016.06.05 Ark. Code R. 048 - DDS Alternative Community Services (ACS) Waiver - Provider Manual Update Transmittal #54
The Arkansas Medical Assistance Program (IVIedicaid) offers certain home and community based services as an alternative to institutionalization. These services are available for eligible individuals with a developmental disability who would otherwise require an intermediate care facility for the mentally retarded (ICF/MR) level of care. The home and community based services to be provided through this waiver are described herein as the DDS Alternative Community Services Waiver Renewal, hereafter referred to as DDS ACS Waiver.
42 CFR § 441.301(b)(1)(ii) states that home and community based waiver services are available only to individuals who are not inpatients (residents) of a hospital, nursing facility (NF) or intermediate care facility for the mentally retarded (ICF/MR) only if payment to the hospital, nursing facility or ICF/MR is being made through private pay or private insurance.
Services provided under this program are as follows:
Supportive living is an array of individually tailored services and activities provided to enable eligible individuals to reside successfully in their own homes, with their families, or in an alternative living residence or setting. The services are designed to assist individuals in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in the home and community based setting.
Only hired caregivers may be reimbursed for supportive living services provided.
Payments for supportive living services will not be made to the parent, stepparent or legal guardian of a person less than 18 years old.
Payments will not be made to a spouse or to the guardian or guardian's spouse when the spouse is named as co-guardian and has the authority to act in such manner for an individual overage 18.
The payments for these services exclude the costs of room and board, including general maintenance, upkeep or improvement to the individual's own home or that of his or her family.
Routine care and supervision for which payment will not be made are defined as those activities that are necessary to assure a person's well being but are not activities that directly relate to active treatment goals and objectives.
See section 270.000 for billing information.
There are three broadly defined service models that are covered through supportive living services. They include residential habilitation supports, residential habilitation reinforcement supports and companion and activities therapy services.
Residential habilitation supports are aimed at assisting the person to acquire, retain or improve his or her skill in a wide variety of areas that directly affect his or her ability to reside as independently as possible in the community. These services provide the supervision and support necessary for a person to live in the community. The supports that may be provided to an eligible individual include the following habilitation areas of need:
Residential habilitation reinforcement supports may be provided to eligible individuals. The services include the following:
NOTE: This does not include nursing services available through Medicaid State Plan.
Community experiences services are a flexible array of supports designed to allow individuals to gain experience and abilities that will prevent institutionalization. Through this broad base of learning opportunities, participants will identify, pursue and gain skills and abilities in activities that reflect their interests.
This model helps to improve community acceptance, employment opportunities and general well-being. The services are preventive, therapeutic, diagnostic and habilitative and will create an environment that will promote a person's optimal functioning.
The model also teaches developmental and living skills in the natural environment or clinic setting to ensure maximum learning and generalization. The services focus on enabling the person to attain or maintain his or her potential functional level and must be coordinated with any physical, occupational or speech therapies listed in the plan of care. These services reinforce skills or lessons taught in school, therapy or other settings.
When supports are provided in a clinic setting and the individual receives four or more hours of support, a noon meal is included in the service.
Services include activities and supports to accomplish individual goals or learning areas, including recreation and/or for specific training or leisure activities. To participate in community experiences activities, an individualized plan of treatment is required. Each activity is then adapted according to the participant's needs. Activities include:
See section 270.000 for billing information.
ACS respite care is defined as services provided to or for waiver participants, regardless of their age, who are unable to care for themselves. It is furnished on a short-term basis because of the absence or need for relief of non-paid individuals, including parents of minors, primary caregivers and spouses of participants, who normally provide the care.
ACS respite care may be provided in the individual's home or place of residence, a foster home, Medicaid certified ICF/MR, group home, licensed respite care facility or licensed/accredited residential mental health facility for participants who have a dual diagnosis.
Room and board is not a covered service except when provided as part of respite care furnished in a facility that is not a private residence but is approved by the state as a respite care facility.
ACS respite care service includes child care support services, which are services that promote access to and participation in child care through a combination of basic child care and support services required to meet the needs of a mentally retarded, developmentally disabled child aged birth to 18 years.
