016.06.18 Ark. Code R. 018
GENERAL INFORMATION
Medicaid (Medical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Adult Behavioral Health Services for Community Independence are covered by Medicaid when provided to eligible Medicaid beneficiaries by enrolled providers.
Outpatient Behavioral Health Services may be provided to eligible Medicaid beneficiaries at provider certified/en roiled sites. Allowable places of service are found in the service definitions located in the Reimbursement section of this manual.
IHeaith Services for Community Independence
All Behavioral iHealth Agencies that provide Aduit Behavioral Health Services for Community Independence must meet specified qualifications for their services and for their staff. Providers with multiple service sites must enroll each site separately and reflect the actual service site on billing claims.
Behavioral Health Agencies that provide Adult Behavioral Health Services for Community Independence must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arionsas Medicaid Program:
Notification is not required when the list of covered health care practitioners remains unchanged from the previous notification.
DWIS shall exclude providers for the reasons stated in 42 U.S.C. § 1320a-7(a) and implementing regulations and may exclude providers for the reasons stated in 42 U.S.C. § 1320a-7(b) and implementing regulations. The following factors shall be considered by DHS in determining whether sanction(s) should be imposed:
Quality Assurance (DPSQA)
A Behavioral Health Agency must be certified by DPSQA in order to enroll into the Medicaid program as a Behavioral Health Agency participating in the Medicaid Adult Behavioral Heaith Services for Community Independence Program must be certified by the DPSQA. The DPSQA Certification Rules for Providers of Outpatient Behavioral Health Services is located at http://humanservices.arkansas.gov/dbhs/Pages/dbhs docs.aspx.
Behavioral Health Agencies must have national accreditation that recognizes and includes all of II le applicant's pruyrams, services and service siles. Any Behavioral HealLh Agency service site associated with a hospital must have a free-standing behavioral health outpatient program national accreditation. Providers must meet all other DPSQA certification requirements in addition to accreditation.
Adult Behavioral Health Services for Community Independence are limited to certified providers who offer Home and Community Based (HCBS) behavioral health services for the treatment of behavioral disorders. All Behavioral Health Agencies participating in the Adult Behavioral Health Services for Community Independence program must be certified by the Division Provider Services and Quality Assurance.
An Adult Behavioral Health Services for Community Independence provider must establish a site specific emergency response plan that complies with the DPSQA Certification Rules for Behavioral Health Agencies. Each agency site must have 24-hour emergency response capability to meet the emergency treatment needs of the beneficiaries served by the site. The provider must implement and maintain a written policy reflecting the specific coverage plan to meet this requirement. A machine recorded voice mail message to call 911 or report to the nearest emergency room in and of itself is not sufficient to meet the requirement.
All Adult Behavioral Health Services for Community Independence providers must demonstrate the capacity to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.
In order to be certified to provide Adult Behavioral Health Services for Community Independence, each Behavioral Health Agency must ensure that they employ staff who are able and available to provide Adult Behavioral Health Services for Community Independence. In order to provide Adult Behavioral Health Services for Community Independence to be reimbursed on a fee-for-service basis by Arkansas Medicaid, the Behavioral Health Agency must meet all applicable staff requirements as required in the Behavioral Health Agency Certification manual.
Each Adult Behavioral Health Services for Community Independence service has specific provider types that are to be employed by the Behavioral Health Agency which can provide specific services, in order to provide and be reimbursed on a fee-for-services basis by Arkansas Medicaid, the Behavioral Health Agency must adhere to all sen/ice specific provider type requirements.
Registered Nursing (RNs) must provide services only within the scope of their individual licensure. The following chart lists the terminology used in this provider manual and explains the licensure, certification and supervision that are required for each performing provider type. Supervision for all Adult Behavioral Health Services for Community Independence service is required as outlined in the Behavioral Health Agency Certification manual.
PROVIDER TYPE | LICENSES | STATE CERTiFICATION REQUIRED | SUPERVISION |
Qualified Behavioral Health Provider- non-degreed | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Qualified Behavioral Health Provider-Bachelors | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Registered Nurse | Registered Nurse (RN) | No, must be a part of a certified agency | Required |
When a Behavioral Health Agency which provides Adult Behavioral Health Services for Community Independence files a claim with Arkansas Medicaid, the staff member who actually performed the service must be Identified on the claim as the rendering provider. This action is taken in compliance with the federal Improper Payments Information Act of 2002 (IPIA), Public Law 107-300 and the resulting Payment Error Rate Measurement (PERM) program initiated by the Centers for Medicare and Medicaid Services (CMS).
As illustrated in the chart in § 211.200, certain Outpatient Behavioral Health performing providers are required to be certified by the Division Provider Services and Quality Assurance. The certification requirements for performing providers are located on the DPSQA website at http://humanservices.arkansas.gov/dbhs/Paqes/dbhs docs.aspx.
A Behavioral Health Agency may not refuse to provide an Adult Behavioral Health Services for Community Independence service to a Medicald-eligible beneficiary who meets the requirements for Adult Behavioral Health Services for Community Independence as outlined in this manual. If a provider does not possess the services or program to adequately treat the beneficiary's behavioral health needs, the provider must communicate this with the beneficiary so that appropriate provisions can be made.
Adult Behavioral Health Services for Community Independence are home and community-based treatment and services which are provided by a Certified Behavioral Health Agency to individuals eligible for Medicaid based upon the following criteria:
Adult Behavioral Health Services for Community Independence are provided to eligible beneficiaries that have a Behavioral Health diagnosis as described in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-5 and subsequent revisions).
Eligibility for services depends on the needs of the beneficiary. Beneficiaries will be deemed eligible for Adult Behavioral Health Services for Community Independence Rehabilitative Level
Services and intensive Level Services based upon tine results of an Independent Assessment performed by an independent entity. The goal of the independent Assessment is to determine the care, treatment, or services that w/iil best meet the needs of the beneficiary initially and over time. Piease refer to the independent Assessment Manual for the Independent Assessment Referral Process.
REHABILiTATIVE LEVEL SERVICES
Home and community based behavioral health services for the purpose of treating mental health and substance abuse conditions. Services shall be rendered and coordinated through a team based approach. A standardized Independent Assessment to determine eligibiiity and a Treatment Plan is required. Rehabilitative Level Services home and community based settings shall include services rendered in a beneficiary's home, community, behavioral heaith clinic/ office, healthcare center, physician office, and/ or school.
