Chapter XV

Subchapter A

20 CAR pt. 570 Arkansas Medicaid State Plan {#sec-20-car-pt.-570 omnilex-key=us-ar-regs-official--title-20-part-570--20 CAR pt. 570}

STATE PLAN UNDER TITLE XIX

OF THE

SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

STATE

ARKANSAS

CFA-AT-80-38 (6PP) AZ 22, 1980

APPROVED BY DHHS/HCFA/OPO DATE: 7 /26/82

TRANSMITTAL NO:

82-13

Revision:

HCFA-PM-87

MARCH 1987

OMB No. 0938-0193

State/Territory:

ARKANSAS

SECTION

PAGE NUMBERS

State Plan Submittal Statement 1

SECTION 1 - SINGLE STATE AGENCY ORGANIZATION

1.1 Designation and Authority

1.2 Organization for Administration

1.3 Statewide Operation

1.4 State Medical Care Advisory Committee

AR STATE

DATE PEC'D JUL 1 1987 DATE APPVB JUL 3 0 1987 DATE EFF See HCFA-179 HCFA 179 87-12

TN NO. 87-12 Supersedes

JUL 3 G 1987

Effective Date See NCFA- 1

Approval Date

TN NO.

82-13

HCFA ID: 1002P/0010P

Revision: HCFA-PM-87-4 MARCH 1987

(BERC)

OMB No. 0938-0193

ARKANSAS

SECTION

PAGE NUMBERS

SECTION 2 - COVERAGE AND ELIGIBILITY

C.1 Application, Determination of Eligibility and Furnishing Medicaid

2.2 Coverage and Conditions of Eligibility

2.3 Residence

2.4 Blindness

2.5 Disability

2.6 Financial Eligibility

2.7 Medicaid Furnished Out of State

STATE JUL 1 1987

: 15 JUL 3 0 1987

See HCFA-179 87-12

TH NO. 87-12 Supersedes TN NO. 82-13

Approval Date JUL 3 0 1987

Effective Date

See HOF9-17'

HCFA ID:

1002P/0010P

Revision: HCFA-PM-87-4 MARCH 1987

(BERC)

OMB No. 0938-0193

SECTION ARKANSAS

PAGE NUMBERS

SECTION 3 - SERVICES: GENERAL PROVISIONS

3.1 Amount, Duration, and Scope of Services

3.2 Coordination of Medicaid with Medicare Purt B

3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases

3.4 Special Requirements Applicable to Sterilization Procedures

3.5 Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries

31a

3.6 Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period

31b

AR STATE

1 DATE RECO JUL 3 0 1987

DATE AFPV Q

See HCFA-179 DATE EL.+ 87-12 HCFA 174

TN No. 21-12 Supersedes

Date JUL 6 1837

Effective Date

See HOFA-1

TN No. 82-13

Approval

HCFA ID:

1002P/0010₽

Revision:

HCFA-PM-87-4

MARCH 1987

(BERC)

OMB No .. 0938-0193

SECTION ARKANSAS

PAGE NUMBERS

SECTION 4 - GENERAL PROGRAM ADMINISTRATION

4.1 Methods of Administration

4.2 Hearings for Applicants and Recipients

4.3 Safeguarding Information on Applicants and Recipients

4.4 Medicaid Quality Control

4.5 Medicaid Agency Fraud Detection and Investigation Program

4.6 Reports

4.7 Maintenance of Records

4.8 Availability of Agency Program Manuals

4.9 Reporting Provider Payments to the Internal Revenue Service

4.10 Free Choice of Providers

4.11 Relations with Standard-Setting and Survey Agencies

12 Consultation to Medical Facilities

4.13 Required Provider Agreement

. 14 Utilization Control

HC.FA-179 81-12 0 1987 1 198Z

4.15 Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases

JUL 3 JUL ....

4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees

Les

4.17 Liens and Recoveries

REC'D APPV'D 179 EFF

4.18 Cost Sharing and Similar Charges

DATE DATE ST E' DAJ HCF

4.19 Payment for Services

1772

TH NO ..!! Supersedes TH No .: 82-13

Approval Date JUL 3 G 1987

Effective Date See NEGA-+1

HCFA ID: 1002P/0010₽

Revision: HCFA-PM-90-2 JANUARY 1990

(BPD)

OMB No. 0938-0193

SECTION

ARKANSAS

PAGE NUMBERS

4.20 Direct Payments to Certain Recipients for Physicians' or Dentists' Services

4.21 Prohibition Against Reassignment of Provider Claims

4.22 Third Party Liability

4.23 Use of Contracts

24 Standards for Payments for Skilled Nursing and Intermediate Care Facility Services

4.25 Program for Licensing Administrators of Nursing Homes

4.26 RESERVED

4.27 Disclosure of Survey Information and Provider or Contractor Evaluation

4.28 Appeals Process for Skilled Nursing and Intermediate Care Facilities

4.29 Conflict of Interest Provisions

4.30 Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals

4.31 Disclosure of Information by Providers and Fiscal Agents

4.32 Income and Eligibility Verification System

4.33 Medicaid Eligibility Cards for Homeless Individuals

79a

4.34 Systematic Alien Verification for Entitlements

79b

4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation

79c

Arkansas STATE

DATE REC'D

3-26-90

DATE APPV'D

5-8-90

JAIE SFF

1-1-90

HCFA 179

94-15

IN NO

Supersedes TN No. 87-12

Approval Date

5/8/90

Effective Date

1/1/90

HCFA ID:

1002P/0010P

Revision: HCFA-PH-87-4 MARCH 1987

(BERC)

OMB No. 0938-0193

SECTION

ARKANSAS

PAGE NUMBERS

SECTION 5 - PERSONNEL ADMINISTRATION

5.1 Standards of Personnel Administration

5.2 RESERVED

5.3 Training Programs; Subprofessional and Volunteer Programs

82:

AR STATE

DATE REC'D JUL 1 1987

DATE APFVD JUL 3 0 1987 DAIE EFF Sec MCFA-129 HCFA 179 87-12

TH No. 27-12 Supersedes TN NO. 82-13

Approval Date JUL 3 0 1987

Effective

Date

See HOFA-11

HCFA

ID: 1002P/0010P

Revision:

HCFA-PH-87-4 MARCH 1987

(BERC)

OMB No. 0938-0193

SECTION

ARKANSAS

PAGE NUMBERS

SECTION 6 - FINANCIAL ADMINISTRATION

6.1 Fiscal Policies and Accountability

6.2 Cost Allocation

6.3 State Financial Participation 85

STATE AR

JUL 1 1987

DATE JUL 3 0 1987

Sec HCFA-179 +1CFA 179 87-12

vił

TN No.

87-12

Supersedes

TH No.

82-13

Approval Date

JUL 3 0 1987

Effective Date

See HOFA-1.

HCPA ID:

1002P/0010P

Revision: HCFA-PM-91-4 ( BPD) OMB No. 0930-

August 1991

ARKANSAS

SECTICH

SECTION 7 - GENERAL PROVISIONS

7.1 Plan Amendments

7.2 Nondiscrimination 87 7.3 Maintenance of AFDC Effort 88 7.4 State Governor's Review 89

viii

TN No.

9151

Superseden

Approval Date

13/11/91

Effective Date

10/1/91

TN No.

82-12

HCFA ID:

7982E

STATE DATE REC'D

11-21-91

DATE APPV'D

12-11-91

DATE EFF

10-1-91

HCFA 179

91-51

Arkansas

LIST OF ATTACHMENTS

No.

Title of Attachments

*1.1-A Attorney General's Certification

*1.1-B Waivers under the Intergovernmental Cooperation Act

1.2-A Organization and Function of State Agency

1.2-B Organization and Function of Medical Assistance Unit

1.2-C Professional Medical and Supporting Staff

1.2-D Description of Staff Making Eligibility Determination

*2.2-A Groups Covered and Agencies Responsible for Eligibility Determinations

* Supplement 1 - Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18

* Supplement 2 - Definitions of Blindness and Disability (Territories only)

* Supplement 3 - Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home

*2.6-A Eligibility Conditions and Requirements (States only)

* Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries

* Supplement 2 - Resource Levels - Categorically Needy, Including Groups with Incomes Up to a Percentage of the Federal Poverty Level, Medically Needy, and other Optional Groups

* Supplement 3 -

Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid

* Supplement 4 - Section 1902(f) Methodologies for Treatment of Income that Differ from those of the SSI Program

*Forms Provided

SUPERSEDES TN. 91-51

STATE Arkansas

CATE RECE 9-30-03

DATE APF / C 12-22-03

A ☒

DATE EFF 8-13-03

HOFA 173 03-11

TN #

03-11

Effective Date

9-13-03

Supersedes TN #

91.51

Approval Date

12-22-03

Revision: HCFA-PM-91-4 AUGUST 1991

( BPD)

OMB No. : 0938-

No . - ARKANSAS Title of Attachment

*3.1-A Amount, Duration, and Scope of Medical and Remedial Care-and: Services Provided to the Categorically Needy

* Supplement 1 - Case Management Services

Supplement 2 - Alternative Health Care Plans for Families Covered Under Section 1925 of the Act

*3.1-B Amount, Duration, and Scope of Services Provided Medically Needy Groups

3.1-C Standards and Methods of Assuring High Quality Care

3.1-D Methods of Providing Transportation

+3.1-Ë Standards for the Coverage of Organ Transplant Procedures

4.11-A Standarda for Institutions

4.14-A Single Utilization Review Methods for Intermediate Care Facilities

4.14-B Multiple Utilization Review Methods for Intermediate Care Facilities

4.16-A Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees

4.17-A Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home

*4.18-A Charges Imposed on Categorically Needy

*4.18-B Medically Needy - Premium

+4.18-C Charges Imposed on Medically Needy and other Optional Groups

*4.18-D Premiums Imposed on Low Income Pregnant Women and Infants

+4.18-E Premiums Imposed on Qualified Disabled and Working Individuals

4.19-A Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care

*Forma Provided

TN No. 91-51

Superseded

TN No.

40-15

Approval Date

12/11/91

Effective Date

10/1/91

HCFA ID:

7982E

Arkansas

STATE CATE REC'D

11-21-91

DATE APPT'D

12-11-91

7-1-91 DATE EFF 91-51 HCFA 17?

Revision:

HCFA-PM-94-3

(MB)

APRIL 1994

State/Territory:

ARKANSAS

Citation

1928 of the Act

1.5 Pediatric Immunization Program

1. The State has implemented a program for the distribution of pediatric vaccines to program- registered providers for the immunization of federally vaccine-eligible children in accordance with section 1928 as indicated below.

a. The State program will provide each vaccine-eligible child with medically appropriate vaccines according to the schedule developed by the Advisory Committee on Immunization Practices and without charge for the vaccines.

b. The State will outreach and encourage a variety of providers to participate in the program and to administer vaccines in multiple settings, e.g., private health care providers, providers that receive funds under Title V of the Indian Health Care Improvement Act, health programs or facilities operated by Indian tribes, and maintain a list of program-registered providers.

c. With respect to any population of vaccine- eligible children a substantial portion of whose parents have limited ability to speak the English language, the State will identify program-registered providers who are able to communicate with this vaccine-eligible population in the language and cultural context which is most appropriate.

STATE Arkansas

DATE REC'D 12-15-94

DATE APPV'D 12-29-94

10-01-94

DATE EFF

94-27

HCFA 177

d. The State will instruct program-registered providers to determine eligibility in accordance with section 1928 (b) and (h) of the Social Security Act.

e. The State will assure that no program- registered provider will charge more for the administration of the vaccine than the regional maximum established by the Secretary. The State will inform program- registered providers of the maximum fee for the administration of vaccines.

f. The State will assure that no vaccine- eligible child is denied vaccines because of an inability to pay an administration fee.

g. Except as authorized under section 1915(b) of the Social Security Act or as permitted by the Secretary to prevent fraud or abuse, the State will not impose any additional qualifications or conditions, in addition to those indicated above, in order for a provider to qualify as a program-registered provider.

TN No. 94.27

Supersedes

Approval Date

12/29/94

Effective Date

10/01/94

TN NO.

Revision:

HCFA-PM-94-3

(MB

) ARKANSAS

APRIL 1994 State/Territory:

Citation

1928 of the

Act

The State has not modified or repealed any Immunization Law in effect ag of May 1, 1993 to reduce the amount of health insurance coverage of pediatric vaccines.

The State Medicaid Agency has coordinated with the State Public Health Agency in the completion of this preprint page.

The State agency with overall responsibility for the implementation and enforcement of the provisions of section 1928 is:

State Medicaid Agency

x ☒ State Public Health Agency

Cinkansas STATE

12-15-94 DATE REC'D

12-29-94 DATE APPV'D

10-01-94 DATE Lff HCFA 179 94-27

TN No. 94-29

Effective Date

10/01/94

Approval Date 12/29/94

Supersedes

TN NO

SUPERSEDES: NONE - NEW PAGE

LE STATE OF ARKANSAS

STATE OF ARKANSAS THE ATTORNEY GENERAL LESLIE RUTLEDGE

CERTIFICATION OF THE STATE ATTORNEY GENERAL. OF THE STATE OF ARKANSAS ON LEGAL, AUTHORITY FOR THE OPERATION OF A MEDICAL, PROGRAM UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

This is to certify that:

(1) The Department of Human Services is the State agency authorized to administer the Title XIX (Medicaid) Program in Arkansas.

(2) The State Department of Human Services is authorized to establish and maintain a medical care program for the indigent sick, and the Director of the Department of Human Services is authorized to promulgate rules and regulations to implement the program so as to qualify for assistance under the Social Security Amendments, or other applicable Federal law, under the provisions of Act 821 of 1989, or A.C.A. Section 20-77-107 (Cum. Supp. 1991).

Leslie Rutledge Attorney General

January 26. 2015 DATE

32 . CENTER STREET SU'TE ZOO . LITTLE ROCK ARKANSAS 72201 TELEPHONE (501) 682-2007 . FAX (501: 082-7395 INTERNET WEBSITE . hag www.hansseng.

Revised: September 30, 2003

State/Territory:

[Arkansas]

Citation

42 CFR

2.1(b) (1)

Except as provided in items 2.1(b)(2) and (3) below, individuals are entitled to Medicaid services under the plan during the three months preceding the month of application, if they were, or on application would have been, eligible. The effective date of prospective and retroactive eligibility is specified in Attachment 2.6-A.

435.914 1902(a)(34) of the Act

1902(e)(8) and 1905(a) of the

(2)

For individuals who are eligible for Medicare cost-sharing expenses as qualified Medicare beneficiaries under section 1902(a)(10)(E)(i) of the Act, coverage is available for services furnished after The end of the month which the individual is first Determined to be a qualified Medicare beneficiary. Attachment 2.6-A specifies the requirements for Determination of eligibility for this group.

Act

1902(a)(47) and

X (3)

Pregnant women are entitled to ambulatory prenatal care under the plan during a presumptive eligibility period in accordance with section 1920 of the Act. Attachment 2.6-A specifies the requirements for Determination of eligibility for this group.

TN # Supersedes TN #

Effective Date Approval Date

Revision:

HCFA-PM-87-4

(BERC)

MARCH 1987

State:

ARKANSAS

Citation

2.3

Residence

435.10 and

Medicaid is furnished to eligible individuals who are residents of the State under 42 CFR 435.403, regardless of whether or not the individuals maintain the residence permanently or maintain it at a fixed address.

435.403, and 1902(b) of the

Act, P.L. 99-272 (Section 9529) and P.L. 99-509 (Section 9405)

Revision:

HCFA-PM-87-4

(BERC)

MARCH 1987

State:

ARKANSAS

Citation

2.4

Blindness

42 CFR 435.530(b)

All of the requirements of 42 CFR 435.530 and 42 CFR

42 CFR 435.531

435.531 are met. The more restrictive definition of

AT-78-90

blindness in terms of ophthalmic measurement used in this

AT-79-29

plan is specified in ATTACHMENT 2.6-A.

Revision: HCFA-PM-92-1 (MB)

FEBRUARY 1992

State:

ARKANSAS

Citation(s)

2.6

Financial Eligibility

42 CFR

(a) The financial eligibility conditions for Medicaid-only eligibility groups and for persons deemed to be cash

435.10 and

Subparts G & H

assistance recipients are described in ATTACHMENT 2.6-A.

1902(a)(10)(A)(i)

(III), (IV), (V),

(VI), and (VII),

1902(a)(10)(A)(ii)

(IX), 1902(a)(10) ☒

(A)(ii)(X), 1902 ☒

(a)(10)(C),

1902(f), 1902(l)

and (m),

1905(p) and (s), 1902(r)(2), and 1920

Revision: HCFA-PM-86-20 (BERC) SEPTEMBER 1986

OMB No .: 0938-0193

State/Territory:

ARKANSAS

Citation

2.7

Medicaid Furnished Out of State

431.52 and 1902(b) of the Act, P.L. 99-272 (Section 9529)

Medicaid is furnished under the conditions specified in 42 CFR 431.52 to an eligible individual who is a resident of the State while the individual is in another State, to the same extent that Medicaid is furnished to residents in the State.

Revision: HCFA-PM-91-4 (BPD) August 1991 January 1, 2014

State:

ARKANSAS

GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION

Agency* Citation(s) Groups Covered

See S14, SPA 2013-015

Revision: HCFA-PM-91-4 (BPD) August 1991 January 1, 2014

Attachment 2.2-A

State:

ARKANSAS

Agency*

Citation(s)

Groups Covered

Mandatory Coverage - Categorically Needy and Other Required

Special Groups (Continued)

N/A

. Deemed Recipients of AFDC

1902(a)(10)(A)(i)(I)

of the Act

b. See S14, SPA 2013-015

DCO

c. See S14, SPA 2013-015

420(a)(22)(A) of the Act

DCO

d. An assistance unit deemed to be receiving AFDC for

406(h) and Act

1902(a)(10)(A)(i)(I) of the

a period of four calendar months because the family becomes ineligible for AFDC as a result of collection or increased collection of support and meets the requirements of section 406(h) of the Act.

1902(a) of the Division of (DCFS)

Act

e. Individuals deemed to be receiving AFDC who meet

Children and Family Services

the requirements of section 473(b)(1) or (2) for whom an adoption assistance agreement is in effect or foster care maintenance payments are being made under title IV-E of the Act.

*Agency that determines eligibility for coverage.

Revision: HCFA-PM-91-4 (BPD) August 1991 January 1, 2014

Attachment 2.2-A

State:

ARKANSAS

Agency*

Citation(s)

Groups Covered

DCO 1902(a)(52)

and 1925 of the Act

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

See S14, SPA #2013-015
Families terminated from AFDC solely because of

earnings, hours of employment, or loss of earned income

disregards entitled up to twelve months of extended benefits in accordance with section 1925 of the Act. (This provision expires on September 30, 1998.)

*Agency that determines eligibility for coverage.

Revision: HCFA-PM-91-4 (BPD) August 1991 January 1, 2014

Attachment 2.2-A

State:

ARKANSAS

Agency* Citation(s)

Groups Covered

See S14, SPA #2013-015

Revised: March 1, 2005 January 1, 2014

State:

ARKANSAS

Agency* Citation(s)

Groups Covered

See S14, SPA #2013-015

*Agency that determines eligibility for coverage.

Revision: HCFA-PM-92-1R March 1992 January 1, 2014

State: ARKANSAS

COVERAGE AND CONDITIONS OF ELIGIBILITY

Agency* Citation(s) Groups Covered

See S14, SPA #2013-015

*Agency that determines eligibility for coverage.

Revision: HCFA-PM- February January 1, 2014

(MB)

State: ARKANSAS

COVERAGE AND CONDITIONS OF ELIGIBILITY

Agency* Citation(s) Groups Covered

See S14, SPA #2013-015

*Agency that determines eligibility for coverage.

Revision: HCFA-PM-92-1R (MB) March 1992 January 1, 2014

State:

ARKANSAS

COVERAGE AND CONDITIONS OF ELIGIBILITY

Agency*

Citation(s)

Groups Covered

DCO

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued) 10. See S14, SPA #2013-015

1902(e)(5) of the Act

a. A woman who, while pregnant, was eligible for, applied for, and receives Medicaid under the approved State plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day period (beginning on the last day of her pregnancy) and for any remaining days in the month in which the 60th day falls.

DCO

1902(e)(6) of the Act

b. A pregnant woman who would otherwise lose eligibility because of an increase in income (of the family in which she is a member) during the pregnancy or the postpartum period which extends through the end of the month in which the 60-day period (beginning on the last day of pregnancy) ends.

*Agency that determines eligibility for coverage.

Revision: HCFA-PM-92 -1R (MB) march 1992 March 1, 2005

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

COVERAGE AND CONDITIONS OF ELIGIBILITY

Agency* Citation(=)

Groups Covered

DCO

1902 (e) (+) of the Act

SOCIAL 42 CFR 435.120 SECURITY ADMINISTRATION (SSA)

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

12. A child born to a woman who is eligible for and receiving Medicaid as categorically needy on the date of the child's birth. The child is deemed eligible for one year from birth as long as the mother remains eligible or would remain eligible if still pregnant and the child remains in the mme household as the mother.

13. Aged, Blind and Disabled Individuals Receiving Cash Assistance

X ☒

a. Individuals receiving SSI.

This includes beneficiaries' eligible spouses and persons receiving SSI benefits pending a final determination of blindness or disability or pending disposal of excess resources under an agreement with the Social Security Administration; and beginning January 1, 1981 persons receiving SSI under section 1619(a) of the Act or considered to be receiving SSI under section 1619 (b) of the Act.

X X ☒ Aged ☒ Blind X ☒

Disabled

92-18

STATE Arkansas

DATE REC'D 3-2-05

DATE APMED 4-5-05

☒ A

DATE EFF 3-1-05

HOFA 179 05-02

* Agency that determines eligibility for coverage. ☒

TN NO. 05-02

Supersedes

Approval Date

4-5-05

Effective Date

3-1-05

TN No. 92-18

Revision:

HCFA-PM-91- 4 AUGUST 1991

( BPD)

ATTACHMENT 2.2-A

Page 6e

March 1, 2005 State:

ARKANSAS

OMB NO. : 0938-

Agency* Citation(s)

Groups Covered

Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

DCO 1634(c) of 15. the Act

LI LI Except in States that apply more restrictive eligibility requirements for Medicaid than under SSI, blind or disabled individuals who -- a. Are at least 18 years of age; b. Lose SSI eligibility because they become entitled to OASDI child's benefits under section 202(d) of the Act or an increase in these benefits based on their disability. Medicaid eligibility for these individuals continues for as long as they would be eligible for SSI, absent their OASDI eligibility. c. . The State applies more restrictive eligibility requirements than those under SSI, and part or all of the amount of the OASDI benefit that caused SSI/SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility. d. The State applies more restrictive requirements than those under SSI, and none of the OASDI benefit is deducted in determining the amount of countable income for categorically needy eligibility.

DCO 42 CFR 435.122

Except in States that apply more restrictive eligibility requirements for Medicaid than under SSI, individuals who are ineligible for SSI or optional State supplements (if the agency provides Medicaid under $435.230), because of requirements that do not apply under title XIX of the Act.

SSA 42 CFR 435.130

Individuals receiving mandatory State supplements.

*Agency that determines eligibility for coverage.

TN No. 05-02

Approval Date

4-5-03

Effective Date

5-1-05

Supersedes

TN No.

91-56

HCFA.ID:

7983E

91-56

Arkansas

DATE READ 3-2-05

DATEAPAVO 7-5-05

DATE EFF 3-1-05

HOFA 179 05-02

Revision:

HCFA-PM-91- 4 AUGUST 1991 March 1, 2005

( BPD)

ATTACHMENT 2.2-A

Page 6g

OMB NO. : 0938-

State:

ARKANSAS

Agency* Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

DCO 42 CFR 435.132

19. Institutionalized individuals who were eligible for Medicaid in December 1973 as inpatients of title XIX medical institutions or residents of title XIX intermediate care facilities, if, for each consecutive month after December 1973, they --

a. Continue to meet the December 1973 Medicaid State plan eligibility requirements; and

b. Remain institutionalized; and

c. Continue to need institutional care.

DCO 42 CFR 435.133

20. Blind and disabled individuals who --

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria; and

b. Were eligible for Medicaid in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet December 1973 eligibility criteria.

*Agency that determines eligibility for coverage.

TN NO. 05-02

Approval Date 04-05-05

Effective Date

3-1-05

Supersedes

TN No. 91-56

HCFA ID: 7983E

STATE Arkansas

DATE RECT 3-2-05

DATE APDV'C: 4-5-05

DATE EFF 3-1-05

HCFA 179 05-02

Revision: HCFA-PM-91-4 ( BPD) AUGUST 1991 March 1, 2005 State: ARKANSAS

ATTACHMENT

2.2-A

Page 7

OMB NO. :

0938-

Agency* Citation(s)

Groups Covered

DCO 42 CFR 435.134

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

21. Individuals who would be SSI/SSP eligible except for the increase in OASDI benefits under Pub. L. 92-336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972.

LI Includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this State's August 1972 plan) .

Includes persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this State's August 1972 plan) .

Not applicable with respect to intermediate care facilities; the State did or does not cover this service.

*Agency that determines eligibility for coverage,

TN No. 05-02

Approval Date

04-05-05

Effective Date

3-1-05

Supersedes

TN NO.

91-56

HCFA ID:

7983E

91-56

STATE Arkansas

DATE RECL. 3-2-05

DATE APVVT. 4-5-05

DATE EFF 3-1-05

HCFA 179 05-02

Revision: HCFA-PM-91-4 ( BPD) AUGUST 1991 March 1, 2005 State: ARKANSAS

ATTACHMENT 2.2-A Page 8 OMB NO. : 0938-

Agency* Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

DCO 42 CFR 435.135

22. Individuals who --

a . Are receiving OASDI and were receiving SSI/SSP but became ineligible for SSI/SSP after April 1977; and

b. Would still be eligible for SSI or SSP if cost-of-living increases in OASDI paid under section 215(1) of the Act received after the last month for which the individual was eligible for and received SSI/SSP and OASDI, concurrently, were deducted from income.

/XI Not applicable with respect to individuals receiving only SSP because the State either does not make such payments or does not provide Medicaid to SSP-only recipients.

LI Not applicable because the State applies more restrictive eligibility requirements than those under SSI.

The State applies more restrictive eligibility requirements than those under SSI and the amount of increase that caused SSI/SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility.

*Agency that determines eligibility for coverage.

No. 05-02

Approval Date

4-5-05

Effective Date

3-1-05

Supersedes

No. 91-56

HCFA ID: 7983E

91-56

STATE Arkansas

DATL: RECI 3-2-05

DATE / PUVO 4-5-05

DATE EFF

3-1-05

RCFA 179

05-02

HCFA-PM-91-4

AUGUST 1991 March 1, 2005 State: ARKANSAS

ATTACHMENT

2.2-A

Page 9 OMB NO. :

0938-

Agency*

Citation(s)

Groups Covered

DCO 1634 of the Act

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

23. Disabled widows and widowers who would be eligible for SSI or SSP except for the increase in their OASDI benefits as a result of the elimination of the reduction factor required by section 134 of Pub. L. 98-21 and who are deemed, for purposes of title XIX, to be SSI beneficiaries or SSP beneficiaries for individuals who would be eligible for SSP only, under section 1634(b) of the Act.

/XI Not applicable with respect to individuals receiving only SSP because the State either does not make these payments or does not provide Medicaid to SSP-only recipients.

LI The State applies more restrictive eligibility standards than those under SSI and considers these individuals to have income equalling the SSI Federal benefit rate, or the SSP benefit rate for individuals who would be eligible for SSP only, when determining countable income for Medicaid categorically needy eligibility.

*Agency that determines eligibility for coverage.

TN No. 05-02

Approval Date

7-5-05

Effective Date

3-1-05

Supersedes TN NO. 91-56

HCFA ID: 7983E

STAT Arkansas

DATE DIEON 3-2-05

DATEIR-ET. 4-5-05

DATE EFF 3-1-05

HOFA 179 05-02

Revision: HCFA-PM-91-10 DECEMBER 1991 March 1, 2005

(MB)

State/Territory: ARKANSAS

Agency* Citation (s)

Groups Covered

1634(d) of the Act DCO

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

24. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least ten years before the divorce became effective, who have attained the age of 50, who are receiving title II payments, and who because of the receipt of title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to receive title II payments, who would be eligible for SSI or SSP if the amount of the title II benefit were not counted as income, and who are not entitled to Medicare Part A.

The State applies more restrictive eligibility requirements for its blind or disabled than those of the SSI program.

In determining eligibility as categorically needy, the State digregards the amount of the title II benefits identified in § 1634 (d) (1) (A) in determining the income of the individual, but does not disregard any more of this income than would reduce the individual's income to the SSI income standard.

In determining eligibility as categorically needy, the State disregards only part of the amount of the benefits identified in $1634(d) (1) (A) in determining the income of the individual which amount would not reduce the individual's income below the SSI income standard. The amount of these benefits to disregarded is specified in Supplement 4 to Attachment 2.6-A.

In determining eligibility as categorically needy, the State chooses not to deduct any of the benefit identified in § 1634(d) (1) (A) in determining the income of the individual

STATE Arkansas

DATE RECO 3-2-05

DATE AFPV'D 1-5-05

DATE EFF 3-1-05

HCFA 179 05-02

91-63

*Agency that determines eligibility for coverage.

TN No.

05-02

Supersedes

TN No.

91-63

Approval Date

4.5-05

Effective Date

3-1-05

Attachment 2.2-A Page 9b

Revision:

HCFA-PM-93-2

(MB)

March 1, 2005

January 1, 2010

State:

ARKANSAS

Agency*

Citation(s)

Groups Covered

DCO

A. Mandatory Coverage - Categorically Needy and Other Required

Special Groups (Continued)

1902(a)(10)(E)(i), 1905(p) and 1860D-14(a)(3)(D) of the Act

Qualified Medicare Beneficiaries --

a. Who are entitled to hospital insurance benefits under Medicare Part A, (but not pursuant to an enrollment under section 1818A of the Act);

b. Whose income does not exceed 100 percent of the Federal poverty level; and

c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the Consumer Price Index (CPI).

(Medical assistance for this group is limited to Medicare cost- sharing as defined in item 3.2 of this plan.)

DCO

1902(a)(10)(E)(ii), 1905(p)(3)(A)(i), and 1905(s) of the Act

Qualified disabled and working individuals --

a. Who are entitled to hospital insurance benefits under Medicare Part A under section 1818A of the Act;

b. Whose income does not exceed 200 percent of the Federal poverty level; and

c. Whose resources do not exceed twice the maximum standard under SSI.

d. Who are not otherwise eligible for medical assistance under Title XIX of the Act.

(Medical assistance for this group is limited to Medicare Part A premiums under section 1818A of the Act.)

*Agency that determines eligibility for coverage.

TN No. Supersedes TN No.

Effective Date:

Approval Date:

Revision: HCFA-PM-93-2 (MB) March 1993 January 1, 2010

State: ARKANSAS

Agency* Citation(s)

Groups Covered

DCO 1902(a)(10)(E)(iii), 1905(p)(3)(A)(ii), and 1860D-14(a)(3)(D) of the Act

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

27. Specified Low-Income Medicare Beneficiaries --

a. Who are entitled to hospital insurance benefits under Medicare Part A, (but not pursuant to an enrollment under section 1818A of the Act);

b. Whose income is greater than 100 percent but less than 120 percent of the Federal poverty level; and

c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the Consumer Price Index (CPI).

(Medical assistance for this group is limited to Medicare Part B premiums under Section 1839 of the Act.)

DCO 1902(a)(10)(E)(iv), 1905(p)(3)(A)(ii), and 1860D-14(a)(3)(D) of the Act

28. Qualified Individuals --

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);

c. Whose income is at least 120 percent but less than 135 percent of the Federal poverty level;

d. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the Consumer Price Index (CPI).

(Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.)

TN No.

Effective Date:

Supersedes TN No.

Approval Date:

Revision: HCFA-PM-95-2 (MB) April 1995 January 1, 2010

State: ARKANSAS

Agency*

Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy and Other Required

Special Groups (Continued)

1634(e) of the Act

a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason of clause (i) or (v) of Section 1611 (e)(3)(A) shall be treated, for purposes of title XIX, as receiving SSI benefits for the month.

b. The State applies more restrictive eligibility standards than those under SSI.

Individuals whose eligibility for SSI benefits are based solely on disability who are not payable for any months solely by reason of clause (i) or (v) of Section 1611 (e)(3)(A), and who continue to meet the more restrictive requirements for Medicaid eligibility under the State plan, are eligible for Medicaid as categorically needy.

*Agency that determines eligibility for coverage.

TN No. Supersedes TN No.

Effective Date:

Approval Date:

Revision: HCFA-PM-91-4 (BPD) August 1991 January 1, 2014

Attachment 2.2-A Page 9c OMB NO .: 0938-

State:

ARKANSAS

Agency*

Citation(s) Groups Covered

N/A 42 CFR 435.210 1902(a)(10)(A)(ii) and 1905(a) of the Act

B. Optional Groups Other Than the Medically Needy

☐ 1. Individuals described below who meet the income and resource requirements of AFDC, SSI, or an optional State supplement as specified in 42 CFR 435.230, but who do not receive cash assistance. ☐ The plan covers all individuals as described above. ☐ The plan covers only the following group or groups of individuals:

Aged Blind Disabled See S14, SPA #2013-015

DCO 42 CFR 435.211

☐ 2. Individuals who would be eligible for AFDC, SSI or an optional State supplement as specified in 42 CFR 435.230, if they were not in a medical institution.

*Agency that determines eligibility for coverage.

Revised: September 30, 2003

State:

[Arkansas]

Agency*

Citation(s)

Groups Covered

Optional (Continued)

Groups Other Than the Medically Needy

42 CFR 435.212

[ ]

The State deems as eligible those individuals who became otherwise ineligible for Medicaid while enrolled in an HMO qualified under Title XIII of the Public Health Service Act, or a managed care organization (MCO), or a primary care case management (PCCM) program, but who have been enrolled in the entity for less than the minimum enrollment period listed below. Coverage under this section is limited to MCO or PCCM services and family planning services described in section 1905(a)(4)(C) of the Act.

1902(e)(2) of

the

Act, P.L.

99-272

(section 9517) 101-508(section

P.L.

X ☒

The State elects not to guarantee eligibility.

The State elects to guarantee eligibility. The minimum enrollment period is _ months (not to exceed six).

The State measures the minimum enrollment period from:

[] The date beginning the period of enrollment in the MCO or PCCM, without any intervening disenrollment, regardless of Medicaid eligibility. [] The date beginning the period of enrollment in the MCO or PCCM as a Medicaid patient (including periods when payment is made under this section), without any intervening disenrollment.

[ ] The date beginning the last period of enrollment in the MCO or PCCM as a Medicaid patient (not including periods when payment is made under this section) without any intervening disenrollment or periods of enrollment as a privately paying patient. (A new minimum enrollment period begins each time the individual becomes Medicaid eligible other than under this section).

*Agency that determines eligibility for coverage.

TN #

03-11

Effective Date

8-13-03

Supersedes TN #

91-63

Approval Date

12-22-03

: Arkansas

CATE NBC O 9-20-03 /A

12-22-03 8-13-03 03 -11

SUPERSEDES. TN- 91-63

Revised: September 30, 2003

State: [Arkansas]

Agency*

Citation(s)

Groups Covered

Optional Groups Other Than Medically Needy (continued)

1932(a)(4) of Act

The Medicaid Agency may elect to restrict the disenrollment of Medicaid enrollees of MCOs, PIHPs, PAHPs, and PCCMs in accordance with the regulations at 42 CFR 438.56. This requirement applies unless a recipient can demonstrate good cause for disenrolling or if he/she moves out of the entity's service area or becomes ineligible.

Disenrollment rights are restricted for a period of months (not to exceed 12 months).

During the first three months of each enrollment period the recipient may disenroll without cause. The State will provide notification, at least once per year, to recipients enrolled with such organization of their right to and restrictions of terminating such enrollment.

X ☒ No restrictions upon disenrollment rights.

1903(m)(2)(H),

In the case of individuals who have become

1902(a)(52) of

ineligible for Medicaid for the brief period described in

the Act

section 1903(m)(2)(H) and who were enrolled with an

P.L. 101-508

MCO, PIHP, PAHP, or PCCM when they became ineligible, the

42 CFR 438.56(g)

Medicaid agency may elect to reenroll those individuals in the same entity if that entity still has a contract.

The agency elects to reenroll the above individuals who are eligible in a month but in the succeeding two months become eligible, into the same entity in which they were enrolled at the time eligibility was lost.

X ☒ The agency elects not to reenroll above individuals into the same entity in which they were previously enrolled.

Agency that determines eligibility for coverage. Arkansas

9-30-03

12-22-03

8-13-03

SUPERSEDE:

91-63 03-11

A ☒

TN # 03-11

Supersedes TN # 91.63

Effective Date

8-13-03

Approval Date

12-22-03

Revision:

HCFA-PM-91-10

(MB)

December 1991

January 1, 2016

Attachment 2.2-A

State/Territory:

ARKANSAS

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)

42 CFR 435.217 Division of County Operations (DCO) and Division of Developmental Disabilities (DDS) 42 CFR 435.217 Division of County Operations (DCO) and Division of Developmental Disabilities (DDS)

☒ 4. A group or groups of individuals who would be eligible for Medicaid under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community-based services under a waiver granted under 42 CFR Part 441, Subpart G would require institutionalization, and who will receive home and community-based services under the waiver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of the State's section 1915(c) waiver under which this group(s) is covered. In the event an existing 1915(c) waiver is amended to cover this group(s), this option is effective on the effective date of the amendment. ☒ 5. PACE participants

*Agency that determines eligibility for coverage.

Revised:

October 24, 2011

January 1, 2014

State: ARKANSAS

Agency* Citation(s)

Groups Covered

See S14, SPA #2013-015

*Agency that determines eligibility for coverage.

TN No. Supersedes TN No.

Effective Date:

Approval Date:

Revision:

HCFA-PM-91-4

August 1991

Revised:

February 10, 1993

January 1, 2014

(BPD)

Attachment 2.2-A Page 13 OMB NO .: 0938-

State: ARKANSAS

Agency* Citation(s)

Groups Covered

See S14, SPA #2013-015

Revision:

HCFA-PM-91-4

August 1991

Revised:

February 10, 1993

January 1, 2014

(BPD)

Attachment 2.2-A Page 13a OMB NO .: 0938-

State: ARKANSAS

Agency* Citation(s)

Groups Covered

See S14, SPA #2013-015

Revision:

HCFA-PM-91-4 (BPD) August 1991

Revised:

February 10, 1993 January 1, 2014

Attachment 2.2-A Page 14 OMB NO .: 0938-

State:

ARKANSAS

Agency* Citation(s)

Groups Covered

See S14, SPA #2013-015

Revision: HCFA-PM-91-4 (BPD) August 1991 January 1, 2014

Attachment 2.2-A

Page 14a OMB NO .: 0938-

State:

ARKANSAS

Agency* Citation(s) Groups Covered

See S14, SPA #2013-015

Revision: HCFA-PM-91-4R AUGUST 1991

State:

ARKANSAS

ATTACHMENT

2.2-A

Page 17

OMB NO. :

0938-

Agency* Citation(s)

Groups Covered

N/A 42 CFR 435. 230 435.121 1902 (a ) ( 10)

(A) ( ii ) (XI )

of the Act

B. Optional Groups Other Than the Medically Needy ( Continued)

11. Section 1902(f) States and SSI criteria States without agreements under section 1616 or 1634 of the Act.

The following groups of individuals who receive a State supplementary payment under an approved optional State supplementary payment program that meets the following conditions. The supplement is --

a. Based on need and paid in cash on a regular basis.

b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for the supplement.

C. Available to all individuals in each classification and available on a Statewide basis.

d. Paid to one or more of the classifications of individuals listed below:

(1) All aged individuals.

(2) All blind individuals.

(3) All disabled individuals.

TN NO. 92-04

Superseded

TN No. 91.56

Approval Date

FEB 2 0 1992

Effective Date MAR 01 1992

HCFA ID:

7983E

STATE

Enkansas

DATE REC'D

FEB 11 1992

DATE APPV'D FEB 2 0 1992

DATE EFF MAR 01 1992

HCFA 179 92-04

Revision:

HCFA-PM-91-4 AUGUST 1991

( BPD)

ATTACHMENT 2.2-A Page 19

March 1, 2005

ARKANSAS

OMB No. : 0938-

State:

Agency* Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)

DCO 42 CFR 435.231 1902 (a) ( 10) (A) ( 11 ) ( V) of the Act

/XI

☒

12. Individuals who are in institutions for at least 30 consecutive days and who are eligible under a special income level. Eligibility begins on the first day of the 30-day period. These individuals meet the income standards specified in Supplement 1 to ATTACHMENT 2.6-A.

LI The State covers all individuals as described above.

☒ The State covers only the following group or groups of individuals:

1902 (a) ( 10) (A) ( ii) and 1905 (a) of the Act X

X ☒ X ☒ ☒ Aged Blind Disabled Individuals under the age of --

21 20 19 18 Caretaker relatives Pregnant women

TN NO. 05-02

Supersedes

TN NO. 91-56

Approval Date

4-5-05

Effective Date

3-1-05

HCFA ID:

7983E

STATE Arkansas

DATE NEC 3-2-05

DATE AAS 0 4-5-05

☒ A

DATE ETF 3-1-05

HCFA 179 0.5-02

Revision:

HCFA-PM-91-4R (BPD) August 1991

Revised:

January 1, 2014

State: ARKANSAS

Agency*

Citation(s)

Groups Covered

Optional Groups Other Than the Medically Needy (Continued)

N/A 1902(e)(3) of the Act

□ ☐

Certain disabled children age 18 or under who are living at home, who would be eligible for Medicaid under the plan if they were in an institution, and for whom the State has made a determination as required under section 1902(e)(3)(B) of the Act.

Supplement 3 to ATTACHMENT 2.2-A describes the method that is used to determine the cost effectiveness of caring for this group of disabled children at home.

14. See S14, SPA #2013-015

TN No. Supersedes

Effective Date:

Approval Date:

TN No.

Revision:

HCFA Region VI February 1994

Revised:

December 1, 2002 January 1, 2014

State:

ARKANSAS

Agency*

Citation

Groups Covered

See S14, SPA #2013-015

*Agency that determines eligibility for coverage.

Attachment 2.2-A Page 23b January 1, 2014

State:

ARKANSAS

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)

1902(e)(12) of the Act

20. A child under age (not to exceed age 19) who has been determined eligible is deemed to be eligible for a total of months (not to exceed 12 months) regardless of changes in circumstances other than attainment of the maximum age stated above.

21. See S14, SPA #2013-015

Revision:

ATTACHMENT 2.2-A PAGE 23d OMB NO .:

State/Territory:

Arkansas

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy

(Continued)

1902(a)(10)(A) [ ] 23. (ii)(XIII) of the Act

BBA Work Incentives Eligibility Group - Individuals with a disability whose net family income is below 250 percent of the Federal poverty level for a family of the size involved and who, except for earned income, meet all criteria for receiving benefits under the SSI program. See page 12c of Attachment 2.6-A

1902(a)(10)(A) [X] (ii)(XV) of the Act

TWWIIA Basic Insurance Group - Individuals with a disability at least 16 but less than 65 years of age whose income and resources do not exceed a standard established by the State. See page 12d of Attachment 2.6-A.

1902(a)(10)(A) [ ] (ii)(XVI) of the Act

TWWIIA Medical Improvement Group Employed individuals at least 16 but less than 65 years of age with a medically improved disability whose income and resources do not exceed a standard established by the State. See page 12h of Attachment 2.6-A.

NOTE: If the State elects to cover this group, it MUST also cover the Basic Insurance Group described in no. 21 above.

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPVID

01-25-01

DA.REF

02-01-01

HulA 1

00-14

TN No. C'0-11/ Supersedes

Approval Date 01-25-01 Effective Date 02-01-01

TN No.

UPERSEDES: NONE - NEW PAGE

Attachment 2.2-A Page 23e OMB NO .:

State:

ARKANSAS

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)

1902(a)(10)(10)(ii)(XVIII) of the Act

☐ 26. Women who:

a. have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under title XV of the Public Health Service Act in accordance with requirements of section 1504 of that Act and need treatment for breast or cervical cancer, including a pre-cancerous condition of the breast or cervix;

b. are not otherwise covered under creditable coverage, as defined in section 2701(c) of the Public Health Service Act;

c. are not eligible for Medicaid under any mandatory categorically needy eligibility group; and

d. have not attained age 65.

1920B of the Act ☐ 27. Women who are determined by a 'qualified entity' (as defined in 1920B(b) based on preliminary information, to be a woman described in 1902(aa) the Act related to certain breast and cervical cancer patients.

The presumptive period begins on the day that the determination is made. The period ends on the date that the State makes a determination with respect to the woman's eligibility for Medicaid, or if the woman does not apply for Medicaid (or a Medicaid application was not made on her behalf) by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the last day.

Revision: HCFA-PM-91-4 ( BPD) AUGUST 1991 March 1, 2005 State: ARKANSAS

ATTACHMENT

2.2-A

Page 24

OMB NO. :

0938-

Agency* Citation(s)

Groups Covered

C. Optional Coverage of the Medically Needy

42 CFR435.301

This plan includes the medically needy.

LI No. ☒ Yes. This plan covers :

DCO

1. Pregnant women who, except for income and/or resources, would be eligible as. categorically needy under title XIX of the Act.

DCO 1902(e) of the Act

DCO 1902 (a) (10) (C) (ii) ( I) of the Act

2. Women who, while pregnant, were eligible for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy-related and postpartum services under the plan for a 60-day period, beginning with the date the pregnancy ends, and any remaining days in the month in which the 60th day falls. 3. Individuals under age 18 who, but for income and/or resources, would be eligible under section 1902 (a) (10) (A) (1) of the Act.

TN No. 05-12 Supersedes

Approval Date

4-5-05

TN No. 91-56

Effective Date 3-1-05

HCFA ID:

7983E

STATE Arkansas

DATE DECT 3-2-05

CATEAM:VE 4.5.05.

DATE SPF 3-1-05

HCFA 179 05-02

91-56

Revision:

HCFA-PM-91-4

(BPD)

August 1991

January 1, 2014

Attachment 2.2-A Page 25 OMB NO .: 0938-

State: ARKANSAS

Agency*

Citation(s)

Groups Covered

C. Optional Coverage of the Medically Needy (Continued)

See S14, SPA #2013-015

N/A

42 CFR 435.308

☐ a. Financially eligible individuals who are not described in section C.3. above and who are under the age of -- 21 20 19 18 or under age 19 who are full-time students in a secondary school or in the equivalent level of vocational or technical training ☒ b. Reasonable classifications of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below: X ☒ (1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

DCFS X ☒ (a) In foster homes (and are under the age of_21 ). DCO X ☒ (b) In private institutions (and are under the age of 21 ).

Revision:

HCFA-PM-91-4 AUGUST 1991 March 1, 2005 State:

( BPD)

ARKANSAS ATTACHMENT 2.2-A Page 25a OMB NO. : 0938-

Agency*

Citation(s)

Groups Covered

C. Optional Coverage of Medically Needy (Continued)

(c)

In addition to the group under b. (1) (a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of ) .

(2)

Individuals in adoptions subsidized in full or part by a public agency (who are under the age of

(3)

Individuals in NFs (who are under the age of ). NF services are provided under this plan.

(4)

In addition to the group under (b) (3) , individuals in ICFs/MR (who are under the age of

DCO

X ☒

(5)

Individuals receiving active treatment as inpatients in psychiatric facilities or programs (who are under the age of 21 ). Inpatient psychiatric services for individuals under age 21 are provided under this plan.

(6)

Other defined groups (and ages), as specified in Supplement 1 of ATTACHMENT 2.2-A.

TN No. 05-02 Supersedes

Approval Date

7-5-05

Effective Date

3-1-05

TN No.

93-07

HCFA ID:

7983E

STATE Arkansas

DATE NERE 3-2-05

DATE APPUD 7-5-05

DATE EFF 7-1-05

HCFA 179 05-02

93-07

Revision:

HCFA-PM-91-4

( BPD)

AUGUST 1991

March 1, 2005

State:

ARKANSAS

ATTACHMENT 2.2-A Page 26 OMB NO. : 0938-

Agency* Citation (s)

Groups Covered

C. Optional Coverage of Medically Needy (Continued)

DCO

42 CFR 435.310 ☒ /XI

6. Caretaker relatives.

DCO

42 CFR 435.320 and 435.330

1X1 ☒

7. Aged individuals.

DCO 42 CFR 435.322 and 435.330

1X1 ☒ 8. Blind individuals.

DCO

42 CFR 435.324 and 435.330

/XI ☒

9. Disabled individuals.

N/A

42 CFR 435.326 11 10. Individuals who would be ineligible if they were not enrolled in an HMO. Categorically needy individuals are covered under 42 CFR 435.212 and the same rules apply to medically needy individuals.

DCO 435.340

11. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible as medically needy in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet the December 1973 eligibility criteria.

No.

05-02

Supersedes

No.

91-56

Approval Date 1-5-05

Effective Date

3-1-05

HCFA ID:

7983E

STATE Arkansas

DATE REC 3-2-05

DATE ARG . C. 4-5-05

A ☒

DATE EFF 3-1-05

HCFA 179 05-02

91-56

Revision:

HCFA Region VI

December

1990

Revised:

March 1, 2005

State:

ARKANSAS

Agency* Citation

Groups Covered

Division of County Operations (DCO)

X ☒ 13. Unemployed Parents

*Agency that determines eligibility for coverage

STATE Arkansas

DATE REC' 3-2-05

DATE AFOOT 4-5-05

DATE EFF 3-1-05

HCFA 179 05-02

TN No.

05-02

Supersedes

TN No.

91-23

Effective Date:

3-1-05

Approval Date:

4-5-05

91-23

STATE Arkansas

DATE REC'D 8-26-05

DATE APPVOLU-17-05

DATE EFF 11-1-05

HCFA 179 05-05

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: ARKANSAS REQUIREMENTS RELATING TO DETERMINING ELIGIBILITY FOR MEDICARE PRESCRIPTION DRUG LOW-INCOME SUBSIDIES

Agency

Citation (s)

Groups Covered

DCO

1935(a) and 1902(a)(66) 42 CFR 423.774 and 423.904

The agency provides for making Medicare prescription drug Low Income Subsidy determinations under Section 1935(a) of the Social Security Act for those individuals who specifically request a state determination. 1. The agency makes determinations of eligibility for premium and cost-sharing subsidies under and in accordance with section 1860D-14 of the Social Security Act; 2. The agency provides for informing the Secretary of such determinations in cases in which such eligibility is established or redetermined; 3. The agency provides for screening of individuals for Medicare cost-sharing described in Section 1905(p)(3) of the Act and offering enrollment to eligible individuals under the State plan or under a waiver of the State plan.

TN No. 05-05

Approval Date

11/17/05

Effective Date

July 1, 2005

Nov 1, 2005

Supersedes TN No.

· New Page

Groups Covered

Optional Groups other than the Medically Needy

In addition to providing State plan HCBS to individuals described in 1915(i)(1), the state may also cover the optional categorically needy eligibility group of individuals described in 1902(a)(10)(A)(ii)(XXII) who are eligible for HCBS under the needs-based criteria established under 1915(i)(1)(A) and have income that does not exceed 150% of the FPL, or who are eligible for HCBS under a waiver approved for the state under Section 1915(c), (d) or (e) or Section 1115 (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. See 42 CFR § 435.219. (Select one):

☒ No. Does not apply. State does not cover optional categorically needy groups. ☐ Yes. State covers the following optional categorically needy groups. (Select all that apply):

(a) [ Individuals not otherwise eligible for Medicaid who meet the needs-based criteria of the ☐ 1915(i) benefit, have income that does not exceed 150% of the federal poverty level, and will receive 1915(i) services. There is no resource test for this group. Methodology used: (Select one): ☐ SSI. The state uses the following less restrictive 1902(r)(2) income disregards for this group. (Describe, if any):

☐ OTHER (describe):

(b) [ Individuals who are eligible for home and community-based services under a waiver ☐ approved for the State under section 1915(c), (d) or (e) (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. Income limit: (Select one): ☐ 300% of the SSI/FBR

☐ Less than 300% of the SSI/FBR (Specify):

Specify the applicable 1915(c), (d), or (e) waiver or waivers for which these individuals would be eligible: (Specify waiver name(s) and number(s)):

(c) [ Individuals eligible for 1915(c), (d) or (e) -like services under an approved 1115 waiver. ☐ The income and resource standards and methodologies are the same as the applicable approved 1115 waiver. Specify the 1115 waiver demonstration or demonstrations for which these individuals would be eligible. (Specify demonstration name(s) and number(s)):

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 114 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, and Baltimore, Maryland 21244-1850.

State: ARKANSAS TN: 18-0016 Effective: 03/01/2019

Approved: 01/09/2019

Supersedes: NONE -- New Page

Groups Covered

Optional Groups other than the Medically Needy

☒ No. Does not apply. State does not cover optional categorically needy groups. ☐ Yes. State covers the following optional categorically needy groups. (Select all that apply): ☐ 1915(i) benefit, have income that does not exceed 150% of the federal poverty level, and will receive 1915(i) services. There is no resource test for this group. Methodology used: (Select one): ☐ SSI. The state uses the following less restrictive 1902(r)(2) income disregards for this group. (Describe, if any):

(a) [ Individuals not otherwise eligible for Medicaid who meet the needs-based criteria of the

☐ OTHER (describe):

(b) [ Individuals who are eligible for home and community-based services under a waiver % ☐ approved for the State under section 1915(c), (d) or (e) (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. Income limit: (Select one): ☐ 300% of the SSI/FBR ☐ Less than 300% of the SSI/FBR (Specify):

State: ARKANSAS TN: 18-0016 Effective: 03/01/2019

§1915(i) State plan HCBS State plan Attachment 2.2-A:

Approved: 01/09/2019

Supersedes: NONE -- New Page

Specify the applicable 1915(c), (d), or (e) waiver or waivers for which these individuals would be eligible: (Specify waiver name(s) and number(s)):

PRA Disclosure Statement

Revision:

HCFA-PM-91-4

(BPD)

August 1991

January 1, 2014

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: ARKANSAS REASONABLE CLASSIFICATIONS OF INDIVIDUALS UNDER THE AGE OF 21, 20, 19 AND 18

See S25, SPA #2013-015

Revision: HCFA-PM-91-4 ( BPD)

SUPPLEMENT 3 TO ATTACHMENT 2.2-A

Revised: AUGUST 1991

Page 1

January 1, 2003

OMB NO. :

0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

ARKANSAS

Method for Determining Cost Effectiveness of Caring for Certain Disabled Children At Home

Not Applicable.

STATE Arkansas

DAT. EC'D 10-24-02

DA. APPV'D 12-16-02

DATE EFF 1-1-03

CFA 179 02-21

SUPERSEDES: TN-

91-56

TN No.

07-21

Supersedes

Approval Date

12-16-02

Effective Date

1-1-03

TN No.

41-56

HCFA ID:

7983E

Revision:

HCFA-PM-92-1

(MB)

February 1992

January 1, 2014

State:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirements

42 CFR Part 435, Subpart G

A. General Conditions of Eligibility

Each individual covered under the plan:

Is financially eligible (using the methods and standards described in Parts B and C of this Attachment) to receive services.

42 CFR Part 435, Subpart F 1902(m) of the Act

Meets the applicable non-financial eligibility conditions.

a. For the categorically needy: (i) See S28, SPA #2013-015.

(ii) For SSI-related individuals, meets the non-financial criteria of the SSI program or more restrictive SSI- related categorically needy criteria.

iii) See S28, SPA #2013-015.

(iv) For financially eligible aged and disabled individuals covered under section 1902(a)(10)(A) (ii)(X) of the Act, meets the non-financial criteria of ☒ section 1902(m) of the Act.

Revision: HCFABPM-91-4 January 1, 2014

(BPD)

Attachment 2.6-A Page 2 OMB No .: 0938-

State:

ARKANSAS

Citation

Condition or Requirement 1

b. For the medically needy, meets the non-financial eligibility conditions of 42 CFR Part 435.

1905 (p) of the Act

c. For financially eligible qualified Medicare beneficiaries covered under section 1902(a)(10)(E)(i) of the Act. meets the non-financial criteria of section 1905(p) of the Act.

1905(s) of the Act

d. For financially eligible qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, meets the non-financial criteria of section 1905(s).

TN No: AR 13-0018 Supersedes TN No.AR 91-56 Approval Date 11-3-2015 Effective Date 1/1/14

State: Arkansas

Date Received: 23 September, 2013 Date Approved: 3 November, 2015

Effective Date: 1 January, 2014

Transmittal Number: 13-0018 MM6

March 1, 1986

STATE:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation

Condition or Requirement

4. State has entered into an Interstate Compact on Adoption and Medical Assistance to provide for reciprocal provision of medical assistance for Title IV-E children, pursuant to Public Law 96-272.

ȘTIMTE AR

ZATE REC'D

3-31-86

DATE APPV'D

4-24-86

DATE EFF

3-1-86

HCFA 179

86-4

Supersedes New

Revision: HCFABPM-91-4 January 1, 2014

(BPD)

Attachment 2.6-A Page 3 OMB No .: 0938-

State:

ARKANSAS

Citation

Condition or Requirement

LEFT BLANK INTENTIONALLY

State: Arkansas

Date Received: 23 September, 2013

Date Approved: 3 November, 2015

Effective Date: 1 January, 2014

Transmittal Number: 13-0018 MM6

Revision: HCFA-PM-91-HR (MB)

March 1992

ATTACHMENT 2.6-A

State/Territory:

ARKANSAS

Citation

Condition or Requirement

42 CFR 435.1008

a. Is not an inmate of a public institution. Public institutions do not include medical institutions, * inceanadiato-care facilities, or publicly operated community residences that serve no more than 16 residents, or certain child care institutions.

42 CFR 435.1008 1905(a) of the Act

b. Is not a patient under age 65 in an institution for mental diseases except as an inpatient under age 22 receiving active treatment in an accredited psychiatric facility or program. 0 Not applicable with respect to individuals under age 22 in psychiatric facilities or programs. Such services are not provided under the plan.

42 CFR 433.145 1912 of the Act

Is required, as a condition of eligibility, to assign his or her own rights, or the rights of any other person who is eligible for Medicaid and on whose behalf the individual has legal authority to execute an assignment, to medical support and payments for medical care from any third party. (Medical support is defined as support specified as being for medical care by a court or administrative order.)

*nursing facilities and intermediate care facilities for the mentally retarded,

TN No.

92-11

Supersedes

Approval Date

4/6/92

Effective Date

3/1/92

TN No.

91.57

STAT CArkansas STATE DATE REC'D 14-1-92

DATE APPV'D

4-6-92

DATE EFF

3-1-92

HCFA 179

92-11

Revision: MCFA-PM-91-A (MB)

March 1992

ATTACHMENT 2.6-A Page 3a. 1

State/Territory:

ARKANSAS

Citation

Condition or Requirement

An applicant or recipient must also cooperate in establishing the paternity of any eligible child and in obtaining medical support and payments for himself or herself and any other person who is eligible for Medicaid and on whose behalf the individual can make an assignment; except that individuals described in $1902(1) (1) (A) of the Social Security Act (pregnant women and women in the post-partum period) are exempt from these requirements involving paternity and obtaining support. Any individual may be exempt from the cooperation requirements by demonstrating good cause for refusing to cooperate.

An applicant or recipient must also cooperate in identifying any third party who may be liable to pay for care that is covered under the State plan and providing Information to assist in pursuing these third parties. Any individual may be exempt from the cooperation requirements by demonstrating good cause for refusing to cooperate.

☒ Assignment of rights is automatic because of State law.

42 CFR 435.910

Is required, as a condition of eligibility, to furnish his/her social security account number (or numbers, if he/she has more than one number), except for aliens seeking medical assistance for the treatment of an emergency medical condition under section 1903(v)(2) of the Social Security Act (section 1137(f)).

IN No. 92-11

Supersedes

Approval Date

4/6/92

Effective Date

3/1/92

TN No.

91-57

STATE 4-1-92 DATE REC'D

31-6-92 GATE APPV'D

3-1-92

DATE EFF 92-11 HCPA 179

Revision:

HCFA-PM-97-2

December 1997

State:

Arkansas

ATTACHMENT 2.6-A

Page 4 OMB No .: 0938-0673

Citation

Condition or Requirement

Posteligibility Treatment of Institutionalized Individuals' Incomes 1. The following items are not considered in the posteligibility process:

1902(o) of the Act

a. SSI and SSP benefits paid under §1611(e)(1)(E) and (G) of the Act to individuals who receive care in a hospital, nursing home, SNF, or ICF.

Bondi v Sullivan (SSI)

b. Austrian Reparation Payments (pension (reparation) payments made under §500 - 506 of the Austrian General Social Insurance Act). Applies only if State follows SSI program rules with respect to the payments.

1902(r)(1) of the Act

c. German Reparations Payments (reparation payments made by the Federal Republic of Germany).

105/206 of P. L. 100-383

d. Japanese and Aleutian Restitution Payments.

(a) of P.L. 103-286

e. Netherlands Reparation Payments based on Nazi, but not Japanese, persecution (during World War II).

10405 of P.L. 101-239

f. Payments from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in the In re Agent Orange product liability litigation, M.D.L. No. 381 (E.D.N.Y.)

6(h)(2) of P.L. 101-426

g. Radiation Exposure Compensation.

12005 of P. L. 103-66

h. VA pensions limited to $90 per month under 38 U.S.C. 5503.

TN No. 98-18 Supersedes 9707

Approval Date 10-22-98

Efective Date 12-1-98

TN No.

STATE arkansas

DATE REC'D 7-27-98 DATE APV 18-22-98 DATE [F 12-1-97

HCFA 179 98-18

Revision:

HCFA-PM-97-2

December 1997

ATTACHMENT 2.6-A Page 4a OMB No .: 0938-0673

State: Arkansas

Citation

Condition or Requirement

1924 of the Act 435.725 435.733 435.832

2. The following monthly amounts for personal needs are deducted from total monthly income in the application of an institutionalized individual's or couple's income to the cost of institutionalized care:

Personal Needs Allowance (PNA) of not less than $30 For Individuals and $60 For Couples For All Institutionalized Persons.

a. Aged, blind, disabled: Individuals $ 40.00 Couples $ 80.00

For the following persons with greater need:

Supplement 15to Attachment 2.6-A describes the greater need; describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; and, where appropriate, identifies the organizational unit which determines that a criterion is met.

