The global payment will be actuarially sound and made to each PASSE on a Per Member Per Month (PMPM) basis. The global capitation payment amount is determined on an annual basis and includes a variety of factors including the results of the Independent Assessment and cost trends.
The PASSE will receive a prorated PMPM for members beginning coverage the same month as assignment to a PASSE. Payments will be prorated for the number of days in the month in which the member is effective with the PASSE.
PASSE Disenrollment will be based upon a determination by DHS that a member is no longer eligible to receive PASSE services. A member will be assigned to the same PASSE if re-enrollment occurs within one-hundred and eighty (180) days of previous disenrollment. Disenrollment will occur because of the following:
DHS complies with 42 CFR § 438.52 in offering a Medicaid beneficiary the choice of PASSE provider.
Any newly identified member that is mandatorily assigned to a PASSE will be assigned based upon the following rules:
The effective date of PASSE assignment will be 7 calendar days after the date of auto-assignment or voluntary enrollment. The PASSE will receive a prorated global payment for individuals beginning coverage the same month as auto-assignment or voluntary enrollment.
Voluntary enrollment into a PASSE is not allowed prior to July 1, 2019.
DHS reserves the right to cap assignment of additional members to the PASSE for any of the following reasons, as determined by DHS in its sole discretion:
An Independent Assessment (IA) is required prior to becoming a member of a PASSE. Not all Medicaid enrollees can be enrolled in a PASSE. Individuals must be in need of behavioral health or developmental disabilities services. An IA is conducted by qualified individual using an assessment instrument approved by DHS.
Beneficiaries who meet the following criteria will be put into Placement Suspension from the PASSE:
The following beneficiaries are eligible for mandatory assignment to a PASSE:
Voluntary enrollment into a PASSE may begin on or after July 1, 2019. In order to voluntarily enroll into a PASSE, a beneficiary must have BH or DD services needs and be identified as meeting a Tier I level of care through the Independent Assessment.
The PASSE will not, on the basis of health status or disability or need for health care services, discriminate against individuals eligible to enroll. The PASSE shall comply with 42 CFR § 438.3(d).
The PASSE cannot transition any assigned member and is responsible for all eligible services provided to that member during the time the member is eligible and a member of that PASSE.
The PASSE may not request disenrollment of a member because of an adverse change in the member's health status, or because of the member's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when, as determined by DHS, his or her continued enrollment in the PASSE seriously impairs the PASSE's ability to furnish services to either this particular member or other members).
The PASSE cannot transition any assigned member and is responsible for all eligible services provided to that member during the time the member is eligible and a member of that PASSE.
A member may voluntarily transition from their assigned PASSE and choose another PASSE within ninety (90) days of initial assignment. A member 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.
There will be a yearly open enrollment period when a mandatorily enrolled member may voluntarily transition to a different PASSE. The annual open enrollment period when a member can transition their PASSE will be established by DHS and will be for no shorter than 30 days on a yearly basis. If no action is taken by the member, they will remain in 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 for the following year.
Cause for transition, as described in 42 CFR § 438.56, is as follows:
Transition from a PASSE will be processed by DHS after request of change by the member. 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 member request for transition was received.
To request a transition, a member should contact:
Arkansas Department of Human Services, Beneficiary Support Center
DHS reserves the right to transition beneficiaries in compliance with 42 CFR 438.56.
As a condition for contracting with the PASSE, DHS has safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the PASSE contracts or the enrollment processes specified in 42 CFR § 438.54 {b).
PASSE
No payment will be made by DHS to a provider other than the capitated payment to a PASSE for services covered under the PASSE Provider Agreement.
DHS must arrange for Medicaid services to be provided without delay to any member of a PASSE of which the PASSE Provider Agreement is terminated and for any member who is disenrolled from a PASSE for any other reason than ineligibility for Medicaid.
DHS must have in effect a transition of care policy to ensure continued access to services during a transition from FFS to a PASSE entity or transition from one PASSE to another when a member, in absence of continued services, would suffer serious determent to their health or be at risk of hospitalization or institutionalization.
The transition of care policy must include the following:
requests for historical utilization data from the new PASSE in compliance with Federal and State law.
DHS will require in the PASSE Provider Agreement that PASSEs implement a transition of care policy consistent with the requirements of this section and at least meets the State defined transition of care policy.
At a minimum, all members who have an existing Person Centered Service Plan (PCSP) will carry that care plan with them when they are enrolled into a PASSE. Each member will be assigned a Care Coordinator who must make contact with that member within 15 business days of the effective date of PASSE enrollment. The PASSE Care Coordinator will have 60 days from PASSE enrollment to conduct a health questionnaire and coordinate a PCSP Development meeting with the member. The PCSP must address any needs noted in the Independent Assessment, the health questionnaire, or any other assessment or evaluation used at the time of PCSP development.
DHS will make Us transition of care policy publicly available and provide instructions to members and potential members on how to access continued services upon transition. At a minimum, the transition of care policy must be described in the quality strategy, under § 438.340, and explained to individuals in the materials to members and potential members, in accordance with 42 CFR § 438.10.
In the case of transitioning between PASSES, the relinquishing PASSE is responsible for timely notification to the receiving PASSE regarding pertinent information related to any special needs of transitioning members. The PASSE, when receiving a transitioning member with special needs, is responsible to coordinate care with the relinquishing PASSE in order that services are not interrupted, and for providing the new member with new accountable providers and care coordinator as well as service information, emergency numbers and instructions on how to obtain services. The PASSE shall assure appropriate medical records, care treatment plans, and care management files are transitioning to the receiving PASSE.
The PASSE should give special attention to beneficiaries that experience the following circumstances:
The PASSE shall have appropriate policies, procedures, and trained staff to manage these transitions and assure continuity of care.
It is the PASSE's responsibility to assure a smooth beneficiary transition and provide continuity of service for at least ninety (90) days or until transition process is complete. [ 42 CFR 438.1]
DHS will monitor the activities of each PASSE and the PASSE program as a whole as defined in CFR 42 §438.66. This includes the conduct of hearings requested by a PASSE or a provider due to alleged anti-competitive practices.
As required by 42 CFR § 447.203, DHS will monitor PASSE organization network providers to ensure members have adequate access to care. DHS has established access standards which the PASSE is required to meet. DHS requires that the PASSE and contract provider networks cooperate with DHS's analysis for access and provide any requested data required to carry out DHS's process for monitoring access to care.
DHS will seek public comment from time to time to identify any areas of concern about access to care or service availability. As required by federal regulation DHS shall perform an analysis of timely access to care at the end of the first year of the PASSE program and at least every three years thereafter for each of the following provider:
The PASSE must submit audited financial reports as outlined in the PASSE Provider Agreement and this manual on an annual basis. The audit must be conducted in accordance with generally accepted accounting principles and generally accepted auditing standards.
The PASSE must retain, and require subcontractors to retain, as applicable, the following information: member grievance and appeal records in § 438.416, base data in § 438.5(c), MLR reports in § 438.8(k), and the data, information, and documentation specified in §§ 438.604, 438.606, 438.608, and 438.610 for a period of no less than 10 years.
A PASSE must maintain a network that is sufficient in numbers and types of providers to ensure that all needed services to attributed members will be adequately accessible without unreasonable delay and within the time and distance requirements set out in this policy. At a minimum, the PASSE must contract with all provider types specified in the Provider Network Standards Table below. The PASSE must ensure provider ratios and provider-specific geographic access standards for members in urban or rural counties are met and maintained throughout the agreement year. For purposes of assessing adequate number and types of providers, DHS will determine provider ratios based upon one hundred twenty percent (120%) of the PASSE's actual monthly enrollment.
Network adequacy is determined based upon the inclusion of Medicaid enrolled providers that have signed a contract with the PASSE to provide services to members that have been attributed to a PASSE. A provider not enrolled as a Medicaid provider will not be counted towards meeting network adequacy.
Provider types listed in the chart below are the providers that are counted towards meeting network adequacy. A performing provider that is a contracted network provider of a PASSE who works at a facility does not mean that the facility will be counted towards meeting network adequacy. For purposes of network adequacy, "facility" includes a site, clinic, group practice, or other organization or business arrangement in which the performing provider is not an employee.
The facility must have a signed contract with the PASSE in order for the facility to be counted towards meeting network adequacy. The PASSE must provide the National Provider Identifier (NPI) of the provider and the facility/group NPI if the entity bills at the facility level (including, if available, the Medicaid ID of the provider) in the required bi-annual network submission on January 30lh and July 30lh for the previous six (6) months.
The PASSE must prepare, submit to DHS for approval, and follow a documented process for credentialing and recredentialing of providers who have signed contracts/agreements with the PASSE. The PASSE must utilize a universal process for providers as described in 249.300 and approved by DHS.