These services are not intended to supplant the responsibility of the parent or guardian. Parents or guardians will be responsible for the cost of basic child care, which is defined as fees charged for services provided in a specific childcare setting the same as for a child who does not have a developmental disability, mental retardation or both.
The services will be provided only in the absence of the primary caregiver during those hours when the caregiver is at work, in job training or at school.
Child care support services may be provided in a variety of settings including a licensed daycare facility, licensed daycare home, the child's home or other lawful childcare setting.
Medicaid pays only for support staff required due to the individual's developmental disability, not for daycare fees.
Services are separate and distinct from educational services provided at a school where attendance is mandated and the primary focus of the institution is the accomplishment of specified educational goals.
The services are separate and distinct from respite care services that are provided on a short-term basis because of the need for relief of those unpaid individuals normally providing the care.
Parents of minors, primary caregivers or a spouse of a participant may not be covered as respite care providers.
See section 270.000 for billing information.
ACS non-medical transportation services are provided to enable individuals served to gain access to DDS ACS and other community services, activities and resources. Activities and resources must be identified and specified in the plan of care.
This service is offered in addition to medical transportation as required under 42 CFR 431.53 and transportation services under the Medicaid State Plan, defined at 42 CFR 440.170(a) (if applicable), and must not replace them.
ACS transportation services must be offered in accordance with the individual's plan of care. Whenever possible, family, neighbors, friends or community agencies that can provide this service without charge must be utilized. In no case will a parent or legal guardian be reimbursed for the provision of transportation for a minor.
See section 270.000 for billing instructions.
ACS waiver coordination services include the responsibility for ensuring the delivery of all direct care services. This responsibility includes:
Fiscal intermediary responsibilities include:
This service assists the individual or guardian to manage and distribute funds contained in the individual Supportive Living budget (inclusive of Respite, Transportation and Community Experiences Services). When the individual or their guardian elects this option, the Division of Disabilities Services will establish a contract with the chosen provider and the person or their guardian. The contract shall address requirements and responsibilities for the following:
The rate of compensation for this service shall be $100 per month plus up to 20% of the supportive living service budget.
See section 270.000 for billing information.
Supported employment is designed for individuals for whom competitive employment at or above the minimum wage is unlikely or who, because of their disabilities, need intensive ongoing support to perform in a competitive work setting.
The services consist of paid employment conducted in a variety of settings, particularly work sites in which individuals without disabilities are employed. In accordance with the federal definition, DDS supports integrated work settings where the employment situation provides frequent, daily social interaction among people with and without disabilities.
The federal standard for integration requires that an individual work in a place where no more than eight people with disabilities work together and where co-workers without disabilities are present in the work setting or in the immediate vicinity.
When supported employment is provided at a work site where individuals without disabilities are employed, payment will be made only for the adaptations, supervision and training required by individuals receiving waiver services as a result of their disabilities. Coverage will not include payment for the supervisory activities rendered as a normal part of the business setting.
Supported employment includes:
The employer is responsible for making reasonable accommodations in accordance with the Americans with Disabilities Act.
Transportation will be provided between the individual's place of residence and the site of the habilitation services, or between habilitation sites when the person receives habilitation services in more than one place, as a component part of the habilitation services. The cost of this transportation is included in the rate paid to providers of the appropriate type of habilitation service (non-medical transportation service).
Supported employment provided as a long-term support must be monitored, at a minimum, to consist of two meetings with the individual participating in supported employment and one employer contact a month.
The job coach, after consultation with each person in supported employment, can determine on a case-by-case basis how to best acquire current information relevant to assessing job stability and the individual's needs.
If on-site monitoring is not necessary to assess stability, alternative methods of gathering information for the twice-monthly assessment may be permitted. This may take a variety of forms, including telephone calls with supervisors and off-site meetings with the individual participating in supported employment as well as visits to the work site.
Supported employment requires related activities to be identified and included in outcomes with an accompanying work plan submitted as documentation of need for service.
Payment for employment services excludes:
Supported employment providers must maintain documentation in each waiver participant's personnel file to support that the individual is not receiving and has exhausted, either by reaching authorized limits, by denial or unavailability, services otherwise funded by P.L. 94-142.
Documentation must include proof from the funded provider where services were exhausted.
See Section 202.200 for other information to be retained for recipient's file.
