Updated PASSE Information

Click the image below to receive comprehensive, updated information on the PASSE systems (as of October 2017). The deadlines have been updated, and if you were wondering what the purpose of the model is, here’s your chance to find out!

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Three PASSEs were officially certified on October 18: Arkansas Advanced Care, ARkansas Total Care and Empower Healthcare Solutions. Read more about them in the image below:

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Therapy Cap PA Requests: Q & A 


The PT, OT, and SH Association Presidents regularly meet with DHS and AFMC to discuss issues that providers have when requesting Prior Authorizations (PAs) for children who need therapy over the 90-minute cap. These are the results of their latest meeting.

Keep track of your questions and email them to be discussed at the next meeting.


The Recap of ArkSHA, ArPTA, and AROTA meeting with AFMC and DDS on 08-25-17:

The following are issues raised by members of ArkSHA, ArPTA and AROTA, and responses from AFMC and DDS.

Issue: Shifting of Units Between Therapist and Assistant

There are still questions regarding the length of time it is taking to shift units from PT/OT/ST to PTA/COTA/SLPA and vice versa. AFMC reports that following completion of the large number of DMS-640 form validations AFMC received many change requests to prior authorizations. AFMC encouraged their staff to continue to process initial DMS-640 validations and that all changes would need to be checked before processing. Currently, AFMC states that they are about 10 days out on corrections and Jarrod McClain, AFMC Director for Clinical Review, indicated that their staff are working diligently to get the updates made as quickly as possible. The updates to the PA’s flow to DXC each night and providers can start billing immediately upon receipt of the changes.

In addition, Jarrod stated that AFMC is working to decrease the timeframe for corrections but they have to ensure that they are getting the correct request ID modified. According to Jarrod, it takes a few days to check and update the claims data extract file. If providers continue to see a delay, please contact Jarrod McClain at AFMC. He will personally see that his staff checks on the status of their request and get it processed.

Issue: Use of evaluations from preschool programs to kindergarten

There was concern from many members as to how long their evaluations will be valid in a schools setting. The consensus is that if the evaluation utilized is an evaluation conducted by a non-educational agency, or by a provider who is not contracted by an educational agency, then the evaluation is good for one year. If an educational agency or a contractor of the educational agency conducted the evaluation, then the evaluation falls under the school-based evaluation criteria of every 3 years.

Issue: Some prior authorizations were only approved after sending in a cover sheet restating information included in the evaluation.

AFMC was aware of this issue and is working to improve their processes for approval. In the meantime, providers are encouraged to highlight justification for medical necessity in the evaluative reports, including statements about how the services recommended are under accepted standards of practice to treat the patient’s condition, how services are complex and will require the skilled services of a qualified therapist, and a statement about therapy prognosis (See Medicaid Manual Section II). Though a cover letter outlining these justifications is not required, providers are encouraged to consider using a cover letter attached to the evaluation to make these medical necessity statements more salient for reviewers.

Issue: Are reviewers actually reading the evaluations or just looking for technical language?

AFMC assured us that they are reading all evaluations. They perform both technical and administrative reviews in order to ensure that all requirements of the evaluative reports are included, as well as a medical necessity review to ensure that justification for medically based services is included.

Issue: I heard that AFMC was using nurse reviewers and not experienced pediatric therapists in each discipline. Is this true?

AFMC utilizes registered nurses to perform the initial reviews of all PA requests. If a request is denied than the request is assessed by an experienced licensed therapists specific to the discipline. If the therapist agrees with the denial it is then sent to a board certified pediatric physician for final review. If a provider does not agree with the denial or would like to request reconsideration they may do so by resubmitting the request.

Issue: What about beneficiaries who receive services from multiple providers for the same service?

AFMC and DDS continue to emphasize the need for care coordination for beneficiaries with multiple providers of the same modality (physical, occupational or speech therapy). Dr. Chad Rodgers, AFMC Medical Director, attended our meeting and reported that the pediatricians and PCPs he has been in contact with are interested in understanding what situations justify the appropriate signing off on multiple prescriptions. He asserts that although he can’t speak for all physicians he personally looks at every request for therapy services before signing them. He recognized that it is difficult to for most physicians to understand why a child needs multiple services. He and assistant director of DDS Elizabeth Pittman stated that it would be beneficial to state on the DMS-640 the specific need for a particular service and that the beneficiary will need the services of multiple therapists. AFMC and DDS are considering a change to the DMS-640 forms in the future to accommodate the different services provided within one discipline. Elizabeth Pittman reported that the new MMIS system (which has an anticipated implementation of summer of 2018) will be less burdensome on providers and will have the ability to disclose is the beneficiary is receiving services from other providers. Until then, providers need to ask during the intake process if the recipient is receiving therapy services from any other provider, and then coordinate as needed. According to Jarrod McClain, only 10 providers have bumped into challenges with the multiple provider issues thus far.

Issue: For short term scripts (i.e. ortho docs who write for 2-6 weeks) that then need an extension once the patient has had a follow-up recheck. What is the most efficient way to keep PA’s from having to be unnecessarily done?

Providers can simply go into Review Point, and click the extend button. The codes will be transferred over and the new prescription can be uploaded. Information about the progress of the patient and continued medical necessity should be included with the extension.

Issue: It has come to the attention of AFMC and DDS that some facilities are sending notices to parents that they should not allow services for their child in the school due to the need for a PA if the school and independent facility are both treating the beneficiary.

Although Medicaid is a “medical” assistance program, it recognizes the importance of school-based services. The federal Medicaid program actually encourages states to use funds from their Medicaid program to help pay for certain healthcare services that are delivered in the schools, providing that federal regulations are followed. The associations stand with AFMC and DDS that sending notices to parents regarding billing for services between schools and independent clinics is not recommended. IDEA laws require schools to provide services to beneficiaries if needed for educational purposes. Schools also must provide therapy that is medically necessary. Therapy services outside of the school setting should not replicate services provided by therapists contracted or working with the school.