Urban counties are those with a population greater than 90,000 citizens as estimated by the United State Census Bureau for the current calendar year.
Urban counties include:
Distance from members to Specialty Provider types and Provider to Enrollee ratio for different provider types will be reported in the required bi-annual network submission that is due to DHS on January 30th and July 30th for the previous 6 months. Each PASSE shall attest and submit documentation that demonstrates the PASSE provider network is compliant with the below standards. If the PASSE is utilizing telemedicine, the PASSE must document what services they allow the usage of telemedicine for, the settings allowed to utilize telemedicine at, and the qualifications for individuals to perform services via telemedicine.
Provider Specialty | Provider Type | Urban | Rural | Provider Ratio |
Arkansas Medicaid Provider Type and associated specialty, if applicable | Maximum Distance (miles) | Maximum Distance (miles) | Providers per Member | |
Primary Care | 01.02,03, 04, 58, 62 | 30 | 60 | 1:250 members |
Pediatrics - Routine/Primary Care | 01.02,03, 04, 58, 62 | 30 | 60 | 1:250 members |
Ambulatory Surgical Center | 28 | 40 | 90 | 1:1,000 members |
Allergy and Immunology | 40 | 90 | 1:500 members | |
Cardiothoracic Surgery | 40 | 90 | 1:1,000 members | |
Cardiovascular Disease | 40 | 90 | 1:500 members | |
Dermatology | 40 | 90 | 1:1,000 members | |
Supportive Living / Respite / Supplemental Support | 67 | n/a | n/a | Ability to provide service in all Arkansas counties |
Environmental Modifications / Adaptive Equipment | 72 | n/a | n/a | Ability to provide service in all Arkansas counties |
Specialized Medical Supplies | 73 | n/a | n/a | Ability to provide service in all Arkansas counties |
Supported Employment | 75 | n/a | n/a | Ability to provide service in all Arkansas counties |
Diagnostic Radiology | 40 | 90 | 1:1,000 members | |
Endocrinology | 40 | 90 | 1:750 members | |
ENT/Otolaryngology | 40 | 90 | 1:750 members | |
Federally Qualified Health Center (FQHC) | 49 | n/a | n/a | Must have at least 1 FQHC enrolled as a network provider |
Gastroenterology | 40 | 90 | 1:750 members | |
General Surgery | 40 | 90 | 1:500 members | |
Gynecology,, OB/GYN | 30 | 60 | 1:250 members | |
Hematology | 40 | 90 | 1:750 members | |
Home Health | 14 | n/a | n/a | Ability to provide service in all Arkansas counties |
Hyperalimentation | 33 | n/a | n/a | Ability to provide service in all Arkansas counties |
Intermediate Care Facility | 12,13 | n/a | n/a | Ability to provide service in all Arkansas counties |
Infectious Diseases | 40 | 90 | 1:1,000 members | |
Nephrology | 40 | 90 | 1:1,250 members | |
Neurology | 40 | 90 | 1:1,000 members | |
Neurosurgery | 40 | 90 | 1:1.000 members | |
Oncology | 40 | 90 | 1:1,000 members | |
Ophthalmology | 22 | 40 | 90 | 1:1,000 members |
Optometry | 22 | 40 | 90 | 1:800 members |
Orthopedic Surgery | 40 | 90 | 1:1,000 members | |
Orthotics and Prosthetics | 16 | 40 | 90 | 1:1,000 members |
Outpatient Dialysis | 34 | 40 | 90 | 1:1,000 members |
Outpatient 1 nf usion/C hemothe r apy | 40 | 90 | 1:3,000 members | |
Personal Care | 32 | n/a | n/a | Ability to provide service in all Arkansas counties |
Pharmacy | 07 | 20 | 50 | 1:1,000 members |
Physical medicine and rehabilitation, Psychiatry | 40 | 90 | 1:1,000 members | |
Plastic Surgery | 40 | 90 | 1:1,000 members | |
Podiatry | 17,48 | 40 | 90 | 1:1,000 members |
Pulmonary | 40 | 90 | 1:1,000 members | |
Rheumatology | 40 - | 90 | 1:1,500 members | |
Rural Health Clinic | 29 | n/a | n/a | Must have at least 1 RHC enrolled as a network provider |
Therapist (Occupational) | 21.42 | 30 | 60 | 1.500 members |
Therapist (Physical) | 21,42 | 30 | 60 | 1:500 members |
Therapist (Speech) | 21,42 | 30 | 60 | 1:500 members |
Urology | 40 | 90 | 1:1,000 members | |
Vascular Surgery | 40 | 90 | 1:1,250 members | |
Ventilator Equipment | 37 | n/a | n/a | Ability to provide service in all Arkansas counties |
Facility/Group/Orqanization | ||||
Provider Specialty | Provider Type | Urban | Rural | Provider Ratio |
Acute Inpatient Hospital | 05 | 30 | 60 | 1 bed: 400 members |
Adult Developmental Day Treatment (ADDT) | 24, AN | n/a | n/a | Ability to provide service in all Arkansas counties |
Critical Care Services - Intensive Care Units (ICUs) | 05 | 30 | 90 | 1 bed: 800 members |
DME | 16 | n/a | n/a | Ability to provide service in all Arkansas counties |
Outpatient Hospital | 05 | 30 | 60 | n/a |
Behavioral Health | ||||
Provider SDecialtv | Provider Type | Urban | Rural | Provider Ratio |
Independently Licensed Clinician -Master's/Doctoral | 19 | 40 | 75 | 1:750 members |
Board Certified Psychiatrist | 01,02,03. 04 | 40 | 75 | 1:500 members |
Inpatient Psychiatric Facility for Individuals Under the Age of 21 | 25 | n/a | n/a | 1 bed:300 members |
Substance Abuse Treatment Provider | 26, R6 | 40 | 120 | 1:750 members |
A PASSE must meet the following time frame standards:
Service Type | Time Frame | Time Frame Goal |
Emergency Care - Medical, Behavioral Health, Substance Abuse | 24 hours a day, 7 days a week | Met 100% of the time |
Behavioral Health Service and Developmental Disability Service Mobile Crisis Response | 24 hours a day, 7 days a week | Met 100% of the time |
Urgent Care - Medical, Behavioral Health, Substance Abuse | Within 24 hours | Met 100% of the time |
Primary Care - Routine, nonurgent symptoms | Within 21 calendar days | Met a 90% of the time |
Behavioral Health, Substance Abuse Care - Routine, nonurgent, non-emergency | Within 21 calendar days | Met [GREATER THAN] 90% of the time |
Prenatal Care | Within 14 calendar days | Met 2[GREATER THAN] 90% of the time |
Primary Care Access to after-hours care | Office number answered 24 hours / 7 days a week by answering service or instructions on how to reach a physician | Met 2 90% of the time |
Preventive visit/well visits | Within 30 calendar days | Met a 90% of the time |
Specialty Care - non-urgent | Within 60 calendar days | Met a 90% of the time |
DHS has the sole discretion to allow a variance of any of these network adequacy standards. 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.
A PASSE must monitor, on an ongoing basis, the ability of its participating providers to furnish all required benefits to members. The state must approve the network monitoring methodology used by the PASSE to validate that network adequacy and access to care standards are being met. A PASSE must monitor and report on the following within the specified timeframe listed: biannual (reports due January 30lh and July 30,ri for the previous 6 months) basis:
In accordance with 42 CFR § 438.70, DHS must ensure the views of beneficiaries, individuals representing beneficiaries, providers, and other stakeholders are solicited and addressed during the design, implementation, and oversight of the PASSE program.
DHS shall maintain a Beneficiary Support System in accordance with 42 CFR § 438.71. The Beneficiary Support System will offer choice counseling for all beneficiaries, assistance for members understanding organized care, and assistance for members who use or express a desire to receive home and community based supportive services.
DHS will annually submit to CMS a summary description of the report(s) received from the PASSES according to 42 CFR § 438.8(k), with the rate certification required in 42 CFR § 438.7. The summary description must include, at a minimum, the amount of the numerator, the amount of the denominator, the MLR percentage achieved, and the number of member months for that MLR reporting year.
The PASSE shall submit the Medical Loss Ratio (MLR) report annually in compliance with 42 CFR § 438.8. In the event of retroactive changes to capitation rates after the contract year end, the PASSE will need to be incorporated into the MLR calculation. If the retroactive capitation rate adjustment occurs after the MLR report has been submitted to the State, a new report incorporating the change will be required to be submitted within 30 days of the capitation rate adjustment payment is made.
The PASSE must have written policies addressing the following:
DHS will, on an annual basis, offer an open enrollment period for all current enrollees to choose a different PASSE for coverage beginning January 1 of the following year. If an individual does not make an active choice to switch PASSEs during the open enrollment period, that individual will remain a member of the same PASSE for the 12 months of the new coverage year provided the individual is otherwise eligible.