€

arkansas

10-22-98 85-68-4

81-85 UTVIDri

STATE BIVO

DATE WY.

b. AFDC related: Children $ 40.00 Adults $ 40.00

For the following persons with greater need:

c. Individual under age 21 covered in the plan as specified in Item B. 7. of Attachment 2.2 -A. $ 40.00

TN No. 98-18 Supersedes

TN No. 97-07

Approval Date 10-22-98

Revision:

HCFA-PM-97-2

December 1997

State:

Arkansas

Citation

Condition or Requirement

For the following persons with greater need:

Supplement 15 to Attachment 2.6-A describes the greater need; describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; and, where appropriate, identifies the organizational unit which determines that a criterion is met.

1924 of the Act

3. In addition to the amounts under item 2. , the following monthly amounts are deducted from the remaining income of an institutionalized individual with a community spouse:

a. The monthly income allowance for the community spouse, calculated using the formula in §1924(d)(2), is the amount by which the maintenance needs standard exceeds the community spouse's income. The maintenance needs standard cannot exceed the maximum prescribed in §1924 (d)(3)(C). The maintenance needs standard consists of a poverty level component plus an excess shelter allowance.

€ ☒

antonio

7-27-98

DATE APPV: 18-22-98

12-1-97 98-18

STATE

DATE REC'D

DATE EFF HCFA 179

x ☒ The poverty level component is calculated using the applicable percentage (set out §1924(d)(3)(B) of the Act) of the official poverty level.

The poverty level component is calculated using a percentage greater than the applicable percentage, equal to %, of the official poverty level (still subject to maximum maintenance needs standard).

The maintenance needs standard for all community spouses is set at the maximum permitted by §1924(d)(3)(C).

Except that, when applicable, the State will set the community spouse's monthly income allowance at the amount by which exceptional maintenance needs, established at a fair hearing, exceed the community spouse's income, or at the amount of any court- ordered support.

TN No. 98-18 Supersedes

Effective Date 12-1-92

TN No 91-56

Revision:

HCFA-PM-97-2

December 1997

State:

Arkansas

ATTACHMENT 2.6-A Page 4c OMB No .: 0938-0673

Citation

Condition or Requirement

In determining any excess shelter allowance, utility expenses are calculated using: x ☒ the standard utility allowance under §5(e) of the Food Stamp Act of 1977; or the actual unreimbursable amount of the community spouse's utility expenses less any portion of such amount included in condominium or cooperative charges.

b. The monthly income allowance for other dependent family members living with the community spouse is: X ☒ one-third of the amount by which the poverty level component (calculated under §1924(d)(3)(A)(i) of the Act, using the applicable percentage specified in §1924 (d)(3)(B) ) exceeds the dependent family member's monthly income.

a greater amounted calculated as follows:

☒

STATE Relaxada DATE REC'D 7-22-98 DATE APPVID 10-22-98

DATE EFF 12-1-98 HCFA 179 78-18

The following definition is used in lieu of the definition provided by the Secretary to determine the dependency of family members under §1924 (d)(1): Reference Attachment 2.6-A, page 5b

c. Amounts for health care expenses described below that are incurred by and for the institutionalized individual and are not subject to payments by a third party:

(i) Medicaid, Medicare, and other health insurance premiums, deductibles, or coinsurance charges, or copayments. (ii) Necessary medical or remedial care recognized under State law but not covered under the State plan. (Reasonable limits on amounts are described in Supplement 3 to ATTACHMENT 2.6-A. )

Approval Date 10/22/98

Revision:

HCFA-PM-97-2

December

1997

State:

Arkansas

ATTACHMENT 2.6-A Page 5 OMB No .: 0938-0673

Citation

435.725 435.733

435.832

arkasand DATE REC'D 7-29-98

DATE APPVID 10-22-98

DATE EFF 12-1-98

98-18

STAT

HCFA 179

435.725 435.733 435.832

Condition or Requirement

4. In addition to any amounts deductible under the items above, the following monthly amounts are deducted from the remaining monthly income of an institutionalized individual or an institutionalized couple:

a. An amount for the maintenance needs of each member of a family living in the institutionalized individual's home with no community spouse living in the home. The amount must be based on a reasonable assessment of need but must not exceed the higher of the:

o AFDC level; or

o Medically needy level:

(Check one)

- AFDC levels in Supplement 1 ☒ Medically needy level in Supplement 1 -- Other: $

b. Amounts for health care expenses described below that have not been deducted under 3.c. above (i.e., for an institutionalized individual with a community spouse), are incurred by and for the institutionalized individual or institutionalized couple, and are not subject to the payment by a third party:

(I) Medicaid, Medicare, and other health insurance premiums, deductibles, or coinsurance charges, or copayments.

(ii) Necessary medical or remedial care recognized under State law but not covered under the State plan. (Reasonable limits on amount are described in Supplement 3 to ATTACHMENT 2.6-A.)

5. At the option of the State, as specified below, the following is deducted from any remaining monthly income of an institutionalized individual or an institutionalized couple:

A monthly amount for the maintenance of the home of the individual or couple for not longer than 6 months if a physician has certified that the individual, or one member of the institutionalized couple, is likely to return to the home within that period:

☒ No. Yes (the applicable amount is shown on page 5a.)

TN No. 98-18 Supersedes TN No. 91-56

Approval Date

10/2/98

Effective Date

12/1/97

Revision: HCFA-PM-97-2

December 1997

State:

Arkansas

ATTACHMENT 2.6-A Page 5a OMB No .: 0938-0673

Citation

Condition or Requirement

Amount for maintenance of home is: $ -

Amount for maintenance of home is the actual maintenance costs not to exceed $

Amount for maintenance of home is deductible when countable income is determined under §1924(d)(1) of the Act only if the individuals' home and the community spouse's home are different.

Amount for maintenance of home is not deductible when countable income is determined under §1924 (d)(1) of the Act.

STATE Orboxson

DATE REC'D 2-32-98 DATE APPV D 10-22-98 DATE EFF 12-1-97

HCFA 179 98-18

TN No. 98-18 Supersedes TN No. 89-43

Approval Date

10/22/98

Effective Date

12/1/97

:ION:

HCFA REGION-VI

November 1989

. sed:

December 1997

Attachment 2.6-4 Page - 56

STATE

ARKANSAS

CITATION

CONDITION OR REQUIREMENT

Definition of dependency

The definition of dependency below is used to define denencent children, carents and siblings for purposes of deducting allowances under Section 1924:

A dependent family member includes minor (under age 18) or dependent (age 18 or over) children, dependent parents, or dependent siblings ( including half- brothers and half-sisters) of the institutionalized spouse or community spouse who live in the home of the community spouse. To qualify as a dependent, an individual must be claimed on the income tax return of the institutionalized spouse or community spouse as a dependent, which must be verified by viewing the tax return.

STATE arkansas

DATE REC'D 2-27-98

DATE APPV 0 10-22-98

DATE EFF 12-1-98

HCFA 179 98-18

No.

98-18

Approval Date 10/22/98

Hective Date 12/1/07

89-43

Supersedes TN No.

Revision:

HCFA-PM-92-1

(MB)

January 2014

State:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation (s)

Condition or Requirement

42 CFR 435.711 435.721, 435.831

C. Financial Eligibility For individuals who are AFDC or SSI recipients, the income and resource levels and methods for determining countable income and resources of the AFDC and SSI program apply, unless the plan provides for more restrictive levels and methods than SSI for SSI recipients under section 1902(f) of the Act, or more liberal methods under section 1902(r)(2) of the Act, as specified below. For individuals who are not AFDC or SSI recipients in a non-section 1902(f) State and those who are deemed to be cash assistance recipients, the financial eligibility requirements specified in this section C apply.

See S28, SPA #2013-015

HCFA-PM-95-7

10/95

(MB)

Revised:

December 1, 2002

ARKANSAS

State:

Citation

Condition or Requirement

x ☒ Supplement 2 to ATTACHMENT 2.6-A specifies the resource levels for mandatory and optional categorically needy poverty level related groups, and for medically needy groups.

Supplement 7 to ATTACHMENT 2.6-A specifies the income levels For categorically needy aged, blind and disabled persons who are covered under requirements more restrictive than SSI.

Supplement 4 to ATTACHMENT 2.6-A specifies the methods for determining income eligibility used by States that have more restrictive methods than SSI, permitted under section 1902(f) of the Act.

Supplement 5 to ATTACHMENT 2.6-A specifies the methods for determining resource eligibility used by States that have more restrictive methods than SSI, permitted under section 1902(f) of the Act.

☒ X Supplement 8a to ATTACHMENT 2.6-A specifies the methods for determining income eligibility used by States that are more liberal than the methods of the cash assistance programs, permitted under section 1902(r) (2) of the Act.

☒ X Supplement 8b to ATTACHMENT 2.6-A specifies the methods for determining resource eligibility used by States that are more liberal than the methods of the cash assistance programs, permitted under section 1902(r) (2) of the Act.

☒ X Supplement 14 to ATTACHMENT 2.6-A specifies income levels used by States for determining eligibility of Tuberculosis- infected individuals whose eligibility is determined under $1902 (z) (1) of the Act.

STATE arkansas

DATE REC'D 9/25/2002

DATE APPVO 12/11/2002

DATE EFF 12/1/2002

HCFA 179 02-14

SUPERSEDES TN- 95-27

IN No.

02-14

Superseden

Approval Date 12/11/2002

Effective Date 12/1/2002

TN No.

95-27

Revision: HCFA-PM-92-1 (MB)

FEBRUARY 1992

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement

1902 (r) (2) of the Act

1. Methods of Determining Income

1902 (e) (6) the Act

(3) Agency continues to treat women eligible under the provisions of sections 1902 (a) (10) of the Act aa eligible, without regard to any changes in income of the family of which she is a member, for the 60-day period after her pregnancy ends and any remaining days in the month in which the 60th day falls.

arkansas

STATE APR 0 6 1992

MAY v & 1992

MAR y 1_1992

92-18 HCFALY

TN No. 92-18 Supersedes

TN No. 91.56

Approval Date

MAY 0 8 1992

Effective Date MAR 0 1 1992

Revision: HCFA-PM-92 -1 FEBRUARY 1992

(MB)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement

42 CFR 435.721

b. Aged individuals. In determining countable

435.831, and 1902(m) (1) (B) (m) (4) and 1902(r) (2) of the Act

income for aged individuals, including aged

individuals with incomes up to the Federal poverty level described in section

1902 (m) (1) of the Act, the following methods are used:

X ☒ The methods of the SSI program only.

The methods of the SSI program and/or any more liberal methods described in Supplement Ba to ATTACHMENT 2.6-A.

arkansas

STATE APR 0 6 1392

ĐẠIC 28TO MAY 0 & 1992

DAYE APPV D MAR 0 1 1992

0/08 BA 92-18 HCIA 177

TN NO. 92-14

Approval Date MAY 0 & 1992

Effective Date MAR 0 1 1992

Supersedes

91-56

TN No.

(MB)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement

1902(e) (6) of the Act

(3) The agency continues to treat women eligible under the provisions of sections 1902 (a) (10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day period after her pregnancy ends and any remaining days in the month in which the 60th day falls.

1905 (p) (1), 1902 (m) (4), and 1902(r) (2) of the Act

f. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under section 1902 (a) (10) (E) (i) of the Act, the following methods are used:

X ☒ The methods of the SSI program only.

SSI methods and/or any more liberal methods than SSI described in Supplement 8a to ATTACHMENT 2.6-A.

For institutional couples, the methods specified under section 1611(e) (5) of the Act.

arkansas STATS APR 0 6 1992

MAY U 3 1992

MAR v.1. 1992

92-18

TN No. 92-18

Supersedes

TN NO. 91-56

Approval Date

MAY 0 0 1992

Effective Date MAR 0 1 1992

Revision: HCFA-PM-93-2 (MB)

MARCH 1993

ATTACHMENT 2.6-A Page 12a

State:

ARKANSAS

Citation

Condition or Requirement

If an individual receives a title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a title II COLA is not counted as income during a "transition period" beginning with January, when the title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual Federal poverty level. For individuals with title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving title II income, the revised poverty levels are effective no later than the date of publication.

1905(s) of the Act 1905(p) of the Act

(1) Qualified disabled and working individuals.

In determining countable income for qualified disabled and working individuals covered under 1902 (a) (10) (E) ( ii) of the Act, the methods of the SSI program are used.

(2) Specified low-income Medicare beneficiaries. In determining countable income for specified low-income Medicare beneficiaries covered under 1902 (a) (10) (E) (iii) of the Act, the same method as in f. is used.

STATE Chatquesto MAR 2 5 1993

DATE REC'D DATE APPV'D MAY 0 3 1993

DATE EFF JAN 0 1 1993

HCFA 179 93-09

TN No.

93.09

Approval Dat MAY 0 3 1993

Effective Date

JAN 0 1 1993

Supersedes

TN No.

92-18

* U.S. C.P.O .: 1993-342-239:80032

Revision:

ATTACHMENT 2.6-A Page 12c OMB No .:

State/Territory:

Arkansas

Citation Condition or Requirement

1902(a)(10)(A) (ii)(XIII) of the Act

(i) Working Individuals with Disabilities - BBA

In determining countable income and resources for working individuals with disabilities under the BBA, the following methodologies are applied:

The methodologies of the SSI program.

The agency uses methodologies for treatment of income and resources more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 (income) and/or Supplement 5 (resources) to Attachment 2.6-A.

The agency uses more liberal income and/or resource methodologies than the SSI program. More liberal methodologies are described in Supplement 8a to Attachment 2.6-A. More liberal resource methodologies are described in Supplement 8b to Attachment 2.6-A.

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

TN No.

State/Territory:

ARKANSAS

Citation

Condition or Requirement

1902(a)(10)(A)(ii)

(XV) of the Act ☒

(ii) Working Individuals with Disabilities - Basic Insurance Group - TWWIIA In determining financial eligibility for working individuals with disabilities under this provision, the following standards and methodologies are applied:

x ☒ The agency does not apply any income or resource standard. NOTE: If the above option is chosen, no further eligibility-related options should be elected.

The agency applies the following income and/or resource standard(s):

. The individual must have net personal income less than 250% of the poverty level for his/her family size.

· Countable resources are determined by family size: 1 (Individual only) $4000 2 $6000

$6200

$6400

Add $200 for each additional member.

State: Arkansas

Date Received: 10-10-13

Date Approved: 1-6-14

Date Effective: 1-1-14

Transmittal Number: 13-09

State/Territory:

ARKANSAS

Citation

Condition or Requirement

1902(a)(10)(A)(ii)

Income Methodologies

(XV) of the Act ☒

In determining whether an individual meets the income standard described above, the agency uses the following methodologies. Regardless of methodology, all earned income is disregarded in determining eligibility under this group.

The income methodologies of the SSI program.

The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6-A.

The agency uses more liberal income methodologies than the SSI program. More liberal methodologies are described in Supplement 8a to Attachment 2.6-A.

State: Arkansas

Date Received: 10-10-13

Date Approved: 1-6-14

Date Effective: 1-1-14

Transmittal Number: 13-09

Approval Date: 6 January, 2014

Date Effective: 1 January, 2014

ATTACHMENT 2.6-A Page 12f OMB No .:

State/Territory: Arkansas

Citation

Condition or Requirement

1902(a)(10)(A) (ii)(XV) of the Act (cont.)

Resource Methodologies

In determining whether the individual meets the resource standard described above, the agency uses the following methodologies.

Unless one of the following items is checked the agency, under the authority of section 1902(r)(2) of the Act, disregards all funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer-sponsored retirement plans such as 401(k) plans, Keogh plans, and employer pension plans. Any disregard involving retirement accounts is separately described in Supplement 8b to Attachment 2.6 -. A

The agency disregards funds held in employer-sponsored retirement plans, but not private retirement plans.

The agency disregards funds in retirement accounts in a manner other than those described above. The agency's disregards are specified in Supplement 8b to Attachment 2.6-A.

STATE ARKANSAS

DATE REC'D 10-31.00

DATE APPV'D 01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

TN No.

State/Territory:

ARKANSAS

Citation

Condition or Requirement

1902(a)(10)(A)(ii) (XV) of the Act ☒ (cont.)

The agency does not disregard funds in retirement accounts.

The agency uses resource methodologies in addition to any indicated above that are more liberal than those used by the SSI program. More liberal resource methodologies are described in Supplement 8b to Attachment 2.6-A.

The agency uses the resource methodologies of the SSI program.

The agency uses methodologies for treatment of resources that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 5 to Attachment 2.6-A.

State: Arkansas

Date Received: 10-10-13

Date Approved: 1-6-14

Date Effective: 1-1-14

Transmittal Number: 13-09

Approval Date: 6 January, 2014

Date Effective: 1 January, 2014

Supersedes TN# 00-14

State/Territory:

ARKANSAS

Citation

Condition or Requirement

1902(a)(10)(A)(ii)

(XV) of the Act ☒

(iii) Working Individuals with Disabilities - Employed Medically Improved Individuals - TWWIIA

In determining financial eligibility for employed medically improved individuals under this provision, the following standards and methodologies are applied:

The agency does not apply any income or resource standard.

NOTE: If the above option is chosen, no further eligibility-related options should be elected.

The agency applies the following income and/or resource standard(s):

State: Arkansas

Date Received: 10-10-13

Date Approved: 1-6-14

Date Effective: 1-1-14

Transmittal Number: 13-09

Approval Date: 6 January, 2014

Date Effective: 1 January, 2014

Revision:

ATTACHMENT 2.6-A Page 12i OMB No .:

State/Territory:

Arkansas

Citation

Condition or Requirement

1902(a)(10)(A) (ii)(XVI) of the Act (cont.) ☒

Income Methodologies

The income methodologies of the SSI program.

The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6-A.

The agency uses more liberal income methodologies than the SSI program. More liberal methodologies are described in Supplement 8a to Attachment 2.6-A.

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

Approval Date 01-25-01 Effective Date 02-01-01

TN No.

Revision:

ATTACHMENT 2.6-A Page 12j OMB No .:

State/Territory: Arkansas

Citation

Condition or Requirement

1902(a)(10)(A) (ii)(XVI) of the Act (cont.)

Resource Methodologies

In determining whether the individual meets the resource standard described above, the agency uses the following methodologies.

The agency disregards funds held in employer-sponsored retirement plans, but not private retirement plans.

The agency disregards funds in retirement accounts in a manner other than those listed above. The agency's disregards are specified in Supplement 8b to Attachment 2.6-A.

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

TN No.

Revision:

ATTACHMENT 2.6-A Page 12k OMB No .:

State/Territory: Arkansas

Citation

Condition or Requirement

1902(a)(10)(A) (ii)(XVI) of the Act (cont.) ☒

The agency does not disregard funds in retirement accounts.

The agency uses the resource methodologies of the SSI program.

The agency uses methodologies for treatment of resources that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 5 to Attachment 2.6-A.

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

Approval Date 01-25-01 Effective Date 02-Ol-ÔI

TN No.

Revision:

ATTACHMENT 2.6-A Page 121 OMB No .:

State/Territory:

Arkansas

Citation

Condition or Requirement

1902(a)(10)(A) (ii)(XVI) and 1905(v)(2) of the Act

Definition of Employed - Employed Medically Improved Individuals - TWWIIA

The agency uses the statutory definition of "employed", i.e., earning at least the minimum wage, and working at least 40 hours per month.

The agency uses an alternative definition of "employed" that provides for substantial and reasonable threshold criteria for hours of work, wages, or other measures. The agency's threshold criteria are described below:

STATE ARKANSAS

DATE REC'D 10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

Effective Date 02-01-01

TN No.

Revision:

ATTACHMENT 2.6-A Page 12m OMB No .:

State/Territory: Arkansas

Citation

Condition or Requirement

1902(a)(10)(A)(ii)(XIII). ☒ (XV), (XVI), and 1916(g) ☒ ☒ of the Act

Payment of Premiums or Other Cost Sharing Charges

For individuals eligible under the BBA eligibility group described in No. 23 on page 23d of Attachment 2.2-A:

The agency requires payment of premiums or other cost-sharing charges on a sliding scale based on income. The premiums or other cost-sharing charges, and how they are applied, are described below:

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

Approval Date 01-25-O1

Effective Date 02-01-01

TN No.

Revision:

ATTACHMENT 2.6-A Page 12n OMB No .:

State/Territory: _ Arkansas

Citation

Condition or Requirement

1902(a)(10)(A)(ii)(XIII), ☒ (XV), (XVI), and 1916(g) ☒ ☒ of the Act (cont.)

For individuals eligible under the Basic Insurance Group described in No. 24 on page 23d of Attachment 2.2-A: NOTE: Regardless of the option selected below, the agency MUST require that individuals whose annual adjusted gross income, as defined under IRS statute, exceeds $75,000 pay 100 percent of premiums. x ☒ The agency requires individuals to pay premiums or other cost-sharing charges on a sliding scale based on income. For individuals with net annual income below 450 percent of the Federal poverty level for a family of the size involved, the amount of premiums cannot exceed 7.5 percent of the individual's income. The premiums or other cost-sharing charges, and how they are applied, are described on page 12p.

STATE ARKANSAS

DATE REC'D

10-31-00

DATE APPV'D

01-25-01

DATE EFF

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

Approval Date 01-25-01

Effective Date 02-01-01

TN No

SUPERSEDES: NONE - NEW PAGE

Revision:

ATTACHMENT 2.6-A Page 120 OMB No .:

State/Territory: _ Arkansas

Citation

Condition or Requirement

1902(a)(10)(A)(ii)(XIII). ☒ (XV), (XVI), and 1916(g) ☒ ☒ of the Act (cont.)

Payment of Premiums or Other Cost Sharing Charges

For individuals eligible under the Medical Improvement Group described in No. 25 on page 23d of Attachment 2.2-A:

NOTE: Regardless of the option selected below, the agency MUST require that individuals whose annual adjusted gross income, as defined under IRS statute, exceeds $75,000 pay 100 percent of premiums.

The agency requires individuals to pay premiums or other cost-sharing charges on a sliding scale based on income. For individuals with net annual income below 450 percent of the Federal poverty level for a family of the size involved, the amount of premiums cannot exceed 7.5 percent of the individual's income.

The premiums or other cost-sharing charges, and how they are applied, are described on page 12p.

STATE ARKANSAS

DATE RIC'D

10-31-00

DATE APPVD

01-25-01

DATE SI-F

02-01-01

HCFA 179

00-14

TN No. 00-14 Supersedes

Approval Date 01-25-01 Effective Date 02-01-01

TN No.

Revision: January 1, 2023

Attachment 2.6-

Page 12p OMB No .:

State/Territory:

ARKANSAS

Citation

Condition or Requirement

1902(a)(10)(A)(ii) (XV), (XVI), and 1916(g) of the Act (cont.)

Premiums and Other Cost-Sharing Charges For the Basic Insurance Group and/or the Medical Improvement Group, the agency's premium or other cost-sharing charges, and how they are applied, are described in Medicaid Premiums and Cost Sharing pages G1 through G3. In future years, cost share amounts will change with the medical component of the CPI-U.

TN: 22-0026 Supersedes TN: 00-14

Effective : 01/01/23 Approved: 02/08/2023

Revision:

HCFA-PM-91-4

(BPD)

ATTACHMENT 2.6-A

AUGUST 1991

Page 18

Revised:

October 1, 1992

ARKANSAS

OMB No .: 0938-

State:

Citation

Condition or Requirement

1902 (a) (10) (A), 1902 (a) (10) (c), 1902(m) (1) (B) and (C), and 1902(r)(2) of the Act

d. Disabled individuals, including individuals covered under section 1902(a) (10) (A)(ii)(X) of the Act. The agency uses the following methods for the treatment of resources:

The methods of the SSI program.

X ☒ SSI methods and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.

Methods that are more restrictive (except for individuals described in section 1902(m) (1) of the Act) and/or more liberal that those under the SSI program. More restrictive methods are described in Supplement 5 to ATTACHMENT 2.6-A and more liberal methods are specified in Supplement 8b to ATTACHMENT 2.6-A.

In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

1902(1) (3) and 1902(r) (2) of the Act

TN NO. 92-40

Supersede

TN No. 91.56

Approval DEC 0 4 1992

Effective Da QCT 0 1 1992

HCFA ID: 7985E

STAT

Gickanna NOV 0 5 1992

DEC 0 4 1992

OCT 0 1, 1992 HCFA 179 92-40

Revision:

HCFA-PM-93-5

MAY 1993

(MB)

State:

ARKANSAS

Citation

Condition or Requirement

1902 (a) (10) (E) (iii) of the Act

k. Specified low-income Medicare beneficiaries covered under section 1902 (a)(10) (E) (fil) of the Act --

The agency uses the same method as in 5.h. of Attachment 2.6-A.

6. Resource Standard - Categorically Needy

a. 1902(f) States (except as specified under items 6.c. and d. below) for aged, blind and disabled individuala:

Same as SSI resource standards.

More restrictive.

The resource standards for other individuals are the same as those in the related cash assistance program.

b. Non-1902 (f) States (except as specified under items 6.c. and d. below)

The resource standards are the same as those in the related cash assistance program.

Supplement 8 to ATTACHMENT 2.6-A specifies for 1902(f) States the categorically needy resource levels for all covered categorically needy groups.

STATE DATE REC'D JUN 1 4 1993

DATE APPV D JUL 0 1 1993

DATE EFF MAY 0 1 1993 HCFA 179 93-22

TN No.

93.22

Approval Dat JUL 0 1 1993

Supersede

TN NO.

71-57

Effective Date

MAY 0 1 1993

Revision: HCFA-PM-91-4 Ry (BPD) March 1992 92-1 R Revised: August 1, 2001 State: Arkansas

Citation

Condition or Requirement

1902(1)(3) (A) and (C) of the Act

e. For children covered under the provisions of section 1902(a) (10)(A) (i)(VII) of the Act, the agency applies a resource standard.

Yes. Supplement 2 to ATTACHMENT 2.6-A specifies the standard which is no more restrictive than the standard applied in the State's approved AFDC plan.

x ☒ No. The agency does not apply a resource standard to these individuals.

1902 (m) (1) (C) and (m) (2) (B) of the Act

f. For aged and disabled individuals described in section 1902(m) (1) of the Act who are covered under section 1902 (a) (10) (A) ( ii) (X) of the Act, the resource standard is:

Same as SSI resource standards.

Same as the medically needy resource standards, which are higher than the SSI resource standards ( if the State covers the medically needy) .

Supplement 2 to ATTACHMENT 2.6-A specifies the resource levels for these individuals.

TN No. 01-13 Supersedes

TN NO.

92-40

Approval Date 07-16-01

Effective Date

08.01.01

STATE Arkansas

DATE REC'D

05-24-01

DATE APPVID

07-16-01

DATE EFF

08-01-01

HCFA 179

Are-01-13

Revision:

HCFA-PM-93-5

May 1993

January 1, 2010

(MB)

Attachment 2.6-A Page 22

State:

ARKANSAS

Citation

Condition or Requirement

1902 (a)(10)(c)(i) of the Act

Resource standard - Medically Needy

a. Resource standards are based on family size. b. A single standard is employed in determining resource eligibility for all groups. c. In 1902(f) States, the resource standards are more restrictive than in 7.b. above for- Aged

STATE Arkansas

Blind Disabled A Supplement 2 to ATTACHMENT 2.6-A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2 to ATTACHMENT 2.6-A so indicates.

DATE REC'D. 12-30-09 DATE APPVID 3-30-10

DATE EFF 1-1-10

HCFA 179 18-02

1902(a)(10)(E), 1905(p)(1)(D), 1905(p)(2)(B) and 1860D-14(a)(3)(D) of the Act

Resource Standard - Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries and Qualified Individuals For qualified Medicare beneficiaries covered under section 1902(a)(10)(E)(i) of the Act, Specified Low-Income Medicare beneficiaries covered under section 1902(a)(10)(E)(iii) of the Act, and Qualified Individuals covered under 1902(a)(10)(E)(iv) of the Act, the resource standard is three times the SSI resource limit, adjusted annually by the increase in the Consumer Price Index (CPI).

1902(a)(10)(E)(ii), 1905(s) and 1860D-14(a)(3)(D) of the Act

Resource Standard - Qualified Disabled and Working Individuals For qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is twice the SSI resource standard.

TN No.

10.02

Supersedes TN No.

93-22

Approval Date 3-30-10

Effective Date

1-1-10

SUPERSEDES: TN-

93-22

Revision:

HCFA-PM-93-5

MAY 1993

(MB)

State:

ARKANSAS

Citation

Condition or Requirement

1902 (u) of the Act

10. Excess Resources

a. Categorically Needy, Qualified Medicare Beneficiaries, Qualified Disabled and Working Individuals, and Specified Low-Income Medicare Beneficiaries Any excess resources make the individual ineligible.

b. Categorically Needy Only

x ☒ This State has a section 1634 agreement with SSI. Receipt of SSI is provided for individuals while disposing of excess resources.

c. Medically Needy

Any excess resources make the individual ineligible.

Gotamoas STATE DATE REC'D JUN 1 4 1993 DATE APPVD JUL 0 1 1993

DATE EFF MAY 0 1,1993 HCFA 177 95-22

TN No.

93.22

Supersede

TN No. 91-56

Approval JUL 0 1 1993

Effective Date MAY 0 1 1993

Revision:

HCFA-PM-91-4 AUGUST 1991

(BPD)

ATTACHMENT 2.6-A Page 24

Revised:

August 1, 1993 State:

ARKANSAS

OMB No. : 0938-

Citation

Condition or Requirement

42 CFR 435.914

11. Effective Date of Eligibility

a. Groups Other Than Qualified Medicare Beneficiaries

(1) For the prospective period.

Coverage is available for the full month if the following individuals are eligible at any time during the month.

Aged, blind, disabled. AFDC-related.

Coverage is available only for the period during the month for which the following individuals meet the eligibility requirements.

X AFDC-related. ☒ ☒ Aged, blind, disabled. X

(2) For the retroactive period.

Coverage is available for three months before the date of application if the following individuals would have been eligible had they applied:

X ☒ Aged, blind, disabled. AFDC-related.

X ☒

Coverage is available beginning the first day of the third month before the date of application if the following individuals would have been eligible at any time during that month, had they applied ..

Aged, blind, disabled. AFDC-related.

TN No. 93.24

Supersed

TN No. 91.56

Approval Date

SEP 0 8 1993

Effective Date

AUG 01 1993

HCFA ID: 7985E

STATE

Arkansas

DATE REC'D KUG 3 1 1993

DATE APPV'D SEP 0 8 1993

DATE EFF AUG 01-1993

HCFA 179 93-24

Revision: HCFA-PM-92-1R (MB) March 1992

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(#) Condition or Requirement

1920(b) (1) of the Act

1902(*) (8) and 1905 (a) of the Act

x ☒

b. For qualified Medicare beneficiaries defined in section 1905(p) (1) of the Act coverage is available beginning with the first day of the month after the month in which the individual is first determined to be a qualified Medicare beneficiary under section 1905 (p) (1). The eligibility determination is valid for --

x ☒ 12 months

6 months months (no less than 6 months and no more than 12 months)

STATE

arkansas

DATE FOXIL

APR u 6 1992

DATE 4PP4D

MAY 0 8 1992

MAR 0 1 1992

HCMA 197

92-18

TN NO. 9211

Supersedes

TN No.

91-56

Approval Date

MAY 0 8 1992

Effective Date

MAR 0 1 1992

ARKANSAS

Citation

Condition or Requirement

1902 (a) (18) and 1902 (f) of the Act

12. Pre-OBRA 93 Transfer of Resources . Categorically and Medically Needy, Qualified Medicare Beneficiaries, and Qualified Disabled and Working Individuals

The agency complies with the provisions of section 1917 of the Act with respect to the transfer of resources.

Disposal of resources at less than fair market value affects eligibility for certain services as detailed in Supplement 9 to Attachment 2.6-A.

1917 (c)

13. Transfer of Assets . All eligibility groups

The agency complies with the provisions of section 1917 (c) of the Act, as enacted by OBRA 93, with regard to the transfer of assets.

Disposal of assets at less than fair market value affects eligibility for certain services as detailed in Supplement 9 (a) to ATTACHMENT 2.6-A, except in instances where the agency determines that the transfer rules would work an undue hardship.

1917 (d)

14. Treatment of Trusts . All eligibility groups

The agency complies with the provisions of section 1917 (d) of the Act, as amended by OBRA 93, with regard to trusts.

The agency uses more restrictive methodologies under section 1902 (f) of the Act, and applies those methodologies in dealing with trusts;

x ☒ The agency meets the requirements in section 1917 (d) (f) (B) of the Act for use of Miller trusts.

The agency does not count the funds in a trust in any instance where the agency determines that the transfer would work an undue hardship, as described in Supplement 10 to ATTACHMENT 2. 6-A.

Arkansas STATE

DATE RECO MAR 2 7 1995

DATE APOYO APR 1 2 195

DATE OF JAN 0+ 1995 MCFA 124 95-02

TN No. 95-05

Supersede TN No. 91-56

Approval Date

APR 1 2 1995

Effective Date

JAN 0 1 1995

Revision:

ARKANSAS HCFARM-07-2 December 1997

State:

Arkansas

ATTACHMENT 2.6-A Page 26a OMB No .. 0938-0673

Citation

Condition or Requirement

1924 of the Act

15.

The agency complies with the provisions of §1924 with respect to income and resource eligibility and posteligibility determinations for individuals who are expected to be institutionalized for at least 30 consecutive days and who have a spouse living in the community.

When applying the formula used to determine the amount of resources in initial eligibility determinations, the State standard for community spouses is:

x ☒ the maximum standard permitted by law; the minimum standard permitted by law; or

$ a standard that is an amount between the minimum and the maximum.

STATE arkansas

DATE REC'D 7-27-98

DATE APPVID 10-22-98

DATE EFF 12-1-92

HCFA 179 98-18

TN No. 98-18

Supersedes

Approval Date

10/22/98

Effective Date

12-1-97

TN No.

SUPERSEDES: NONE NEW PAGE ☒

1. Redacted sections removed per approved MAGI SPA 13-0015MM.

2. Removed Page 3b per approved MAGI SPA 13-0015MM1.

3. Redacted aree per approved MAGI SPA 13-0015MM.

4. Redacted area per approved MAGI SPA 13-0015MM.

5. Page 11a removed from State Plan per approved MAGI SPA 13-0015MM.

6. Redacted area per approved MAGI SPA 13-0015MM.

7. Redacted area per approved MAGI SPA 13-0015MM.

Pages 19, 19a, and 9b were removed per approved MAGI SPA 13-0015MM. 8. Page 21 was removed from State Plan per approved MAGI SPA 13-0015MM. 9. Redacted section per approved MAGI SPA 13-0015MM.

CMS

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

Eligibility Groups - Mandatory Coverage Pregnant Women

S28

42 CFR 435.116

1902(a)(10XAXi)(III) and (IV) 1902(a)(10KAXii)I). (IV) and (IX) 1931(b) and (d) 1920

☒ Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state.

☒

The state attests that it operates this eligibility group in accordance with the following provisions;

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for fingeris under this group in accordance with section 1931 of the Act. if they meet the income standard for state \ Ovents and Other Caretaker Relatives at 42 CFR 435.110. ☒ Yes ☐ No

replaced by SPA 22-0027 Please see the following pages

☒ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4.

☒ MAGI-based income methodologies are used in calculating h income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ☒ Income standard used for this group

☒ [ Minimum income standardOyce entered and approved by CMS. the minimum income standard cannot be changed.)

The state bo dola come standard higher than 133% FPL established as of December 19. 1989 for determining eligib Pregnant women, or as of July 1, 1989, had authorizing legislation to do so.

Yes @ No ☒

The minimum income standard for this eligibility group is 133% FPL. ☒ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant

☒ women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

An attachment is submitted.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families). 1902(a)10XA Ki)(III) (qualified pregnant women), 1902(a) 10XAKIXIV) (mandatory poverty level-

related pregnant women). 1902(a)(10)(AXiiXIX) (optional poverty level-related pregnant women). 1902(a)(10) ☒

(AXiiXI) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)( 10XAXiiXIV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23. 2010, converted to a MAGI-equivalent percent of FPL.

Revision:

HCFA-PM-91-4 (BPD) AUGUST 1991

Revised:

January 1, 2014

State:

ARKANSAS

INCOME ELIGIBILITY LEVELS

See S30, SPA #2013-015

Revision: HCFA-PM-92-1 JANUARY 2014

State:

ARKANSAS

INCOME ELIGIBILITY LEVELS

See S30, SPA #2013-015

Revision:

HCFA-PM-91-4 (BPD) AUGUST 1991

Revised:

January 1, 2014

State:

ARKANSAS

INCOME ELIGIBILITY LEVELS (Continued)

See S30, SPA #2013-015

Revision: HCFA-PM-91-4 (BPD) JANUARY 2014

Supplement 1 to Attachment 2.6-A Page 4 OMB No .: 0938-

State:

ARKANSAS

INCOME ELIGIBILITY LEVELS (Continued)

See S30, SPA #2013-015

Revision: HCFA-PM-92- I FEBRUARY 1992 Revised: January 1, 2003

(M3)

SUPPLEMENT 1 TO ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

INCOME ELIGIBILITY LEVELS (Continued)

3. Aged and Disabled Individuals (Aged Individuals Only)

The levelg for determining income eligibility for groups of aged and disabled individuals under the provisions of section 1902 (m) (4) of the PM 93-5 Act are as follows:

Based on 80 percent of the official Federal income poverty line.

Family Size

Income Level

If an individual receives a title II benefit, any amount attributable to the most recent increase in the monthly insurance benefit as a resultofa title II COLA is not counted as income during a "transition period" beginning with January, when the title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual Federal poverty level.

For individuals with title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving title II income, the sevised poverty Levels are effective no later than the beginning of the month following the date of publication.

SUPERSEDES. TN- 02-16

STATE Arkansas

DATE RECO 11:1-02

DATE APPV D 12-20-02

DATE EFF 1-1-03

HCFA 179 AR 02-23

TN NO. Supersedes

02-23

Approval Date

12-20-02

Effective Date

1-1-02-03

TN NO.

02-16

HCPA ID:

79858

Revision:

HCFA-Region VI

October 1991

Revised: April 1, 1992

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

INCOME ELIGIBILITY LEVELS ( Continued)

C. QUALIFIED MEDICARE BENEFICIARIES WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL

The levels for determining income eligibility for groups of qualified Medicare beneficiaries under the provisions of section 1905 (p) (2) (A) of the Act are as follows:

a. Based on the following percent of the official Federal income poverty level :

Eff. Jan. 1, 1989: 11 85 percent 11 percent ( no more than 100)

Eff.' Jan. 1, 1990: LI 90 percent percent ( no more than 100)

Eff. Jan. 1, 1991: 100 percent

Eff. Jan. 1, 1992: 100 percent

b. Levels :

Family Size

Income Levels

$ 567.50

$ 765.83

CA. QUALIFIED DISABLED WORKING INDIVIDUALS WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL

The levels for determining income eligibility for groups of qualified disabled working individuals under the provisions of section 1905(s) of the Act are as follows:

Family Size

Income Levels

$ 1,135.00

$ 1,531.66

TN No. 92-15

Approval Date 4/28/92

Effective Date

4/1/92

Supersedos

TN No.

91-56

HeFA ID! 7985E

STATE CAckausar

DATE REC'D 4.2.92

DATE APPV'D 1-28-92

DATE EFF

4-1-92

HCFA 179 92-15

Revision:

HCFA-PM-91-4 AUGUST 1991

(BPD)

Revised:

January 1, 2014

Supplement 2 to Attachment 2.6-A

State:

ARKANSAS

RESOURCE LEVELS

See S30, SPA #2013-015

Revision:

HCFA-PM-91-4 (BPD) AUGUST 1991

Revised:

January 1, 2014

Supplement 2 to Attachment 2.6-A

State:

ARKANSAS

See S30, SPA #2013-015

Revision:

HCFA-PM-91-4 (BPD) AUGUST 1991

Revised:

JANUARY 2014

Supplement 2 to Attachment 2.6-A

State:

ARKANSAS

See S30, SPA #2013-015

Revision:

HCFA-PM-92-1 FEBRUARY 1992

(MB)

Revised:

JANUARY 2014

Supplement 2 to Attachment 2.6-A

State:

ARKANSAS

See S30, SPA #2013-015

Revision:

HCFA-PM-92-2 MARCH 1992

(MB)

Revised:

JANUARY 2014

State:

ARKANSAS

See S30, SPA #2013-015

Revision: HCFA-PM-85-3 MAY 1985 Revised: October 1, 2019

State: ARKANSAS

REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

. Must be incurred no earlier than the three-month period preceding the month of application.

· The non-covered expenses must be prescribed by a Medical professional (e.g., a physician, dentist, optometrist, chiropractor, etc.).

· Payments for cosmetic/elective procedures (e.g., face lifts or liposuction) will not be allowed except when prescribed by a medical professional.

. Amount is the least of the fee recognized by Medicaid, Medicare, or the average cost allowed by a commercial health insurance plan in Arkansas.

· Expenses incurred as a result of the imposition of a transfer of assets penalty, are not allowed.

· Expenses resulting from the failure to obtain prior approval from applicable private insurance, Medicare, or Medicaid, due to the service being medically unnecessary, are not allowed.

. Deduction is not allowed for procedures allowed by Medicaid when prior authorization is denied due to the service being medically unnecessary.

· Expenses when a third party (including Medicaid) is liable for the expenses, even if provided by an out- of-network provider, are not allowed.

· General health insurance premiums paid by someone other than the recipient (excluding the community spouse) who is not a financially responsible relative and repayment is not expected to be paid back to the third party by the recipient, are not allowed.

TN No.

19-0007

Approval Date

05/01/2019

Effective Date

10/01/2019

Supersedes TN No.

90-0031

Revised: January 1, 2014

State: ARKANSAS

MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902 (r) (2) OF THE ACT*

[ ] Section 1902 (f) State

X] ☒ Non-Section 1902 (f) State

*More liberal methods may not result in exceeding gross income limitations under section 1903(f).

TN No.

Supersedes TN No.

Approval Date

Effective Date

Revision:

HCFA-PM-91-4 November 1, 2001

(BPD)

Revised:

January 1, 2014

State: ARKANSAS

MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT* ☒ Non-Section 1902(f) State

☐ Section 1902(f)

See S30, SPA #2013-015

Revision:

HCFA-PM-91-4 (BPD) December 1, 2002

Revised:

January 1, 2014

State/Territory: ARKANSAS LESS RESTRICTIVE METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT*

See S55, SPA #2013-015

Supplement 8b to Attachment 2.6-A Page 2 OMB No .: 0938-

State: ARKANSAS

MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)(2) OF THE ACT

☐ Section 1902(f) State

☒ Non-Section 1902(f) State

State: ARKANSAS

MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902 (r) (2) OF THE ACT

Section 1902 (f) State

☒

Non-Section 1902 (f) State

For ARSeniors (Section 1902(m)) the difference between $2,000.00 for individuals and $3,000.00 for couples, and the QMB resource level for individuals and couples, as appropriate, is excluded; thereby effectively setting the resource limit for ARSeniors at the appropriate QMB resource level.

TN No.

Supersedes TN No.

Approval Date

Effective Date

State/Territory:

ARKANSAS

LESS RESTRICTIVE METHODS OF TREATING RESOURCES

UNDER SECTION 1902(r)(2) OF THE ACT

See S55, SPA #2013-015

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Arkansas

STATE LONG-TERM CARE INSURANCE PARTNERSHIP

The following more liberal methodology applies to individuals who are eligible for medical assistance under one of the following eligibility groups:

1902(r)(2) 1917(b)(1)(C) Categorically needy individuals in nursing facilities and home & community based waiver programs under the special income level (300%) defined at 1902 (a)(10)(A)(ii)(V)."

An individual who is a beneficiary under a long-term care insurance policy that meets the requirements of a "qualified State long-term care insurance partnership" policy (partnership policy) as set forth below, is given a resource disregard as described in this amendment. The amount of the disregard is equal to the amount of the insurance benefit payments made to or on behalf of the individual. The term "long-term care insurance policy" includes a certificate issued under a group insurance contract.

X ☒ The State Medicaid Agency (Agency) stipulates that the following requirements will be satisfied in order for a long-term care policy to qualify for a disregard. Where appropriate, the Agency relies on attestations by the State Insurance Commissioner (Commissioner) or other State official charged with regulation and oversight of insurance policies sold in the state, regarding information within the expertise of the State's Insurance Department.

STATE Arkansas

DATE REC'D 11-30-07

DATE APPV'D 2-21-08

DATE EFF 7-1-08

HCFA 179 07-19

TN No. 07-19 Supersedes

Approval Date

2-21-08

Effective Date

7-1-08

TN. No.

State:

Arkansas

STATE LONG-TERM CARE INSURANCE PARTNERSHIP

. The policy is a qualified long-term care insurance policy as defined in section 7702B(b) of the Internal Revenue Code of 1986.

. The policy meets the requirements of the long-term care insurance model regulation and long-term care insurance model Act promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000) as those requirements are set forth in section 1917(b)(5)(A) of the Social Security Act.

· The policy was issued no earlier than the effective date of this State plan amendment.

· The insured individual was a resident of a Partnership State when coverage first became effective under the policy. If the policy is later exchanged for a different long-term care policy, the individual was a resident of a Partnership State when coverage under the earliest policy became effective.

. The policy meets the inflation protection requirements set forth in section 1917(b)(1)(C)(iii)(IV) of the Social Security Act.

· The Commissioner requires the issuer of the policy to make regular reports to the Secretary that include notification regarding when benefits provided under the policy have been paid and the amount of such benefits paid, notification regarding when the policy otherwise terminates, and such other information as the Secretary determines may be appropriate to the administration of such partnerships.

. The State does not impose any requirement affecting the terms or benefits of a partnership policy that the state does not also impose on non-partnership policies.

. The State Insurance Department assures that any individual who sells a partnership policy receives training, and demonstrates evidence of an understanding of such policies and how they relate to other public and private coverage of long-term care.

. The Agency provides information and technical assistance to the Insurance Department regarding the training described above.

Arkansas

11-30-07

2-21-08

7-1-08

07-19

STATE

DATE REC'D

DATE APPV'D

DATE EFF

HCFA 179

TN No. 07-19 Supersedes

Approval Date

2-21-08

Effective Date 7-1-08

Revision:

State

Agency

December,

1993

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ARKANSAS

State:

TRANSFER OF RESOURCES

1917 of the Act The agency provides for the denial of eligibility by reason of disposal of resources for less than fair market value.

Section 303 (b) of P.L. 100-360

A. The criteria for determining the period of in- eligibility are:

1. Effective July 1, 1988 (except for inter- spousal transfers), no period of ineligi- bility will be imposed on an individual for uncompensated transfers unless the individual is an inpatient of a medical institution or nursing facility who transferred resources without compensation 30 months prior to institutionalization, if a Medicaid recipient at the beginning of institutionalization, or 30 months prior to application, if not Medicaid eligible at the beginning of institutionalization.

a. The agency uses a procedure which provides for a period of ineligibility that will be the lesser of:

i. 30 months, or

ii. A number of months equal to the uncompensated value of the trans- ferred resources divided by $1500. Any remainder from the division will be disregarded.

b. No individual is ineligible by reasons of A.1. if:

CHEkansas STATE DATE REC'D 12-20-93

01-19-94 DATE APPV'D DATE EFF 12-01-93

9332 HCFA 179

i. The resource transferred was a home, and title to the home was transferred to:

(a) a child of the institution- alized individual who is under age 21 or who is blind or disabled (as determined by SSI or MRT) ;

93.87

TN No. Supersedes

Approval Date

01/19/94

Effective Date

12/01/93

TN NO.

Supplement 9 to Attachment 2.6-A, Pages 1, 2, 3, 4, 5, 5a, 5b, 6, and 7, Approved 10-18-89 and 9-20-85, TN 89-31 and TN 85-10

Revision: State

Agency

December, 1993

SUPPLEMENT 9 TO ATTACHMENT 2.6-A Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ARKANSAS

State:

(b) a son or daughter of the institutionalized individual who resided in the home for at least two years before the applicant was admitted to the medical institution or nursing facility, and who provided care which enabled the institu- tionalized individual to remain at home during that period; or

(c) a sibling of the institution- alized individual who had an equity interest in the home for at least one year before the applicant was admitted to the medical institution or nursing facility.

ii. The resources were transferred to (or to another for the sole benefit of) a blind or permanently and totally disabled child (as determined by SSI or MRT) .

iii. A satisfactory showing is made that the individual intended to dispose of the resources at FMV or for other valuable consideration, or that the resources were transferred exclusively for a purpose other than to qualify for medical assistance.

iv. It is determined that denial of eligibility would work an undue hardship. Undue hardship exists if each condition below is met:

DATE REC'D 12-30-93 DATE APPVID 01-19-94

STATE

DATE BFF 12-01-93 HCFA 179 13.32

(a) counting uncompensated value would make an individual ineligible;

(b) lack of assistance would de- prive the individual of food and shelter;

(c) the individual's combined total of gross income and countable resources (no income disregards allowed) do not exceed the applicable federal benefit rate (NF income limit) ; and

TN No. 9337

Supersedes

Approval Date 01/19/94

Effective Date

12/01/93

TN NO. Supplement 9 to Attachment 2.6-A, Pages 1, 2, 3, 4, 5, 5a, 5b, 6, and 7, Approved 10-18-89 and 9-20-85, TX 89-31 and TN 85-10

Revision:

State Agency

December,

1993

SUPPLEMENT 9 TO ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ARKANSAS

(d) The resource (s) cannot be re- covered from the individual (s) to whom the resource(s) was transferred without compen- sation due to loss, destruc- tion, theft, or other extraor- dinary circumstances.

P.L. 101-66 8/10/93

2. Effective October 1, 1993, the transfer of asset provisions are in accordance with OBRA of 1993, as follows:

a. The look back period will be 36 months (or 60 months in the case of transfers to trusts) ;

b. There will be no cap on the period of ineligibility;

c. There will be no overlapping of periods of ineligibility;

d. The period of ineligibility for the uncompensated transfer of assets shall be determined as follows:

· The total value of all resources transferred will be divided by the average monthly cost to a private pay nursing facility resident;

· The total annual income diverted will be multiplied by the life expectancy of the individual and divided by the average monthly cost to a private pay nursing facility resident;

e. No period of ineligibility shall be im- posed on an individual for uncompensated transfers if denial of eligibility would work an undue hardship.

The exceptions to the period of ineligi- bility will be applied, as mandated by OBRA.

CALamar

Af.

STAIG DATE REC'D 16-70-93 01-19-97 DATE AFPVD

DATE EFF 12-01-93

93.37 HCFA 1799

TN No.

99-87

Supersenes

Approval Date

TN No. Supplement 9 to Attachment 2.6-A, Pages 1, 2, 3, 4, 5, 5a, 5b, 6, and 7, Approved 10-18-89 and 9-20-85, TN 89-31 and TN 85-10

01/19/94

Effective Date

12/01/93

Revision: HCFA -PM-95-1 March 1995

(MB )

SUPPLEMENT 9 (a) to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

1917 (c) The agency provides for the denial of certain Medicaid services by reason of disposal of assets for less than fair market value.

1. Institutionalized individuals may be denied certain Medicaid services upon disposing of assets for less than fair market value on or after the look-back date.

The agency withholds payment to institutionalized individuals for the following services :

Payments based on a level of care in a nursing facility;

Payments based on a nursing facility level of care in a medical institution;

Home and community-based services under a 1915 waiver.

2. Non . institutionalized individuals :

The agency applies these provisions to the following non- institutionalized eligibility groups. These groups can be no more restrictive than those set forth in section 1905 (a) of the Social Security Act :

The agency withholds payment to non- institutionalized individuals for the following services :

Home health services (section 1905 (a) (7) ) ;

Home and community care for functionally disabled and elderly adults (section 1905 (a) (22) ) ;

Personal care services furnished to individuals who are not inpatients in certain medical institutions, as recognized under agency law and specified in section 1905 (a) (24) .

The following other long-term care services for which medical assistance is otherwise under the agency plan:

Chekansas

MAR 2 7 1995

APP 1 2 1995

JAN 0 2 1995

93-02

TN NO. 95-05

Approval Date APR 1 2 1995

Effective Date

CAN Q 1-1005

Supersedes

Revision :

HCFA - PM - 95 -1

March 1995

(MB ) SUPPLEMENT 9 (a) to ATTACHMENT 2.6-A

State :

ARKANSAS

TRANSFER OF ASSETS

3 . Penalty Date- - The beginning date of each penalty period imposed for an uncompensated transfer of assets is: X ☒ the first day of the month in which the asset was transferred; the first day of the month following the month of transfer.

4 . Penalty Period - Institutionalized Individuals- - In determining the penalty for an institutionalized individual, the agency uses :

× ☒

the average monthly cost to a private patient of nursing

facility services in the ageuxxxstate;

the average monthly cost to a private patient of nursing facility services in the community in which the individual is institutionalized.

5. Penalty Period - Non- institutionalized Individuals -- The agency imposes a penalty period determined by using the same method as is used for an institutionalized individual, including the use of the average monthly cost of nursing facility services;

imposes a shorter penalty period than would be imposed for institutionalized individuals, as outlined below:

TAIE Arkansas STATE MAR 2 7 1995 CATE BECD

CATE AFP. D APR 1 2 1995 JAN Q 1 1995 CA:3 2 ::

95-03 HOLAI.

TN NO. 95-05

Approval Date

WPR 1 2 1995

Effective Date

JAN 0 1 1995

Supersedea

TN NOS! ! DERSEDES.

NONE . NEW PAGE

Revision: HCFA - PM - 95 -1 March 1995

(MB ) SUPPLEMENT 9 (a) to ATTACHMENT 2.6-A

State :

ARKANSAS

TRANSFER OF ASSETS

6. Penalty period for amounts of transfer less than cost of nursing facility care --

a. Where the amount of the transfer is less than the monthly cost of nursing facility care, the agency:

× ☒ does not impose a penalty;

imposes a penalty for less than a full month, based on the proportion of the agency's private nursing facility rate that was transferred.

b. Where an individual makes a series of transfers, each less than the private nursing facility rate for a month, the agency:

☒ does not impose a penalty;

imposes a series of penalties, each for less than a full month.

7. Transfers made so that penalty periods would overlap -- The agency:

x ☒ totals the value of all assets transferred to produce a single penalty period;

calculates the individual penalty periods and imposes them sequentially.

8. Transfers made so that penalty periods would not overlap -. The agency : X ☒ assigns each transfer its own penalty period; uses the method outlined below:

Arkansas STATE

MAP 2 7 1995

APR 1 2 1995

JAN 0 1 1995

95-02

TN No. 95-05

٩٢٢

1 2 1995

Effective Date

JAN 0 1 1005

Supersedes

Approval, DateRACE

TN NOS. IPERSEDES: RONE - NEW PAGE

(MB )}

State:

ARKANSAS

TRANSFER OF ASSETS

9. Penalty periods . transfer by a spouse that results in a penalty period for the individual --

(a) The agency apportions any existing penalty period between the spouses using the method outlined below, provided the spouse is eligible for Medicaid. A penalty can be assessed against the spouse, and some portion of the penalty against the individual remains.

If a community spouse enters a nursing facility, any remaining penalty period is divided and shared equally by both spouses.

(b) If one spouse is no longer subject to a penalty, the remaining penalty period must be served by the remaining spouse .

10. Treatment of income as an asset - -

When income has been transferred as a lump sum, the agency will calculate the penalty period on the lump sum value.

The agency will impose partial month penalty periods.

When a stream of income or the right to a stream of income has been transferred, the agency will impose a penalty period for each income payment.

For transfers of individual income payments, the agency will impose partial month penalty periods.

X ☒ For transfers of the right to an income stream, the agency will use the actuarial value of all payments transferred.

The agency uses an alternate method to calculate penalty periods, as described below:

STATO

Arkansas MAR 2 7 1995

APR 1 2 1995 JAN C 1 1095 95-13

HOMAI:

TN No. 95-05

Supersedes

Approval Date

VR 12 1995

Effective Date

JAN 6 1 1005

TN NOC!IDERSEDES.

NONE . NEW PAGE

Revision :

HCFA - PM-95 - 1

March 1995

State :

ARKANSAS

TRANSFER OF ASSETS

11. Imposition of a penalty would work an undue hardship -- The agency does not apply the transfer of assets provisions in any case in which the agency determines that such an application would work an undue hardship. The agency will use the following procedures in making undue hardship determinations:

Determine current ownership of the assets. purpose of the transfer, and compensation received.

Notify the individual of penalty period to be imposed for uncompensated transfer unless convincing evidence is provided that purpose of the transfer was for a reason other than establishing eligibility.

If rebuttal is unacceptable to agency, allow an appeal and agency hearing.

The following criteria will be used to determine whether the agency will not count assets transferred because the penalty would work an undue hardship:

Counting uncompensated value would make an individual ineligible.

Lack of assistance would deprive the individual of food. shelter anc care cetermined to be medically necessary.

The individual's total assets are not great enough to pay for nursing facility care for a month: if income is over the federal limit, an income trust must be established.

The transferred assets cannot be recovered due to loss, destruction, theft or other extraordinary circumstances.

Arkansas STATE MAR 2 7 1995

413 APR 1 2 1995

... . JAN 0 + 1995 42-05

TN No. 95-05

Supersede6

Approval Date

APR 1 2 1995

Effective Date

JAN Q 1 1995

TN NO SUPERSEDES.

NONE - NEW PAGE

SUPPLEMENT 9 (b) to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

1917 (c) FOR TRANSFERS OF ASSETS FOR LESS THAN FAIR MARKET VALUE MADE ON OR AFTER FEBRUARY 8, 2006, the agency provides for the denial of certain Medicaid services.

1. Institutionalized individuals are denied coverage of certain Medicaid services upon disposing of assets for less than fair market value on or after the look-back date.

The agency does not provide medical assistance coverage for institutionalized individuals for the following services :

Nursing facility services;

Nursing facility level of care provided in a medical institution;

Home and community-based services under a 1915 (c) or (d) waiver.

STATE Arkansas

DATE REC'D 9-26-06

DATE APPV'D 12-18-06

DATE EFF 10-1-06

HOFA 179 06-15

TN No. 06 -15 Supersedes

Approval Date

12-18-06

Effective Date 10-1-06

TN No. None-New

SUPPLEMENT 9 (b) to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

2. Non-institutionalized individuals:

X ☒ The agency applies these provisions to the following non-institutionalized eligibility groups. These groups can be no more restrictive than those set forth in section 1905 (a) of the Social Security Act : Individuals eligible under Home and Community Based Services waivers under 1915(c) .

The agency withholds payment to non-institutionalized individuals for the following services:

Home health services (section 1905 (a) (7) ) ;

Home and community care for functionally disabled elderly adults (section 1905 (a) (22) ) ; Personal care services furnished to individuals who are not inpatients in certain medical institutions, as recognized under agency law and specified in section 1905 (a) (24) . x ☒ The following other long-term care services for which payment for medical assistance is otherwise made under the agency plan:

Any services provided to individuals under a Home and Community Based Services waivers under 1915 (c) or (d).

STATE Arkansas DATE REC'D 9-26-06

DATE APPUD 12-18-06

DATE EFF

10-1-06

HOFA 179

06-15

TN No. 06-15 Supersedes

Approval Date

12-18-06

Effective Date

10-1-06

TN No. None-New

SUPPLEMENT 9 (b) to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

3. Penalty Date -- The beginning date of each penalty period imposed for an uncompensated transfer of assets is the later of :

. the first day of a month during or after which assets have been transferred for less than fair market value;

x ☒ The State uses the first day of the month in which the assets were transferred The State uses the first day of the month after the month in which the assets were transferred or

. the date on which the individual is eligible for medical assistance under the State plan and is receiving institutional level care services described in paragraphs 1 and 2 that, were it not for the imposition of the penalty period, would be covered by Medicaid;

AND which does not occur during any other period of ineligibility for services by reason of a transfer of assets penalty.

STATE Arkansas

DATE REC'D 9-26-06

DATE APPVD 12-18-06

DATE EFF 10-1-06

HOFA 179 06-15

TN No. 06-15 Supersedes

Approval Date

12-18-06

Effective Date

10-1-06

TN No. None-New

SUPPLEMENT 9 (b) to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

4 . Penalty Period - Institutionalized Individuals -- In determining the penalty for an institutionalized individual, the agency uses:

X ☒ the average monthly cost to a private patient of nursing facility services in the State at the time of application;

the average monthly cost to a private patient of nursing facility services in the community in which the individual is institutionalized at the time of application.

5. Penalty Period - Non-institutionalized Individuals -- The agency imposes a penalty period determined by using the same method as is used for an institutionalized individual, including the use of the average monthly cost of nursing facility services;

imposes a shorter penalty period than would be imposed for institutionalized individuals, as outlined below:

6. Penalty period for amounts of transfer less than cost of nursing facility care --

Where the amount of the transfer is less than the monthly cost of nursing facility care, the agency imposes a penalty for less than a full month, based on the option selected in item 4.

The state adds together all transfers for less than fair market value made during the look-back period in more than one month and calculates a single period of ineligibility, that begins on the earliest date that would otherwise apply if the transfer had been made in a single lump sum.

STATE Arkansas

DATE RECT 9-26-06

DATE APPVD 12-18-06

DATE EFF 16-1-06

HOFA 179 06-15

TN NO. 06-15 Supersedes

TN No. None-New

Approval Date

12-18-06

Effective Date

10-1-06

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State :

ARKANSAS

TRANSFER OF ASSETS

7. Penalty periods - transfer by a spouse that results in a penalty period for the individual --

(b) If one spouse is no longer subject to a penalty, the remaining penalty period must be served by the remaining spouse.

8. Treatment of a transfer of income --

When income has been transferred as a lump sum, the agency will calculate the penalty period on the lump sum value.

When a stream of income or the right to a stream of income has been transferred, the agency will impose a penalty period for each income payment.

x ☒ For transfers of individual income payments, the agency will impose partial month penalty periods using the methodology selected in 6. above.

x ☒ For transfers of the right to an income stream, the agency will base the penalty period on the combined actuarial value of all payments transferred.

STATE Arkansas

DATE RECC 9-26-06

DATE APPLE 12-18-06

DATE EFT

10-1-06

HOFA 179

06-15

TN NO. 06-15 Supersedes

Approval Date

12-18-06

Effective Date

10-1-06

TN No. None-New

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

9. Imposition of a penalty would work an undue hardship --

The agency does not impose a penalty for transferring assets for less than fair market value in any case in which the agency determines that such imposition would work an undue hardship. The agency will use the following criteria in making undue hardship determinations :

Application of a transfer of assets penalty would deprive the individual :

(a) Of medical care such that the individual's health or life would be endangered; or

(b) Of food, clothing, shelter, or other necessities of life.

10. Procedures for Undue Hardship Waivers

The agency has established a process under which hardship waivers may be requested that provides for:

(a) Notice to a recipient subject to a penalty that an undue hardship exception exists;

(b) A timely process for determining whether an undue hardship waiver will be granted; and

These procedures shall permit the facility in which the institutionalized individual is residing to file an undue hardship waiver application on behalf of the individual with the consent of the individual or the individual's personal representative.