Issue: A representative at DHS has stated that physical therapy re-eval codes are no longer a valid code as of July 1st. Has anything changed in the recent rule change?

Reevaluation codes are not currently and haven’t been a reimbursable code. The two billable codes for physical therapy services are 97001 and 97110.

Solution to Denied PAs for Therapy Providers

MSL has been made aware that there’s a lot of confusion on submitting PAs to request more than 90 minutes of therapy for children since the therapy cap was implemented on July 1, 2017. Lainey has talked with AFMC and DHS as well as the OT Association President who has been successful in submissions.


You need a separate statement letter that answers the following questions individual to the child’s case:

1. How does the therapy administered effectively treat the beneficiary’s condition?

2. What gives you a reasonable expectation that the beneficiary is experiencing meaningful improvement or that the therapy is preventing worsening of the beneficiary’s current condition?

3. How are the frequency, intensity, and duration of the requested therapy services realistic for the age of the child?

List the question and provide the answer. Make sure you provide the other information listed there as well. AFMC told Lainey today that they will deny any submission that does not have this requirement. If you have received denial with 3 statements that say you didn’t meet the requirement, try resubmitting with this.






Making Sense of the Manuals for Public Comment

Screen Shot 2017-07-17 at 10.36.45 AMDHS released several manuals to the Medicaid website on July 13, 2017 that are available for public comment until August 11. Once public comment ends, these rules will be sent through the legislative committees and passed as law.

“In accordance with federal and state law, the Division of Medical Services of the Arkansas Department of Human Services must advertise and make available for public comment proposed new and amended rules and other documents, such as certain initial waiver requests and waiver renewals.”

However, they released over 60 documents actually, which may have left you feeling confused about which one needs your comment or what’s in them all. Here’s your guide to wading through the state terminology and legalese.


RULE #1: When you send in your comments, make sure to list the document that you wish to comment on!

RULE #2: Make sure you send your comments to the appropriate person.


Send your comments to Shelby.Maldonado@dhs.arkansas.gov, and as long as you’ve included the right document title, she will be able to direct it to the correct person.

  • If you’re viewing this on a phone or tablet, you might want to turn it to the side (landscape) to view the width of the table well. The right 2 columns are what MSL has added to help with the list that DHS provided.

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Instead of scrolling through the long table, which can be confusing, this list of topics can get you straight to what you want to see. Click the link to go directly to the corresponding manual in the table.

 


The following table will attempt to explain what each document is (memo, explanation letter, mark up with changes, or new manual), what it contains, and possibly some documents to assist you. Remember, the list of topics above can assist you in finding what you need much faster.