The annual open enrollment period when a member can transition their PASSE will be established by DHS and will be for no shorter than 30 days on a yearly basis.
A member may voluntarily transition from their assigned PASSE and choose another PASSE within ninety (90) days of initial assignment. A member will not be permitted to change their PASSE more than once within a twelve (12) month period, unless:
Arkansas Department of Human Services, Beneficiary Support Center
DHS reserves the right to transition beneficiaries in compliance with 42 CFR 438.56.
A member may not change their PASSE outside of the 90-day period following initial assignment or during the annual open enrollment period, unless cause for transition is met.
Cause for transition, as described in 42 CFR § 438.56, is as follows:
The PASSE must submit to DHS an electronic file of the PASSE provider network directory and network services on a monthly basis. The PASSE provider network directory or a link to the PASSE provider network directory will be posted on the Arkansas Medicaid website. The PASSE must maintain a provider network directory that, at a minimum, does the following:
The PASSE must allow each member to choose his or her health professional to the extent possible and appropriate.
The PASSE is responsible for assigning each member to a PCP,
The PASSE must adhere to all provider-member (enrollee) communication requirements as described in 42 CFR § 438.102.
The PASSE may only market to potential beneficiaries through its website or printed material distributed by DHS's choice counselors.
Marketing means any communication from the PASSE, or any of its agents, participating providers, direct service providers, or independent contractors, to a member of another PASSE or a potential member that can reasonably be interpreted as intended to influence that individual to enroll, remain enrolled or reenroll in the PASSE, or to disenroll from or not enroll in another PASSE.
A PASSE may only distribute information to a current member of their PASSE. Other than the welcome information if a member transitions to their PASSE, a PASSE cannot provide any information to a Medicaid member that is a member of another PASSE. Participating providers and direct service providers cannot distribute information to a Medicaid member about enrolling in a specific PASSE. The only allowable information that can be distributed to Medicaid beneficiaries by participating providers and direct service providers will be information that is provided by DHS.
All marketing materials and activities must be approved by DHS in advance of use. DHS may impose sanctions on the PASSE, participating providers, and direct service providers if there is a failure to adhere to the marketing material requirements and restrictions.
The PASSE must ensure that its members are not held liable for any of the following:
Cost sharing is not allowed for members assigned to a PASSE.
The 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. The PASSE is required to submit to DHS minutes and/or reports indicating the activities carried out by the Consumer Advisory Council on a quarterly basis.
At a minimum, the Consumer Advisory Council must:
The PASSE must adhere to 42 CFR § 438.114 in regards to coverage and payment for emergency and post stabilization services
The Arkansas Insurance Department (AID) will ensure that each PASSE meets solvency standards to remain licensed as a Risk-Based Provider Organization.
The PASSE is required to ensure that a member has access to all allowed Medicaid state plan services, including those authorized under the 1915(i) amendment, and CES waiver services. State plan services also include therapy services and services through the Early Periodic Screening Diagnosis and Treatment (EPSDT) program for children.
The PASSE must comply with Sections 1902[LESS THAN]a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and Federal regulations at 42 CFR § Part 441 Subpart B that require EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services.
The PASSE must ensure that network providers and the PASSE itself complies with 42 CFR § 438.206.
Pursuant to 42 CFR § 438.66 governing state monitoring requirements and this Manual, DHS will assess the ability and capacity of the PASSE to satisfactorily perform in the following areas:
A PASSE must monitor, on an ongoing basis, the ability of its participating providers to furnish all required benefits to members. The state must approve the network monitoring methodology used by the PASSE to validate that network adequacy and access to care standards are being met. A PASSE must monitor and report on the following within the specified timeframe listed: biannual {reports due January 30m and July 30th for the previous 6 months) basis:
Care Coordinators or case managers who are employed or subcontracted by an organization that has responsibility for the development and delivery of a service plan for an enrollee shall not fulfill the responsibility of the PASSE to provide care coordination for that individual. Additionally, Care Coordinators shall not be related by consanguinity (3rd degree or less) or marriage to the individual enrollee, his or her paid caregivers, or anyone financially responsible for the individual.
An individual must meet the following qualifications to provide care coordination to PASSE beneficiaries;
OR
Have at least one (1) year of experience working with developmentally or intellectually disabled clients or behavioral health clients;
Coordination of Benefits (COB) refers to the activities involved in determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance, or program that is liable to pay for health care services. The PASSE is responsible for TPL.
Medicaid is the payor of last resort unless specifically prohibited by applicable State or Federal law. This means the PASSE shall pay for covered services only after all other sources of payment have been exhausted, e.g. the insurance carrier of a tortfeasor. The PASSE shall take reasonable measures to identify potentially legally liable third party sources.
If the PASSE discovers the probable existence of a liable third party that is not known to DHS, or identifies any change in coverage, the PASSE must report the information within thirty (30) days of discovery via the TPL File. Failure to report these cases may result in a sanction.
The PASSE shall coordinate benefits in accordance with 42 CFR § 433.135, so that costs for services otherwise payable by the PASSE are cost avoided or recovered from a liable third party [ 42 CFR § 434.6(a)(9)]. The term "State" shall be interpreted to mean "PASSE" for purposes of complying with the Federal regulations referenced above. The PASSE may require subcontractors to be responsible for coordination of benefits for services provided pursuant to Ihe PASSE Provider Agreement. The two methods used for coordination of benefits are Cost Avoidance and Post-Payment Recovery. The PASSE shall use these methods as described in Federal and State policies.
The PASSE shall cost avoid a claim if it has established the probable existence of a liable party at the time the claim is filed. There may be limited circumstances when cost avoidance is prohibited, and the PASSE must apply post-payment recovery processes.
For purposes of cost avoidance, establishing liability takes place when the PASSE receives confirmation that another party is, by statute, contract, or agreement, legally responsible for the payment of a claim for a healthcare item or service delivered to a PASSE member. If the probable existence of a party's liability cannot be established, the PASSE must adjudicate the claim, and then utilize post-payment recovery if necessary. If DHS determines that the PASSE is not actively engaged in cost avoidance activities, the PASSE may be subject to sanctions.
If a third-party insurer requires the member to pay any copayment, coinsurance or deductible, the PASSE is responsible for making these payments for Medicaid covered services.
The PASSE is delegated the responsibility for coordination of benefits payment activities with legally liable third parties, including Medicare. For dual eligible members, the PASSE shall coordinate Medicare fee-for-service (FFS) crossover claims payment activities with the Medicare Benefits Coordination and Recovery Center (BCRC) in accordance with 42 CFR § 438.3(t).
The PASSE shall be registered with the BCRC as a trading partner to electronically process Medicare FFS crossover claims. An Attachment to the existing DHS Medicare FFS Coordination of Benefits Agreement (COBA) shall be executed by PASSE to register as a BCRC trading partner. Upon completion of the registration process, the BCRC shall issue each PASSE a unique COB ID number. The PASSE will electronically receive data from the BCRC to coordinate payment of Medicare FFS crossover claims only. The PASSE shall be exempt from BCRC crossover processing fees to the same extent as DHS.
Upon completion of trading partner registration, PASSE shall coordinate with the BCRC regarding the sending, receipt and transmission of necessary BCRC-provided data files and file layouts, including eligibility and claim data files. PASSE shall begin adjudicating Medicare FFS crossover claims upon completion of BCRC readiness review activities and receipt of BCRC approval.
Further information and resources for PASSE regarding the Medicare FFS COBA process and BCRC requirements are available at:
The PASSE shall not deny a claim for timeliness if the untimely claim submission results from a provider's reasonable efforts to determine the extent of liability.
Post-payment recovery is necessary in cases where the PASSE has not established the probable existence of a liable third-party at the time services were rendered or paid for, was unable to cost-avoid, or post-payment recovery is required. In these instances, the PASSE must adjudicate the claim and then utilize post-payment recovery processes which include: Pay and Chase, Retroactive Recoveries Involving Commercial Insurance Payor Sources, and other third-party liability recoveries.
Upon identification of a potentially liable third party for any of the above situations, the PASSE shall, within 10 business days, report the potentially liable third party to DHS for determination of a mass tort, total plan case, or joint case. Failure to report these cases may result in sanctions or other administrative remedy. A mass tort case is a case where multiple plaintiffs or a class of plaintiffs have filed a lawsuit against the same tortfeasor(s) to recover damages arising from the same or similar set of circumstances {e.g. class action lawsuits) regardless of whether any reinsurance or Fee-For-Service payments are involved. A total plan case is a case where payments for services rendered to the member are exclusively the responsibility of the PASSE; no reinsurance or Fee-For-Service payments are involved. By contrast, a "joint" case is one where Fee-For-Service payments and/or reinsurance payments are involved. The PASSE shall cooperate with DHS's authorized representative in all collection efforts.