STATE Arkansas

DATE RECT

9-26-06

DATEAR. 0) 12-18-06

DATE EFF 10-1-06

HCFA :79

06-15

TN No. 06-15 Supersedes

Approval Date

12-18-06

Effective Date

10-1-06

TN No. None-New

SUPPLEMENT 9 (b) to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

TRANSFER OF ASSETS

11. Bed Hold Waivers For Hardship Applicants

The agency provides that while an application for an undue hardship waiver is pending in the case of an individual who is a resident of a nursing facility:

Payments to the nursing facility to hold the bed for the individual will be made for a period not to exceed days (may not be greater than 30) .

¥ STATE Arkansas 5

9-26-06 DATE REC'D

DATE APPY D 12-18-06 ☒ A

DATE EFF

10-1-06

HOF4 779

06-15

TN NO. 06-15 Supersedes

Approval Date

12-18-06

Effective Date

10-1-06

TN No. None-New

Revision:

HCFA - PM-95-1

March 1995

(MB ) SUPPLEMENT 10 to ATTACHMENT 2.6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ARKANSAS

The agency does not apply the trust provisions in any case in which the agency determines that such application would work an undue hardship.

The following criteria will be used to determine whether the agency will not count assets transferred because doing so would work an undue hardship:

Refer to Supplement 9(a) to Attachment 2.6-A, Page 5.

Under the agency's undue hardship provisions, the agency exempts the funds in an irrevocable burial trust.

The maximum value of the exemption for an irrevocable burial trust is $ .

Frekanzas STATE 7 1995

MAD @ DATE PIC D MAX E CATE PFTD APR 1 2 1995

DATE E.F. JAN 0 1 1005 92:05 HCFA :77

95.05

TN No.

Supersedes

TN No. 91-26

Approval Date

APR 1 2 1005

Effective Date

JAN 0 1 1995

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE ARKANSAS METHODOLOGIES FOR TREATMENT OF RESOURCES THAT ARE MORE LIBERAL THAN THOSE OF THE SSI PROGRAM

For aged, blind and disabled Individuals, including Qualified Medicare Beneficiaries, Non-Home Income Producing Property, such as mineral and timber rights, rented farm land, and rented dwellings, will continue to be excluded from resources if it meets the pre-5/1/90 SSI $6000/6% rule, which was terminated by Section 8014 of OBRA, 1989. This rule will not apply to cash assistance recipients, to those individuals deemed to be cash assistance recipients; to qualified disabled working individuals (QDWIs) or to COBRA continuation recipients. (Arkansas has not elected to provide coverage to the COBRA continuation recipients.)

TN No.

91-12

Approval Date

12/5/91

Effective Date

4/1/91

Supersedes TN No.

82-12

SIAL.

(Trkamer)

IF MiYD

12-5-91

4-1-91

91-17

ICIAIN

REVISED:

April 1, 1991

SUPPLEMENT 13 to ATTACHMENT 2.6-A

SECTION 1924 PROVISIONS

A. Income and resource eligibility policies used to determine eligibility for institutionalized individuals who have spouses living in the community are consistent with Section 1924.

B. In the determination of resource eligibility, the State resource standard is the minimum

spousal resource standard established at Section 1924(n) (2) (A) of the Social Security Act.

C. The definition of undue hardship for purposes of determining if institutionalized spouses receive Medicaid in spite of having excess countable resources is described below:

Undue hardship exists if each condition below is met:

1. counting uncompensated value would make an individual ineligible.

2. lack of assistance would deprive the individual of food and shelter.

3. the individual's combined total of gross income and countable resources (no income disregards allowed) do not exceed the applicable federal benefit rate (LTC income limit); and

4. the resource(s) cannot be recovered from the individual(s) to whom the resource(s) was transferred without compensation due to loss, destruction, theft or other extraordinary circumstance.

STATE

DATE REC'D

5-6-91

DATE APPV'D

7-8-91

DATE EFF

4-1-91

HCFA 179

91-16

TN No. 91-16

Approval Date

7/8/91

Effective Date

4/1/91

Supersedes TN No.

90-12

Revision:

HCFA-PM-95-7

Revised:

December 1, 2002

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

ARKANSAS

ELIGIBILITY CONDITIONS AND REQUIREMENTS

INCOME AND RESOURCE REQUIREMENTS FOR TUBERCULOSIS (TB) INFECTED INDIVIDUALS

For TB infected individuals under 1902(z)(1) of the Act, the income and resources eligibility levels are as follows:

The resource standard is the SSI resource limit with more liberal methods as described in Supplement 8b to Attachment 2.6-A.

The income standard is the SSI break-even amount computed by multiplying the SSI Federal Benefit Rate by 2, plus $85. This standard should be compared to the individual's actual gross income with more liberal methods as described in Supplement 8a to Attachment 2.6-A.

arkansas STATE

DATE REY 9-25-2002

DATE A- 12-11-2002

DATE EFS 12-1-2002 HCFA 179 02-14

SUPERSEDES. TN-

95-21

TN No.

02-14

Supersedes TN No.

95-27

Approval Date

12-11-2002

Effective Date

12-1-2002

Revision:

HCFA-PM-97-2 December 1997

Revised:

July 1, 1999

SUPPLEMENT 15 TO ATTACHMENT 2,6-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Arkansas

VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE

Greater Need - Description (Reference Attachment 2.6-A, Page 4a, item a)

. Up to first $100.00 of earned income is disregarded for recipients in Nursing facilities whose physician's plan of care prescribes a self- employed activity as a therapeutic or rehabilitative measure. The total earned income disregarded and personal needs allowance cannot exceed $140.00.

. In order to foster self worth and to enhance recipients' level of productivity and quality of life, earned income from competitive and sheltered work opportunities, up to the SSI SPA, is disregarded for recipients in ICF/MR facilities. In addition, up to a $40.00 personal needs allowance will be deducted from any other income.

. For individuals receiving a VA pension limited to $90.00 per month under Section 8003 of P.L. 101-508 and Section 601 of P.L. 102-568, the personal needs allowance is the greater of the amount permitted to be paid under Section 8003 (up to $90.00) or amount specified in this section.

STATE arkansas

DATE REC'D 4-26-99 DATE APPY D 6-16-99

DATE UFF 7-1-99

HCFA !77 99-01

TN No

99-01

Supersedes

Approval Date

6-16-99

Effective Date

7-1-99

TN No.

98-18

STATE MILIONY

DATE RECT 9-26-06

DATE APPV 12-18-06

SUPPLEMENT 16 TO ATTACHMENT 2.6-A

DATE EFF

10-1-06

HOFA 179

06-15

State:

DISQUALIFICATION FOR LONG-TERM CARE ASSISTANCE FOR INDIVIDUALS WITH SUBSTANTIAL HOME EQUITY

1917(f) The State agency denies reimbursement for nursing facility services and other long-term care services covered under the State plan for an individual who does not have a spouse, child under 21 or adult disabled child residing in the individual's home, when the individual's equity interest in the home exceeds the following amount:

X ☒ $500,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000).

An amount that exceeds $500,000 but does not exceed $750,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000).

The amount chosen by the State is .

This higher standard applies statewide.

This higher standard does not apply statewide. It only applies in the following areas of the State:

This higher standard applies to all eligibility groups.

This higher standard only applies to the following eligibility groups:

The State has a process under which this limitation will be waived in cases of undue hardship.

TN No.

06-15

Supersedes

TN No. None - New

Approval Date

12-18-06

Effective Date

10-1-06

State: Arkansas

ASSET VERIFICATION SYSTEM

1940(a)

1. The Agency will provide for the verification of assets for purposes of determining or redetermining Medicaid eligibility for aged, blind and disabled Medicaid applicants and recipients using an Asset Verification System (AVS) that meets the following minimum requirements.

A. The request and response system must be electronic:

(1) Verification inquiries must be sent electronically via the internet or similar means from the Agency to the financial institution (FI).

(2) The system cannot be based on mailing paper-based requests.

(3) The system must have the capability to accept responses electronically.

B. The system must be secure, based on a recognized industry standard of security (e.g., as defined by the U.S. Commerce Department's National Institute of Standards and Technology, or NIST).

C. The system must establish and maintain a database of Fls that participate in the Agency's AVS.

D. Verification requests also must be sent to FIs other than those identified by applicants and recipients, based on some logic such as geographic proximity to the applicant's home address, or other reasonable factors whenever the Agency determines that such requests are needed to determine or redetermine the individual's eligibility.

E. The verification requests must include a request for information on both open and closed accounts, going back up to 5 years.

TN No. 13-23

Approval Date 12/12/13

Effective Date 10/1/13

Supersedes TN No.

New Page

State: Arkansas

Date Received: 9/30/13

Date Approved: 12/12/13

Date Effective: 10/1/13

Transmittal Number: 13-23

State: Arkansas

ASSET VERIFICATION SYSTEM

2. System Development

A. The Agency itself will build and maintain an AVS. In 3 below, describe how the system will meet the requirements in Section 1.

B. x ☒ The Agency will hire the following contractor to build and maintain an AVS.

In 3 below, identify the contractor, if known, and describe how the system will meet the requirements in Section 1.

C. The Agency will be joining a consortium to develop an AVS.

In 3 below, identify the States participating in the consortium. Also identify the contractor, if known, who will build and maintain the consortium's AVS, and how the system will meet the requirements in Section 1.

D. The Agency already has a system in place that meets the requirements for an acceptable AVS:

In 3 below, describe how the system meets the requirements in Section 1.

E. Other alternative not included in A. - D. above.

In 3 below, describe this alternative approach how it will meet the requirements in Section 1.

TN No. 13-23 Supersedes TN No. New Page

Approval Date 12/12/13

Effective Date 10/1/13

State: Arkansas

Date Received: 9/30/13

Date Approved: 12/12/13

Date Effective: 10/1/13

Transmittal Number: 13-23

October 1, 2013

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Arkansas

ASSET VERIFICATION SYSTEM

3. Provide the AVS implementation description and other information requested for the implementation approach checked in Section 2.

Arkansas Department of Human Services intends to implement an AVS system and is currently working with Health Management Systems (HRS) to develop and implement an AVS system.

State: Arkansas

Date Received: 9/30/13

Date Approved: 12/12/13

Date Effective: 10/1/13

Transmittal Number: 13-23

State: ARKANSAS

METHODOLOGY FOR IDENTIFICATION OF APPLICABLE FMAP RATES

The State will determine the appropriate FMAP rate for expenditures for individuals enrolled in the adult group described in 42 CFR 435.119 and receiving benefits in accordance with 42 CFR Part 440 Subpart C. The adult group FMAP methodology consists of two parts: an individual-based determination related to enrolled individuals, and as applicable, appropriate population-based adjustments.

Part 1 - Adult Group Individual Income-Based Determinations

For individuals eligible in the adult group, the state will make an individual income-based determination for purposes of the adult group FMAP methodology by comparing individual income to the relevant converted income eligibility standards in effect on December 1, 2009, and included in the MAGI Conversion Plan (Part 2) approved by CMS on 03/31/2014 . In general, and subject to any adjustments described in this SPA, under the adult group FMAP methodology, the expenditures of individuals with incomes below the relevant converted income standards for the applicable subgroup are considered as those for which the newly eligible FMAP is not available. The relevant MAGI-converted standards for each population group in the new adult group are described in Table 1.

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

Table 1: Adult Group Eligibility Standards and FMAP Methodology Features

Covered Populations Within New Adult Group

Applicable Population Adjustment

Population Group

Relevant Population Group Income Standard For each population group, indicate the lower of: . The reference in the MAGI Conversion Plan (Part

Resource Proxy

Enrollment Cap

Special Circumstances

Other Adjustments

to the relevant income standard and the appropriate cross-reference, or · 133% FPL. If a population group was not covered as of 12/1/09, enter "Not covered".

Enter "Y" (Yes), "N" (No), or "NA" in the appropriate column to indicate if the population adjustment will apply to each population group. Provide additional information in corresponding attachments.

Parents/Caretaker Relatives

See Attachment A, Column C, Line 1 of the CMS approved MAGI Conversion Plan.

No No

Disabled Persons, non- institutionalized

See Attachment A, Column C, Line 2 of the CMS approved MAGI Conversion Plan including any subsequent CMS approved modifications to the MAGI Conversion Plan.

No No

Disabled Persons, institutionalized

See Attachment A, Column C, Line 3 of the CMS approved MAGI Conversion Plan including any subsequent CMS approved modifications to the MAGI Conversion Plan.

Children Age 19 or 20

See Attachment A, Column C, Line 4 of the CMS approved MAGI Conversion Plan including any subsequent CMS approved modifications to the MAGI Conversion Plan.

N/A

Childless Adults

See Attachment A. Column C. Line 5 of the CMS approved MAGI Conversion Plan including any subsequent CMS approved modifications to the MAGI Conversion Plan.

N/A

The numbers in this summary chart will be updated automatically in the case of modifications in the CMS approved MAGI Conversion Plan.

Part 2 - Population-based Adjustments to the Newly Eligible Population Based on Resource Test, Enrollment Cap or Special Circumstances

A. Optional Resource Criteria Proxy Adjustment (42 CFR 433.206(d))

1. The state:

☐ Applies a resource proxy adjustment to a population group(s) that was subject to a resource test that was applicable on December 1, 2009.

☒

Does NOT apply a resource proxy adjustment (Skip items 2 through 3 and go to Section B).

Table 1 indicates the group or groups for which the state applies a resource proxy adjustment to the expenditures applicable for individuals eligible and enrolled under 42 CFR 435.119. A resource proxy adjustment is only permitted for a population group(s) that was subject to a resource test that was applicable on December 1, 2009.

The effective date(s) for application of the resource proxy adjustment is specified and described in Attachment B.

2. Data source used for resource proxy adjustments:

The state:

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

☐ Applies existing state data from periods before January 1, 2014. ☐ Applies data obtained through a post-eligibility statistically valid sample of individuals.

Data used in resource proxy adjustments is described in Attachment B.

3. Resource Proxy Methodology: Attachment B describes the sampling approach or other methodology used for calculating the adjustment.

B. Enrollment Cap Adjustment (42 CFR 433.206(e))

1. ☐ An enrollment cap adjustment is applied by the state (complete items 2 through 4).

☒ An enrollment cap adjustment is not applied by the state (skip items 2 through 4 and go to Section C).

TN 14-01

Approval Date

07/15/2014

Effective Date

01/01/2014

2. Attachment C describes any enrollment caps authorized in section 1115 demonstrations as of December 1, 2009 that are applicable to populations that the state covers in the eligibility group described at 42 CFR 435.119 and received full benefits, benchmark benefits, or benchmark equivalent benefits as determined by CMS. The enrollment cap or caps are as specified in the applicable section 1115 demonstration special terms and conditions as confirmed by CMS, or in alternative authorized cap or caps as confirmed by CMS. Attach CMS correspondence confirming the applicable enrollment cap(s).

3. The state applies a combined enrollment cap adjustment for purposes of claiming FMAP in the adult group: ☐ Yes. The combined enrollment cap adjustment is described in Attachment C ☐ No.

4. Enrollment Cap Methodology: Attachment C describes the methodology for calculating the enrollment cap adjustment, including the use of combined enrollment caps, if applicable.

C. Special Circumstances (42 CFR 433.206(g)) and Other Adjustments to the Adult Group FMAP Methodology

1. The state:

☐ Applies a special circumstances adjustment(s). ☒ Does not apply a special circumstances adjustment.

2. The state: ☐ Applies additional adjustment(s) to the adult group FMAP methodology (complete item 3).

☒ Does not apply any additional adjustment(s) to the adult group FMAP methodology (skip item 3 and go to Part 3).

3. Attachment D describes the special circumstances and other proxy adjustment(s) that are applied, including the population groups to which the adjustments apply and the methodology for calculating the adjustments.

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

TN 14-01

Approval Date -

07/15/2014

Effective Date -

01/01/2014

Part 3 - One-Time Transitions of Previously Covered Populations into the New Adult Group

A. Transitioning Previous Section 1115 and State Plan Populations to the New Adult Group

☒ Individuals previously eligible for Medicaid coverage through a section 1115 demonstration program or a mandatory or optional state plan eligibility category will be transitioned to the new adult group described in 42 CFR 435.119 in accordance with a CMS-approved transition plan and/or a section 1902(e)(14)(A) waiver. For purposes of claiming federal funding at the appropriate FMAP for the populations transitioned to new adult group, the adult group FMAP methodology is applied pursuant to and as described in Attachment E, and where applicable, is subject to any special circumstances or other adjustments described in Attachment D. ☐ The state does not have any relevant populations requiring such transitions.

Part 4 - Applicability of Special FMAP Rates

A. Expansion State Designation

The state:

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

☒ Does NOT meet the definition of expansion state in 42 CFR 433.204(b). (Skip section B and go to Part 5)

☐ Meets the definition of expansion state as defined in 42 CFR 433.204(b), determined in accordance with the CMS letter confirming expansion state status, dated -

B. Qualification for Temporary 2.2 Percentage Point Increase in FMAP.

The state:

☐ Does NOT qualify for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7).

☐ Qualifies for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7), determined in accordance with the CMS letter confirming eligibility for the temporary FMAP increase, dated . The state will not claim any federal funding for individuals determined eligible under 42 CFR 435.119 at the FMAP rate described in 42 CFR 433.10(c)(6).

Approval Date

07/15/2014

Effective Date - 01/01/2014

Part 5 - State Attestations

The State attests to the following:

A. The application of the adult group FMAP methodology will not affect the timing or approval of any individual's eligibility for Medicaid.

B. The application of the adult group FMAP methodology will not be biased in such a manner as to inappropriately establish the numbers of, or medical assistance expenditures for, individuals determined to be newly or not newly eligible.

ATTACHMENTS

Not all of the attachments indicated below will apply to all states; some attachments may describe methodologies for multiple population groups within the new adult group. Indicate those of the following attachments which are included with this SPA:

☒ Attachment A - Conversion Plan Standards Referenced in Table 1 ☐ Attachment B - Resource Criteria Proxy Methodology ☐ Attachment C - Enrollment Cap Methodology ☐ Attachment D - Special Circumstances Adjustment and Other Adjustments to the Adult Group FMAP Methodology ☒ Attachment E - Transition Methodologies

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN -

14-01

Approval Date -

07/15/2014

Effective Date

01/01/2014

Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan ARKANSAS

02/28/2014

Population Group

Net standard as of 12/1/09

Converted standard for FMAP claiming

Same as converted eligibility standard? (yes, no, or n/a)

Source of information in Column C (New SIPP conversion or Part 1 of approved state MAGI conversion plan)

Data source for Conversion (SIPP or state data)

Conversions for FMAP Claiming Purposes

Parents/Caretaker Relatives Dollar standards by family size

$108.33

$124

new SIPP conversion

$216.66

$237

$275.00

$301

SIPP

$333.33

$364

$383.33

$420

$441.66

$483

$500.00

$547

$558.33

$610

$616.66

$674

$675.00

$737

add-on

$58.33

$64

Noninstitutionalized Disabled Persons

$108.33 $216.66

$108 $217

new SIPP conversion

SIPP

Dollar standards Single Couple

Institutionalized Disabled Persons SSI FBR%

300%

ABD conversion template

n/a

Children Age 19-20

n/a

Childless Adults

n/a

n/a: Not applicable.

State: Arkansas

Date Received: 13 December, 2013

Date Approved: 15 July, 2014

Effective Date: 1 January, 2014

Transmittal Number: 14-01

Revision:

HCFA-PM-94-5

APRIL 1994

(MB )

State/Territory:

ARKANSAS

SECTION 3 - SERVICES: GENERAL PROVISIONS

Citation

3.1 Amount, Duration, and Scope of Services

42 CFR Part 440,

Subpart B

1902 (a), 1902 (e),

1905 (a), 1905 (p) , 1915, 1920, and 1925 of the Act

(a) Medicaid is provided in accordance with the requirements of 42 CFR Part 440, Subpart B and sections 1902 (a), 1902 (e), 1905 (a) , 1905 (p), 1915, 1920, and 1925 of the Act.

(1) Categorically needy.

Services for the categorically needy are described below and in ATTACHMENT 3.1-A. These services include:

1902 (a) ( 10) (A) and 1905 (a) of the Act

( i) Each item or service listed in section 1905 (a) (1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, section 1905 (r) and 42 CFR Part 441, Subpart B.

(ii) Nurse-midwife services listed in section 1905 (a) (17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under State law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provide agreements with the Medicaid agency without regard to whether the nurse-midwife is unde. the supervision of, or associated with, a physician or other health care provider.

Not applicable. Nurse-midwives are not authorized to practice in this State.

Gickcansay STATE

5-18-94 DATE PEC'D 6-7-94 JATE A-PV D DATE EFF 41-1-94 94.09 HCFA 179

TN NO.

94-09

Super sede

TN No.

93.39

Approval Date

6/7/94

Effective Date

4/1/94

19a

Revision:

HCFA-PM-91-4 AUGUST 1991 State/Territory:

( BPD) OMB No. : 0938- ARKANSAS

Citation

1(a) (1) Amount, Duration, and Scope of Serviceet

Categorically Moody (Continued}

1902(e) (5) the Act

(i11)

Pregnancy-related, including family planning services, and postpartum services for a 60-day period (beginning on the day pregnancy ende) and any remaining days in the month in which the 60th day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

(iv) Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

1902 (a) (

(v) Services related to pregnancy ( including

clause

(VII)

prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of sections 1902 (a) ( 10) (A) ( 1) ( IV) and 1902(a) (10) (A) (11) ( IX) of the Act.

of the

matter

following of the Act

(B) F

TN No. 91.53

Supersedeg

TN No. 90-61

Approval Date

DEC 13 1991

Effective Date

OCT - 1 1991

HCFA ID: 7982E

STATE DATE REC'D NOV 21 1991 DEC 1 3 1991 DATE APPV'D

OCT - 1 1991 DATE EFF

41-23 HCFA 179

Revision:

HCFA Region VI (MB) November 1992

Revised:

April 1, 2008

State: Arkansas

STATE Arkansas

DATE RECT 1-28-08

DATE APPV'D 2-28-08

DATE EFF 4-1-08

HCFA 179 07-23

Citation

3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)

1902(a)(10)(D)

(vi) Home health services are provided to individuals entitled to nursing facility services as indicated in item 3.1(b) of this plan.

1902(e)(7) of the Act (vii) Inpatient services that are being furnished to infants and children described in section 1902(1)(1)(B) through (D), or section 1905(n)(2) of the Act on the date the infant or child attains the maximum age for coverage under the approved state plan will continue until the end of the stay for which the inpatient services are furnished.

1902(e)(9) of the Act

X (viii) ☒ Respiratory care services are provided to ventilator dependent individuals as indicated in item 3.1(h) of this plan.

1902(a)(52) and 1925 of the Act 1905(a)(23) and 1929

(ix) ☒ Services are provided to families eligible under section 1925 of the Act as indicated in item 3.5 of this plan.

(x) ☒ Home and Community Care for Functionally Disabled Elderly Individuals, as defined, described and limited in Supplement 2 to Attachment 3.1-A and Appendices A-G to Supplement 2 to Attachment 3.1-A.

1915(j)

X ☒

(xi) Self-Directed Personal Assistance Services, as described and limited in Supplement 4 to Attachment 3.1-A.

ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those services, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy. PACE and Self-Directed Personal Assistance Services are also included in Attachment 3.1-A.

SUPERSEDES: TN- 01-44

Approval Date

3-28-08

Effective Date

4-1-08

Revision:

HCFA-PM-91- 4R (BPD)

AUGUST 1991

OMB No. :

0938-

State/Territory:

ARKANSAS

Citation

3.1

Amount,

Duration, and Scope of Services ( continued)

42 CFR Part 440,

(a) ( 2 )

Medically needy.

Subpart B

This State plan covers the medically needy ... The services described below and in ATTACHMENT 3.1-B are provided. Services for the medically needy include:

1902 (a) (10) (C) ( of the Act

iv)

(1)

If services in an institution for mental diseases or an intermediate care facility for

42 CFR 440.

220

the mentally retarded (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in section 1905 (a) (1) through (5) and (17) of the Act, or seven of the services listed in section 1905 (a) ( 1) through (20). The services are provided as defined in 42 CFR Part 440, Subpart A and in sections 1902, 1905, and 1915 of the Act. 1 Not applicable with respect to nurse-midwife services under section 1902 (a) (17). Nurse-midwives are not authorized to practice in this State.

1902 (e) (5) of

(ii) Prenatal care and delivery services for pregnant women.

the Act

(42 C+K 440. 140 AND 440. 160)

TN NO.

92-04

FEB 2 0 1992

Supersedes

Approval Date

TN NO.

9-58

MAR 01 1992 Effective Date

HCFA ID:

7982E

arkansas STATE

DATE REC'D

FEB 11 1992

DATE APPV'S

FEB 2 0 1992

DATE EFF

MAR 01 1992

HCFA 179

92-04

Revision:

HCFA-PM-91- 4R

AUGUST 1991

( BPD)

OMB No. : 0938-

State/Territory:

ARKANSAS

Citation

3.1 (a) (2)

Amount, Duration, and Scope of Services: Medically Needy (Continued]

(iii) Pregnancy-related, including family planning services, and postpartum services for a 60-day period (beginning on the day the pregnancy ends ) and any remaining days in the month in which the 60th day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

(K/(iv) ☒ Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

(V) Ambulatory services, as defined in ATTACHMENT 3.1-B, for recipients under age 18 and recipients entitled to institutional services.

LI Not applicable with respect to recipients entitled to institutional services; the plan does not cover those services for the medically needy.

(vi) Home health services to recipients entitled to nursing facility services as indicated in item 3. 1 (b) of this plan.

(vii) Services in an institution for mental diseases for individuals over age 65 ..

42 CFR 440.140, 440. 150, 4$6.160, Subpart B. 442.441, (viii) Services in an intermediate care facility for the mentally retarded. Subpart C 1902 (a) (20) and (21) of the Act. ☒ (ix) Inpatient psychiatric services for individuals under age 2].

1902 (a) (10) (C)

TN No.

92-06

Supersedes

TN No. 91-5-59

Approval Date

12/16/92

Effective Date

3/1/92

HCFA ID: 7982E

Arkansas)

2-24-92

12-16-92 3-1-92

92-06

Revision:

HCFA-PM-93- 5 (MB)

May 1993

Revised:

April 1, 2008

State:

Arkansas

STATE Arkansas

DATE RECT 1-28-08

DATE APPV'D 3-28-08

DATE EFF

4-1-08

HCFA 179

07-23

Citation

3.1(a)(2)

Amount, Duration, and Scope of Services: Medically Needy (Continued)

1902(e)(9) of Act

(x) Respiratory care services are provided to ☒ ventilator dependent individuals as indicated in item 3.1(h) of this plan.

1905(a)(23) and 1929 of the Act 1915(j)

(xi) Home and Community Care for Functionally ☒ Disabled Elderly Individuals, as defined, described and limited in Supplement 2 to Attachment 3.1-A and Appendices A-G to Supplement 2 to Attachment 3.1-A.

Self-Directed Personal Assistance Services, as described and limited in Supplement 1 to Attachment 3.1-B.

ATTACHMENT 3.1-B identifies the services provided to each covered group of the medically needy; specifies all limitations on the amount, duration, and scope of those items; and specifies the ambulatory services provided under this plan and any limitations on them. It also lists the additional coverage (that is in excess of established service limits) for pregnancy- related services and services for conditions that may complicate the pregnancy.

SUPERSEDES: TN-

93-22

TN # 07-23 Supersedes

Approval Date

3-28-08

Effective Date

4-1-08

TN# 93-22

Revision:

HCFA-PM-97-3

(CMSO)

December 1997

State:

ARKANSAS

Citation

1902 (a) (10) (E) (i) and clause (VIII) of the matter following (F), and 1905 (p) (3) of the Act

1902 (a) (10) (E) (ii) and 1905(s) of the Act

1902 (a) (10) (E) (iii) and 1905 (p) (3) (A) (ii) of the Act

1902 (a) (10) (E) (iv) ( I) 1905 (p) (3) (A) (ii), and 1933 of the Act

3.1 Amount, Duration, and Scope of Services (continued)

(a) (3) Other Required Special Groups: Qualified Medicare Beneficiaries

Medicare cost sharing for qualified Medicare beneficiaries described in section 1905(p) of the Act is provided only as indicated in item 3.2 of this plan.

(a) (4) (i) Other Required Special Groups: Qualified Disabled and Working Individuals

Medicare Part A premiums for qualified disabled and working individuals described in section 1902 (a) (10) (E) (ii) of the Act are provided as indicated in item 3.2 of this plan.

(ii) Other Required Special Groups: Specified Low-Income Medicare Beneficiaries

Medicare Part B premiums for specified low-income Medicare beneficiaries described in section 1902 (a) (10) (E) (iii) of the Act are provided as indicated in item 3.2 of this plan.

(iii) Other Required Special Groups: Qualifying Individuals - 1

Medicare Part B premiums for qualifying individuals described in 1902 (a) (10) (E) (iv) (I) and subject to 1933 of the Act are provided as indicated in item 3.2 of this plan.

arkansas

4/2/98

5/15/98

January 1, 198 98-03

SUPERSEDES: TN. 93-09

TN No.

98-03

Supersedeş

TN No.

93.09

Approval Date

slist48

Effective Date

January 1, 1998

21a

Revision:

HCPA-PM-97-3 December 1997

( CHSO)

Revised:

January 1, 2003 State:

ARKANSAS

1925 of the

(a) (5)

Other Required Special Groups: Familien

Act

Receiving Extended Medicaid Benefita

Extended Medicaid benefits for families described in section 1925 of the Act are provided as indicated in item 3.5 of this plan.

STATE Arkansas

CATE RECO 31 Mar 2003

DATE APPTO 6 May 2003

DATE EFF 1 Jan 2003

HCFA 179 A12 03-04

SUPERSEDES: IN- 98-03

TN No. A12 03-04

Supersedes

Approval Date

6 May 2002

Effective Date

1 Jan 2003

TN No. AR 98-03

21b

Revision:

HCFA-PM-91- AUGUST

1991

( BPD) OMB No. : 0938-

State/Territory: ARKANSAS

Citation

3.1

(a) (6)

Amount, Duration, and Scope of Services: Limited

Coverage for Certain Aliens (continued)

1902(a) and 1903(v) of the Act

( iii) Aliens who are not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law who meat the eligibility conditions under this plan, except for the requirement for receipt of AFDC, SSI, or a State supplementary payment, are provided Medicaid only for care and services necessary for the treatment of an emergency medical condition ( including emergency labor and delivery) as defined in section 1903(v) (3) of the Act.

1905 (a) (9)

(a)

(7)

Homeless Individuals.

the Act

Clinic services furnished to eligible individuals who do not reside in a permanent dwelling or do not have a fixed home or mailing address are provided without restrictions regarding the site at which the services are

PRESUMPTIVELY ELIGIBLE PREGNANT WOMEN furnished.

1902 (a) (47)

18/

Peratory prenatal care tos pregnant

and 1920 of

women is provided during a presumptive

the Act

eligibility period if the care is furnished by a provider that is eligible for payment under the State plan.

42 CFR 441.55

(a) (9)

EPSDT Services.

50 FR 43654

1902 (a) (43)

The Medicaid agency meets the requirements of

1905 (a) (4 )

(B),

sections 1902 (a) (43) , 1905 (a) (4) (B), and

and 1905 (r)

1905 (r) of the Act with respect to early and

the Act

periodic screening, diagnostic, and treatment ( EPSDT) services.

TN NO. 9204

Approval Date FEB 2 0 1992

MAR 01 1992

Supersedes

TN NO.

91.53

Effective

Date

HCFA ID:

7982E

Tak any

STATE FEB 11 1992

DATE RECI DATE APPV'D FEB 2 0 1992

DATE EFF MAR 01 1992

92.04 HCFA 179

Revision:

AUGUST

HCFA-PM-91- 4 1991 State/Territory:

( BPD) ARKANSAS

OMB No. : 0938-

Citation

3.1 (a) (9)

Amount, Duration, and Scope of Services: EPSDT Services (continued)

42 CFR

441.60

The Medicaid agency has in effect agreements with continuing care providers. Described below are the methods employed to assure the providers* compliance with their agreements.

42 CFR 440.240 and 440.250

(a) ( 10)

Comparability of Serviceg Except for those items or services for which sections 1902 (a) , 1902 (a) ( 10), 1903(v), 1915

1902(a) and 1902

and 1925 of the Act, 42 CFR 440.250, and

(a) ( 10),

1902 (a) (52) ,

section 245A of the Immigration and

1903 (v),

1915(g),

and

Nationality Act, permit exceptions:

1925 (b) (4) of the Act (1)

Services made available to the categorically needy are equal in amount, duration, and scope for each categorically needy person.

(ii)

The amount, duration, and scope of services made available to the categorically needy are equal to or greater than those made available to the medically needy.

(if1)

Services made available to the medically needy are equal in amount, duration, and scope for each person in a medically needy coverage group.

(iv)

Additional coverage for pregnancy-related services and services for conditions that may complicate the pregnancy are equal for categorically and medically needy.

9152

TN No.

Approval Date

DEC 1 3 1991

Effective Date

OCT - 1 1991

Supersedes- TN No. 90-35 87-21 90.33

HCFA ID: 7982E

(Arkansas) 1

STATE

DATE REC'D

NOV 2 1 1991 DATE AFPV'D DEC 1 3 1991

DATE EFF OCT - 1.1991

41-53 HCFA 179

Revision:

HCFA - Region VI

November 1990

State

ARKANSAS

Citation

42 CFR Part 440, Subpart B 42 CFR 441.15 AT-78-90 AT-80-34

Section 1905(a) (4) (A) of Act (Sec. 4211(f) of P.L. 100-203).

3.1 (b)

Eone health services are provided in accordance with the requirements of 42 CFR 441.15.

(1) Rome health services are provided to all categorically needy individuals 21 years of age or over.

(2) Eome health services are provided to all categorically needy individuals under 21 years of age.

Yes

Not applicable. The State clan does not provide for nursing facility services for such individuals.

(3) Bome health services are provided to the medically needy:

Yes, to all

Yes, to individuals age 21 or over; nursing facility services are provided.

Yes, to individuals under 20e 21; nursing facility services are provide

No; nursing facility services are not provided.

Not applicable: the medically needy are not included under this plan

STATE Gotasas

DATE REC'D DEC 19 1990

DATE APPV'D 4-14-91

DATE EFF

OCT - 1 1990

HCFA 179

90-61

TN #

90-61

Super sedes

# 80-07

Approval Date

Effective Date

OCT - 1 1990

Revision:

HCFA-PM-93-8

December 1993

(BPD)

State/Territory:

ARKANSAS

Citation

3.1

Amount,

Duration, and Scope of Services (continued)

42 CFR 431.53

Assurance of Transportation

Provision is made for assuring necessary transportation of recipients to and from providers. Methods used to assure such transportation are described in ATTACHMENT 3.1-D.

42 CFR 483.10

Payment for Nursing Facility Services The State includes in nursing facility services at least the items and services specified in 42 CFR 483.10 (c) (8) (i).

Arkansas STATE DATE REC'D 12-30-93 DATE

APPV'D

01-19-94

DATE CFF

12-01-93

HCFA 179

93-36

TN No. 93-36

Supersede

TN No. 91-23

Approval Date

01/19/94

Effective Date

12/11/93

25 .:

Revision: HCFA-AT-80-38 (BPP) May 22, 1980

State-

ARKANSAS.

Citation

3.1(d)

Methods and Standards to Assure

CFR 440.260 AT-78-90

Quality of Services

The standards established and the methods used to assure high quality care. are described in ATTACHMENT 3.1-C.

IN # 76.29 Super sedes IN #

Approval Date

2/2/11

Effective Date

8/25/76

26.2

Revision: RCFA-AT-80-38 (BPP)

May 22, 1980

State

ARKANSAS

Citation

3.1(e)

Family Planning Services

42 CFR 441.20 AT-78-90

The requirements of 42 CFR 441.20 are met regarding freedom from coercion or pressure of mind and conscience, and freedom of = choice of method to be used for family planning.

IN # 76.29 Super sedes IN +

Approval Date

2/2/21

Effective Date

8/25/76

Revision:

HCFA-PM-87-5

(BERC)

APRIL, 1987

State/Territory:

ARKANSAS

Citation 42 CFR 441.30 AT-78-90 :

3.1 (f) (1) Optometric Services

Optometric services (other than those provided .. under 55435.531 and. 436.531) are not -nowsbut ::: were previously provided under the plan .: Services of the type an optometrist is legally authorized to perform are -specifically included ... in the term "physicians' services" under this plan and are reimbursed whether furnished by a physician or an optometrist.

Yes.

No .. The conditions described in the first sentence apply but the term "physicians !: services". does. not. specifically include -* services of the type an optometrist isy legally authorized to perform .-

Not applicable. The conditions in the . first sentence do not apply.

1903 (1) (1) of the Act, P.L. 99-272 (Section 9507)

(2) Organ Transplant Procedures

Organ transplant procedures are provided.

1 No.

☒ Yes. Similarly situated individuals are treated alike and any restriction on the facilities that may, or practitioners who may, provide those procedures is consistent with the accessibility of high quality care to individuals eligible for the procedures under. this plan. Standards for the+ coverage of organ transplant procedures are described at ATTACHMENT 3.1-E.

.. A'E AR

JUL 1 1987

JUL & C 19871

Seo HCFA-179

8212

TN No.

87-12

Supersedes

Approval Date

Effective Date

Au HCFA- 175

TN NO.

76:29

HCFA ID: 1008P/0011P

Revision:

HCFA-PM-87-4 MARCH 1987

(BERC)

OMB No. :

Revised:

January 1, 2002 State/Territory:

ARKANSAS

Citation 42 CFR 431.110(b) AT-78-90

3.1 (g) Participation by Indian Health Service Facilities

Indian Health Service facilities are accepted as providers, in accordance with 42 CFR 431.110(b), on the same basis as other qualified providers.

1902(e)(9) of the Act, P.L. 99-509 (Section 9408)

(h) Respiratory Care Services for Ventilator-Dependent Individuals

Respiratory care services, as defined in section 1902(e) (9) (C) of the Act, are provided under the plan to individuals who --

(1) Are medically dependent on a ventilator for life support at least six hours per day;

(2) Have been so dependent as inpatients during a single stay or a continuous stay in one or more hospitals, SNEs or ICFs for the lesser of --

11 30 consecutive days;

☒ 24 days (the maximum number of inpatient days allowed under the State plan);

(3) Except for home respiratory care, would require respiratory care on an inpatient basis in a hospital, SNF, or ICF for which Medicaid payments would be made;

(4) Have adequate social support services to be cared for at home; and

(5) Wish to be cared for at home.

/XI ☒ Yes. The requirements of section 1902(e) (9) of the Act are met.

LI Not applicable. These services are not included in the plan.

STATE Arkansas

DATE REC'D

01-07-02

DATE APF V O

01-16-02

DATE EFE

01-01-02

HCFA 179

Arl-01-44

TN No. AR-01-44 Supersedes

TN No.

An-87-12

Approval Date

01-16-02

Effective Date

01-01-02

HCFA ID:

1008P/0011P

Revision: HCFA-PM-93-5 ( MB )

MAY 1993 State: Citation

ARKANSAS

3.2

Coordination of

Medicaid with Medicare

and Other

Insurance

(a) Premiuma

(1) Medicare Part A and Part B

1902 ( a) (10) (E) (i) and 1905 (p) (1) of the Act

(i) Qualified Medicare Beneficiary ☒ ( OMB ) The Medicaid agency pays Medicare Part A premiums ( if applicable) and Part 8 premiums for individuals in the QMB group defined in Item A.25 of ATTACHMENT 2.2-A, through the group premium payment arrangement, unless the agency has a Buy-in agreement for such payment, as indicated below. Buy-In agreement for: X ☒ Part A X Part B ☒ The Medicaid agency pays premiums, for which the beneficiary would be liable, for enrollment in an HMO participating in Medicare.

Grkanzas STATE JUN 1 4 1993 DATE REC'D

DATE APPY'D 1111 0 1 1993 MAY 0 1 1993 DATE EFF

95-22 HCFA 179

TN No. 93.22

Supersede

Approval 0 1 1993

Effective Date

MAY 0 1 1993

TN NO. 43-09

29a

Revision:

BCFA-PM-97-3 ( CMSO)

December 1997

Revised: January 1, 2003 State:

ARKANSAS

Citation

1902 ( a) { 10) (E) ( ii) and 1905 (s) of the Act

(ii) Qualified Disabled and Working Individual (ODNT) The Medicaid agency pays Medicare Part A premiums under a group premium payment arrangement, subject to any contribution required as described in ATTACHMENT 4.18-8, for individuals in the QDWI group defined in item A.26 of ATTACHMENT 2.2-A of this plan.

1902 ( a) (10) (3) ( iii) and 1905 (p) (3) (A) (ii) of the Act

(iii) Specified Low-Income Medicare Beneficiary ( STM3) The Medicaid agency pays Medicare Part B premium under the State buy- in process for individuals in the SLMB group defined in item A.27 of ATTACHMENT 2.2-A of this plan.

1902 (a) (10) (B) ( iv) ( I) ,

(iv) Qualifying Individual-1

1905 (p) (3) (A) (ii), and

101-11

1933 of the Act

The Medicaid agency pays Medicare Part B premiums under the State buy- in process for individuals described in 1902 (a) (10) (E) ( iv) ( I) and subject to 1933 of the Act.

SUPERSEDES: IN- 98-03

STATE Arkansas

DATE REC : 31 Mar 2003.

DATE A 2. 1 6 May 2003

DATE EFE 1. Jan 2003

HCFA 179 AR

03-04

TH NO. AR 03-04

Supersedes

Approval Date

6 May 2003

Effective Date

1 Jan 2003

TN NO. AR 98-03

Revision:

HCFA-PM-97-3

December 1997

(CMSO)

State:

ARKANSAS

Citation

1843 (b) and 1905 (a) of the Act and 42 CFR 431.625

(vi) Other Medicaid Recipients

The Medicaid agency pays Medicare Part B premiums to make Medicare Part B coverage available to the following individuals:

X ☒ All individuals who are: (a) receiving benefits under titles I, IV-A, X, XIV, or XVI (AABD or SSI); b) receiving State supplements under title XVI; or c) withing a group listed at 42 CFR 431.625 (d) (2) .

Individuals receiving title II or Railroad Retirement benefits.

Medically needy individuals (FFP is not available for this group) .

1902 (a) (30) and 1905(a) of the Act

(2) Other Health Insurance

X ☒ The Medicaid agency pays insurance premiums for medical or any other type of remedial care to maintain a third party resource for Medicaid covered services provided to eligible individuals (except individuals 65 years of age or older and disabled individuals, entitled to Medicare Part A but not enrolled in Medicare Part B).

arkansas DALE KICH 41248 W/ 1E APPTD 5/15/98

January 1, 1998 98-03

SUPERSEDES: TN.

93-04-

TN No.

98-03

Supersedes

TN No.

93-09

Approval Date

5/5/98

Effective Date

January !

1948

Revision: HCFA-PM-93-2 MARCH 1993

( MB )

State:

ARKANSAS

Citation

(b) Deductibles/Coinsurance

(1) Medicare Part A and B

1902 (a) ( 30), 1902 (n) , 1905 (a) , and 1916 of the Act

Supplement 1 to ATTACHMENT 4.19-8 describes the methods and standards for establishing payment rates for services covered under Medicare, and/or the methodology for payment of Medicare deductible and coinsurance amounts, to the extent available for each of the following groups.

Sectione 1902 ( a ) ( 10 ) ( E) ( i) and 1905 (p) (3) of the Act

(1) Qualified Medicare Beneficiaries ( OMAS )

The Medicaid agency pays Medicare Part A and Part 8 deductible and coinsurance amounts for OMBs ( subject to any nominal Medicaid copayment) for all services available under Medicare.

1902 (a) ( 10), 1902 (a) (30), and 1905(a) of the Act

(ii) Other Medicaid Recipients

The Medicaid agency pays for Medicaid services also covered under Medicare and furnished to recipients entitled to Medicare ( subject to any nominal Medicaid copayment). For services furnished to individuals who are described in section 3.2 (a) ( 1) ( iv), payment is made an follows:

X ☒ For the entire range of services available under Medicare Part B. Only for the amount, duration, and scope of services otherwise available under this plan.

1902 (a) (10), 1902 (a) (30) , 1905 (a), and 1905 (p) of the Act

arkansas STATE DATE REC'D MAR 2.5 1993 DATE APPV'D MAY 0 3 1993 DATE EFF JAN 0 1 1993

A I

93-09 HCFA 179

( iii) Dual Eligible -- OMB plus

The Medicaid agency pays Medicare Part A and Part B deductible and coinsurance amounts for all services available under Medicare and pays for all Medicaid services furnished to individuals eligible both as QMBs and categorically or medically needy ( subject to any nominal Medicaid copayment ) .

TN No. 93-09

Supersedes TN No. 92-04

Approval Da MAY 0 3 1993

Effective Date JAN 0 1 1993

42 CFR 431.625

Revision:

BCPA-NT-80-38 (BPP)

May 22, 1980

State

ARKANSAS

Citation

42 CFR 441.101, 42 CFR 431.620 (c) and (d) AT-79-29

3.3 Medicaid for Individuals Age 65 or Over in Institutions for Nental Diseases

Medicaid is provided for individuals 65 years of age or older who are patients in institutions for mental diseases.

Yes. The requirements of 42 CFR Part. 441, Subpart C, and 42 CFR 431.620 (c) and (d) are.met.

Not applicable. Medicaid is not provided to aged individuals in such institutions under this plan.

76-29

Supersedes

IN +

Approval Date

2/2/12

Effective Date

8/25/76

Revision:

BCFA-AT-80-38 (BPP)

May 22, 1980

State ARKANSAS

Citatiat

42 CFR 441.252. AT-78-99

3.4 Special Requirements Applicable to - Sterilization Procedures

ALL requirements of 42 CFR Part 441, Subpart F are met.

IN #

79-1

Super sedes

T +

Approval Date

3/22/79

Effective Date

2/6/79

Revision:

HCFA-PM-91-4

AUGUST 1991

( BPD)

OMA No. :

0938-

State:

ARKANSAS

Citation

1902 (a) (52) and 1925 of the Act

3.5 Families Receiving Extended Medicaid Benefita

(a) Services provided to families during the first 6-month period of extended Medicaid benefits under Section 1925 of the Act are equal in amount, duration, and scope to services provided to categorically needy AFDC recipients as described in ATTACHMENT 3.1-A (or may be greater if provided through a caretaker relative employer's health insurance plan) .

(b) Services provided to families during the second 6-month period of extended Medicaid benefits under section 1925 of the Act are --

☒ Equal in amount, duration, and scope to services provided to categorically needy AFDC recipients as described in ATTACHMENT 3.1-A (or may be greater if provided through a caretaker relative employer's health insurance plan) .

LI Equal in amount, duration, and scope to services provided to categorically needy AFDC recipients, (or may be greater if provided through a caretaker relative employer's health insurance plan) minus any one or more of the following acute services:

Nursing facility services (other than services in an institution for mental diseases} for individuals 21 years of age or older.

Medical or remedial care provided by licensed practitioners.

Home health services.

TN No. 9:53

Approval Date DEC 1 3 1991

Effective Date

OCT - 1 1991

Supersedes

TN No.

90-28

HCFA ID:

7982E

(Transas STATE NOV 2 1 1991 DATE REC'D

DATE APPV'D

DEC 1 3 1991

UCT - 1 1991 DATE EFF

HCFA 179

1/32

31b

Revision:

HCFA-PM-91- 4 AUGUST 1991 State:

( BPD) OMB No. : 0938- ARKANSAS

Citation

3.5

Familien Receiving Extended Medicaid Benefits (Continued)

Private duty nursing services.

Physical therapy and related services.

Other diagnostic, screening, preventive, and rehabilitation services.

Inpatient hospital services and nursing facility services for individuals 65 years of age or over in an institution for mental diseases.

Intermediate care facility services for the mentally retarded.

Inpatient psychiatric services for individuals under age 21.

Hospice services.

Respiratory care services.

Any other medical care and any other type of remedial care recognized under State law and specified by the Secretary.

TN No. 91.53

Supersede

TN No.

91-28

approval Date

DEC 1 3 1991

OCT - 1 1991

Effective Date

HCFA ID: 7982E

Arkansas STATE

DATE REC'D

NOV 2 1 1991

DATE APPV'D

DEC 1 3 1991

DATE EFF

ufc - 1 1991

HCFA 179

91-33

31c

Revision:

HCFA-PM-91- 4

( BPD)

AUGUST 1991

State:

ARKANSAS

OMB No. :

0938-

Citation

3.5 Families Receiving Extended Medicaid Benefits (Continued)

The agency pays the family's premiums, enrollment fees, deductibles, coinsurance, and similar costs for health plans offered by the caretaker's employer as payments for medical assistance --

lat 6 monthe

2nd 6 months

LI The agency requires caretakers to enroll in employers' health plans as a condition of eligibility.

1st 6 mos. LI 2nd 6 mos.

(d)// (1) The Medicaid agency provides assistance to families during the second 6-month period of extended Medicaid benefits through the following alternative methods:

LI Enrollment in the family option of an employer's health plan.

LI Enrollment in the family option of a State employee health plan.

LI Enrollment in the State health plan for the uninsured.

LI Enrollment in an eligible health maintenance organization (HMO) with a prepaid enrollment of less than 50 percent Medicaid recipienta (except recipients of extended Medicaid) .

943

TN No. 100

Supersedes

TN No. 70-28

Approval Date

DEC 1 3 1991

Effective Date

OCT - 1 1991

HCFA ID: 7982E

STATE DATE REC'D

Trokanses NOV 21 1991

DATE APPV'D DEC 1 3 1991

DATE EFF 0GT - 1.1991 HCFA 179 11-33

31d

Revision:

HCFA-PM-91-4 AUGUST 1991

( BPD) ARKANSAS

OMB No. :

0938-

State:

Citation

3.5 (

Families Receiving Extended Medicaid Benefit Continued)

(2)

Supplement 2 to ATTACHMENT 3.1-A specifies and describes the alternative health care plan(s) offered, including requirements for assuring that recipients have access to services of adequate quality.

The agency --

(1)

Pays all premiums and enrollment fees imposed on the family for such plan(s) .

(ii) Pays all deductibles and coinsurance imposed on the family for such plan(s) .

TN No. 91.53

Approval Date DEC 1 3 1991

OCT - 1 1991

Supersedes

Effective Date

TN NO. 50-28

HCFA ID:

7982E

Gick inzero

STATE

NOV 2 1 1991

DATE REC'D

DATE APPV'D DEC 1 3 1991

DATE EFF

OCT - 1 1991

HCFA 179 91.53

Revision: HCFA Region VI

May 1990

State/Territory:

ARKANSAS

Enrollment :: in site:ble health maintenance organisation (HMO) that has an enrollment of less than 50 percent of Medicaid recipients. who are not recipients of extended Medicaid.

Supplement : to ATTACHMENT J'-A specifies and describes the alternative health care plan(s ) offered. including requirements for assuring that recipients have access to services of adequace quality.

( 2 ) The agency --

( 1) Pays all premiums and enrollment fees imposed on the family for such plan(s).

/_/ (ii) Pays all deductibles and coinsurance imposed on the family for such planis).

STATE Giekanou DATE REC'D 529-90

DATE APPV'O 6-6-90

ATE EFF 4-1-90

CFA 179 9028

none-new tage

31f

Revision:

HCFA - Region VI

DECEMBER 1990

State/Territory:

ARKANSAS

Sec 1905 (o) (3) of

3.8

Additional amounts

for Nursing

the Act. (Sec 6408 (c)

Facility Residents

of P.L. 100-239 and

Sec 4705 of P.L. 101-508)

When hospice care is furnished to an individual residing in a nursing facility, the hospice is paid an additional amount on routine home care and continuous home care days to take into account the room and board furnished by the facility. The additional amount paid to the hospice on behalf of an individual residing in a nursing facility equals at least 95 percent of the per diem rate that would have been paid to the nursing facility for that individual in that facility under this State Plan.

TN NO 90-67

Supersedes

Approval Date

1/4/91

Effective Date

4/1/90

Tn Nó

Mitage

Mikanous STATE DATE REC'D 12-20-90

DATE AMV'D

3-18-91

DATE :F

4-1-90

HCFA 179

90-64

Revision: HCFA-Region VI October 1991 REVISED: January 1, 1992

ATTACHMENT 3.1-A

State/Territory: ARKANSAS

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

1. Inpatient hospital services other than those provided in an institution for mental diseases.

Provided:

No limitations ☒ With limitations*

2.8. Outpatient hospital services." Provided: L No limitations ☒ With limitations*

1X1

b. Rural health clinic services and other ambulatory services furnished by a rural health clinic and covered under the Plan. ☒ X - Provided: LI No limitations ☒ With limitations*

Not provided.

c. Federally qualified health center ( FOHC) services and other ambulatory services that are covered under the plan and furnished by an FOHC in accordance with section 4231 of the State Medicaid Manual ( HCFA-Pub. 45-4).

Provided :

No limitations

1X1

☒ /With limitations*

3. Other laboratory and x-ray services. Provided:

. No limitations ☒ /X/With limitations*

*Description provided on attachment.

TN No. 91.64

Approval Date JUL 29 1992

Effective Dat JAN 01 1992

Supersed

TN No. 91-54

STATE Garbanzos

HCTA ID: 7986E

DATE REC'D DEC 3 0 1991

DATE APPV'D JUL 2.9 1992

DATE EFF JAN 0 1 1992

HCFA 179

91-64

☒ Supersedes -TN-91-54

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2026

CATEGORICALLY NEEDY

1. Inpatient Hospital Services

Inpatient admissions to an acute care/general hospital will be allowed up to seven (7) days of service per admission when determined inpatient care is medically necessary. On the eighth day of hospitalization, if the physician determines the patient should not be discharged on the eighth day of hospitalization, the hospital may request an extension of inpatient days.

Inpatient admissions to a rehabilitative hospital will be allowed up to ten (10) days of service per admission when determined inpatient care is medically necessary. Extension of benefits will be available when medically necessary. Medically necessary inpatient days are available to individuals under age 1 without regard to corresponding hospital day limit and extension procedures

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: July 1, 2026

1. Inpatient Hospital Services (continued)

Substance Use Disorder Residential Treatment provided in Acute Care Hospitals for Individuals under age 21

For Inpatient Substance Use Disorder Residential Treatment Unit admissions will follow a 100% prior authorization process to determine medical necessity for inpatient admission utilizing the American Society of Addition Medicine (ASAM) criteria. Inpatient Substance Use Disorder Residential Treatment Unit Services are not covered when provided in an Institution for Mental Disease (IMD).

ATTACHMENT 3.1-A Page 1a(1)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2021

CATEGORICALLY NEEDY

1. Inpatient Hospital Services (continued)

Acute Crisis Unit

Effective for dates of service on or after July 1, 2021, Hospital Acute Crisis Units are covered for eligible Medicaid clients who are experiencing a psychiatry or substance use disorder, or both, crisis that does not meet the need for inpatient hospitalization. These units provide hospital diversion and step-down services in a safe environment with psychiatry and substance use disorder services available on-site, as well as on- call psychiatry available 24 hours per day. They must ensure the following services are available at a minimum:

A. ongoing assessment and observation;

B. crisis intervention;

C. psychiatric, substance, and co-occurring treatment; and

D. initiation of referral mechanisms for independent assessment and care planning.

Services are available for up to 96 hours per encounter. Providers must initiate an extension of benefits request for medical necessity approval prior to providing services beyond 96 hours.

This expenditure is being paid as inpatient hospital because the definition of outpatient limits services to less than a 24-hour period. (42 CFR 440.2)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

September 1, 1999

1. Inpatient Hospital Services

A. Rehabilitative Hospital

1. Augmentative Communication Device (ACD) Evaluation - Effective for dates of service on or after September 1, 1999, Augmentative Communication Device (ACD) evaluation is covered for eligible Medicaid recipients of all ages. One ACD evaluation may be performed every three years based on medical necessity. The benefit limit may be extended for individuals under age 21.

STATE arkansas

DATE RECO 6-28-99

DATE APPV'O 9-17-99 DATE OF 9-1-99 HCFA 179 29-10

SUPERSEDES: NONE - NEW PAGE ☒

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 1b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: August 1, 2003

CATEGORICALLY NEEDY

2.a. Outpatient Hospital Services

(1) For the purpose of determining amount, duration and scope, outpatient hospital services are divided into four types of services:

· Emergency services

· Outpatient surgical procedures

. Non-emergency services

· Therapy/treatment services

Emergency Services

The determination of an emergency medical condition will be in compliance with Section 1867 of the Social Security Act.

A retrospective review will be performed by the Professional Review Organization (PRO) on a sampling of paid claims.

Non-emergency services may be necessary in the outpatient hospital setting when qualified physicians are not available in their offices or walk-in clinics to carry out the necessary treatment.

STATE Arkansas

DATE REC'D 1 Jul 2003

DATE APPY O 8 Aug 2003

DATE EFF 1 Sep 2003

HCFA 179 AR 03-07

ATTACHMENT 3.1-A Page 1c

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 2009

CATEGORICALLY NEEDY

2.a. Outpatient Hospital Services (Continued)

Outpatient Surgical Procedures

Coverage of outpatient surgical procedures are limited to procedures which the Arkansas Medicaid Program has determined to be safe and effective when performed on an outpatient basis.

Since outpatient surgical procedures are limited to approved medically necessary services, no additional benefit limitations are imposed.

Treatment/Therapy Services

The covered outpatient hospital treatment/therapy services include, but are not limited to the following:

· Dialysis

· Radiation therapy

· Chemotherapy administration

· Physical therapy

· Occupational therapy

· Speech therapy

· Respiratory therapy

· Factor 8 injections

· Burn therapy

Treatment/therapy services are included in the outpatient hospital services limit of twelve (12) visits per State Fiscal Year.

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 2023

CATEGORICALLY NEEDY

2.a. Outpatient Hospital Services (Continued)

Non-Emergency Services

Outpatient hospital services other than those which qualify as emergency, outpatient surgical procedures and treatment, and therapy services are covered as non-emergency services.

Benefit Limit

Outpatient hospital services are limited to a total of twelve (12) visits a year. This yearly limit is based on the State Fiscal Year - July 1 through June 30. Outpatient hospital services include the following:

· non-emergency outpatient hospital and related physician and nurse practitioner services; and

· outpatient hospital therapy and treatment services and related physician and nurse practitioner services.

For services beyond the 12-visit limit, an extension of benefits will be provided if medically necessary. The following diagnoses are considered categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection; renal failure; opioid use disorder when the visit is part of a Medication Assisted Treatment Plan; and pregnancy. All other diagnoses are subject to prior authorization before benefits can be extended.

Outpatient hospital services are not benefit limited for recipients in the Child Health Services (EPSDT) Program.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

September 1, 1999

2.a. Outpatient Hospital Services (Continued)

Augmentative Communication Device (ACD) Evaluation

Effective for dates of service on or after September 1, 1999, Augmentative Communication Device (ACD) evaluation is covered for eligible Medicaid recipients of all ages. One ACD evaluation may be performed every three years based on medical necessity. The benefit limit may be extended for individuals under age 21.

STATE arkansas

DATE REC'D 6-28-99

DATE APPID 9-12-99

DATE SFF- 9-1 - 99

HCFA 179 78-10

SUPERSEDES: NONE - NEW PAGE ☒

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2022

CATEGORICALLY NEEDY

2.b. Rural Health Clinic Services

Rural health clinic services are limited to sixteen (16) encounters a year for clients twenty-one (21) years of age and older. This yearly limit is based on the State Fiscal Year (July I through June 30). The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, federally qualified health center encounters, and advanced practice registered nurse services, or a combination of the seven.

Extensions of the benefit limit will be available if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the limit. Clients under age twenty-one (2l) in the Child Health Services (EPSDT) Program are not benefit limited.

Rural health clinic core services are defined as follows:

1. Physicians' services, advanced practice registered nurse's services, and physician assistant services when properly supervised;

2. Services and supplies furnished as an incident to professional services;

Services and supplies "incident to" the professional services of physicians, physician assistants or advanced practice registered nurses are those which are commonly furnished in connection with these professional services, are generally furnished in the rural health center office, and are ordinarily rendered without charge or included in the clinic's bills; e.g., laboratory services, ordinary medications and other services and supplies used in patient primary care services.

3. Clinical psychologist services;

4. Clinical social worker services;

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 2023

CATEOGORICALLY NEEDY

2.b. Rural Health Clinic Services

5. Services of nurse midwives

6. Visiting nurse services on a part-time or intermittent basis to home-bound patients (limited to areas in which there is a shortage of home health agencies).

Rural health clinic ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the Rural health clinic offers such a service (e.g. dental, visual, etc.). The "other ambulatory services" that are provided by the Rural health clinic will count against the limit established in the plan for that service.

Medication Assisted Treatment visits do not count against the Rural Health Clinic encounter benefit limit when the visit is part of a Medication Assisted Treatment plan.

2.c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by a FQHC in accordance with Section 4231 of the State Medicaid Manual (NCFA - Pub. 45-4). Federally qualified health center services are limited to sixteen (16) encounters per client, per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or older. The applicable benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, rural health clinic encounters, and advanced practice registered nurse services, or a combination of the seven.

For federally qualified health center core services beyond the benefit limit, extensions will be available if medically necessary. Beneficiaries under age twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit limited.

FQHC hospital visits are limited to one (1) day of care for inpatient hospital covered days regardless of the number of hospital visits rendered. The hospital visits do not count against the FQHC encounter benefit limit.

Medication Assisted Treatment visits do not count against the FQHC encounter benefit limit when the visit is part of a Medication Assisted Treatment plan.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 2023

CATEGORICALLY NEEDY

2.c. Federally Qualified Health Center (FQHC) services and other ambulatory services that are covered under the plan and furnished by a FQHC in accordance with Section 4231 of the State Medicaid Manual (HCFA - Pub. 45-4). (Continued)

Covered FQHC core services are defined as follows:

· physician services;

· services and supplies incident to physician's services (including drugs and biologicals that cannot be self-administered);

· Immunizations provided based on recommendations of the Advisory Committee on Immunization Practices (ACIP) and their administration;

· physician assistant services;

· nurse practitioner services;

· clinical psychologist services;

· clinical social worker services;

· licensed certified social worker services;

· licensed professional counselor services;

· licensed mental health counselor services;

· licensed marriage and family therapist services;

· services and supplies incident to clinical psychologist, clinical social worker, licensed certified social worker, licensed professional counselor, licensed mental health counselor, and licensed marriage and family therapist services as would otherwise be covered if furnished by or incident to physician services; and

· part-time or intermittent nursing care and related medical supplies (home health) which meets the definition found at 42 CFR 440.70.

