016.06.09 Ark. Code R. 012
The Arkansas Medicaid Program offers certain home and community-based outpatient services as an alternative to nursing home placement. These services are available to disabled individuals age 21 through 64 who have received a determination of physical disability by SSI/SSA or DHS Medical Review Team (MRT) and who, without the provision of home and community-based services, would require a nursing facility (NF) level of care. The participant's income must be equal to or less than 300% of the SSI eligibility limit.
The community-based services offered through the Alternatives for Adults with Physical Disabilities Home and Community-Based Waiver, described herein as Alternatives, are as follows:
These services are designed to maintain Medicaid eligible beneficiaries at home in order to preclude or postpone institutionalization of the individual.
Please note that in accordance with 42 CFR 441.301(b)(l)(ii), alternatives services are not covered for inpatients of nursing facilities, hospitals or other inpatient institutions.
The client intake and assessment process includes application for waiver services at the Department of Human Services (DHS) county office in the beneficiary's resident county, a determination of categorical eligibility, a nursing facility level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
NOTE: Revisions to a participant's plan of care may only be made by the DAAS Rehab Counselor or RN.
Once an application has been approved, waiver services must be provided in order for eligibility to continue. Unless stated otherwise below, the county Department of Human Services (DHS) office must be notified immediately by the DAAS Rehab Counselor or RN when waiver services are discontinued and action will be initiated by the DHS county office to close the waiver case.
An individual cannot receive waiver services while in an institution. The following policy applies to active waiver cases when the participant is hospitalized or enters a nursing facility for an expected stay of short duration.
NOTE: The Arkansas Medicaid Program considers an individual an inpatient of a facility beginning with the date of admission. Therefore, payment to the hospital begins on the date of admission. Payment to the hospital does not include the date of discharge.
If Attendant Care Services are billed on the same day the waiver participant is admitted to the hospital or any other inpatient facility, Attendant Care Services are not billable. If Attendant Care services are provided on the same day the waiver participant comes home from the inpatient facility, Attendant Care Services are billable.
All payments for waiver services provided during an inpatient stay will be subject to Recoupment. Recoupments will include the date of admission.
When a waiver participant is absent from the home for reasons other than institutionalization, the DHS county office will not be notified unless the participant does not return home within 30 days. If, after 30 days, the participant has not returned home and the providers can no longer deliver services as prescribed by the plan of care (e.g., the participant has left the state and the return date is unknown), the DAAS Rehab Counselor or RN will notify the DHHS county office. Action will be taken by the DHHS county office to close the waiver case. No alternatives services are covered during a participant's absence.
Because the provider has more frequent contact with the participant, the provider may become aware of changes in the participant's status sooner than the DAAS Rehab Counselor or DHS County Office. It is the provider's responsibility to report these changes immediately so proper action can be taken. Providers must complete the Provider Communication Form (AAS-9502) and send it to the DAAS Rehab Counselor or RN. A copy must be retained in the provider's participant case record. Whether the change may or may not result in action by the DHS county office, providers must report all changes in the participant's status to the DAAS Rehab Counselor orRN.
Attendant Care Service is assistance to a medically stable, physically disabled participant in accomplishing tasks of daily living that the participant is unable to complete independently. Assistance may vary from actually doing a task for the participant, to assisting the participant to perform the task or to providing safety support while the participant performs the task. Housekeeping activities that are incidental to the performance of care may also be furnished. Housekeeping activities as described above may not exceed 20% of the Attendant's overall time worked as authorized on the waiver plan of care. Attendant Care Services may also include supervision, companion services, socialization, and transportation assistance when it is incidental to providing Attendant Care services, accompanying a participant to assist with shopping, errands, etc.
Parti cipants who can comprehend the rights and accept the responsibilities of consumer-directed care may wish to have Alternatives Attendant Care Services included on their plan of care. The participant's plan of care will be submitted to the attending physician for his or her review and approval.
C To aid in the Attendant Care recruitment process, participants will be apprised of the minimum qualifications set forth for provider certification (See section 213.220) and the Medicaid enrollment and reimbursement process. The participant will be instructed to notify the DAAS Rehab Counselor or RN when an attendant has been recruited. The DAAS Waiver Counselor or RN will facilitate the development of a formal service agreement between the participant and the Attendant, using the form AAS-9512, Attendant Care Service Agreement. Instructions are provided with the Attendant Care packet.
D When the AAS-9512, Attendant Care Service Agreement, is finalized, the Attendant will apply for DAAS certification and Medicaid provider enrollment. The DAAS Rehab Counselor or RN or designee will assist as needed to expedite this process. As an enrolled Medicaid provider, the attendant will be responsible for all applicable Medicaid participation requirements, including claims submission.
Service agreements and required tax documents do not transfer from one waiver client to another or from one waiver provider to another. All service agreements and tax forms are specific to each employer and employee working arrangement.