Prior to negotiating a settlement on a total plan case, the PASSE shall notify DHS to ensure that there is no reinsurance or Fee-For-Service payment that has been made by DHS. Failure to report these cases prior to negotiating a settlement amount may result in sanction or other administrative remedy.
The PASSE shall report settlement information to DHS using a format specified by DHS, within 10 business days from the settlement date. Failure to report these cases may result in sanctions or other administrative remedy determined by DHS.
All TPL reporting requirements are subject to validation through periodic audits and/or operational reviews which may include the PASSE submission of an electronic extract of the casualty cases, including open and closed cases. Data elements may include, but are not limited to: the member's first and last name; Medicaid ID; date of incident; claimed amount; paid/recovered amount; and case status. DHS shall provide the format and reporting schedule for this information to PASSE.
The PASSE is required to ensure that a member has access to all allowed Medicaid state PASSE and CES waiver services, including therapy services and services through the Early Periodic Screening Diagnosis and Treatment (EPSDT) program for children.
The PASSE must comply with Sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and Federal regulations at 42 CFR § Part 441 Subpart B that require EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services.
The PASSE cannot provide an incentive, monetary or otherwise, to Provider for withholding Medically Necessary Services. All services provided to PASSE members must be medically necessary for each member. The PASSE must ensure that services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished.
The PASSE may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition of the enrollee. The PASSE may place appropriate limits on a service for utilization control, provided the services furnished can reasonably achieve their purpose.
The PASSE must ensure compliance with 42 CFR § 438.210.
The PASSE must prepare, submit to DHS for approval, and follow a documented process for credentialing and recredentialing of providers who have signed contracts/agreements with the PASSE. Credentialing must be completed before final execution of the contract with the provider.
The PASSE may not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act.
The PASSE's network provider selection policies and procedures, consistent with 42 CFR § 438.12, must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.
Payments made by a PASSE to its providers to promote efficiency and effectiveness of services, improve quality of care, and promote most appropriate utilization in the most appropriate setting. Such payments may be made as part of a PASSE's Quality Assessment and Performance Improvement (QAPI) strategy.
Provider incentives based on value are allowed and encouraged. Payments based on volume to increase inappropriate utilization (including denial of services) will not be permitted.
The PASSE must disclose any value-based payment arrangement with AID.
The PASSE must provide DHS an assurance of compliance with any applicable consent decrees impacting Arkansas Medicaid providers.
Requirements
The PASSE must provide DHS an assurance of compliance with the current Arkansas Preferred Drug List.
Insurance Department
The PASSE must provide DHS an assurance of compliance with payment methodology requirements by the Arkansas Insurance Department.
For any medical records and any other health and enrollment information that identifies a particular member, each PASSE must use and disclose such individually identifiable health information in accordance with the privacy requirements in § 42 CFR Part 2 and 45 CFR parts 160 and 164, subparts A and E, to the extent that these requirements are applicable.
The PASSE must have an internal grievance process to address member concerns and complaints. The grievance process must:
The PASSE must submit a grievance log with their quarterly report.
When the Division of Medical Services {DMS) takes an adverse action against a PASSE or member, the PASSE or member may request a fair hearing to appeal the adverse action.
To do so, the member or PASSE must follow the procedures in the Medicaid Provider Manual, Sections 160.000 & 190.000.
When an adverse decision/adverse action has been taken by a PASSE, the following appeals are available in response to that adverse decision/adverse action:
The PASSE must adhere to the Arkansas Administrative Procedure Act, Ark. Code Ann. §§ 25-15-201 ef seq. in the conduct of appeals and hearings.
The PASSE appeal process must be approved by DHS. This requires that:
The PASSE must send written notice to members of significant changes to the appeals process at least thirty (30) days prior to implementation.
In general, payment to providers is based on good faith negotiation between the PASSE and providers reflecting rates and quality. If a PASSE or a provider believes that the other party is not negotiating in good faith and is engaged in anti-competitive practices, either party may request DHS to convene a hearing to present evidence to support its claim. Such evidence must include upper and lower payment amounts paid for the same services, except for value-based payments, to other providers. The hearing will be public. Such a hearing is not mediation. There is no obligation on the part of DHS to make a determination of wrong doing. A PASSE must disclose the use of value based payments to the provider type at issue, but shall not be required to disclose the methodology for making value based payments.
The PASSE must ensure compliance with 42 CFR § 438.230. The PASSE entity maintains ultimate responsibility for adhering and otherwise fully complying with all terms and conditions of this provider manual and the PASSE Provider Agreement.
The PASSE must adopt practice guidelines that adhere to 42 CFR § 438.236. The PASSE must disseminate the guidelines to all affected providers and, upon request, to members and potential members. All decisions for utilization management, member education, coverage of services, and other areas to which the practice guidelines apply are consistent with the guidelines.
Each PASSE must have a health information system that collects, analyzes, integrates, and reports data and can achieve the objectives of 42 CFR § 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of Medicaid eligibility.
DHS requires that the PASSE health information system complies with the following:
DHS requires that the PASSE submits to DHS the following data:
The PASSE shall operate and maintain claims operational processes and systems that ensure the verification, processing, accurate and timely adjudication and payment of claims. This includes appropriate auditing of claims for NCCI edits. The claim process and systems shall result in timely payment of provider claims for eligible PASSE members. The PASSE shall have a process for resolution of provider claim disputes and member grievance and appeals for denial of claims payment. [ 42 CFR § 438.242(a)].
Additionally, the PASSE must include information in its remittance advice which informs providers of instructions and timeframes for the submission of claim disputes and corrected claims. All paper remittance advices must describe this information in detail. Electronic remittance advices must either direct providers to the link where this information is explained or include a supplemental file where this information is explained.
The related remittance advice must be sent with the payment, unless the payment is made by electronic funds transfer (EFT). Any remittance advice related to an EFT must be sent to the provider, no later than the date of the EFT. The PASSE must provide provider with electronic file transfer and Data Exchange Requirements, for specific standards related to electronic claims and receiving electronic remittance advice and EFT payment.
When PASSE needs to recoup a claim payment due to a claim being determined to be the payment responsibility of another PASSE organization or third party insurer; the PASSE is responsible to inform the provider to file with the correct financial responsible payer. The responsible PASSE shall not deny a clean claim on the basis of lack of timely filing if the provider submits a clean claim to the responsible PASSE no later than 60 days from the date of the recoupment, 12 months from the date of service, or 12 months from date that eligibility is posted, whichever date is later.
The PASSE shall ensure that for each form type (Professional/Institutional), that 95% of all clean claims are adjudicated within 30 days of receipt of the clean claim and 99% are adjudicated within 60 days of receipt of the clean claim.
The PASSE is required to reimburse providers for previously denied or recouped claims, if the provider was subsequently denied payment by the primary insurer based on timely filing limits or lack of prior authorization and the member failed to initially disclose additional insurance coverage.
The provider shall have 90 days from the date they become aware that payment will not be made to submit a new claim to the PASSE which includes the documentation from the primary insurer that payment will not be made. Documentation includes but is not limited to any of the following items establishing that the primary insurer has or would deny payment based on timely ftling limits or lack of prior authorization.
The PASSE's claims processes, as well as its prior authorization and concurrent review process, must minimize the likelihood of having to recoup already-paid claims. Any individual recoupment in excess of $50,000 per provider, or Tax Identification Number within a Contract year or greater than 12 months after the date of the original payment must be approved by DHS.
When recoupment amounts for a Provider TIN cumulatively exceed $50,000 during a Contract year (based on recoupment date), the PASSE must report the cumulative recoupment monthly to the designated DHS contact.
The Contractor must void encounters for claims that are recouped in full. For recoupments that result in a reduced claim value or adjustments that result in an increased claim value, replacement encounters must be submitted. DHS may validate the submission of applicable voids and replacement encounters upon completion of any approved recoupment. Replaced or voided encounters must reach adjudicated status within 120 days of the approval of the recoupment.
If the PASSE or DHS reverses a decision to deny, limit, or delay authorization of services, and the member received the disputed services while an appeal was pending, the PASSE shall process a claim for payment from the provider in a manner consistent with the PASSE's decision or DHS direction and applicable statutes, rules, policies, and PASSE Provider Agreement terms. The provider shall have 90 days from the date of the reversed decision to submit a clean claim to the PASSE for payment. For all claims submitted as a result of a reversed decision, the PASSE is prohibited from denying claims for untimeliness if they are submitted within the 90 day timeframe. The PASSE is also prohibited from denying claims submitted as a result of a reversed decision because the member failed to request continuation of services during the appeals/hearing process as a member's failure to request continuation of services during the appeals/hearing process is not a valid basis to deny the claim.