INTENSIVE LEVEL SERVICES
The most intensive behavioral health services for the purpose of treating mental health and substance abuse conditions. Services shall be rendered and coordinated through a team based approach. Eligibility for Intensive Level services will be determined by a standardized independent Assessment. Intensive level Adult Behavioral Health Services for Community independence treatment services are available-if deemed medically necessary and eligibility is determined by way of the standardized Independent Assessment.
A Treatment Plan is required for eligible beneficiaries who are determined to be qualified for Adult Behavioral Health Services for Community Independence through the standardized Independent Assessment. The Treatment Plan should build upon the information from any Behavioral Health provider and information obtained during the standardized Independent Assessment.
The Treatment Plan must be included in the beneficiary's medical record and contain a written description of the treatment objectives for that beneficiary. It also must describe:
The Treatment Plan for a beneficiary that is eligible for Adult Behavioral Health Services for Community Independence must be completed by a mental health professional within 14 calendar days of the beneficiary entering care (first billable service) or within 14 days of an eligibility detennination for beneficiaries receiving Arkansas Medicaid healthcare benefits on a medical Spenddown basis at a certified Behavioral Health Agency and must be signed and dated by a physician licensed in Arkansas. Subsequent revisions in the master treatment plan will be approved in writing (signed and dated) by the mental health professional as well as signed and dated by a physician licensed in Arkansas. Revisions to the Treatment Plan for Adult Behavioral Health Services for Community Independence must occur at least annually, in conjunction with the results from the Independent Assessment. Reimbursement for Treatment Plan revisions more frequently than once per year is not allowed unless there is a documented clinical change in circumstance of the beneficiary or if a beneficiary is re-assessed by the Independent Assessment vendor which results in a change of Tier.
The Treatment Plan should be based on the beneficiary's articulation of the problems or needs to be addressed in treatment and the areas of need Identified in the standardized Independent Assessment. Each problem or need must have one or more clearly defined behavioral goals or objectives that will allow the beneficiary, provider and others to assess progress toward achievement of the goal or objective. For each goal or objective, the Treatment Plan must specify the treatment inten/ention(s) determined to be medically necessary to address the problem or need and to achieve the goal(s) or objective(s).
Covered outpatient services include home and community-based services to Medlcaid-eligible beneficiaries. Beneficiaries eligible for Adult Behavioral Health Services for Community Independence shall be served with an array of treatment services outlined on their Treatment Plan in an amount and duration designed to meet their medical needs.
Services not covered under the Adult Behavioral Health Services for Community Independence benefit include, but are not limited to:
Certified Behavioral Health Agencies which provide Adult Behavioral Health Services for Community Independence are required to have relationships with a board certified or board eligible psychiatrist who provides appropriate supervision and oversight for all medical and treatment sen/ices for beneficiaries with behavioral health needs. A physician will supervise and coordinate all psychiatric and medical functions as indicated in the Treatment Plan that is required for beneficiaries receiving Adult Behavioral Health Services for Community Independence. Medical responsibility shall be vested in a physician licensed in Arkansas that signs the Treatment Plan of the beneficiary.
independence
Beneficianes receiving Aduit Behavioral Health Services for Community Independence must have a signed prescription for services by a psychiatrist or physician. Medicaid will not cover any Adult Behavioral Health Services for Community Independence without a current prescription signed by a psychiatrist or physician and eligibility determined by a standardized Independent Assessment. The signed Treatment Plan will serve as the prescription for beneficiaries that are eligible for Rehabilitative Level Services and Therapeutic Communities/Planned Respite in Intensive Level Services.
Prescriptions shall be based on consideration of an evaluation of the enrolled beneficiary. The prescription of the services and subsequent renewals must be documented in the beneficiary's medical record.
Beneficiaries determined through an Independent Assessment to be eligible to receive Rehabilitative Level Services (Tier 2) or Intensive Level Services (Tier 3) do not require a Primary Care Physician (PGP referral).
All Adult Behavioral Health Services for Community Independence receiving Arkansas Medicaid healthcare benefits on a medical Spenddown basis are retrospectively reviewed for medical necessity.
Procedure codes requiring retrospective review for authorization:
National Codes | Required IWodifler | Service Title | |
H2023 | U4 | Supportive Employment | |
H0043 | U4 | Supportive Housing | |
H0035 | U4 | Partial Hospitalization | |
H2017 | UB, U4 | Adult Rehabilitative Day Service | |
H2017 | UA, U4 | Adult Rehabilitative Day Service | |
H2017 | U3, U4 | Adult Life Skills Development | |
H2017 | U4, U5 | Adult Life Skills Development | |
H0019 | HQ, UC, | U4 | Therapeutic Communities - Level 1 |
H0019 | HQ, U4 | Therapeutic Communities - Level 2 | |
Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable for each procedure.
Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying that the beneficiary is eligible for Arkansas Medicaid prior to rendering services.
Fifteen-Minute Units, unless otherwise stated
Adult Behavioral Health Services for Community Independence must be billed on a per unit basis as indicated in the service definition, as reflected in a daily total, per beneficiary, per service.
Time spent providing services for a single beneficiary may be accumulated during a single, 24"hour calendar day. Providers may accumulatively bill for a single date of service, per beneficiarv. per Adult Behavioral Health Services for Community Independence service. Providers are not allowed to accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per Adult Behavioral Health Services for Community Independence service, based on the established procedure codes. No rounding is allowed.
The sum of the days' time, in minutes, per service will determine how many units are allowed to be billed. That number must not be exceeded. The total of minutes per service must be compared to the following grid, which determines the number of units allowed.
15 Minute Units | Timeframe |
One{1) unit = | 8-24 minutes |
Two (2) units = | 25-39 minutes |
Three (3) units = | 40-49 minutes |
Four (4) units = | 50-60 minutes |
60 minute Units | Timeframe |
One (1) unit = | 50-60 minutes |
Two (2) units = | 110-120 minutes |
Three (3) units = | 170-180 minutes |
Four (4) units = | 230-240 minutes |
Five (5) units = | 290-300 minutes |
Six (6) units = | 350-360 minutes |
Seven (7) units= | 410-420 minutes |
Eight (8) units= | 470-480 minutes |
30 Minute Units | Timeframe |
One (1) unit = | 25-49 minutes |
Two (2) units = | 50-60 minutes |
in a single claim transaction, a provider may bill only for service time accumulated within a single day for a single beneficiary. There is no "carryover" of time from one day to another or from one beneficiary to another.
Documentation in the beneficiary's record must reflect exactly how the number of units is determined.
No more than four (4) units may be billed for a single hour per beneficiary or proyider of the service.