FQHC ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the FQHC offers such a service, (e.g. dental, etc.). The "other ambulatory services" that are provided by the FQHC will count against the limit established in the plan for that service.

Effective:

10/01/2023

Approved:

12/08/2023

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised:

October 1, 2023

CATEGORICALLY NEEDY

3. Other Laboratory and X-Ray Services

Other professional and technical laboratory and radiological services are covered when ordered and provided under the direction of a physician or other licensed practitioner of the healing arts within the scope of his or her practice, as defined under 42 CFR 440.30 in an office or similar facility other than a hospital outpatient department or clinic.

Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY, July 1 - June 30), and radiology/other services benefits are separately limited to five hundred dollars ($500) per SFY. Radiology/other services include, but are not limited to, diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).

Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. The five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services benefit limit, do not apply to services provided to recipients under twenty-one (21) years of age enrolled in the Child Health Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program.

(1) The following diagnoses are specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services health benefit limits: (a) Malignant neoplasm; (b) HIV infection; and (c) renal failure. The cost of related diagnostic laboratory services, and radiology/other services will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limits or the five hundred dollars ($500) per SFY radiology/other services health benefit limits.

(2) Drug screening will be specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services health benefit limit when the diagnosis is for Opioid Use Disorder (OUD), and the screening is part of a Medication Assisted Treatment (MAT) plan. The cost of these screenings will not be included in the calculation of the recipient's five hundred dollars ($500) diagnostic laboratory services health benefit limit.

(3) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory services benefit limit or the five hundred dollars ($500) per SFY radiology/other services health benefit limits. The cost of these procedures will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, or the recipient's five hundred dollars ($500) per SFY radiology/other services health benefit limits.

(4) Portable X-Ray Services are subject to the five hundred dollars ($500) per SFY radiology/other services benefit limit. Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. Services may be provided to an eligible recipient in their place of residence upon the written order of the recipient's physician. Portable X-ray services are limited to the following:

a. Skeletal films that involve arms and legs, pelvis, vertebral column, and skull;

b. Chest films that do not involve the use of contrast media; and

c. Abdominal films that do not involve the use of contrast media.

(5) Two (2) chiropractic X-rays are covered per SFY. Chiropractic X-Ray Services are subject to the five hundred dollars ($500) benefit limit per SFY for radiology/other services. Extensions of the radiology/other services benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 1g

AMOUNT, DURATION AND SCOPE OF

SERVICES PROVIDED

Revised: October 1, 1990

CATEGORICALLY NEEDY

4.a. Nursing Facility Services (other than services in an Institution for mental diseases) for Individuals 21 years of age or older.

A Registered Nurse and a Physician Reviewer assess medical needs and make medical eligibility determinations and patient level of care classifications for applicants referred by a physician for nursing home care.

Nursing facility services include coverage of prescription medications within the State's formulary without limitations.

Tokansas

STATE DATE REC DEC 19 1990

4-19-91 DATE APPV'O

CATE EFF

OCT - 1 1990

HCFA 179

90-61

Grapesseles : 89-16

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY

ATTACHMENT 3.1-A Page 1h

Revised: October 1, 2023

4.b Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found.

(1) No limitations on services within the scope of the program (except for consultations, home health services and personal care services) if services are EPSDT related. Extension of the benefit limit for consultations (2 per State Fiscal Year), home health services (50 visits per State Fiscal Year), personal care services (64 hours per calendar month), personal care transportation (50 units per date of service per recipient), physical therapy evaluations (2 per State Fiscal Year), occupational therapy evaluations (2 per State Fiscal Year), speech- language therapy evaluations (4 units per State Fiscal Year), and chiropractor X-ray services (2 per State Fiscal Year) will be provided if medically necessary for recipients in the Child Health Services (EPSDT) Program.

Medical Screens are provided based on the recommendations of the American Academy of Pediatrics. Immunizations are provided based on recommendations of the Advisory Committee on Immunization Practices (ACIP).

The State will provide other health care described in Section 1905(a) of the Social Security Act that is found to be medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, even when such health care is not otherwise covered under the State Plan.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2024

CATEGORICALLY NEEDY

4.b Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(2) Apnea (Cardiorespiratory) Monitors

Apnea (cardiorespiratory) monitors are provided for eligible recipients in the EPSDT Program. Use of the apnea monitors must be medically necessary and prescribed by a physician. Prior authorization is not required for the initial one-month period. If the apnea monitor is needed longer than the initial month, prior authorization is required.

(3) Early Intervention Day Treatment (EIDT) Services

EIDT clinics provide clinic-based evaluation and treatment services for the purpose of early intervention and prevention to eligible recipients in the EPSDT Program. Beneficiaries that have yet to reach school-age may receive EIDT services year-round. School-age beneficiaries can only receive EIDT services during the summer when school is not in session.

A beneficiary must receive an evaluation referral signed and dated by the beneficiary's primary care provider (PCP) to receive EIDT services. For a beneficiary that has yet to reach school-age, the beneficiary's PCP must have completed an approved developmental screen for the beneficiary within the twelve (12) months immediately preceding the date of the evaluation referral. A comprehensive developmental evaluation is a required component of determining EIDT eligibility for beneficiaries who have yet to reach school age. School-age beneficiaries must have a documented qualifying intellectual or developmental disability diagnosis as defined in Ark. Code Ann. § 20-48-101(4) to receive EIDT services during the summer when school is not in session.

A prescription is required for all early intervention and prevention services at an EIDT clinic. If the beneficiary's PCP determines EIDT services are medically necessary based on the results of the beneficiary's evaluations or qualifying medical diagnosis, then the PCP would issue a prescription on a DMS-642 YTP (year-round treatment prescription), or on a DMS-642 STP (summer only treatment prescription) depending on whether the beneficiary had reached school age. The PCP will include the amount and duration of each EIDT service a beneficiary is to receive on the appropriate form. A beneficiary receiving EIDT services is required to receive a new comprehensive developmental evaluation, if applicable, and prescription every twelve (12) months to continue receiving EIDT services.

Since EIDT services are clinic-based services, these services cannot be delivered through telemedicine or at any location other than the licensed EIDT clinic. EIDT providers are considered all-inclusive, meaning a beneficiary attending an EIDT should have all of their habilitative occupational therapy, physical therapy, and speech-language pathology service needs performed by the EIDT program at the EIDT clinic.

OCT-29-2008 07:56 CMS

214 767 0322 P.02

ATTACHMENT 3.1-A

Page 1j

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 4, 2008

CATEGORICALLY NEEDY

4.b Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(4) RESERVED

(

(5) Private Duty Nursing to enhance the effectiveness of ventilator or tracheotomy equipment treatment for ventilator dependent beneficiaries or high technology non-ventilator beneficiaries Enrolled providers are Private Duty Nursing Agencies licensed by Arkansas Department of Human Services, Division of Health. Services are provided by Registered Nurses or Licensed Practical Nurses licensed by the Arkansas State Board of Nursing.

it int change aper stateo est 10/29/08 S. H.

A. Ventilator Dependent Beneficiaries or

B. High Technology Non-Ventilator Dependent Beneficiaries

Beneficiaries under age 21 to receive PDN Nursing Services must require constant supervision, visual assessment and monitoring of both equipment and patient.

Services are limited to eligible Medicaid beneficiaries in the EPSDT Program. Private duty nursing services for non-ventilator dependent beneficiaries include patients requiring at least two of the following services:

(1) Intravenous Drugs (e.g. chemotherapy, pain relief or prolonged IV antibiotics)

(2) Hyperalimentation - parenteral or enteral

(3) Respiratory - Tracheostomy or Oxygen Supplementation

(4) Total Care Support for ADLs and close patient monitoring

These services require prior authorization. Services may be provided in the beneficiaries' home, a Division of Developmental Disabilities (DDS) community provider facility or a public school. (Home does not include an institution.) Prior authorization is required. Private duty nursing medical supplies are limited to a maximum reimbursement of $80.00 per month, per beneficiary With substantiation, the maximum reimbursement may be extended.

SUPERSEDES: TN- 06-16

STATE ARKANSAS

DATE REC

6-11-08

DATE APOV'D

8-12-08

DATE EFF

4-4-08

HCFA 179

01-21

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 1k

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: February 1, 1991

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

6. Cochlear Implants

Coverage of Cochlear implantation is limited to recipients in the EPSDT Program. This procedure requires a prior authorization.

STATE DATE REC'D APK - 4 NJUT

DATE APPV'D MAY - 9 1991 DATE EFF FEB - 1 1991 HCFAUT 91-12

Supersoles: 90-16

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 1L

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: December 1, 1991

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(7) Dentures

Dentures are provided to eligible Medicaid recipients in the Child Health Services""

(EPSDT) Program with prior authorization from the Medical Assistance Section

:8) Hearing Aid Dealers

Supplies prescribed instrument after medical clearance and upon recommendation of an audiologist to eligible recipients in the Child Health Services (EPSDT) Program. Maintenance of instrument provided with prior approval from the Utilization Review Section.

(9) Audiologist Services

Provision of audiometric testing and hearing aid evaluation to eligible recipients in the Child Health Services (EPSDT) Program.

Chickansas

DEG 30 1991

DEC 14 1992

☒

DEC 0 1 1991

91.59

Supersoler TN 91-28

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 1m

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 1991

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(10) Hearing Alda

from BY Call der Rohe essere Hosting aid to tilted to two options per ch

month Tyrod With pyrker might tention additional services may be profkhi #

(11) Eye Prostheses

Eye prostheses are provided for eligible Medicaid recipients in the Child Health Services (EPSDT) Program with prior authorization from the Medical Assistance Section.

(12) Desensitization Injections Limited to eligible Medicaid recipiente In the Child Health Services (EPSDT)

Program

ARKALBOS JUL 07 1991 NOV 19 1991

91428

Superselas: 91-15; 90-02

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 2017

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services(42 CFR 440.130(d))

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Outpatient Behavioral Health Services (OBHS)

As part of the Behavioral Health transformation within the state of Arkansas, DMS is creating a more integrated and client-focused behavioral health care system. These changes were developed in coordination with the Division of Behavioral Health Services (DBHS), providers, representatives of the Arkansas System of Care, beneficiaries and other key stakeholders.

A. Scope

Care, treatment and services provided by a certified Behavioral Health Services provider to Medicaid-eligible beneficiaries. These services are available to all eligible Medicaid beneficiaries. Services which require an Independent Assessment are indicated by the statement, "Eligibility for this service is determined by an Independent Assessment and must be prior authorized."

DMS has set forth in policy the settings in which each individual service may be provided. Each service shown below includes the place of service allowable for that procedure.

B. Services

i .: Individual Behavioral Health Counseling*

DEFINITION: Individual Behavioral Health Counseling, including tobacco cessation counseling, is a face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration.

*All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

i .: Individual Behavioral Health Counseling(continued)*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

ii. Group Behavioral Health Counseling*

DEFINITION: Group Behavioral Health Counseling, including tobacco cessation, is a face-to-face treatment provided to a group of beneficiaries. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support his/her rehabilitation effort, and to minimize relapse. Services must be congruent with the age and abilities of the beneficiary, client- centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present*

DEFINITION: Marital/Family Behavioral Health Counseling with Beneficiary Present, including tobacco cessation, is a face-to-face treatment provided to one or more family members in the presence of a beneficiary for the benefit of the beneficiary. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

iv. Marital/Family Behavioral Health Counseling without Beneficiary Present*

DEFINITION: Marital/Family Behavioral Health Counseling without Beneficiary Present, including tobacco cessation, is a face-to-face treatment provided to one or more family members outside the presence of a beneficiary for the benefit of the beneficiary. Services must be congruent with the age and abilities of the beneficiary or family member(s), client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter- family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

v. Group Psychoeducation*

DEFINITION: Psychoeducation provides beneficiaries and their families with pertinent information regarding mental illness, substance abuse, and tobacco cessation, and teaches problem-solving, communication, and coping skills to support recovery for the benefit of the beneficiary. Psychoeducation can be implemented in two formats: multifamily group and/or single family group. Due to the group format, beneficiaries and their families are also able to benefit from support of peers and mutual aid. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence.

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the Provider must have Arkansas State Infant Mental Health Certification.

vi. Multi-Family Behavioral Health Counseling*

DEFINITION: Multi-Family Behavioral Health Counseling, including tobacco cessation, is a group therapeutic intervention using face-to-face verbal interaction between two (2) to a maximum of nine (9) beneficiaries and their family members or significant others for the benefit of the beneficiary. Services are a more cost- effective alternative to Family Behavioral Health Counseling, designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services may pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

vii. Mental Health Diagnosis*

DEFINITION: Mental Health Diagnosis is a clinical service for the purpose of determining the existence, type, nature, and appropriate treatment of a mental illness or related disorder as described in the DSM-IV or subsequent revisions. This service may include time spent for obtaining necessary information for diagnostic purposes. The psychodiagnostic process may include, but is not limited to: a psychosocial and medical history, diagnostic findings, and recommendations. This service must include a face-to-face component and will serve as the basis for documentation of modality and issues to be addressed (plan of care). Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence.

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

viii. Interpretation of Diagnosis*

DEFINITION: Interpretation of Diagnosis is a direct service provided for the purpose of interpreting and communicating the results of psychiatric or other medical exams, procedures, or accumulated data. Services also include diagnostic activities, as needed, and/or advising the beneficiary and his/ her family of the ramifications of the diagnosis. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence.

For beneficiaries under the age of 18, the time may be spent face-to-face with the beneficiary; the beneficiary and the parent(s) or guardian(s); or alone with the parent(s) or guardian(s). For beneficiaries over the age of 18, the time may be spent face-to-face with the beneficiary and the spouse, legal guardian or significant other.

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

ix. Substance Abuse Assessment*

Substance Abuse Assessment is a service that identifies and evaluates the nature and extent of a beneficiary's substance abuse condition using the Addiction Severity Index (ASI) or an assessment instrument approved by DBHS and DMS. The assessment must screen for and identify any existing co-morbid conditions. The assessment should assign a diagnostic impression to the beneficiary, resulting in a treatment recommendation and referral appropriate to effectively treat the condition(s) identified.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

ix. Substance Abuse Assessment (continued)*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician;

x. Psychological Evaluation*

DEFINITION: Psychological Evaluation for personality assessment includes psychodiagnostic assessment of a beneficiary's emotional, personality, and psychopathology. This service may reflect the mental abilities, aptitudes, interests, attitudes, motivation, emotional and personality characteristics of the beneficiary.

Allowable Performing Provider - Licensed Psychologist, Licensed Psychological Examiner and a Licensed Psychological Examiner - Independent

xi: Pharmacologic Management*

DEFINITION: Pharmacologic Management is a service tailored to reduce, stabilize or eliminate psychiatric symptoms. This service includes evaluation of the medication prescription, administration, monitoring, and supervision and informing beneficiaries regarding medication(s) and its potential effects and side effects in order to make informed decisions regarding the prescribed medications. Services must be congruent with the age, strengths, and accommodations necessary for disability and cultural framework.

Allowable Performing Provider - Advanced Practice Nurse or a Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

xii: Psychiatric Assessment*

DEFINITION: Psychiatric Assessment is a face-to-face psychodiagnostic assessment conducted by a licensed physician or Advanced Practice Nurse (APN), preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under age 18). This service is provided to determine the existence, type, nature, and most appropriate treatment of a behavioral health disorder.

Allowable Performing Provider - Advanced Practice Nurse or a Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-A Page 1o

Revised: January 1, 2021

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(14) RESERVED

(15) Physical Therapy and Related Services

a. Physical Therapy

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Effective for dates on or after January 1, 2021, evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary.

(3) Services must be prescribed by a physician and provided by or under the supervision of a qualified physical therapist.

A qualified physical therapist assistant may provide services under the supervision of a licensed physical therapist.

All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.

(4) Effective for dates of service on or after July 1, 2017, individual and group therapy are limited to six (6) units per week. Extensions of the benefit limit will be provided if medically necessary.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2021

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(15) Physical Therapy and Related Services (Continued)

b. Occupational Therapy

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Services must be prescribed by a physician and provided by or under the supervision of a qualified occupational therapist.

A qualified occupational therapist assistant may provide services under the supervision of a licensed occupational therapist.

All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.

(3) Effective for dates on or after January 1, 2021, evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary.

(4) Effective for dates of service on or after July 1, 2017, individual and group occupational therapy are limited to six (6) units per week. Extensions of the benefit limit will be provided if medically necessary.

c. Services for individuals with speech, hearing and language disorders (provided by or under the supervision of a speech pathologist or audiologist)

(1) Speech-language pathology services are limited to Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Speech-language pathology services must be referred by a physician and provided by or under the supervision of a qualified speech-language pathologist.

A qualified speech-language therapist assistant may provide services under the supervision of a licensed speech-language therapist.

All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.

(3) Evaluations are limited to four (4) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary.

(4) Effective for dates of service on or after July 1, 2017, individual and group speech-language pathology services are limited to six (6) units per week. Extensions of the benefit limit will be provided if medically necessary.

Approval: 11-9-2020 Effective Date:1-1-2021

ATTACHMENT 3.1-A Page 1q

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 2014

CATEGORICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(16) Dental Services

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Procedures which may be provided to recipients in the Child Health Services (EPSDT) Program without prior authorization are:

a. Initial radiographs taken in conjunction with preparation of a treatment plan.

b. Periodic oral exam, prophylaxis, topical fluoride and/or fluoride varnish for children in the Child Health Services (EPSDT) Program.

c. Emergency treatment. One visit without prior authorization is payable for any emergency. Procedures payable without prior authorization when provided as emergency care include:

1. All necessary radiographs.

2. Extraction of up to three teeth for relief of pain or acute infections.

3. Control of bleeding.

4. Treatment for relief of pain resulting from injuries to the oral cavity or related services.

5. Emergency services provided to patients in hospitals or long term care facilities.

All other procedures require prior authorization from the Medical Assistance Section. A full mouth radiograph is limited to once every five years. Periodic oral exam, prophylaxis, fluoride treatment, fluoride varnish and bite-wing X-rays are limited to once per 6 (six) months plus 1 (one) day. Scaling is limited to one per state fiscal year (July 1 through June 30). Periapical X-rays are limited to four (4) per recall visit. Any limits will be exceeded based on medical necessity.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

February 15, 1995

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

17. Rehabilitative Services for Persons with Physical Disabilities (RSPD)

8. Residential Rehabilitation Center Services

. Restorative Therapies Behavioral Rehabilitation Life Skills Training for Rehabilitation

. Individual and Group Counseling

Assessment Services

. Nursing Care

Residential Rehabilitation Center Services are available to eligible Medicaid recipients under age 21 in the Child Health Services (EPSDT) Program. There is no established benefit limit other than medical necessity as determined by the Professional Review Organization (PRO). The medical necessity criteria includes need for services in the residential setting. Persons needing rehabilitative services on a less intense basis than provided in the inpatient setting may receive outpatient rehabilitative services through other appropriate service categories included in the state plan, e.g., outpatient hospital, physical therapy, occupational therapy and speech therapy, rehabilitative services for persons with mental illness (RSPMI) and home health.

Fitanses STATE DATE REC'D JAN /1 2 1995

DATE APEV'D FEB 2 2 1995

DATE E !. F FEB 1 5 1995 415-01 HCFA 179

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

February 1, 2001

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age. and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services

1. School-Based Mental Health Services

Services are limited to eligible Medicaid recipients under age 21 in the Child Health Services (EPSDT) Program.

b. A referral must be made by a Medicaid enrolled physician documenting services are medically necessary.

c. Services are provided at the school or in the home when the home is considered to be an educational setting for a child who is enrolled in the public school system. The home is not considered a place of service when the parent elects to home school the child.

d. The State assures that eligible Medicaid recipients will be given free choice of providers within and outside the school setting.

0. Provider Qualifications

The Arkansas Medicaid program has established provider participation requirements for school-based mental health services.

In order to ensure quality and continuity of care, School Districts and/or Education Services Cooperatives that are School-Based Mental Health Service Providers approved to receive Medicaid reimbursement must ensure that contractors and personnel engaged as Licensed School-Based Mental Health Practitioners meet specific Medicaid qualifications. Practitioners licensed as school-based mental health services provider personnel may provide the services according to their scope of practice as identified by the licensure requirements. Services will be provided by the following:

Arkansas

Jan 01, 2001 Mar 24.2001

Feb 01, 2001

00-013

DATE APPV'D DATE EFF HCFA 179

STATE

DATE REC'D

1. School Psychology Specialist (licensed by the Arkansas Department of 1klucation (ADE)

2. 1.icensed Certified Social Worker (licensed by the Arkansas Social- Work Licensing Board)

3. Licensed Masters Social Worker (licensed by the Arkansas Social- Work Licensing Board;

4. Psychological Examiner (licensed by the Arkansas Board of Examiners in Psychology)

5. Licensed Psychologist dlicensed by the Arkansas Board of Examinets in Psychology )

6. Licensed Professional Counselor (licensed by the Arkansas Board of I'vantimes in Counseling)

7. Liveused Associale Counselor (licensed by the Arkansas Board of i vamimes in ( omuscling )

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2017

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services (42 CFR 440.130(d)) (continued)

1. School-Based Mental Health Services (continued)

f. Covered Services (continued)

1. Individual Behavioral Health Counseling - A face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition, including tobacco cessation. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration.

2. Mental Health Diagnosis - A clinical service for the purpose of determining the existence, type, nature, and appropriate treatment of a mental illness or related disorder as described in the DSM-IV or subsequent revisions. This service may include time spent for obtaining necessary information for diagnostic purposes. The psychodiagnostic process may include, but is not limited to: a psychosocial and medical history, diagnostic findings, and recommendations. This service must include a face-to-face component and will serve as the basis for documentation of modality and issues to be addressed (plan of care). Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence.

3. Psychological Evaluation - Psychological Evaluation for personality assessment includes psychodiagnostic assessment of a beneficiary's emotional, personality, and psychopathology. This service may reflect the mental abilities, aptitudes, interests, attitudes, motivation, emotional and personality characteristics of the beneficiary.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2017

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services (42 CFR 440.130(d)) (continued)

1. School-Based Mental Health Services (continued)

f. Covered Services (continued)

4. Interpretation of Diagnosis - A direct service provided for the purpose of interpreting the results of psychiatric or other medical exams, procedures, or accumulated data. Services may include diagnostic activities and/or advising the beneficiary and his/ her family. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength- based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. The time may be spent face-to-face with the beneficiary; the beneficiary and the parent(s) or guardian(s); or alone with the parent(s) or guardian(s). For beneficiaries over the age of 18, the time may be spent face-to-face with the beneficiary and the spouse, legal guardian or significant other.

5. Marital/Family Behavioral Health Counseling with Beneficiary Present - A face-to-face treatment provided to one or more family members in the presence of a beneficiary for the benefit of the beneficiary, including tobacco cessation. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

6. Crisis Intervention - An unscheduled, immediate, short-term treatment activity provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services, which can include interventions, stabilization activities, coping strategies and other various activities to assist the beneficiary in crisis, are designed to stabilize the person in crisis, prevent further deterioration and provide immediate indicated treatment in the least restrictive setting. The services provided are expected to reduce or eliminate the risk of harm to the person or others in order to stabilize the beneficiary. (These activities include evaluating a Medicaid-eligible beneficiary to determine if the need for crisis services is present.)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services (continued)

1. School-Based Mental Health Services (42 CFR 440.130(d)) (continued)

f. Covered Services (continued)

7. Group Behavioral Health Counseling - Face-to-face treatment provided to a group of beneficiaries, including tobacco cessation. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support his/her rehabilitation effort, and to minimize relapse. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children

ELIGIBILITY FOR SERVICES

The following recipients are eligible for rehabilitative services to children as set forth in this Section:

A. General Eligibility

1. Categorically Needy Medicaid recipients.

B. Specific Eligibility

1. The recipient must be age twenty (20) years or less, and

2. Require rehabilitative mental health services based on recommendation of a physician or other licensed and/or certified practitioner of the healing arts acting within their scope of practice as defined in state law and/or regulations.

DURATION OF SERVICES

Each Title XIX EPSDT recipient is eligible for covered rehabilitative services in accordance with 42 CFR 440.130(d) which are medically necessary. There shall be a determination, made by a child service agency designated by state law and/or regulations, at Title 9, Chapter 30 of the Arkansas Code to make such a determination, that the child continues to be either at risk of abuse or neglect or is abused or neglected. The Division of Medical Services, as the entity authorized to determine medical necessity, reserves the right to request additional information to determine medical necessity.

COVERED SERVICES

A covered service is a specific non-residential or residential rehabilitative service determined to be medically necessary, as defined above, and included in a child's treatment plan prepared by a qualified provider of rehabilitative services to children. These services are designed to ameliorate psychological or emotional problems related to neglect and/or abuse, to restore psychological or emotional functioning which was impaired by the problems related to neglect

STATE ARKANSAS

DATE REC'D

07-16-01

DATE APPV'D

08-31-01

DATE EFF

10-01-98

HCFA 179

AR-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

and/or abuse, and to assist the child in improving or maintaining his/her highest functioning level. The following services are covered when provided according to the plan of care and when care is provided by professional state licensed and/or certified psychiatrists, psychologists, counselors, and social workers acting within their scope of practice as defined in state law and/or regulations.

1. Evaluation, Assessment, and Plan of Care Development - This non-residential service includes the initial assessment of a child's service needs and the development of a Care Plan to address those needs.

(a) The evaluation and assessment shall:

(1) Be based on informed clinical opinion;

(2) Be conducted by a team of professionals trained to utilize appropriate evaluative methods and procedures and acting within their scope of practice or responsibility as defined in State law and/or regulations; and

(3) Include an evaluation of the child's cognitive development, social and emotional development and adaptive development.

(b) The plan of care shall contain:

(1) A written plan using the information derived from the evaluation and assessment;

(2) A statement of the child's present level of functioning in the domains examined in the evaluation and assessment;

(3) A statement of the specific services and supports necessary to meet the unique needs of the child, the setting in which the services are to be delivered, the frequency and method of delivery, and the anticipated duration of services;

STATE ARKANSAS

DATE REC'D

07-16-01

DATE APPVD

08-31-01

DATE EFF

10-01-98

HCFA 179

AR-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

(4) A statement of the persons responsible for implementing the plan of care; and

(5) A statement of the functional outcomes expected to be achieved though the provision of services and supports.

2. Therapeutic Foster Care - This residential service is provided to children whose plan of care indicates a need for a structured and consistent home environment in order to learn to manage their behavior. This twenty-four hour service consists of face-to-face interventions with a child to assist the child in understanding the consequences of inappropriate behaviors and adhering to a behavioral routine which minimizes inappropriate behaviors and their consequences. This service is provided for the purpose of the development, restoration, and/or maintenance of the child's mental or emotional growth and the development, restoration, and/or maintenance of the skills to manage his/her mental or emotional condition.

3. Residential Treatment - This residential service provides twenty-four hour treatment to children whose psychological or emotional problems related to neglect and/or abuse can best be restored by residential treatment in accordance with the child's plan of care. The objective of this service is to assist the child in improving or maintaining his/her highest functioning level through individual and group therapeutic interventions to improve or maintain the skills needed to safely and securely interact with other persons, through symptom management to allow the child to identify and minimize the negative effects of psychiatric or emotional symptoms which interfere with the child's personal development and community integration, and through supportive counseling with a child to develop, restore and/or maintain the child's mental or emotional growth.

PROVIDER QUALIFICATION

Rehabilitative services for children will be provided only through qualified provider agencies. Qualified provider agencies must meet the following rehabilitative services for children criteria:

1. [ lave full access to all pertinent records concerning the child's needs for services including records of the Arkansas District Courts, local Children's Service Agencies, and State Child and Family Services Agency,

SUPERSEDES. TN- 98-11

STATE Arkansas

DATE REC'D 12-10-01

DATE APPV'O 12-21-01

DATE EFF 04-01-02

HCFA 179 AR-41-35

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

2. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population,

3. Have a minimum of one year's experience in providing all core elements of rehabilitative services for children,

4. Have an administrative capacity to ensure quality of services in accordance with State and Federal requirements,

5. Have a financial management capacity and system that provides documentation of services and costs in, conformity with generally accepted accounting principles,

6. Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and

7. Have a demonstrated ability to meet all State and Federal laws governing the participation of providers in the State Medicaid program, including the ability to meet Federal and State requirements for documentation, billing, and audits.

SERVICE SETTINGS

Rehabilitative services for children will be provided in the least restrictive setting appropriate to the child's assessed condition, plan of care, and service needs. Services shall be provided to children in one of the following settings:

1. Non-residential services provided to children who reside in a family home setting will be provided either in the child's home or in the customary place of business of a qualified provider.

2. Residential services provided to children who reside outside of a family home will be provided in an appropriately state licensed and/or certified facility including:

(a) Therapeutic foster homes licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Boardtant the Arkansas Department of Human Services.

STATE ARKANSAS

DATE RECO

07-16-01

DATE APPVID 08-31-01

DATE EFF

10-01-98

HCFA 179 Are-98-11

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

October 1, 1998

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

3. Services shall not be reimbursed when provided in the following settings:

(a) Nursing facilities,

(b) Intermediate care facilities for the mentally retarded, and

FREEDOM OF CHOICE

The State assures that the provision of rehabilitative services for children will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

1. Eligible recipients will have free choice of any qualified provider of rehabilitative services for children, and

2. Eligible recipients will have free choice of the providers of other medical care as covered elsewhere under the Plan.

COMPARABILITY OF SERVICES

The State assures that the provision of rehabilitative services for children will not limit an individual's access to medically necessary services in violation of section 1902(a)(10) of the Act.

1. Rehabilitative services for children will be made available to all children for whom this service is determined to be medically necessary, and

2. All medically necessary health care services described in section 1905(a) will be provided to all EPSDT eligible recipients.

STATE ARKANSAS

DATE REC'D

07-16-01

DATE APPV'D

08-31-01

DATE EFF

10-01-98

HCFA 179

AR-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

46. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth

ELIGIBILITY FOR SERVICES

The following recipients are eligible for rehabilitative services to youth as set forth in this Section:

A. General Eligibility

1. Categorically Needy Medicaid recipients.

B. Specific Eligibility

1. The recipient must be age twenty (20) years or less, and

DURATION OF SERVICES

Each Title XIX EPSDT recipient is eligible for covered reliabilitative services in accordance with 42 CFR 440.130(d) which are medically necessary. There shall be a determination, made by a youth services agency designated by state law and/or regulations, at Title 9, Chapter 28 of the Arkansas Code to make such a determination, that the youth continues to be either at risk of delinquency or is delinquent and is in need of those services specified at Title 9, Chapter 28 of the Arkansas Code. The Division of Medical Services, as the entity authorized to determine medical necessity, reserves the right to request additional information to determine medical necessity.

STATE arkansas

DATE RECO

08-06-98

DATE APAVD 05-14-01

DATE EFE 10-01-98

HCF: 179

AR-98-12

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

COVERED SERVICES

A covered service is a specific in-home or out-of-home non-residential or residential rehabilitative service determined to be medically necessary, as defined above, and included in a youth's treatment plan prepared by a qualified/certified provider of rehabilitative services to youth. These services are designed to ameliorate psychological or emotional problems of youth, which contribute to delinquent behavior and placement or the risks of placement in the youth services system. They are designed to restore psychological or emotional functioning of the youth to assist him/her in achieving or maintaining his/her highest functioning level. The following services are covered when provided in a setting appropriate to the plan of care and when care is provided through a certified provider of rehabilitative services for youth.

1. Diagnosis and Evaluation - This non-residential service provides assessment of the nature and extent of a youth's physical, emotional, educational and behavioral problems and recommendations for treatment strategies to remedy the identified problems. The specific diagnostic services provided and level of sophistication of reports produced are based on the individual needs of the referring agency. Allowable components include:

(a) Social assessment,

(b) Psychological evaluation,

(d) Consultation with the referring agency, and

(e) A medical evaluation, if the assessment indicates a physical association with the emotional and/or behavioral problem(s).

STATE: Arkansas

DATE RECIO 08-06-48 DATE APPI/O 06-14-01

DATE EFF

10-01-98

HCFA 179 AR-98-12

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

2. Therapy - This non-residential service provides for a therapeutic relationship between the client and a "qualified therapist" for the purpose of accomplishing changes that are identified as goals in the case plan through the use of various counseling techniques. Services to specific individuals include:

(a) Individual therapy,*

(b) Group therapy,*

(d) Consultation with the referral source.

Qualified therapist is defined as a Master's level professional or Bachelor's level professional supervised by a Master's level clinician, or a Master's level psychologist supervised by a Ph. D. level psychologist who is licensed in the State of Arkansas in either psychology, social work or professional counseling. To be considered as a "Qualified Therapist" the individual must be in good standing before the board to which he or she is licensed.

3. Emergency Shelter - This residential service provides services for youth whose circumstances or behavioral problems necessitate immediate removal from their homes or for youth released from a youth services facility who need temporary placement in the community until long term residential arrangements can be made. Emergency Shelter services include:

(a) Additional evaluation of the nature and extent of a youth's emotional and behavioral problems, including social assessment psychological evaluation, psychiatric evaluation and consultation with the referring agency, and

(b) Interventions to address the youth's emotional and behavioral problems.

The extent and depth of services provided to a youth in the Emergency Shelter program depends upon the individual needs of the youth and the referral source.

* Effective April 1, 2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.

SUPERSEDES· TN- 98-12

STATE Arkansas

DATE RECO 12-10-01

DATE APPV'D 12-21-01

DATE EFF 04-01-02

HCFA 173 AR-01-35

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

4. Therapeutic Foster Care - This residential service provides intensive therapeutic care for children provided in family homes which operate within a comprehensive residential treatment system or as an adjunct to a mental health treatment program and for which a service fee is paid to specially trained foster families. Care givers who provide this service in their homes, if not specially trained, are specifically qualified to provide the service because they have an educational or a professional background that attests to qualification equal to or greater than that of care givers who have received special training. Children to whom this service is provided have physical, emotional, or behavioral problems which cannot be remedied in their own home, in a routine foster parenting situation, or in a residential program.

5. Therapeutic Group Home - This residential service provides twenty-four hour intensive therapeutic care provided in a small group home setting for youth with emotional and/or behavior problems which cannot be remedied by less intensive treatment, as diagnosed by a qualified professional. The program is offered to prepare a juvenile for less intensive treatment, independent living, or to return to the community.

6. Residential Treatment - This residential service provides twenty-four hour treatment service available for up to one year for each individual, for youth whose emotional and/or behavioral problems, as diagnosed by a qualified professional, cannot be remedied in his or her own home. Residential Treatment services require the formulation and implementation of an individualized treatment plan with time-framed, measurable objectives for each youth.

Qualified professional is defined as a Master's level professional or Bachelor's level professional supervised by a Master's level clinician, or a Master's level psychologist supervised by a Ph. D. level psychologist who is licensed in the State of Arkansas in either psychology, social work or professional counseling. To be considered as a "Qualified Professional" the individual must be in good standing before the board to which he or she is licensed.

SUPERSEDES. TN- 98-12

STATE Arkansas

DATE REC'D 12-10-01

DATE APPV D 12-21-01

DATE EFF 04-01-02

HCFA 179 AR-01-35

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

PROVIDER QUALIFICATION

Rehabilitative services for youth will be provided only through qualified providers and provider agencies. Qualified rehabilitative services for youth provider agencies must meet the following criteria. Care is provided by qualified therapists , other qualified professionals and staff, qualified by experience and/or training, of certified rehabilitative services providers for youth. Rehabilitative services providers for youth must:

1. Be certified by the State Youth Services Agency as having programs and professional staff capable of delivering the rehabilitative services offered under the Plan,

2. Have full access to all pertinent records concerning the youth's needs for services including records of the Arkansas District Courts, local Youth Service Agencies, and State Youth Services Agency,

3. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population,

4. Have a minimum of one year's experience in providing rehabilitative services for youth,

5. Have an administrative capacity to ensure quality of services in accordance with State and Federal requirements,

6. Have a financial management capacity and system that provides documentation of services and costs in conformity with generally accepted accounting principles,

7. Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and

STATE Arkansas

DATE :200 08-06-98

DATE APPVS 05-14-01 DATE EFF 10-01-98

HCFA 1Ty AR-98-12

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

8. Have a demonstrated ability to meet all State and Federal laws governing the participation of providers in the State Medicaid program, including the ability to meet Federal and State requirements for documentation, billing and audits.

SERVICE SETTINGS

Rehabilitative services for youth will be provided in the least restrictive setting appropriate to the youth's assessed condition, plan of care and service. Services shall be provided to youth in one or more of the following settings:

1. Non-residential services provided to youth who reside in a family home setting will be provided either in the youth's home or in the customary place of business of a qualified provider.

2. Residential services provided to youth who reside outside of a family home will be provided in an appropriately state licensed and/or certified setting including:

(a) Emergency shelter facilities licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services,

(b) Residential treatment facilities licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services, and

(c) Therapeutic foster and group homes licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services.

STATE Arkansas DATE NED C 08-06-98 DATE APPVO 0 5-14-01 DATE EFF 10 -01-48 HCFA 179 AR-98-12

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

SERVICE SETTINGS(Continued)

3. Services shall not be reimbursed when provided in the following settings:

(a) Nursing facilities,

(b) Intermediate care facilities for the mentally retarded, and

FREEDOM OF CHOICE

The State assures that the provision of rehabilitative services for youth will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

1. Eligible recipients will have free choice of any the qualified providers of rehabilitative services for youth, and

2. Eligible recipients will have free choice of the providers of other medical care as covered elsewhere under the Plan.

COMPARABILITY OF SERVICES

The State assures that the provision of rehabilitative services for youth will not limit an individual's access to medically necessary services in violation of section 1902(a) (10) of the Act.

1. Rehabilitative services for youth will be made available to all children for whom this service is determined to be medically necessary, and

2. All medically necessary health care services described in section 1905(a) will be provided to all EPSDT eligible recipients.

STATE Arkansas 1

DATE RECO 08-06-48 DATE APPVO 05-14-01 DATE GFP 10-01-98 HCFA 179 AR-98-12 :

SUPERSEDES: NONE . NEW PAGE

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 1, 2002

CATEGORICALLY NEEDY

46. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

21. Other Licensed Practitioners

1. Licensed Certified Social Worker (LCSW)

a. Services are limited to Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT) Program.

b. Services must be provided by a licensed certified social worker (LCSW) who has a Master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education (CSWE). The LCSW must be State licensed and certified to practice as a Licensed Certified Social Worker (LCSW) in the State of Arkansas and in good standing with the Arkansas Social Work Licensing Board.

c. A referral must be made by a Medicaid enrolled physician documenting services are medically necessary. Covered outpatient LCSW services are:

1. Diagnosis

2. Interpretation of Diagnosis

3. Crisis Management Visit

4. Individual Outpatient - Therapy Session*

5. Marital/Family Therapy*

6. Individual Outpatient - Collateral Services*

7. Group Outpatient - Group Therapy*

2. Licensed Professional Counselors (LPC)

a. Services are limited to Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT) Program.

b. Services must be provided by a licensed professional counselor (LPC) who must possess a Master's degree in mental health counseling from an accredited college or university. The LPC must be licensed as a Licensed Professional Counselor and be in good standing with the Arkansas Board of Examiners in Counseling.

c. A referral must be made by a Medicaid enrolled physician documenting medical necessity. Covered outpatient LPC services are:

Diagnosis

STATE Arkansas

Interpretation of Diagnosis
Crisis Management Visit

12-10-01 DATE RECO

Individual Outpatient - Therapy Session

DATE APPY D (2-21-01

Marital/Family Therapy*

DATE EFF 04-01-02

Individual Outpatient - Collateral

Services* FCFA 179 AR-01-35

Group Outpatient - Group Therapy*

* Effective April 1, 2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.

SUPERSEDES: TN- CO-06

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-A Page 1yyyyy

Revised: March 1, 2014

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

21. Other Licensed Practitioners (Continued)

3. Licensed Marriage and Family Therapist (LMFT)

a. Services are limited to Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT) Program.

b. Services must be provided by a licensed marriage and family therapist (LMFT) who must possess a Master's degree in mental health counseling from an accredited college or university. The LMFT must be licensed as a Licensed Marriage and Family Therapist and in good standing with the Arkansas Board of Examiners in Counseling.

c. A referral must be made by a Medicaid enrolled physician documenting services are medically necessary. Covered outpatient LMFT services are:

1. Diagnosis

2. Interpretation of Diagnosis

3. Crisis Management Visit

4. Individual Outpatient - Therapy Session*

5. Marital/Family Therapy*

6. Individual Outpatient - Collateral Services*

7. Group Outpatient - Group Therapy*

* Effective April 1, 2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

February 1, 2002

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

23. Developmental Rehabilitation Services

Developmental Rehabilitation Services are early intervention services for eligible Medicaid recipients under three years of age that have been identified as medically necessary and recommended by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law. This program covers two basic services:

1. Developmental Testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report, per hour. (Limited to four (4) one hour units per calendar year.)

I ☒

Arkansas

12 -4-01

DATE APPVID 02-11-02

02-01-02 AR 01-33

STATE

DATE REC'D

DATE EFF

HCFA 179

This service provides a diagnostic process necessary for the purpose of determining a child's initial and continuing eligibility, developmental status and need for medically necessary developmental services. This includes:

a. The assessment of motor, language, adaptive and/or cognitive functioning by standardized developmental instruments such as Bayley Scales of Infant Development, Early Learning Accomplishment Profile, Brigance Test of Development, etc. Specific activities include the administration of a minimum of two test Instruments, interpretation of test scores with informed clinical opinion, and provision of a written narrative report.

b. Developmental functioning in each of these areas describes the level on which the child is currently functioning as compared to other children of the same chronological age, and the skills to be remediated.

c. Results will be included in the development of the IFSP. Developmental testing does not include medical, speech therapy, occupational therapy, physical therapy, audiological or vision evaluations.

2. Therapeutic Activities; direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes. (Limited to four (4) 15-minute units per week.)

a. This service is provided to the child and the child's parent/family to promote acquisition of skills in developmental areas (cognitive, motor, adaptive, communication). These rehabilitative services include:

1) the planned interaction of personnel, materials, time and space, to provide direct, medically necessary therapeutic intervention to the child;

2) provision of information to the family therapeutic curriculum planning;

3) provision of information to the family related to establishing the skill level and enhancing the development of the child.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

February 1, 2002

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

23. Developmental Rehabilitation Services (continued)

2. Therapeutic Activities (continued)

b. Therapeutic intervention will focus on developmentally appropriate individualized skills training and support to foster, promote and enhance child engagement in daily activities, functional independence and social interaction.

c. Assistance will be provided to family/caregivers in the identification and utilization of opportunities to incorporate therapeutic intervention strategies in daily life activities that are natural and normal for the child and family.

d. Child progress and mastery of functional skills to reduce or overcome limitations resulting from developmental delays will be continuously monitored by the Developmental Therapist.

e. Therapeutic activities may be provided in an individual session only.

3. A provider of Developmental Testing and Therapeutic Activities must be certified through the Arkansas Department of Human Services, Developmental Disabilities Services as a Developmental Therapist or Developmental Therapy Assistant. Certification requirements are:

a. A Developmental Therapist is a qualified professional, licensed by the Arkansas Department of Education, who has completed an additional certification requirement of a 24 hour training course and passed a competency based assessment with a minimum score of 80%. Developmental Testing Services must be provided by a Developmental Therapist.

b. A Developmental Therapy Assistant is a qualified paraprofessional who holds a minimum of a high school diploma and has two years experience working with children with disabilities. The Developmental Therapy Assistant must complete an initial 24 hour training course and pass a competency based assessment with a minimum score of 80%. The Assistant must work under the supervision of the Developmental Therapist and must be supervised 10% of the time spent in direct interaction with the recipient. A Developmental Therapy Assistant may provide only Therapeutic Activities services.

Developmental Rehabilitation Services may be provided in the recipient's home, in the community, or in a clinical setting. These services require prior authorization.

Extension of the benefit limit will be provided if medically necessary.

STATE Arkansas

DATE RECO 12-4-01

DATE APPVID_02-11-02

DATE EFF

02-01-02

HCFA 179 Ar 01-33

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services

Substance Abuse Treatment Services (SATS) are provided for eligible recipients in the Child Health Services (EPSDT) Program. Services must be medically necessary and require prior authorization.

The SATS program covers the following services:

A. Addiction Assessment

B. Treatment Planning

C. Care Coordination

D. Multi-person (family) Group Counseling

E. Individual Counseling

F. Group Counseling

G. Marital/Family Counseling

H. Medication Management

Please refer to Attachment 3.1-A, Page 1zz.3 for the service descriptions, definitions, established benefit limits and individual qualified provider requirements. Benefit limits may be extended based on medical necessity.

SATS Qualified Provider Requirements

SATS providers must hold certification from the Division of Behavioral Health Services (DBHS) as a Substance Abuse Treatment Services provider in order to enroll as a SATS Medicaid provider.

The following requirements must be met for DBHS/OADAP certification:

A. Providers must be licensed by Division of Behavioral Health Services, Office of Alcohol and Drug Abuse Prevention (OADAP).

B. Providers must submit a written request from the organization's Chief Executive Officer (CEO) to DBHS for certification by DBHS as a SATS Provider.

C. The request for certification by DBHS must include a copy of the provider's accreditation, most recent accreditation survey, and correspondence between the provider and the accrediting organization since the most recent accreditation survey.

D. A list of service delivery sites, including each site's address, telephone number, and fax number must be submitted. Each site from which SATS services are delivered must be included under the provider's accreditation. Proof of this accreditation must be submitted with the request for certification of a site.

E. Current CARF, JCAHO, or COA, that includes accreditation of the pertinent outpatient alcohol and/or other drug abuse treatment component (OADAP Licensure Standards for Alcohol and/or Other Drug Abuse Treatment Programs p. 11). Current nationally accredited behavioral health programs without specific alcohol and drug treatment certification will need to obtain accreditation of their substance abuse program prior to receiving certification as a SATS provider of substance abuse treatment.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

F. Provisional, Conditional, Preliminary, Pending, Expedited or Deferred Accreditations are not acceptable.

G. The provider must: notify its accrediting organization in writing of all new or additional SATS services implemented subsequent to the provider's most recent accreditation survey; provide DBHS with a copy of the notification letter; and affirm in writing to DBHS that the new service(s) will be included in the provider's next regularly scheduled accreditation survey, if not surveyed before that time. Provider organization opening new services sites must follow DBHS certification policy and procedures.

H. DBHS must be authorized to receive information directly from the accrediting organization and to provide information directly to the accrediting organization, as it relates to SATS. DBHS will furnish these documents to providers at their request.

I. DBHS retains the right to request information in connection with licensure, accreditation, certification, provision or billing of SATS services; to perform site visits at anytime; and to conduct scheduled or unannounced visits, to insure entities are providing SATS services in accordance with the information that was submitted to DBHS. During a site visit the provider must allow access to all sites, policies and procedures, patient records, financial records, and any other documentation necessary to ascertain that services were/are of a quality which meets professionally recognized standards of health care.

J. Providers must adhere to evidence-based practices as approved by DBHS for specific populations and services provided.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions

The following service definitions were developed by a work group composed of members from the Division of Behavioral Health Services, the Division of Medical Services and providers. The service definitions also contain sections that address the maximum units allowable, and unit definitions.

SERVICES:

ADDICTION ASSESSMENT

DEFINITION:

The Substance Abuse Assessment Service identifies and evaluates the nature and extent of an individual's use/abuse/addiction to alcohol and/or other drugs and identifies but does not diagnose any existing co-morbid conditions. A standardized assessment instrument, approved by DBHS and DMS, must be used to complete the assessment process. The assessment process results in the assignment of a diagnostic impression, patient placement recommendation for treatment regimen appropriate to the condition and situation presented by the recipient, and referral into a service or level of care appropriate to effectively treat the condition(s) identified. A 9 panel test is part of the assessment to assist in the recipient's self-report of the alcohol and drug use and to develop an accurate diagnosis, referral and treatment plan. The 9 Panel Test is a screening test for marijuana, cocaine, benzoylecgonine, PCP, Morphine and its related metabolites derived from opium (opiates), methamphetamines (including Ecstasy), methadone, amphetamines, barbiturates, and benzodiazepines.

Benefit limit/Unit Definition: 1 per episode; 1 assessment per SFY

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have a collaborative agreement with a physician licensed in state of Arkansas

· Licensed Alcoholism and Drug Abuse Counselor (LADAC)

· Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)

· Certified Co-Occurring Disorder Professional - Diplomate Level (CCDP-D)

With the addition of substance abuse credentials (LADAC, ACADC, CCDP-D), the following persons may provide substance abuse clinical services:

· Licensed Certified Social Worker (LCSW) and Licensed Master Social Worker (LMSW). (LMSW must be under approved supervision)

· Licensed Professional Counselor (LPC) and Licensed Marriage and Family Therapist (LMFT) are independent practice and don't require supervision, and Licensed Associate Counselor (LAC) - must have approved supervision

· Psychologist

· Psychological Examiner (LPE-I) licensed to practice independently

· Psychological Examiner (LPE) under the supervision of a Psychologist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

TREATMENT PLANNING

DEFINITION:

A developed plan in cooperation with the individual (parent or guardian if the individual is under 18) to deliver specific addiction services to the individual to restore, improve or stabilize the individual's condition. The plan must be based on individualized service needs identified in the completed Addiction Assessment. The plan must include goals for the medically necessary treatment of identified problems, symptoms and addiction issues. The plan must identify individuals or treatment teams responsible for treatment, specific treatment modalities prescribed for the individual, and time limitations for services.

Benefit Limit/Unit Definition: 1 per episode; 1 per SFY

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have a collaborative agreement with a Physician licensed in state of Arkansas

· Licensed Alcoholism and Drug Abuse Counselor (LADAC)

· Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)

· Certified Co-Occurring Disorder Professional - Diplomate Level (CCDP-D)

With the addition of substance abuse credentials (LADAC, ACADC, CCDP-D) the following persons may provide substance abuse clinical services:

· Licensed Certified Social Worker (LCSW) and Licensed Master Social Worker (LMSW). (LMSW must be under approved supervision)

· Psychologist

· Psychological Examiner (LPE-I) licensed to practice independently

· Psychological Examiner (LPE) under the supervision of a Psychologist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

CARE COORDINATION

DEFINITION:

Care Coordination services are services that will assist the client and family in gaining access to needed medical, social, educational, and other services. Care Coordination will be provided using a wrap-around or recovery model and will include the following activities: input into the treatment planning process, coordination of the treatment planning team, referral to services and resources identified in the treatment plan, facilitating linkages between levels of care, and monitoring and follow up activities that are necessary to ensure the goals identified in the treatment plan are met or need to be revised. Care Coordination services ensure communication and collaboration between agencies, providers and other individuals necessary to implement the goals identified in the treatment plan.

Benefit limit/Unit Definition: 12 units per SFY; 15 Minute Unit

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

A care coordinator must have the following credentials:

The following persons may provide substance abuse Care Coordinator Services under Arkansas Medicaid while under the supervision of a Certified Clinical Supervisor (CCS) recognized by the Arkansas Substance Abuse Certification Board or Registered Clinical Supervisor recognized by the Arkansas Board of Examiners of Alcoholism and Drug Abuse Counselors (BEADAC):

· Certified Alcohol and Drug Counselor (CADC)

· Certified Co-Occurring Disorder Professional - Bachelors Level (CCDP-B)

· Certified Co-Occurring Disorder Professional - Associate Level (CCDP-A)

· Licensed Associate Alcoholism and Drug Abuse Counselor (LAADAC)

· Counselor in Training (CIT) as defined by ADAP licensing standards

The staff ratios shall not exceed 30 clients to 1 care coordinator.

The Case Planning Team must include a credential practitioner and a care coordinator. The Credential Practitioner must also hold one or more of the following Credentials: CCDP-D, LADAC, or ACADC.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

MULTI-PERSON (FAMILY) GROUP COUNSELING

DEFINITION:

Multi-Person (Family) Counseling Services is a group therapeutic intervention using face to face verbal interaction between 2 to a maximum of 9 recipients and their family members or significant others. The Multi- Person (Family) Group Counseling Service provided to a group composed of family members of more than one recipient that is designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. The goal being to support the rehabilitation and recovery effort. Multi-Family Group Counseling must be prescribed on the Treatment Plan to address familial problems or needs and to achieve goals or objectives specified on the Treatment Plan.

Benefit limit/Unit Definition: 6 units/day; 48 units per SFY; 15 Minute Unit

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have a collaborative agreement with a physician licensed in state of Arkansas

· Licensed Alcoholism and Drug Abuse Counselor (LADAC)

· Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)

· Certified Co-Occurring Disorder Professional - Diplomate Level (CCDP-D)

With the addition of substance abuse credentials (LADAC, ACADC, CCDP-D) the following persons may provide substance abuse clinical services:

· Licensed Certified Social Worker (LCSW) and Licensed Master Social Worker (LCSW). (LMSW must be under approved supervision)

· Psychologist

· Psychological Examiner (LPE-I) licensed to practice independently

· Psychological Examiner (LPE) under the supervision of a Psychologist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

INDIVIDUAL COUNSELING

DEFINITION:

Individual Counseling services includes the face to face counseling services necessary to initiate and support the rehabilitation effort, orient the recipient to the treatment process, develop the ongoing treatment plan, augment the treatment process, intervene in a problem area, contingency management, prevent a relapse situation, continuing care or provide ongoing psychotherapy as dictated by the recipient's needs.

Benefit limit/Unit Definition: 6 units/month; 48 units/SFY; 15 Minute Unit

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have a collaborative agreement with a Physician licensed in state of Arkansas

· Licensed Alcoholism and Drug Abuse Counselor (LADAC)

· Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)

· Certified Co-Occurring Disorder Professional - Diplomate Level (CCDP-D)

With the addition of substance abuse credentials (LADAC, ACADC, CCDP-D) the following persons may provide substance abuse clinical services:

· Licensed Certified Social Worker (LCSW) and Licensed Master Social Worker (LMSW). (LMSW must be under approved supervision)

· Psychologist

· Psychological Examiner (LPE-I) licensed to practice independently

· Psychological Examiner (LPE) under the supervision of a Psychologist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

GROUP COUNSELING

DEFINITION:

Face-to-face interventions provided to a group of beneficiaries on a regularly scheduled basis to improve one's capacity to deal with problems that are a result of and/or contribute to substance abuse. The professional uses the emotional interactions of the group's members to assist them in implementing each beneficiary's master treatment plan, orient the beneficiary to the treatment process, support the rehabilitation effort, and to minimize relapse. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

Benefit limit/Unit Definition: 6 units/day; 48 units per SFY; 15 Minute Unit

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have a collaborative agreement with a Physician licensed in state of Arkansas

· Licensed Alcoholism and Drug Abuse Counselor (LADAC)

· Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)

· Certified Co-Occurring Disorder Professional - Diplomate Level (CCDP-D)

With the addition of substance abuse credentials (LADAC, ACADC, CCDP-D) the following persons may provide substance abuse clinical services:

· Licensed Certified Social Worker (LCSW) and Licensed Master Social Worker (LMSW). (LMSW must be under approved supervision)

· Psychologist

· Psychological Examiner (LPE-I) licensed to practice independently

· Psychological Examiner (LPE) under the supervision of a Psychologist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

MARITAL/FAMILY COUNSELING

DEFINITION:

Face-to-face treatment provided to more than one member of a family simultaneously in the same session, or treatment with an individual family member (i.e. Spouse or Single Parent) that is specifically related to achieving goals identified on the recipient's master treatment plan. The identified recipient must be present for this service. Services are to be congruent with the age, strengths, needed accommodations for disability, and cultural framework of the recipient and his/her family. These services are to be utilized to identify and address marital/family dynamics and improve/strengthen marital/family interactions and functioning in relationship to the recipient, the recipient's condition and the condition's impact on the marital/family relationship.

Benefit limit/Unit Definition: 6 units/day; 48 units per SFY; 15 Minute Unit

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have a collaborative agreement with a Physician licensed in state of Arkansas

· Licensed Alcoholism and Drug Abuse Counselor (LADAC)

· Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)

· Certified Co-Occurring Disorder Professional - Diplomate Level (CCDP-D)

With the addition of substance abuse credentials (LADAC, ACADC, CCDP-D) the following persons may provide substance abuse clinical services:

· Licensed Certified Social Worker (LCSW) and Licensed Master Social Worker (LMSW). (LMSW must be under approved supervision)

· Psychologist

· Psychological Examiner (LPE-I) licensed to practice independently

· Psychological Examiner (LPE) under the supervision of a Psychologist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (Continued)

Substance Abuse Treatment Service Definitions (continued)

SERVICES:

MEDICATION MANAGEMENT

DEFINITION:

This service is a direct service and is provided to the recipient by a Physician or APN with prescriptive authority. It includes pharmacologic management, including medication assessment, prescription, use and review of medication. This service is limited to the prescribing of psychotropic medications and those medications necessary to treat addiction related medical conditions and medication assisted addiction treatment.

Benefit limit/Unit Definition: 2 units/month; 12 units per SFY; 15 Minute Unit

STAFFING REQUIREMENTS: (All staff must have a contractual or salaried employee relationship with the certified SATS Provider.)

· Board certified or board eligible Psychiatrist

· Other licensed physician in state of Arkansas

· Advanced Practice Nurse (APN) and Physicians Assistant who have collaborative agreement with a Physician licensed in state of Arkansas

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (42 CFR 440.130(d)) (Continued)

The transition process to eliminate the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the SATS program will begin being transitioned to the Outpatient Behavioral Health Program starting on July 1, 2017. SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any or SATS provider for a service provided after June 30, 2018.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

January 1, 2025

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

25. Applied Behavioral Analysis (ABA) Therapy

(1) Applied Behavior Analysis (ABA) therapy is only one component of services to treat Autism Spectrum Disorder (ASD). ABA therapy services are provided in accordance with 42 CFR 440.130(c).

(2) ABA therapy services must be prescribed by the beneficiary's Arkansas Medicaid assigned primary care provider (PCP);

(3) ABA therapy services must be performed by a:

a. Board-certified behavior analyst (BCBA) who must have board-certified behavior analyst (or more advanced) certification in good-standing from the Behavior Analyst Certification Board;

b. Board-certified assistant behavior analyst (BCaBA) who must have board-certified assistant behavior analyst certification in good-standing from the Behavior Analyst Certification Board; or

c. Registered behavior technician (RBT) who must have registered behavior technician certification in good-standing from the Behavior Analyst Certification Board.

Approval: 11-07-2024

ATTACHMENT 3.1-A Page 1zz.13

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

January 1, 2025

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

25. Applied Behavioral Analysis (ABA) Therapy (Continued)

4. ABA therapy services include the following components:

a. Behavior identification assessment services, which include the following components:

i. Performing required comprehensive evaluations; and

ii. Developing the initial individualized treatment plan (ITP);

b. ABA therapy treatment services, which includes delivering ABA therapy treatment services directly to the beneficiary in accordance with the beneficiary's ITP;

c. Adaptive behavior treatment with protocol modification services, which includes the following components:

i. Actively training or assisting a BCaBA or RBT with the delivery of services to a beneficiary during an ABA therapy treatment session;

ii. Conducting clinical observation of and data collection on the beneficiary's progress towards ITP goals and objectives during an ABA therapy treatment session; and

iii. Adjusting and updating the ITP as required;

d. Family adaptive behavior treatment services, which are meetings between the beneficiary's parent(s)/guardian(s) or other appropriate caregiver and the supervising BCBA, where the supervising BCBA:

i. Discusses the beneficiary's progress;

ii. Provides any necessary technical or instructional assistance to the parent/guardian in connection with service delivery;

iii. Answers any parent/guardian or beneficiary questions and concerns; and

iv. Discusses any necessary changes to the beneficiary's individualized treatment plan.

Approval: 11/07/25

Revision:

HCFA-PM-93-5 MAY 1993

(MB)

Revised:

September 30, 2011

State/Territory:

ARKANSAS

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

4.a. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

Provided: ☒ No limitations PA*

☐ With limitations*

4.b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found .*

4.c. Family planning services and supplies for individuals of child-bearing age. Provided: ☐ No limitations ☒ With limitations*

4.d. Tobacco cessation counseling services for pregnant women

Provided: ☐ No limitations ☒ With limitations*

5.a. Physicians' services whether furnished in the office, the patient's home, a hospital, a nursing facility or elsewhere.

Provided: ☐ No limitations ☒ With limitations*

5.b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act).

Provided: ☐ No limitations ☒ With limitations*

6. Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by State law.

6.a. Podiatrists' services.

Provided: ☐ No limitations ☒ With limitations*

*Description provided on attachment.

ATTACHMENT 3.1-A Page 2a

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2022

CATEGORICALLY NEEDY

4.c. Family Planning Services

(1) Comprehensive family planning services are limited to an original examination and up to three follow-up visits annually. This limit is based on the state fiscal year - July 1 through June 30.

4.d.

(1) Face-to-Face Tobacco Cessation Counseling Services provided (by):

[X] (i) By or under supervision of a physician; ☒

☒ X] (ii) By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; * or

(iii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time)

*describe if there are any limits on who can provide these counseling services

(2) Face-to-Face Tobacco Cessation Counseling Services Benefit Package for Pregnant Women

Provided: ☒ [X] No limitations 1 With limitations*

*Any benefit package that consists of less than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12 month period (eight (8) per year) should be explained below.

Please describe any limitations:

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2022

5. a. Physicians' services, whether furnished in the office, the client's home, a hospital, a skilled nursing facility, or elsewhere

(1) For clients twenty-one (21) years of age or older, services provided in a physician's office, a patient's home, a nursing home, or elsewhere are limited to sixteen (16) visits per state fiscal year (SFY) (July 1 through June 30).

(a) Benefit Limit Details

The benefit limit will be considered in conjunction with the benefit limit established for rural health clinic, federally qualified health center, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services and advanced practice registered nurse or a combination of the seven. Clients under age twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit limited.

(b) Extension of Benefits

For physicians' services, medical services provided by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, advanced practice registered nurse, or rural health clinic core services beyond the benefit limit, extensions will be available if medically necessary.

(i) The following diagnoses are considered categorically medically necessary and are exempt from benefit extension requirements: Malignant neoplasm; HIV infection and renal failure.

(ii) Additionally, physicians' visits for pregnancy in the outpatient hospital are exempt from benefit extension requirements.

(i) Each attending physician/dentist is limited to billing one day of care for inpatient hospital covered days regardless of the number of hospital visits rendered.

(ii) Surgical procedures which are generally considered to be elective require a prior authorization from the Utilization Review Section.

(iii) Desensitization injections - Refer to Attachment 3.1-A, Item 4.b. (12).

(iv) Organ transplants are covered as described in Attachment 3.1-E.