Document Title Document Description Assisting docs/info
Interested Persons and Providers Letter for DDS Standards for Certification, Investigation and Monitoring; State Plan Amendment 2017-011; Child Health Management Services provider manual update; and Developmental Day Treatment Clinic Services provider manual update IPLtrSPA17-011.doc memo
(SPA011 – 1 of 15)
State Plan Amendment 2017-011 Attachment 3.1A 1i SPA17-011-31A1i.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, CATEGORICALLY NEEDY (page as it will appear in new manual)
(SPA011 – 2 of 15) Page 1i
State Plan Amendment 2017-011 Attachment 3.1A 1i with tracked changes SPA17-011-31A1i-markup.doc SAME MANUAL PAGE: mark up that shows changes
(SPA011 – 3 of 15) Page 1i
State Plan Amendment 2017-011 Attachment 3.1A 4A SPA17-011-31A4A.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, CATEGORICALLY NEEDY (page as it wil appear in new manual)
(SPA011 – 4 of 15) Page 4a
State Plan Amendment 2017-011 Attachment 3.1A 4A with tracked changes SPA17-011-31A4A-markup.doc SAME MANUAL PAGE: mark up that shows changes
(SPA011 – 5 of 15) Page 4a
State Plan Amendment 2017-011 Attachment 3-1B 2h SPA17-011-31B2h.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, MEDICALLY NEEDY (page as it wil appear in new manual)
(SPA011 – 6 of 15) Page 2h
State Plan Amendment 2017-011 Attachment 3-1B 2h SPA17-011-31B2h-markup.doc SAME MANUAL PAGE: mark up that shows changes
(SPA011 – 7 of 15) Page 2h
State Plan Amendment 2017-011 SPA17-011-31B4b.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, MEDICALLY NEEDY (page as it wil appear in new manual)
(SPA011 – 8 of 15) Page 4b
State Plan Amendment 2017-011 SPA17-011-31B4b-markup.doc SAME MANUAL PAGE: mark up that shows changes 1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact
(SPA011 – 9 of 15) Page 4b
DDS Standards for Certification, Investigation and Monitoring – Redline DDS-Stnds-Redline.doc DDS STANDARDS for Certification, Investigation, an Monitoring for Center-Based Community Services  1. Summary DDTCS-CHMS 2. Info
(SPA011 – 10 of 15) entire manual, mark up that shows changes
DDS Standards for Certification, Investigation and Monitoring DDS-Stnds-Clean.doc DDS STANDARDS for Certification, Investigation, an Monitoring for Center-Based Community Services
(SPA011 – 11 of 15) entire manual, as it will appear
CHMS-2-17 Provider Manual Update Transmittal Letter CHMS-2-17.doc letter that explains which parts of the CHMS manual have been changed
(SPA011 – 12 of 15)
CHMS-2-17 Provider Manual Update CHMS-2-17up.doc CHMS Manual mark up with changes. 1. Summary DDTCS-CHMS 2. Info
(SPA011 – 13 of 15)
DDTCS-2-17 Provider Manual Update Transmittal Letter DDTCS-2-17.doc letter that explains which parts of the DDTCS manual have been changed
(SPA011 – 14 of 15)
DDTCS-2-17 Provider Manual Update DDTCS-2-17up.doc DDTCS Manual mark up with changes. 1. Summary DDTCS-CHMS 2. Info
(SPA011 – 15 of 15)
Interested Persons and Providers Letter for State Plan Amendment 2017-010, Outpatient Behavioral Health Services and Inpatient Psychiatric Provider Manual Updates and Residential Community Reintegration Program Certification IPLtrSPA17-010.doc memo
(SPA010 – 1 of 8)
State Plan Amendment 2017-010 Attachment 3.1 A SPA010-Attach3-1A.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, CATEGORICALLY NEEDY (page as it will appear in new manual – NO MARK UP AVAILABLE)
(SPA010 – 2 of 8) Page 6c17a
State Plan Amendment 2017-010 Attachment 3.1 B SPA010-Attach3-1B.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, MEDICALLY NEEDY (page as it will appear in new manual – NO MARK UP AVAILABLE)
(SPA010 – 3 of 8) Page 5f17a
Residential Community Integration Program Certification ResCommReintCert.doc Residential Community Integration Program Certification
(SPA010 – 4 of 8) entire manual as it will appear NO MARK UP AVAILABLE
Inpatient Psychiatric (INPPSYCH-1-17) Provider Manual Update Transmittal Letter INPPSYCH-1-17.doc Letter that shows the changes to Manual Update for Inpatient Psychiatric Services for Under Age 21
(SPA010 – 5 of 8)
INPPSYCH-1-17 Provider Manual Update INPPSYCH-1-17up.doc Manual Update for Inpatient Psychiatric Services for Under Age 21
(SPA010 – 6 of 8) entire manual as it will appear NO MARK UP AVAILABLE
Outpatient Behavioral Health Services (OBHS-1-17) Provider Manual Update Transmittal Letter OBHS-1-17.doc Letter that shows the changes to Manual Update for Outpatient Behavioral Health Services
(SPA010 – 7 of 8)
OBHS-1-17 Provider Manual Update OBHS-1-17up.doc Manual Update for Outpatient Behavioral Health Services
(SPA010 – 8 of 8) entire manual, mark up that shows changes
Interested Persons and Providers Letter for Independent Assessment Manual IPLtrAR_IA.doc memo
(AR_IA – 1 of 2)
AR Independent Assessment Manual AR_IA_July_17.doc New manual for Independent Assessment 1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact
(AR_IA – 2 of 2)
Interested Persons and Providers Letter for DDS Policy 1076 -Appeals IPLtrDDS1076.doc memo
(1076 – 1 of 3)
DDS Policy 1076 with Tracked Changes DDS1076-Appeals-markup.doc DDS Policy APPEALS Manual
(1076 – 2 of 3) entire manual, mark up that shows changes 1. Summary Appeals
2. Info Policy 1076 Appeals
DDS Policy 1076 -Clean DDS1076-Appeals-clean.doc DDS Policy APPEALS Manual
(1076 – 3 of 3) entire manual, as it will appear
Interested Persons and Providers Letter for DDS Policy 1086 IPLtrDDS1086.doc memo
(DDS1086 – 1 of 3)
DDS Policy 1086 with tracked changes DDS1086-HDC-markup.doc DDS Human Development Center Admission and Discharge Rules Policy Manual
(DDS1086 – 2 of 3) entire manual, mark up that shows changes 1. 1086 HDC Rules Summary

2. 1086 Info

DDS Policy 1086 DDS1086-HDC.doc DDS Human Development Center Admission and Discharge Rules Policy Manual
(DDS1086 – 3 of 3) entire manual, as it will appear
Interested Persons and Providers Letter for Medical Services Policy Manual Sections E-600 through E-670 and Appendix R IPLtrABLE.doc memo
(ABLE – 1 of 2)
Medical Services Policy Manual Sections E-600 through E-670 and Appendix R ABLE.pdf Able Act Policy Manual: Eligibility Factors, Contributions, Withdrawals, Expenses, Exclusions,
(ABLE – 2 of 2) entire manual, as it will appear – NO MARK UP AVAILABLE
Interested Persons and Providers Letter for Community and Employment (CES) 1915 (c) Waiver, DDSCES-1-17 Provider Manual Update and Certification Standards for CES Providers IPLtrDDSCES.doc memo C Waiver
(CES – 1 of 5)
DDS Community and Employment Supports (CES) Waiver Minimum Certification Standards DDSCESCertStand-markup.doc DDS Community and Employment Supports (CES) Waiver Minimum Certification Standards
(CES – 2 of 5) entire manual, mark up that shows changes 1. Summary of Changes