NOTE: For services provided by a Qualified Beiiavioral Heaith Provider (QBHP), tlie accumulated time for tlie Adult Behavioral Health Services for Community Independence program service, per date of service, is one total, regardless of the number of QBHPs seeing the beneficiary on that day. For example, two (2) QBHPs see the same beneficiary on the same date of service and provides Adult Life Skills Development {HCPCS Code H2017, U3, U4). The first QBHP spends a total of 10 minutes with the beneficiary. Later in the day, another QBHP provides Adult Life Skills Development (HCPCS Code H2017, U3, U4)tothe same beneficiary and spends a total oif 15 minutes. A total of 25 minutes of Behavioral Assistance (CPT Code 2019) was provided, whicii equals (two) 2 allowable units of service. Only one QBHP may be shown on the claim as the performing provider.
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://m6dicaid.mmis.arkansas.gov/Provider/Docs/fees.aspxunder the provider manual section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.
Adult Behavioral Health Services for Community Independence providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary. View a CMS-1500 sample form.
Section III of this manual contains information about available options for electronic claim submission.
Adult Behavioral Health Services for Community Independence are billed on a per unit or per encounter basis as listed. All services must be provided by at least the minimum staff within the licensed or certified scope of practice to provide the service.
Benefits are separated by Level of Service.
Prior to reimbursement for Rehabilitative Level Services or Intensive Level Services, a standardized Independent Assessment will determine eligibility and need for Rehabilitative Level
Services or Intensive Level Services. The standardized Independent Assessment will be performed by an independent entity as indicated in the Arkansas Medicaid Independent Assessment Manual.
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0035, U4 | Mental health partial hospitalization treatment, less than 24 hours | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
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 should maintain a staff-to-patient ratio of 1:5 to ensure necessary therapeutic services and professional monitoring, control, and protection. This sen/ice shall include at a minimum intake, individual therapy, group therapy, and psychoeducation. Partial Hospitalization shall be at a minimum (5) five hours per day, of which 90 minutes must be a documented service provided by a Mental Health Professional. If a beneficiary receives other services during the week but also receives Partial Hospitalization, the beneficiary must receive, at a minimum, 20 documented hours of services on no less than (4) four days in that week. | * Start and stop times of actual program participation by beneficiary * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must coincide with the master treatment plan * Beneficiary's response to the treatment must include current progress or lack of progress toward symptom reduction and attainment of goals * Rationale for continued Partial Hospitalization Services, including necessary changes to diagnosis, master treatment plan or medication(s) and plans to transition to less restrictive services * All sery/ices provided must be clearly documented in the medical record * Staff signature/credentials | |
NOTES | UNIT | BENEFIT LIMITS |
Partial hospitalization may include drug testing, medical care other than detoxification and other appropriate services depending on the needs of the individual. The medical record must indicate the services provided during Partial Hospitalization. | Per Diem | DAILY MAXIMUM THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF DAYS THAT MAY BE BILLED {extension of benefits can be requested): 40 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | A provider may not bill for any other services on the same date of service. | |
ALLOWED MODE{S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Partial Hospitalization must be provided in a facility that is certified by tiie Division of Behavioral Health Services as a Partial Hospitalization provider | 11,49,52,53 | |
EXAMPLE ACTIVITIES | ||
Care provided to a client who is not ill enough to need admission to facility but who has need of more intensive care in the therapeutic setting than can be provided in the community. This service shall include at a minimum intake, individual and group therapy, and psychosocial education. Partial hospitalization may include drug testing, medical care other than detoxification and other appropriate services depending on the needs of the Individual. | ||
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
H2017, UB, U4 - QBHP Bachelors or RN H2017, UA, U4 - QBHP Non-Degreed | Psychosocial rehabilitation sen/ices |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
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 | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how treatment used address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objiectives * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature |
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 witti 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. | |
NOTES | UNll BENEFIT LIMITS |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS |
Adult - Ages 18 and Above | The follovtfing codes cannot be billed on the Same Date of Service: H2015 - Individual Recovery Support, Bachelors H2015 - Individual Recovery Support, Non-Degreed H2015 - Group Recovery Support, Bachelors H2015 - Group Recovery Support, Non-Degreed |
ALLOWED MODE(S) OF DELIVERY | TIER |
Face-to-face | Rehabilitative |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE |
* Qualified Behavioral Health Provider-Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse {Use Code H2019 with HK,HN modifiers) | 04,11,12,13, 14. 22, 23, 31, 32, 33, 49, 50, 52, 53,57,71,72,99 |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2023, U4 | Supportive Employment | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
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. This service replaces traditional vocational approaches that provide intermediate work experiences (prevocational work units, transitional employment, or sheltered workshops), which tend to isolate beneficiaries from mainstream society. Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with beneficiary * Place of Service (If 99 is used, specific location and rationale for location must be Included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
60 Minutes | QUARTERLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 60 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | A provider can bill up to 60 units per quarter (Quarters are defined as January-March, April-June, July-September, October-December) prior to an extension of benefits. A provider cannot bill any H2017 code on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider- Non-Degreed * Registered Nurse | 04, 11,12, 16,49,53,57,99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0043, U4 | Supportive Housing | |
SERVICE DESCRIPTION | MINIIVIUM DOCUMENTATION REQUIREMENTS | |
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 facilitates the individual's recovery journey. 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 v/ith the criminal justice system. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
60 Minutes | QUARTERLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 60 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | A provider can bill up to 60 units per quarter (Quarters are defined as January-March, April-June, July-September, October-December) prior to an extension of benefits. | |
A provider cannot bill any H2017 code on the same date of service. | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider-Bachelors * Qualified Behavioral Health Provider-Non-Degreed * Registered Nurse | 04, 11, 12, 16,49,53,57,99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
H2017, U3, U4 - QBHP Bachelors or RN H2017, U4, U5- QBHP Non-degreed | Comprehensive community support services |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Life Skills Development services are designed to assist beneficiaries in acquiring the skills needed to support an independent lifestyle and promote an improved sense of self-worth. Life skills training is designed to assist in setting and achieving goals, learning independent living skills, demonstrate accountability, and making goal-directed decisions related to independent living (i.e., educational/vocational training, employment, resource and medication management, self-care, household maintenance, health, wellness and nutrition). 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. | * Date of Service * Names and relationship to the beneficiary of all persons Involved * Start and stop times of actual encounter with beneficiary * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature |
NOTES | UNIT BENEFIT LIMITS |