–

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 10, 2018

CATEGORICALLY NEEDY

5. a. Physicians' Services (Continued)

(6) Consultations, including interactive consultations (telemedicine), are limited to two (2) per recipient per year in a physician's office, patient's home, hospital or nursing home. This yearly limit is based on the State Fiscal Year (July 1 through June 30). This limit is in addition to the yearly limit described in Item 5.(1). Extensions of the benefit limit will be provided if medically necessary for recipients.

(7) Abortions are covered when the life of the mother would be endangered if the fetus were carried to term or for victims of rape or incest. The circumstances must be certified in writing by the woman's attending physician. Prior authorization is required.

5. b. Medical and surgical services furnished by a dentist (in accordance with Section 1905 (a)(5)(B) of the Act).

Medical services furnished by a dentist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for recipients age 21 and older.

The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, rural health clinic services, office medical services furnished by an optometrist and certified nurse midwife services. Recipients will be allowed twelve (12) visits per State Fiscal Year for medical services furnished by a dentist, physicians' services, rural health clinic services, office medical services furnished by an optometrist, certified nurse midwife services or advanced practice nurse or registered nurse practitioner services or a combination of the six. For physicians' services, medical services provided by a dentist, office medical services furnished by an optometrist, certified nurse midwife services or rural health clinic core services beyond the 12 visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

Surgical services furnished by a dentist are not benefit limited.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: September 27, 2006

CATEGORICALLY NEEDY

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law.

a. Podiatrists' Services

Services are limited to two (2) visits per State Fiscal Year (July 1 through June 30). The benefit limit for State Fiscal Year 1992 will be calculated beginning with services provided on or after December 1, 1991. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

b. Optometrists' Services

Examination of eyes and provision of glasses and/or contact lens and other diagnostic screening, preventive and rehabilitative services and treatment of conditions found for eligible persons. The following limits are imposed:

(1) One eye exam every twelve (12) months for eligible beneficiaries 21 years of age and older.

STATE Arkansas

DATE REC'D 9-21-06

DATE APPV'D 2.7-07

DATE EFF

9-27-06

HCFA 179

06-14

SUPERSEDES: TN- 02-02

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2022

CATEGORICALLY NEEDY

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. (Continued)

b. Optometrists' Services (Continued)

(2) One eye exam every twelve (12) months for eligible client under 21 years of age in the Child Health Services (EPSDT) Program. Extensions of the benefit limit will be available if medically necessary for clients in the Child Health Services (EPSDT) Program.

(3) Office medical services provided by an optometrist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or older.

The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, Federally Qualified Health Center services, certified nurse midwife services, and advanced practice registered nurses, or a combination of the seven. For services beyond the benefit limit, extensions will be available if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the limit.

c. Chiropractors' Services

(1) Services are limited to licensed chiropractors meeting minimum standards promulgated by the Secretary of HHS under Title XVIII.

(2) Services are limited to treatment by means of manual manipulation of the spine which the chiropractor is legally authorized by the State to perform.

(3) Effective for dates of service on or after July 1, 1996, chiropractic services will be limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for eligible Medicaid clients twenty-one (21) years or older. Services provided to clients under age twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit limited.

(4) Effective for dates of service on or after January 1, 2018, chiropractic services do not require a referral by the client's primary care provider (PCP).

d. Advanced Practice Registered Nurses (APRN)

For clients twenty-one (21) years of age or older, services provided in an advanced practice registered nurse's office, a patient's home, or nursing home are limited to sixteen (16) visits per state fiscal year (July 1 through June 30).

The benefit limit will be in conjunction with the benefit limit established for physicians' services, rural health clinic, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services and federally qualified health center, or a combination of the seven. For services beyond the established benefit limit, extensions will be available if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the limit. Clients in the Child Health Services (EPSDT) Program are not benefit limited.

Revisions

HCFA-PM-91-4 AUGUST 1991

( BPD)

ATTACHMENT 3.1-A.

Pago 3

OMB No. :

0938-

State/Territory:

ARKANSAS.

AMOUNT; DURATION; AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY WEEDY

b. Optometrista' services. ☒ Provided: 11 No limitations ☒ With limitations

Not provided.

c. Chiropractors' services. ☒ Provided: No limitations 1X/ ☒ With limitations*

Not provided.

d. Other practitioners' services. ☒ Provided: Identified on attached sheet with description of limitations, if any.

Not provided.

7. Home health services.

a. Intermittent or part-time nursing services provided by a home health agency or by a registered nurse when no home health agency exists in the area.

Provided: No limitations ☒

V With limitations*

b. Home health aide services provided by a home health agency.

Provided: No limitations LX

☒ (With limitations*

c. Medical supplies, equipment, and appliances suitable for use in the home.

Provided: No limitations ☒ With limitations* y

*Description provided on attachment.

TN No. 9184

DEC 1 3 1991

Effective Date OCT - 1 1991

Supersede TN NO. 91.28

Approval Date

HCFA ID:

7986E

STATE

Orkanen

DATE REC'D NOV 2 2 1991

DATE APPV'D DEC 1 3 1991

DATE EFF

OCT - 1 1991

HCFA 179 91-24

Revisioni

HCFA-PM-91-4 AUGUST 1991

( BPD)

ATTACHMENT 3.1-A

Page 3a

OMB No. : 0938-

State/Territory:

ARKANSAS

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

d. Physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility. ☒ Provided: LI No limitations ☒ /With limitations*

Not provided.

8. Private duty nursing services. ☒ Provided: LI No limitations ☒ With limitations*

Not provided. PA*

*Description provided on attachment.

TN No.

91.54

Approval Date

DEC 1 3 1991

Effective Date

OCT - 1 1991

Supersedeg

TN No.

89.47

HCFA ID:

7986E

Cokansas

STATE NOV 2 2 1991 DATE REC'D

DEC 1 3 1991 DATE APPV'D OCT - 1 1991 DATE EFF 91.54 HCFA 179

A ☒

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 3a

AMC JNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 1991

CATEGORICALLY NEEDY

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice and defined by State law. (Continued)

6.d. Other Practitioners' Services

(1) Hearing Aid Dealers

Refer to Attachment 3.1-A, Item 4.b. (8).

(2) Audiologists

Refer to Attachment 3.1-A, Item 4.b. (9).

(3) Optical Labs

Provides eyeglasses and eyeglass repair to eligible recipients.

(4) Nurse Anesthetists

Services limited to licensed nurse anesthetists.

ARKANSAS JUL 0 1991 NOV 19 1991 ☒

JUL 0 1 1901

41-38

Aspersides 90-48

ATTACHMENT 3.1-A Page 3b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2024

CATEGORICALLY NEEDY

6. Medical Care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. (Continued)

6.d. Other Practitioners' Services (Continued)

(5) Psychologists

Refer to Attachment 3.1-A, Item 4.b. (13).

(6) Obstetric - Gynecologic and Gerontological Nurse Practitioner

Refer to Attachment 3.1-A, Item 24 for coverage limitations.

(7) Pharmacists

(8) Licensed Registered Nurse Sexual Assault Nurse Examiner-Pediatric/Adolescent (SANE-P) certified by the International Association of Forensic Nurses working under the supervision of a licensed Advanced Practice Registered Nurse (APRN).

ATTACHMENT 3.1-A Page 3b(1)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2024

CATEGORICALLY NEEDY

6. Medical Care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. (Continued)

6.d. Other Practitioners' Services (Continued)

(11) Emergency Medical Technicians who are licensed to provide advanced life support and basic life support services.

Approved: 11/05/2024

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 1, 2002

CATEGORICALLY NEEDY

7.a. Home Health Services

7.b. Based on a physician's prescription as to medical necessity provided to eligible recipients at their place of residence not to include institutions required to provide these services. For services above 50 visits per recipient per State Fiscal Year, the provider must request an extension. Extension of the benefit limit will be provided for all recipients, including EPSDT, if determined medically necessary.

7.c. Medical supplies, equipment, and appliances suitable for use in the home.

(1) Medical supplies are covered for eligible Medicaid recipients when determined medically necessary and prescribed by a physician. Services are provided in the recipient's home (Home does not include a long term care facility.) Supplies are limited to a maximum reimbursement of $250.00 per month, per recipient. As medical supplies are provided to recipients through the Home Health Program and the Prosthetics Program, the maximum reimbursement of $250.00 per month may be provided through either program or a combination of the two. However, a recipient may not receive more than $250.00 in supplies whether received through either of the two programs or a combination of the two unless an extension has been granted. Extensions will be considered for recipients under age 21 in the Child Health Services (EPSDT) Program if documentation verifies medical necessity. The provider must request an extension of the established benefit limit.

(2) Durable Medical Equipment (DME) - Services are covered in the recipient's home if prescribed by the recipient's physician as medically necessary. Some DME requires prior authorization. DME is limited to specific items. Specific DME is listed in Section III of the Prosthetics Provider Manual.

(3) Augmentative Communication Device

Services for recipients under age 21 are covered as a result of a Child Health Services (EPSDT) screening/referral. Services for recipients over age 21 are covered if prescribed by the recipient's physician as medically necessary. Prior authorization is required.

(4) Specialized Wheelchairs

Specialized Wheelchairs are provided for eligible recipients of all ages if prescribed by the recipient's physician as medically necessary. Prior authorization is required for some items. These items are listed in Section III of the Prosthetics Provider Manual.

STATE Arkansas

DATE REC'D 04-01-02

DATE APPVD 04-17-02

DATE EFF 04-01-02

HCFA 179 AR 02-10

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2022

CATEGORICALLY NEEDY

7. Home Health Services (Continued)

7.c. In accordance with 42 CFR 440.70(b)(3) medical supplies, equipment and appliances are suitable for use in any setting in which normal life activities take place. (Continued)

(5) Diapers/Underpads

Diapers/underpads are limited to $130.00 per month, per beneficiary. The $130.00 benefit limit is a combined limit for diapers/underpads provided through the Prosthetics Program and Home Health Program. The benefit limit may be extended with proper documentation. Only patients with a medical diagnosis other than infancy which results in incontinence of the bladder and/or bowel may receive diapers. This coverage does not apply to infants who would otherwise be in diapers regardless of their medical condition. Providers cannot bill for underpads/diapers if a beneficiary is under the age of three years.

(6) DME/Continuous Glucose Monitors.

A. Continuous Glucose Monitors (CGM) will be covered for Arkansas Medicaid clients.

B. A prior authorization (PA) will be required and the service will be provided for those clients who meet medical necessity.

7.d. Physical therapy, occupational therapy, or speech-language pathology and audiology services provided by a home health agency or medical rehabilitative facility.

Physical therapists must meet the requirements outlined in 42 CFR 440.110(a).

Services under this item are limited to physical therapy when provided by a home health agency and prescribed by a physician. Effective for dates of service on or after July 1, 2017, individual and group physical therapy are limited to six (6) units per week. Effective for dates on or after January 1, 2021, physical therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limits will be provided if medically necessary for eligible Medicaid recipients.

8. Private Duty Nursing to enhance the effectiveness of treatment for ventilator-dependent beneficiaries or non-ventilator dependent tracheotomy beneficiaries

Enrolled providers are Private Duty Nursing Agencies licensed by Arkansas Department of Health. Services are provided by Registered Nurses or Licensed Practical Nurses licensed by the Arkansas State Board of Nursing.

Services are covered for Medicaid-eligible beneficiaries age 21 and over when determined medically necessary and prescribed by a physician.

Beneficiaries 21 and over to receive PDN Nursing Services must require constant supervision, visual assessment and monitoring of both equipment and patient. In addition, the beneficiary must be:

A. Ventilator dependent (invasive) or

B. Have a functioning trach

1. requiring suctioning and

2. oxygen supplementation and

3. receiving Nebulizer treatments or require Cough Assist / inexsufflator devices.

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

December 01, 2020

8. Private Duty Nursing Services (Continued)

In addition, at least one (1) from each of the following conditions must be met:

1. Medications:

· Receiving medication via gastrostomy tube (G-tube)

· Have a Peripherally Inserted Central Catheter (PICC) line or central port

2. Feeding:

· Nutrition via a permanent access such as G-tube, Low-Profile Button, or Gastrojejunostomy tube (G-J tube). Feedings are either bolus or continuous.

· Parenteral nutrition (total parenteral nutrition)

Services are provided in the beneficiary's home, a Division of Developmental Disabilities (DDS) community provider facility, or a public school. (Home does not include an institution.) Prior authorization is required. Private duty nursing medical supplies are limited to a maximum reimbursement of $80.00 per month, per beneficiary. With substantiation, the maximum reimbursement may be extended.

Revision:

HCFA-PM-85-3

( BERC)

MAY 1985

ATTACHMENT 3.1-A Page 4

Revised:

August 1, 1989

ARKANSAS

OUB NO. : 0938-0193

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY HEKDY

9. Clinic services. X ☒ Provided: 11 No limitations 1X/

☒

With limitations*

Not provided.

10. Dental services. ☒ Provided: LI No limitations With limitations*

Not provided. PA*

11. Physical therapy and related services.

a. Physical therapy. 1X/ ☒ Provided: 11 No limitations 1X1 With limitations*

Not provided.

b. Occupational therapy. ☒ Provided: 11 No limitations 1X1

☒

With limitations*

Not provided.

c. Services for individuals with speech, hearing, and language disorders (provided by or under the supervision of a speech pathologist or audiologist).

/ XI ☒ Provided: / / No limitations 181 With limitations*

Not provided.

*Description provided on attachment.

STATE ARK

DATE REC'D

DATE APPV'D

DATE SFF

HCFA 179

TN No.

Supersedes TN No. 1.5 -27

Approval Date

Effective Date

HCFA ID: 0069P/0002P

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

ATTACHMENT 3.1-A Page 4a

Revised: January 1, 2021

9. Clinic Services

(1) Adult Developmental Day Treatment (ADDT) Services

Limited to comprehensive day treatment centers offering the following core services to beneficiaries age 18 and above:

a. Assessment and Treatment Plan Development, 2 units per year

b. Adult Day Habilitation Services, 5 units per day, 1 hour each

c. Provision of noon meal

Optional Services available through ADDT in conjunction with core services are as follows:

a. Physical therapy - Services must be prescribed by a physician and provided by or under the supervision of a qualified physical therapist.

b. Speech-language therapy - Services must be referred by a physician and provided by or under the supervision of a qualified speech pathologist.

c. Occupational therapy - Services must be prescribed by a physician and provided by or under the supervision of a qualified occupational therapist.

Occupational, Physical, and Speech-Language Therapy Services are provided in accordance with Items 3.1-A.4b(15), 3.1-A.11, 3.1-

B.4b(15), and 3.1-B(11).

Extensions of the benefit limit for all ADDT services will be provided if medically necessary.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 2004

CATEGORICALLY NEEDY

9. Clinic Services (Continued)

(2) Family Planning Clinic Services

Services limited to family planning, reproductive health services and supplies.

(3) Maternity Clinic-Services

Limited to antepartum and postpartum services.

(4) Ambulatory Surgical Center Services

Ambulatory surgical center facility services are limited to those services furnished in connection with or directly related to a surgical procedure covered by the Medicaid agency.

(5) End-Stage Renal Disease (ESRD) Facility Services

Covered services include:

a) Outpatient hemodialysis and peritoneal dialysis treatment in a Title XVIII certified ESRD facility.

b) Training for individuals who have been selected by their physician to participate in the peritoncal self-dialysis program.

Beneficiaries aged 21 and older are limited to 3 hemodialysis treatments per week. Beneficiaries under the age of 21 in the Child Health Services (EPSDT) Program are not benefit limited.

STATE

Arkansas

DATE RECU

7-13-09

DATE APOUR

9-23-04

DATE EFF

10-1-04

HCFA 179

04-11

SUPERSEDES IN- 91-28

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

10. Dental Services

Refer to Attachment 3.1-A, Item 4.b. (16) for information regarding dental services for EPSDT eligible children under age 21.

Dental services are available for Medicaid beneficiaries age 21 and over but most are benefit limited. Specific benefit limits and prior authorization requirements for beneficiaries age 21 and over are detailed in the Dental Provider Manual.

There is an annual benefit limit of $500 for dental services for adults. Extractions and fees paid to the dental lab for the manufacture of dentures are excluded from the annual limit.

All dentures, whether full or partial, must be provided by the one dental lab under contract with the Arkansas Medicaid Program to manufacture dentures. For adults, there is lifetime limit of one set of dentures. This policy applies to both:

· Medicaid eligible beneficiaries age 21 and over and

· Medicaid eligible beneficiaries under 21 whose eligibility is based on a "pregnant woman aid category" AND whose Medicaid ID number ends in the 100 series (100 through 199).

ATTACHMENT 3.1-A Page 4d

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2021

CATEGORICALLY NEEDY

Speech-Language Pathology services and qualified Speech-Language Pathologists meet the requirements set forth in 42 CFR 440.110. Speech-Language Pathology Assistants work under the supervision of the Speech-Language Pathologist in accordance with the State's licensing and supervisory requirements.

Physical Therapy services and qualified Physical Therapists meet the requirements set forth in 42 CFR 440.110. Physical Therapy assistants work under the supervision of the Physical Therapist in accordance with the State's licensing and supervisory requirements.

Occupational Therapy services and qualified Occupational Therapists meet the requirements set forth in 42 CFR 440.110. Occupational Therapy assistants work under the supervision of the Occupational Therapist in accordance with the State's licensing and supervisory requirements.

Audiology services and qualified Audiologists meet the requirements set forth in 42 CFR 440.110.

A. Occupational, Physical and Speech-Language Therapy

1. Refer to Attachment 3.1-A, Item 4.b. (15) for therapy services for recipients under age 21.

2. For recipients over age 21, effective for dates of services on or after July 1, 2017, individual and group therapy are limited to six (6) units per week per discipline. For recipients over age 21, Speech-language therapy evaluations are limited to four (4) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary.

3 For recipients over age 21, effective for dates on or after January 1, 2021, physical therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). For recipients over age 21, effective for dates on or after January 1, 2021, occupational therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit for the evaluation will be provided if medically necessary.

B. Speech-Language Therapy

Speech Generating Device (SGD) Evaluation - Effective for dates of service on or after September 1, 1999, Speech Generating Device (SGD) evaluation is covered for eligible Medicaid recipients of all ages. One SGD evaluation may be performed every three years based on medical necessity. The benefit limit may be extended for individuals under age 21.

Revision: HCFA-PM-85-3 ( BERC)

MAY 1985

ARKANSAS

ATTACHMENT 3.1-A Page. S OMA NO. : 0938-0193

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

a. Prescribed drugs.

☒ Provided: 11 No limitations 181 With limitations* 181

Not provided.

b. Dentures.

1 ×1.

☒ With limitations* ☒ Provided: 11 No limitations 1x1

Not provided. PA*

c. Prosthetic devices.

☒ Provided: 11 No limitations /XI With limitations* 11 Not provided. PA*

d. Eyeglasses. ☒ Provided: 11 No limitations

With limitations*

LI Not provided. PA*

13, Other diagnostic, screening. preventive, and rehabilitative services, i.e., other than those provided elsewhere in the plan.

a. Diagnostic services.

Provided: / / No limitations 1 With limitations*

☒ Not provided.

APPROVED LY DHHAS/HCFACTO

NOV 7 1985

*Description provided on attachment.

THISMETTAL NO:

85-21

IN No. 85-21 Supersedes

Approval Date

285

Effective Date

MAY 1 1985

TN No.

79-5

HCFA ID: 0069P/0002P

ATTACHMENT 3.1-A Page 5a

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised:

October 1, 2023

CATEGORICALLY NEEDY

12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist

a. Prescribed Drugs

(1) Each recipient age twenty-one (21) or older may have up to six (6) prescriptions each month under the program. Family Planning, tobacco cessation, prescription drugs for opioid or alcohol use disorder as part of a Medication Assisted Treatment plan, EPSDT, high blood pressure, hypercholesterolemia, blood modifiers, diabetes and respiratory illness inhaler prescriptions do not count against the prescription limit.

(2) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

(3) The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid recipients, for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses - with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 C.F.R. §423.104 (f) (1) (ii) (A) - to full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit - Part D.

The following excluded drugs, set forth on the Arkansas Medicaid Pharmacy Vendor's Website, are covered:

a. select agents when used for weight gain

b. select agents when used for the symptomatic relief of cough and colds

c. select prescription vitamins and mineral products, except prenatal vitamins and fluoride

d. select nonprescription drugs

(4) The State will reimburse only for the drugs of pharmaceutical manufacturers who have entered into and have in effect a rebate agreement in compliance with Section 1927 of the Social Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3), or 1927(d) apply. The State permits coverage of participating manufacturers' drugs, even though it may be using a formulary or other restrictions. Utilization controls will include prior authorization and may include drug utilization reviews. Any prior authorization program instituted after July 1, 1991 will provide for a 24-hour turnaround from receipt of the request for prior authorization. The prior authorization program also provides for at least a seventy-two (72) hour supply of drugs in emergency situations.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: May 1, 2022

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

a. Prescribed Drugs (continued)

(4) The state is in compliance with section 1927 of the Social Security Act. The state will cover drugs of Federal rebate participating manufacturers. The state is in compliance with reporting requirements for utilization and restrictions to coverage. Pharmaceutical manufacturers can audit utilization data.

The state will be negotiating supplemental rebates in the Medicaid program in addition to the Federal rebates provided for in Title XIX. Rebate agreements between the state and pharmaceutical manufacturer(s) will be separate from the Federal rebates.

Effective May 1, 2022, CMS has authorized the state of Arkansas to enter into a multi-state supplemental rebate pool, using a Preferred Drug List (PDL) to maximize state supplemental rebates. The state will continue to select products participating in the federal rebate program that will be in its Preferred Drug List Program and will only receive state supplemental rebates for manufacturer's supplemental covered products included on the PDL.

A rebate agreement between the state and a participating drug manufacturer for drugs provided to the Medicaid program, submitted to CMS on May 24, 2016, and entitled, State of Arkansas Supplemental Rebate Agreement, has been authorized by CMS. Any additional versions of rebate agreements negotiated between the state and manufacturer(s) after May 24, 2016, will be submitted to CMS for authorization.

The state supplemental rebate agreements would apply to the drug benefit, both fee-for-service and those paid by contracted Medicaid managed care organizations (MCOs), under prescribed conditions in Attachment C of the State of Arkansas Supplemental Rebate Agreement. State supplemental rebate agreements would apply to beneficiaries, including those made eligible under the Affordable Care Act receiving fee-for-service benefits and those that are enrolled under a Medicaid managed care organization agreement.

Supplemental rebates received by the State in excess of those required under the National Drug Rebate Agreement will be shared with the Federal government on the same percentage basis as applied under the national rebate agreement.

All drugs covered by the program, irrespective of a supplemental rebate agreement, will comply with the provisions of the national drug rebate agreement.

The supplemental rebate program does not establish a drug formulary within the meaning of 1927(d)(4) of the Social Security Act.

Effective May 1, 2022, CMS has authorized the state of Arkansas to enter into value/outcomes- based contracts with manufacturers on a voluntary basis. The conditions of the value/outcomes- based contract would be agreed upon by both the state and manufacturer.

The unit rebate amount is confidential and cannot be disclosed for purposes other than rebate invoicing and verification, in accordance with Section 1927(b)(3)(D) of the Social Security Act.

(5) Pursuant to 42 U.S.C. Section 1396r-8 the state is establishing a preferred drug list with prior authorization for drugs not included on the preferred drug list. Prior authorization will be provided within a 24-hour turn-around from receipt of request and a 72-hour supply of drugs in emergency situations.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: September 30, 2011

CATEGORICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

a. Prescribed Drugs (continued)

Prior authorization will be established for certain drug classes, particular drugs or medically accepted indication for uses and doses.

The state will appoint a Pharmaceutical and Therapeutic Committee or utilize the drug utilization review committee in accordance with Federal law.

When a pharmacist receives a prescription for a brand or trade name drug, and dispenses an innovator multisource drug that is subject to the Federal Upper Limits (FULs), the innovator multisource drug must be priced at or below the FUL or the prescription hand annotated by the prescriber "Brand Medically Necessary". Only innovator multisource drugs that are subject to the Federal Upper Limit at 42 CFR 447.332(a) and dispensed on or after July 1, 1991, are subject to the provisions of Section 1903(i)(10)(B) of the Social Security Act.

For drugs listed on the Arkansas Medicaid Generic Upper Limit List, the upper limit price will not apply if the prescribing physician certifies in writing that a brand name drug is medically necessary.

The Arkansas Medicaid Generic Upper Limit List is comprised of State generic upper limits on specific multisource drug products and CMS identified generic upper limits on multisource drug products.

The Medicaid agency will provide coverage of prescription and over-the-counter (OTC) smoking/tobacco cessation covered outpatient drugs for pregnant women as recommended in "Treating Tobacco Use and Dependence - 2008 Update: A Clinical Practice Guideline" published by the Public Health Service in May 2008 or any subsequent modification of such guideline.

ATTACHMENT 3.1-A Page 5b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 2009

CATEGORICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

b. Dentures

Refer to Attachment 3.1-A, Item 4.b (7) for coverage of dentures for Child Health Services (EPSDT) recipients.

Dentures are available for eligible Medicaid beneficiaries age 21 and over, but are benefit limited. Specific benefit limits and prior authorization requirements for beneficiaries age 21 and over are detailed in the Dental Provider Manual.

Dentures are excluded from the annual limit but are limited to one set per lifetime.

c. Prosthetic Devices

(1) Eye Prostheses - Refer to Attachment 3.1-A, item 4.b.(11).

(2) Hearing Aids, Accessories and Repairs - Refer to Attachment 3.1-A, Item 4.b.(10).

(3) Pacemakers and internal surgical prostheses when supported by invoice.

(4)

a. Parenteral hyperalimentation services, including fluids, supplies and equipment, when provided in the recipient's home. Home does include a nursing facility (NF) and intermediate care facility for the mentally retarded (ICF-MR). Service requires prior authorization.

b. Enteral nutrition services, including fluids, supplies and equipment, when provided in the recipient's home. Home does not include a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR) because this service is included and reimbursed as an NF and ICF-MR benefit as described in Attachment 3.1-A, Item 4.a. Service requires prior authorization.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

CATEGORICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

c. Prosthetic Devices (Continued)

(5) Orthotic Appliances

Services for recipients under age 21 are not benefit limited.

Services for recipients age 21 and over are limited to $3,000 per State Fiscal Year (July 1 through June 30). When the Medicaid maximum allowable for an orthotic appliance is $500 or more, prior authorization is required. Specific covered orthotic appliances are listed in Section III of the Prosthetics Provider Manual.

(6) Prosthetic Devices

Services for recipients under age 21 are not benefit limited.

Services for recipients age 21 and over are limited to $20,000 per State Fiscal Year (July 1 through June 30). When the Medicaid maximum allowable for a prosthetic device is $1,000 or more, prior authorization is required. Specific covered prosthetic devices are listed in Section III of the Prosthetics Provider Manual.

STATE Arkansas

DATE REGIO 03-18-02

DATE APPVD 04-15-02

DATE EFF 07-01-02

HCFA 179 AR 02-09

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 27, 2006

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

d. Eyeglasses

For the provision of glasses and/or contact lens for eligible beneficiaries, the following limits are imposed:

(1) One pair of glasses every twelve (12) months for eligible beneficiaries 21 years of age and over. Repairs to glasses or professional service for repairing glasses are covered for eligible beneficiaries 21 years of age and over. Replacement of glasses is covered for post cataract patients with prior authorization.

(2) One pair of glasses every twelve (12) months for eligible beneficiaries under 21 years of age in the Child Health Services (EPSDT) Program. One replacement pair of glasses every twelve (12) months for eligible beneficiaries under 21 years of age in the Child Health Services (EPSDT) Program. Repairs to glasses or professional service for repairing glasses are covered for eligible beneficiaries under 21 years of age. Under special circumstances, additional glasses may be authorized.

(3) Contact lenses are covered for beneficiaries of all ages if either of the following conditions are exhibited by the patient:

a. Medical necessity

b. Cataract patients

Prior authorization is required by the Medical Assistance Section. Lens replacement for all beneficiaries is allowed as medically necessary.

STATE Arkansas

DATE REC'D 9-21-06

DATE APPV'O

2-7-07

DATE EFF

9-27-06

HCFA 179

06-14

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A

AMOUNT. DURATION AND SCOPE OF

SERVICES PROVIDED

March 1, 1990

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan.

a. Diagnostic services - Not provided.

STATE CATE NICO DATE APPV'D

ERKanser 2-26-90 3-13-90

DATE EFF

3-1-90

HCFA /79

90-09

Superccdes- Done-Ben Page

Revision:

HCFA-Region VI November 1990

Revised:

March 1, 2026

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY SERVICES PROVIDED

b. Screening Services

Provided No Limitations With Limitations* X

☒ Not Provided

c. Preventive services

☒ Provided No Limitations ☒ With Limitations*

Not Provided

_ _

d. Rehabilitative services

☒

Provided

No Limitations

X ☒

With Limitations*

Not Provided

14. Services for individuals age 65 or older in institutions for mental diseases

a. Inpatient hospital services

Provided

No Limitations With Limitations* X ☒ Not Provided

b. Nursing facility services

☒ Not Provided c. Provided No Limitations

With Limitations* X

*Description provided on attachment

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: March 1, 2026

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

a. Diagnostic services - Not Provided.

b. Screening services - Not Provided.

c. Preventive services - Provided, with limitation.

Vaccines:

Arkansas covers vaccines and vaccine administration which includes approved vaccines recommended by the Advisory Committee on Immunization Practices (an advisory committee established by the Secretary, acting through the Director of the Centers for Disease Control and Prevention).

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-A Page 6a1A March 1, 2026

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

c. Preventive Services-Provided with Limitation (continued)

Certified Community-based Doulas:

A Certified Community-based Doula is a trained professional who provides emotional, physical, and informational support during the prenatal, labor, delivery, and postpartum periods. Certified Community-based Doula services must be recommended by a physician or other licensed practitioner of the healing arts acting within their scope of practice under state law.

Certified community-based doulas shall provide only the following services:

1. Childbirth education;

2. Assistance with navigating the healthcare system;

3. Client advocacy before, during, and after the birth of a child;

4. Connection with community resources; and

5. Continuous emotional and physical support throughout labor and birth and intermittently during the prenatal and postpartum periods.

Services shall include support during a hospital delivery and during the prenatal and postpartum periods as defined through rules established by the Arkansas Department of Human Services.

To be eligible to provide services, Doulas must be:

(1) Certified by the Department of Health in accordance with state law; and (2) At least eighteen (18) years of age and have an NPI number.

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-A Page 6a1C March 1, 2026

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

c. Preventive Services-Provided with Limitation (continued)

Breastfeeding and Lactation Consultants:

A breastfeeding and lactation consultant is a trained professional specializing in providing medically appropriate care to aid in milk expression or infant nutrition. Breastfeeding and Lactation Consultant services must be recommended by a physician or other licensed practitioner of the healing arts acting within their scope of practice under state law.

Breastfeeding and lactation consultant services are medically appropriate outpatient services or hospital services, or both, provided by a breastfeeding and lactation consultant during pregnancy and through the extended postpartum period to aid in milk expression or infant nutrition. Components of Breastfeeding and Lactation Consultant services include individual outpatient consultation and group classes.

To be eligible to provide services, Breastfeeding and Lactation Consultants must:

· Be at least eighteen (18) years of age and have an NPI number; and

· Have one of the following certifications:

1. An International Board-Certified Lactation Consultant; or

2. A Certified Lactation Counselor;

· Certified Lactation Counselors must be certified by either the (1) International Breastfeeding Institute or (2) Academy of Lactation Policy and Practice;

" Certified Lactation Counselors are required to be supervised by a Medicaid enrolled healthcare provider to receive reimbursement. Supervision is defined as being employed by one of the following:

A. An agency led by an International Board-Certified Lactation Consultant;

B. A physician, advanced practice nurse, or physician assistant

C. A local health unit or

D. A hospital

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE OF ARKANSAS

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-A Page 6a1G March 1, 2026

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services

1. Rehabilitative Services for Persons with Mental Illness (RSPMI)

A comprehensive system of care for behavioral health services has been developed for use by RSPMI providers. The changes to the program were developed in coordination with providers, representatives of the Arkansas System of Care and other key stakeholders.

DMS is seeking first to revise service definitions and methods within this program to meet the needs of persons whose illnesses meet the definitions outlined in the American Psychiatric Association Diagnostic and Statistical Manual.

Covered mental health services do not include services provided to individuals aged 21 to 65 who reside in facilities that meet the Federal definition of an institution for mental disease. Coverage of RSPMI services within the rehabilitation section of Arkansas' state plan that are provided in IMD's will be discontinued as of September 1, 2011.

A. Scope

A range of mental health rehabilitative or palliative services is provided by a duly certified RSPMI provider to Medicaid-eligible beneficiaries suffering from mental illness, as described in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV and subsequent revisions).

DMS has set forth in policy the settings in which each individual service may be provided. Each service shown below includes the place of service allowable for that procedure.

Services:

· SERVICE: Mental Health Evaluation/Diagnosis DEFINITION: The cultural, developmental, age and disability -relevant clinical evaluation and determination of a beneficiary's mental status; functioning in various life domains; and an axis five DSM diagnostic

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 1, 2012

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

formulation for the purpose of developing a plan of care. This service is required prior to provision of all other mental health services with the exception of crisis interventions. Services are to be congruent with the age, strengths, necessary, accommodations for disability, and cultural framework of the beneficiary and his/her family.

Setting information could be summarized in the description if the State would like to include this information.

This service must be performed by a physician or mental health professional and is necessary to determine how best to proceed in developing an array of rehabilitative treatment services for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Psychological Evaluation

DEFINITION: A Psychological Evaluation employs standardized psychological tests conducted and documented for evaluation, diagnostic, or therapeutic purposes. The evaluation must be medically necessary, culturally relevant; with reasonable accommodations for any disability, provide information relevant to the beneficiary's continuation in treatment, and assist in treatment planning. All psychometric instruments must be administered, scored, and interpreted by the qualified professional.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Psychiatric Diagnostic Assessment DEFINITION: A direct face-to-face service contact occurring between the physician or Advanced Practice Nurse and the beneficiary for the purpose of evaluation. Psychiatric Diagnostic Assessment includes a history, mental status, and a disposition, and may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies. (See Section 224.000 for additional requirements.)

This service must be performed by a physician or Advanced Practice Nurse and is necessary to determine how best to proceed in developing an array of rehabilitative treatment services for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: April 1, 2012

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

An APN performing the Psychiatric Diagnostic Assessment MUST meet the following:

1. Licensed by the Arkansas State Board of Nursing

2. Practicing with licensure through the American Nurses Credentialing Center

3. Practicing under the supervision of an Arkansas-licensed psychiatrist who has an affiliation with the RSPMI program and with whom the Advanced Practice Nurse has a collaborative agreement. Prior to the initiation of the treatment plan, the findings of the Psychiatric Diagnostic Assessment conducted by the Advanced Practice Nurse must be discussed with the supervising psychiatrist. The collaborative agreement must comply with all Board of Nursing requirements and must spell out, in detail, what the nurse is authorized to do and what age group they may do it to.

4. Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act

5. Practicing within an Advanced Practice Nurse's experience and competency level

· SERVICE: Master Treatment Plan

DEFINITION: A developed plan in cooperation with the beneficiary (parent or guardian if the beneficiary is under 18), to deliver specific mental health services to the beneficiary to restore, improve or stabilize the beneficiary's mental health condition. The plan must be based on individualized service needs identified in the completed Mental Health Diagnostic Evaluation. The plan must include goals for the medically necessary treatment of identified problems, symptoms and mental health conditions. The plan must identify individuals or treatment teams responsible for treatment, specific treatment modalities prescribed for the beneficiary, time limitations for services, and documentation of medical necessity by the supervising physician.

This service must be performed by a physician and licensed mental health professionals in conjunction with the beneficiary and is necessary for developing an array of rehabilitative treatment services according to goals and objectives for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Periodic Review of Master Treatment Plan

DEFINITION: The periodic review and revision of the master treatment plan, in cooperation with the beneficiary, to determine the beneficiary's progress or lack of progress toward the master treatment plan goals and objectives; the efficacy of the services provided; and continued medical necessity of services. This includes a review and revision of the measurable goals and measurable objectives directed at the medically necessary treatment of identified symptoms/mental health condition, individuals or treatment teams responsible for treatment, specific treatment modalities, and necessary accommodations that will be provided to the beneficiary, time limitations for services, and the medical necessity of continued

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

services. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

This service must be performed by a physician and licensed mental health professionals in conjunction with the beneficiary to ensure that the array of rehabilitative treatment services is producing the desired outcome according to goals and objectives and to determine if the maximum reduction of a mental disability restoration of the beneficiary to his or her best possible functional level is progressing.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Interpretation of Diagnosis

DEFINITION: A face-to face therapeutic intervention provided to a beneficiary in which the results/implications/diagnoses from a mental health diagnosis evaluation or a psychological evaluation are explained by the professional who administered the evaluation. Services are to be congruent with the age, strengths, necessary accommodations, and cultural framework of the beneficiary and his/her family.

This service must be performed by a physician or licensed mental health professional to assist the beneficiary and his or her primary support persons in understanding what is necessary for developing an array of rehabilitative treatment services for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Individual Psychotherapy

DEFINITION: Face-to-face treatment provided by a licensed mental health professional on an individual basis. Services consist of structured sessions that work toward achieving mutually defined goals as documented in the master treatment plan. Services are to be congruent with the age, strengths, needed accommodations necessary for any disability, and cultural framework of the beneficiary and his/her family. The treatment service must reduce or alleviate identified symptoms, maintain or improve level of functioning, or prevent deterioration.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

This service must be performed by a licensed mental health professional and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Marital/Family Psychotherapy - Beneficiary is not present DEFINITION: Face-to-face treatment provided to more than one member of a family simultaneously in the same session or treatment with an individual family member (i.e. Spouse or Single Parent) that is specifically related to achieving goals identified on the beneficiary's master treatment plan. The identified beneficiary is not present for this service. Services are to be congruent with the age, strengths, needed accommodations for any disability, and cultural framework of the beneficiary and his/her family. These services identify and address marital/family dynamics and improve/strengthen marital/family interactions and functioning in relationship to the beneficiary, the beneficiary's condition and the condition's impact on the marital/family relationship.

When all three conditions are taken together, it would be necessary to address marital/family dynamics and improve/strengthen the marital/family interactions and functioning in order o focus on the Medicaid eligible beneficiary's condition and how it can be improved.

The reason for providing this service is to improve the integrity of the patient's support system and documentation must reflect how the therapy accomplishes that rather than becoming therapy for the caregiver in and of itself.

The service may only be provided by a mental health professional practicing within the scope of their licensure.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Marital/Family Psychotherapy - Beneficiary is present DEFINITION: Face-to-face treatment provided to more than one member of a family simultaneously in the same session or treatment with an individual family member (i.e. Spouse or Single Parent) that is specifically related to achieving goals identified on the beneficiary's master treatment plan. The identified beneficiary must be present for this service. Services are to be congruent with the age, strengths, needed accommodations for disability, and cultural framework of the beneficiary and his/her family. These services are to be utilized to identify and address marital/family dynamics and improve/strengthen marital/family interactions and functioning in relationship to the beneficiary, the beneficiary's condition and the condition's impact on the marital/family relationship.

Please refer to Provider Qualifications on page 6a18.

· Individual Outpatient - Speech Therapy, Speech Language Pathologist Scheduled individual outpatient care provided by a licensed speech pathologist supervised by a physician to a Medicaid-eligible beneficiary for the purpose of treatment and remediation of a communicative disorder deemed medically necessary. See the Occupational, Physical and Speech Therapy Program Provider Manual for specifics of the speech therapy services.

This service must be performed by licensed speech language pathologist and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

· Individual Outpatient - Speech Therapy, Speech Language Pathologist Assistant Scheduled individual outpatient care provided by a licensed speech pathologist assistant supervised by a qualified speech language pathologist to a Medicaid-eligible beneficiary for the purpose of treatment and remediation of a communicative disorder deemed medically necessary. See the Occupational, Physical and Speech Therapy Program Provider Manual for specifics of the speech therapy services.

This service must be performed by licensed speech language pathologist assistant and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· Group Outpatient - Speech Therapy, Speech Language Pathologist Contact between a group of Medicaid-eligible beneficiaries and a speech pathologist for the purpose of speech therapy and remediation. See the Occupational, Physical and Speech Therapy Provider Manual for specifics of the speech therapy services. Group Outpatient - Speech Therapy, Speech Language Pathologist Assistant

Contact between a group of Medicaid-eligible beneficiaries and a speech pathologist assistant for the purpose of speech therapy and remediation. See the Occupational, Physical and Speech Therapy Provider Manual for specifics of the speech therapy services.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Group Outpatient - Group Psychotherapy DEFINITION: Face-to-face interventions provided to a group of beneficiaries on a regularly scheduled basis to improve behavioral or cognitive problems which either cause or exacerbate mental illness.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

The professional uses the emotional interactions of the group's members to assist them in implementing each beneficiary's master treatment plan. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Therapeutic Day/Acute Day Treatment DEFINITION: This service includes the administration of individual, family/marital and group therapies, face to face interventions and supportive services and is designed to be more intensive in nature than rehabilitative day services.

The providers are a combination of licensed professionals (psychologist, LCSW, LPC, LPE, RN, and paraprofessionals. Licensed professionals must supervise the milieu and a physician must provide oversight. Paraprofessionals must be supervised by a licensed professional.

Short-term daily array of continuous, highly structured, intensive outpatient services provided by a mental health professional. These services are for beneficiaries experiencing acute psychiatric symptoms that may result in the beneficiary being in imminent danger of psychiatric hospitalization and are designed to stabilize the acute symptoms. These direct therapy and medical services are intended to be an alternative to inpatient psychiatric care and are expected to reasonably improve or maintain the beneficiary's condition and functional level to prevent hospitalization and assist with assimilation to his/her community after an inpatient psychiatric stay of any length. These services are to be provided by a team consisting of mental health clinicians, paraprofessionals and nurses, with physician oversight and availability. The team composition may vary depending on clinical and programmatic needs but must at a minimum include a licensed mental health clinician and physician who provide services and oversight. Services are to be congruent with the age,

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

These services must include constant staff supervision of beneficiaries and physician oversight.

This service must be performed and overseen by a multidisciplinary team of physician, licensed mental health professional and mental health paraprofessional staff and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Crisis Intervention

DEFINITION: Unscheduled, immediate, short-term treatment activities provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services are designed to stabilize the person in crisis, prevent further deterioration, and provide immediate indicated treatment in the least restrictive setting. (These activities include evaluating a Medicaid-eligible beneficiary to determine if the need for crisis services is present.)

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Physical Examination - Psychiatrist or Physician Physical Examination - Psychiatric Mental Health Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse Practitioner

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

DEFINITION: A general multisystem examination based on age and risk factors to determine the state of health of an enrolled RSPMI beneficiary.

This service must be performed by a psychiatrist, physician, psychiatric mental health clinical nurse specialist or psychiatric mental health advanced nurse practitioner and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Pharmacologic Management by Physician (formerly Medication Maintenance by a physician) Pharmacologic Management by Mental Health Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse Practitioner DEFINITION: Provision of service tailored to reduce, stabilize or eliminate psychiatric symptoms by addressing individual goals in the master treatment plan. This service includes evaluation of the medication prescription, administration, monitoring, and supervision and informing beneficiaries regarding medication(s) and its potential effects and side effects in order to make informed decisions regarding the prescribed medications. Services must be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

· SERVICE: Medication Administration by a Licensed Nurse DEFINITION: Administration of a physician-prescribed medication to a beneficiary. This includes preparing the beneficiary and medication; actual administration of oral, intramuscular and/or subcutaneous medication; observation of the beneficiary after administration and any possible adverse reactions; and returning the medication to its previous storage.

This service must be performed by a qualified, licensed health care professional and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Group Outpatient - Pharmacologic Management by a Physician DEFINITION: Therapeutic intervention provided to a group of beneficiaries by a licensed physician involving evaluation and maintenance of the Medicaid-eligible beneficiary on a medication regimen with simultaneous supportive psychotherapy in a group setting. This includes evaluating medication prescription, administration, monitoring, and supervision; and informing beneficiaries regarding medication(s) and its potential effects and side effects. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

This service must be performed by a physician and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

· SERVICE: Routine Venipuncture for Collection of Specimen DEFINITION: The process of drawing a blood sample through venipuncture (i.e., inserting a needle into a vein to draw the specimen with a syringe or vacutainer) or collecting a urine sample by catheterization as ordered by a physician or psychiatrist.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Collateral Intervention, Mental Health Professional DEFINITION: A face-to-face contact by a mental health professional with caregivers, family members, other community-based service providers or other Participants on behalf of and with the expressed written consent of an identified beneficiary in order to obtain or share relevant information necessary to the enrolled beneficiary's assessment, master treatment plan , and/or rehabilitation. The identified beneficiary does not have to be present for this service. Services are to be congruent with the age, strengths, needed accommodations for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Collateral Intervention, Mental Health Paraprofessional DEFINITION: A face-to-face contact by a mental health paraprofessional with caregivers, family members, other community- based service providers or other Participants on behalf of and with the expressed written consent of an identified beneficiary in order to obtain

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

or share relevant information necessary to the enrolled beneficiary's assessment, master treatment plan, and/or rehabilitation. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. The identified beneficiary does not have to be present for this service.

This service must be performed by a mental health paraprofessional under the supervision of a licensed mental health professional and is necessary as part of an array of other rehabilitative treatment services used together when clinically indicated according to a master treatment plan for maximum reduction of a mental disability and to restore the beneficiary to his or her best possible functional level.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Crisis Stabilization Intervention, Mental Health Professional

DEFINITION: Scheduled face-to-face treatment activities provided to a beneficiary who has recently experienced a psychiatric or behavioral crisis that are expected to further stabilize, prevent deterioration, and serve as an alternative to 24-hour inpatient care. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Crisis Stabilization Intervention, Mental Health Paraprofessional

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Intervention, Mental Health Professional (formerly On- Site and Off-Site Interventions, MHP) DEFINITION: Face-to-face medically necessary treatment activities provided to a beneficiary consisting of specific therapeutic interventions as prescribed on the master treatment plan to re-direct a beneficiary from a psychiatric or behavioral regression or to improve the beneficiary's progress toward specific goal(s) and outcomes. These activities may be either scheduled or unscheduled as the goal warrants. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Intervention, Mental Health Paraprofessional (formerly On-Site and Off-Site Intervention, Mental Health Paraprofessional) DEFINITION: Face-to-face, medically necessary treatment activities provided to a beneficiary consisting of specific therapeutic interventions prescribed on the master treatment plan, which are expected to accomplish a specific goal or objective listed on the master

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

treatment plan. These activities may be either scheduled or unscheduled as the goal or objective warrants. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 6a18.

· SERVICE: Rehabilitative Day Service for Persons under Age 18 DEFINITION: An array of face-to-face interventions providing a preplanned and structured group program for identified beneficiaries that improve emotional and behavioral symptoms of youth diagnosed with childhood disorders, as distinguished from the symptom stabilization function of acute day treatment. These interventions are person- and family-centered, age-appropriate, recovery based, culturally competent, must reasonably accommodate disability, and must have measurable outcomes. These activities are designed to assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their mental illness. The intent of these services is to enhance a youth's functioning in the home, school, and community 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 positive peer interactions, appropriate social/family interactions, and managing overt expression of symptoms like impulsivity and anger; daily living and self-care skills, such as personal care and hygiene, and daily structure/use of time; cognitive skills, such as problem solving, developing a positive self-esteem, and reframing, money management, community integration, understanding illness, symptoms and the proper use of medications; and any similar skills required to implement a beneficiary's master treatment plan.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 6a18.

· Rehabilitative Day Service for Persons Ages 18-20 Apply the above definition and requirements (except Staff to Client Ratios, which are outlined below). Additional information: Use code H2017 with no modifier to claim for services provided to beneficiaries for ages 18-20.

· SERVICE: Adult Rehabilitative Day Service DEFINITION: Adult Rehabilitative day services provide a continuing, organized program of rehabilitative, therapeutic and supportive health services, and supervision to individuals who are mentally ill and who, due to the severity of their impairment, are in need of face to face interventions provided in a structured group program. This service is designed for long-term recovery and self-sufficiency.

Adult Rehabilitative day services provide rehabilitative and health services directed toward meeting the health restoration and maintenance needs of the beneficiary in a facility-based program providing specialized rehabilitation.

Services may include:

A. Goal compliance,

B. Problem solving,

C. Patient Safety

D. Task completion

E. Pharmaceutical supervision and/or

G. Health monitoring.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

An array of face-to-face interventions providing a preplanned and structured group program for identified beneficiaries that aimed at long- term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These interventions are person- and family-centered, recovery based, culturally competent, 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 beneficiary as an active and productive member of his/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 a beneficiary's master treatment plan .

This service also includes the administration of individual intervention services, individual therapy, group therapy and supportive services, but are designed to assist with beneficiary functioning on a day to day basis within the community.

The providers are licensed mental health professionals and paraprofessionals under their supervision.

Please refer to Provider Qualifications on page 6a18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

B. Provider Qualifications

Rehabilitative Services for Persons with Mental Illness (RSPMI) are limited to certified providers who offer core mental health services for the treatment and prevention of mental disorders. The provider must be certified as an RSPMI provider by the Division of Behavioral Health Services. Providers not certified by the Division of Behavioral Health Services may not provide these services.

Providers for each specific RSPMI service, as detailed in the scope of the program section, must practice within the scope of their Arkansas licensure. Individuals providing RSPMI services must be:

1. Licensed in the State of Arkansas as a mental health professional as defined in the RSPMI provider manual;

2. Medical records librarian as defined in the RSPMI provider manual;

3. Licensed in the State of Arkansas as a Psychiatrist - The psychiatrist may provide oversight, medical care, or both. If the psychiatrist does not provide all medically necessary RSPMI medical care, then a medical doctor may provide medical care in addition to a psychiatrist;

4. Licensed Psychologist or Licensed Psychological Examiner

5. Licensed Physician or

6. Certified Mental Health Paraprofessional, under the direct supervision of a Licensed Mental Health Professional

See Section 213.000 of the RSPMI provider manual for additional provider qualifications.

Qualified professionals must be present to furnish all medically necessary RSPMI services, including all services in each patient's care plan.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2007

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

1. Rehabilitative Services for Persons with Mental Illness (RSPMI)(continued)

The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) and Licensed Mental Health Practitioner (LMHP) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI and LMHP programs will begin being transitioned to the Outpatient Behavioral Health Program starting on July 1, 2017. RSPMI and LMHP will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI or LMHP provider for a service provided after June 30, 2018.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 2012

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (Continued)

2. Rehabilitative Services for Persons with Physical Disabilities (RSPD)

a. Extended Rehabilitative Hospital Services

Extended Rehabilitative Hospital Services are services for the rehabilitation of patients with various neurological, musculo-skeletal, orthopedic and other medical conditions following stabilization of their acute medical conditions. Extended Rehabilitative Hospital Services are a global service, covering all rehabilitative, psychological and/or social services required of the admitting facility for licensure, certification and/or accreditation.

The following services are included in the global coverage of an Extended Rehabilitative Hospital:

1) Restorative Therapies

2) Behavioral Rehabilitation

3) Life Skills Training

4) Individual and Group Counseling

5) Assessment Services

6) Nursing Care

Persons eligible for admission must have at least one of the following neurological conditions: Post acute traumatic or acquired brain injury. This includes and is limited to viral encephalitis, meningitis, aneurysms, cerebral vascular accident/stroke, post-operative tumors, anoxia, hypoxias, toxic encephalopathies, refractory seizure disorders and congenital neurological brain disorders. These conditions can be with or without moderate to severe behavioral disorders secondary to a brain injury.

An Extended Rehabilitative Hospital must be licensed by the Division of Health as a Rehabilitative Hospital. An Extended Rehabilitative Hospital must also be certified as a Title XVIII (Medicare) Rehabilitative Hospital provider. Extended Rehabilitative Hospital services are provided by a licensed practitioner who is directly related to the beneficiary's rehabilitative adjustment.

Extended Rehabilitative Hospital services provided are limited to thirty (30) days per state fiscal year, July 1 through June 30, for ages 21 and older. No extensions will be considered. However, beneficiaries who are under the age of 21 years and in the Child Health Services (EPSDT) Program are not limited to the thirty (30) day annual benefit limit. The thirty (30) day annual benefit limit only applies to services provided in an RSPD facility and does not include days counted toward any other Medicaid Program benefit limit, e.g., hospital, nursing home, etc.

Service delivery is delivery is the same as inpatient hospital services described in Attachment 3.1-A, Page 1a, Item 1, minus the room and board component.

Extended Rehabilitative Hospital Services are available to eligible Medicaid recipients of all ages when medically necessary as determined by the PRO. Services are limited to 30 days per State Fiscal Year for beneficiaries age 21 and older. Recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (Continued)

3. Outpatient Behavioral Health Services (OBHS)

A. Scope

DMS has set forth in policy the settings in which each individual service may be provided. Each service shown below includes the place of service allowable for that procedure.

B. Services

i .: Individual Behavioral Health Counseling*

DEFINITION: Individual Behavioral Health Counseling, including tobacco cessation, is a face-to- face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

B. Services

ii. Group Behavioral Health Counseling*

DEFINITION: Group Behavioral Health Counseling, including tobacco cessation, is a face-to-face treatment provided to a group of beneficiaries. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support his/her rehabilitation effort, and to minimize relapse. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present (continued)*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

iv. Marital/Family Behavioral Health Counseling without Beneficiary Present*

DEFINITION: Marital/Family Behavioral Health Counseling without Beneficiary Present, including tobacco cessation, is a face-to-face treatment provided to one or more family members outside the presence of a beneficiary for the benefit of the beneficiary. Services must be congruent with the age and abilities of the beneficiary or family member(s), client-centered and strength- based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

v. Group Psychoeducation*

* All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

v. Group Psychoeducation (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the Provider must have Arkansas State Infant Mental Health Certification.

vi. Multi-Family Behavioral Health Counseling*

DEFINITION: Multi-Family Behavioral Health Counseling, including tobacco cessation, is a group therapeutic intervention using face-to-face verbal interaction between two (2) to a maximum of nine (9) beneficiaries and their family members or significant others. Services are a more cost-effective alternative to Family Behavioral Health Counseling, designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services may pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

vii. Mental Health Diagnosis*

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

vii. Mental Health Diagnosis (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

iii. Interpretation of Diagnosis*

DEFINITION: Interpretation of Diagnosis is a direct service provided for the purpose of interpreting the results of psychiatric or other medical exams, procedures, or accumulated data. Services may include diagnostic activities and/or advising the beneficiary and his/ her family. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence.

* All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

viii. Interpretation of Diagnosis (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

ix. Substance Abuse Assessment*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician;

* All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

x. Psychological Evaluation*

Allowable Performing Provider - Licensed Psychologist, Licensed Psychological Examiner and a Licensed Psychological Examiner - Independent

xi: Pharmacologic Management*

Allowable Performing Provider - Advanced Practice Nurse or a Physician

xii: Psychiatric Assessment*

Allowable Performing Provider - Advanced Practice Nurse or a Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xiii. Treatment Plan*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Treatment Plan is a plan developed in cooperation with the beneficiary (or parent or guardian if under 18) to deliver specific mental health services to restore, improve, or stabilize the beneficiary's mental health condition. The Plan must be based on individualized service needs as identified in the completed Mental Health Diagnosis, independent assessment, and independent care plan. The Plan must include goals for the medically necessary treatment of identified problems, symptoms and mental health conditions. The Plan must identify individuals or treatment teams responsible for treatment, specific treatment modalities prescribed for the beneficiary, and time limitations for services. The plan must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and demonstrate cultural competence.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

xiv. Crisis Stabilization Intervention*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Crisis Stabilization Intervention are scheduled face-to-face treatment activities provided to a beneficiary who has recently experienced a psychiatric or behavioral crisis that are expected to further stabilize, prevent deterioration and serve as an alternative to 24-hour inpatient care. Services can include interventions, stabilization activities, coping strategies and other various activities to assist the beneficiary in crisis. The services provided are expected to reduce or eliminate the risk of harm to the person or others in order to stabilize the beneficiary. Services are to be congruent with the age, strengths, needed accommodation for any disability and cultural framework of the beneficiary and his/her family.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xv: Partial Hospitalization*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Partial Hospitalization is an intensive nonresidential, therapeutic treatment program. It can be used as an alternative to and/or a step-down service from inpatient residential treatment or to stabilize a deteriorating condition and avert hospitalization. The program provides clinical treatment services in a stable environment on a level equal to an inpatient program, but on a less than 24-hour basis. The environment at this level of treatment is highly structured and should maintain a staff-to-patient ratio of 1:5 to ensure necessary therapeutic services and professional monitoring, control, and protection. This service shall include at a minimum intake, individual therapy, group therapy, and psychoeducation. Partial Hospitalization shall be at a minimum (5) five hours per day, of which 90 minutes must be a documented service provided by a Mental Health Professional. If a beneficiary receives other services during the week but also receives Partial Hospitalization, the beneficiary must receive, at a minimum, 20 documented hours of services on no less than (4) four days in that week.

Allowable Performing Provider - Must be certified by the Department of Human Services as a Partial Hospitalization provider.

xvi: Behavioral Assistance*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Behavioral Assistance is a specific outcome oriented intervention provided individually or in a group setting with the child/youth and/or his/her caregiver(s) that will provide the necessary support to attain the goals of the treatment plan. Services involve applying positive behavioral interventions and supports within the community to foster behaviors that are rehabilitative and restorative in nature. The intervention should result in sustainable positive behavioral changes that improve functioning, enhance the quality of life and strengthen skills in a variety of life domains.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed

* All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xvii. Family Support Partners*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Family Support Partners is a service provided by peer counselors, or Family Support Partners (FSP), who model recovery and resiliency for caregivers of children or youth with behavioral health care needs for the benefit of the beneficiary. Family Support Partners come from legacy families and use their lived experience, training, and skills to help caregivers and their families identify goals and actions that promote recovery and resiliency of the beneficiary. FSPs are required to be trained and certified by the State as a FSP to provide this service.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

xviii: Peer Support*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Peer Support is a consumer centered service provided by individuals who self-identify as someone who has received or is receiving behavioral health services and thus is able to provide expertise not replicated by professional training. Peer providers are trained and certified peer specialists who self-identify as being in recovery from behavioral health issues. Peer support is a service to work with beneficiaries to provide education, hope, healing, advocacy, self-responsibility, a meaningful role in life, and empowerment to reach fullest potential. Specialists will assist with navigation of multiple systems (housing, supportive employment, supplemental benefits, building/rebuilding natural supports, etc.) which impact beneficiaries' functional ability. Peer Support is a person-centered service with a recovery focus which allows beneficiaries the opportunity to direct their own recovery and advocacy process. This service promotes skills for coping with and managing symptoms while utilizing natural resources and the preservation and enhancement of community living skills. Services are provided on an individual or group basis, and in either the beneficiary's home or community environment.

Allowable Performing Provider - Certified Peer Support Specialist; and a Certified Youth Support Specialist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xix. Individual Pharmacologic Counseling*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: A specific, time limited one-to-one intervention by a nurse with a beneficiary and/or caregivers, related to their psychopharmological treatment. The service should encompass all the parameters to make the beneficiary and/or family understand the diagnosis prompting the need for the medication and any life style modification required.

Allowable Performing Provider -Registered Nurse

xx: Group Pharmacologic Counseling*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: A specific, time limited intervention provided to a group of beneficiaries and/or caregivers by a nurse, related to their psychopharmological treatment. The service should encompass all the parameters to make the beneficiary and/or family understand the diagnosis prompting the need for the medication and any life style modification required.

Allowable Performing Provider - Registered Nurse

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxi. Intensive Outpatient Substance Abuse Treatment*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Intensive Outpatient services provide group based, non-residential, intensive, structured interventions consisting primarily of counseling and education to improve symptoms that may significantly interfere with functioning in at least one life domain (e.g., familial, social, occupational, educational, etc.). Services are goal oriented interactions with the individual or in group/family settings. This community based service allows the individual to apply skills in "real world" environments. Such treatment may be offered during the day, before or after work or school, in the evening or on a weekend. The service also provides a coordinated set of individualized treatment services to persons who are able to function in a school, work, and home environment but are in need of treatment services beyond traditional outpatient programs. Treatment may appropriately be used to transition persons from higher levels of care or may be provided for persons at risk of being admitted to higher levels of care. Intensive outpatient programs provide 9 or more hours per week of skilled treatment, 3 - 5 times per week in groups of no fewer than three and no more than 12 clients.

Allowable Performing Provider - Behavioral Health Agency that is certified by the Department of Human Services as an Intensive Outpatient Substance Abuse Treatment provider The Intensive Outpatient Substance Abuse Treatment provider shall have practitioners appropriately licensed and certified to deliver Intensive Outpatient Substance Abuse Treatment.

xxii: Individual Life Skills Restoration*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Individual Life Skills Restoration is a service that provides support and training for beneficiaries on a one-on-one basis. This service includes behavioral modeling to restore a beneficiary's skills needed to support an independent lifestyle and restore a strong sense of self-worth. This service should be a strength-based, culturally appropriate process that integrates the youth into their community as they develop their recovery plan. In addition, it aims to restore the ability of youth in setting and achieving goals, and restoring independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxiii. Group Life Skills Restoration*

Group Life Skills Restoration is a service that provides support and training for beneficiaries in a group setting of up to six (6) beneficiaries with one staff member or up to ten (10) beneficiaries with two staff members. This service includes behavioral modeling to restore a beneficiary's skills needed to support an independent lifestyle and restore a strong sense of self-worth. This service should be a strength-based, culturally appropriate process that integrates the youth into their community as they develop their recovery plan. In addition, it aims to restore the ability of youth in setting and achieving goals, and restoring independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living.

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: group

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

xxiv: Child and Youth Support Services*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Child and Youth Support Services are clinical, time-limited services for principal caregivers for the benefit of the beneficiary designed to restore a child's positive behaviors and compliance with parents at home; and restore a child's social skills, including understanding of feelings, conflict management, academic engagement, school readiness, and cooperation with teachers and other school staff for the benefit of the beneficiary. This service is intended to assist the parent in managing their child's symptoms of their illness and training the parents in effective interventions and techniques for working with the schools for the benefit of the beneficiary.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxv. Psychosocial Rehabilitation Services - Working Environment*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Psychosocial Rehabilitation Services - Working Environment is designed to assist beneficiaries restore skills needed to promote and sustain independence and stability in their working environment. The service actively facilitates the restoration of skills needed to acquire a job.

Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

xxvi: Psychosocial Rehabilitation Services - Living Environment *

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Psychosocial Rehabilitation Services - Living Environment is designed to assist beneficiaries restore skills needed to promote and sustain independence and stability in their living environment. An emphasis is placed on the development and strengthening of natural supports in the community.

Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

CATEGORICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxvii. Adult Life Skills Development

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Adult Life Skills Development services are designed to assist beneficiaries in restoring skills needed to support an independent lifestyle and promote an improved sense of self- worth. Adult Life skills Development is designed to restore the beneficiary's ability to set and achieve goals, restore independent living skills, restore the ability to demonstrate accountability, and restore the ability to make goal-directed decisions related to independent living.

Allowable Performing Provider -Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

xxviii: Therapeutic Communities

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Therapeutic Communities are highly structured residential environments in which the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability. Services address the broad range of needs identified through a person-centered and directed planning process. Therapeutic Communities employs community-imposed consequences and earned privileges as part of the recovery and growth process.

Example services include, but are not limited to, a combination of Individual Behavioral Health Counseling, Group Behavioral Health Counseling, Psychoeducation, Marital-Family Behavioral Health Counseling, Multi-Family Behavioral Health Counseling, Crisis Stabilization Intervention, Peer Support, Individual Pharmacologic Counseling, Group Pharmacologic Counseling, Adult Life Skills Development and Psychosocial Rehabilitative Services.

This service will not be paid for within an Institution for Mental Disease (IMD)

This service does not include payment for room and board of the beneficiary.

Therapeutic Community shall be certified by the Department of Human Services as a Therapeutic Communities provider.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

January 1, 2022

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

1. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxix. Crisis Care - De-escalation*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Crisis Care - De-escalation provides temporary direct care for a beneficiary in the beneficiary's community that is not facility-based. Crisis Care - De-escalation services de-escalate stressful situations and provide a therapeutic outlet. Crisis Care includes behavioral interventions that keep beneficiaries in their current situation and reduces the need for acute hospitalization or other higher levels of care. Crisis Care shall be indicated in the treatment plan.

This service will not be paid for within an Institution for Mental Disease (IMD).

This service does not include payment for room and board of the beneficiary.

Crisis Care - De-escalation provider must be certified by the Department of Human Services as a Crisis Care - De-escalation provider.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.

xxx. Acute Crisis Units*

Definition: Acute Crisis Units provide brief 96 hours or less) crisis treatment services to persons over the age of 17 who are experiencing a psychiatry and/or substance abuse-related crisis and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and step-down services in a safe environment with psychiatry and/or substance abuse services on-site at all times as well as on-call psychiatry available 24 hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occurring treatment; and initiate referral mechanisms for independent assessment and care planning as needed.

This service will not be paid for within an Institution for Mental Disease (IMD).

This service does not include payment for room and board of the beneficiary.

Acute Crisis Unit must be certified by Department of Human Services as an Acute Crisis Unit.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

An Extension of Benefit for medical necessity is required for admissions exceeding ninety-six (96) hours.

*All medically necessary 1905(a) services, that correct or ameliorate physical and mental illnesses and conditions, are covered for EPSDT eligible beneficiaries, ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

Approval Date:

Effective Date:

01/01/2022

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

January 1, 2022

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)

xxxi. Crisis Intervention*

DEFINITION: Crisis Intervention is an unscheduled, immediate, short-term treatment activity provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and their family. These services, which can include interventions, stabilization activities, evaluation, coping strategies, and other various activities to assist the beneficiary in crisis, are designed to stabilize the person in crisis, prevent further deterioration, and provide immediate indicated treatment in the least restrictive setting. The services provided are expected to reduce or eliminate the risk of harm to the person or others in order to stabilize the beneficiary.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician

xxxii. Substance Abuse Detoxification*

Definition: Substance Abuse Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize beneficiaries by clearing toxins from the beneficiary's body. Services are short-term, may be provided in a crisis unit, residential, or outpatient setting, and may include evaluation, observation, medical monitoring, and addiction treatment. Detoxification seeks to minimize the physical harm caused by the abuse of substances and prepares the beneficiary for ongoing treatment.

This service will not be paid for within an Institution for Mental Disease (IMD).

This service does not include payment for room and board of the beneficiary.

Substance Abuse Detoxification Unit must be certified by the Department of Human Services as a Substance Abuse Detoxification provider.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.

Six encounters are allowed per State Fiscal Year (July 1 through June 30). Extension of Benefits for Medically Necessary Encounters beyond the first six (6) is required.

*All medically necessary 1905(a) services, that correct or ameliorate physical and mental illnesses and conditions, are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

TN: 2021-0005 Approval Date: 08/26/2021 Effective Date: 01/01/2022 Supersedes: TN 16-0008

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

October 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxxiii: Residential Community Reintegration Services*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Residential Community Reintegration Services are designed to serve as an intermediate level of care between Inpatient Psychiatric Facilities and Outpatient Behavioral Health Services. Twenty-four hour per day intensive therapeutic care is provided in a small group home setting for individuals under 21 years of age with emotional and/or behavior problems which cannot be remedied by less intensive treatment to prevent acute or sub-acute hospitalization. The program is also offered as a step-down or transitional level of care to prepare a beneficiary for less intensive treatment. Services include all medically necessary Outpatient Behavioral Health Services (OBHS) to address the beneficiary's behavioral health needs.

This service will not be paid for within an Institution for Mental Disease (IMD).

This service does not include payment for room and board of the beneficiary.

Residential Community Reintegration sites shall be certified by the Department of Human Services as a Residential Community Reintegration provider.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

* All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)

C. Provider Agency Qualifications

Outpatient Behavioral Health Services (OBHS) may be provided by appropriately certified providers who offer core behavioral health services for treatment and rehabilitation of behavioral health issues. The provider must be certified as an OBHS provider by the Department of Human Services (DHS). Providers not certified by DHS are not qualified to provide these services.

D. Performing Provider Qualifications

Outpatient Behavioral Health Services (OBHS) are limited to certified providers who offer core behavioral health services for treatment and rehabilitation of behavioral health issues. The provider must be certified as an OBHS provider by the Department of Human Services (DHS). Providers not certified by DHS are not qualified to provide these services.

Providers for each specific OBHS service are certified by DHS. Any provider licensed by the State must practice within their scope of Arkansas licensure. Individuals providing OBHS services must be one of the following:

1. Licensed in the State of Arkansas as a Clinician:

a. Licensed Clinical Social Worker (LCSW)

b. Licensed Marital and Family Therapist (LMFT)

c. Licensed Psychologist (LP)

d. Licensed Psychological Examiner - Independent (LPEI)

e. Licensed Professional Counselor (LPC)

f. Licensed Master Social Worker (LMSW)

g. Licensed Associate Counselor (LAC)

h. Licensed Psychological Examiner (LPE)

i. Provisionally Licensed Psychologist (PLP)

2. Licensed Physician

3. Licensed Advanced Nurse Practitioner (limited to Adult Psychiatric Mental health Clinical Nurse Specialists, Child Psychiatric Mental Health Clinical Nurse Specialist, Adult Psychiatric Mental Health APN and Family Psychiatric Mental Health APN)

4. Licensed Registered Nurse

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)

5. Certified Qualified Behavioral Health Providers (includes Certified Peer Support Specialist, Certified Youth Support Specialist, and Certified Family Support Partner), under direct supervision of an individual licensed in the State of Arkansas as a Clinician that is an allowable performing provider of a service as indicated in D., 1.,a - e.

a. Certified Peer Support Specialists, Certified Youth Support Specialists, and Certified Family Support Partners are certified by DHS and must adhere to the mandated training requirements to become certified. The requirements to become and maintain certification are as follows:

i. Must complete 40 hours of QBHP training

ii. Must complete annual ongoing training approved by Arkansas DHS

iii. Must have lived experience

iv. Must ensure and document that all Certified Peer Support Specialists, Certified Youth Support Specialists, and Certified Family Support Partners are under supervision of a mental health professional as defined in Section 13., d., 3., c., 1 above.

b. Qualified Behavioral Health Providers are certified by the Behavioral Health Agency that they work for. In order to become certified as a Qualified Behavioral Health Provider, the Agency must provide and document that each Qualified Behavioral Health Provider has completed the required training and the Agency must issue a certificate to the Qualified Behavioral Health Provider. The requirements to become and maintain certification are as follows:

i. Must complete 40 hours of QBHP training, which includes, but is not limited to, topics such as behavior management, group interaction, listening techniques, and knowledge of behavioral health illnesses.

ii. Must complete, at a minimum, 8 hours of annual in-service training

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

February 15, 1995

CATEGORICALLY NEEDY

14. Services for Individuals Age 65 or Older in Institutions for Mental Diseases

a. Inpatient Hospital Services

Not provided.

b. Nursing Facility Services Not provided.

STATE DATE REUM CATE APPVC

Arkansas JAN 1 2 1995

FEB 2 2 1995

DATE EFF HCFA 179

FEB 15 1005 93-01

3.1-A, Page 6C

SUPERSEDES: TN -

94-06

Revision:

HCFA - Region VI

November 1990

Revised:

January 1, 2013

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

15. Services in an intermediate care facility for the mentally retarded, as defined in Section 1905(d), (other than in an institution for mental diseases) for individuals who are determined, in accordance with Section 1902(a)(31)(A), to be in need of such care. ☒ Provided: ☒ No limitations ☐ With limitations* ☐ Not provided. PA*

16. Inpatient psychiatric facility services for individuals under 22 years of age. ☒ Provided: ☐ No limitations ☒ With limitations* ☐ Not provided. PA*

17. Nurse-midwife services. ☒ Provided: ☐ No limitations ☒ With limitations* ☐ Not provided.

18. Hospice care (in accordance with section 1905(o) of the Act). ☒ Provided: ☐ No limitations ☒ With limitations* ☐ Not provided. ☒ Provided in accordance with section 2302 of the Affordable Care Act

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 7a

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: October 1, 1990

15. Services in an intermediate care facility for the mentally retarded, as defined In Section 1905(d), (other than In an institution for mental diseases) for individuals who are determined, in accordance with Section 1902(a) (31) (A), to be in need of such care.

A Registered Nurse and a Physician Reviewer assess medical needs and make medical

eligibility determinations and patient level of care classifications for applicants referred by a physician for nursing home care.

ICF/MR services Include coverage of prescription medications within the State's formulary without limitations.

Grasas

STATE DATE REC'D DEC 1 9 1990

DATE APPVID 4-19-91

DATE EFF OCT - 1 1990

90-61 HCFA 179

Supersales: 89-46

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 7b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY Revised: March 1, 1993

16. Inpatient Psychiatric Facility Services for Individuals Under 22 Years of Age

Inpatient Psychiatric Providers which are inpatient psychiatric hospitals must be:

. licensed as a psychiatric hospital by the State agency which licenses psychiatric hospitals and

· certified by the Medicare Certification Team as meeting the conditions of participation as a psychiatric hospital in the Title XVIII (Medicare) Program.

Inpatient Psychiatric Providers which are inpatient psychiatric residential treatment facilities must be:

accredited as meeting the child and adolescent standards of the Joint Commission on Accreditation of Healthcare Organizations and

· licensed by the Arkansas Department of Human Services, Division of Children and Family Services as a psychiatric residential treatment facility. (Applicable only to Inpatient Psychiatric Providers located in Arkansas.)

Inpatient Psychiatric Providers which are inpatient psychiatric programs in a psychiatric facility must be:

accredited es meeting the child and adolescent standards of the Joint Commission on Accreditation of Healthcare Organizations.

Inpatient Psychiatric Providers which are inpatient psychiatric programs in a psychiatric hospital must:

· be in a psychiatric hospital licensed as a psychiatric hospital by the State agency which licenses psychiatric hospitals;

. be in a psychiatric hospital certified by the Medicare Certification Team as meeting the conditions of participation as a psychiatric hospital in the Title XVIII (Medicare) Flogram and

have an Inpatient psychiatrie program whisk is accredited ne meeting the child and adolescent standards of the Jefft Commission on Accreditation of Healthcare Organizations.

STATE CARanse

$15 RECO MAR 0 5 1993

CHE APPVD MAR 22 1993

MAR 0 1 1993 93.08

HOLA VAN

Annessedet 5, 87-31

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 7c

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 1991

CATEGORICALLY NEEDY

16. Inpatient Psychiatric Facility Services for Individuals Under 22 Years of Age (Continued)

Inpatient psychiatric services reimbursable under the Arkansas Medicaid Program must be provided:

· by an Inpatient Psychiatric Provider selected by the recipient;

· by an Inpatient Psychiatric Provider enrolled in the Arkansas Medicaid Program;

. to an eligible Arkansas Medicaid recipient before the recipient reaches age 21 or, if the recipient was receiving inpatient psychiatric services at the time they reached 21 years of age, services may continue until the recipient no longer requires the services or the recipient becomes 22 years of age, whichever comes first.

· with certification from the independent or facility based team (whichever is appropriate in accordance with 42 CFR 441.153) that the recipient meets the criteria for inpatient psychiatric services;

· with prior authorization from the Medicaid Agency Review Team and

· under the direction of a physician (contracted physicians are acceptable).

Granjas STAT

9-23-91

MATE APPV'O 10-21-91 CATE EME 10-1-91

HOFUVYZ 91.40

Supersales: 88-04

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: August 1, 2008

17. Nurse-Midwife Services

Any person possessing the qualifications for a registered nurse in the State of Arkansas who is also certified as a nurse-midwife by the American College of Nurse-Midwives, upon application and payment of the requisite fees to the Arkansas State Board of Nursing, be qualified for licensure as a certified nurse-midwife. A certified nurse-midwife meeting the requirements of Arkansas Act 409 of 1995 is authorized to practice nurse- midwifery.

Services provided by a certified nurse midwife are limited to twelve (12) visits a year for beneficiaries age 21 and older. This yearly limit is based on the State Fiscal Year (July 1 through June 30). The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, office medical services furnished by an optometrist and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries under age 21 in the Child Health Services (EPSDT) program are not benefit limited.

SUPERSEDES TN 04-12

HCFA 179

DATE EFF

DATE APDV'D DATE REC 5

STATE

08-18

8/1/08

12/19/08

9/30/08

Arkansas

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: November 1, 2006

18. Hospice Care

· The hospice patient must be terminally ill which is defined as having a medical prognosis with a life expectancy of six months or less. The terminal illness must be certified by the patient's attending physician and hospice services prescribed.

· Patients must voluntarily elect to receive hospice services and choose the hospice provider. Hospice election is by "election periods". Election periods in the Arkansas Medicaid Hospice Program correspond to the election periods established for Medicare. The initial hospice election period is of 90 days duration and is followed by a second 90-day election period. The patient is then eligible for an unlimited number of 60-day election periods.

· Election of the hospice benefit results in a waiver of the beneficiary's rights to payment for only those services which are related to the treatment of the terminal illness or related conditions and common to both Title XVIII and Title XIX. The beneficiary does not waive rights to payment for services related to the terminal illness that are unique to Title XIX.

· Hospice services must be provided primarily in a patient's residence.

A patient may elect to receive hospice services in a nursing facility or an intermediate care facility for the mentally retarded (ICF/MR) if the hospice and the facility have a written agreement under which the hospice takes full responsibility for the professional management of the patient's hospice care, and the facility agrees to provide room and board to the patient.

· Hospice services must be provided consistent with a written plan of care.

· Dually eligible (Medicare and Medicaid) beneficiaries must elect hospice care in the Medicare and Medicaid hospice programs simultaneously to be eligible for Medicaid hospice services.

Revision:

HCFA - PM-94-7

SEPTEMBER 1994

(MB)

ATTACHMENT 3.1 -A Page 8 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

ARKANSAS

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

19. Cibe management services and Tuberculosis related services

d. Case management services as defined in, and to the group specified in, Supplement 1 Lo ATTACHMENT 3.1:A ( in accordance with section 1905 (a) (19) or section 1915 (g) of the Act) .

X ☒ Provided: X

☒ With limitations

Rot provided.

. Special tuberculosis (TB) related services under section 1902 (z) (2) (F) of the Act. Provided: With limitations*

X ☒ Not provided.

20. Extended services for pregnant women

a. Pregnancy- related and postpartum services for a 60-day period after the pregnancy end: and any remaining days in the month in which the 60th day falla. Additional coverage ++

b. Services for any other medical conditions that may complicate pregnancy . X ☒ Additional coverage ++

++ Attached is a description of increases in covered services beyond limitations for all groups described in this attachment and/or any additional services provided to pregnant women only.

*Description provided on attachment.

STATE 19-12-94 DATE REC'D

9-15-94 DATE APPV'D

9-1-94 DATE EFF

94-22 HCFA 179

TN No.

94-22

Supersede TN NO. 94-12

Approval Date

9/15/94

Effective Date

9/1/94

Revision:

HCFA-PM-91-4R (BPD) August 1991

Revised:

January 1, 2014

State/Territory: ARKANSAS

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

21. Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period by an eligible provider (in accordance with section 1920 of the Act). ☐ Provided: ☐ No limitations ☒ With limitations* ☒ Not provided.

22. Respiratory care services (in accordance with section 1902(e)(9)(A) through (C) of the Act). ☒ Provided: ☐ No limitations ☒ With limitations* with Prior Authorization

☐ Not provided.

23. Certified pediatric or family nurse practitioners' services. ☒ Provided: ☐ No limitations ☒ With limitations*

*Description provided on attachment.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 1991

CATEGORICALLY NEEDY

19. Case Management Services

Refer to Supplement 1 to Attachment 3.1-A.

20. Extended Services for Pregnant Women

a. Pregnancy-related and postpartum services for a 60 day period after the pregnancy ends and for any remaining days in the month in which the 60th day falls.

Services provided will only be pregnancy-related services, postpartum services and family planning. Sixty (60) days of postpartum care is covered if the individual is Medicaid eligible at delivery.

b. Services for any other medical conditions that may complicate pregnancy.

(1) Risk Assessment

A medical, nutritional, and psychosocial assessment by the physician or registered nurse to designate patients as high or low risk.

(a) Medical assessment using the Hollister Maternal/Newborn Record System to include:

· medical history

· menstrual history

· pregnancy history

(b) Nutritional assessment to include:

· 24 hour diet recall

· Screening for anemia

· weight history

(c) Psychosocial assessment to include criteria for an identification of psychosocial problems which may adversely affect the patient's health status.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 8b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 1991

CATEGORICALLY NEEDY

20. Extended Services for Pregnant Women (Continued)

b. Services for any other medical conditions that may complicate pregnancy. (Continued)

(1) Risk Assessment (Continued)

Pregnant women who are assessed as high risk, by definition, have medical conditions or circumstances which complicate the pregnancy. These patients need more medical services and attention in an effort to ensure a healthy birth outcome. Some conditions which complicate the pregnancy, and are therefore considered high risk, are:

Teenage pregnancies -Diabetes Toxemia

MAXIMUM:

2 per pregnancy

(2) Case Management Services

Refer to Item 19 and_Supplement 1 to Attachment 3.1-A.

chod Management services ara reimbursed celog a monthly fre -At the

milmom of 2 contacte per month most be provided sobre management io

modi and care plan development And

management contact may bo with the patientother profetslansky family

Girkansas STATE

17-29-91 DATE REC'D

8-22-91 DATE APPV'D

7-1-91 DATE EFF

191-30 HCFA 179

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY April 1, 1987

20. Extended Services for Pregnant Women (Continued)

b. Services for any other medical conditions that may complicate pregnancy. (Continued)

(3) Perinatal Education

Educational classes provided by a health professional (Public Health Nurse, Nutritionist, or Health Educator) to include:

· = pregnancy

· labor and delivery

· reproductive health

· postpartum care

· nutrition in pregnancy

These educational classes are designed to prevent the development of conditions which may complicate the pregnancy or to provide information to the pregnant woman in caring for herself during a pregnancy which may already have complicating factors.

MAXIMUM: 6 classes (units) per pregnancy

AR STATE

DATE PIC D JUL 1 1987

O JUL 3 0 1987

VALE APPY 5.Alt 8: See MCFA-179 HON NY 87-12

Supersedes 86-26

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

April 1, 1987

20. Extended Services for Pregnant Women (Continued)

b. Services for any other medical conditions that may complicate pregnancy. (Continued)

(4) Nutritional Consultation - Individual

Services provided for high risk pregnant women by a registered dietitian or a nutritionist eligible for registration by the Commission on Dietetic Registration to include at least one of the following:

· an evaluation to determine health risks due to nutritional factors with development of a nutritional care plan

· nutritional care plan follow-up and reassessment as indicated

By definition, this service is covered only for women with high risk pregnancies. This service is appropriate for women whose complications require nutritional education for treatment of the complication (such as diabetics).

MAXIMUM: 9 units per pregnancy (1 unit equals 1 client visit)

STATE AR

DATE REC'D JUL 1 1987

DATE APPV DA JUL 3 0 1987 DATE EFF See HCFA-179 HCFA 179 82-12

new page

AMOUNT; DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

April 1, 1987

20. Extended Services for Pregnant Women (Continued)

b. Services for any other medical conditions that may complicate pregnancy. (Continued)

Services provided for high risk pregnant women by a licensed social work to include at least one of the following:

. : an evaluation to determine health risks due. to psychosocial factors with development of a social work care plan

· social work plan follow-up, appropriate intervention and referrals

By definition, this service is only covered for women with high risk pregnancies. This service is appropriate for women whose complications require social work consultation as an essential element of treatment in dealing with the complication (such as a teenager with no place to live).

MAXIMUM: 6 units per pregnancy (1 unit equals ] client visit)

STATE AR

DATE REC'D

JUL 1 1987

DATE APPV'D

JUL 3 0 1987

DATE ELF

Sue MCFA 179

HCFA 179

87-12

new page

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: March 1, 2011

CATEGORICALLY NEEDY

20. Extended Services for Pregnant Women (Continued)

b. Services for any other medical conditions that may complicate pregnancy. (Continued)

(6) Early Discharge Home Visit

If a physician chooses to discharge a low-risk mother and newborn from the hospital early (less than 24 hours), the physician or registered nurse employee may provide a home visit to the mother and baby within 72 hours of the hospital discharge; or the physician may request an early discharge home visit from any clinic that provides perinatal services. Visits will be done by physician order (includes hospital discharge order).

A physician may order a home visit for the mother and/or infant discharged later than 24 hours if there is specific medical reason for home follow-up.

These services are preventive in nature to try to avoid post-partum complications.

Pregnancy-Related Substance Abuse Treatment Services (SATS) are provided for Medicaid eligible pregnant women through the last day of the month in which the 60th post partum day falls. Services are provided based on medical necessity and require prior authorization.

The SATS program covers the following services:

A. Addiction Assessment

B. Treatment Planning

C. Care Coordination

D. Multi-person (family) Group Counseling

E. Individual Counseling

F. Group Counseling

G. Marital/Family Counseling

H. Medication Management

Please refer to Attachment 3.1-A, Page 1zz.3 for the service descriptions, definitions, benefit limits and individual qualified provider requirements. Benefit limits may be extended based on medical necessity.

SATS Qualified Provider

SATS providers must hold certification from the Division of Behavioral Health Services (DBHS) as a SATS provider in order to enroll as a Substance Abuse Treatment Services Medicaid provider.

The following requirements must be met for DBHS/OADAP certification:

A. Providers must be licensed by Division of Behavioral Health Services, Office of Alcohol and Drug Abuse Prevention (OADAP).

B. Providers must submit a written request from the organization's Chief Executive Officer (CEO) to DBHS for certification by DBHS as a SATS Provider.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

March 1, 2011

CATEGORICALLY NEEDY

20. Extended Services for Pregnant Women (Continued)

b. Services for any other medical conditions that may complicate pregnancy. (Continued)

(7) Pregnancy-Related Substance Abuse Treatment Services (SATS) (Continued)

F. Provisional, Conditional, Preliminary, Pending, Expedited or Deferred Accreditations are not acceptable.

J. Providers must adhere to evidence-based practices as approved by DBHS for specific populations and services provided.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: January 1, 2014

21. RESERVED

22. Respiratory care services (in accordance with Section 1902(e)(9)(A) through (C) of the Act).

Respiratory care for ventilator-dependent individuals means services that are not otherwise available under the State's Medicaid plan, provided on a part-time basis in the recipient's home by a respiratory therapist or other health care professional trained in respiratory therapy to an individual who ---

a. Is medically dependent on a ventilator for life support at least 6 hours per day;

b. Has been so dependent for at least a number of consecutive days (number is based on maximum number of days authorized under the State plan, whichever is less) as an inpatient in one or more hospitals, NFs, or ICFs/MR;

c. Except for the availability of respiratory care services, would require respiratory care as an inpatient in a hospital, NF, or ICF/MR and would be eligible to have payment made for inpatient care under the State plan;

d. Has adequate social support services to be cared for at home;

e. Wishes to be cared for at home; and

f. Receives services under the direction of a physician who is familiar with the technical and medical components of home ventilator support, and who has medically determined that in-home care is safe and feasible for the individual.

1. Ventilator Equipment (i.e., ventilator, suction pump, oxygen concentrator, liquid oxygen, liquid oxygen walker and reservoir, ventilator supplies and hospital bed) including 24-hour availability of respiratory therapy and equipment maintenance, with prior authorization.

2. Respiratory therapy/treatment services for ventilator-dependent recipients under age 21, with prior authorization.

Revision: HCFA-PM-91-4 ( BPD)

AUGUST 1991

Revised:

JULY 1, 1997

State/Territory:

ARKANSAS

ATTACHMENT 3.1-A Page 9 OMB No. : 0938-

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

24. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary. a. Transportation. / XI ☒ Provided: LI No limitations ☒ With limitationg*

Not provided.

b. Services of Christian Science nurses.

Provided: LI No limitations 11 With limitations*

Not provided. ☒ 1X/

c. Care and services provided in Christian Science sanitoria.

Provided: LI No limitations With limitations* ☒ 1X1

Not provided.

d. Nursing facility services for patients under 21 years of age. ☒ With limitations* ☒ Provided: 11 No limitations 1 X

Not provided.

e. Emergency hospital services. LX_/ ☒ Provided: LI No limitations ☒ / Wwith limitations+

Not provided. f. Personal care services in recipient's home/ prescribed in accordance with a plan of treatment and provided by a qualified person under version cards red mich or ase ger Provided : No limitations With limitations*

Not provided. SEE ITEM 26.

*Description provided on attachment.

TN No. Supersedes

Approval Date

Effective Date

TN No.

HCFA ID: 7986E

STATE Arkansas DATE REC Stina7

DATE -. ..

8/12/94

☒ A

DALE ...

Milay

HCfA 175

97-03

SUPERSEDES: TN . 91-43

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

January 1, 2024

CATEGORICALLY NEEDY

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary.

a. Transportation

(1) A. Ground Ambulance Services

Payment will be made for ambulance services, provided the conditions below are met and the services are provided in accordance with laws, regulations and guidelines governing ambulance services under Part B of Medicare. These services are equally available to all beneficiaries. The use of medical transportation must be for health-related purposes and reimbursement will not be made directly to Title XIX beneficiaries.

I. For transportation of beneficiaries when medically necessary as certified by a physician to a hospital, to a nursing home from the hospital or beneficiary's home, to the beneficiary's home from the hospital or nursing home, from a hospital (after receiving emergency outpatient treatment) to a nursing home if a beneficiary is bedridden, and from a nursing home to another nursing home if determined necessary by the Office of Long Term Care. Emergency service is covered only through licensed emergency ambulance companies. Services not allowed by Title XVIII but covered under Medicaid will be reimbursed for Medicare/Medicaid beneficiaries.

II. For services provided at an alternative location or destination to which an ambulance is dispatched, and the ambulance service treatment is initiated from a 911 call that is documented in the records of the ambulance service. Alternative destination means a lower-acuity facility that provides medical services.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

January 1, 2024

CATEGORICALLY NEEDY

Alternative location is the location to which an ambulance is dispatched, and the ambulance service treatment is initiated from a 911 call that is documented in the records of the ambulance service. Alternative destination means a lower-acuity facility that provides medical services, including:

. A federally qualified health center;

. An urgent care center;

. A physician's office or medical clinic, as chosen by the beneficiary;

. A behavioral or mental healthcare facility

Excluded alternative destinations are facilities that provide a higher-acuity medical service or medical services for a routine chronic condition, such that they would be considered as destinations for which transportation under (1) above would occur:

· Emergency Room;

· Critical Access Hospital;

· Rural Emergency Hospital;

· Dialysis center;

· Hospital;

· Private residence;

· Skilled nursing facility

B. Air Ambulance Services

Air ambulance services are provided to Arkansas Medicaid beneficiaries only in emergencies.

Air ambulance providers must be licensed by the Arkansas Ambulance Boards and enrolled as a Title XVIII, Medicare Provider.

(2) Early Intervention Day Treatment (EIDT) and Adult Developmental Day Treatment (ADDT) Transportation

EIDT and ADDT providers may provide transportation to and from their facility. The Medicaid transportation broker must provide transportation to and from the nearest qualified medical provider for the purpose of obtaining medical treatment.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: January 1, 2006

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary.

a. Transportation (Continued)

(3) Non-Emergency

(a) Public Transportation

STATE Arkansas

DATE REC'D 10-20-05

DATE APPVID 1- 17-05

DATE EFF 1-1-06

HCFA 179 05-10

Effective for dates of service on or after December 1, 2001, public transportation services are available when provided by an enrolled Medicaid public transportation provider to an eligible Medicaid beneficiary being transported to or from a medical facility to receive medical care services covered by the Arkansas Medicaid Program. Transportation will be covered from the point of pick-up to the medical facility or from the medical facility to the point of delivery. The following benefit limits are established. One unit of service = 1 mile. The benefit limits do not apply to EPSDT beneficiaries.

Effective for dates of service on or after January 1, 2006, public transportation services are available when provided by an enrolled Medicaid public transportation provider to a full benefit dual eligible being transported to or from a pharmacy to receive prescriptions covered under the Medicare Prescription Drug Benefit- Part D.

· Public Transportation, Taxi, Intra-City, One Way - may be billed once per day, per beneficiary for a maximum of 15 units. Extensions of the established benefit limits will be considered if medically necessary. The provider must request an extension.

· Public Transportation, Taxi, Intra-City, Round Trip - may be billed once per day, per beneficiary for a maximum of 30 units. Extensions of the established benefit limits will be considered if medically necessary. The provider must request an extension.

· Public Transportation, City-to-City - may be billed once per day. per beneficiary for a maximum of 50 units. Extensions of the established benefit limits will be considered if medically necessary. The provider must request an extension.

· Public Transportation, ADA Accessible Van, Intra-City. One Way - may be billed once per day. per beneficiary for a maximum of 15 units. The provider may request an extension of the benefit limit if medically necessary by submitting documentation including the purpose of the trip and the provider's name and address.

SUPERSEDES: IN. 01-22

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

Revised: January 1, 2006

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary. (Continued)

a. Transportation (Continued)

(3) Non-Emergency (Continued)

(a) Public Transportation (Continued)

STATE Arkansas

DATE REC'D 10-20-05

DATE APPV'D 11-17-05

DATE EFF 1-1-06

HCFA 179 05-10

· Public Transportation, ADA Accessible Van, Intra-City, Round Trip - may be billed once per day, per beneficiary for a maximum of 30 units. The provider may request an extension of the benefit limit if medically necessary by submitting documentation including the purpose of the trip and the provider's name and address.

· Public Transportation, ADA Accessible Van, Intrastate Authority - may be billed once per day, per beneficiary for a maximum of 50 units. The provider may request an extension of the benefit limit if medically necessary by submitting documentation including the purpose of the trip and the provider's name and address.

(b) Non-Public Transportation

Effective for dates of service on or after December 1, 2001, non-public transportation services are available when provided by an enrolled Medicaid transportation provider to an eligible Medicaid beneficiary transported to or from a medical provider to receive medical services covered by the Arkansas Medicaid Program. Transportation will be covered from the point of pick-up to the medical service delivery site and from the medical service delivery site to the beneficiary's return destination.

Effective for dates of service on or after January 1, 2006, non-public transportation services are available when provided by an enrolled Medicaid non-public transportation provider to a full benefit dual eligible being transported to or from a pharmacy to receive prescriptions covered under the Medicare Prescription Drug Benefit- Part D.

The following benefit limits are established. The benefit limits do not apply to EPSDT beneficiaries.

This service may be billed once per day, per beneficiary for a maximum of 300 miles per date of service.

SUPERSEDES .N. 01-22

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-A Page 9b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: December 1, 2019

CATEGORICALLY NEEDY

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary.

a. Transportation (Continued)

(4) Volunteer Transportation

Volunteer carriers are reimbursed for providing transportation to recipients to medical services provided the carriers are registered by the Arkansas Department of Human Services and Medical Services and the medical services are part of the case plan. A General Relief check is issued by local Human Services staff for payment of Medicaid transportation if a licensed carrier is not available.

These services may be billed once per day, per recipient for a maximum of 300 miles per day. The benefit limit does not apply to EPSDT recipients.

b. Services of Christian Science Nurses - Not Provided.

c. Care and services provided in Christian Science sanitoria - Not Provided.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: August 1, 2001

CATEGORICALLY NEEDY

23. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary. (Continued)

d. Nursing facility services for patients under 21 years of age.

Nursing facility services include coverage of prescription medications within the State's formulary without limitations.

e. Emergency Hospital Services

Limited to immediate treatment and removal of patient to a qualifying hospital as soon as patient's condition warrants.

f. Critical Access Hospital (CAH)

Services that are furnished by an instate provider that meets the requirements for participation in Medicaid as a CAH and are of a type that would be covered by Medicaid if furnished by a Medicaid enrolled instate hospital to a Medicaid recipient. Services that are not permitted under CAH licensure requirements are not covered by Medicaid.

Inpatient CAH services do not include nursing facility services furnished by a CAH with a swing-bed approval.

CAH services are subject to the same benefit limits as inpatient and outpatient hospital services as described in Attachment 3.1-A, Items 1 and 2a.

STATE Arkansas

DATE REC O 05-30-01

DATE APPVO 08-03-01

DATE SES 08-01-01

HCFA 179 AR-01-14

ATTACHMENT 3.1-A Page 9d

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: December 1, 2001

CATEGORICALLY NEEDY

24. Pediatric or family nurse practitioners' services as defined in Section 1905(a)(21) of the Act (added by Section 6405 of OBRA '89).

Services are limited to 12 nurse practitioner visits per State Fiscal Year, July 1 through June 30. This yearly limit does not apply to recipients in the Child Health Services (EPSDT) program.

Refer to Attachment 3.1-A, Item 6.d.(6) for obstetric-gynecologie and gerontological nurse practitioner services.

STATE Arkansas

DATE REC'D 09-18-01

DATE APPV'D 10-30-01

DATE GEC 12-01-01

HOE .. . 5 AL-01-25

SUPERSEDES: TN- 92-32

Revision:

HCFA-PM-94-9

December 1994

Revised:

July 1, 2009

STATE: ARKANSAS

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

25. Home and Community Care for Functionally Disabled Elderly Individuals, as defined, described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A.

provided X ☒ not provided

26. Personal care services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease that are (A) authorized for the individual by a physician in accordance with a plan of treatment, (B) provided by an individual who is qualified to provide such services and who is not a member of the individual's family, and (C) furnished in a home. X ☒ Provided: X ☒ State Approved (Not Physician) Service Plan Allowed X

X ☒

☒ Services Outside the Home Also Allowed Limitations Described on Attachment

Not Provided.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 1, 2008

CATEGORICALLY NEEDY

Not provided.

SUPERSEDES: TN- 04-17

STATE Arkansas

DATE REC 6-30-08

DATE APPV'D 9-23-08

☒ A

DATE EFF 4-1-08

ICFA 179 08-13

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE: ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2019

CATEGORICALLY NEEDY

1. Personal Care

A. 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.

B. 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 -

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

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

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

C. The State defines "a member of the individual's family" as:

1. A spouse,

2. A minor's parent, stepparent, foster parent or anyone acting as a minor's parent,

3. A minor's "guardian of the person" or anyone acting as a minor's "guardian of the person" or

4. An adult's "guardian of the person" or anyone acting as an adult's "guardian of the person".

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

1. Legal guardian; or

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

E. Personal care services are covered for categorically needy individuals only.

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

1. 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.

2. 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.

G. 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.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2004

CATEGORICALLY NEEDY

27. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 3 to Attachment 3.1-A.

☒ Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service. No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service.

1905(a)(26) and 1934 ☒ Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 3 to Attachment 3.1-A.

ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. (Note: Other programs to be offered to Categorically Needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Categorically Needy beneficiaries would also list the additional coverage -that is in excess of established service limits-for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

STATE Arkansas

DATE REC'D 6 Jan 04

DATE APPVID 26 Mar 04

DATE EFF 1

Jul 04

HCFA 179 04-01

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE: ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

April 1, 2008

27. Program of All-Inclusive Care for the Elderly (PACE)

Refer to Supplement 3 to Attachment 3.1-A.

STATE Arkansas

DATE REC'D 1-28-08

DATE APPVID 3-28-08

DATE EFF 4-1-08

HCFA 179 07-23

SUPERSEDES: NONE - NEW PAGE

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

April 1, 2008

CATEGORICALLY NEEDY

28. Self-Directed Personal Assistance Services

☒ Self-Directed Personal Assistance Services, as described in Supplement 4 to Attachment 3.1-A.

X ☒ Election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects Self-Directed Personal Assistance Services as a State Plan service delivery option.

No election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects not to add Self-Directed Personal Assistance Services as a State Plan service delivery option.

SUPERSEDES: NONE - NEW PAGE

STATE Arkansas

DATE REC'D 1-28-08

DATE APPV'O 3-28-08

DATE EFF 4-1-08

HCFA 179 07-23

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE: ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

April 1, 2008

28. Self-Directed Personal Assistance Services Refer to Supplement 4 to Attachment 3.1-A.

SUPERSEDES: NONE - NEW PAGE

STATE ARKANSAS

DATE RECT 1-28.08

DATE APPV'D 3-28-08

DATE EFF 4-1-08

HCFA 179 07-23

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

April 10, 2018

29. Telemedicine Services

Telemedicine is the use of electronic information and communication healthcare technology to deliver healthcare services including without limitation, the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient. Telemedicine includes store-and-forward technology and remote patient monitoring.

Coverage Template for Freestanding Birth Center Services

Attachment 3.1A: Freestanding Birth Center Services

28. (i) Licensed or Otherwise State-Approved Freestanding Birth Centers

Provided:

No limitations With limitations ☒ None licensed or approved Please describe any limitations:

28. (ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center

Provided:

No limitations With limitations (please describe below) ☒ Not Applicable (there are no licensed or State approved Freestanding Birth Centers) Please describe any limitations: X

Please check all that apply:

(a) Practitioners furnishing mandatory services described in another benefit category and otherwise covered under the State plan (i.e., physicians and certified nurse midwives).

(b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife). *

(c) Other health care professionals licensed or otherwise recognized by the State to provide these birth attendant services (e.g., doulas, lactation consultant, etc.) .*

*For (b) and (c) above, please list and identify below each type of professional who will be providing birth center services:

State/Territory: Arkansas AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY GROUP(S)

30. Coverage of Routine Patient Cost in Qualifying Clinical Trials

*The state needs to check each assurance below.

Provided: 01/01/2022

I. General Assurances:

Routine Patient Cost - Section 1905(gg)(1)

X __ Coverage of routine patient cost for items and services as defined in section 1905(gg)(1) that ☒ are furnished in connection with participation in a qualified clinical trial.

Qualifying Clinical Trial - Section 1905(gg)(2)

X_A qualified clinical trial is a clinical trial that meets the definition at section 1905(gg)(2). ☒

Coverage Determination - Section 1905(gg)(3)

X_A determination with respect to coverage for an individual participating in a qualified clinical

☒ trial will be made in accordance with section 1905(gg)(3).

PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 210 of the Consolidated Appropriations Act of 2021 amending section 1905(a) of the Social Security Act (the Act), by adding a new mandatory benefit at section 1905(a)(30). Section 210 mandates coverage of routine patient services and costs furnished in connection with participation by Medicaid beneficiaries in qualifying clinical trials effective January 1, 2022. Section 210 also amended sections 1902(a)(10)(A) and 1937(b)(5) of the Act to make coverage of this new benefit mandatory under the state plan and any benchmark or benchmark equivalent coverage (also referred to as alternative benefit plans, or ABPs). Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unlessit displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938- 1148 (CMS-10398 #74). Public burden for all of the collection of information requirements under this control number is estimated to take about 56 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 SecurityBoulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

State Plan under Title XIX of the Social Security Act State/Territory: Arkansas Section 1905(a)(29) Medication Assisted Treatment (MAT)

Citation: 3.1-A Amount, Duration, and Scope of Services

[Please check the box below to indicate if this benefit is provided for the categorically needy (3.1-A) or medically needy only (3.1-B)]

X 1905(a)(29) MAT as described and limited in _Supplement 5 _to Attachment 3.1-A. ☒

PRA Disclosure Statement - This use of this form is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing section §1905(a)(29) of the Social Security Act. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #68). Public burden for all of the collection of information requirements under this control number is estimated to take about 25 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Revision:

HCFA-PM-87-4

MARCH 1987

(BERC)

SUPPLEMENT 1 TO "ATTACHMENT 3.1-A .

OMB No .: 0939-0193

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT-

Stato/Territory:

ARKANSAS

CASE MANAGEMENT SERVICES

A. Target Group: Pregnant Women

B. Areas of State in which services will be provided:

Entire State.

Only in the following geographic areas (authority of section 1915(g) (1) of the Act is invoked to provide services less than Statewide:

STATE DATE REC'D JUL 1 1987

DATE APLY D

A-

DATE OFF

See HCFA-179

HCFA 179

87-12

C. Comparability of Services

Services are provided in accordance with section 1902(a) (10) (B) of the Act.

Services are not comparable in amount, duration, and scope. Authority of section 1915(g) (1) of the Act is invoked to provide services without regard to the requirements of section 1902(a) (10) (B) of the Act.

D. Definition of Services: Case Management Services are services by a physician, a licensed social worker, or registered nurse which will assist pregnant women eligible under Medicaid in gaining access to needed medical, social, educational, & other services. (Ex .: locating a source of services, making an appointment for services, arranging transportation, arranging hospital admission, locating a physician to deliver newborn, follow-up to verify appointment, reschedule appt. )

E. Qualification of Providers:

Physician or clinic that provides perinatal services and employs specified staff.

TH No. 87-12 Supersedes

IN No. new

Approval Date

JUL 3 0 1987

Effective Date

Au HCFA- 179

Revision: HCFA-PM-87-

(BERC)

MARCH 1987

SUPPLEMENT 1 TO"ATTACHMENT 3.1-A Page 2 OMB. No .: 0939-0193

State/Territory:

ARKANSAS

F. The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a) (23) of the Act.

1. Eligible recipients will have free choice of the providers of case management services.

2. Eligible recipients will have free choice of the providers of other medical care under the plan.

G. Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

AR STATE

DATE RFC'D JUL 1 1987

DATE APPV'D JUL 3 0 1987 DATE EFF Se HCFA-179 HCFA 174 8712

)

TH No. 82-12 Supersedes TV No. new

Approval Date

JUL 2 0 1967

Effective Date

Lu ALFA

179

Supplement 1 to Attachment 3.1-A Page 3 January 1, 2016

Revised:

State/Territory: ARKANSAS TARGETED CASE MANAGEMENT SERVICES [Target Group]

Target Group (42 Code of Federal Regulations 441.18(8)(i) and 441.18(9)):

Targeted Populations:

TCM services, when prescribed by a physician or other medical professional designated by the Division of Medical Services, are available to beneficiaries age 60 and older as well as beneficiaries age 21 and older with a physical disability or aged 65 and older who participate in the ARChoices in Homecare (ARChoices) 1915(c) waiver program who:

· have limited functional capabilities in two or more ADLs or IADLs, resulting in a need for coordination of multiple services and/or other resources; OR

· are in a situation or condition which poses imminent risk of death or serious bodily harm and one who demonstrates the lack of mental capacity to comprehend the nature and consequences of remaining in that situation or condition.

Case-management services will be made available for up to consecutive days of a covered stay in a medical institution for individuals age 21 and over transitioning from an institution to a community setting. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions. (State Medicaid Directors Letter (SMDL), July 25, 2000)

Areas of State in which services will be provided (§1915(g)(1) of the Act):

X Entire State ☒

Only in the following geographic areas: [Specify areas]

Comparability of services (§§1902(a)(10)(B) and 1915(g)(1))

Services are provided in accordance with §1902(a)(10)(B) of the Act.

x ☒ Services are not comparable in amount duration and scope (§1915(g)(1)).

Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan who reside in a community setting or are transitioning to a community setting, in gaining access to needed medical, social, educational, and other services.

State Agency

Supplement 1 to Attachment 3.1-A

Revised: October 1, 2012

State/Territory: ARKANSAS TARGETED CASE MANAGEMENT SERVICES [Target Group]

Targeted Case Management includes the following assistance:

Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include:

· taking client history;

· identifying the individual's needs and completing related documentation; and

· gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

Assessments/Reassessments are required, at least, annually.

Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:

· specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

· includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and

· identifies a course of action to respond to the assessed needs of the eligible individual;

Care Plans must be renewed, at least, annually.

Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including:

· activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and

Monitoring and follow-up activities:

· activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met:

1. services are being furnished in accordance with the individual's care plan;

2. services in the care plan are adequate; and

3. changes in the needs or status of the individual are reflected in the care plan.

Supplement 1 to Attachment 3.1-A Page 5

Revised:

August 1, 2021

State/Territory: ARKANSAS TARGETED CASE MANAGEMENT SERVICES [Target Group]

Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers, according to established program guidelines.

Monitoring visits may be as frequent as necessary, within established Medicaid maximum allowable limitations.

Monitoring is allowed through regular contacts with service providers at least every other month to verify that appropriate services are provided in a manner that is in accordance with the service plan and assuring through contacts with the beneficiary, at least every other month, that the beneficiary continues to participate in the service plan and is satisfied with services.

Face to face monitoring contacts must be completed as often as deemed necessary, based on the professional judgment of the TCM, but no less frequent than established in Medicaid TCM program policy.

Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs. (42 CFR 440.169(e))

Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)):

Case management providers must be certified by the Division of Provider Services and Quality Assurance on an annual basis, unless approved otherwise by the Division of Medical Services, based on performance evaluations or other approved data.

Supplement 1 to Attachment 3.1-A Page 6

Revised:

July 1, 2020

In order to be certified by the Division of Provider Services and Quality Assurance, the provider must meet the following qualifications:

A. Be located in the state of Arkansas

B. Be licensed as a Class A or Class B Home Health Agency or Private Care Agency by the Arkansas Department of Health or a unit of state government or be a private or public incorporated agency whose stated purpose is to provide case management to the elderly or adults with physical disabilities.

C. Is able to demonstrate one year of experience in performing case management services (experience must be within the past 3 years);

D. Be able to demonstrate one year of experience in working specifically with individuals in the targeted group (experience must be within the past 3 years);

E. Have an administrative capacity to insure quality of services in accordance with state and federal requirements;

F. Have the financial management capacity and system that provides documentation of services and costs;

G. Have the capacity to document and maintain individual case records in accordance with state and federal requirements;

H. Be able to demonstrate that the provider has current liability coverage, and

I. Employ qualified case managers who reside in or near the area of responsibility and who meet at least one of the following qualifications:

1. Licensed in the state of Arkansas as a social worker (Licensed Master Social Worker or Licensed Certified Social Worker), a registered nurse, or a licensed practical nurse;

2. Have a bachelor's degree from an accredited institution in a health and human services or related field; or

3. Have two years' experience in the delivery of human services, including without limitation having performed satisfactorily as a case manager for a period of two years (experience must be within the past three years).

A copy of the current certification must accompany the provider application and Medicaid contract.

Supplement 1 to Attachment 3.1-A Page 7

State/Territory: ARKANSAS TARGETED CASE MANAGEMENT SERVICES [Target Group]

Freedom of choice (42 CFR 441.18(a)(1):

The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan.

2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)):

N/A_Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services:

Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6):

The State assures the following:

· Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan.

· Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

· Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Revised:

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.18(a)(7)):

At a minimum, providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii)The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, ☒ coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

Limitations:

Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c))

In addition, TCM services are limited to a maximum of 50 hours (200 15-minute units) per SFY.

State/Territory: ARKANSAS

CASE MANAGEMENT

A. Target Group:

Medicaid recipients age twenty-two and older who are diagnosed as having a developmental disability of mental retardation., cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or require treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.

B. Areas of State in which services will be provided:

[X] ☒ Entire State.

. [ ] Only in the following geographic areas (authority of section 1915(g)(1) of the Act) is invoked to provide services less than Statewide.

C. Comparability of Services:

[] Services are provided in accordance with section 1902(a)(10)(B) of the Act.

[X] ☒ Services are not comparable in amount, duration, and scope. Authority of section 1915(g)(1) of the Act is invoked to provide services without regard to the requirements of section 1902(a)(10)(B) of the Act.

D. Definition of Services:

Case management services are defined as referral for services or treatment. It is an activity under which responsibility for locating, coordinating and monitoring necessary and appropriate services for an individual rests with a specific person. Case management services will assist Medicaid recipients in gaining access to needed medical, social, educational and other services. These medical, social, educational and other services include services provided under the Arkansas Medicaid State Plan as well as those services not provided under the Arkansas Medicaid State Plan.

TN No. q4=11

Approval Date

IJUL 0 6 1994

Effective Date

'AUG 0 1 1994

Supersedes TN No.

911-02

Ciltansas

JUN 0 9 1994

JUL 0 6 1994

€

LAUG O 1 1994

94-11

State Agency

Supplement 1 to Attachment 3.1-A

Page 9

Revised:

July 1, 2007

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group: Medicaid recipients age twenty-two and older who are diagnosed as having a developmental disability of mental retardation, cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or require treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.

D. Definition of Services (Continued):

Targeted Case Management Services are limited to 104 hours per SFY.

The following are targeted case management service descriptions:

· Assessment/Service Plan Development: Face to face contact with the beneficiary and contact with other professionals, caregivers, or other parties on behalf of the beneficiary. Assessment is performed for the purpose of collecting information about the beneficiary's situation and to determine functioning and to determine and identify the beneficiary's problems and needs. Service Plan Development includes ensuring the active participation of the Medicaid-eligible beneficiary. The goals and actions in the care plan must address medical, social, education and other services needed by the Medicaid-eligible beneficiary. The maximum units allowed for this service may not exceed twelve (12) units per assessment/service plan visit with beneficiaries age 22 and over.

· Service Management/Referral and Linkage: Activities and contacts that link Medicaid-eligible beneficiaries with medical, social, education providers and/or other programs and services that are capable of providing needed services. Functions and processes that include contacting service providers selected by the beneficiary and negotiation for the delivery of services identified in the service plan. Contacts with the beneficiary and/or other professionals, caregivers, or other parties on behalf of the beneficiary may be a part of service management.

· Service Monitoring/Service Plan Updating: Activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the Medicaid-eligible beneficiary. Verifying through regular contacts with service providers at least every other month that appropriate services are provided in a manner that is in accordance with the service plan and assuring through contacts with the beneficiary, at least monthly, that the beneficiary continues to participate in the service plan and is satisfied with services. The maximum units for this service may not exceed four (4) units per monitoring visit when providers are dealing with beneficiaries age 22 and over.

STATE

Ar KansAs

DATE RECT

5-2:07

DATE APPV'O

12-11-07

DATE EFF

7-1-07

HICFA 179 07-08

SUFERSEDES: TN-

94-11

State Agency

Supplement 1 to Attachment 3.1-A

Revised:

Page 10

July 1, 2007

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

Medicaid recipients age twenty-two and older who are diagnosed as having a developmental disability of mental retardation, cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or require treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.

D. Definition of Services (Continued):

Refer to Attachment 4.19-B, Page 7a, C. for the definition of a unit of service.

STATE Arkansas

DATE RECT 5-9-09

DATE APPYO 12-11-07

A ☒

DATE EFF 7-1-07

HCFA 179 07-08

SUFERSEDES: TN- 94 - 11

Supplement 1 to Attachment 3.1-A Page 11

Revised:

July 1, 2007

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

E. Qualification of Providers:

Providers of targeted case management services for recipients as described above must be a Division of Developmental Disabilities Services Certified Case Manager who must maintain the following information

(1) Documentation of a high school diploma or GED.

(2) Documentation of the successful completion of the DDS Certified Case Management Training.

(3) Documentation of two years of experience of working with individuals with disabilities.

(4) Documentation of a successful completion of a criminal background check and adult and child maltreatment registry checks.

(5) In addition, the individual must provide two letters of reverence and sign a Code of Ethics agreement.

STATE Arkansas

DATE RECT 5-2-07

DATE APOYO 12-11-07

DATE EFF 7-1-07

HCFA 179 07-08

SUFERSEDES: TN-

94-11

Revised:

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

F. The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

(1)Eligible recipients will have free choice of the providers of case management services. (2)Eligible recipients will have free choice of the providers of other medical care under the plan.

G. Targeted case management services under the plan are not integral to the administration of another non-medical program and do not duplicate other services made to public agencies or private entities under other program authorities for this same purpose.

STATE Arkansas

DATE RECT S-7-07

DATE APDV'D 12-11-07

DATE EFF 7-1-08

HCFA 179 07-08

SUFERSEDES: TN- 94-11

State/Territory: ARKANSAS

CASE MANAGEMENT

A. Target Group:

Medicaid recipients age twenty-one and younger who experience developmental delays; have a diagnosed physical or mental condition which has a high probability of resulting in a developmental delay; are determined to be at risk of having substantial developmental delay if early intervention services are not provided; are diagnosed as having a developmental disability which is attributable to mental retardation, cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or requires treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.

B. Areas of State in which services will be provided:

[X] Entire State. ☒

[] Only in the following geographic areas (authority of section 1915(g)(1) of the Act) is invoked to provide services less than Statewide:

C. Comparability of Services:

[] Services are provided in accordance with section 1902(a)(10)(B) of the Act.

D. Definition of Services:

TN No. 94-11

Approval Date

JUL 0 6 1994

'AUG 0 1 1994

Supersedes TN No.

94-62

Effective Date

Clickansas

JUN 0 9 1994

WUL 06 >_ A

AUG 0.1. 1994

947-11

Revised:

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

D. Definition of Services (Continued):

The following are targeted case management service descriptions. Effective for dates of service on or after December 1, 1997, prior authorization is required.

· Assessment/Updating: Face to face contact with the recipient and contact with other professionals, caregivers, or other parties on behalf of the recipient. Assessment is performed for the purpose of collecting information about the recipient's situation and functioning and determining and identifying the recipient's problems and needs. Updating includes reexamining the recipient's needs and identifying changes which have occurred since the previous assessment. Updating includes measuring the recipient's progress toward service plan goals.

· Service Management: Functions and processes which include initial development of a service plan identifying the type of services to be pursued, which must be related to the recipient's needs identified in the assessment, contacting service providers selected by the recipient and negotiating for the delivery of services identified in the service plan and altering the service plan as the recipient's needs change. Contacts with the recipient and/or other professionals, caregivers, or other parties on behalf of the recipient may be a part of service management.

TN No.

Approval Date

Effective Date

Supersedes TN No.

STATS Cukansas

DATE REC . September 24 199"

October 30, 1997

Aletmbks 1, 1997

HOPA 179

97-13

Revised:

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

D. Definition of Services (Continued):

Service Monitoring: Verifying through regular contacts with service providers that appropriate services are provided in a manner which is in accordance with the service plan and assuring through regular contact with the recipient that the recipient continues to participate in the service plan and is satisfied with services.

Refer to Attachment 4.19-B, Page 7, B. for the definition of a unit of service.

(Arkansas JUN 0 9 1994 JUL 0 6 1994

AUG 0 1 1994

944-11 HCFA:NY

TN No.

94-11

Approval Date

'JUL 0 6 1994

Effective Date

AUG 0 1 1994

Supersedes TN No.

94-02

Revised:

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

E. Qualification of Providers:

Providers of targeted case management services for recipients as described above must:

" be certified by the Division of Developmental Disabilities Services as having successfully completed a Case Management Training Program, or

. be certified as an individual recognized and funded by the Arkansas Department of Education as an Early Childhood Coordinator who is responsible for implementing special education services under PL 99-457.

Arkansas İ

JUN 0 9 1994

JUL 0 6 1>>* AUG 0 1 1994 pf-11

TN No.

94-11

Approval Date

TJUL 0 6 1994

Effective Date

AUG 0 1 1994

Supersedes TN No.

94-02

Revised:

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

Medicaid recipients age twenty-one and younger who experience developmental delays; have a diagnosed physical or mental condition which has a high probability of resulting in a developmental delay; are determined to be at risk of having substantial developmental delay if early intervention services are not provided; are diagnosed as having a developmenti disability which is attributable to mental retardation, cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or requires treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.

F. The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

(1) Eligible recipients will have free choice of the providers of case management services.

(2) Eligible recipients will have free choice of the providers of other medical care under the plan.

G. Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Arkansas JUN 0 9 1994 JUL 0 6 1994

AUG D 1,1994

94-11.

TN No. 94-11

Approval Date $ IJUL 0 6 1994

Effective Date

AUG 0 1 1994

Supersedes TN No.

94-62

Supplement 1 to Attachment 3.1-A

State/Territory: ARKANSAS CASE MANAGEMENT-

A. Target Group:

This service will be reimbursed when provided to children who are Medicaid recipients age 0-20 who are at risk of deliquency as evidenced by being in the care or custody of the Department of Human Services, Division of Youth Services (DYS) or under the care of a designated provider (specified by DYS) for assessment, supervision or treatment.

B. Areas of State in which services will be provided:

[x] ☒ Entire State.

[ ] Only in the following geographic areas (authority of section 1915(g)(1) of the Act) is invoked to provide services less than Statewide.

C. Comparability of Services:

[ ] Services are provided in accordance with section 1902(a)(10)(B) of the Act.

[x] ☒ Services are not comparable in amount, duration and scope. Authority of section 1915(g)(1) is invoked to provide services without regard to the requirements of section 1902(a)(10)(B) of the Act.

< ☒

CANTNIN

1/4/98

3/1/98 98-01 7/21/98

CANY

Definition of Services:

Targeted case management services are those that assist an individual in the target group in accessing needed medical, social, educational, and other services appropriate to the needs of the individual. Case management assistance includes the following activities:

1. Client Intake through identifying programs appropriate for the individual's needs, and providing assistance to the individual in accessing those programs.

2. Assessment of the recipients family/community circumstances and service needs in order to coordinate the identification, accessing and the delivery of services.

3. Case Planning with the recipient, care giver and other parties, as appropriate to identify the care, services and resources required to meet the recipient's needs and how they might be most appropriately delivered.

TN No.

Approval Date

Effective Date

Supplement 1 to Attachment 3.1-A

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

This service will be reimbursed when provided to children who are Medicaid recipients age 0-20 who are at risk of delinquency as evidenced by being in the care or custody of the Department of Human Services, Division of Youth Services (DYS) or under the care of a designated provider (specified by DYS) for assessment, supervision or treatment.

D. Definition of Services: (Continued)

4. Service Coordination and Monitoring through linkage, referral, coordination, facilitation, documentation and recipient specific advocacy to ensure the recipients access to the care, services and resources identified in the case plan. This is accomplished by personal, written or electronic contacts with the recipient, his/her family or care giver, service providers and other interested parties:

5. Case Plan Reassessment will be periodically conducted to determine and document whether or not medical, social, educational or other services continue to be adequate to meet the goals identified in the case plan. Activities include assisting recipients to access different medical, social, educational or other needed care and services beyond those already identified and provided.

LARanDas

1/4/98

4/21/98

31,198

98-01

13.0

HCFA 179

Qualification of Providers:

Case management services will be provided only through qualified provider agencies. Qualified case management services provider agencies must meet the following criteria:

Have full access to all pertinent records concerning the child's needs for services including records of the Arkansas District Judicial Courts, Central Arkansas Observation and Assessment Center and the County and State Youth Services Agency,

Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population,

Have a minimum of one year's experience in providing all core elements of case management services to the target populations,

Have an administrative capacity to ensure quality of services in accordance with State and Federal requirements,

IN No.

Approval Date

Effective Date

Supersedes IN No.

Supplement 1 to Attachment 3.1-A

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

E. Qualification of Providers: (Continued)

. Have a financial management capacity and system that provides documentation of services and costs in accordance with OMB A-87 principles,

. Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and

Have a demonstrated ability to meet all State and Federal laws governing the participation of providers in the State Medicaid program, including the ability to meet Federal and State requirements for documentation, billing and audits.

LIKEDAGO

1/14/98

7/21/98

311/98

98-01

HGFA 179

freedom of Choice:

The State assures that the provision of case management services to children in the care.or custody of the Division of Youth Services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

Eligible recipients will have free choice of the qualified providers of case management service, and

Eligible recipients will have free choice of the providers of other medical care as covered elsewhere under the Plan.

G. Non-Duplication of Payment:

Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

IN No.

Approval Date

Effective Date

Supersedes IN No.

SUPERSEDES: TN .

97-20

Supplement 1 to Attachment 3.1-A

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

G. Non-Duplication of Payment (Continued):

To the extent any eligible recipients in the identified target population are receiving targeted case management services from another agency as a result of being members of other covered target groups, the provider agency will ensure that case management activities are coordinated to avoid unnecessary duplication of services and the State assures that it will not seek Federal matching for the case management services that are duplicative.

STATE arkansas

DATE REC'D 1/4/98

DATE APPV'O

7/21/98

DATE EFF

3/198

HICFA 177

98-01

SUPERSEDES: TN -

97-20

IN No.

Approval Date

Effective Date

Supersedes IN No.

Supplement 1 to Attachment 3.1-A Page 17 Revised: November 1, 1997

State/Territory: ARKANSAS CASE MANAGEMENT

RESERVED

arkansas 11/18/97

12/9/47

11/1/97

97-20

SUPERSEDES: TN . 92-39

State Agency

Supplement 1 to Attachment 3.1-A Page 18 Revised: November 1, 1997

State/Territory: ARKANSAS CASE MANAGEMENT

RESERVED

arkansas

STATE 11/18/47 DATE RECT

12/9/97

DATE ARVO 11/1/97 DATE CFF

97.20 HCFA 179

SUPERSEDES: TN - 92.39

State Agency

Supplement 1 to Attachment 3.1-A Page 19 Revised: November 1, 1997

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: ARKANSAS CASE MANAGEMENT

RESERVED

arkansas STATE

11/18/97 DATE PICD

12/9/7 DATE APPY D

A ☒

11/1/97 DATE Eni

HCFA 17?