2. Info – CES Waiver

DDS Community and Employment Supports (CES) Waiver Minimum Certification Standards DDSCESCertStand.doc DDS Community and Employment Supports (CES) Waiver Minimum Certification Standards
(CES – 3 of 5) entire manual, as it will appear
Developmental Disabilities Services Community and Employment Supports (DDSCES1-17) Provider Manual Update Transmittal Letter DDSCES-1-17.doc Letter that shows the changes to Manual Update for Arkansas Medicaid Health Care Providers – DDS Community and Employment Supports (CES)
(CES – 4 of 5)
DDSCES-1-17 Provider Manual DDSCES-1-17up.doc Manual Update for Arkansas Medicaid Health Care Providers – DDS Community and Employment Supports (CES)
(CES – 5 of 5) entire manual, mark up that shows changes 1. Summary of Changes
2. Info – CES Waiver
Interested Persons and Providers Letter for Provider-Led Arkansas Shared Savings Entity (PASSE) Waiver and New Provider Manual IPLtrPASSE.doc memo
(PASSE 1 of 5)
Provider-led Arkansas Shared Savings Entity Program – Phase I PASSEWvr.pdf PASSE Program Information B Waiver
1. Summary of PASSE
2. Info & Financial Impact
(PASSE 2 of 5)
Provider-led Arkansas Shared Savings Entity Spreadsheet SpreadsheetPASSEWvr.pdf PASSE Information – Enrollment Projections, Costs
(PASSE 3 of 5)
PASSE-New-17 Provider Manual Update Transmittal Letter PASSE-New-17.doc letter that explains Provider-Led Arkansas Shared Savings Entity (PASSE) Program manual
(PASSE 4 of 5)
PASSE-New-17 Provider Manual Update PASSE-New-17up.doc New PASSE Manual
(PASSE 5 of 5) entire manual, mark up 1. Summary of PASSE
2. Info & Financial Impact
Interested Persons and Providers Letter for Independent Assessment for Personal Care and Criminal Background Check Requirements for Providers IPLtrIA.doc memo
(IA – 1 of 22)
State Plan Amendment 2017-009 with Tracked Changes SPA17-009-markup.doc STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT: AMOUNT, DURATION AND SCOPE OF
SERVICES PROVIDED, CATEGORICALLY NEEDY (mark up that shows changes
(IA – 2 of 22) Page 10aa
State Plan Amendment 2017-009 SPA17-009.doc SAME MANUAL PAGE: as it will appear
(IA – 2 of 22) Page 10aa
ARChoices in Home Care Home and Community-Based 2176 Waiver (ARCHOICES-1-17) Provider Manual Update Transmittal Letter ARCHOICES-1-17.doc letter that explains changes to ARChoices In Homecare Home and Community-Based 2176 Waiver Manual
(IA – 3 of 22)
ARCHOICES-1-17 Provider Manual Update ARCHOICES-1-17up.doc ARChoices In Homecare Home and Community-Based 2176 Waiver Manual
(IA – 4 of 22) entire manual, mark up that shows changes
Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT-1-17) Provider Manual Update Transmittal Letter EPSDT-1-17.doc letter that explains changes to Arkansas Medicaid Health Care Providers – EPSDT Manual
(IA – 5 of 22)
EPSDT-1-17 Provider Manual Update EPSDT-1-17up.doc Arkansas Medicaid Health Care Providers – EPSDT Manual change
(IA – 6 of 22) Section II, mark up that shows changes IA required for certain home health clients
1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact
Home Health (HOMEHLTH-1-17) Provider Manual Update Transmittal Letter HOMEHLTH-1-17.doc letter that explains changes to Arkansas Medicaid Health Care Providers – Home Health Manual
(IA – 7 of 22)
HOMEHLTH-1-17 Provider Manual Update HOMEHLTH-1-17up.doc Arkansas Medicaid Health Care Providers – Home Health Manual change
(IA – 8 of 22) Section II, mark up that shows changes background check changes
Hospice (HOSPICE-1-17) Provider Manual Update Transmittal Letter HOSPICE-1-17.doc letter that explains changes to Arkansas Medicaid Health Care Providers – Hospice Service manual
(IA – 9 of 22)
HOSPICE-1-17 Provider Manual Update HOSPICE-1-17up.doc Arkansas Medicaid Health Care Providers – Hospice Service manual changes
(IA – 10 of 22) Section II, mark up that shows changes background check, IAs for personal care
1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact
IndependentChoices (INCHOICE-1-17) Provider Manual Update Transmittal Letter INCHOICE-1-17.doc letter that expains changes to Arkansas Medicaid Health Care Providers – IndependentChoices Manual
(IA – 11 of 22)
INCHOICE-1-17 Provider Manual Update INCHOICE-1-17up.doc Arkansas Medicaid Health Care Providers – IndependentChoices Manual changes
(IA – 12 of 22) Section II, mark up that shows changes various changes included background checks
Personal Care (PERSCARE-1-17) Provider Manual Update Transmittal Letter PERSCARE-1-17.doc letter that explains changes to Arkansas Medicaid Health Care Providers – Personal Care manual
(IA – 13 of 22)
PERSCARE-1-17 Provider Manual Update PERSCARE-1-17up.doc Arkansas Medicaid Health Care Providers – Personal Care Manual changes
(IA – 14 of 22) Section II, mark up that shows changes
Private Duty Nursing Services (PDN-1-17) Provider Manual Update Transmittal Letter PDN-1-17.doc letter that explains changes to the Arkansas Medicaid Health Care Providers – Private Duty Nursing Services manual
(IA – 15 of 22)
PDN-1-17 Provider Manual Update PDN-1-17up.doc Arkansas Medicaid Health Care Providers – Private Duty Nursing Services Manual changes
(IA – 15 of 22) Section II, mark up that shows changes background checks
Physician (PHYSICN-3-17) Provider Manual Update Transmittal Letter PHYSICN-3-17.doc letter that explains changes to the Physician/ Independent Lab/CRNA/Radiation Therapy Center manual
(IA – 17 of 22)
PHYSICN-3-17 Provider Manual Update PHYSICN-3-17up.doc Physician/ Independent Lab/CRNA/Radiation Therapy Center manual changes
(IA – 18 of 22) Section II, mark up that shows changes IA requirement
1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact
Rural Health Clinic (RURLHLTH-1-17) Provider Manual Update Transmittal Letter RURLHLTH-1-17.doc letter that explains changes to the Rural Health Clinic Services manual
(IA – 19 of 22)
RURLHLTH-1-17 Provider Manual Update RURLHLTH-1-17up.doc Rural Health Clinic Services manual changes
(IA – 20 of 22) Section II, mark up that shows changes IA requirement
1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact
Section I (SecI-3-17) All Provider Manuals Update Transmittal Letter SecI-3-17.doc letter that explains the changes to the Arkansas Medicaid Health Care Providers – All Providers manual
(IA – 21 of 22)
SecI-3-17 All Provider Manuals Update SecI-3-17up.doc Arkansas Medicaid Health Care Providers – All Providers manual
(IA – 22 of 22) Section II, mark up that shows changes IA requirement
1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact

Medicaid Saves Lila

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This is my sweet girl, Lila. She’s active and intelligent. She loves to swing, eat blackberries, and paint. Don’t you dare turn your back on her because she’s mischievous too! She loves her friends, family, and kitty-cats. She is absolutely the most wonderful thing I’ve ever done with my life, and she just so happens to have Down Syndrome.