15 Minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED {extension of benefits can be requested): 292 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider-Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse | 04,11.12.16,49,53,57.99 | |
CPT-' /HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
H0038,U4 | Supportive Employment |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS - |
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 | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual contact * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how treatment used address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objectives * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration |
* Plan for next contact, if any * Staff signature/credentials/date of signature | ||
NOTES | UNIT | BENEFIT LIMITS |
15 minutes | YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 120 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | Provider can only bill for 120 units (combined between H0038 and H0038, U8) per SFY | |
ALLOWED MODE(S) OF DELIVERY' | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Certified Peer Support Specialist * Certified Youth Support Specialist | 03, 04, 11, 12, 13,14,15,16, 22, 23, 31, 32. 33, 34,49,50,52,53.57.71,72,99 | |
EXAMPLE ACTIVITIES | ||
Peer support may include assisting tlieir 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. | ||
CPT'D/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
S0220, U4 | S0220: Treatment Plan |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Treatment Plan is a plan developed in cooperation with the beneficiary (or parent or guardian If under 18) to deliver specific mental health services to restore, improve, or stabilize the beneficiary's mental health condition. The Plan must be based on individualized service needs as identified in the completed Mental Health Diagnosis, independent assessment, and independent care plan. The Plan must include goals for the medically necessary treatment of identified problems, symptoms and mental health conditions. The Plan must identify individuals or treatment teams responsible for treatment, specific treatment modalities prescribed for the beneficiary, and time limitations for services. The plan must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the | * Date of Service (date plan is developed) * Start and stop times for development of plan * Place of service * Diagnosis * Beneficiary's strengths and needs * Treatment goal(s) developed in cooperation with and as stated by beneficiary that are related specifically to the beneficiary's strengths and needs * Measurable objectives * Treatment modalities - The specific services that will be used to meet the measurable objectives * Projected schedule for service delivery, |
beneficiary and demonstrate cultural competence. | including amount, scope, and duration * Credentials of staff who will be providing the services * Discharge criteria * Signature/credentials of staff drafting the document and primary staff who will be delivering or supervising lire delivery of the specific services/ date of signature(s) * Beneficiary's signature (or signature of parent, guardian, or custodian of beneficiaries under the age of 18}/ date of signature * Physician's signature indicating medical necessity/date of signature | |
NOTES | ||
This service may be billed when the beneficiary is determined to be eligible for services. Revisions to the Treatment Plan for Adult Behavioral Health Services for Community Independence must occur at least annually, in conjunction with the results from the Independent Assessment. Reimbursement for Treatment Plan revisions more frequently than once per year is not allowed unless there is a documented clinical change in circumstance of the beneficiary or if a beneficiary is re-assessed by the Independent Assessment vendor which results in a change of Tier. It is the responsibility of the primary mental health professional to insure that all individuals working with the client have a clear understanding and worl[LESS THAN] toward the goals and objectives stated on the treatment plan. | 30 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 2 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 4 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | Must be reviewed annually | |
ALLOWED MOpE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS * Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse | PLACE OF SERVICE 03, 04,11,12,14, 33, 49. 50, 53, 57, 71, 72 | |
* Physician |
GPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2017 - QDHP Bachelors or RN H2017 - QBHP Non-Degreed | Psychosocial rehabilitation services, per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
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. | Date of Service Names and relationship to the beneficiary of all persons involved Start and stop times of actual encounter Place of Service {When 99 is used, specific location and rationale for location must be included) Client diagnosis necessitating service Document how treatment used address goals and objectives from the master treatment plan Information gained from contact and how it relates to master treatment plan objectives Impact of information received/given on the beneficiary's treatment Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration Plan for next contact, if any Staff signature/credentials/Date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
15 Minutes | YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 292 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | ||
ALLOWED MODE{S) OF DELIVERY | TIER | |
Face-to-face | 2 | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider-Bachelors * Qualified Behavioral Health Provider-Non- | 03, 04, 11, 12, 13, 14, 15, 16, 22, 23, 31, 32, 33, 34,49,50,52,53,57,71,72,99 | |
Degreed |
Eligibility for intensive level services Is determined by the Intensive Level Services standardized Independent Assessment.
Prior to reimbursement for any Intensive level service, a beneficiary must be deemed Tier 111 by the Behavioral Health Independent Assessment.
Eligibility for entry into a residential setting requires adherence to appropriate Medicaid rules regarding that residential setting. Eligibility for Therapeutic Communities requires that an Individualized Treatment Plan be developed for the beneficiary.
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0019, HQ, UC,U4-Level 1 H0019, HQ, U4-Level2 | Behavioral health; long-term residential (nonmedical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem. | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
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. | * Date of Service * Names and relationship to the beneficiary of all persons Involved * Place of Service * Document how interventions used address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objectives * Impact of Information received/given on the beneficiary's treatment * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
Therapeutic Communities Level will be determined by the following: * Functionality based upon the Independent Assessment Score * Outpatient Treatment History and Response * Medication * Compliance with Medication/Treatment | Per Diem | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be |
Eligibility for this service is determined by the Intensive Level Services standardized Independent Assessment. Prior to reimbursement for Therapeutic Communities In Intensive Level Services, a beneficiary must be eligible for Rehabilitative Level Services as determined by the standardized Independent Assessment. The beneficiary must then also be determined by an Intensive Level Services Independent Assessment to be eligible for Therapeutic Communities. | requested): H0019, HQ-180 H0019, HQ, HK-185 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults - Ages 18 and Above | A provider cannot bill any other services on the same date of service. | |
PROGRAM SERVICE CATEGORY | ||
Intensive | ||
ALLOWED MODE{S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Therapeutic Communities must be provided in a facility that is certified by the Division of Behavioral Health Services as a Therapeutic Communities provider | 14,21,51,55 | |
Electronic and paper claims now require the same national place of service codes.
Place of Service | POS Codes |
Homeless Shelter | 04 |
Office (Behavioral Health Agency Facility Service Site) | 11 |
Patient's Home | 12 |
Assisted Living Facility | 13 |
Group Home | 14 |
Mobile Unit | 15 |
Temporary Lodging | 16 |
Inpatient Hospital | 21 |
Custodial Care Facility | 33 |
Independent Clinic | 49 |
Federally Qualified Health Center | 50 |
Psychiatric Facility- Partial Hospitalization | 52 |
Community Mental Health Center | 53 |
Non-Residential Substance Abuse Treatment Facility | 57 |
Public Health Clinic | 71 |
Rural 1 lealth Clinic | 72 |
Other | 99 |
1915(i) State plan Home and Community-Based Services Administration and Operation
The state implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit For elderly and disabled individuals as set forth below.