The PASSE shall submit a Claims operations performance report as specified by DHS in the PASSE Provider Agreement. The PASSE shall develop and implement an internal ongoing claims audit function that will include, at a minimum, the following:
The PASSE shall audit that provider contract terms and rates are loaded correctly. This can be performed on a regular or periodic basis and consist of a random, statistically significant sampling of all claims and contracts in effect at the time of the audit. The audit sampling methodology must be documented in policy and the PASSE should review the contract loading of both large groups and individual practitioners at least once during a PASSE contract cycle, in addition to any time a contract change is initiated during that timeframe. The findings of the audits described above must be documented and any deficiencies noted in the resulting reports must be met with corrective action.
In addition, in the event of a system change or upgrade, the PASSE shall also be required to initiate an independent audit of the Claim Payment/Health Information Systems. The findings and recommendation from the audit should be submitted to DHS.
Encounter data submission to DHS is specified in the PASSE Provider Agreement, including the specifications for submitting encounter data to the State in standardized ASC X12N 837 and NCPDP formats, and the ASC X12N 835 format as appropriate. As part of the readiness review process, DHS will review and validate that the encounter data collected, maintained, and submitted to the State by the PASSE meets the requirements of this section. The State must have procedures and quality assurance protocols to ensure that enrollee encounter data submitted is a complete and accurate representation of the services provided to the enrollees under the PASSE Provider Agreement between the State and the PASSE.
The PASSE is required to submit encounter data reports on a monthly basis to DHS. An encounter is a service or procedure provided to a PASSE member by a provider that is compensated by any possible means (e.g. Fee-for-service, capitation, fee-foMime, or salary). This includes any service or procedure that is provided directly by the PASSE. The PASSE Provider agreement will specify the exact requirements for encounter claims submission to DHS.
The PASSE must report encounter data in the following standard format:
The PASSE must retain, and require subcontractors to retain, as applicable, the following information: member grievance and appeal records in § 438.416, base data in § 438.5(c), MLR reports in § 438.8(k), and the data, information, and documentation specified in §§ 438.604, 438.606, 438.608, and 438.610 for a period of no less than 10 years.
The PASSE must report to DHS any sanctions imposed upon any provider, both in-network an out of network.
The PASSE Provider Agreement must comply with mandating provider identification of provider-preventable conditions as a condition of payment, as well as the prohibition against payment for provider-preventable conditions as set forth in § 434.6(a)(12) and § 447.26 of this chapter. The PASSE must report all identified provider-preventable conditions to DHS.
Provider credentialing is a detailed process that reviews provider qualifications and career history including their education, training, residency and licenses as well as specialty certificates. DHS will accept the standards set by regulatory and accreditation organizations such as the National Committee for Quality Assurance (NCQA), Commission on the Accreditation of Rehabilitation Facilities (CARF), and The Joint Commission (TJC).
Starting January 1, 2020 the PASSE must have a credential review committee that approves or denies the final credentialing of its providers. The PASSE must demonstrate that it verifies primary source qualification data including:
All current Medicaid providers will be deemed as credentialed during calendar year 2019. Starting January 1, 2020, the PASSE must credential all network providers.
The PASSE may approve temporary provider credentials for up to 6 months pending completion of the full credential review. DHS may grant a variance for extending the temporary period following a demonstration of cjood cause._________________________________________________
The PASSE may deem the credential for providers who have already been approved and credentialed by another PASSE for up to 6 months pending completion of the full credential review. DHS may grant a variance for extending the temporary period following a demonstration of good cause.
The PASSE must submit the electronic status file of providers who have submitted a credential application, are in a pended status, have received temporary credential approval and if credentialing was denied, the reason for denial of credentials.
Credentialing and recredentialing is required on the following provider types:
Providers must be recredentialed not less than every three years unless more frequently due to a change in the clinical scope of services of a provider.
No later than January 1,2020, the PASSEs shall use a uniform standard credential application that must be submitted on-line and electronically and jointly select a single Contracted Credentialing Vendor Organization (CVO) according to specifications established by DHS. The costs of a CVO will be equally shared by the PASSEs. DHS shall establish a credentialing work group among the PASSEs for the purpose of setting credentialing process requirements.
Pursuant to sections 1932(c), 1903(a)(3){C)(ii). 1902(a)(4), and 1902(a)(19) of the Act, CMS sets forth:
Specifications for a quality assessment and performance improvement program (QAPI) that DHS must require each PASSE to implement and maintain,
As used in these sections of the PASSE Medicaid Provider Manual:
DHS requires that each PASSE establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its members that includes the elements identified in this section.
The comprehensive quality assessment and performance improvement program must include at least the following elements:
DHS must:
Each PASSE must inform DHS if they have been accredited by a private independent accrediting entity. If a PASSE has been accredited by a private independent accrediting entity, the PASSE must authorize the private independent accrediting entity to provide DHS a copy of its most recent accreditation review, including:
DHS will make the accreditation status of each PASSE available to the general public on the Arkansas Medicaid PASSE website.
Each year, DHS must collect data from each PASSE with which it contracts and issue an annual quality rating for each PASSE based on the data collected, using the Medicaid managed care quality rating system adopted under 42 CFR § 438.334.
DHS, in accordance with 42 CFR § 438.340, must draft and implement a written quality strategy for assessing and improving the quality of health care services furnished by the PASSE. This State quality strategy must be made available on the Arkansas Medicaid website.
DHS may provide quality incentive payments from the quality incentive pool to PASSEs who meet specific performance measurements as identified in the PASSE Provider Agreement. Quality incentive payments would be in addition to the global payment.
DHS, in accordance with 42 CFR § 438.350, must ensure that an External Quality Review Organization (EQRO) performs an annual External Quality Review for each PASSE. DHS must ensure that the EQRO meets the minimum requirements of 42 CFR § 438.354. DHS must contract with an EQRO in accordance with 42 CFR § 438.356. The EQR must contain the mandatory activities as required in 42 CFR § 438.358 and can contain the optional activities listed in the same section.
To avoid duplication, DHS may use information from a Medicare or private accreditation review of a PASSE to provide information for the annual EQR instead of conducting one or more of the EQR activities if the following conditions are met:
If DHS uses information from a Medicare or private accreditation review, DHS must ensure that all such information is furnished to the EQRO for analysis and inclusion in the report described in § 438.364(a).
DHS must identify in its quality strategy under § 438.340 the EQR activities for which it has exercised the option described in this section, and explain the rationale for DHS's determination that the Medicare review or private accreditation activity is comparable to such EQR activities.
DHS may exempt a PASSE from EQR if the following conditions are met:
When the State exercises this option, the State must obtain either of the following:
If an exempted PASSE has been reviewed by a private accrediting organization, DHS must require the PASSE provides DHS with a copy of all findings pertaining to its most recent accreditation review if that review has been used for either of the following purposes:
These findings must include, but need not be limited to, accreditation review results of evaluation of compliance with individual accreditation standards, noted deficiencies, corrective action plans, and summaries of unmet accreditation requirements.
DHS must ensure that the EQR results in an annual detailed technical report that summarizes findings on access and quality of care, including:
DHS cannot substantively revise the content of the final EQR technical report without evidence of error or omission.
DHS contract with a qualified EQRO to produce and submit to DHS an annual EQR technical report in accordance with this section. The State must finalize the annual technical report by April 30th of each year.
DHS must:
DHS must make the information specified in this section available in alternative formats for persons with disabilities, when requested. The information released under section may not disclose the identity or other protected health information of any patient.
If a PASSE fails to meet the quality metrics, as specified in the PASSE Provider Agreement, DHS may take action to correct the failure of impose penalties on the PASSE. DHS's actions may include, but are not limited to:
Pursuant to Act 775 of the 2017 Arkansas General Session, DHS will utilize data submitted from the PASSE to measure the performance of the following:
Each PASSE must report on and meet the quality metric reporting standards as outlined in this provider manual and the PASSE Provider Agreement.