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She might smile a lot, but her life hasn’t been easy. Born almost a month early due to multiple complications, Lila spent some time in the NICU. She’s overcome multiple illnesses and surgeries, including open heart surgery soon after her first birthday and many others since. In fact, we have received 2 new diagnoses this year alone, and she’ll have at least one surgery.

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My husband and I are proud Arkansans. We’re educated, hard-working, tax-paying citizens. At the time of Lila’s birth, we lived in another state. Despite the fact that we both had good jobs and primary insurance coverage, we struggled to provide for her needs. When we moved back to Arkansas, Lila was significantly delayed in many areas.

IMG_6519 Our friends told us about TEFRA, a type of Medicaid funding that provides for disabled children and that requires the family to pay a premium. Our primary insurance pays first for all that it will cover, and Medicaid makes sure that Lila doesn’t go without the rest. We gladly pay a monthly fee for this essential assistance!

Lila now receives medical treatments that she needs from specialists and Occupational, Physical, and Speech therapy. She attends a school where she is loved and accepted, and they practice important skills in the classroom to prepare her for mainstream Kindergarten. Lila is constantly learning the necessary skills to be independent: speaking new words, learning to feed herself, to dress herself, and to climb stairs. One of my favorite moments was the first time I ever heard her say, “Ma Ma.” Can you imagine waiting 4 years to hear that?

IMG_2776We never expected to need Medicaid. Even though we’d paid taxes for years for Medicaid, we didn’t know that a person’s life can change drastically in a moment – a car accident, a stroke, a job loss, a cancer diagnosis, a chromosomal difference – to cause them to need Medicaid. We thought that if we worked hard enough, we could take care of ourselves and Lila. But no matter how hard we work or what we give up, we just can’t afford to provide for all of Lila’s needs. Now, because of Medicaid, Lila is thriving, and we’re not being crushed under the weight of Lila’s ever-growing medical debt. We have hope that she will continue to develop and someday be a valued, contributing member of society. We are incredibly thankful for Medicaid.

We tell everyone we can how essential Medicaid is! Lila has visited the Capitol and state lawmakers multiple times to represent herself and friends like her. Since she can’t speak much yet, my husband and I tell them how much Medicaid is literally saving lives. I can’t wait for the day that Lila will tell them herself. She brings a beauty and light to this dark world, and we will never stop fighting for her!

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Catch up on the Provider Led Model (PASSE)

PASSE stands for Provider-owned Arkansas Shared Savings Entities, and this new Provider-led model is required by a law passed by the Arkansas State Legislature last spring. DHS has been told to achieve a certain amount of Medicaid cost savings, and the theory is that this model should achieve them through better management of care. Over the next year and a half, we will see a shift in the management of Medicaid care for certain recipients under the Developmental Disabilities Services and Behavioral Health Services Divisions of DHS through the implementation of this model.

During the transition time, each recipient will undergo an Independent Assessment to determine services given, and then each recipient will be assigned to one of the PASSEs. Right now, we don’t know how many PASSEs there will be or which partners each will include. That should all become clear after June 15, 2007. Once the recipient receives information about which PASSE he or she has been assigned to, he or she will have 90 days to switch to a new PASSE if desired. Everyone will be on a different timeline, so recipients won’t really be able to compare situations early on.

This transition will take place throughout 2017 and 2018 as PASSEs slowly take on responsibility. In 2019, the PASSEs will take on all responsibility of managing the care and funds for each recipient they’ve been assigned. Providers will then bill the PASSE for each client, which means that the providers have to participate in probably all PASSEs to be “in network” for their current clients and future clients.

As said before, this will only affect certain clients – classified as Tier 2 and Tier 3 – for both DD and BH. Tier 2 and 3 people are defined differently by DD and BH, but basically it’s determined by level of care needed.

As we’ve all seen, this is very complicated, and a lot of information has already been shared. Here’s your chance to catch up!

Basic questions answered

See DHS Presentations from public meetings that occurred in April 2017.

Read the law that was passed during this past spring session.

See DHS’s answers to your questions.

See in depth information from DHS about the PLM.

Therapy Associations Update on Therapy Cap

Many thanks to the therapy association reps for their hard work and for sending this statement to be shared with us (regarding the 90 minute therapy cap to take effect July 1, 2017):

“In order to provide clarity, representatives from ArkSHA, AROTA, and ArPTA met with representatives from Medicaid, DDS and AFMC and had many questions answered. Stakeholder input was provided and we feel that our voices were heard. Not interrupting children’s services was discussed and will be addressed. A formal statement outlining the 90 minute rule and PA process will be delivered within 7 business days by Melissa Stone, DDS Director. We have been asked to respect this timeline as the written procedures are being finalized by DDS and AFMC.”

Providers: PASSE Information

This information regards Act 775 (Provider Led Organized Care). If you haven’t read that, please do.

Deadlines are approaching with the formation of the PASSEs. The letter of intent deadline was extended to June 15, but many want your commitment by June 1. That being said, some of you still have questions.

First of all, will you be affected? You may or may not serve Tier 2 and/or Tier 3 patients of the BH and/or DDS populations. If you don’t, this may not affect you. However, if you want to keep your options open to serve them in the future, you probably need to at least participate in PASSEs. In the DD population, a Tier 1 patient can become a Tier 2 or 3 simply by being accepted into the Waiver program, but as you know, with the long waiting list, they could continue to receive services from their current providers. If you aren’t participating, that person will have to find another provider.