Select one:
IZI (By checking this box the state assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specify the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies):
(Check all agencies and/or entities that perform each function):
(Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function):
A contracted vendor will perform reviews of service plans, authorizations for State plan HCBS, quality assur and quality improvement activities, and utilization management for the services contained within this 1915(i) HCBS State Plan benefit.
The State contracted with an outside vendor to establish rates for the services contained within this this 1915 HCBS State Plan benefit.
(By checking the following boxes the State assures that):
* related by blood or marriage to the individual, or any paid caregiver of the individual
* financially responsible for the individual
* empowered to make financial or health-related decisions on behalf of the individual
* providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the state, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. (If the state chooses this option, specify the conflict of interest protections the state will implement):
Number Served
(Specify for year one. Years 2-5 optional):
Annual Period | From | To | Projected Number of Participants |
Year 1 | Jan. 1, 2019 | Dec. 31, 2019 | 2,000 |
Year 2 | Jan. 1, 2020 | Dec. 31, 2020 | |
Year 3 | Jan. 1, 2021 | Dec. 31, 2021 | |
Year 4 | Jan. 1, 2022 | Dec. 31, 2022 | |
Year 5 | Jan. 1, 2023 | Dec. 31, 2023 |
Financial Eligibility
D The State does not provide State plan HCBS to the medically needy.
IZI The State provides State plan HCBS to the medically needy. (Select one):
D The state elects to disregard the requirements section of 1902(a)(10)(C)(i)(III) of the Social Security Act relating to community income and resource rules for the medically needy. When a state makes this election, individuals who qualify as medically needy on the basis of this election receive only 1915(i) services.
IZI The state does not elect to disregard the requirements at section 1902(a)(10)(C)(i)(III) of the Social Security Act.
Evaluation/Reevaluation of Eligibility
Directly by the Medicaid agency X By Other (specify State agency or entity under contract with the State Medicaid agency):
The individual must have a behavioral health diagnosis and have received a Tier 2 or Tier 3 on the functional assessment for HCBS behavioral health services conducted by DHS's third party vendor.
The assessor must have a Bachelor's Degree or be a registered nurse with one (1) year of experience with mental health populations.
Behavioral Health clients:
Behavioral health clients must undergo the Independent Assessment and be deemed a Tier 2 or Tier 3 annually.
The criteria take into account the individual's support needs, and may include other risk factors: (Specify the needs-based criteria):
The individual must have a behavioral health diagnosis and have received a Tier 2 or Tier 3 on the functional assessment for HCBS behavioral health services conducted by DHS's third party vendor.
The functional assessment takes into account the individuals' ability to provide his or her own support, as well as other natural support systems, as well as the level of need to accomplish ADLs and IADLs.
There are needs-based criteria for receipt of institutional services and participation in certain waivers that are more stringent than the criteria above for receipt of State plan HCBS. If the state has revised institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional services and participating in certain waivers on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer require that level of care. (Complete chart below to summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions):
State plan HCBS needs-based eligibility criteria | NF (& NF LOC** waivers) | ICF/IID (& ICF/IID LOC waivers) | Applicable Hospital* (& Hospital LOC waivers) |
Behavioral Health: 1) Have a documented behavioral health diagnosis; and 2) Assessed as a Tier 2 or 3 on the independent assessment. | Must meet at least one of the following three criteria as determined by a licensed medical professional: 1. The individual is unable to perform either of the following: A. At least one (1) of the three (3) activities of daily living (ADLs) of transferring/locomotion, eating or toileting without extensive assistance from or total dependence upon another person; or, B. At least two (2) of the three (3) activities of daily living (ADLs) of transferring/locomotion, eating or toileting without limited assistance from another person; or, 2. The individual has a primary or secondary diagnosis of Alzheimer's disease or related dementia and is cognitively impaired so as to require substantial supervision from another individual because he or she engages in inappropriate behaviors which pose serious health or safety hazards to himself or others; or, 3. The individual has a diagnosed medical condition which requires monitoring or assessment at least once a day by a licensed medical professional and the condition, if untreated, would be life-threatening. 4. No individual who is | 1) Diagnosis of developmental disability that originated prior to age of 22; 2) The disability has continued or is expected to continue indefinitely; and 3) The disability constitutes a substantial handicap to the person's ability to function without appropriate support services, including but not limited to, daily living and social activities, medical services, physical therapy, speech therapy, occupational therapy, job training and employment. Must also be in need of and able to benefit from active treatment and unable to access appropriate services in a less restrictive setting. | There must be a written certification of need (CON) that states that an individual is or was in need of inpatient psychiatric services. The certification must be made at the time of admission, or if an individual applies for Medicaid while in the facility, the certification must be made before Medicaid authorizes payment. Tests and evaluations used to certify need cannot be more than one (1) year old. All histories and information used to certify need must have been compiled within the year prior to the CON. In compliance with 42 CFR 441.152, the facility-based and independent CON teams must certify that: A. Ambulatory care resources available in the community do not meet the treatment needs of the beneficiary; B. Proper treatment of the beneficiary's psychiatric condition requires inpatient services under the direction of a physician and C. The services can be reasonably expected to prevent further regression or to improve the beneficiary's condition so that the |
otherwise eligible for waiver services shall have his or her eligibility denied or terminated solely as the result of a disqualifying episodic medical condition or disqualifying episodic change of medical condition which is temporary and expected to last no more than twenty-one (21) days. However, that individual shall not receive waiver services or benefits when subject to a condition or change of condition which would render the individual ineligible if expected to last more than twenty-one (21) days. | services will no longer be needed. |
*Long Term Care/Chronic Care Hospital **LOC= level of care
The State will target this 1915(i) State plan HCBS benefit to individuals in the following eligibility groups:
The 1915(i) State plan HCBS benefit is targeted to individuals with a behavioral health diagnosis who have high needs as indicated on a functional assessment.