Metric | Target | Reporting to DHS (Frequency/Content) |
The care coordinator's assigned caseload will be limited to a maximum of 50 attributed members. | £90% of care coordinators will have a caseload of £50 members | Quarterly/ Details of monthly caseload for each care coordinator employed, including the names of each member in the care coordinator's caseload |
Metric | Target | Reporting to DHS (Frequency/Content) |
Care coordinators must initiate contact with each member within 15 business days after effective date of PASSE coverage. | £75% of care coordinators will contact each member within 15 business days after effective date of PASSE coverage | Quarterly/ Details of initial contact time frame with each member after attribution to PASSE, including, but not limited to, date of attribution, date of initial contact and date of completed contact |
Metric | Target | Reporting to DHS (Frequency/Content) |
Care coordinators must follow up with members within seven (7) business days of visit to Emergency Room, or discharge from Hospital or In-Patient Psychiatric Unit/Facility | £50% of care coordinators will follow up with members within seven (7) business days of visit to Emergency Room, or discharge from Hospital or Inpatient Psychiatric Unit/Facility | Quarterly/ Details of follow up with members within (7) business days of visit to Emergency Room, or discharge from Hospital or In-Patient Psychiatric Unit/Facility, including but not limited to action or treatment plan to prevent/avoid such visits in the future |
-------------------------------------- Metric | ' --- ' Target | Reporting to DHS (Frequency/Content) |
Care coordinator must ensure that all members have selected a Primary Care Physician (PCP), confirm that the member is seeing the PCP as needed, and if necessary, to assist members with selecting/providing a referral to a PCP | £80% of members will have selected a PCP and are on a PCP's caseload | Quarterly/ Details about: 1. The number of members that have been referred to and have been assigned a PCP; |
The PASSE must report on the National Core Indicators (NCI) for its Developmental Disabilities specialty providers on a yearly basis. This report is due to DHS no later than July 31 each year for the previous 12 months.
The PASSE must comply with the requirements in 42 CFR §§ 438.604, 438.606, 438.608 and 438.610, as applicable.
DHS must comply with the requirements of 42 CFR § 438.602.
For the data, documentation, or information specified in 42 CFR § 438.604 and § 260.300 of this provider manual, DHS requires that the data, documentation or information the PASSE submits to DHS must be certified by either the PASSE's Chief Executive Officer; Chief Financial Officer; or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer so that the Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification.
The certification provided by the individual in paragraph (a) of this section must attest that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR § 438.604 and § 260.300 of this provider manual is accurate, complete, and truthful.
DHS requires that the PASSE must submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR § 438.604(a) and (b) and § 260.300 of this provider manual.
The PASSE may not knowingly have an individual involved in a relationship with the PASSE that is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in nonprocurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549.
The PASSE may not knowingly have an individual involved in a relationship with the PASSE who is an individual or entity who is an affiliate, as defined in the Federal Acquisition Regulation at 48 CFR 2.101, of a person described in paragraph (a)(1) of this section.
The PASSE may not have a relationship with an individual or entity that is excluded from participation in any Federal health care program under section 1128 or 1128A of the Act.
The relationships described above are as follows:
The PASSE must establish functions and activities governing program integrity in order to reduce the incidence of Fraud and Abuse and shall comply with all state and federal program integrity requirements, including but not limited to the applicable provisions of the Social Security Act, § § 1128,1902,1903, and 1932; 42 CFR § § 431, 433, 434, 435, 438, 441, 447, and 455 ; 45 CFR Part 75 ; Arkansas Law and Rules, and the PASSE Provider Agreement.
In accordance with applicable law, this provider manual, and the terms of the PASSE Provider Agreement, DHS may impose sanctions and/or remedies for failure to comply with any provision of applicable law, this provider manual, or the terms of the PASSE Provider Agreement.
Each PASSE will be monitored by DHS to ensure that all requirements set forth in this manual and the PASSE Provider Agreement are adhered to. This includes adherence with any applicable laws or regulations. Sanctions or remedies that can be imposed by DHS include, but are not limited to, one (1) or more of the following:
DHS may impose sanctions specified in this provider manual, in the PASSE Provider Agreement and any sanction specified in 42 CFR § 438 based upon determinations on findings from onsite surveys, member or other complaints, financial status, or any other source. DHS may impose intermediate sanctions if it makes any determinations specified below:
The types of intermediate sanctions that DHS may impose include the following:
Other State agencies retain authority to impose additional sanctions under State statutes or State regulations that address areas of noncompliance specified in § 438.700, as well as additional areas of noncompliance. Nothing in this section prevents State agencies from exercising that authority.
If the DHS imposes civil monetary penalties as provided under 42 CFR § 438.702(a)(1), the maximum civil money penalty DHS may impose varies depending on the nature of the PASSE's action or failure to act, as provided in this section.
Specific limits:
For premiums or charges in excess of the amounts permitted under the Medicaid program, the maximum amount of the penalty is $25,000 or double the amount of the excess charges, whichever is greater. The State must deduct from the penalty the amount of overcharge and return it to the affected enrollees.
If DHS imposes temporary management under 42 CFR § 438.702(a)(2), DHS may do so only if it finds (through onsite surveys, member or other complaints, financial status, or any other source) any of the following:
DHS must impose temporary management (regardless of any other sanction that may be imposed) if it finds that a PASSE has repeatedly failed to meet substantive requirements in sections 1903(m) or 1932 of the Act. DHS must also grant members the right to terminate enrollment from the PASSE which has been sanctioned without cause, as described in § 438.702(a)(3), and must notify the affected members of their right to terminate enrollment from the PASSE which has been sanctioned.
DHS may not delay imposition of temporary management to provide a hearing before imposing this sanction.
DHS may not terminate temporary management until it determines that the PASSE can ensure that the sanctioned behavior will not recur.
DHS has the authority to terminate a PASSE Provider Agreement and enroll that PASSE's members in other PASSEs, if the State determines that the PASSE has failed to do either of the following:
DHS must give the affected entity timely written notice that explains the following:
Before terminating a PASSE agreement, DHS must provide the PASSE a pre-termination hearing. The State must do all of the following:
After DHS notifies a PASSE that it intends to terminate the PASSE Provider Agreement, DHS may do the following:
DHS must give CMS written notice whenever it imposes or lifts a sanction for violations listed in § 438.700.
The notice must adhere to all of the following requirements:
DHS may recommend that CMS impose a denial of payment sanction on a PASSE if DHS determines that the PASSE acts of fails to act as specified in § 438.700(b)(1) through (6).
DHS' determination becomes CMS' determination for purposes of section 1903(m)(5)(A) of the Act unless CMS reverses or modifies it within 15 days.
If DHS's determination becomes CMS' determination under this section, DHS must take all of the following actions:
If the PASSE submits a timely response to the notice of sanction, DHS-
DHS's decision under this section becomes CMS' decision unless CMS reverses or modifies the decision within 15 days from date of receipt by CMS.
If CMS reverses or modifies DHS's decision, the agency sends the PASSE a copy of CMS' decision.
CMS, based upon the recommendation of DHS, may deny payment to DHS for new members of the PASSE under section 1903(m)(5)(B)(ii) of the Act in the following situations:
Under 42 CFR § 438.726(b), CMS' denial of payment for new members automatically results in a denial of agency payments to the PASSE for the same enrollees. (A new member is a member that applies for enrollment after the effective date that the PASSE is notified of the sanction.)
Effective Date-of Sanction - If the PASSE does not seek reconsideration, a sanction is effective 15 days after the date the PASSE is notified under this section of the decision to impose the sanction.
If the PASSE seeks reconsideration, the following rules apply:
CMS retains the right to independently perform the functions assigned to DHS under paragraphs (a) through (d) of §438.730
At the same time that DHS sends notice to the PASSE under paragraph (c)(1) of 42 CFR § 438.730, CMS forwards a copy of the notice to the OIG.
CMS conveys the determination described in paragraph (b) of 42 CFR § 438.730 to the OIG for consideration of possible imposition of civil money penalties under section 1903(m)(5)(A) of the Act and part 1003 of this title. In accordance with the provisions of part 1003, the OIG may impose civil money penalties on the PASSE in addition to, or in place of, the sanctions that may be imposed under this section.
The PASSE Provider Agreement with a PASSE must provide that payments provided for under the contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS under § 438.7 30(e).
The PASSE is responsible for the credentialing of home and community based service (HCBS) providers. All HCBS providers must be enrolled in Arkansas Medicaid as an HCBS provider. In order to enroll in Arkansas Medicaid as a Home and Community Based Service provider, the HCBS provider must be credentialed as such by the PASSE.
The PASSE is responsible for providing Rehabilitative Level Behavioral Health Services that will improve the health of beneficiaries who need intensive levels of specialized care due to the behavioral health issues. Rehabilitative Level Behavioral Health Services are for individuals who have been identified to meet Tier II Level of Care as determined by DHS through the Behavioral Health I ndependent Assessment. At this level of need, services are provided in a counseling services setting but the level of need requires a broader array of services.
Rehabilitative Level Services are Home and community based behavioral health services with care coordination for the purpose of treating mental health and/or substance abuse conditions. Services shall be rendered and coordinated through a team based approach. Rehabilitative Level Services home and community based settings shall include services rendered in, but not limited to, a beneficiary's home, community, behavioral health clinic/ office, healthcare center, physician office, and/ or school.
