Arkansas

Prevocational services are available to ARChoices waiver participants with physical disabilities who wish to join the general workforce. Prevocational Services comprises a range of learning and experiential type activities that prepare a participant for paid employment or self-employment in the community.

Prevocational services are as follows:

Development and teaching of general employability skills (non-job-task-specific strengths and skills) directly relevant to the participant’s pre-employment needs and successful participation in participant paid employment. These skills are: ability to communicate effectively with supervisors, coworkers, and customers; an understanding of generally accepted community workplace conduct and dress; the ability to follow directions; the ability to attend to tasks; workplace problem-solving skills and strategies; general workplace safety and mobility training; the ability to navigate local transportation options; and skills related to obtaining paid employment. Excluded are services involving development or training of job-specific or job-task oriented skills.

Career exploration activities designed to develop an individual career plan and facilitate the participant’s experientially based informed choice regarding the goal of individual paid employment. These may include business tours, informational interviews, job shadows, benefits education and financial literacy, assistive technology assessment, and local job exploration events. The expected outcome of career exploration activities is a written, actionable, PCSP designed to lead to community employment or self-employment for the participant.

The expected outcome of prevocational services is individual employment in the general workforce, or self- employment, in a setting typically found in the community, where the participant interacts with individuals without disabilities, other than those providing services to the participant or other individuals with disabilities, to the same extent that individuals without disabilities in comparable positions interact with other persons; and for which the participant is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

Prevocational services may be provided one-to-one or in a small group format and may be provided as a site-based service or in a community setting, consistent with requirements of the ARChoices provider manual.

All prevocational services must be prior approved in the participant’s PCSP, and delivered and documented consistent with requirements of the ARChoices provider manual.

Reimbursement is not permitted for Respite Care services provided by a waiver participant’s:

Spouse;

Legal guardian of the person; or

Attorney-in-fact granted authority to direct the participant’s care.

Prevocational services exclude any services otherwise available to the participant under a program funded under section 110 of the Rehabilitation Act of 1973 (Rehab Act), the Individuals with Disabilities Education Act (IDEA), or any other federally funded (non-Medicaid) source. Proper documentation shall be maintained in the file of each participant receiving prevocational services under the waiver.

Limits on the amount, duration, or frequency of this service:

The total amount of all prevocational services provided to any participant shall not exceed $2,500 per lifetime. The amount of career exploration activities provided per participant shall not exceed 30 hours. Duration of prevocational services provided to any given participant shall be limited to 180 days (six months). Services not completed within this timeframe are not covered.

Attendant care services available under the ARChoices program consists of direct human assistance with specific types of tasks, provided such tasks are:

Reasonable and medically necessary, supported by the participant’s latest independent assessment, and consistent with the participant’s Level of Care;

Not available from another source (including without limitation family members, a member of the participant’s household, or other unpaid caregivers; a Medicaid State Plan covered service; the Medicare program; the participant’s Medicare Advantage plan [including targeted or other supplemental benefits offered by the plan]; the participant’s Medicare prescription drug plan; and private long-term care, disability, or supplemental insurance coverage);

Expressly authorized in the participant’s PCSP;

Not in excess of or otherwise inconsistent with limits on the amount, frequency, or duration of services specified in the Task and Hour Standards;

Provided by qualified, Medicaid-enrolled providers and in compliance with all applicable Arkansas Medicaid program regulations and provider manuals; and

Provided in compliance with all applicable Arkansas scope of practice laws and regulations pertaining to nurses, physicians, skilled therapists, and other professionals.

The specific types of tasks covered under attendant care services are as follows:

Activities of Daily Living (ADLs):

Eating (i.e., feeding assistance during meal times and encouraging fluids, excluding tube feeding and total parenteral nutrition and meal preparation);

b. Toileting;

c. Personal hygiene and grooming (i.e., face shaving; nail trimming; shampooing, brushing, or combing of hair; and menstrual hygiene);

Dressing;

Bathing or showering; and/or Mobility/ambulating (i.e., functional mobility, moving from seated to standing, getting in and out of bed).