[TICK] Option for Phase-in of Services and Eligibility. If the state elects to target this 1915(i) State plan HCBS benefit, it may limit the enrollment of individuals or the provision of services to enrolled individuals in accordance with 1915(i)(7)(B)(ii) and 42 CFR 441.745(a)(2)(ii) based upon criteria described in a phase-in plan, subject to CMS approval. At a minimum, the phase-in plan must describe:
(By checking the following box the State assures that):
i. | Minimum number of services. The minimum number of 1915(i) State plan services (one or more) that an individual must require in order to be determined to need the 1915(i) State plan HCBS benefit is: One. |
ii. | Frequency of services. The state requires (select one): |
X | The provision of 1915(i) services at least monthly |
Monthly monitoring of the individual when services are furnished on a less than monthly basis If the state also requires a minimum frequency for the provision of 1915(i) services other than monthly (e.g., quarterly), specify the frequency: |
Home and Community-Based Settings
(By checking the following box the State assures that):
(Explain how residential and non-residential settings in this SPA comply with Federal home and community-based settings requirements at 42 CFR 441.710(a)(1)-(2) and associated CMS guidance. Include a description of the settings where individuals will reside and where individuals will receive HCBS, and how these settings meet the Federal home and community-based settings requirements, at the time of submission and in the future):
(Note: In the Quality Improvement Strategy (QIS) portion of this SPA, the state will be prompted to include how the state Medicaid agency will monitor to ensure that all settings meet federal home and community-based settings requirements, at the time of this submission and ongoing.)
The 1915(i) State plan HCBS benefit is subject to the HCBS Settings requirements and therefore must be included in the State Wide Transition Plan.
The Division of Medical Services (DMS) is the State Medicaid Agency (SMA) responsible for operating this 1915(i) State plan benefit impacted by the HCBS Settings Rule. The purpose of this waiver is to support individuals within specific eligibility categories who have a behavioral health diagnosis and who choose to receive services within their community. Each individual receiving a service within this 1915(i) State plan benefit are required to have a Treatment Plan which will offer an array of services that allow flexibility and choice for the participant.
Individuals served by the 1915(i) State plan benefit choose to reside in the community and receive HCBS services in their home. The home may be the person's home, the home of a family member or friend, a group home, a provider owned or controlled apartment, or the home of a staff person who is employed by the HCBS provider. It is assumed that people who live in their own home or the home of a family member or friend who is not paid staff receive services in a setting that complies with requirements found at 42 CFR 441.301(c)(4).
DMS and its agent (including DDS) will monitor the development of the Treatment Plan and the provision of services. Information on the HCBS Settings rule will be included in annual training opportunities for DMS's monitoring staff.
Assessment of Compliance with Residential and Non-Residential Settings Requirements
An inter-divisional HCBS Settings working group has met regularly since 2014 and will continue to meet during the implementation of the STP. The working group consists of representatives from DAAS, DDS, and Division of Medical Services (DMS) within the Arkansas Department of Human Services. The working group initially met to review the new regulations and develop the initial STP and corresponding timeline. DMS will convene this working group to set applicable standards for PASSE HCBS settings. It will be expected that PASSE organizations implement these standards, and the federal HCBS Settings Rule into their provider agreements and credentialing standards.
Agents of DMS will be assigned to review teams. The review teams will conduct reviews of randomly selected provider owned or controlled apartments and group homes.
Upon completion of the review, notes from the review team member will be summarized in a standard report and sent to the Provider and the PASSE. The report will summarize the visit, noted areas needing improvement that were observed and documented, requested clarification of provider policies and procedures and/or a corrective action plan. A deadline will be given to the provider and the PASSE to provide this information and technical assistance for DMS and the Settings working group will be provided.
Ongoing Training
DMS and the HCBS Settings working group will develop and conduct PASSE and provider trainings, as well as provided tailored technical assistance to partially compliant and non-compliant providers.
Heightened Scrutiny
DMS recognizes that certain settings are presumed non-compliant with the HCBS Settings requirements. Specifically, some home and community based settings have institutional qualities - those settings that are publicly or privately owned facilities that provide inpatient treatment, those settings that are located on the grounds of, or immediately adjacent to, a public institution, or those settings that have the effect of isolating individuals from the broader community. These settings include those that are located on or near the grounds of an institution and settings which may isolate individuals from the community. These settings include group homes located on the grounds of or adjacent to a public institution, numerous group homes co-located on a single site, a disability-specific farm-like service setting and apartments located in apartment complexes also occupied by persons who do not receive HCBS services. DMS will identify these settings and require the PASSE implement heightened scrutiny for those settings presumed not to be home and community based.
Person-Centered Planning & Service Delivery
(By checking the following boxes the state assures that):
There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with need for HCBS. (Specify qualifications):
For the behavioral health population, the assessor must have a Bachelor's Degree or be a registered nurse with one (1) year of experience with mental health populations.
The Treatment Plan must be completed by a licensed practitioner and signed by a Physician.
During the development of the Treatment Plan for the individual, everyone in attendance is responsible for supporting and encouraging the member to express their wants and desires and to incorporate them into the Treatment Plan when possible.
Each participant has the option of choosing their 1915(i) State plan service provider. If, at any point during the course of treatment, the current provider cannot meet the needs of the participant, they must inform the participant as well as their Primary Care Physician / Person Centered Medical Home
(Describe the process by which the person-centered service plan is made subject to the approval of the Medicaid agency):
All 1915(i) FFS Behavioral Health Service providers must create a Treatment Plan for any beneficiary who is receiving 1915(i) FFS Behavioral Health Services. The Treatment Plan must be created within 14
calendar days of the beneficiary entering care (first billable service) or within 14 days of an eligibility determination for beneficiaries receiving Arkansas Medicaid healthcare benefits on a medical Spenddown basis at a certified Behavioral Health Agency and must be signed and dated by a physician licensed in Arkansas. The Treatment Plan is 100% retrospectively reviewed by the Division of Medical Services (or its' contractor).
Medicaid Agency | X Operating Agency | Case Manager |
Services
Definition: Participant-direction means self-direction of services per §1915(i)(1)(G)(iii).
Election of Participant-Direction. (Select one):
© The state does not offer opportunity for participant-direction of State plan HCBS.______________
o
o | Every participant in State plan HCBS (or the participant's representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available for participants who decide not to direct their services. |
o | Participants in State plan HCBS (or the participant's representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the state. (Specify criteria): |
o o | Participant direction is available in all geographic areas in which State plan HCBS are available. |
Participant-direction is available only to individuals who reside in the following geographic areas or political subdivisions of the state. Individuals who reside in these areas may elect self-directed service delivery options offered by the state, or may choose instead to receive comparable services through the benefit's standard service delivery methods that are in effect in all geographic areas in which State plan HCBS are available. (Specify the areas of the state affected by this option): |
Financial Management is not furnished. Standard Medicaid payment mechanisms are used. |
Financial Management is furnished as a Medicaid administrative activity necessary for administration of the Medicaid State plan. |
The state does not offer opportunity for participant-employer authority. | ||
Participants may elect participant-employer Authority (Check each that applies): | ||
D | Participant/Co-Employer. The participant (or the participant's representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in | |
D | conducting employer-related functions. | |
Participant/Common Law Employer. The participant (or the participant's representative) is | ||
the common law employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the participant's agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions. | ||
The state does not offer opportunity for participants to direct a budget. | |
Participants may elect Participant-Budget Authority. | |
Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the amount of the budget over which the participant has authority, including the method for calculating the dollar values in the budget based on reliable costs and service utilization, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information about these method(s) must be made publicly available and included in the person-centered service plan.): | |
Expenditure Safeguards. (Describe the safeguards that have been established for the timely prevention of the premature depletion of the participant-directed budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards. |
Quality Improvement Strategy
Quality Measures
(Describe the state's quality improvement strategy. For each requirement, and lettered sub-requirement, complete the table below):
(Table repeats for each measure for each requirement and lettered sub-requirement above.)