Agency Attendant Care services are the provision of assistance to a medically stable and/or physically disabled person to accomplish those tasks of daily living that the individual is unable to complete independently and that are performed by an Attendant Care employee hired by an agency selected by the waiver participant. Assistance may vary from actually doing a task for the individual to assisting the individual with the task or to providing safety support while the individual performs the task. Housekeeping activities that are incidental to the performance of care may also be furnished. Housekeeping activities as described above may not exceed 20% of the attendant's overall time worked as authorized on the waiver plan of care. Agency Attendant Care Services may also include supervision, companion services, socialization, and transportation assistance when it is incidental to providing Attendant Care Services while accompanying a participant to assist with shopping, errands, etc.
If Agency Attendant Care Services are selected, participants may choose to have their services provided through an agency that is certified by the Division of Aging and Adult Services to provide Agency Attendant Care. When the participant chooses to have Attendant Care Services provided through an agency, the participant may choose one of two agency Attendant Care Services options:
) participant/co-employer where the participant functions as the co-employer (managing employer) of employees hired by an Attendant Care agency, and the agency manages the hiring and fiscal responsibilities or 2) a traditional agency model for Attendant Care Services where the agency performs both the managing of the Attendant Care employee and hiring and fiscal responsibilities.
If the participant chooses the traditional agency model option, the agency performs both the responsibilities of managing the Attendant Care employee and the hiring and fiscal responsibilities. Participants who decide to have their Attendant Care services provided through an agency may wish to have Alternatives Agency Attendant Care Services included on their plan of care. The participant's plan of care is submitted to the participant's attending physician for his or her review and approval.
Class A or Class B Home Health Agencies licensed by the Arkansas Department of Human Services to provide personal care and enrolled in the Arkansas Medicaid Program as a personal care provider may apply to enroll as a Medicaid Alternatives Agency Attendant Care provider.
Private Care agencies licensed by the Arkansas Department of Human Services to provide personal care and enrolled in the Arkansas Medicaid Program as a personal care provider may apply to enroll as a Medicaid Alternatives Agency Attendant Care provider.
The responsibilities of the providers of case management services include, but are not limited to:
* Orientation to the concept of consumer-direction
* Providing skills training on how to recruit, interview, hire, evaluate, manage or dismiss Attendants
* Providing support services
* Assessing the individual's service needs to assist in accessing services that currently may or may not be in place. This does not refer to a medical assessment or replace any eligibility requirements for any Medicaid program
* Routinely monitoring Alternatives participants' needs, employer status, and circumstances and reporting findings according to program policy to DAAS
* Providing management reports to DAAS
* Reporting changes and required information to DAAS, as required by policy
* Attending training as provided or required by DAAS
* Referring the waiver participant to resources to assist in meeting their needs
* Scheduling appointments related to gaining access to medical, social, educational and other services appropriate to the participant's needs. This includes, but is not limited to, medical appointments, transportation services and appointments with DHS.
* Performing face to face or telephone contacts with the participant and/or other individuals for the purpose of assistance in meeting the participant's needs
* Assisting a waiver participant in completing the application for types of assistance
* Conferencing with others, on behalf of the applicant, to assist in the application process for accessing services
* Referring waiver participant for community resources, such as energy assistance, legal assistance, emergency housing
* Training Attendant Care provider in proper billing procedures
* Explaining APD program policy and monitoring compliance
* Securing 3 separate bids for environmental modifications/adaptive equipment service as required by policy. If the case manager is an employee of a provider type 84 that is submitting a bid to provide a waiver service, the case manager may not assist the waiver participant in securing the other two required bids.
Providers must maintain all records regarding the participation of the beneficiary and the provider in the Arkansas Medicaid Program for a period of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. The records must be made available to authorized representatives of the Arkansas Division of Medical Services, the Arkansas Division of Aging and Adult Services, the state Medicaid Fraud Control Unit, representatives of the Department of Human Services and its authorized agents or officials.
All documentation must be made available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider's place of business. If an audit determines that recoupment is necessary, there will be only thirty (30) days after the date of the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted at a later date.
DHS requires retention of all records for six (6) years. All medical records shall be completed promptly, filed and retained for a minimum of six (6) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish records upon request may result in sanctions being imposed.
Each Case Manager (CM) must maintain a tickler system for tracking purposes.
When Alternatives for Adults with Physical Disabilities Waiver services are denied, the participant may request a fair hearing from the Department of Human Services according to sections 191.000 - 191.006 of the Arkansas Medicaid Provider Manuals.
Appeal requests must be submitted to the Department of Human Services Appeals and Hearings Section. View or print DHS Appeals and Hearings Section contact information.
A provider may request reconsideration of a Medicaid Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification to the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and, if necessary, will contact the provider to arrange a conference. Regardless of the Program decision, the provider will be afforded the opportunity for a full explanation of the factors involved and the Program decision. Wthin 20 calendar days of receipt of the request for review, the Assistant Director will notify the provider of the action to be taken by the Division or the date for the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
Prior to payment for this service, the waiver participant is required to secure 3 separate itemized bids for the same service. The bids are reviewed by the DHS Rehab Counselor, DHS RN or designee prior to submission for Medicaid payment.
Each claim must be signed by the provider, the waiver participant, and the DHS Rehab Counselor, DHS RN, or designee. A statement of satisfaction form must be signed by the waiver participant prior to any claim being submitted.
016.06.09 Ark. Code R. 012