Behavioral Assistance is a specific outcome oriented intervention provided individually or in a group setting with the child/youth and/or his/her caregiver(s) that will provide the necessary support to attain the goals of the treatment plan. Services involve applying positive behavioral interventions and supports within the community to foster behaviors that are rehabilitative and restorative in nature. The intervention should result in sustainable positive behavioral changes that improve functioning, enhance the quality of life and strengthen skills in a variety of life domains.
Behavioral Assistance is designed to support youth and their families in meeting behavioral goals in various community settings. The service is targeted for children and adolescents who are at risk of out-of-home placement or who have returned home from residential placement and need flexible wrap-around supports to ensure safety and support community integration. The service is tied to specific treatment goals and is developed in coordination with the youth and their family. Behavioral Assistance aids the family in implementing safety plans and behavioral management plans when youth are at risk for offending behaviors, aggressions, and oppositional defiance. Staff provides supports to youth and their families during periods when behaviors have been typically problematic - such as during morning preparation for school, at bedtime, after school, or other times when there is evidence of a pattern of escalation of problem difficult behaviors. The service may be provided in school classrooms or on school busses for short periods of time to help a youth's transition from hospitals or residential settings but is not intended as a permanent solution to problem difficult behaviors at school.
A continuum of care provided to recovering individuals living in the community based on their level of need. This service includes educating and assisting the individual with accessing supports and services needed. The service assists the recovering individual to direct their resources and support systems. Activities include training to assist the person to learn, retain, or improve specific job skills, and to successfully adapt and adjust to a particular work environment. This service includes training and assistance to live in and maintain a household of their choosing in the community. In addition, transitional services to assist individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration.
An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified beneficiaries that aimed at long-term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person- and family-centered, recovery-based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the beneficiary as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety or anger; behavioral skills, such as proper use of medications, appropriate social interactions and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms and reframing; community integration skills and any similar skills required to implement a beneficiary's master treatment plan.
Peer Support is a consumer centered service provided by individuals (ages 18 and older) who self-identify as someone who has received or is receiving behavioral health services and thus is able to provide expertise not replicated by professional training. Peer providers are trained and certified peer specialists who self-identify as being in recovery from behavioral health issues. Peer support is a service to work with beneficiaries to provide education, hope, healing, advocacy, self-responsibility, a meaningful role in life, and empowerment to reach fullest potential. Specialists will assist with navigation of multiple systems (housing, supportive employment, supplemental benefits, building/rebuilding natural supports, etc.) which impact beneficiaries' functional ability. Services are provided on an individual or group basis, and in either the beneficiary's home or community environment.
Peer support may include assisting their peers in articulating their goals for recovery, learning and practicing new skills, helping them monitor their progress, assisting them in their treatment, modeling effective coping techniques and self-help strategies based on the specialist's own recovery experience, and supporting them in advocating for themselves to obtain effective services.
A service provided by peer counselors, of Family Support Partners (FSP), who model recovery and resiliency for caregivers of children and youth with behavioral health care needs or developmental disabilities. FSP come from legacy families and use their lived experience, training, and skills to help caregivers and their families identify goals and actions that promote recovery and resiliency and maintain independence. A FSP may assist, teach and model appropriate child-rearing strategies, techniques and household management skills. This service provides information on child development, age-appropriate behavior, parental expectations, and childcare activities. It may also assist the member's family in securing resources and developing natural supports.
Family Support Partners serve as a resource for families with a child, youth, or adolescent receiving behavioral health or developmental disability services. Family Support Partners help families identify natural supports and community resources, provide leadership and guidance for support groups, and work with families on: individual and family advocacy, social support for assigned families, educational support, systems advocacy, lagging skills development, problem solving technics and self-help skills.
A specific, time limited one-to-one intervention by a nurse with a beneficiary and/or caregivers, related to their psychopharmological treatment. Pharmaceutical Counseling involves providing medication information orally or in written form to the beneficiary and/or caregivers. The service should encompass all the parameters to make the beneficiary and/or family understand the diagnosis prompting the need for the medication and any lifestyle modification required.
A service that provides support and training for youth and adults on a one-on-one or group basis. This service should be a strength-based, culturally appropriate process that integrates the member into their community as they develop their recovery plan or habilitation plan. This service is designed to assist members in acquiring the skills needed to support as independent a lifestyle as possible, enable them to reside in their community (in their own home, with family, or in an alternative living setting), and promote a strong sense of self-worth. In addition, it aims to assist members in setting and achieving goals, learning independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living.
Topics may include: educational or vocational training, employment, resource and medication management, self-care, household maintenance, health, socialization, community integration, wellness, and nutrition. For clients with developmental or intellectual disability, supportive life skills development may focus on acquiring skills to complete activities of daily living (ADLs) and instrumental activities of daily living (lADLs), such as communication, bathing, grooming, cooking, shopping, or budgeting.
Child and Youth Support Services are clinical, time-limited services for principal caregivers designed to increase a child's positive behaviors and encourage compliance with parents at home; working with teachers/schools to modify classroom environment to increase positive behaviors in the classroom; and increase a child's social skills, including understanding of feelings, conflict management, academic engagement, school readiness, and cooperation with teachers and other school staff. This service is intended to increase parental skill development in managing their child's symptoms of their illness and training the parents in effective interventions and techniques for working with the schools.
Services might include an In-Home Case Aide. An In-Home Case Aide is an intensive, time-limited therapy for youth in the beneficiary's home or, in rare instances, a community based setting. Youth served may be in imminent risk of out-of-home placement or have been recently reintegrated from an out of-home placement. Services may deal with family issues related to the promotion of healthy family interactions, behavior training, and feedback to the family.
Supportive Employment is designed to help beneficiaries acquire and keep meaningful jobs in a competitive job market. The service actively facilitates job acquisition by sending staff to accompany beneficiaries on interviews and providing ongoing support and/or on-the-job training once the beneficiary is employed.
Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system.
Supportive Housing is designed to ensure that beneficiaries have a choice of permanent, safe, and affordable housing. An emphasis is placed on the development and strengthening of natural supports in the community. This service assists beneficiaries in locating, selecting, and sustaining housing, including transitional housing and chemical free living; provides opportunities for involvement in community life; and fosters independence.
Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system.
Partial Hospitalization is an intensive nonresidential, therapeutic treatment program. It can be used as an alternative to and/or a step-down service from inpatient residential treatment or to stabilize a deteriorating condition and avert hospitalization. The program provides clinical treatment services in a stable environment on a level equal to an inpatient program, but on a less than 24-hour basis. The environment at this level of treatment is highly structured, and there should be a staff-to-patient ratio sufficient to ensure necessary therapeutic services. Partial Hospitalization may be appropriate as a time-limited response to stabilize acute symptoms, transition (step-down from inpatient), or as a stand-alone service to stabilize a deteriorating condition and avert hospitalization.
A short-term, on-site, face-to-face therapeutic response to a member experiencing a behavioral health crisis for the purpose of identifying, assessing, treating and stabilizing the situation and reducing immediate risk of danger to the member or others consistent with the member's risk management/safety plan, if available. This service is available 24 hours per day, seven days per week, and 365 days per year; and is available after hours and on weekends when access to immediate response is not available through appropriate agencies.
The service includes a crisis assessment, engagement in a crisis planning process, which may result tn the development /update of one or more Crisis Planning Tools (Safety Plan, Advanced Psychiatric Directive, etc.) that contain information relevant to and chosen by the beneficiary and family, crisis intervention and/or stabilization services including on-site face-to-face therapeutic response, psychiatric consultation, and urgent psychopharmacology intervention, as needed; and referrals and linkages to all medically necessary behavioral health services and supports, including access to appropriate services and supports, including access to appropriate services along the behavioral health continuum of care.
A home or family setting that that consists of high intensive, individualized treatment for the member whose behavioral health or developmental disability needs are severe enough that they would be at risk of placement in a restrictive residential setting.
A therapeutic host parent is trained to implement the key elements of the member's PCSP in the context of family and community life, while promoting the PCSP's overall objectives and goals. The host parent should be present at the PCSP development meetings and should act as an advocate for the member.
A continuum of care provided to recovering members living in the community. Recovery Support partners may educate and assist the individual with accessing supports and needed services, including linkages to housing and employment services. Additionally, the Recovery Support Partner assists the recovering member with directing their resources and building support systems. The goal of the Recovery Support Partner is to help the member integrate into the community and remain there.
A set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize the member by clearing toxins from his or her body. Detoxification (detox) services are short term and may be provided in a crisis unit, inpatient, or outpatient setting. Detox services may include evaluation, observation, medical monitoring, and addiction treatment. The goal of detox is to minimize the physical harm caused by the abuse of substances and prepare the member for ongoing substance abuse treatment.