Requirement | Requirement 1: Service Plans Address Needs of Participants are reviewed annually and document choice of services and providers. |
Discovery | |
Discovery Evidence (Performance Measure) | The percentage of treatment plans developed by Behavioral Health Agencies which provide 1915(i) State Plan HCBS that meet the requirements of 42 CFR § 441.725. Numerator: Number of treatment plans that adequately and appropriately address the beneficiary's needs. Denominator: Total Number of treatment plans reviewed. |
Discovery Activity (Source of Data & sample size) | All treatment plans are retrospectively reviewed as well as all HCBS services provided to eligible individuals by DMS (or its contractor). The data will be produced by the Behavioral Health Agencies and must remain in the medical record of the beneficiary. |
Monitoring Responsibilities (Agency or entity that conducts discovery activities) | DMS or its agents |
Requirement | Requirement 1: Service Plans |
Frequency | When services are approved for medical necessity retrospectively. |
Remediation | |
Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) | The Behavioral Health Agency will be responsible for remediating deficiencies in treatment plan of their beneficiaries. If there is a pattern of deficiencies noticed, action may be taken against the Behavioral Health Agency, up to and including, instituting a corrective action plan or sanctions pursuant to the Medicaid Provider Manual. |
Frequency (of Analysis and Aggregation) | Data will be aggregated and findings will be reported on a annual basis. If a pattern of deficiency is noted, this may be made public. |
Requirement | Requirement 2: Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; (b) the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the approved state plan for 1915(i) HCBS. |
Discovery | |
Discovery Evidence One (Performance Measure) | All beneficiaries must be independently assessed in order to qualify for 1915(i) State plan HCBS eligibility. There are system edits in place that will not allow those who have not received an independent assessment to received 1915(i) State Plan HCBS. In order to maintain eligibility for 1915(i) State plan HCBS, the beneficiary must be re-assessed on an annual basis. Numerator: The number of beneficiaries who are evaluated and assessed for eligibility in a timely manner. Denominator: The total number of beneficiaries who are identified for the 1915(i) HCBS State Plan Services eligibility process. |
Discovery Activity One (Source of Data & sample size) | A 100% sample of the application packets for beneficiaries who undergo the eligibility process will be reviewed for compliance with the timeliness standards. The data will be collected from the Independent Assessment Vendor. |
Monitoring Responsibilities (Agency or entity that conducts | DMS or its agents |
discovery activities) | |
Discovery Evidence Two | The Percentage of beneficiaries for whom the appropriate eligibility process and instruments were used to determine initial eligibility for HCBS State Plan Services. Numerator: Number of beneficiaries' application packets that reflect appropriate processes and instruments were used. Denominator: Total Number of application packets reviewed. |
Discovery Activity Two | A 100% sample of the application packets for beneficiaries who went through the eligibility determination process will be reviewed. The data will be collected from the Independent Assessment Vendor. |
Monitoring Responsibility | DMS or its agents. |
Discovery Evidence Three | The percentage of beneficiaries who are re-determined eligible for HCBS State Plan Services before their annual treatment plan expiration date. Numerator: The number of beneficiaries who are re-determined for eligibility timely (before expiration of treatment plan). Denominator: The total number of beneficiaries re-determined eligible for HCBS State Plan Services. |
Discovery Activity Three | A 100% sample of the application packets for beneficiaries who went through the eligibility re-determination process will be reviewed. The data will be collected from the Independent Assessment Vendor. |
Monitoring Responsibilities | DMS or its agents. |
Requirement | Requirement 2: Eligibility Requirements |
Frequency | Sample will be selected and reviewed quarterly. |
Remediation | |
Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for | For Independent Functional Assessments: The Independent Assessment Vendor is responsible for developing and implementing a quality assurance process, which includes monitoring for accuracy, data consistency, integrity, and completeness of assessments, and the performance of staff. This must include a desk review of assessments with a statistically significant sample size. Of the reviewed assessments, 95% must be accurate. The Independent Assessment Vendor submits monthly reports to DHS's contract monitor. When deficiencies are noted, a corrective action plan will be implemented with the Vendor. |
remediation) | |
Frequency (of Analysis and Aggregation) | Data will be aggregated and reported quarterly. |
Requirement | Requirement 3: Providers meet required qualifications. |
Discovery | |
Discovery Evidence (Performance Measure) | In order to enroll as a Medicaid provider, a Behavioral Health Agency must be certified by the Division of Provider Services and Quality Assurance. Numerator: Number of Behavioral Health Agencies that currently have Division of Provider Services and Quality Assurance certification. Denominator: Number of Behavioral Health Agencies enrolled in Arkansas Medicaid. |
Discovery Activity (Source of Data & sample size) | 100% of Behavioral Health Agencies will be reviewed to ensure certification by Division of Provider Services and Quality Assurance. Without this certification, the provider cannot enroll or continue to be enrolled in Arkansas Medicaid. |
Monitoring Responsibilities (Agency or entity that conducts discovery activities) | DMS, DPSQA, or its agents |
Requirement | Requirement 4: Settings meet the home and community-based setting requirements as specified in this SPA and in accordance with 42 CFR 441.710(a)(1) and (2). |
Discovery | |
Discovery Evidence (Performance Measure) | Percentage of provider owned apartments or homes that meet the home and community-based settings requirements. Denominator: Number of provider owned apartments and homes that meet the HCBS Settings requirements in 42 CFR 441.710(a)(1) & (2). Numerator: Number of provider owned apartments and homes that are reviewed by the DMS Settings review teams. |
Discovery Activity (Source of Data & sample size) | Review of the Settings Review Report sent to Behavioral Health Agencies. The reviewed apartments or homes will be randomly selected. A typical review will consist of at least 10% of each Behavioral Health Provider's apartments and homes (if they own any) each year. |
Monitoring Responsibilities (Agency or entity that conducts discovery activities) | DMS or its agents. |
Requirement | Requirement 5: The SMA retains authority and responsibility for program operations and oversight. |
Discovery | |
Discovery Evidence (Performance Measure) | Number and percentage of policies developed must be promulgated in accordance with the DHS agency review process and the Arkansas Administrative Procedures Act (APA). Numerator: Number of policies and procedures appropriately promulgated in accordance with agency policy and the APA; Denominator: Number of policies and procedures promulgated. |