Instrumental Activities of Daily Living (IADLs):

Meal planning and preparation for meals consumed only by the participant;

Laundry for the participant or incidental to the participant’s care;

Shopping for food, clothing, and other essential items required specifically for the health and maintenance of the participant;

Housekeeping (i.e., cleaning of areas directly used by the participant); and

Assistance with medications (to the extent permitted by nursing scope of practice laws).

Health-related tasks, subject to the following:

“Health-related tasks” mean the following attendant activities:

Performing and recording simple measurements of body weight, blood glucose, heart pulse, blood pressure, temperature (forehead, tympanic, or oral), respiratory rate, and blood oxygen saturation, if in physician’s order or medical plan of care. Attendant must use an appropriate weight scale and FDA-approved, hand-held personal health monitoring device(s);

Additional assistance with the participant’s self-administration of prescribed medications;

Emptying and replacing colostomy and ostomy bags; and/or

Other tasks DAABHS may specify in the ARChoices provider manual; and

b. Any such health-related tasks performed:

i. Are consistent with all applicable State scope of practice laws and regulations;

ii. Within the documented skills, training, experience, and other relevant competencies of the attendant performing the task;

iii. For the care and safety of the participant, do not require monitoring or supervision of the attendant by a licensed physician, registered nurse, licensed physical therapist, or licensed occupational therapist;

iv. Are necessary to meet specific needs of the participant consistent with the PCSP by a licensed physician or registered nurse; and

v. Are tasks that the participant is unable to perform for themselves without hands-on assistance, direct supervision, and/or active cueing of the attendant.

In the ARChoices program, attendant care services exclude all of the following:

1. Medical, skilled nursing, pharmacy, skilled therapy services, medical social services, or medical technician services of any kind, including without limitation aseptic or sterile procedures; application of dressings; medication administration; injections; observation and assessment of health conditions, other than as permitted for the health- related tasks above; insertion, removal, or irrigation of catheters; tube or other enteral feedings; tracheostomy care; oxygen administration; ventilator care; drawing blood; and care and maintenance of any medical equipment;

2. Services within the scopes of practice of licensed cosmetologists, manicurists, electrologists, or aestheticians, except for necessary assistance with personal hygiene and basic grooming;

3. Services provided for any person other than the participant, including without limitation a provider, family member, household resident, or neighbor;

4. Companion, socialization, entertainment, or recreational services or activities of any kind, including, but not limited to, game playing, television watching, arts and crafts, hobbies, and other activities pursued for pleasure, relaxation, or fellowship;

5. Cleaning of any spaces of a home or place of residence (including without limitation the kitchen, bathroom, living room, dining room, family room, and utility or storage rooms, and the floors, furnishings, and appliances therein) shared by the participant with one or more adults who are, together or separately, physically able to perform housekeeping of these areas; and

6. Habilitation services, including but not limited to, assistance in acquiring, retaining, or improving self-help, socialization, and/or adaptive skills.

Participants may choose to receive authorized attendant care services through any of the following:

1. Home health agency licensed as Class A by the Arkansas State Board of Health, and enrolled as a Medicaid provider;

2. Home health agency licensed as Class B by the Arkansas State Board of Health, and enrolled as a Medicaid provider;

3. Private care agency licensed by the Arkansas State Board of Health, and enrolled as a Medicaid provider; or

4. Consumer-directed attendant care through Independent Choices, the Arkansas self-directed personal assistance benefit under section 1915(j) of the Social Security Act, provided the participant is capable of self-directing the assistance and subject to the requirements of the Independent Choices provider manual and applicable provider qualifications and certification.