The PASSE is responsible for providing Intensive Level Behavioral Health Services that will improve the health of beneficiaries who need intensive levels of specialized care due to the behavioral health issues. Intensive Level Behavioral Health Services are for individuals who have been identified to meet Tier II I Level of Care as determined by DHS through the Behavioral Health Independent Assessment. Eligibility for this level of need will be identified by additional criteria, which could lead to inpatient admission or residential placement.
Intensive Level Services are the most intensive behavioral health services for the purpose of treating mental health and/or substance abuse conditions. Services shall be rendered and coordinated through a team based approach with a focus on discharge planning.
Therapeutic Communities are highly structured residential environments or continuums of care in which the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability. Services address the broad range of needs identified by the person served. Therapeutic Communities employs community-imposed consequences and earned privileges as part of the recovery and growth process. In addition to daily seminars, group counseling, and individual activities, the persons served are assigned responsibilities within the therapeutic community setting. Participants and staff members act as facilitators, emphasizing personal responsibility for one's own life and self-improvement. The service emphasizes the integration of an individual within his or her community, and progress is measured within the context of that community's expectation.
The Residential Community Reintegration Program is designed to serve as an intermediate level of care between Inpatient Psychiatric Facilities and home and community-based behavioral health services. The program provides twenty-four hour per day intensive therapeutic care provided in a small group home setting for children and youth with emotional and/or behavior problems which cannot be remedied by less intensive treatment. The program is intended to prevent acute or sub-acute hospitalization of youth, or incarceration. The program is also offered as a step-down or transitional level of care to prepare a youth for less intensive treatment. A Residential Community Reintegration Program shall be appropriately certified by the Department of Human Services to ensure quality of care and the safety of beneficiaries and staff.
A Residential Community Reintegration Program shall ensure the provision of educational services to all beneficiaries in the program. This may include education occurring on campus of the Residential Community Reintegration Program or the option to attend a school off campus if deemed appropriate in according with the Arkansas Department of Education.
Temporary direct care and supervision for a beneficiary due to the absence or need for relief of the non-paid primary caregiver. Planned respite can occur at medical or specialized camps, day-care programs, the member's home or place of residence, the respite care provider's home or place of residence, foster homes, a Human Development Center, or a licensed respite facility.
The primary purpose of Planned Respite is to relieve the principal care giver of the member with a behavioral health or developmental disability need so that stressful situations are de-escalated and the care giver and member have a therapeutic and safe outlet.
Emergency Respite is temporary direct care and supervision for a member who is experiencing an acute behavioral crisis or developmental disability need. Emergency respite can in a facility setting, including a Human Development Center
The primary purpose of Emergency Respite is to de-escalate stressful situations and return the member back into the community
The purpose of Community and Employment Support (CES) Waiver services are to support individuals of all ages who have a developmental disability, meet ICF level of care and require waiver support services to live in the community and prevent institutionalization.
The goals of the CES Waiver are to support beneficiaries in all major life activities, promote community inclusion through integrated employment options and community experiences, and provide comprehensive care coordination and service delivery under the 1915(b) PASSE Waiver Program.
CES Supported Employment is a tailored array of services that offers ongoing support to members with the most significant disabilities to assist in their goal of working in competitive integrated work settings for at least minimum wage. It is intended for individuals for whom competitive employment has not traditionally occurred, or has been interrupted or intermittent as a result of a significant disability, and who need ongoing supports to maintain their employment.
CES Supported Employment consists of the following supports:
Supportive living is an array of individually tailored services and activities to enable members to reside successfully in their own home, with family or in an alternative living setting (apartment, or provider owned group home). Supportive living services must be provided in an integrated community setting.
Supportive living includes care, supervision, and activities that directly relate to active treatment goals and objectives set forth in the member's PCSP. It excludes room and board expenses, including general maintenance, upkeep, or improvement to the home.
Supportive living supervision and activities are meant to assist the member to acquire, retain, or improve skills in a wide variety of areas that directly affect the person's ability to reside as independently as possible in the community. The habilitation objective to be served by each activity should be documented in the member's PCSP. Examples of supervision and activities that may be provided as part of supportive living include:
Adaptive equipment is a piece of equipment, or product system that is used to increase, maintain, or improve functional capabilities of members, whether commercially purchased, modified, or customized. The adaptive equipment services include adaptive, therapeutic, or augmentative equipment that enables a member to increase, maintain, or improve their functional capacity to perform daily life tasks that would not be possible otherwise.
Consultation by a medical professional must be conducted to ensure the adaptive equipment will meet the needs of the member.
Adaptive equipment includes enabling technology, such as safe home modifications, that empower members to gain independence through customizable technologies that allow them to safely perform activities of daily living without assistance while still providing monitoring and response for those members, as needed. Enabling technology allows members to be proactive about their daily schedule and integrates member choice.
Adaptive equipment also includes Personal Emergency Response Systems (PERS), which is a stationary or portable electronic device used in the member's place of residence and that enables the member to secure help in an emergency. The system is connected to a response center staffed by trained professionals who respond to activation of the device. PERS services may include the assessment, purchase, installation, and monthly rental fee.
Computer equipment, including software, can be included as adaptive equipment. Specifically, computer equipment includes equipment that allows the member increased control of their environment, to gain independence, or to protect their health and safety.
Vehicle modifications are also included as adaptive equipment. Vehicle modifications are adaptions to an automobile or van to accommodate the special needs of the member. The purpose of vehicle modifications is to enable the member to integrate more fully into the community and to ensure the health, safety, and welfare of the member. Vehicle modifications exclude: adaptations or modifications to the vehicle that are of general utility and not of direct medical or habilitative benefit to the member; purchase, down payment, monthly car payment or lease payment; or regularly scheduled maintenance of the vehicle.
Community Transition Services are non-recurring set-up expenses for members who are transitioning from an institutional or provider-operated living arrangement, such as an ICF or group home, to a living arrangement in a private residence where the member or his or her guardian is directly responsible for his or her own living expenses.
Community Transition service activities include those necessary to enable a member to establish a basic household, not including room and board, and may include:
Community Transition Services should not include payment for room and board; monthly rental or mortgage expense; regular food expenses, regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes.
Consultation services are clinical and therapeutic services which assist the individual, parents, legally responsible persons, responsible individuals and service providers in carrying out the member's PCSP. Consultation activities are provided by professionals licensed as one of the following:
These services are direct in nature. The PASSE will be responsible for maintaining the necessary information to document staff qualifications. Staff, who meets the certification criteria necessary for other consultation functions, may also provide these activities. These activities include, but are not limited to:
Crisis Intervention is delivered in the member's place of residence or other local community site by a mobile intervention team or professional. Intervention shall be available 24 hours a day, 365 days a year. Intervention services shall be targeted to provide technical assistance and training in the areas of behavior already identified. Services are limited to a geographic area conducive to rapid intervention as defined by the provider responsible to deploy the team or professional. Services may be provided in a setting as determined by the nature of the crisis; i.e., residence where behavior is happening, neutral ground, local clinic or school setting, etc., for persons participating in the Waiver program and who are in need of non-physical intervention to maintain or re-establish a behavior management or positive programming plan.
Modifications made to the member's place of residence that are necessary to ensure the health, welfare and safety of the member or that enable the member to function with greater independence and without which, the member would require institutionalization. Examples of environmental modifications include the installation of wheelchair ramps, widening doorways, modification of bathroom facilities, installation of specialized electrical and plumbing systems to accommodate medical equipment, installation of sidewalks or pads, and fencing to ensure non-elopement, wandering or straying of members with decreased mental capacity or aberrant behaviors.
Exclusions include modifications or repairs to the home which are of general utility and not for a specific medical or habilitative benefit; modifications or improvements which are of an aesthetic value only; and modifications that add to the total square footage of the home.
Environmental modifications that are permanent fixtures to rental property require written authorization and release of current or future liability from the property owner.
Supplemental Support services meet the needs of the member to improve or enable the continuance of community living. Supplemental Support Services will be based upon demonstrated needs as identified in a member's PCSP as unforeseen problems arise that, unless remedied, could cause a disruption in the member's services or placement, or place the member at risk of institutionalization.
Caregiver respite services are provided on a short term basis to members unable to care for themselves due to the absence of or need for relief to the non-paid primary caregiver. Caregiver respite services do not include room and board charges.
Receipt of respite does not necessarily preclude a member from receiving other services on the same day. For example, a member may receive day services, such as supported employment, on the same day as caregiver respite services.
When caregiver respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Caregiver respite should not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Caregiver respite services are not to supplant the responsibility of the parent or guardian.
Caregiver respite services may be provided through a combination of basic child care & support services required to meet the needs of a child.
Caregiver respite may be provided in the following locations:
Additional supply items are covered as a Waiver service when they are considered essential and medically necessary for home and community care.
016.06.18 Ark. Code R. 012