How many PASSEs are there? Why does this seem so secretive? Well, there are at least 4 forming. One PASSE has been pretty public, has released some plans, and were involved in passing the law.  They have held one public meeting. Others have formed and are trying to meet the regulations by June 15. These are common business practices, and some can’t release info until legalities are finalized. I hope to see public meetings from the others soon. It’s a pretty competitive situation right now, so a lot of information is not public. Each PASSE will try to convince you as to why you should invest with them. They are competing since there are only so many partners and investors available. There is a time limit for them, but you still have a little time to make a good investment decision. However, if you report to a board, you probably want to get them info as soon as possible.

Why should you invest? Part of the rules are that each PASSE must collect a savings/investment fund by December 2017 to be able to assume risk of managing funds for Tiers 2 and 3 of DDS and BHS. So that’s one reason each PASSE needs investors to give them money. Investors in a PASSE take on the risk together but also share in the rewards if money is saved. If each PASSE does not raise enough money and show a diverse group of partners to serve each need around the state, they will not pass certification. That’s why it’s pretty competitive to get you to invest with them and only them.

How are investment and participation different? As I understand it, participation requires nomoney from you. You can officially participate with any or all PASSEs once they’re certified to take on clients in order to be “in network” for the people they manage Medicaid funds for.

Any other important info? Each affected client will be attributed to one PASSE once he/she has received the Independent Assessment. The patient or caregiver will have 90 days to change to another PASSE. As said before, if you’re not a participant in that PASSE, you may lose the client. The Independent Assessment will determine what services are medically necessary for each patient, so you might expect some changes there. A lot of details have yet to be worked out.

Where can you get details about each PASSE? If you want to invest or hear more from each PASSE, just send me your email address, and I’ll send it to them. They will send the info they’re allowed to share.

DDS Answers Our Questions – Part 2

Author: Lainey Morrow, Founder of Medicaid Saves Lives
Direct quotations from  Interview with Melissa Stone at her office on October 6, 2016
Forrest Steele, Assistant Director was also present.

I was again able to meet with Ms. Melissa Stone, Director of Disability Services (a Division of DHS), and she answered some more of your questions. Some questions required other people to answer, and I’m still waiting on that information. I invite you to comment on the answers given because Ms. Stone has agreed to meet with me again this week. I’d like to take some of your comments back to her.


Is Independent Assessment on the table now?

Melissa: “It’s completely separate from this entire rule change. So I think we talked a little bit last time about transformation efforts within the special needs population, which would be Division of Developmental Disabilities, Behavioral Health, and Division of Aging and Adult Services. We are constructing a request for a proposal (RFP), which is the state vehicle to put a contract in place. There’s a lot that goes with a request for a proposal or request for qualifications (RFQ). You have to put out a document of kind of what you’re trying to buy, so that we can allow competitive bidders to bid on it. And there’s an entire process on how we rank them, and it’s very in depth, and it’s overseen by the Department of Finance and Administration. And that’s the only way we put contracts in place. Before we even put the contract in place, that particular RFP or RFQ is reviewed by the legislature. So we are in the beginning stages of… getting together the requirements for that vehicle, and we hope – it’s actually going to be run for us by the Department of Finance – and we hope that a draft version is out on our website next month so people can submit comments on that particular contract vehicle. So what we know for sure right now is back in 2008, the Center for Medicare and Medicaid, which we’ll refer to as CMS, passed a regulation that’s commonly referred to as Conflict Free Case Management. Conflict Free Case Management has essentially four elements, and what it says is if you pay for home and community based services under a waiver, which we operate a waiver here, because we have 4200 people on a waiver, if you pay through a waiver, [the Federal government is] going to mandate that you come into compliance, all states, with Conflict Free Case Management. One of the essential elements of Conflict Free Case Management is an independent, third party assessment. So that’s where this started. It’s a requirement. We are out of compliance. When I got into this seat, we had been operating on extensions. For various reasons, we had to get off of those extensions, and we’re having to come into compliance, and it’s been this long journey that we have been on with the providers who own and operate and run home and community based programs for clients on our waiver.”
Forrest: “And when that mentions conflict, does that talk about conflict of interest?”
Melissa: “Yes, thank you, Forrest. So we’re talking about the, it’s to eliminate any appearance or any actual conflict of interest. So not only do they say you need to do an independent third party assessment, you also need to have someone that does the client’s case management that’s in no way, shape, or form associated with the organization who provides direct day-to-day services. So this is a total shift on how we’ve been operating because up until, and even to this day, if you choose a provider, you can choose them to do your case management and your direct care. There we have a requirement they can’t be the same person but you can pick the same provider. So this has been like I said a journey to get providers on board with this idea, in agreement with how we’re going to move forward to comply with this regulation. We had several large stakeholder meetings with this group of individuals, these people who own and operate waiver programs, we have about 90 of them I would say, and they decided that they felt like contracting it out, and I agree with them, would be the cleanest, easiest way to comply with this regulation. So that’s how this process started for us. Those clients meet an eligibility criteria called Institutional Level of Care. It’s the same eligibility criteria that you have to meet to be a resident at an intermediate care facility. So the state of Arkansas, DDS, operates 5 intermediate care facilities, which are commonly referred to as human development centers.  And then there’s private intermediate care facilities. The people on the waiver, and the people at the private and the human development centers are all deemed to be institutional level of care. Because of that reasoning, we are moving forward with doing independent assessments, the same independent assessment, on that entire eligibility population. So that is the only thing that is 100% for sure. And that’s what I’ve been talking about at stakeholder meetings and I’ve talked about over at the legislature. Those are the things we would like to move forward with for reasons of federal compliance. But as far as any other population of people with developmental disabilities or delays, we have not decided on that. And I know that a lot of the comments are wrapping these two together, and I understand why. I understand why they’re being wrapped together. Because it’s all being discussed at the same time. But I will say that for this rule, this rule is completely separate from anything going on with Independent Assessment.”
Lainey: “So there will be an opportunity to comment on this?”
Melissa: “We’ll put it up on the website, and we will actually send out notice. And it will be up there for 30 days.”


What other cuts have been considered before these?