Attendant care may be provided in a participant’s home or while accompanying the participant to other locations, including without limitation for medical appointments or community activities. In accordance with 42 CFR 441.301(b)(1)(ii), ARChoices services may not be provided to inpatients of nursing facilities, hospitals or other inpatient institutions except for inpatient respite services. Notwithstanding the foregoing, pursuant to Section 3715 of the CARES Act, Section 1902(h)(1) of the Social Security Act, services are not prohibited as specified if the services are (a) identified in an individual’s person-centered plan (or comparable plan of care), (b) provided to meet needs of the individual that are not met through the provision of hospital services; (c) not a substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under applicable requirement; and (d) designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities. Moreover, such services may be covered and reimbursable on days when the participant has been admitted to an inpatient hospital. Under such circumstances, attendant care services may be covered or reimbursable, availability of Arkansas Medicaid State Plan Services notwithstanding. The provided attendant care services may not exceed approved prior authorized rate for the service in place prior to hospitalization. Attendant care services shall not be duplicative of services available in the acute care hospital setting, Attendant care services shall be provided to ensure a smooth transition between the acute care hospital setting and the home and community-based setting. Furthermore, under attendant care services provided while hospitalized shall be billed the typical rate as set forth in Appendix I-2-a.

Limits on the amount, duration, or frequency of this service:

1. The aggregate amount, frequency, and duration of attendant care services must be consistent with the aggregate amounts, frequencies, and durations calculated by DHS for the participant in accordance with the Arkansas Medicaid Task and Hour Standards (“THS”), as issued by DAABHS and posted publicly on the DHS website with the ARChoices waiver provider manual. DAABHS will publish and periodically update the THS as necessary, following a public notice and comment process. The THS specifies limits on each ADL, IADL, and health-related task at the intensity of human assistance needed for the task, including maximum frequency (by day or week or month), maximum minutes per task allowable, and maximum hours by day, week, or month. Any aggregate amounts, frequencies, or durations in excess of the weekly or monthly limits calculated by DHS for the participant in accordance with the THS are not covered. 2. Attendant care services are not available (not covered and not reimbursable) through the ARChoices program when and to the extent any of the following may apply: a. When reasonably comparable or substitute services are available to the participant through an Arkansas Medicaid State Plan benefit including without limitation the personal care services, home health services, and private duty nursing services; b. When assistance with the equivalent ADL, IADL, or health-related task(s) is covered under an Arkansas Medicaid State Plan benefit but determined as medically unnecessary for the participant during adjudication of a prior authorization request or utilization review; c. When assistance with the comparable ADL, IADL, or health-related task(s) is available through targeted or supplemental benefits offered by the participant’s Medicare Advantage plan; d. When attendant care services delivered through a home health agency or private care agency are provided by the waiver participant’s (i) spouse; (ii) legal guardian of the person; or (iii) attorney-in-fact granted authority to direct the participant’s care; e. On dates of service when the participant: i. Receives Medicare home health aide services, whether through traditional Medicare fee-for-service or a Medicare Advantage plan of any kind for the same tasks; ii. Receives targeted or other supplemental benefits from a Medicare Advantage plan of any kind, where such supplemental services are reasonably comparable to or duplicative of attendant care services, personal care services, or self-directed personal assistance; iii. Spends more than five hours at an adult day services or adult day health services facility, unless prior approved in writing by the DHS PCSP/CC Nurse; iv. Receives long-term or short-term, facility-based respite care; and/or v. Receives services from an inpatient hospital, nursing facility, assisted living facility, hospice facility, or residential care facility, unless approved in writing by a DHS PCSP/CC Nurse as reasonable and necessary given the time of day of the facility admission or discharge, the need for transition assistance, or an inpatient hospital admission incident to an emergency department visit or direct inpatient admission by the attending physician; f. When a duplicate claim for the same performance of the same task is paid or submitted for personal care services, self-directed personal assistance, or home health aide services under the Medicaid State Plan; and/or g. For a task that was not actually performed. Attendant care may be provided in a beneficiary’s home or while accompanying the beneficiary to other locations, including without limitation for medical appointments or community activities. In accordance with 42 CFR 441.301(b)(1)(ii), ARChoices services may not be provided to inpatients of nursing facilities, hospitals or other inpatient institutions except for inpatient respite services. (1) Notwithstanding the foregoing, pursuant to Section 3715 of the CARES Act, Section 1902(h)(1) of the Social Security Act, services are not prohibited as specified if the services are (a) identified in an individual’s person-centered plan (or comparable plan of care), (b) provided to meet needs of the individual that are not met through the provision of hospital services; (c) not a substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under applicable requirement; and (d) designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities. Moreover, such services may be covered and reimbursable on days when the participant has been admitted to an inpatient hospital or institution. Under such circumstances, attendant care services may be covered or reimbursable, availability of Arkansas Medicaid State Plan Services notwithstanding. The provided attendant care services may not exceed approved prior authorized rate for the service in place prior to hospitalization.