Discovery Activity (Source of Data & sample size) | 100% of policies developed must be reviewed for compliance with the agency policy and the APA. |
Monitoring Responsibilities (Agency or entity that conducts discovery activities) | DMS or its agents |
Requirement | Requirement 5: The SMA retains authority and responsibility for program authority and oversight. |
Frequency | Continuously, and as needed, as each policy is developed and promulgated. |
Remediation | |
Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) | DHS's policy unit is responsible for compliance with Agency policy and with the APA. In cases where policy or procedures were not reviewed and approved according to DHS policy, remediation includes DHS review of the policy upon discovery, and approving or removing the policy. |
Frequency (of Analysis and Aggregation) | Each policy will be reviewed for compliance with applicable DHS policy and the APA. |
Requirement | Requirement 6: The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. |
Discovery | |
Discovery Evidence One (Performance Measure) | The SMA will make payments to Behavioral Health Agencies providing 1915(i) State plan HCBS. In order for payment to occur, the provider must be enrolled as a Medicaid provider. There is not an option for a non-enrolled provider to receive payment for a service. |
Discovery Activity One (Source of Data & sample size) | Review of claims payments via MMIS. |
Monitoring Responsibilities (Agency or entity that conducts discovery activities) | DMS or its agents |
Requirement | Requirement 7: The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. |
Discovery | |
Discovery Evidence (Performance Measure) | Number and percentage of Behavioral Health Agencies that meet criteria for abuse and neglect reporting training for staff Numerator: Number of provider agencies investigated who complied with required Abuse and neglect training set out in the Behavioral Health Agency certification; Denominator: Total number of provider agencies reviewed or investigated. |
Discovery Activity (Source of Data & sample size) | During certification or re-certification of Behavioral Health Agencies, DPSQA will ensure that appropriate training is in place regarding abuse, neglect, and exploitation for all Behavioral Health Agency personnel. |
Monitoring Responsibilities (Agency or entity that conducts discovery activities) | DMS, DPSQA or its agents |
Requirement | Requirement 7: The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. |
Frequency | Annually, and continuously, as needed, when a compliant is received. |
Remediation |
Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) | DQPSA will investigate all complaints regarding abuse, neglect, and exploitation. |
Frequency (of Analysis and Aggregation) | As necessary |
System Improvement
(Describe the process for systems improvement as a result of aggregated discovery and remediation activities.)
The State will continuously monitor the utilization of 1915(i) FFS services for the eligible populations. The State will monitor treatment plans that are required for beneficiaries and will retrospectively approve services.
The State will investigate and monitor any complaints about Behavioral Health Agencies providing any 1915(i) FFS services.
The State (including DMS, DPSQA, and its agents) will be responsible for oversight of Behavioral Health Agencies providing 1915(i) FFS services.
On-going monitoring will occur.
The State will utilize multiple methods to evaluate the effectiveness of system changes. These may include site reviews, contract reviews, claims data, complaints, and any other information that may provide a method for evaluating the effectiveness of system changes.
Methods and Standards for Establishing Payment Rates
HCBS Case Management | |
HCBS Homemaker | |
HCBS Home Health Aide | |
HCBS Personal Care | |
HCBS Adult Day Health | |
HCBS Habilitation | |
D | HCBS Respite Care |
For Individuals with Chronic Mental Illness, the following services: | |
0 | HCBS Day Treatment or Other Partial Hospitalization Services |
Based on the information gained from the peer state analysis and the consideration of adjustment factors such as Bureau of Labor Statistics (BLS) along with Geographic Pricing Cost Index (GPCI) to account for economic differences, the state was able to select appropriate rates from fee schedules published by peer states. Once this rate information was filtered according to Arkansas requirements a "state average rate" was developed. This "state average rate" consisting of the mean from every peer state's published rate for a given procedure served as the base rate for the service, which could then be adjusted by previous mentioned factors (BLS), (GPCI) etc. | |
HCBS Psychosocial Rehabilitation | |
HCBS Clinic Services (whether or not furnished in a facility for CMI) | |
0 | Other Services (Specify below): |
For all other services, the rate methodology is based on the information gained from the peer state analysis and the consideration of adjustment factors such as Bureau of Labor Statistics (BLS) along with Geographic Pricing Cost Index (GPCI) to account for economic differences, the state was able to select appropriate rates from fee schedules published by peer states. Once this rate information was filtered according to Arkansas requirements a "state average rate" was developed. This "state average rate" consisting of the mean from every peer state's published rate for a given procedure served as the base rate for the service, which could then be adjusted by previous mentioned factors (BLS), (GPCI) etc. | |
Optional Groups other than the Medically Needy
In addition to providing State plan HCBS to individuals described in 1915(i)(1), the state may also cover the optional categorically needy eligibility group of individuals described in 1902(a)(10)(A)(ii)(XXII) who are eligible for HCBS under the needs-based criteria established under 1915(i)(1)(A) and have income that does not exceed 150% of the FPL, or who are eligible for HCBS under a waiver approved for the state under Section 1915(c), (d) or (e) or Section 1115 (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. See 42 CFR § 435.219. (Select one):
[TI CK] No. Does not apply. State does not cover optional categorically needy groups.
[] Yes. State covers the following optional categorically needy groups. (Select all that apply):
[] SSI. The state uses the following less restrictive 1902(r)(2) income disregards for this group. (Describe, if any):
[] OTHER (describe):
Income limit: (Select one):
[] 300% of the SSI/FBR
[] Less than 300% of the SSI/FBR (Specify):___________%
Specify the applicable 1915(c), (d), or (e) waiver or waivers for which these individuals would be eligible: (Specify waiver name(s) and number(s)):
_______________________________________________________________________
Specify the 1115 waiver demonstration or demonstrations for which these individuals would be eligible. (Specify demonstration name(s) and number(s)):
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 114 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, and Baltimore, Maryland 21244-1850.
016.06.18 Ark. Code R. 018