Individuals are limited to a maximum of thirty-two (32) units (8 hours) of supported employment services per date of service.
See section 270.000 for billing information.
ACS adaptive equipment service provides for the purchase, leasing and, as necessary, repair of adaptive, therapeutic and augmentative equipment required to enable individuals to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise.
Adaptive equipment needs for supportive employment for a person are also included. This service may include specialized medical equipment such as devices, controls or appliances that will enable the person to perceive, to control or to communicate with the environment in which they live.
Equipment may only be covered if not available to the individual from any other source. Professional consultation must be accessed to ensure that the equipment will meet the needs of the individual. All items must meet applicable standards of manufacture, design and installation.
Computer equipment may be approved when it allows the participant control of his or her environment, assists in gaining independence or when it can be demonstrated that it is necessary to protect the health and safety of the person. Computers will not be purchased to improve socialization or educational skills.
Printers may be approved for non-verbal persons.
Computer desks or other furniture items will not be covered.
Communication boards are allowable devices. Computers may be approved for communication when there is substantial documentation that a computer will meet the needs of the person more appropriately than a communication board.
Software will be approved only when required to operate the accessories included for environmental control or to provide text-to-speech capability.
Personal emergency response systems (PERS) may be approved when they can be demonstrated as necessary to protect the health and safety of the participant. PERS are electronic devices that enable individuals to secure help in an emergency. The individual may also wear a portable "help" button to allow for mobility. The system is connected to the individual's telephone and programmed to signal a response center once a "help" button is activated. The response center must be staffed by trained professionals.
PERS services are limited to individuals who live alone or who are alone for significant parts of the day and have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision.
The annual expenditure for adaptive equipment is $7500.00 per person. If the person is also receiving environmental modification services, the COMBINED annual expenditure cannot exceed $7500.00.
ACS specialized medical supplies include items necessary for life support and the ancillary supplies and equipment necessary for the proper functioning of such items. Non-durable medical equipment not available under the Medicaid State Plan may also be provided as an ACS specialized medical supply. All items provided must be specified in the individual's multi-agency plan of service (MAPS) and must be in addition to any medical equipment and supplies covered as a Medicaid State Plan service. Items that are not of direct medical or remedial benefit to the individual are excluded from this service.
Additional supply items are covered as a waiver service when they are considered essential for home and community-care. Covered items include:
Incontinence undergarments, ostomy and colostomy supplies, nutritional supplements and non-prescription medications must be ordered by a physician for recipients. A physician, psychologist or court of law must order drug and/or alcohol screening.
Item(s) must be included in the plan of care. When the items are included in Medicaid State Plan services, this service will be an extension of such services.
The supplemental support service helps improve or enable the continuance of community living, allow the opportunity to participate in integrated leisure, recreational, social and educational activities and make a positive difference in the life of the waiver participant. Supplemental support service includes:
Up to two meals each day is an allowable service. As an example, food that is obtained from restaurants, catering services and fast food outlets and which may be consumed on or off the site where the purchase is made is allowable.
The supplemental support service will be based upon demonstrated needs as identified in a person's treatment plan to be included in the plan of care as emergencies arise.
The supplemental support service is not allowed to be used for rent, lease or house payments or for the purchase of food (groceries, such as purchased at a grocery store, market, farm, etc.) or any other room-and-board type of services.
This service can be accessed only as a last resort. Lack of other available resources must be proven.
The maximum annual allowance is $1200.00 and this reimbursement must reduce the maximum allowable for the service, specialized medical needs, by the same amount of dollars that are used for this service. The total dollars used for the two services combined CANNOT exceed $3600.00 annually.
Case management services refer to a system of ongoing monitoring of the provision of services included in the waiver participant's multi-agency plan of service (MAPS). Case managers initiate and oversee the process of assessment of the individual's level of care and the review of MAPS at specified reassessment intervals.
Case management services include responsibility for locating, coordinating and monitoring:
The intent of case management services is to enable waiver participants to receive a full range of appropriate services in a planned, coordinated, efficient and effective manner.
Case management services consist of the following activities:
Case management services are optional for some level categories and are available at three levels of service. They are:
The level is determined by the needs or options of the person receiving waiver services as defined in sections 230.000 through 230.300.