Supported Employment is a tailored array of services that offers ongoing support to members with the most significant disabilities to assist in their goal of working in competitive integrated work settings for at least minimum wage. It is intended for individuals for whom competitive employment has not traditionally occurred, or has been interrupted or intermittent as a result of a significant disability, and who need ongoing supports to maintain their employment.

Supported employment services may include any combination of the following services: vocational/job related discovery and assessment, person centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job carving, training and systematic instructions, job coaching, benefits support, training and planning, transportation, asset development, and career advancement services, extended supported employment supports, and other workplace support services including services not specifically related to job skill training that enable the waiver client to be successful in integrating into the job setting. The service array may also be utilized to support individuals who are self-employed.

Transportation between the member’s place of residence and the employment site is included as a component of supported employment services when there is no other resource for transportation available.

The service provider must maintain the following documents to demonstrate compliance and delivery of this service- any job development plan or transition plan for job supports, remuneration statement (paycheck stub) and member’s

work schedule.

Limits on the amount, duration, or frequency of this service:

Must be documented in the PCSP

A continuum of care provided to recovering clients living in the community based on their level of need. This service includes educating and assisting the clients with accessing supports and services needed. The service assists recovering individuals to direct their resources and support systems.

Activities include training to assist the clients to improve employability, and to successfully adapt and adjust to a particular environment. Adult rehabilitation day treatment includes training and assistance to live in and maintain a household of their choosing in the community. In addition, activities can include transitional services to assist clients after receiving a higher level of care. The goal of this service is to promote and maintain community integration.

Adult rehabilitative day treatment is an array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified individuals that are aimed at long-term recovery and maximization of self-sufficiency. These rehabilitative day activities are person and family centered, recovery based, culturally competent, and provided needed accommodation for any disability. These activities must also have measurable outcomes directly related to the individual’s treatment plan. Day treatment activities assist the individual with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the individual as an active and productive member of his or her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety or anger; behavioral skills, such as proper use of medications, appropriate social interactions and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management, and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms and reframing; community integration skills and any similar skills required to implement the client’s behavioral health treatment plan. Meals and transportation are not included in the rate for Adult Rehabilitation Day Treatment. Adult rehabilitation day treatment can occur in a variety of clinical settings for adults, similar to adult day cares or adult day clinics.

Limits on the amount, duration, or frequency of this service:

None.

A continuum of care provided to recovering clients living in the community based on their level of need. This service includes educating and assisting the clients with accessing supports and services needed. The service assists recovering clients to direct their resources and support systems.

Activities include training to assist the clients to improve learn, retain or improve specific job skills and to successfully adapt and adjust to a particular work environment. This service includes training and assistance to live in and maintain a household of their choosing in the community. In additional, transitional services to assist beneficiaries in stepping down after receiving a higher level of care. The goal of this service is to promote and maintain community integration.

This service includes an array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified clients that are aimed at long-term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person and family centered, recovery based, culturally competent, and provide needed accommodation for any disability and must have measurable outcomes. These activities assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the client as an active and productive member of his or her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety or anger; behavioral skills, such as proper use of medications, appropriate social interactions and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management, and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms and reframing; community integration skills and any similar skills required to implement the client’s behavioral health treatment plan.