97-20

SUPERSEDES: TN - 92-39

Supplement 1 to Attachment 3.1-A Page 20 Revised: November 1, 1997

State/Territory: ARKANSAS CASE MANAGEMENT

RESERVED

512.7C arkansas LATE NOT 11/18/97 DATE AC24 12/4/97

A ☒

DATE HE

11/1/97

FCFA 17:

97-20

SUPERSEDES: TN - 92-39

Supplement 1 to Attachment 3.1-A Page 21 Revised: January 1, 1998

State/Territory: ARKANSAS

CASE MANAGEMENT

A. Target Group:

This service will be reimbursed when provided to children who are Medicaid recipients age 0-20 who are either at risk of abuse or neglect or are abused or neglected children and are in the care or custody of the Department of Human Services, Division of Children and Family Services (DCFS).

B. Areas of State in which services will be provided:

[x] ☒ Entire State.

[ ] Only in the following geographic areas (authority of section 1915(g)(1) of the Act) is invoked to provide services less than Statewide.

C. Comparability of Services:

[ ] Services are provided in accordance with section 1902(a)(10)(B) of the Act.

D. Definition of Services:

1. Client Intake through identifying programs appropriate for the individual's needs, and providing assistance to the individual in accessing those programs.

2. Assessment of the recipients family/community circumstances and service needs in order to coordinate the identification, accessing and the delivery of services.

3. Case Planning with the recipient, caregiver and other parties, as appropriate to identify the care, services and resources required to meet the recipient's needs and how they might be most appropriately delivered.

TN No.

Approval Date

Effective Date

Supersedes T'N No.

93-14

STATE arkansas

DATE REC'D

January 6, 1148

DATE APPV'D

april à 1998

☒

DATE EFF

January 1, 998

HCFA 179 97-23

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

This service will be reimbursed when provided to children who are Medicaid recipients age 0-20 who are either at risk of abuse or neglect or are abused or neglected children and or in the care or custody of the Department of Human Services, Division of Children and Family Services (DCFS).

D. Definition of Services (Continued):

4. Service Coordination and Monitoring through linkage, referral, coordination, facilitation, documentation and recipient specific advocacy to ensure the recipients access to the care, services and resources identified in the case plan. This is accomplished by personal, written or electronic contacts with the recipient, his/her family or caregiver, service providers and other interested parties.

E. Qualification of Providers:

Case management services will be provided only through qualified provider agencies. Qualified case management services provider agencies must meet the following criteria:

. Have full access to all pertinent records concerning the child's needs for services including records of the Arkansas Family Courts and the State Child Welfare and Protection Agency,

. Must ensure 24-hour availability of case management services and continuity of those services,

. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population,

. Have a minimum of five years experience in provide all core elements of case management services to the target populations,

. llave an administrative capacity to ensure quality of services in accordance with State and Federal requirements,

TN No.

Approval Date

Effective Date

Supersedes IN No.

93-14

OuiKanDas STATE DATE REC D January 1, 1995 DATE APPID april , 1998 DAIC ELF Janeway 1, 1995 HCFA 179 917-25

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

This service will be reimbursed when provided to children who are Medicaid recipients age 0-20 who are either at risk of abuse or neglect or abused or neglected children and are in the care or custody of the Department of Human Services, Division of Children and Family Services (DCFS).

E. Qualification of Providers (Continued):

· Have a financial management capacity and system that provides documentation of services and costs in accordance with OMB A-87 principles,

· Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and

· Have a demonstrated ability to meet all State and Federal laws governing the participation of providers in the State Medicaid program, including the ability to meet Federal and State requirements for documentation, billing and audits.

Individual case managers working for provider agencies must meet the following minimum qualifications:

. have a minimum of a bachelor's degree in social work, sociology, psychology or a related field, and

. function under a supervisor who, at minimum possesses the formal education equivalent of a bachelor's degree in social work, sociology, or a related field; plus four years experience in child welfare or human services.

F. Freedom of Choice:

The State assures that the provision of case management services to children in the care or custody of the Division of Children and Family Services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

. Eligible recipients will have free choice of the qualified providers of case management services.

TN No.

Approval Date

Effective Date

Supersedes TN No.

93-14

STATE arkansas DATE REGO January 6, Kad DATE APPVID 1998 04.12 EFF January 1, 1948 HCPAIN 97-23

State/Territory: ARKANSAS

CASE MANAGEMENT

Target Group:

F. Freedom of Choice (Continued):

. Eligible recipients will have free choice of the providers of other medical care as covered elsewhere under the Plan.

G. Non-Duplication of Payment:

Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. To the extent any eligible recipients in the identified target population are receiving targeted case management services from another provider agency as a result of being members of other covered target groups, the provider agency will ensure that case management activities are coordinated to avoid unnecessary duplication of services and the State assures that it will not seek Federal matching for the case management services that are duplicative.

IN No.

Approval Date

Supersedes TN No.

93-14

Effective Date

STA: DAIF . AMIA'I,

arkanais January 6, 1998 april 1, 1998 ☒ A\

DAR UF F .. 2. 177.

January 1, 1998 97-23

State/Territory: ARKANSAS

CASE MANAGEMENT

A. Target Group: By invoking the exception to comparability allowed by 1915 (g)(1) of the Social Security Act, this service will be reimbursed when provided to persons who are not receiving case management services under an approved waiver program, not placed in an institution and are:

· Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

B. Areas of State in which services will be provided: [X] ☒ Entire State.

[ 1 Only in the following geographic areas (authority of section 1915(g)(1) of the Act) is invoked to provide services less than Statewide:

C. Comparability of Services:

Services are provided in accordance with section 1902(a)(10)(B) of the Act.

TN No. 01-01

Approval Date

04-20.01

Effective Date

01-12-01

Supersedes TENERLOSULC: DRIVE . NEW PAGE

STATE Arkansas

DATE REC'D 01-22-01

DATE / PPV D

04-20 01

A ☒

DATE EFF

01-12.01

HCFA 179

AK 01.01

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

By invoking the exception to comparability allowed by 1915 (g)(1) of the Social Security Act, this service will be reimbursed when provided to persons who are not receiving case management services under an approved waiver program, not placed in an institution and are:

. Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

D. Definition of Services:

Case management is a service instrument by which service agencies assist an individual in accessing needed medical, social, educational, and other support services. Consistent with the requirements of Section 1902(a)(23) of the Act, the providers will monitor client treatment to assure that clients receive services to which they are referred. One case management unit is the sum of case management activities that occur within a day. These activities include:

0 A written comprehensive assessment of the child's needs, including analysis of recommendations (e.g. medical records) regarding client's service needs; this does not include the performance of medical/psychological evaluations - it only includes the review of the records of those evaluations in order to assess the child's needs.

0 Arranging for the delivery of the needed services as identified in the assessment;

0 Assisting the recipient in accessing needed services;

TN No.

CI-01

Approval Date

04- 20. 01

Effective Date

01-12-01

Supersedes TN No.

SW PAGI

Arkansas STATE

DATE RECO

01-22-01

DATE APPV D

04-20-01

DATE EFF

01-12-01

HCFA 179

AK.01.01

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group: By invoking the exception to comparability allowed by 1915 (g)(1) of the Social Security Act, this service will be reimbursed when provided to persons who are not receiving case management services under an approved waiver program, not placed in an institution and are:

. Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses,

D. Definition of Services (Continued):

0 Monitoring the child's progress by making referrals to service providers through telephone, written or personal contacts, tracking the child's appointments, performing follow-up on services rendered, and performing periodic reassessments of the child's changing needs (including reviews of child's medical records);

0 Preparing and maintaining case records; documenting contacts, services needed, reports, the child's progress, etc .;

TN No. 01-01

Approval Date

04-20.01

Effective Date

01-12-01

Supersedes TN Ng

SUPEROLDEST NONE - NEW PAGE

STATE Arkansas

DATE REC D 01-22-01

DATE APPV'O 04.20.01

DATE EFF

01-12-01

HCFA 173 AK-01.01

State/Territory: ARKANSAS CASE MANAGEMENT

· Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

D. Definition of Services (Continued):

0 Special Restrictions -

. Medicaid reimbursement shall not be sought for clients who are in institutional placement.

TN No.

01-01

Approval Date

04-20-01

Effective Date

01-12-01

Supersede IN NOGURENN LAL: NONE - NEW PAGE

STATE Arkansas

DATE RECD) 01-22-01

DATE A PV D 04-20-01

DATE EFF 01. 12 . 01

HCFA 179 Are-01-01

State/Territory: ARKANSAS CASE MANAGEMENT

. Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

E. Qualifications of Providers:

Providers must be certified as a Medicaid provider meeting the following criteria:

1. Demonstrated capacity to provide all core elements of case management

assessment

care/services plan development

linking/coordination of services

reassessment/followup

2. Appropriate staff for case management include: registered nurses, licensed social workers, pediatricians, registered dieticians, parent aides and clerical support staff who are credentialed as explained in section E.3 on Pages 30 and 31 or who are under the direct supervision of an appropriately credentialed case manager.

TN No. 01-01

Approval Date

04-20-01

Effective Date

01-12-01

Supersedes TN NOSUPERSEDES: NONE - NEW PAGE

STATE Arkansas

DATE RECD 01.22-01

DATE APPV D 04.20.01

DATE EFF 01-12-01

HCFA 179 12-01-01

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

. Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

E. Qualifications of Providers (Continued):

3. Qualifications of Credentialed Case Manager:

· Registered Nurse - must be licensed as a registered nurse by the Arkansas Board of Nursing and have satisfactorily completed a one month CMS case management orientation.

· Social Worker - must be a licensed social worker in the State of Arkansas or be qualified through education, training or experience to work in a social work roll and have satisfactorily completed a one month CMS case management orientation.

· Pediatrician - must be a licensed M. D. in the State of Arkansas and have satisfactorily completed a one month CMS case management orientation.

TN No. 01-01

Approval Date 04- 20- 01

Effective Date

01 12-01

Supersedes TN No. SUPERSEDES: NONE - NEW PAGE

STATE Arkansas

DATE REC'D 01-22.01

DATE APPV D 04-20-01

DATE EFF 01-12-01

HCFA 179 AK-01- 01

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group: By invoking the exception to comparability allowed by 1915 (g)(I) of the Social Security Act, this service will be reimbursed when provided to persons who are not receiving case management services under an approved waiver program, not placed in an institution and are:

· Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

. SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

E. Qualifications of Providers (Continued):

3. Qualifications of Credentialed Case Manager (Continued):

· Employed parent of a child with special health care needs. Employed by CMS for the purpose of assisting families to access services and who complete the one month orientation with CMS. A parent cannot be case manager for his or her own child.

· Clerical Support Staff who have two years of experience with a program for children with special health care needs in assisting families to obtain needed medical, social and educational services and have demonstrated the ability to assist families appropriately to access needed services.

TN No. 01-01

Approval Date

04-20-01

Effective Date

01-12-01

Supersedes TN No.

SUPERSEULS: NONE - NEW PAGE

STATE Arkansas

DATE REC'D 01-22-01

DATE APPV D 04.20-01

DATE EFF

01-12-01

HCFA 179

AR.01.01

State/Territory: ARKANSAS CASE MANAGEMENT

Target Group:

. Aged 0-21 and meet the medical eligibility criteria of Children's Medical Services (CMS), the State's Title V Children with Special Health Care Needs Agency, or;

· SSI/TEFRA Disabled Children's Program clients aged 0-16 with any diagnoses.

F. The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

. Eligible recipients will have free choice of the providers of case management services.

· Eligible recipients will have free choice of the providers of other medical care under the plan.

· Service plan will be developed with family and primary care physician (PCP). PCP prescription and referral requirements will be waived.

G. The State assures that an agreement will be entered into between the Title V agency, Children's Medical Services, and the Medicaid agency, which will fully comply with the provision of 42 CFR 431.615 to avoid duplication of Title V and Medicaid services.

H. Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

TN No. 01.01 Approval Date 04-20 01

Effective Date

01-12-01

Supersedes TN NISUPERSEDES: NONE - NEW PAGE

STATE Arkansas

DATE REC'D 01 - 22. 01

DATE APPV D

04-20-01

DATE EFF

01-12-01

HCFA 179

A2-01. 01

A. Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

Individuals who are enrolled in an Arkansas Medicaid program other than the ARHOME program residing in the community and not while inpatient in a hospital and are either pregnant with a high-risk pregnancy, as evidenced by a high-risk pregnancy diagnosis, OR received high-risk pregnancy TCM services while pregnant and delivered the baby within the previous twelve (12) months.

Target group includes individuals transitioning to a community setting. Case-management services will be made available for up to consecutive days of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions). (State Medicaid Directors Letter (SMDL), July 25, 2000)

B. Areas of State in which services will be provided (§1915(g)(1) of the Act):

X_ Entire State ☒

Only in the following geographic areas:

C. Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) Services are provided in accordance with §1902(a)(10)(B) of the Act.

X ☒ Services are not comparable in amount duration and scope (§1915(g)(1)).

D. Definition of services (42 CFR 440.169):

Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management may be delivered through home visits and includes the following assistance:

1. Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include:

· Taking client history;

· Identifying the individual's needs and completing related documentation; and

· Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

· Assessments/Reassessments are required at least annually.

TN# 2022-0024 Approval Date 4-19-2024_Effective Date_01-01-2023 Supersedes TN# New

TARGETED CASE MANAGEMENT SERVICES High-Risk Pregnant Women

Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

D. Definitions of Services (continued)

2. Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:

· Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

· Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and

· Identifies a course of action to respond to the assessed needs of the eligible individual;

· Care plans must be updated/renewed at least annually.

3. Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including:

· Activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and

4. Monitoring and follow-up activities:

· Activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met:

o Services are being furnished in accordance with the individual's care plan;

o Services in the care plan are adequate; and

o Changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

TN# 2022-0024 Approval Date 4-19-2024_Effective Date_01-01-2023 Supersedes TN# New

TARGETED CASE MANAGEMENT SERVICES High-Risk Pregnant Women

Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

D. Definition of Services (continued)

Case managers will continue to monitor and follow-up on the care plan while conducting case management activities, including assessments, referrals and linkages to service providers, during visits. The visits may be as frequent as needed by the client but must be at least every 30 days, which will allow regular assessment of the plan implementation. The case manager will assess the services or community resources received and adequacy of the services. The case manager also will identify the beneficiaries' action steps, determine whether they require additional support or adjustments of services or activities and document relevant activities/changes. At least annually the care plan must be fully reviewed with beneficiaries to ensure the activities are relevant, appropriate and are being followed and update the plan as necessary. Beneficiary interviews may occur through a home visit, face-to face office visit, or other contact method that allows gathering the information needed.

☒ X __ Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs. (42 CFR 440.169(e))

TARGETED CASE MANAGEMENT SERVICES High-Risk Pregnant Women

Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

E. Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)):

Hospital providers licensed as general hospitals with an obstetrics unit with a model recognized by the U.S. Department of Health and Human Services Home Visiting Evidence of Effectiveness (HOMEVEE) program to be effective in improving maternal and child health that have applied and been approved to become Maternal Life360 providers. The hospital may use its own staff or subcontract for case management. Case managers employed by the hospital will have no direct relationship with the inpatient department, and case management services will not be provided by the inpatient or acute unit of the hospital. Case managers will be focused on the person-centered care delivered for the beneficiaries in the community and will not duplicate coordination provided through other hospital-delivered services. Case managers delivering this benefit must be able to provide all components of targeted case management within their scope of practice. Case managers must also meet the following criteria:

· A minimum or a high school diploma or GED and experience with early childhood education, childhood development, or social work, family support, maternity, or case management services, or demonstrated comparable experience or competency through educational or other professional activities to provide the required TCM services for the population.

F. Freedom of choice (42 CFR 441.18(a)(1)):

The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan.

2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)): Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services:

TN# 2022-0024 Approval Date 4-19-2024_Effective Date_01-01-2023 Supersedes TN# New

TARGETED CASE MANAGEMENT SERVICES High-Risk Pregnant Women

Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

G. Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)):

The State assures the following:

1. Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan.

2. Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

3. Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

H. Payment (42 CFR 441.18(a)(4)):

I. Case Records (42 CFR 441.18(a)(7)):

Providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii)The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

TARGETED CASE MANAGEMENT SERVICES High-Risk Pregnant Women

Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

J. Monitoring

Providers must meet established standards that measure services under this program/state plan service to eligible beneficiaries. The State will monitor performance on these standards through monthly expenditure reporting and quarterly progress reporting. Providers will use the MMIS to enroll individuals and enter visits provided in order to monitor individual enrollment and services rendered. The state will also review quality metrics for individual provider- and system-level goals.

The state will ensure that providers meet acceptable performance, including the process and health outcomes and case documentation/program reporting, and will address any identified non-compliance for these services. Audits will ensure case records are maintained as required.

K. Limitations:

Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

TN# 2022-0024 Approval Date_4-19-2024_Effective Date_01-01-2023 Supersedes TN# New

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)):

Eligible juveniles as defined in §1902(nn) (individuals who are under 21 years of age and determined eligible for any Medicaid eligibility group, or individuals determined eligible for the mandatory eligibility group for former foster care children age 18 up to age 26, immediately before becoming an inmate of a public institution or while an inmate of a public institution) who are within 30 days of their scheduled date of release from a public institution following adjudication, and for at least 30 days following release.

Post Release TCM Period beyond 30 day post release minimum requirement: ☒ State will provide TCM beyond the 30-day post release requirement. [explain]:

TCM services will be allowable beyond the 30-day post-release period as determined medically necessary.

Areas of State in which services will be provided (§1915(g)(1) of the Act): ☒ Entire state

Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) ☒ Services are not comparable in amount duration and scope (§1915(g)(1)).

Definition of services (42 CFR 440.169): Targeted case management (TCM) services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services.

Targeted Case Management includes the following assistance:

Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include:

· taking client history;

· identifying the individual's needs and completing related documentation; and

· gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

PRA Disclosure Statement - This use of this form is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 15 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

The periodic reassessment is conducted every (check all that apply):

☒ 1 month ☐ 3 months ☐ 6 months ☐ 12 months ☐ Other frequency [explain]: Click or tap here to enter text.

Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:

· specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

· identifies a course of action to respond to the assessed needs of the eligible individual;

Referral and related activities, including referrals to appropriate care and services available in the geographic region of the home or residence of the eligible juvenile, where feasible (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including:

Monitoring and follow-up activities are: activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met:

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

· services are being furnished in accordance with the individual's care plan;

· services in the care plan are adequate; and

· changes in the needs or status of the individual are reflected in the care plan.

Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

Frequency of additional monitoring: Specify the type and frequency of monitoring (check all that apply) ☒ Telephonic. Frequency: Monthly ☒ In-person. Frequency: Monthly

☐ Other [explain]: Click or tap here to enter text.

☒ Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs. For instance, a case manager might also work with state children and youth agencies for children who are involved with the foster care system.

(42 CFR 440.169(e))

☒ If another case manager is involved upon release or for case management after the 30-day post release mandatory service period, states should ensure a warm hand off to transition case management and support continuity of care of needed services that are documented in the person-centered care plan. A warm handoff should include a meeting between the eligible juvenile, and both the pre-release and post-release case manager. It also should include a review of the person-centered care plan and next steps to ensure continuity of case management and follow-up as the eligible juvenile transitions into the community.

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): [Specify provider qualifications that are reasonably related to the population being served and the case management services furnished.]

Targeted case management services are provided only through qualified providers. Qualified case management providers must meet the following criteria:

A. The provider must be enrolled with Arkansas Medicaid.

B. The provider must have a minimum of one year's experience in providing all core elements of case management services to the target populations.

C. The provider must have the financial management capacity and system that provides documentation of services and costs in conformity with generally accepted accounting principles.

D. The provider must have a capacity to document and maintain individual case records in accordance with state and federal requirements.

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

Freedom of choice (42 CFR 441.18(a)(1)): ☒ The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act. ☐

1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan.

2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)): ☐ Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services:

[Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that individuals within the target groups receive needed services below.]

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): ☒ The state assures the following:

· Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan.

· Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plans.

· Delivery of TCM and the policies, procedures, and processes developed to support implementation of these provisions are built in consideration of the individuals release and will not effectuate a delay of an individual's release or lead to increased involvement in the juvenile and adult justice systems.

Payment (42 CFR 441.18(a)(4)):

☒ The state assures payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.18(a)(7)): ☒ The state assures providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii)The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. ☐

Limitations:

☒ The state assures that case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES

Transmittal Number: 25-0016-A

Supersedes Transmittal Number: NEW

State: ARKANSAS

1905(a)(13)(B) - Attestation for Vaccines and Vaccine Administration

Arkansas maintains a method of monitoring ACIP notifications of changes to recommendations to ensure that coverage and billing codes are updated to comply with those revisions.

Effective: 10/01/2023

Approved:

12/08/2023

State/Territory: ARKANSAS PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY

I. Eligibility

The State determines eligibility for PACE enrollees under rules applying to community groups.

A ._ X_The State determines eligibility for PACE enrollees under rules applying to institutional groups as provided ☒ for in section 1902(a)(10)(A)(ii)(VI) of the Act (42 CFR 435.217 in regulations). The State has elected to cover under its State plan the eligibility groups specified under these provisions in the statute and regulations. The applicable groups are:

A special income level equal to 300% of the SSI Federal Benefit (FBR) (42 CFR 435.236)

(If this option is selected, please identify, by statutory and/or regulatory reference, the institutional eligibility group or groups under which the State determines eligibility for PACE enrollees. Please note that these groups must be covered under the State's Medicaid plan.)

Spousal impoverishment rules will be used in determining eligibility for the 435.236 group.

B. The State determines eligibility for PACE enrollees under rules applying to institutional groups, but chooses not to apply post-eligibility treatment of income rules to those individuals. (If this option is selected, skip to II - Compliance and State Monitoring of the PACE Program.

C. ☒ The State determines eligibility for PACE enrollees under rules applying to institutional groups, and applies post-eligibility treatment of income rules to those individuals as specified below. Note that the post-eligibility treatment of income rules specified below are the same as those that apply to the State's approved HCBS waiver(s). X

Regular Post Eligibility

1. X ☒ SSI State. The State is using the post-eligibility rules at 42 CFR 435.726. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee's income.

(a). Sec. 435.726 -- States which do not use more restrictive eligibility requirements than SSI.

1. Allowances for the needs of the: ☒ (A.) Individual (check one)

X_The following standard included under the State plan (check one): ☒

(a) SSI

(b) Medically Needy (c) X

☒ The special income level for the institutionalized (d) Percent of the Federal Poverty Level: %

(e) Other (specify):

Supplement 3 to Attachment 3.1-A Page 34 July 1, 2004

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: ARKANSAS PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY

2. N/A The following dollar amount: $ Note: If this amount changes, this item will be revised. 3. N/A_The following formula is used to determine the needs allowance:

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3.

(B.) Spouse only (check one):

1. SSI Standard

2. Optional State Supplement Standard

3. Medically Needy Income Standard

4. The following dollar amount: $

Note: If this amount changes, this item will be revised.

5 The following percentage of the following standard that is not greater than the standards above:

% of standard. 6. The amount is determined using the following formula:

7. ☒ Not applicable (N/A)

(C.) Family (check one): 1. AFDC need standard

2. Medically needy income standard

The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size.

3. The following dollar amount: $

Note: If this amount changes, this item will be revised.

4. The following percentage of the following standard that is not greater than the standards above: % of standard.

5. The amount is determined using the following formula:

6. Other 7.

☒ Not applicable (N/A)

(2). Medical and remedial care expenses in 42 CFR 435.726.

SUPERSEDES: NONE - NEW PAGE

STATE Arkansas

DATE RECIO 6 Jan 04

DATE APPV'D 26 Mar 04

DATE EFE 1 Jul 04

HCFA 179 04-01

State/Territory: ARKANSAS PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY

Regular Post Eligibility

2. N/A 209(b) State, a State that is using more restrictive eligibility requirements than SSI. The State is using the post-eligibility rules at 42 CFR 435.735. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee's income.

(a) 42 CFR 435.735-States using more restrictive requirements than SSI.

1. Allowances for the needs of the:

(A.) Individual (check one) ☒

1. The following standard included under the State plan (check one):

(a) _SSI

(b) Medically Needy

(d) Percent of the Federal Poverty Level: %

(e) Other (specify):

2. The following dollar amount: $ Note: If this amount changes, this item will be revised.

3. The following formula is used to determine the needs allowance:

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3.

(B.) Spouse only (check one):

1. The following standard under 42 CFR 435.121:

2. The Medically needy income standard

3. The following dollar amount: $

Note: If this amount changes, this item will be revised.

4 The following percentage of the following standard that is not greater than the standards above: % of standard.

5. The amount is determined using the following formula:

6. Not applicable (N/A)

STATE Arkansas

DATE RECO 6 Jan 04

DATE APPVID 26 Mar 04

DATE EFF 1 Jul 04

HCFA 179 04-01

Supplement 3 to Attachment 3.1-A Page 36 July 1, 2004

State/Territory: ARKANSAS PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY

(C.) Family (check one):

1. AFDC need standard

2. Medically needy income standard

3. The following dollar amount: $ Note: If this amount changes, this item will be revised.

4. The following percentage of the following standard that is not greater than the standards above: % of standard.

5. The amount is determined using the following formula:

6. Other

7. Not applicable (N/A)

(b) Medical and remedial care expenses specified in 42 CFR 435.735.

Spousal Post Eligibility

3. ☒ State uses the post-eligibility rules of Section 1924 of the Act (spousal impoverishment protection) to determine the individual's contribution toward the cost of PACE services if it determines the individual's eligibility under section 1924 of the Act. There shall be deducted from the individual's monthly income a personal needs allowance (as specified below), and a community spouse's allowance, a family allowance, and an amount for incurred expenses for medical or remedial care, as specified in the State Medicaid plan.

(a.) Allowances for the needs of the:

1. Individual (check one)

(A).

X ☒

The following standard included under the State plan (check one):

1. SSI 2. Medically Needy

3. ☒ The special income level for the institutionalized

4. Percent of the Federal Poverty Level: %

5. Other (specify):

STATE Arkansas

DATE REC'D 6 Jan 04

DATE APPV'D 26 Mar 04

DATE EFF 1 Jul 04

HCFA 179 04-01

(B). N/A_The following dollar amount: $ Note: If this amount changes, this item will be revised.

If this amount is different than the amount used for the individual's maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735, explain why you believe that this amount is reasonable to meet the individual's maintenance needs in the community:

II. Rates and Payments

A. The State assures CMS that the capitated rates will be less than the cost to the agency of providing State plan approved services to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the amount the state would have otherwise paid for a comparable population.

1. ☐ Rates are set at a percent of the amount that would have otherwise been paid for a comparable population.

2. ☐ Experience-based (contractors/State's cost experience or encounter data) (please describe)

3. ☐ Adjusted Community Rate (please describe)

4. ☒ Other (please describe) See Page 37A for description of the rate setting methodology for Program of All-Inclusive Care for the Elderly (PACE).

Approved: 7/13/2026

State/Territory: ARKANSAS

PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY

Program of All-Inclusive Care for the Elderly (PACE)

The Arkansas PACE amount that would otherwise have been paid (AWOP) for a PACE-comparable population and capitation rate amounts are developed for Medicaid Only and Dual Eligible populations and may be further stratified by additional factors as appropriate. The state uses the most recent available Medicaid - claims and eligibility data for a comparable population. The data used in the AWOP and PACE rate calculations is limited to recipients 55 or older who are eligible for nursing facility level of care or ARChoices Waiver level of care, and who are eligible for PACE but not enrolled in the program.

The base year data used in the AWOP and rate development is no more than three years prior to the rate year and is trended forward using the historical claims and eligibility information extracted for the PACE- comparable population. The claims data includes all services included in the state plan. Only claims that were actually paid are included in the analysis to create a historical per-member-per-month rate.

Base data, including Medicaid claims and eligibility data, are summarized by rate cell and category of service. Adjustments are then applied to project the base period data to the rating period and to reflect expected future costs. These adjustments include, but are not limited to, completion factors for incurred but not reported claims, removal of pharmacy rebates, fee schedule changes, and trend assumptions to account for changes in utilization, service mix, and unit costs. An adjustment is also applied to reflect state administrative expenses.

The projected AWOP reflects the expected costs of the comparable population for the rating period and is developed on a per member per month basis for each rate cell.

Rates are developed for the appropriate rate categories. All appropriate adjustments are considered in the development of the rates.

In setting the PACE capitation rates, a managed care adjustment is applied to reduce the AWOP amounts by a percentage established by the state which reflects anticipated reductions in health care service costs resulting from the reduction in nursing facility services and increase in non-institutional care for PACE enrollees relative to the population underlying the AWOP development.

The percentage is determined by evaluating per member per month (PMPM) cost using the base data adjusted for the actual mix of PACE participants residing in the community, and dampening based on expected acuity for PACE vs. non-PACE home and community-based services. Historical financial performance for the PACE organizations is reviewed to validate the reasonableness of the final capitation rates.

The AWOPs and capitation rates will be rebased/recalculated every two years and the rebasing calculations will be completed for two calendar years (Jan-Dec). Separate AWOPs will be submitted for each year of the proposed two-year rating period. The rebasing/recalculations will be completed in accordance with the methodology described above and consistent with CMS rate-setting guidance.

II. Rates and Payments (continued)

B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner.

C. The State will submit all capitated rates to CMS for prior approval, and will include the name, organizational affiliate of any actuary used, and attestation/description of the capitation rates.

III. Enrollment and Disenrollment

The State assures that there is a process in place to provide for dissemination of enrollment and disenrollment data between the State and the State Administering Agency. The State assures that it has developed and will implement procedures for the enrollment and disenrollment of participants in the State's management information system, including procedures for any adjustment to account for the difference between the estimated number of participants on which the prospective monthly payment was based and the actual number of participants in that month.

Revised:

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services

Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation.

i. Eligibility

The State determines eligibility for Self-Directed Personal Assistance Services: A. X X ☒ In the same manner as eligibility is determined for traditional State Plan personal care services, described in Item 24 of the Medicaid State Plan. B. ☒ In the same manner as eligibility is determined for services provided through a 1915(c) Home and Community-Based Services Waiver.

ii. Service Package

The State elects to have the following included as Self-Directed Personal Assistance Services: A. X

☒ State Plan Personal Care and Related Services, to be self-directed by individuals eligible under the State Plan.

B. ☒ Services included in the following Section 1915(c) Home and Community-Based Services waiver(s) to be self-directed by individuals eligible under the waiver(s). The State assures that all services in the impacted waiver(s) will continue to be provided regardless of service delivery model. Please list waiver names and services to be included. X

ARChoices Attendant Care

iii. Payment Methodology

A. The State will use the same payment methodology for individuals self-directing their PAS under section 1915(j) as that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services.

Supplement 4 to Attachment 3.1-A Page 2 January 1, 2019

Revised:

OMB Approved 0938-1024

1915(j) Self-Directed Personal Assistance Services (Continued)

iii. Payment Methodology (Continued) C. X

☒ The State will use a different reimbursement methodology for individuals self-directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. Amended Attachment 4.19-B page(s) are attached.

iv. Use of Cash

A. ☒ X The State elects to disburse cash prospectively to participants self-directing personal assistance services. The State assures that all Internal Revenue Service (IRS) requirements regarding payroll/tax filing functions will be followed, including when participants perform the payroll/tax filing functions themselves.

B. The State elects not to disburse cash prospectively to participants self-directing personal assistance services.

v. Voluntary Disenrollment

The State will provide the following safeguards to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional service delivery models.

When the participant voluntarily elects to discontinue participation in IndependentChoices, DHS professional staff will discuss with the individual the reason for disenrollment and assist the individual in resolving any barriers or problems that may exist in preventing continuation. If the participant wishes to continue with the option to disenroll, DHS professional staff will assist by informing the participant of traditional agency personal care providers in the participant's area. DHS professional staff will assist with the coordination of agency services to the degree requested by the participant.

IndependentChoices can continue until agency services are established or the participant may elect to use informal supports until agency services are established.

The timeframes discussed under involuntary disenrollment do not apply to voluntary disenrollment. The request of the participant will be honored whether they ask to be disenrolled immediately or at anytime in the future. DHS professional staff will coordinate the participant's wishes to the degree requested by the participant. This may include self-advocation by the participant and asking DHS professional staff to coordinate agency services with the participant's preferred provider. In some instances the participant may wish to forego agency personal assistance services and choose to rely on family or friends. If the participant requests that DHS professional staff coordinate the agency services, DHS staff will ascertain when services can be started. DHS staff will then close the IndependentChoices case the day before agency services begin. Regardless of the situation, the State will assure that there will not be an interruption in delivering necessary services unless it is the preference of the participant to depend on informal supports.

Revised:

January 1, 2019

OMB Approved 0938-1024

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

vi. Involuntary Disenrollment

A. The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to traditional service delivery model are noted below.

Participants may be disenrolled for the following reasons:

1. Health and Welfare: Any time DPSQA feels the health and welfare of the participant is compromised by continued participation in the IndependentChoices Program, the participant may be returned to the traditional personal care program. Prior to this point counseling entity's support coordinator has worked with the participant offering suggestions, identifying or changing representatives or employees to better meet the needs of the consumer, making in-home visits as needed by APS or HCBS RNs, and working to resolve these concerns. If no resolution is available, meeting the participant's health and well-being needs is of most importance; including referral back to the traditional model.

2. Change in Condition: Should the participant's cognitive ability to direct his/her own care diminish to a point where the participant can no longer self-direct and there is no responsible representative available to direct the care the counseling entity's support coordinator will seek out sources of support. If no resources are available, the IndependentChoices case will be closed. The participant will be informed of the pending closure by letter. The letter will include a list of traditional personal care agencies serving the participant's area. If the participant is also a 1915(c) waiver recipient, an e-mail will be auto generated to the HCBS RN or targeted case manager. The e-mail to the HCBS RN or targeted case manager is auto generated and populated with the appropriate names once a closure date is entered in the database. The e-mail will inform the HCBS RN or targeted case manager of the pending closure of the IndependentChoices case necessitating a change in the HCBS service plan. Within five days of sending the letter the counseling entity's support coordinator will follow up with the participant to determine which agency the participant may wish to choose. The counseling entity's support coordinator will coordinate the referral with the agency provider. However, if the participant declines agency services, the counseling entity's support coordinator will respect the choice made by the participant. The participant may choose to have their needs met by informal caregivers.

3. Misuse of Allowance: A notice will be issued should the participant or the representative who manages their cash allowance: 1) fail to pay related state and federal payroll taxes; 2) use the allowance to purchase items unrelated to personal care needs; 3) fail to pay the salary of a personal assistant; or 4) misrepresent payment of a personal assistant's salary. The counseling entity's support coordinator will discuss the violations with the participant and allow the participant to take corrective action including restitution if applicable. The participant will be permitted to remain in the program, but will be assigned to the fiscal intermediary, who will provide maximum bookkeeping support and services. The participant or representative will be notified that further failure to follow the expenditure plan will result in disenrollment and a report filed with Office of Medicaid Inspector General when applicable.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

vi. Involuntary Disenrollment (Continued)

Should an unapproved expenditure or oversight occur a second time, the participant/ representative will be notified that their IndependentChoices case is being closed and the participant is being returned to traditional personal care. Office of Medicaid Inspector General is informed of situations as required. The State will assure interruption of services will not occur while the participant is transitioning from IndependentChoices to traditional services.

4. Underutilization of Allowance: The fiscal intermediary is responsible for monitoring the use of Medicaid funds received on behalf of the participant. If the participant is underutilizing the allowance and not using the allowance according to their cash expenditure plan, the fiscal intermediary will inform the counseling entities through quarterly reports and monthly reports upon request. The counseling entity's support coordinator will discuss problems that are occurring with the participant and their support network. Together the parties will resolve the underutilization. The counseling entity's support coordinator will continue to monitor the participant's use of their allowance through both reviewing of reports and personal contact with the participant. If a pattern of underutilization continues to occur, future discussions will focus on what is in the best interest of the participant in meeting their ADLs even if the best solution is a return to agency services. Unused funds are returned to the Arkansas Medicaid program within 45 days upon disenrollment. Funds accrued in the absence of a savings plan will be returned to the Arkansas Medicaid program within a twelve month filing deadline. Exceptions to involuntary disenrollment may be considered if the participant has been hospitalized for an extended period of time or has had a brief visit out of state with approval by the participant's physician. Person-centered planning allows the flexibility of decision making based on individual needs that best meet the needs of the participant.

5. Failure to Assume Employer Authority: Failure to Assume Employer Authority occurs when a participant fails to fulfill the role of employer and does not respond to counseling support. Participants who fail in their employer responsibilities but do not have a representative will be given the opportunity to select a representative who can assume employer responsibilities on behalf of the participant. Disenrollment will not occur without guidance and counseling by the counseling entity's support coordinator or by the fiscal intermediary. When this occurs, the counseling entity's support coordinator will coordinate agency personal care services to the degree requested by the participant. The participant may wish to self-advocate from a list provided by the counseling entity's support coordinator, ask the counseling entity's support coordinator to coordinate, or may simply wish to receive personal assistance services informally. The participant's wishes will be respected.

B. The State will provide the following safeguards to ensure continuity of services and assure participant health, safety and welfare during the period of transition between self-directed and traditional service delivery models.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

vi. Involuntary Disenrollment (Continued)

When a participant is involuntarily disenrolled, a notice of intent to close the IndependentChoices case will be mailed to the participant. The notice will allow a minimum of 10 days but no more than 30 days before IndependentChoices enrollment will be discontinued, depending on the situation. During the transition period, the counseling entity's support coordinator will work with the participant/representative to assure services are provided to help the individual transition to the most appropriate personal care services available.

vii. Participant Living Arrangement

Any additional restrictions on participant living arrangements, other than homes or property owned, operated or controlled by a provider of services, not related by blood or marriage to the participant are noted below.

There are no additional restrictions on living arrangements.

viii. Geographic Limitations and Comparability A. X ☒ The State elects to provide self-directed personal assistance services on a statewide basis.

B. The State elects to provide self-directed personal assistance services on a targeted geographic basis. Please describe:

C. The State elects to provide self-directed personal assistance services to all eligible populations.

D. ☒ The State elects to provide self-directed personal assistance services to targeted populations. Please describe: Age 18 and older. X

E. The State elects to provide self-directed personal assistance services to an unlimited number of participants.

F. ☒ The State elects to provide self-directed personal assistance services to 7500 participants, at any given time. X

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

x. Service Plan

The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider's influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence.

Not applicable. The state will not allow entities who provide other Medicaid State Plan services to be responsible for developing the self-directed service plan.

xi. Quality Assurance and Improvement Plan

The State's quality assurance and improvement plan is described below, including:

i. How it will conduct activities of discovery, remediation and quality improvement in order to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement; and

i. The system performance measures, outcome measures and satisfaction measures that the State will monitor and evaluate.

Many activities evaluate the overall performance of the IndependentChoices program such as:

· The IndependentChoices program uses a database to track a wide array of data, and uses all of the data it stores. Data entry drives end user functionality through form and e-mail generation, field calculation, data cross-referencing, and notices and reports. The reporting capabilities can help to monitor every element of operations such as: case particulars, work reports and management and operational tools. Use of the database supports discovery, remediation, and quality improvements.

· Using a DHS-approved assessment tool to determine the resources in time required to provide care in the home.

· Reports received from Financial Management Services provider received on a quarterly basis used by DHS Independent Choices QA staff to determine why underutilization of the Cash Expenditure Plan occurs and how underutilization can be resolved.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

All individual facets of the program work in a continuum to identify, remediate and improve the quality of services and the satisfaction of program participants while improving the overall performance of the program. Each phase of the program is described, detailing how assurances are met through the Arkansas Quality Assurance and Improvement Plan described below.

Monitoring and Oversight

The Division of Medical Services (DMS) retains responsibility for the administration and oversight of all Medicaid programs. The Division of Provider Services and Quality Assurance (DPSQA) is the operating agency for the IndependentChoices program and responsible for the day-to-day operations. Both Divisions are part of the Arkansas Department of Human Services. DPSQA will be responsible for executing the Quality Assurance and Improvement Plan with monitoring and oversight by DMS.

DPSQA will provide DMS with a monthly report comparing status of current data to previous year data. Examples included in the report may include but are not limited to the following:

· Enrollment activities

· Status of pending applications

· Status of active case load

· Participants who also receive home and community based services (HCBS)

· Medicaid Cost for IndependentChoices including participant-directed cost for HCBS services

· Detailed information for cost data for the most current month including cost of participant's budget and support services.

· Year in Progress, count of participants, contact notes, home visits, new enrollments for the current month, year to date and accumulative prior year experiences.

Lines of communication between the two Divisions are established and utilized to discuss additional needs and concerns that either Division may have.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

The IndependentChoices database is designed in such a way that discovery and remediation go hand in hand; not only for the DHS Independent Choices QA staff, nurses and contractors, but also for management staff. By design, the efficiency of the database enhances the DHS Independent Choices QA staff's ability to monitor the program without being overly burdened by paperwork. Examples on the following pages may include but are not limited to:

The database quantifies:

· referrals received during the month,

· persons disenrolling,

The database identifies:

· reasons for disenrolling from the program,

· IndependentChoices participants who also receive HCBS waiver services,

· the HCBS RN assigned to the participant,

· the participant's physician,

· physician's fax number,

· date of next reassessment due.

The database tracks and creates exception reports when standards are not met and quantifies results. Some examples of the reports are:

· time between the date of referral, the nurse's home visit, and receipt of the assessment from the DHS Independent Assessment Contractor,

· time between the referral and the actual enrollment

· number of home visits made by HCBS RN's within a timeframe.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Each active and pending record contained within the database only includes data fields that are used in reporting. Each participant record may include the following:

· representative information, if applicable,

· participant's employee,

· participant's back-up worker,

· directions to the participant's home,

· nurse tracking,

· Independent Choices QA tracking,

· contact notes,

· HCBS ARChoices service plan for persons receiving both ARChoices and IndependentChoices.

These data elements will assist the DHS Independent Choices QA staff and nurses in performing their duties by allowing timely management and monitoring of each participant's case. The database allows nurses, DHS Independent Choices QA staff or contractors to set health risk indicators identifying program participants who may require more frequent monitoring.

The data allows nurses and DHS Independent Choices QA staff to run reports from their case load. Automated highlights on specific data elements draw the nurse or DHS Independent Choices QA staff attention to areas that require special attention. Highlighted data fields represent the following:

· assessment performed by the DHS Independent Assessment Contractor but not received by DPSQA,

· date enrollment forms sent to a potential enrollee but not returned.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Reports are available to management to monitor quality of services provided to program participants and performance of staff. The reports identify program strengths and weaknesses or individual areas of concern. Reports compare data elements over periods of time to measure progress of corrective actions. As issues are identified they are addressed with appropriate staff to determine a new course of action through issuing new policy, enacting new procedures, clarifying an existing policy or procedure, or developing additional training. Identified issues continue to be monitored to determine if the corrective action is resolving the concern and is achieving the expected outcomes.

These reports allow flexibility to generate data based on any specified period of time, by a nurse, DHS Independent Choices QA staff, contractor or by management. Reporting frequencies range from daily, monthly, or annually. Policy dictates a maximum period of time for completion of specific tasks with the focus on completing necessary tasks that allow the program participant to direct and meet their own health care needs.

Reporting is used to identify and remediate problems, improve program operation and to evaluate staff performance.

The database stores contact notes documenting IndependentChoices QA staff and contractors' communication with program participants. Policy requires each contact note to be entered into the participant's record to enhance the ability of management to address concerns expressed by the participant, a legislator, the Governor's Office, etc., with a quick review of the contact notes.

Examples of data elements found in the nurse tracking database portion may include, but is not limited to these data elements describing some of the following characteristics:

· Level of care tier category

· principal diagnosis,

· secondary diagnoses,

· participant well cared for,

· strong informal supports,

· no concerns noted,

· need for frequent counseling entity's support coordinator contact.

Revised:

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Contact notes may include the following:

· person initiating the call,

· person receiving the call,

· date and time of call,

· subject of contact

· description of communication,

· complaint indicator

· whom complaint is directed toward

· date of complaint resolution

Nurses are supported by the Nurse Case Load Report that quantifies the active and pending caseload for each nurse by describing the following:

· by county, the number of active and pending clients with or without home and community-based services,

· data is also displayed in the aggregate by nurse per assigned counties.

The DHS Independent Assessment Contractor uses a DHS-approved assessment tool to define the participant's medical needs relative to the amount of resources required to care for the person in the home. The DHS-approved assessment tool is similar to the MDS assessment performed in nursing homes but is specifically designed for the community environment. The assessment results in a level of care tier defining the degree of functional impairment. These results help define the population served in addition to using a scientifically scaled and validated assessment instrument. The use of this assessment helps to more clearly describe the medical complexities of program participants as they strive to remain in the community and avoid institutionalization.

Monitoring occurs in various other ways such as:

· Underutilization of the allowance could be the first indication that a participant may be experiencing difficulty directing their own care. It could indicate the beginning of a decline in cognitive function, impairing the participant's ability to direct their care, a need for a representative or decision making partner; a loss of worker; or it may be nothing more than not submitting the timesheets in a timely manner. Each counseling entity's support coordinator works with his or her participants to determine the cause of the underutilization. The counseling entity's support coordinator and participant work together to resolve the problem with the counseling entity's support coordinator providing further assistance, as needed, or by the participant meeting his or her responsibilities as an employer. The counseling entity's support coordinator follows- up with additional calls to the participant and monitors future underutilization reports for reoccurrences.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

· Site visits to the contractors are made at a minimum bi-annually and more often if needed. The purpose of the site visit may be to provide an in-service, address concerns, or to evaluate performance. If during an evaluation deficiencies are noted, DPSQA may provide additional in-services, require an acceptable corrective action plan, monitor the corrective action plan, withhold payment or terminate the contract.

Participant Feedback

The DPSQA and its counseling and fiscal contractors support and encourage participant communication by provision of a toll-free number. Participants may pose questions and voice concerns using the toll-free number. Incoming calls from participants and outgoing calls from counseling entity's support coordinators or contractors are entered into the participant's individual electronic record. If the communication is an expressed complaint the counseling entity's support coordinator follows DPSQA required reporting procedures for documenting and resolving the complaint. Resolutions may include policy or procedural changes. Monitoring will continue to determine if the change has any impact or if the problem needs additional review.

A DHS appeal process is available for decisions made concerning Medicaid eligibility. An internal appeal process is available for participants when they are in disagreement with the number of hours recommended by the HCBS RN, involuntary disenrollment or if they have disagreements with their counseling entity's support coordinator or fiscal agent. The purpose of the internal appeal is to allow the participant a voice in the decision and a way to mediate any misunderstandings between the participant and the IndependentChoices program. Additional supporting information may be shared during this time. DPSQA will issue a letter to the participant within five days from the date the internal appeal is conducted. Most disagreements are resolved prior to a participant initiating a request for a fair hearing and appeal. A formal Medicaid Fair Hearing is available when services are reduced, suspended, eliminated, or upon loss of Medicaid eligibility.

Supplement 4 to Attachment 3.1-A Page 15 January 1, 2019

Revised:

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Information and Assistance

Brochures are available for marketing purposes and are provided to any of the 75 county offices upon request.

Each participant receives a program handbook to convey program guidelines and expectations. Examples of information provided may include any of the following and is subject to additions and deletions as needs arise:

· Overview of the IndependentChoices program

· Overview of support services

· Use of a representative (Decision-Making Partner)

· Eligibility

· Participant rights

· Participant responsibilities

· Personal assistance services

· Other Medicaid services

· Medicaid waiver services

· Expectations from counseling entity's support coordinator, nurse, bookkeeper

· Participant's enrollment duties

· Confidentiality

· When participant-direction begins

· Case Expenditure Plan

· Record Keeping

· Payroll

· Timesheets

· Hiring, training, conflict resolution, and termination of personal assistant

· Adult protective services

· Support services monitoring

· Reassessments

· Appeal rights

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Participants may also receive in-home visits, newsletters, questionnaires, and contact by phone to support participants wishing to direct their own care.

Participants can speak with their counseling entity's support coordinator or the fiscal intermediary from 8:00 a.m. until 4:30 p.m., Monday through Friday, except for legal holidays or during inclement weather. After hours the participant may leave a message; the counseling entity's support coordinator will return the call within one working day. Complaints are entered by the receiving party whether that is the counseling entity's support coordinator or the fiscal intermediary.

A packet of communication forms is provided to each participant to report a change, to revoke and/or change disclosure of information and to appeal adverse decisions. The counseling entity's support coordinator may also verbally take information related to changes in address or phone number.

Health and Welfare

Each participant must have an individual back-up plan to handle situations when the participant's primary employee is unavailable. The participant identifies a person who is willing to assume the tasks of the primary employee. The participant determines the risk involved and how the risk is mitigated based on their own individual needs. Inquiry of the use of the back-up plan occurs during phone communication with the participant. Reports from the IndependentChoices database can identify any program participant without a back-up personal attendant and if there is a conflict regarding a representative serving as a paid back- up personal attendant. The counseling entity's support coordinator initiates communications with the participant to begin remediation.

The counseling entity's support coordinator and fiscal entities will work closely together to provide information necessary for each entity to perform their duties. Frequent and thorough communication facilitates this good working relationship.

The database assists in addressing health and welfare concerns by allowing monitoring and management of each individual file by:

· identifying a participants representative, employee, physician, back-up worker, directions to the home, results of the Independent Assessment, and updates by the counseling entity's support coordinator assisting the participant in the IndependentChoices program, and;

· documenting all communications with the program participants.

Revised:

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Financial Accountability

DPSQA assures that payments are made to Medicaid eligible participants by:

· accessing Medicaid eligibility data prior to enrolling a person into IndependentChoices to assure eligibility for Medicaid and the IndependentChoices program;

· IndependentChoices program logic implemented by the Arkansas Medicaid fiscal intermediary, interfaces with the Medicaid Management Information System (MMIS) to edit against creation of an allowance for any participant who is no longer Medicaid eligible or is institutionalized;

· DPSQA maintains the MMIS eligibility file for IndependentChoices. The Arkansas fiscal intermediary reads the MMIS eligibility file to create claims for the IndependentChoices program. DPSQA queries on a weekly basis the Medicaid data warehouse to identify persons who are deceased, entered a nursing home, or have lost Medicaid eligibility. Once identified, the IndependentChoices eligibility segment is closed by DHS Independent Choices QA staff on a weekly basis. Through contact with the participant or participant's family or representative this information is obtained prior to the update of the MMIS;

· DPSQA also queries the Medicaid data warehouse to identify IndependentChoices participants who have had an acute hospitalization. Once identified, DPSQA informs the program participant, FMS provider and the counseling entity by letter that the participant's allowance paid prospectively during the hospitalization must be returned to the Medicaid program. The day of admission and day of discharge are allowable days;

· preventing duplication of agency and consumer-directed services by informing agency provider by fax seven days in advance the date the participant will begin directing their own personal care services.

Revised:

Supplement 4 to Attachment 3.1-A Page 18 January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Qualified Providers

IndependentChoices counseling and fiscal providers assist program participants in all phases of program participation. Some of the examples of the work by these providers may include but is not limited to any of the work activities below:

· enrollment of new participants;

· develop and implement participant-directed budget;

· coordinate with FMS provider and DPSQA;

· orientation to IndependentChoices and the philosophy of participant direction;

· offer skills training to the degree desired by the participant on how to recruit, interview, hire, evaluate, manage or dismiss assistants;

· participant-directed counseling support services;

· monitoring IndependentChoices participants/representatives;

· monitor over and under expenditures of Cash Expenditure Plan;

· provide quarterly reports to DPSQA;

· manage the individual budget on behalf of the participant;

· process payroll and support payment for other qualified services and supports;

· report and pay state and federal income taxes, FICA, Medicare, and state and federal unemployment taxes;

· verify citizenship status of workers;

· serve as the fiscal agent of the participant per IRS rules;

· issues reports to DPSQA;

· communicate with counseling entity's support coordinator on budget changes;

· inform participants of their individual budget balance.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xi. Quality Assurance and Improvement Plan (Continued)

Qualified Providers (continued)

DPSQA is responsible for the following activities:

· monitor the counseling and fiscal providers to ensure compliance with the spirit of participant-direction and that appropriate counseling, fiscal and programmatic procedures are maintained;

· serve as the liaison between counseling agency, fiscal provider, Medicaid Management Information System (MMIS), and the Arkansas Medicaid fiscal intermediary;

· monitor the process to reimburse the counseling agency and fiscal provider for services provided to program participants.

Quality assurance measures previously discussed, assist DPSQA in discovery and remediation to assure high standards in the offering and management of the participant-directed personal care program. The IndependentChoices program establishes, as its foundation, a person- centered approach that guides not only DPSQA, but counseling and fiscal providers as well.

xii Risk Management

A. The risk assessment methods used to identify potential risks to participants are described below:

The HCBS RN or the counseling entity's support coordinator is the catalyst for identifying potential risks. In-home visits by either party help to identify risks involved in the current home environment as well as potential risks involved with self-direction. The counseling entity's support coordinator or the HCBS RN can identify risks that may be environmental in nature such as throw rugs, uneven floors, etc. or the DHS-approved assessment tool may identify potential risks such as not receiving a flu vaccine, etc. Based on the HCBS RN's observation and the DHS-approved assessment tool, the HCBS RN after receiving notification from the counseling entity's support coordinator will discuss the potential risks identified with the individual. If the HCBS RN determines that a representative is needed, the RN will inform the counseling entity's support coordinator.

When the HCBS RN determines that a person is in need of a representative, the nurse will inform the counseling entity's support coordinator and the counseling entity's support coordinator will work with the participant to determine if there is someone who knows the participant's likes, dislikes, and preferences and is willing to accept the responsibilities to represent the participant in the IndependentChoices program.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xii. Risk Management (Continued)

The counseling entity's support coordinator is responsible for working with the participant to determine who can serve as the representative. The counseling entity's support coordinator will then work with the representative to teach, educate and work with the proposed representative so that the representative is fully aware of the responsibilities they are accepting in representing a person in a participant-directed program.

If the HCBS RN arrives and the participant is experiencing cognitive impairment and no informal supports are present, the participant will be discouraged from enrolling unless an informal support system can be identified, including someone to act as a representative decision maker. Participation in IndependentChoices requires the participant or their representative to be assertive in their role as employer and accept the risks, rights and responsibilities of directing their own care. If a representative is unavailable and the potential enrollee is incapable of performing these tasks without health and safety risks the person will not be enrolled. Blatant health and welfare concerns will not be compromised if solutions cannot be identified and enacted.

In addition to the HCBS RN's involvement there is communication with other agency providers providing home and community based services, with all parties having a vested interest in the health and welfare of the participant. This communication assists the operating agency to respond to any voiced concern with self-directed care.

The Participant Responsibilities and Agreement Form, which details all the requirements of self- direction, identifies areas where the individual may not be able to meet their responsibilities.

B. The tools or instruments used to mitigate identified risks are described below.

Every opportunity is afforded a participant to direct their own care, but the participant must accept and assume employer responsibility. Counseling support is available to help the participant, but ultimately it is the determination of the participant to succeed that determines whether participant direction will be a successful program for them. The IndependentChoices program requires a participant to make good decisions in order to assure that their personal assistance needs are met.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xii. Risk Management (Continued)

When a participant needs a representative, the program allows for appointment of a Decision-Making Partner (DMP) who is willing to act and assume the employer role for the participant. The counseling entity's support coordinator is the person responsible for working with the participant or the participant's family in the appointment of a Representative or decision-making partner. Each time a Representative or DMP is appointed the enrollment of the DMP is similar to a new participant enrollment. The Representative or DMP must be at least 18 years of age and able and willing to meet the following requirements:

· Possess knowledge of the participant's preferences

· Be willing to meet and uphold all program requirements

· Be willing to sign tax form and verify timesheets,

· Show a strong personal commitment to the participant

· Visit the participant at least weekly

· Uphold all duties without influence by the personal assistant or paid back-up worker

· Obtain approval from the participant and a consensus from other family members of the participant to serve as the DMP

· Be willing to submit to a criminal background check

· Be available to discuss the program hours

Once the participant has appointed a Representative or DMP, there are specific forms that must be completed.

If at any time DPSQA learns that the participant's personal attendant is not providing the care agreed upon, the counselor will contact the participant/representative to ascertain the ability of the participant/representative to fulfill the role of employer. This discussion is to seek what types of assistance or support the participant or representative may need. A review of recurring instances of noncompliance could be reason for involuntary disenrollment.

When persons affiliated with the IndependentChoices program suspect abuse or neglect causing potential for health and safety risk to the participant by the representative, family members, personal attendant, or others, the participant will be referred to Adult Protective Services.

Revised:

January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xii. Risk Management (Continued)

C. The State's process for ensuring that each service plan reflects the risks that an individual is willing and able to assume, and the plan for how identified risks will be mitigated, is described below.

The service plan is a result of the Independent Assessment and a form designated by DHS and will list the risks identified in the assessment. The service plan will also require the nurse to list any other risks identified through observation that were not identified through the Independent Assessment or form designated by DHS, or risks identified by the participant, representative or interested parties through a participant-centered approach. The service plan will identify the plan or actions needed to mitigate the risks and who is responsible for each action. The service plan requires the signature of the participant/representative, agreeing to the service plan and what the participant/representative is willing to do to mitigate risk.

D. The State's process for ensuring that the risk management plan is the result of discussion and negotiation among the persons designated by the State to develop the service plan, the participant, the participant's representative, if any, and others from whom the participant may seek guidance, is described below.

IndependentChoices nurses and counseling entity's support coordinator are trained to apply a participant-centered approach in developing all plans with the participant. Participants are always encouraged to invite friends and family members who have a personal commitment to the participant to be present in all meetings between the participant and nurse or counseling entity's support coordinator. Identified risks will be discussed with the participant/representative and interested parties to determine a plan to mitigate the risk. The nurse and counseling entity's support coordinator are there to facilitate and guide the discussion and identify concerns with any discussed approaches to mitigation of risk.

Revised:

Supplement 4 to Attachment 3.1-A Page 23 January 1, 2019

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xiii. Qualifications of Providers of Personal Assistance

A. The State elects to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.

B. X

☒ The State elects not to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.

xiv. Use of Representative

A. ☒ X X The State elects to permit participants to appoint a representative to direct the provision of self- directed personal assistance services on their behalf. i. ☒ The State elects to include, as a type of representative, a State-mandated representative. Please indicate the criteria to be applied.

If the participant has been diagnosed with a mental or cognitive impairment such as mental retardation, dementia, Alzheimer;s Disease, etc., the participant or family members close to the participant will be required to choose a representative in order to participate or continue to participate in IndependentChoices. If the participant has not been diagnosed with a mental condition, but the DPSQA RN and counseling staff determines through the Self-Assessment instrument, discussions with the participant, and sometimes a trial period of self-direction with enhanced counseling, that the individual's cognitive abilities are not sufficient to self-direct, the participant will be required to choose a representative. The counseling staff will work with the participant to establish a representative, using all avenues to find one if necessary. If the participant refuses to select a representative or the participant cannot find anyone who can act in that capacity after all avenues have been exhausted, the counseling entity's support coordinator will coordinate with the participant to transition the participant to the traditional personal care provider of choice.

B. The State elects not to permit participants to appoint a representative to direct the provision of self- directed personal assistance services on their behalf.

xv. Permissible Purchases

a. ☒ The State elects to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance. b. The State elects not to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance. X

Revised:

OMB Approved 0938-1024

State: ARKANSAS

1915(j) Self-Directed Personal Assistance Services (Continued)

xvi. Financial Management Services

A. ☒ X The State elects to employ a Financial Management Entity to provide financial management services to participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.

i. The State elects to provide financial management services through a reporting or subagent through its fiscal intermediary in accordance with Section 3504 of the IRS Code and Revenue Procedure 80-4 and Notice 2003-70; or

ii. ☒ X The State elects to provide financial management services through vendor organizations that have the capabilities to perform the required tasks in accordance with Section 3504 of the IRS Code and Revenue Procedure 70-6. (When private entities furnish financial management services, the procurement method must meet the requirements set forth in Federal regulations 45 CFR Section 74.40 - Section 74.48.)

iii. The State elects to provide financial management services using "agency with choice" organizations that have the capabilities to perform the required tasks in accordance with the principles of self-direction and with Federal and State Medicaid rules.

B. The State elects to directly perform financial management services on behalf of participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.

Section 1905(a)(29) Medication Assisted Treatment (MAT)

General Assurances [Select all three checkboxes below.]

☒

MAT is covered under the Medicaid state plan for all Medicaid beneficiaries who meet the

medical necessity criteria for receipt of the service for the period beginning October 1, 2020.

☒ The state assures coverage of Naltrexone, Buprenorphine, and Methadone and all of the forms of these drugs for MAT that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).

☒ The state assures that Methadone for MAT is provided by Opioid Treatment Programs that meet the requirements in 42 C.F.R. Part 8.

Service Package

The state covers the following counseling services and behavioral health therapies as part of MAT: [Please describe in the text fields as indicated below.]

Please set forth each service and components of each service (if applicable), along with a description of each service and component service.

Individual Behavioral Health Counseling, Group Behavioral Health Counseling, Marital/Family Behavioral Health Counseling that involves the participation of a non-Medicaid eligible is for the direct benefit of the client. The service must actively involve the client in the sense of being tailored to the client's individual needs. There may be times when, based on clinical judgment, the client is not present during the delivery of the service, but remains the focus of the service.

Section 1905(a)(29) Medication Assisted Treatment (MAT)

Please include each practitioner and provider entity that furnishes each service and component service.

1. Physicians, Physician Assistants, and Nurse Practitioners may provide counseling and behavioral health therapies.

2. Licensed Behavioral Health Practitioners: Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), Licensed Marital and Family Therapists (LMFT), This group's role is to provide the behavioral and substance use disorder counseling required

Section 1905(a)(29) Medication Assisted Treatment (MAT)

Please include a brief summary of the qualifications for each practitioner or provider entity that the state requires. Include any licensure, certification, registration, education, experience, training and supervisory arrangements that the state requires.

Physicians and Nurse Practitioners must be Licensed in Arkansas. Physician Assistants must have a legal agreement to practice under an Arkansas Licensed Physician per Arkansas statute. Licensed Psychologists (LP), Licensed Psychological Examiners - Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must possess a current and valid Arkansas license.

State Plan under Title XIX of the Social Security Act State/Territory: Arkansas

Section 1905(a)(29) Medication Assisted Treatment (MAT)

Utilization Controls [Select all applicable checkboxes below.] ☒ The state has drug utilization controls in place. (Check each of the following that apply) ☐ Generic first policy ☒ Preferred drug lists ☐ Clinical criteria ☒ Quantity limits

☐ The state does not have drug utilization controls in place.

Limitations

[Describe the state's limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT.]

Quantity limits for MAT drugs are set per label. The oral drugs have a therapeutic duplication edit to prevent multiple buprenorphine oral dosage forms. There are no hard limitations for counseling and behavioral therapies related to MAT because authorizations of medically necessary services are available.

Revision:

HCPA-PM-86-20

( BERC)

ATTACHMENT 3.1-B Page 1

SEPTEMBER

1986

Revised:

December 1, 1991

OMB No. 0938-0193

State/Territory:

ARKANSAS

AMOUNT. DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY GROUP (S) :

ALL

The following ambulatory services are provided.