See section 270.000 for billing information.
Consultation services assist waiver participants, parents and/or guardians and/or responsible individuals, community living services providers and alternative living setting providers in carrying out the participant's service plan.
Eligible individuals may receive twenty-five (25) hours of consultation services per waiver-eligible year.
See section 270.000 for billing information.
Crisis center is a service provided in a crisis center equipped to provide short-term intervention.
Services include 24-hour emergency care services for individuals eligible for waiver services with priority given to individuals with a dual diagnosis or based upon clinical judgment that a high probability exists that further evaluation and assessment will identify a dual diagnosis.
Individuals who are court ordered for alternate placement or who are involved with the court system in Arkansas, according to Act 609 of 1995, may be considered eligible.
Individuals served by the waiver who have significant behavioral disorders and are in need of temporary intensive management or transition may also receive services.
This service will accommodate individuals who, by the nature of the emergency or court order time frames, have not been incorporated into the typical level of care categorical eligibility process or who are in need of transition.
Admission is limited to individuals in a crisis situation where their current placement is no longer viable and an immediate alternate placement cannot be identified. Individuals, depending on the crisis situation or intensity, may receive services in one of three levels.
Placement in the crisis center may only be approved in no greater than 3-month increments. This does not imply that a person must remain for a minimum of 3 months. This period of time must be used for stabilization, identification of alternate placements with emphasis on family reunification (when appropriate) and identification of support mechanisms to facilitate transition. A person may be transitioned to the least restrictive environment available at the earliest possible time that will assure the highest probability of success.
All persons must have a pre-approved interim plan of care that permits options based upon the level of need. Each plan is specific to pre-identified treatment needs with the amount or intensity of each service option adjustable within a maximum daily reimbursement rate. Appropriate psychiatric supports will be available. Medical needs will be met through private, Medicaid State Plan or other funding sources.
See section 270.000 for billing information.
Current eligibility for the Arkansas Medicaid Program must be verified as part of the in-take and assessment process for admission into the ACS Waiver Program. Medicaid eligibility is determined by the Division of Developmental Disabilities Services or by the Social Security Administration for SSI Medicaid eligibles.
Failure to obtain any required eligibility determination, whether initial or subsequent (time bound) re-assessments, will result in the individual's case being closed. Once closure has occurred, the affected person will have to make a new request for services through the waiver program intake process.
For the supportive living arrangements, the Medicaid eligibility date is retroactive to the date the Medicaid application is received at the DDS Medicaid Unit or no more than three months prior to the receipt of the Medicaid application, whichever is less.
The pervasive level of care is defined as needs that require constant supports provided across environments that are potentially life sustaining in nature. Supports are intrusive and long term and include a combination of any available waiver supports provided 24 hours a day, 7 days a week for 365 days a year with case management at the highest level (minimum of one personal visit and one other contact monthly). Sublevels are:
The limited level of care is defined as supports that are anticipated to be consistent for the foreseeable future. They are individually time-limited and may be intermittent in nature and are subject to re-evaluation every 12 months. This level of support requires parental support, group settings and community assistance available to the individual.
Intermittent and time-limited supports are supports for primary caregiver relief, employment training, transitional supports, crisis behavior management and assisted living supports.
Case management for this Level I is a minimum of one visit per quarter. When case management is not chosen as a service component there must be a willing, responsible adult to assume all case management functions. Sublevels are:
Supported living arrangements: Provided for beneficiaries of DDS-funded supported living arrangements. General revenue must be available and in use for the existing service level with supporting general revenue to be used for the payment of Medicaid match in order for waiver conversion to occur. There are two categories of supported living arrangements:
In the traditional service model, services are delivered through a DDS and Medicaid licensed service provider network with all services coordinated and obtained through a case management provider.
Individuals or guardians determine provider choice from this network and may change providers upon written notice to DDS. In the traditional service model, the direct care service provider is responsible to advertise for, interview, hire, supervise, train and otherwise manage an employment workforce who provides supported living care.
Services are provided on a fee for service or cost reimbursement methodology. In this model, providers may provide both case management and direct care services.