Limits on the amount, duration, or frequency of this service:

Staff to client ratio: 1:15 Daily Maximum of Units: 6

Supported Employment is designed to help clients acquire and keep meaningful jobs in a competitive job market. The service actively facilitates job acquisition by sending staff to accompany individuals on interviews and providing ongoing support and/or on-the-job training once the individual is employed. This service replaces traditional vocational approaches that provide intermediate work experiences (prevocational work units, transitional employment, or sheltered workshops), which tend to isolate clients from mainstream society. Supported employment services are individualized and may include any combination of the following services: vocational/job-related discovery or assessment, person-centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job carving, training and systematic instruction, job coaching, benefits and work-incentives planning and management, asset development and career advancement services. Other workplace support services including services not specifically related to job skill training that enable the individual to be successful in integrating into the job setting. Services may be provided in integrated community work settings in the general workforce. Services may be provided in the home when provided to establish home-based self-employment. Services may be provided in either a small group setting or on an individual basis. Transportation is not included in the rate for this service. Supported employment must be competitive, meaning that wages must be at or above the State’s minimum wage or at or above the customary wage and level of benefits paid by the employer for the same or similar work. Service settings may vary depending on individual need and level of community integration and may include the individual’s home.

Limits on the amount, duration, or frequency of this service:

None.

A person-centered service where adult peers provide expertise not replicated by professional training. Peer support providers are trained peer specialists who work with individuals to provide education, hope, healing, advocacy, self-responsibility, a meaningful role in life, and empowerment to reach fullest potential. Peer support specialists may assist with navigation of multiple systems (housing, supported employment, supplemental benefits, building/rebuilding natural supports, etc.) which improve the individual’s functional ability. Services are provided on an individual or group basis and may be provided in the home or the community.

Limits on the amount, duration, or frequency of this service:

None.

A service that provides support and training for youth and adults on a one-on-one or group basis. This service should be a strength-based, culturally appropriate process that integrates the individual into their community as they develop their recovery plan or habilitation plan. This service is designed to assist individuals in acquiring the skills needed to support as independent a lifestyle as possible, enable them to reside in their community (in their own home, with family, or in an alternative living setting), and promote a strong sense of self-worth. In addition, it aims to assist individuals in setting and achieving goals, learning independent life skills, demonstrating accountability, and making goal oriented decisions related to independent living. Services are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system. Other topics may include: educational or vocational training, employment, resource and medication management, self-care, household maintenance, health, socialization, community integration, wellness, and nutrition. The PCSP should address the recovery or habilitation objective of each activity performed under Life Skills Development and Support. In a group setting, an individual to staff ratio of 10:1.

Limits on the amount, duration, or frequency of this service:

None.

Personal Care

Personal care services are provided by a personal care aide to assist with a client’s physical dependency needs. The personal care aide must have at least 24 hours classroom training and a minimum of supervised practical training of 16 hours provided by or under the supervision of a registered nurse for a total of no less than 40 hours.

Personal care services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or institution for mental disease that are –

Authorized for the individual in accordance with a service plan approved by the State;

Provided by an individual who is qualified to provide such services; and

Furnished in a home, and at the State’s option, in another location, including licensed residential care facilities and licensed assisted living facilities.

The State defines “a member of the individual’s family” as:

A spouse,

A minor’s parent, stepparent, foster parent or anyone acting as a minor’s parent,

A minor’s “guardian of the person” or anyone acting as a minor’s “guardian of the person” or

An adult’s “guardian of the person” or anyone acting as an adult’s “guardian of the person”.

Under no circumstances may Medicaid reimbursement be made for personal care services rendered by the client’s:

Legal guardian; or

Attorney-in-fact granted authority to direct the client’s care.

Personal care services are covered for categorically needy individuals only.

Personal care services are medically necessary, prescribed services to assist clients with their physical dependency needs.

Personal care services involve “hands-on” assistance, by a personal care aide, with a client’s physical dependency needs (as opposed to purely housekeeping services). Personal care services also include employment-related personal care associated with transportation.

The tasks the aide performs are similar to those that a nurse’s aide would normally perform if the client were in a hospital or nursing facility.

Prior authorization is required for personal care pursuant to the Independent Assessment for all beneficiaries. Personal care services for adults 21 years of age or older are limited to a maximum of 64 hours per calendar month.