Program Integrity Reforms
Personal Care and Home-Based Services
Briefing for Personal Care Stakeholders
Craig Cloud | Director, Division of Aging and Adult Services
Spring 2017
Arkansas Program Integrity Reforms for Personal Care and Home-Based Services
Personal Care and Home-Based Services
Primary Objectives for Program Integrity Reforms
1. Adopt best practices from other states and expert recommendations.
2. Meet new, emerging federal expectations.
3. Increase capabilities to coordinate care and improve care transitions as well as
monitor access, outcomes, payment integrity, and compliance.
4. Improve cost-effectiveness. Eliminate duplication and inappropriate or unnecessary
services.
5. Ensure services are provided as claimed and are provided according to prior
authorizations / approved plans.
6. Increase provider accountability for qualifications, performance, claims accuracy,
and compliance.
7. Establish environment for upcoming reforms, including comprehensive, independent
assessment of all LTSS needs and tiered levels of care for LTSS.
8. To the extent possible, apply program integrity policies equally across all types of
providers of personal care and home-based services.
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Personal Care and Home-Based Services
Four Core Program Integrity Reforms
For All Personal Care Services, Both State Plan Personal Care and Self-Directed
Personal Assistance in Independent Choices:
1. Prior authorization of services for all adults age 21+ including those over 65:
• Physician approval / signature requirement is removed.
• Replaced with new comprehensive, evidence-based independent assessment
process and State prior authorization.
For All Personal Care and Home-Based Service Providers – including personal
care, self-directed assistance, HCBS attendant care, home health nursing and
aide, therapies, in-home hospice, private duty nursing, and meals:
2. Electronic Visit Verification (EVV) system.
3. Unique individual identifiers for each person providing any service.
4. Expanded background checks, fingerprinting, and identity verification.
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Personal Care and Home-Based Services
What These Reforms Do Not Change....
The Program Integrity Reforms Described Today:
• Do not change provider payment rates.
• Do not change the types of benefits covered by Arkansas
Medicaid under the State Plan or the HCBS waivers.
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Personal Care and Home-Based Services
Overview of Core Program Integrity Reforms
1 Prior Authorization for All Types of Personal Care for Adults 21+
Require prior authorization (PA) of all personal care services, regular and self-directed, for
beneficiaries age 21 year or older (PA is already required for services to those under 21).
Is based on DHS medical necessity guidelines and in context with all other State Plan,
HCBS, and Medicare services being provided.
Personal care PA requests for adults adjudicated by DHS staff following assessment by
independent assessment contractor. Requirement for physician sign-off is eliminated.
Plan is to integrate medical necessity determination and prior authorization of all personal
care services with new independent assessment and care planning process for HCBS.
Other services, such as HCBS attendant care services, would not be authorized if
authorized personal care services are sufficient to meet the individual’s assessed needs.
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Personal Care and Home-Based Services
Overview of Core Program Integrity Reforms
2 Electronic Visit Verification (EVV)
Providers must use DHS-approved Electronic Visit Verification (EVV) system.
New federal law requires EVV for all personal care and home health services.
In Arkansas, EVV use will be required for all personal care aides, HCBS attendant care
aides, IndependentChoices personal assistants, home health nurses and aides,
therapists, private duty nurses, meal delivery, and hospice staff providing in-home
services.
DHS will use EVV data to verify services are delivered, adjudicate claims, identify
changes in needs, monitor utilization, and help inform assessments, prior authorizations,
care plan, site visits, audits, and care coordination.
DHS will select a qualified EVV vendor(s) and may allow providers to use other preapproved EVV vendor systems provided they meet State standards.
EVV use and visit data required as a condition of claims payment.
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Personal Care and Home-Based Services
Overview of Core Program Integrity Reforms
3 Unique Identifiers for All Individuals Providing In-Home Services
DHS will assign unique identification numbers to each individual providing any kind of
in-home service covered under the Medicaid State Plan or a HCBS waiver.
Includes individual identifiers for personal care aides, attendant care aides,
IndependentChoices personal assistants, home health nurses and aides, therapists, private
duty nurses, meal delivery, and hospice staff providing in-home services.
Require use of the individual identifier in provider certification, all claims, electronic visit
verification, and medical records / service records.
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Personal Care and Home-Based Services
Overview of Core Program Integrity Reforms
4 Expanded Background Checks
Comprehensive, independent criminal background checks of all individuals providing inhome services, including personal care, self-directed assistance, HCBS, home health,
therapies, hospice, and private duty nursing.
Includes identity verification and fingerprinting. Option for mandatory drug test (only with
cause). Background checks required initially and every three years.
Background checks also required include owners, managers, and supervisors of home
health, personal care, hospice, and private duty nursing providers; supervising RNs; and
case managers.
Part of expanded accountability initiative, which will include monitoring visits of providers
and service delivery sites for program integrity and compliance.
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Personal Care and Home-Based Services
Implementation of the Program Integrity Reforms
1. Upcoming Policy-Making Documents for Public Comment in April 2017:
• Simple State Plan Amendment (SPA) on prior authorization.
• DHS provider manual changes for all four reforms – prior authorization, EVV,
unique identifiers, and expanded background checks.
2. Following Public Comment Period:
• CMS review of the final SPA. This is a routine SPA.
• Legislative review of the DHS provider manual changes.
3. Implementation Activities Will Include:
• Notification of current personal care / self-directed assistance recipients, the
physician community, and other stakeholders.
• Consultations with provider stakeholders on implementation, including EVV
system requirements, training needs, and timelines.
• Extensive training of providers on the new policies and procedures. Necessary IT
systems changes.
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Personal Care and Home-Based Services
Questions?
Suggestions?
Thank You!
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