Through the self-directed model, individuals needing supported living services have the option of hiring and otherwise managing their direct caregivers. When this option is chosen, the person, their parent or legal guardian is responsible for advertisement, interviewing, supervising and otherwise directing the caregiver(s).
They are responsible for compliance with all state and federal laws, rules and regulations pertaining to employment and compensation inclusive of drug screens and criminal background checks, withholdings and reporting to the government.
The individual's chosen direct service provider fiscal intermediary/agent will be responsible to assist in all aspects as fiscal intermediary. Responsibilities include:
The self-directed model option applies to non-medical transportation and respite care. Waiver coordination is included as a function of the direct service provider.
DDS ACS Waiver providers use the CIVIS-1500 claim form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid recipients. Each claim should contain charges for only one recipient.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.
The following procedure codes and any associated modifier(s) must be billed for DDS ACS Waiver Services. Prior authorization is required for all services.
|
Procedure Code |
Ml |
M2 |
P A |
Description |
Unit of Service |
POS for Paper Claims |
POS for Electronic Claims |
|
A0080 |
Y |
ACS Non-Medical Transportation |
1 Year |
0 |
99 |
||
|
H2016 |
Y |
ACS Supportive Living (Individual) |
1 Year |
4,0 |
12,99 |
||
|
H2016 |
UB |
Y |
ACS Supportive Living (Group) |
1 Year |
4,0 |
12,99 |
|
|
H20231 |
Y |
Supported Employment |
15 Minutes |
0 |
99 |
||
|
S5151 |
Y |
ACS Respite Care |
1 Year |
4,0 |
12,99 |
||
|
T2020 |
Y |
Community Experiences |
1 Year |
4,0 |
12,99 |
||
|
T2020 |
UA |
Y |
Community Experiences |
1 Year |
4,0 |
12,99 |
|
|
T2022 |
Y |
Case Management Services |
1 Month |
4,0 |
12,99 |
||
|
T2024 |
Y |
ACS Waiver Coordination |
1 Year |
4,0 |
12,99 |
||
|
T20252 |
Y |
Consultation Services |
1 Hour |
4,0 |
12,99 |
||
|
T20283 |
Y |
ACS Specialized Medical Supplies |
1 Year |
4,0 |
12,99 |
||
|
T2034 |
Y |
Crisis Center |
1 Year |
0,4 |
99, 12 |
||
|
T20344 |
U1 |
UA |
Y |
ACS Crisis Intervention Services |
1 Hour |
0,4 |
99, 12 |
NOTE Providers may continue to use modifiers 22 and 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 22 will be replaced with UA and modifier 52 will be replaced with UB.
1 Individuals are limited to a maximum of 32 units (8 hours) of supported employment services per date of service.
A breakdown of the supported employment units of service includes:
One unit = 15 minutes to 21 minutes Two units = 22 minutes to 37 minutes Three units = 38 minutes to 52 minutes Four units = 53 minutes to 67 minutes
2 Beneficiaries may receive twenty-five (25) hours of ACS consultation services per waiver-eligible year.
3 Reimbursement cannot exceed $300 per month.
4 Crisis intervention services may require a maximum of 24 hours of service during any one day.
The following list contains the procedure codes used for ACS physical adaptations. Physical adaptations have a benefit limit of $7500 per year.
|
Procedure Code |
M1 |
M2 |
P A |
Description |
POS for Paper Claims |
POS for Electronic Claims |
|
K0108 |
Y |
***(ACS environmental modifications) Other accessories |
4 |
12 |
||
|
S5160 |
Y |
***(Adaptive equipment, personal emergency response system [PERS], installation and testing) Emergency response system; installation and testing |
4 |
12 |
||
|
S5161 |
Y |
***(Adaptive equipment, personal emergency response system [PERS], service fee, per month, excludes installation and testing) Emergency response system; service fee, per month (excludes installation and testing) |
4 |
12 |
||
|
S5162 |
Y |
***(Adaptive equipment, personal emergency response system [PERS], purchase only) Emergency response system; purchase only |
4 |
12 |
||
|
S5165 |
U1 |
Y |
***(ACS adaptive equipment) Home modifications, per service |
4 |
12 |
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
Refer to section 272.200 for definitions of the place of service codes listed above.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.