Melissa: “We have been working for a long time at the department to come up with ways that we can transform the services that we provide here across all divisions, not just across Medicaid divisions. So we, and I think Cindy Gillespie, the director, has really made vast improvements. She came in and did a shared service model, where we rather than having a group of people within each division who do contracts, and a group of people within each division who do finance, and a group of people who do human resource and hiring… she has designed a shared service model, which is just as simplistic as it sounds which is they are just floating out here to the left, each one of the divisions utilizes those offices for those functions, but every division is not silo’d in doing their own hiring, their own contracting, their own finance. And what it’s done for us so far, and it went into effect in July, and of course, we are still implementing because, you know, we have over 7,000 employees here. So you know, you’re turning a gigantic ship when you do a transformation like this. We have already seen the benefit of being able to start looking at bulk contracting to save money. So instead of DDS buying bread and Behavioral Health buying bread, we now are looking at, could we get bigger bang for our buck by putting in a bigger contract, negotiating it well, and getting a better price for all of us to get bread. And that is in the beginning stages, and we can already see a difference. And the same thing with finance. It’s not the DD budget versus the DCFS budget. Okay, let’s look at where your funding is coming from. How can we maximize federal dollars more appropriately across the department. So now that it’s a shared service model, there’s one financial officer division, he’s looking across the entire department to see what could we do differently to utilize our dollars better, and we’re already seeing that occurring. So there’s estimated savings with both of those shared services… we fully anticipate seeing savings from just operating our administrative functions differently like this.

I know that it feels very personal to OT, PT, and Speech, but we’re talking about a DDS transformation that we’re trying to accomplish to ensure better quality of care across all programs. The same thing is happening with Division of Aging Adult Services and with Behavioral Health because those three divisions are the highest spending in Medicaid. It’s the fewest amount of people, but it’s the highest dollar amount. And you would expect that. Those are people who need services, those populations, but we are looking at ways that we can be more efficient with those 3 populations.”


If this current proposal fails, will this be moving to managed care?

Melissa: “I think it’s premature to make that kind of correlation. Of course, we’re hoping this passes, but I would not make that correlation. And I wouldn’t want to assume anything.
Lainey: “So what do you say to people who are afraid of that?”
Melissa: “Managed care has been on the table for some time now. We actually were under managed care several years ago for a period of time. I think it’s just a reaction or a possible remedy to what we’re facing right now when it comes to Medicaid sustainability. We are trying to put transformation efforts in place that will help sustain Medicaid, and this [proposal] is one of them. But managed care is also an option that’s being discussed that would help sustain the program.”
Forrest: “I think at this point, people who are having these discussions aren’t really eliminating anything as a potential option that’s so important. Keeping the options open as we move forward.”


What area in DDS in the biggest concern?

Are there more modifications coming that we need to be aware of?

Melissa: “I would say that the modification that is coming that is being discussed that we just went over is the Independent Assessment process. And like I said, the only 2 programs that we have definitively come out and said we would like to pursue in terms of Independent Assessment are the clients that are on the waiver and the ones entering intermediate care facilities. I wouldn’t say that one area is more concerning than the other. I mean, we are literally looking at every program within DDS to see how we can make it more efficient. But we have been doing that for over, I mean literally, since maybe the past 2 years that I’ve been really involved with it. And I’ll tell you, based on looking at those areas, we’ve put processes in place in our human development centers, we’ve moved to this shared service model, we’re looking at the therapy thresholds and the Independent Assessments right now with those 2 populations.”


How much do you plan on reducing our TEFRA premium?

Melissa: “There is no proposed plan to reduce the TEFRA premium at this time.”


What will happen when the therapy centers cannot afford to hire someone to do all these prior authorizations?

Melissa: “I just want to reiterate that the PA process, like I said the provider workgroup is putting together specs. We’re not trying to make this as difficult as possible. I don’t anticipate there being that kind of paperwork to turn in that would require hiring additional staff to handle it.”
Lainey: “Well, this person said that they were told that all of the kids would have to be seen at the cap that is being set even when they need more because they won’t have enough staff.”
Melissa: “Well, I hope a therapist didn’t say that because if a child needs more, and is deemed to need more under evaluation, I would hope that they would turn the paperwork in to get a child more.”


Say they do an evaluation, and the child needs 120 minutes. That means they have to submit a PA for the extra. So what if they begin treatment for the full amount until they get the approval, and when it comes, Medicaid would back-pay that? But if not, the center would owe the money. That would mean that they would be very confident in the PAs they’re sending in.

Melissa: “So this is a provider that clearly does business with Medicaid frequently. This is a practice that we have in place for other programs. We don’t have the specs back, but I’m going to log that in as a comment.”
Lainey: “That’s the way that it worked with our daughter while we were waiting for TEFRA. Is that how this will work because it already works that way in a lot of cases?”
Melissa: “Well, it’s a very good suggestion.”
Forrest: “And it does sort of fit the norm.”
Melissa: “And it does fit kind of what we do in other programs.”
Lainey: “It does, I just think the concern would be staffing. Can they sustain – it just depends on the turn around time with the proposal, which you’re going to write in is really a short time like you intend, then it wouldn’t be that long. But with the TEFRA approval it’s 2-3 months, and her provider was treating her and paying their people out of their own budget until they get that money back. Three months is a long time to hold that.”


We’ve heard that Independent Assessments might only be applied to day-treatment centers like Access, Easter Seals, and the Allen School. There are many other centers out there that could need quality control. That doesn’t seem fair to us or the centers. Why as a parent wouldn’t I just take my kid to a center that isn’t going to be subjected to this?

