One Therapy Rule – Part 1

MSL has done some research on a change coming our way. You may have heard of it – the “One Therapy Rule,” formally known as the EIDT Program. Watch this video and stay tuned for your opportunity to take action.

PASSE Q&A Follow-up

DHS recently hosted a FB live about the PASSE to answer our questions, but some of your questions were not answered at that time. The images below show DHS’s follow-up answers to some of the questions.

For those of you who would like to go back and watch the Facebook live video from January 19, click here.





Live Q&A with DHS about PASSEs

MSL took your questions to DHS, and they answered live on Facebook. This video has several good demonstrations and answers that you might need to see. The PASSEs will start taking clients in February 2018.

Watch the video:

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!

Screen Shot 2017-10-31 at 9.36.43 AM

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.