Melissa: “There will be no carve out for certain providers or certain clinics. Anything that is implemented will be across the board for a program, not a private company.”
Lainey: “Do you think they meant PA? Because from your description, Independent Assessment doesn’t…”
Melissa: “I think there’s fear out there about Independent Assessments. They have been discussed. They have been mentioned by the Stephens group. They have been discussed. Their initial recommendation was for Independent Assessments across Medicaid programs, so there’s been talk of this Independent Assessment that’s concerned providers for months. So it’s unclear to me whether or not they’re talking about PA process or Independent Assessment.”
Lainey: “Yeah, the terminology is hard to get…”
Melissa: “But regardless, it’s the same answer because anything implemented by DHS will be for a program, and there won’t be special exceptions for a private entity.”


Who will this additional entity be and what credentials do they possess? Are their credentials any greater than mine?

Melissa: “So the provider workgroup, that is made up of these clinicians OT, PT, and Speech, have said from the very beginning, and I fully agree, that whoever is brought on board to review Prior Authorization paperwork, they will need to be qualified, and they will need to be clinicians. But here again, these are specs that would be in that [RFP] or [RFQ] document that we have not begun drafting that I anticipate will be out for a draft for public comment in the spring. And these are things that we can put into that, we can put requirements in there of what kind of credentials the people would possess as well as the turn-around time. And all of those specifics.”

Is this team superseding the physicians?

Melissa: “So within Medicaid, we have a medical necessity definition for everything that Medicaid does, and Medicaid is made up of doctors, clinicians, nurses who are very familiar with this process of sometimes 2 doctors do not agree. Sometimes our Medicaid doctors and an outside doctor do not agree. That’s why there’s always a very clear appeal process in place. There will be such an appeal process in place for this.”
Lainey: “So when they disagree, do they contact the doctor? Or do they just deny it?”
Melissa: “Whoever they’re not agreeing with is notified of course because they have a right to appeal. And so they are given paperwork that shows how they go through that process.”


Ms. Stone has said, “If a child needs more therapy, then they’ll receive more therapy.” How does that support Medicaid Sustainability if we are assured the child will receive what they need?

Melissa: “Qualified recipients who need therapy will be allowed therapy.”
Lainey: “Basically, I guess she’s saying if nothing is changing, then there would be no cost savings.”
Melissa: “We anticipate cost savings.”
Lainey: “That sounds scary. My daughter [because of her diagnosis] in most cases gets the max… but not everyone’s kid is that kid. There are people who are [worried], namely people whose children don’t have a diagnosis.”
Melissa: “And I feel that from the comments, it’s mostly the kids that are just like my own.”
Lainey: “Is it okay [for me to share] that?”
Melissa: “Yeah. We went to the Dennis Development Center, and they can’t pinpoint exactly why he’s delayed, but he gets OT and Speech. And those are the cases that are scaring the families. But I have no doubt in my mind that the therapists who see him during their evaluation, which a standard, nationally-used speech and OT evaluation is what they used on him, that those evaluations wouldn’t speak for themselves. And they do if I’m trying to receive Prior Authorizations through my insurance. The therapists that have come to me that aren’t concerned, such as Access Schools who sent out an email to their families, they feel like they can justify the need. They’re professionals, they stand behind the minutes they’ve been prescribing, and they’re confident that their children won’t receive disruption.”


Is there any wiggle room with the 90 minute threshold?

Melissa: “We are getting that comment, and we’re looking at that.”
Lainey: “So you might consider that? Would that start this whole thing over?”
Melissa: “Yes. We are looking at that as well.”
Lainey: “I think that would satisfy some people to know that you’re at least considering 120.”
Melissa: “Absolutely, we’re considering every comment… we’re going to spend time based on the comments looking at the data to see what’s appropriate – if we need to come off the 90 minutes and how we need to react to the public comment based on the data.”


Federal CMMS puts out a report on improper payments and their impact on costs. The 2015 report said…less than 60% were due to Administrative error; about 30% were due to inability to authenticate eligibility. Less than 1 percent was due to not being deemed as medically necessary. We would have to have many deemed as not medically necessary to achieve the projection shown in the public notice.

Melissa: “This is showing a lot of reasons why the federal government and that would trickle down to why the state is looking to put some quality control metrics in place when you see that there’s that many millions of dollars that were administrative or process error, and you go down and only one million of improper payments was due to not medically necessary. It’s showing that it’s not that they’re denying it because it’s not medically necessary. They’re denying claims because of these other reasons, and the dollar amounts are actually astounding. In my mind, that supports the idea that quality control is needed and could be very useful.”
Lainey: “So what do you say to their point that the smallest number is not medical necessity, which is their view of why we’re doing PAs?”
Melissa: “Well, we’ve never come out and said that medical necessity is the reason we’re doing PAs. We’ve consistently messaged that we’re doing this as a quality control. The reasons that are laid out in this question show the need for quality control, and it doesn’t show that it’s because we are going to deny therapy that’s medically necessary to save money.


Why don’t consumers or guardians get to see what charges are being made in their names or their children’s names?

Melissa: “We need to talk about this with the Medicaid person. That’s definitely worth looking at.”


The Governor just created a taskforce to investigate fraud within the system itself – provider fraud. This office looks at people receiving maximum services to establish medical need. The office is staffed by highly qualified nurses and medical professionals. What is this office finding that might prompt a state-wide cut of services? Was this office consulted when determining the medical necessity for 90 minutes?

Melissa: “So the Medicaid Integrity Unit is run by a man named John Park, who they do investigate allegations of waste, fraud, and abuse. He would not be involved with programmatic changes such as this.”



The following questions were asked, but they require someone from the Medicaid office to answer them. I have requested the name and number of someone who can answer:

  • Why is Medicaid cutting back on my daughter’s hearing aids and supplies?
  • Why is TEFRA lumped in with Medicaid?
  • I’d like to know how they reached the number of $56 million in savings. The DMS 640 says that the TOTAL spent on all 3 therapies in 2015 was $151 million. That’s a 37% cut in spending. Is the information on the DMS 640 not representative of actual costs for these therapies?
  • Are they going to reduce our TEFRA premiums?
  • What’s going to happen to the behavioral health people who just had their services cut?