Outpatient Hospital Services

Pural Health Clinic Services

Faceraily Qualified Health Center Services

-aboratory and X-Ray Services Cariy and Periodic Screening. "tagnosis ann Treatrent Family Planning Services

Physician Services Private Duty Nursing Services Optometrists' Services Chiropractors' Services ** Sther Practitioners' Services ** hearing aid dealers, quoiologists Home Health Services

Clinic Services Cental Services **

Physical Therapy and Related Services ** Prescribed Drugs

Dentures **

Prosthetic Devices ** hearing aids, eye prostheses

Christiansas

Eyeglasses

DEC 30 1991

Nurse Midwife Services

DEC 1 4 1992

Targeted Case Management

DEC QI 199U

Transportation Nurse Practitioner Services

*Description provided on attachment.

** These services limited to EPSDT.

TN No.

91.59

Superseder

TN No.

91-28

Approval D

DEC 14 1992

Effective

DEC 0 1 1991

91.59

Revision: HCFA-Region VI - R

ATTACHMENT 3.1-B

October 1991

State/Territory:

ARKANSAS

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY GROUP (S) :

ALL

1. Inpatient hospital services other than those provided in an institution for mental diseases. ☒ &/Provided: L No limitations ☒ /Wwith limitations*

2. a. Outpatient hospital services. X

☒ With limitations* ☒ Provided: 7 'No limitations ☒ With limitations* b. Rural health clinic services and other ambulatory services furnished by a rural health clinic and covered under the Plan. ☒ WProvided : 1 'No limitations LX

C. Federally qualified health center ( FQHC) servies and other ambulatory services that are covered under the plan and furnished by an FOHC in accordance with section 4231 of the State Medicaid Manual ( HCFA-Pub. 45-4).

X ☒ Provided:

No limitations ☒ With limitations* X

3. Other laboratory and X-ray services. ☒ Provided: LI No limitations ☒ /X/with limitations*

4. a. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older. /_/Provided : Z No limitations 1 With limitations*

b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found. ☒ Provided Not provided

c. Family planning services and supplies for individuals of childbearing age. ☒ Provided: 1 No limitations ☒ WWith limitations*

*Description provided on attachment.

TN No. 92-06

Supersedes

TN NO.

91.5264

Approval Date

12/16/92

Effective Date

3/1/92

HCFA ID:

7986E

CArkansas 2124-92 12-16-92 3-1-92 92-06

State/Territory: ARKANSAS

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S):

4.d. Tobacco cessation counseling services for pregnant women ☒ Provided: ☐ No limitations ☒ with limitations*

e. Medication-Assisted Treatment for opioid use disorders when provided as part of a Medication Assisted Treatment plan ☒ Provided: ☐ No limitations ☒ with limitations*

5.a. Physicians' services, whether furnished in the office, the patient's home, a hospital, a nursing facility, or elsewhere.

☒ Provided: ☐ No limitations ☒ with limitations*

b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). ☒ Provided: ☐ No limitations ☒ with limitations*

*Description provided on attachment.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2026

MEDICALLY NEEDY

1. Inpatient Hospital Services

Inpatient admissions to a rehabilitative hospital will be allowed up to ten (10) days of service per admission when determined inpatient care is medically necessary. Extension of benefits will be available when medically necessary. Medically necessary inpatient days are available to individuals under age 1 without regard to the corresponding hospital day limit and extension procedures.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2026

MEDICALLY NEEDY

1. Inpatient Hospital Services (continued)

Substance Use Disorder Residential Treatment provided in Acute Care Hospitals for Individuals under age 21

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2021

MEDICALLY NEEDY

1. Inpatient Hospital Services (continued)

Acute Crisis Unit

A. ongoing assessment and observation;

B. crisis intervention;

C. psychiatric, substance, and co-occurring treatment; and

D. initiation of referral mechanisms for independent assessment and care planning.

Services are available for up to 96 hours per encounter. Providers must initiate an extension of benefits request for medical necessity approval prior to providing services beyond 96 hours.

This expenditure is being paid as inpatient hospital because the definition of outpatient limits services to less than a 24-hour period. (42 CFR 440.2)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

September 1, 1999

1. Inpatient Hospital Services

A. Rehabilitative Hospital

STATE arkansas

DATE RECO) 6-28-99

DATE AFFID 9-17-19A

DAlu Eff 9-1-99.

HCFA 179 99-10

SUPERSEDES: NONE - NEW PAGE ☒

ATTACHMENT 3.1-B

Page 2b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: August 1, 2003

MEDICALLY NEEDY

2.a. Outpatient Hospital Services

(1) For the purpose of determining amount, duration and scope, outpatient hospital services are divided into four types of services:

. Emergency services

· Outpatient surgical procedures

. Non-emergency services

· Therapy/treatment services

Emergency Services

The determination of an emergency medical condition will be in compliance with Section 1867 of the Social Security Act.

A retrospective review will be performed by the Professional Review Organization (PRO) on a sampling of paid claims.

Non-emergency services may be necessary in the outpatient hospital setting when qualified physicians are not available in their offices or walk-in clinics to carry out the necessary treatment.

STATE Arkansas

DATE RE: / / Jul 2003

DATE APPY C 8 Aug 2003

DATE EFF 1 Sep 2003

ACFA 179 AR 03-07

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2009

MEDICALLY NEEDY

2.a. Outpatient Hospital Services (Continued)

Outpatient Surgical Procedures

Coverage of outpatient surgical procedures are limited to procedures which the Arkansas Medicaid Program has determined to be safe and effective when performed on an outpatient basis.

Since outpatient surgical procedures are limited to approved medically necessary services, no additional benefit limitations are imposed.

Treatment/Therapy Services

The covered outpatient hospital treatment/therapy services include, but are not limited to the following:

· Dialysis

· Radiation therapy

· Chemotherapy administration

· Physical therapy

· Occupational therapy

· Speech therapy

· Respiratory therapy

· Factor 8 injections

· Burn therapy

Treatment/therapy services are included in the outpatient hospital services limit of twelve (12) visits per State Fiscal Year.

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised:

October 1, 2023

MEDICALLY NEEDY

2.a. Outpatient Hospital Services (Continued)

Non-Emergency Services

Outpatient hospital services other than those which qualify as emergency, outpatient surgical procedures and treatment, and therapy services are covered as non-emergency services.

Benefit Limit

· non-emergency outpatient hospital and related physician and nurse practitioner services; and

· outpatient hospital therapy and treatment services and related physician and nurse practitioner services.

For services beyond the 12-visit limit, an extension of benefits will be provided if medically necessary. The following diagnoses are considered categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection; renal failure; opioid use disorder when the visit is part of a Medication Assisted Treatment plan, and pregnancy. All other diagnoses are subject to prior authorization before benefits can be extended.

Outpatient hospital services are not benefit limited for recipients in the Child Health Services (EPSDT) Program.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

September 1, 1999

2.a. Outpatient Hospital Services (Continued)

Augmentative Communication Device (ACD) Evaluation

STATE arkansas

DATE RECD 6-28-99

DAIS AFPYD 9-17-99

9-1-99

HICFA 17? 99-10

SUPERSEDES: NONE

☒ NEW PAGE

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2022

MEDICALLY NEEDY

2.b. Rural Health Clinic Services

Rural health clinic services are limited to sixteen (16) visits a year for clients twenty-one (21) years or older. This yearly limit is based on the State Fiscal Year (July I through June 30). Rural health clinic encounters will be considered in conjunction with the benefit limit established for physician services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, federally qualified health center encounters, and advanced practice registered nurse services, or a combination of the seven. Benefit limit extensions will be available if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the service limit. Clients under age twenty-one (2l) in the Child Health Services (EPSDT) Program are not benefit limited.

Rural health clinic core services are defined as follows:

1. Physicians' services, advanced practice registered nurses' services, and services of physician assistants when provided under proper supervision;

2. Services and supplies furnished as an incident to professional services;

Services and supplies "incident to" the professional services of physicians, physician assistants, or advanced practice registered nurses, are those which are commonly furnished in connection with these professional services, are generally furnished in the rural health clinic office, and are ordinarily rendered without charge or included in the clinic's bills; e.g., laboratory services, ordinary medications and other services and supplies used in patient primary care services.

3. Clinical psychologist services;

4. Clinical social worker services;

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

Revised: October 1, 2023

2.b. Rural Health Clinic Services

5. Services of nurse midwives; and

6. Visiting nurse services on a part-time or intermittent basis to home-bound patients (limited to areas in which there is a shortage of home health agencies).

Rural health clinic ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the rural health clinic offers such a service (e.g. dental, visual, etc.). The "other ambulatory services" that are provided by the rural health clinic will count against the limit established in the plan for that service.

Medication Assisted Treatment visits do not count against the Rural Health Clinic encounter benefit limit when the diagnosis is for opioid use disorder and is part of a Medication Assisted Treatment plan.

Federally qualified health center services are limited to sixteen (16) encounters per client, per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or older. The applicable benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, rural health clinic encounters, and advanced practice registered nurse services, or a combination of the seven.

Benefit extensions will be available if medically necessary. Clients under age twenty-one (21) in the Child Health Services (EPSDT) Program are not benefit limited.

Medication Assisted Treatment visits do not count against the FQHC encounter benefit limit when the diagnosis is for opioid use disorder and is part of a Medication Assisted Treatment plan.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

January 1, 2022

MEDICALLY NEEDY

Covered FQHC core services are defined as follows:

· physician services;

· services and supplies incident to physician's services (including drugs and biologicals that cannot be self-administered);

· pneumococcal vaccine and its administration and influenza vaccine and its administration;

· physician assistant services;

· nurse practitioner services;

· clinical psychologist services;

· clinical social worker services;

· licensed certified social worker services;

· licensed professional counselor services;

· licensed mental health counselor services;

· licensed marriage and family therapist services;

· services and supplies incident to clinical psychologist, clinical social worker services, licensed certified social worker, licensed professional counselor, licensed mental health counselor and licensed marriage and family therapist services as would otherwise be covered if furnished by or incident to physician services; and

· part-time or intermittent nursing care and related medical supplies to a homebound individual, in the case of those FQHCs that are located in an area in which the Secretary has determined there is a shortage of home health agencies.

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 2023

MEDICALLY NEEDY

3. Other Laboratory and X-Ray Services

Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY, July 1-June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY. Radiology/other services include, but are not limited to, diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).

(1) The following diagnoses are specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services health benefit limits: (a) Malignant neoplasm; (b) HIV infection; and (c) renal failure. The cost of related diagnostic laboratory services and radiology/other services will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit or the five hundred dollars ($500) per SFY radiology/other services health benefit limit.

(3) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory services benefit limit or five hundred dollars ($500) per SFY radiology/other services health benefit limit. The cost of these procedures will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit or the recipient's five hundred dollars ($500) per SFY radiology/other services health benefit limit.

(4) Portable X-Ray Services are subject to the five hundred dollars ($500) per SFY X-ray services benefit limit. Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. Services may be provided to an eligible recipient in their residence upon the written order of the recipient's physician. Portable X-ray services are limited to the following:

a. Skeletal films that involve arms and legs, pelvis, vertebral column, and skull;

b. Chest films that do not involve the use of contrast media; and

c. Abdominal films that do not involve the use of contrast media.

4.a. Nursing Facility Services - Not Provided

ATTACHMENT 3.1-B Page 2g

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2021

MEDICALLY NEEDY

4.b Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found.

(1) No limitation on services within the scope of the program, except for consultations, home health services if services are EPSDT related. Extension of the benefit limit for consultations (2 per State Fiscal Year), home health services (50 visits per State Fiscal Year), physical therapy evaluations (2 per State Fiscal Year), occupational therapy evaluations (2 per State Fiscal Year), speech-language therapy evaluations (4 units per State Fiscal Year), and chiropractor X-ray services (2 per State Fiscal Year) will be provided if medically necessary for recipients in the Child Health Services (EPSDT) Program.

Medical Screens are provided based on the recommendations of the American Academy of Pediatrics. Childhood immunizations are provided based on the Advisory Committee on Immunization Practices (ACIP).

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2018

MEDICALLY NEEDY

4.b Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(2) Apnea (Cardiorespiratory) Monitors ☒

Apnea (cardiorespiratory) monitors are provided for eligible recipients in the EPSDT Program. Use of the apnea monitors must be medically necessary and prescribed by a physician. Prior authorization is not required for the initial one month period. If the apnea monitor is needed longer than the initial month, prior authorization is required.

(3) Early Childhood Intervention Day Treatment (EIDT) Services

EIDT services provide diagnosis and evaluation for the purpose of early intervention and prevention for eligible recipients in the EPSDT Program. Services are provided, if identified by an Independent Assessment in accordance with the Independent Assessment Manual, in multi-disciplinary clinic based setting as defined in 42 CFR § 440.90.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 2015

MEDICALLY NEEDY

4.b Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(4) RESERVED

(5) Private Duty Nursing to enhance the effectiveness of treatment for ventilator-dependent beneficiaries or high technology non-ventilator beneficiaries

Enrolled providers are Private Duty Nursing Agencies licensed by Arkansas Department of Human Services, Division of Health. Services are provided by Registered Nurses or Licensed Practical Nurses licensed by the Arkansas State Board of Nursing.

Beneficiaries under age 21 to receive PDN Nursing Services must require constant supervision, visual assessment and monitoring of both equipment and patient. PDN services may be covered for Medicaid beneficiaries under 21 who meet the following requirements:

A. Medicaid-eligible ventilator-dependent (invasive) beneficiaries when determined medically necessary and prescribed by a physician or

B. Medicaid-eligible beneficiaries under age 21 who are:

1. In the Child Health Services (EPSDT) Program, and

2. High technology non-ventilator dependent beneficiary requiring at least two (2) of the following services:

(1) Intravenous Drugs (e.g. chemotherapy, pain relief or prolonged IV antibiotics)

(2) Hyperalimentation - parenteral or enteral

(3) Respiratory - Tracheostomy or Oxygen Supplementation

(4) Total Care Support for ADLs and close patient monitoring

These services require prior authorization. Services may be provided in the beneficiaries' home, a Division of Developmental Disabilities (DDS) community provider facility or a public school. (Home does not include an institution.) Prior authorization is required. Private duty nursing medical supplies are limited to a maximum reimbursement of $80.00 per month, per beneficiary. With substantiation, the maximum reimbursement may be extended.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-B Page 2j

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: February 1, 1991 MEDICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

6. Cochlear Implants

Coverage of Cochlear implantation is limited to recipients in the EPSDT Program. This procedure requires a prior authorization.

STATE Ortanses

DATE PEC'D

APR - 4.1991

DATE APPV'D MAY - 9 1991

DATE EFF

FEB - 1 1991

HCFA 179/

97-15

Superse les : 90-16

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-B Page 2k

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: December 1, 1991

MEDICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(7) Dentures

Dentures are provided to eligible Medicaid recipients in the Child Health Services" (EPSDT) Program with prior authorization from the Medical Assistance Section.

(a) Hearing Aid Dealers

(9) Audiologist Services

Provision of audiometric testing and hearing aid evaluation to eligible recipients in the Child Health Services (EPSDT) Program.

arkansas

DE£ 3.0 1991

DEC 14 1992

DEC U 1 1991

91-59

Supersular TN 91-28

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-8 Page 2L

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: July 1, 1991

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(10) Hearing Alds

from the Uderson nerwy factkyt How to wd w wiited to we epwhite per ok month portion with portor authoribation I dedon't conviene may be worked middle Wy manmary

(11) Eye Prostheses Eye prostheses are provided for eligible Medicaid recipients in the Child Health Services (EPSDT) Program with prior authorization from the Medical Assistance Section.

(12) Deneltration Infectionin

Limited to clioity Medicaldi rectsiente in the Child Health Services (EPEDT)

Program,

DUCKONDAS JUL 01 1991 NOV 19 1991

91-28

Logicise Ses : 91.15; 90.48

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2017

MEDICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d))

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Outpatient Behavioral Health Services (OBHS)

A. Scope

DMS has set forth in policy the settings in which each individual service may be provided. Each service shown below includes the place of service allowable for that procedure.

B. Services

i .: Individual Behavioral Health Counseling*

DEFINITION: Individual Behavioral Health Counseling, including tobacco cessation, is a face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

i .: Individual Behavioral Health Counseling(continued)*

ii. Group Behavioral Health Counseling*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present*

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present(continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized. .

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

iv. Marital/Family Behavioral Health Counseling without Beneficiary Present*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

v. Group Psychoeducation*

*Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the Provider must have Arkansas State Infant Mental Health Certification.

vi. Multi-Family Behavioral Health Counseling*

DEFINITION: Multi-Family Behavioral Health Counseling, including tobacco cessation, is a group therapeutic intervention using face-to-face verbal interaction between two (2) to a maximum of nine (9) beneficiaries and their family members or significant others. Services are a more cost-effective alternative to Family Behavioral Health Counseling, designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services may pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition. Services must be congruent with the age and abilities of the beneficiary, client- centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

vii. Mental Health Diagnosis*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

viii. Interpretation of Diagnosis*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

ix. Substance Abuse Assessment*

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

ix. Substance Abuse Assessment (continued)*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician;

x. Psychological Evaluation*

Allowable Performing Provider -Licensed Psychologist, Licensed Psychological Examiner and a Licensed Psychological Examiner - Independent

xi: Pharmacologic Management*

Allowable Performing Provider - Advanced Practice Nurse or a Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

July 1, 2017

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(13) Psychology Services (42 CFR 440.130(d)) (continued)

(2) Outpatient Behavioral Health Services (OBHS)(continued)

xii: Psychiatric Assessment*

Allowable Performing Provider - Advanced Practice Nurse or a Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

ATTACHMENT 3.1-B Page 2n

Revised: January 1, 2021

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(14) RESERVED

(15) Physical Therapy and Related Services

a. Physical Therapy

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(3) Services must be prescribed by a physician and provided by or under the supervision of a qualified physical therapist.

A qualified physical therapist assistant may provide services under the supervision of a licensed physical therapist.

All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2021

MEDICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(15) Physical Therapy and Related Services (Continued)

b. Occupational Therapy

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Services must be prescribed by a physician and provided by or under the supervision of a qualified occupational therapist.

A qualified occupational therapist assistant may provide services under the supervision of a licensed occupational therapist.

All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.

c. Services for individuals with speech, hearing and language disorders (provided by or under the supervision of a speech-language pathologist or audiologist)

(1) Speech-language pathology services are limited to Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Speech-language pathology services must be referred by a physician and provided by or under the supervision of a qualified speech-language pathologist.

A qualified speech-language therapist assistant may provide services under the supervision of a licensed speech-language therapist.

All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.

(3) Evaluations are limited to four (4) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit for the evaluation will be provided if medically necessary.

Approval: 11-9-2020 Effective Date: 1-1-2021

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: July 1, 2014

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

(16) Dental Services

(1) Services are limited to eligible Medicaid recipients in the Child Health Services (EPSDT) Program.

(2) Procedures which may be provided to recipients in the Child Health Services (EPSDT) Program without prior authorization are:

a. Initial radiographs taken in conjunction with preparation of a treatment plan.

b. Periodic oral exam, prophylaxis, topical fluoride and/or fluoride varnish for children in the Child Health Services (EPSDT) Program.

c. Emergency treatment. One visit without prior authorization is payable for any emergency. Procedures payable without prior authorization when provided as emergency care include:

1. All necessary radiographs.

2. Extraction of up to three teeth for relief of pain or acute infections.

3. Control of bleeding.

4. Treatment for relief of pain resulting from injuries to the oral cavity or related services.

5. Emergency services provided to patients in hospitals or long term care facilities.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 1998

MEDICALLY NEEDY

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

17. Rehabilitative Services for Persons with Physical Disabilities (RSPD)

a. Residential Rehabilitation Center Services

· Restorative Therapies

· Behavioral Rehabilitation

· Life Skills Training for Rehabilitation

· Individual and Group Counseling

· Assessment Services

· Nursing Care

STATE arkansas DATE $350 5-18-98

10-29-99 DAIS G- 7-1-98

HCFA 17} 98-09

SUPERSED-7 TN . 97-14

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

February 1, 2001

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services

1. School-Based Mental Health Services

a. Services are limited to eligible Medicaid recipients under age 21 in the Child Health Services (EPSDT) Program.

b. A referral must be made by a Medicaid enrolled physician documenting services are medically necessary.

d. The State assures that eligible Medicaid recipients will be given free choice of providers within and outside the school setting.

c. Provider Qualifications

The Arkansas Medicaid program has established provider participation requirements for school-based mental health services.

In order to ensure quality and continuity of care, School Districts and/or Education Services Cooperatives that are School-Based Mental Health Service Providers approved to receive Medicaid reimbursement must ensure that contractors and personnel engaged as Licensed School-Based Mental Health Practitioners meet specific Medicaid qualifications, Practitioners licensed as school-based mental health services provider personnel may provide the services according to their scope of practice as identified by the licensure requirements. Services will be provided by the following:

Arkansas

Jan 01, 2001

Mar 26, 2001

Feb 01,2001

00-13

STATE

DATE RECO

DATE APPV'D

DATE EFF HCFA 179

1. Schoof Psychology Specialist (licensed by the Arkansas Department of Education (ADE)

2. Licensed Certified Social Worker (licensed by the Arkansas Social- Work Licensing Board)

3. Licensed Masters Social Worker (licensed by the Arkansas Social- Work Licensing Board)

4. Psychological Examiner (licensed by the Arkansas Board of Examiner> in P'sychology )

5. Licensed Psychologist Cieensed by the Arkansas Board of Examiners in Psychology )

0. Licensed Professional Counselor (licensed by the Arkansas Board of I waminers in ( mumscling)

7 Licensed Associate & Quesefor theensed In the Arkansas Board of I saminers in { unosthingi

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

July 1, 2017

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services (42 CFR 440.130(d)) (continued)

1. School-Based Mental Health Services (continued)

f. Covered Services (continued)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services (42 CFR 440.130(d)) (continued)

1. School-Based Mental Health Services (continued)

f. Covered Services (continued)

6. Crisis Intervention -An unscheduled, immediate, short-term treatment activity provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services, which can include interventions, stabilization activities, evaluation, coping strategies and other various activities to assist the beneficiary in crisis, are designed to stabilize the person in crisis, prevent further deterioration and provide immediate indicated treatment in the least restrictive setting. The services provided are expected to reduce or eliminate the risk of harm to the person or others in order to stabilize the beneficiary.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2017

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

18. Rehabilitative Services (42 CFR 440.130(d)) (continued)

1. School-Based Mental Health Services (continued)

f. Covered Services (continued)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

October 1, 1998

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children

ELIGIBILITY FOR SERVICES

The following recipients are eligible for rehabilitative services to children as set forth in this Section:

A. General Eligibility

1. Medically Needy Medicaid recipients.

B. Specific Eligibility

1. The recipient must be age twenty (20) years or less, and

DURATION OF SERVICES

COVERED SERVICES

STATE ARKANSAS

DATE REC'D 07-16-01

DATE APPV'D 08-31-01

DATE EFF

10-01-98

HCFA 179

AR-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

(a) The evaluation and assessment shall:

(1) Be based on informed clinical opinion;

(3) Include an evaluation of the child's cognitive development, social and emotional development and adaptive development.

(b) The plan of care shall contain:

(1) A written plan using the information derived from the evaluation and assessment;

(2) A statement of the child's present level of functioning in the domains examined in the evaluation and assessment;

STATE ARKANSAS

DATE REC'D 07-16-01

DATE APPV'D 08-31-01

DATE EFF 10-01-98

HCFA 179 AV-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

(4) A statement of the persons responsible for implementing the plan of care; and

(5) A statement of the functional outcomes expected to be achieved though the provision of services and supports.

3. Residential Treatment - This residential service provides twenty-four hour treatment to children whose psychological or emotional problems related to neglect and/or abuse can best be restored by residential treatment in accordance with the child's plan of care. The objective of this service is to assist the child in improving or maintaining his/her highest functioning level through individual and group therapeutic interventions to improve or maintain the skills needed to safely and securely interact with other persons, through symptom management to allow the child to identify and minimize the negative effects of psychiatric or emotional symptoms which interfere with the child's personal development and community integration, and through supportive counseling with a child to develop. restore and/or maintain the child's mental or emotional growth.

PROVIDER QUALIFICATION

Rehabilitative services for children will be provided only through qualified provider agencies. Qualified provider agencies must meet the following rehabilitative services for children criteria:

1. Have full access to all pertinent records concerning the child's needs for services including records of the Arkansas District Courts, local Children's Service Agencies, and State Child and Family Services Agency,

STATE Arkansas

DATE REC'D 12. - 10-6/

DATE APPV'D

12-21-01

DATE EFF

04-01-02

HCFA 179

AR-01-35

SUPERSEDES: TN-

98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

2. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population,

3. Have a minimum of one year's experience in providing all core elements of rehabilitative services for children,

4. Have an administrative capacity to ensure quality of services in accordance with State and Federal requirements,

5. Have a financial management capacity and system that provides documentation of services and costs in, conformity with generally accepted accounting principles,

6. Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and

SERVICE SETTINGS

1. Non-residential services provided to children who reside in a family home setting will be provided either in the child's home or in the customary place of business of a qualified provider.

2. Residential services provided to children who reside outside of a family home will be provided in an appropriately state licensed and/or certified facility including:

STATE ARKANSAS

DATE REC'D 07-16-01

DATE APPVID 08-31-01

DATE EFF 10-01-98

HCFA 179 ARC-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

19. Rehabilitative Services for Children (Continued)

3. Services shall not be reimbursed when provided in the following settings:

(a) Nursing facilities,

(b) Intermediate care facilities for the mentally retarded, and

FREEDOM OF CHOICE

The State assures that the provision of rehabilitative services for children will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

1. Eligible recipients will have free choice of any qualified provider of rehabilitative services for children, and

2. Eligible recipients will have free choice of the providers of other medical care as covered elsewhere under the Plan.

COMPARABILITY OF SERVICES

The State assures that the provision of rehabilitative services for children will not limit an individual's access to medically necessary services in violation of section 1902(a)(10) of the Act.

1. Rehabilitative services for children will be made available to all children for whom this service is determined to be medically necessary, and

2. All medically necessary health care services described in section 1905(a) will be provided to all EPSDT eligible recipients.

STATE ARKANSAS

DATE REC'D 07-16-01

DATE APPV D

08-31-01

DATE EFF

10-01-98

HCFA 179

AR-98-11

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth

ELIGIBILITY FOR SERVICES

The following recipients are eligible for rehabilitative services to youth as set forth in this Section:

A. General Eligibility

1. Medically Needy Medicaid recipients.

B. Specific Eligibility

1. The recipient must be age twenty (20) years or less, and

DURATION OF SERVICES

Each Title XIX EPSDT recipient is eligible for covered rehabilitative services in accordance with 42 CFR 440.130(d) which are medically necessary. There shall be a determination, made by a youth services agency designated by state law and/or regulations, at Title 9, Chapter 28 of the Arkansas Code to make such a determination, that the youth continues to be either at risk of delinquency or is delinquent and is in need of those services specified at Title 9, Chapter 28 of the Arkansas Code. The Division of Medical Services, as the entity authorized to determine medical necessity, reserves the right to request additional information to determine medieal necessity.

STATE

Arkansas

DATETIECC

08-06-98

DATE APPV

05-14-01

DATE EFF

10-01-98

HCFA 17g

AR-98-12

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

COVERED SERVICES

(a) Social assessment,

(b) Psychological evaluation,

(d) Consultation with the referring agency, and

(c) A medical evaluation, if the assessment indicates a physical association with the cmotional and/or behavioral problem(s).

STATE Arkansas

DATE RECO

08-06-98

DATE APPVS

05-14-01

DATE EFF

10-01-98

HCFA 17g AR-98-12

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

2. Therapy* - This non-residential service provides for a therapeutic relationship between the client and a "qualified therapist" for the purpose of accomplishing changes that are identified as goals in the case plan through the use of various counseling techniques. Services to specific individuals include:

(a) Individual therapy,*

(b) Group therapy,*

(d) Consultation with the referral source.

(b) Interventions to address the youth's emotional and behavioral problems.

The extent and depth of services provided to a youth in the Emergency Shelter program depends upon the individual needs of the youth and the referral source.

* Effective April 1, 2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.

SUPERSEDES: TN- 98-12

STATE Arkansas

DATE RECU

12-10-01

DATE APPV'D

12-21-01

DATE EFF

04-01-02

HCFA 179

AR-01-35

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

SUPERSEDES. TN- 98-12

STATE Arkansas

DATE REC'D 12-10-01

DATE APPVU

12-21-01

DATE EFS

04-01-02

HCFA 179

AR-01-35

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

PROVIDER QUALIFICATION

Rehabilitative services for youth will be provided only through qualified providers and provider agencies. Qualified rehabilitative services for youth provider agencies must meet the following criteria. Care is provided by qualified therapists, other qualified professionals and staff, qualified by experience and/or training, of certified rehabilitative services providers for youth. Rehabilitative services providers for youth must:

1. Be certified by the State Youth Services Agency as having programs and professional staff capable of delivering the rehabilitative services offered under the Plan,

3. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population,

4. Have a minimum of one year's experience in providing rehabilitative services for youth,

5. Have an administrative capacity to ensure quality of services in accordance with State and Federal requirements,

6. Have a financial management capacity and system that provides documentation of services and costs in conformity with generally accepted accounting principles,

7. Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and

STATE Arkansas

DATE REC'D

08-06-98

DATE APOVO 05-14-01

DATE EFF

10-01-98

HCF/ 173

AR-98 -12

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

SERVICE SETTINGS

1. Non-residential services provided to youth who reside in a family home setting will be provided either in the youth's home or in the customary place of business of a qualified provider.

2. Residential services provided to youth who reside outside of a family home will be provided in an appropriately state licensed and/or certified setting including:

3. Services shall not be reimbursed when provided in the following settings:

(a) Nursing facilities,

(b) Intermediate care facilities for the mentally retarded, and

STATE Arkansas

DATE RECO

08-06-48

DATE APAYS 05-14-01

DATE OFF

10-01-98

HCFA 179 AR-48-12

SUPERSEDES: NONE . MEIN DAGE

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 1998

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

20. Rehabilitative Services to Youth (Continued)

FREEDOM OF CHOICE

The State assures that the provision of rehabilitative services for youth will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act.

1. Eligible recipients will have free choice of any the qualified providers of rehabilitative services for youth, and

2. Eligible recipients will have free choice of the providers of other medical care as covered elsewhere under the Plan.

COMPARABILITY OF SERVICES

The State assures that the provision of rehabilitative services for youth will not limit an individual's access to medically necessary services in violation of section 1902(a)(10) of the Act.

1. Rehabilitative services for youth will be made available to all children for whom this service is determined to be medically necessary, and

2. All medically necessary health care services described in section 1905(a) will be provided to all EPSDT eligible recipients.

STATE Arkansas

DATE REST

08-06-98

DATE ARVI

05-14-01

DATE EFF

10-01-98

HCFA 179

AR-98-12

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

21. Other Licensed Practitioners

1. Licensed Certified Social Worker (LCSW)

a. Services are limited to Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT) Program.

c. A referral must be made by a Medicaid enrolled physician documenting services are medically necessary. Covered outpatient LCSW services are:

1. Diagnosis

2. Interpretation of Diagnosis

3. Crisis Management Visit

4. Individual Outpatient - Therapy Session*

5. Marital/Family Therapy*

6. Individual Outpatient - Collateral Services*

7. Group Outpatient - Group Therapy*

2. Licensed Professional Counselors (LPC)

a. Services are limited to Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT) Program.

c. A referral must be made by a Medicaid enrolled physician documenting medical necessity. Covered outpatient LPC services are:

Diagnosis 2. Interpretation of Diagnosis

STATE Arkansas

Crisis Management Visit 4. Individual Outpatient - Therapy Session!

DATE REC'D 12-10-61

DATE APPV D 12-21-01

Marital/Family Therapy*

EFF 04-01-62

Individual Outpatient - Collateral ServiceDATE
Group Outpatient - Group Therapy*

HCFA 179 ArL-01-35

Effective April 1, 2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.

SUPERSEDES: TN- 01-17

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

March 1, 2014

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

21. Other Licensed Practitioners (Continued)

3. Licensed Marriage and Family Therapist (LMFT)

a. Services are limited to Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT) Program.

c. A referral must be made by a Medicaid enrolled physician documenting services are medically necessary. Covered outpatient LMFT services are:

1. Diagnosis

2. Interpretation of Diagnosis

3. Crisis Management Visit

4. Individual Outpatient - Therapy Session*

5. Marital/Family Therapy*

6. Individual Outpatient - Collateral Services*

7. Group Outpatient - Group Therapy*

* Effective April 1, 2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

February 1, 2002

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

23. Developmental Rehabilitation Services

5

ArkanJAS

12-4-01

02-11-02

02-01-02 AR 01-33

a. The assessment of motor, language, adaptive and/or cognitive functioning by standardized developmental instruments such as Bayley Scales of Infant Development, Early Learning Accomplishment Profile, Brigance Test of Development, etc. Specific activities include the administration of a minimum of two test instruments, interpretation of test scores with informed clinical opinion, and provision of a written narrative report.

STATE

DATE REC'D

DATE APPV'O

DATE EFF HCFA 179

c. Results will be included in the development of the IFSP. Developmental testing does not include medical, speech therapy, occupational therapy, physical therapy, audiological or vision evaluations.

1) the planned interaction of personnel, materials, time and space, to provide direct, medically necessary therapeutic intervention to the child;

2) provision of information to the family therapeutic curriculum planning;

3) provision of information to the family related to establishing the skill level and enhancing the development of the child.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

February 1, 2002

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

23. Developmental Rehabilitation Services (continued)

2. Therapeutic Activities (continued)

d. Child progress and mastery of functional skills to reduce or overcome limitations resulting from developmental delays will be continuously monitored by the Developmental Therapist.

e. Therapeutic activities may be provided in an individual session only.

Developmental Rehabilitation Services may be provided in the recipient's home, in the community, or in a clinical setting. These services require prior authorization.

Extension of the benefit limit will be provided if medically necessary.

STATE

Arkansas

DATE REC D

12-4 -01

DATE APPV'D

02-11-02

DATE EFF

02-01-02

HCFA 179 AR 01-33

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: March 1, 2011

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services

Substance Abuse Treatment Services (SATS) are provided for eligible recipients in the Child Health Services (EPSDT) Program. Services must be medically necessary and require prior authorization.

The SATS program covers the following services:

A. Addiction Assessment

B. Treatment Planning

C. Care Coordination

D. Multi-person (family) Group Counseling

E. Individual Counseling

F. Group Counseling

G. Marital/Family Counseling

H. Medication Management

SATS Qualified Provider Requirements

SATS providers must hold certification from the Division of Behavioral Health Services (DBHS) as a Substance Abuse Treatment Services provider in order to enroll as a SATS Medicaid provider.

The following requirements must be met for DBHS/OADAP certification:

A. Providers must be licensed by Division of Behavioral Health Services, Office of Alcohol and Drug Abuse Prevention (OADAP).

B. Providers must submit a written request from the organization's Chief Executive Officer (CEO) to DBHS for certification by DBHS as a SATS Provider.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: March 1, 2011

MEDICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (continued)

F. Provisional, Conditional, Preliminary, Pending, Expedited or Deferred Accreditations are not acceptable.

J. Providers must adhere to evidence-based practices as approved by DBHS for specific populations and services provided.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

24. Substance Abuse Treatment Services (42 CFR 440.130(d)) (Continued)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

January 1, 2025

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

25. Applied Behavioral Analysis (ABA) Therapy

(1) Applied Behavior Analysis (ABA) therapy is only one component of services to treat Autism Spectrum Disorder (ASD). ABA therapy services are provided in accordance with 42 CFR 440.130(c).

(2) ABA therapy services must be prescribed by the beneficiary's Arkansas Medicaid assigned primary care provider (PCP);

(3) ABA therapy services must be performed by a:

a. Board-certified behavior analyst (BCBA) who must have board-certified behavior analyst (or more advanced) certification in good-standing from the Behavior Analyst Certification Board;

b. Board-certified assistant behavior analyst (BCaBA) who must have board-certified assistant behavior analyst certification in good-standing from the Behavior Analyst Certification Board; or

c. Registered behavior technician (RBT) who must have registered behavior technician certification in good-standing from the Behavior Analyst Certification Board.

Approval: 11/07/2024

Effective Date : 01-01-25

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

ATTACHMENT 3.1-B Page 2xx.5

January 1, 2025

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found. (Continued)

25. Applied Behavioral Analysis (ABA) Therapy (Continued)

4. ABA therapy services include the following components:

a. Behavior identification assessment services, which include the following components:

i. Performing required comprehensive evaluations; and

ii. Developing the initial individualized treatment plan (ITP);

b. ABA therapy treatment services, which includes delivering ABA therapy treatment services directly to the beneficiary in accordance with the beneficiary's ITP;

c. Adaptive behavior treatment with protocol modification services, which includes the following components:

i. Actively training or assisting a BCaBA or RBT with the delivery of services to a beneficiary during an ABA therapy treatment session;

ii. Conducting clinical observation of and data collection on the beneficiary's progress towards ITP goals and objectives during an ABA therapy treatment session; and

iii. Adjusting and updating the ITP as required;

d. Family adaptive behavior treatment services, which are meetings between the beneficiary's parent(s)/guardian(s) or other appropriate caregiver and the supervising BCBA, where the supervising BCBA:

i. Discusses the beneficiary's progress;

ii. Provides any necessary technical or instructional assistance to the parent/guardian in connection with service delivery;

iii. Answers any parent/guardian or beneficiary questions and concerns; and

iv. Discusses any necessary changes to the beneficiary's individualized treatment plan.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

October 1, 2023

MEDICALLY NEEDY

4.c. Family Planning Services

(1) Comprehensive family planning services are limited to an original examination and up to three (3) follow-up visits annually. This limit is based on the state fiscal year (July 1 through June 30).

4.d. (1) Face-to-Face Tobacco Cessation Counseling Services provided (by):

[X] (i) By or under supervision of a physician; ☒

[X] (ii) By any other health care professional who is legally authorized to furnish such services under ☒

State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; * or

*Describe if there are any limits on who can provide these counseling services

Arkansas Medicaid does not limit who can provide these counseling services at this time so long as they meet (ii) and (iii).

** Any benefit package that consists of less than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12-month period (eight (8) per year) should be explained below.

(2) Face-to-Face Tobacco Cessation Counseling Services Benefit Package for Pregnant Women

Provided: ☒ ] No limitations ☐ With limitations*

*Any benefit package that consists of less than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12-month period (eight (8) per year) should be explained below.

4.e. Prescription drugs for treatment of opioid use disorder

a. Preferred prescription drugs (preferred on the PDL) used for treatment of opioid or alcohol use disorder require no prior authorization and do not count against the monthly prescription limits when prescribed as part of a Medication Assisted Treatment plan.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

July 1, 2022

MEDICALLY NEEDY

5. a. Physicians' Services

For clients twenty-one (21) years of age or older, services provided in a physician's office, a patient's home, or nursing home or elsewhere are limited to sixteen (16) visits per state fiscal year (July 1 through June 30).

The benefit limit will be in conjunction with the benefit limit established for advance practice registered nurse services, rural health clinic, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, and federally qualified health center, or a combination of the seven.

For services beyond the established visit limit, extensions will be available if medically necessary. Clients in the Child Health Services (EPSDT) Program are not benefit limited.

(1) The following diagnoses are considered categorically medically necessary and are exempt from benefit extension requirements: Malignant neoplasm; HIV infection and renal failure.

(2) Physicians' visits for pregnancy in the outpatient hospital are exempt from benefit extension requirements.

(3) Each attending physician or dentist is limited to billing one day of care for inpatient hospital covered days regardless of the number of hospital visits rendered.

(4) Surgical procedures which are generally considered to be elective require prior authorization from the Utilization Review Section.

(5) Desensitization injections - Refer to Attachment 3.1-A, Item 4.b. (12).

(6) Organ transplants are covered as described in Attachment 3.1-E.

(7) Consultations, including interactive consultations (telemedicine), are limited to two (2) per recipient per year in a physician's office, advanced practice registered nurse's office, patient's home, hospital, or nursing home. This yearly limit is based on the State Fiscal Year (July 1 through June 30). This limit is in addition to the yearly limit described in Item 5.(1). Extensions of the benefit limit will be available if medically necessary.

(8) Abortions are covered when the life of the mother would be endangered if the fetus were carried to term or for victims of rape or incest. The circumstances must be certified in writing by the woman's attending physician. Prior authorization is required.

5. b. Medical and surgical services furnished by a dentist (in accordance with Section 1905 (a)(5)(B) of the Act).

Medical services furnished by a dentist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or older.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: August 1, 2008

5. b. Medical and surgical services furnished by a dentist (in accordance with Section 1905 (a)(5)(B) of the Act). (continued)

The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, rural health clinic services, office medical services furnished by an optometrist, certified nurse midwife services and services provided by an advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the 12 visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

Surgical services furnished by a dentist are not benefit limited.

SUPERSEDES IN 04-12

HCFA 179

DATE EFF

DATE APPV'D DATE REC "

STATE

08-18

8/1/08

12/19/08

9/30/08

Arkansas

Revision:

HCFA-PH-86-20

( BERC)

ATTACHMENT 3.1-B

SEPTEMBER 1986

Revised:

July 1, 1991

State/Territory:

ARKANSAS

AMOUNT. DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP (S) : ALL

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law,

a. Podiatrists' Services

☒

Provided:

No limitations

☒

With limitations*

b. Optometrists' Services

1X1

☒ With limitations* ☒ Provided: 17 No limitations 1X

c. Chiropractors' Services

☒

Provided:

No limitations

☒

With limitations*

d. Other Practitioners' Services

☒ Provided: No limitations ☒ With limitations*

7 . Home Health Services

SOSCEDINHO

USE: 6 ANNI

86.15

Intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area. 1X1 ☒ Provided:

No limitations ☒ 1X1 With limitations* Home health aide services provided by a home heaith agency. ☒ Provided: No limitations ☒ With limitations*

Medical supplies. equipment, and appliances suitable for use in the home.

☒ 1X1

Provided:

No limitations ☒ With limitations*

d. Physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

☒ Provided: 11 No limitations 1X1 ☒ With limitations*

*Description provided on attachment.

TH No.

9728

Superned

TU No. 41-23

Approval Date

1/19/91

Effective Date

7/1/91

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 27, 2006

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law.

a. Podiatrists' Services

b. Optometrists' Services

(1) One eye exam every twelve (12) months for eligible beneficiaries 21 years of age and older.

SUPERSEDES: TN- 02-02

STATE Arkansas

DATE REC'D 9-21-06

DATE APPV'D 2-7-07

DATE EFF

9-27-06

HCFA 179

06-14

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY July 1, 2022

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. (Continued)

b. Optometrists' Services (Continued)

(2) One eye exam every twelve (12) months for eligible clients under twenty-one (21) years of age in the Child Health Services (EPSDT) Program. Extensions of the benefit limit will be available if medically necessary for clients in the Child Health Services (EPSDT) Program.

(3) Office medical services provided by an optometrist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, federally qualified health center, certified nurse midwife, and services provided by an advanced practice registered nurse, or a combination of the seven. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the twelve (12) sixteen (16) visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

c. Chiropractors' Services

(1) Services are limited to licensed chiropractors meeting minimum standards promulgated by the Secretary of HHS under Title XVIII.

(2) Services are limited to treatment by means of manual manipulation of the spine which the chiropractor is legally authorized by the State to perform.

(3) Effective for dates of service on or after July 1, 1996, chiropractic services will be limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for eligible Medicaid recipients age 21 and older. Services provided to recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

(4) Effective for dates of service on or after January 1, 2018, chiropractic services do not require a referral by the beneficiary's primary care physician (PCP).

d. Advanced Practice Registered Nurses

The benefit limit will be in conjunction with the benefit limit established for physicians' services, rural health clinic, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services, and federally qualified health center or a combination of the seven. For services beyond the established limit, extensions will be available if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the limit. Clients in the Child Health Services (EPSDT) Program are not benefit limited.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-8 Page 3c

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: July 1, 1991

MEDICALLY NEEDY

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice and defined by State law. (Continued)

6.d. Other Practitioners' Services

(1) Hearing Aid Dealers

Refer to Attachment 3.1-B, Item 4.b.(8).

(2) Audiologisis

Refer to Attachment 3.1-8, Item 4.b. (9).

(3) Optical Labs

Provides eyeglasses and eyeglass repair to eligible recipients.

(4) Nurse Anesthetists

Services limited to licensed nurse anesthetists.

ARKANSAS JUL 07 1991 NOV 19.1991 1 A

97-28 19 Daperso les: 90-48

ATTACHMENT 3.1-B Page 3d

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2024

MEDICALLY NEEDY

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. (Continued)

6.d. Other Practitioners' Services (Continued)

(5) Psychologists

Refer to Attachment 3.1-A, Item 4.b.(13).

(6) Obstetric - Gynecologic and Gerontological Nurse Practitioner

Refer to Attachment 3.1-B, Item 21 for coverage limitations.

(7) Pharmacists

(8) Licensed Registered Nurse Sexual Assault Nurse Examiner- Pediatric/Adolescent (SANE-P) certified by the International Association of Forensic Nurses working under the supervision of a licensed Advanced Practice Registered Nurse (APRN).

ATTACHMENT 3.1-B Page 3d(1)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2024

MEDICALLY NEEDY

6. Medical Care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. (Continued)

6.d. Other Practitioners' Services (Continued)

(11) Emergency Medical Technicians who are licensed to provide advanced life support and basic life support services.

Approved: 11/05/2024

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

MEDICALLY NEEDY

7.a. Home Health Services

7.c. Medical supplies, equipment, and appliances suitable for use in the home.

(3) Augmentative Communication Device

(4) Specialized Wheelchairs

STATE Arkansas DATE REC'T 04-01-02

DATE APP 04-17-02

DATE EFF 04-01-02

HCFA 179 AR 02-10

SUPERSEDES: TN- AR 01-37

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2022

MEDICALLY NEEDY

7. Home Health Services (Continued)

7.c. In accordance with 42 CFR 440.70(b)(3) medical supplies, equipment and appliances are suitable for use in any setting in which normal life activities take place. (Continued)

(5) Diapers/Underpads

Diapers/underpads are limited to $130.00 per month, per recipient. The $130.00 benefit limit is a combined limit for diapers/underpads provided through the Prosthetics Program and Home Health Program. The benefit limit may be extended with proper documentation. Only patients with a medical diagnosis other than infancy which results in incontinence of the bladder and/or bowel may receive diapers. This coverage does not apply to infants who would otherwise be in diapers regardless of their medical condition. Providers cannot bill for underpads/diapers if a recipient is under the age of three years.

(6) DME/Continuous Glucose Monitors.

A. Continuous Glucose Monitors (CGM) will be covered for Arkansas Medicaid clients.

B. A prior authorization (PA) will be required and the service will be provided for those clients who meet medical necessity.

7.d. Physical therapy, occupational therapy, or speech-language pathology and audiology services provided by a home health agency or medical rehabilitative facility.

Services under this item are limited to physical therapy when provided by a home health agency and prescribed by a physician. Effective for dates of service on or after July 1, 2017, individual and group physical therapy are limited to six (6) units per week. Effective for dates of service on or after January 1, 2021, physical therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary for eligible Medicaid recipients.

Revision:

HCFA-PH-86-20

( BERC)

ATTACHMENT 3.1-B

SEPTEMBER

1986

Page 4

Revised:

July 1, 1991

OMB No. 0938-0193

State/Territory: ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP (S) : ALL

8. Private duty nursing services.

1X1

Provided:

No limitations

1X1

With limitations*

PA*

9. Clinic services.

1X Provided: No limitations

With limitations*

10. Dental services. ☒ IXi Provided:

No limitations

With limitations* PA*

11. Physical therapy and related services.

a. Physical therapy. ☒ Provided: No limitations 1X1 With limitations*

b. Occupational therapy.

1X1 Provided: I No limitations 1X1 With limitations*

c. . Services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist. 1X1 Provided : No limitations 1X1 With limitations*

12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

a. Prescribed drugs. 1X1 Provided:

No limitations 1X1 With limitations*

b. Dentures.

Provided:

No limitations 1X With limitations* PA*

*Description provided on attachment.

CREases

JUN10, JUL - 2 91

JUL - 1 1991

91-23

DATE REC'D

MAIL APPV'D

STATE

DATE EFF HCFA 179

TN No. 91-23 Supersedes

TN No. 90-46

Approval Date

JUL - 2 1991

Effective Date

JUL - 1 1991

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised: December 1, 2020

MEDICALLY NEEDY

8. Private Duty Nursing to enhance the effectiveness of treatment for ventilator-dependent beneficiaries or non- ventilator dependent tracheotomy beneficiaries.

Enrolled providers are Private Duty Nursing Agencies licensed by the Arkansas Department of Health. Services are provided by Registered Nurses or Licensed Practical Nurses licensed by the Arkansas State Board of Nursing.

Services are covered for Medicaid-eligible beneficiaries age twenty-one (21) and over when determined medically necessary and prescribed by a physician.

Beneficiaries twenty-one (21) and over to receive PDN Nursing Services must require constant supervision, visual assessment, and monitoring of both equipment and patient. In addition, the beneficiary must be:

A. Ventilator dependent (invasive) or

B. Have a functioning trach requiring:

1. suctioning;

2. oxygen supplementation; and

3. receiving Nebulizer treatments or require Cough Assist / in-exsufflator devices.

In addition, at least one (1) from each of the following conditions must be met:

1. Medications:

· Receiving medication via gastrostomy tube (G-tube)

· Have a Peripherally Inserted Central Catheter (PICC) line or central port

2. Feeding:

· Nutrition via a permanent access such as G-tube, Low-Profile Button, or Gastrojejunostomy tube (G-J tube). Feedings are either bolus or continuous.

· Parenteral nutrition (total parenteral nutrition)

ATTACHMENT 3.1-B Page 4b

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

January 1, 2021

MEDICALLY NEEDY

9. Clinic Services

(1) Adult Developmental Day Treatment (ADDT) Services

Limited to adult day treatment centers offering the following core services to beneficiaries age eighteen (18) and above:

a. Assessment and Treatment Plan Development, two (2) units per year

b. Adult Day Habilitation Services, five (5) units per day, one (1) hour each day

c. Provision of noon meal

Optional Services available through Adult Developmental Day Treatment (ADDT) in conjunction with core services are as follows:

a. Physical therapy-Services must be prescribed by a physician and provided by or under the supervision of a qualified physical therapist.

b. Speech-language therapy-Services must be prescribed by a physician and provided by or under the supervision of a qualified Speech Pathologist.

c. Occupational therapy-Services must be prescribed by a physician and provided by or under the supervision of a qualified Occupational therapist.

Occupational, Physical, and Speech-Language Therapy Services are provided in accordance with Items 3.1-A.4b(15), 3.1-A.11, 3.1-B.4b(15), and 3.1-B(11).

Extensions of the benefit limit for all ADDT services will be provided if medically necessary.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: October 1, 2004

MEDICALLY NEEDY

9. Clinic Services (Continued)

(2) Family Planning Clinic Services

Services limited to family planning, reproductive health services and supplies.

(3) Maternity Clinic Services

Limited to antepartum and postpartum services.

(4) Ambulatory Surgical Center Services

Ambulatory surgical center facility services are limited to those services furnished in connection with or directly related to a surgical procedure covered by the Medicaid agency.

(5) End-Stage Renal Disease (ESRD) Facility Services

Covered services include:

a) Outpatient hemodialysis and peritoneal dialysis treatment in a Title XVIII certified ESRD facility.

b) Training for individuals who have been selected by their physician to participate in the peritoneal self-dialysis program.

Beneficiaries aged 21 and older are limited to 3 hemodialysis treatments per week. Beneficiaries under the age of 21 in the Child Health Services (ESPDT) Program are not benefit limited.

STATE Arkansas

DATE RECT 7-13-04

CATE APFVU 9-23-04

DATE EFF 10-1-04

HCFA 179 04-11

SUPERSEDED J - 91-28

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: September 1, 2010

MEDICALLY NEEDY

10. Dental Services

There is an annual benefit limit of $500 for dental services for adults. Extractions and fees paid to the dental lab for the manufacture of dentures are excluded from the annual limit.

· Medicaid eligible beneficiaries age 21 and over and

· Medicaid eligible beneficiaries under 21 whose eligibility is based on a "pregnant woman aid category" AND whose Medicaid ID number ends in the 100 series (100 through 199).

Refer to Attachment 3.1-B, Item 4.b. (16) for information regarding dental services for EPSDT eligible children under age 21.

ATTACHMENT 3.1-B

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: January 1, 2021

MEDICALLY NEEDY

Audiology services and qualified Audiologists meet the requirements set forth in 42 CFR 440.110.

A. Occupational, Physical and Speech-Language Therapy

1. Refer to Attachment 3.1-A, Item 4.b. (15) for therapy services for recipients under age 21.

2. For recipients over age 21, effective for dates of services on or after July 1, 2017, individual and group therapy are limited to six (6) units per week per discipline. For recipients over age 21, speech-language therapy evaluations are limited to four (4) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary.

3 For recipients over age 21, effective for dates on or after January 1, 2021, physical therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). For recipients over age 21, effective for dates on or after January 1, 2021, Occupational therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30).

A. Speech-Language Therapy

Speech Generating Device (SGD) Evaluation - Effective for dates of service on or after September 1, 1999, Speech Generating Device (SGD) evaluation is covered for eligible Medicaid recipients of all ages. One SGD evaluation may be performed every three (3) years based on medical necessity. The benefit limit may be extended for individuals under age 21.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-B Page 4f

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

December 1, 1991

(RESERVED)

Aupersiles-Mone-New Page

arkansas STATE

DEG 3 0 1991

DEC 14 1992

A DECU 1 1991 91-19

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

Revised:

October 1, 2023

MEDICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist

a. Prescribed Drugs

(1) Each recipient age twenty-one (21) or older may have up to six (6) prescriptions each month under the program. Family Planning, tobacco cessation, prescription drugs for opioid or alcohol use disorder when part of a Medication Assisted Treatment plan, EPSDT, high blood pressure, hypercholesterolemia, blood modifiers, diabetes and respiratory illness inhaler prescriptions do not count against the prescription limit.

(2) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

The following excluded drugs, set forth on the Arkansas Medicaid Pharmacy Vendor's Website, are covered:

a. select agents when used for weight gain:

b. select agents when used for the symptomatic relief of cough and colds:

c. select prescription vitamins and mineral products, except prenatal vitamins and fluoride:

d. select nonprescription drugs:

(4) The State will reimburse only for the drugs of pharmaceutical manufacturers who have entered into and have in effect a rebate agreement in compliance with Section 1927 of the Social Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3), or 1927(d) apply. The State permits coverage of participating manufacturers' drugs, even though it may be using a formulary or other restrictions. Utilization controls will include prior authorization and may include drug utilization reviews. Any prior authorization program instituted after July 1, 1991, will provide for a 24-hour turnaround from receipt of the request for prior authorization. The prior authorization program also provides for at least a 72-hour supply of drugs in emergency situations.

TN: AR-23-0017

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: May 1, 2022

MEDICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

a. Prescribed Drugs (continued)

All drugs covered by the program, irrespective of a supplemental rebate agreement, will comply with the provisions of the national drug rebate agreement.

The supplemental rebate program does not establish a drug formulary within the meaning of 1927(d)(4) of the Social Security Act.

Effective May 1, 2022, CMS has authorized the state of Arkansas to enter into value/outcomes-based contracts with manufacturers on a voluntary basis. The conditions of the value/outcomes-based contract would be agreed upon by both the state and manufacturer.

The unit rebate amount is confidential and cannot be disclosed for purposes other than rebate invoicing and verification, in accordance with Section 1927(b)(3)(D) of the Social Security Act.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 30, 2011

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

a. Prescribed Drugs (continued)

Prior authorization will be established for certain drug classes, particular drugs or medically accepted indication for uses and doses.

The state will appoint a Pharmaceutical and Therapeutic Committee or utilize the drug utilization review committee in accordance with Federal law.

The Arkansas Medicaid Generic Upper Limit List is comprised of State generic upper limits on specific multisource drug products and CMS identified generic upper limits on multisource drug products.

b. Dentures

Refer to Attachment 3.1-B Item 4.b(7) for coverage of dentures for Child Health Services (EPSDT) recipients.

Dentures are excluded from the annual limit but are limited to one set per lifetime.

Revision: HCFA - Region VI November 1990 REVISED: December 1, 1991

State/Territory: ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ALL

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

c. Prosthetics devices. ☒ Provided: ☐ No limitations ☒ With limitations* PA*

d. Eyeglasses. ☒ Provided: ☐ No limitations ☒ With limitations*

PA*

13. Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in the plan.

a. Diagnostic services. ☐ Provided: ☐ No limitations ☐ With limitations*

b. Screening services.

☐

Provided:

☐

No limitations

☐

With limitations*

c. Preventive services. ☐ Provided: ☐ No limitations ☐ With limitations*

d. Rehabilitative services. ☒ Provided: ☐ No limitations ☒ With limitations*

14. Services for individuals age 65 or older in institutions for mental diseases.

a. Inpatient Hospital services. ☐ Provided: ☐ No limitations ☐ With limitations*

b. Nursing facility services. ☐ Provided: ☐ No limitations ☐ With limitations*

*Description provided on attachment.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS

ATTACHMENT 3.1-B

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

January 1, 1993

MEDICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

c. Prosthetic Devices

(1) Eye Prostheses - Refer to Attachment 3.1-B, Item 4.b. (11).

(2) Hearing Aids, Accessories and Repairs - Refer to Attachment 3.1-B, Item 4.b. (10).

(3) Pacemakers and internal surgical prostheses when supported by invoice.

(4) a.

Parenteral hyperalimentation services, including fluids, supplies and

equipment, when provided in the recipient's home. Home does

include a nursing facility (NF) and Intermediate care facility for the

mentally retarded (ICF-MR). Service requires prior authorization.

Enteral nutrition services, including fluids, supplies and equipment,

when provided in the recipient's home. Home does not Include a

nursing facility (NF) or Intermediate care facility for the mentally

retarded (ICF-MR) because this service is included and reimbursed

as an NF and ICF-MR benefit as described in Attachment 3.1.B, Item A.a .. Service requires prior authorization.

Arkansas

DEC 2 8 1992 JAN 2 1 1993 | A ☒

JAN 0 1 1993

92-42

Supersales: TN 91-28

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised:

April 1, 2002

MEDICALLY NEEDY

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

c. Prosthetic Devices (Continued)

(5) Orthotic Appliances

Services for recipients under age 21 are not benefit limited.

(6) Prosthetic Devices

Services for recipients under age 21 are not benefit limited.

STATE Arkansas

DATE REC'D 03-18-02

DATE APPV'D 04-15-02

DATE EFF 04-01-02

HCFA 179 AB 02-09

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 27, 2006

12. Prescribed drugs, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist (Continued)

d. Eyeglasses

For the provision of glasses and/or contact lens for eligible beneficiaries, the following limits are imposed:

(3) Contact lenses are covered for beneficiaries of all ages if either of the following conditions are exhibited by the patient:

a. Medical necessity

b. Cataract patients

Prior authorization is required by the Medical Assistance Section. Lens replacement for all beneficiaries is allowed as medically necessary.

STATE Arkansas

DATE REC'D 9-21-06

DATE APPV'O

2-7-07

DATE EFF

9-27-06

HCFA 179

06-14

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: March 1, 2026

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

a. Diagnostic services - Not Provided.

b. Screening services - Not Provided.

c. Preventive services - Provided, with limitation

Vaccines:

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-B Page 5d1A March 1, 2026

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

c. Preventive Services- Provided with Limitation (continued)

Certified Community-based Doulas:

Certified community-based doulas shall provide only the following services:

1. Childbirth education;

2. Assistance with navigating the healthcare system;

3. Client advocacy before, during, and after the birth of a child;

4. Connection with community resources; and

5. Continuous emotional and physical support throughout labor and birth and intermittently during the prenatal and postpartum periods.

Services shall include support during a hospital delivery and during the prenatal and postpartum periods as defined through rules established by the Arkansas Department of Human Services.

To be eligible to provide services, Doulas must be:

(1) Certified by the Department of Health as provided in accordance with state law;

(2) At least eighteen (18) years of age and have an NPI number.

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-B Page 5d1C March 1, 2026

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

c. Preventive Services-Provided with Limitation (continued)

Breastfeeding and Lactation Consultants:

To be eligible to provide services, Breastfeeding and Lactation Consultants must:

· Be at least eighteen (18) years of age and have an NPI number and

· Have one of the following certifications:

1. An International Board-Certified Lactation Consultant; or

2. A Certified Lactation Counselor;

· Certified Lactation Counselors must be certified by the (1) International Breastfeeding Institute or (2) Academy of Lactation Policy and Practice.

" Certified Lactation Counselors are required to be supervised by a Medicaid enrolled healthcare provider to receive reimbursement. Supervision is defined as being employed by one of the following:

A. An agency led by an International Board-Certified Lactation Consultant;

B. A physician, advanced practice nurse, or physician assistant

C. A local health unit or

D. A hospital

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED

ATTACHMENT 3.1-B Page 5d1G March 1, 2026

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services

1. Rehabilitative Services for Persons with Mental Illness (RSPMI)

A. Scope

DMS has set forth in policy the settings in which each individual service may be provided. Each service shown below includes the place of service allowable for that procedure.

Services:

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 1, 2012

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Setting information could be summarized in the description if the State would like to include this information.

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Psychological Evaluation

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

Revised: April 1, 2012

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

An APN performing the Psychiatric Diagnostic Assessment MUST meet the following:

1. Licensed by the Arkansas State Board of Nursing

2. Practicing with licensure through the American Nurses Credentialing Center

4. Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act

5. Practicing within an Advanced Practice Nurse's experience and competency level

· SERVICE: Master Treatment Plan

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Periodic Review of Master Treatment Plan

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

services. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Interpretation of Diagnosis

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Individual Psychotherapy

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

The service may only be provided by a mental health professional practicing within the scope of their licensure.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

These services must include constant staff supervision of beneficiaries and physician oversight.

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Crisis Intervention

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Physical Examination - Psychiatrist or Physician Physical Examination - Psychiatric Mental Health Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse Practitioner

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

DEFINITION: A general multisystem examination based on age and risk factors to determine the state of health of an enrolled RSPMI beneficiary.

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Group Outpatient - Pharmacologic Management by a Physician

DEFINITION: Therapeutic intervention provided to a group of beneficiaries by a licensed physician involving evaluation and maintenance of the Medicaid-eligible beneficiary on a medication regimen with simultaneous supportive psychotherapy in a group setting. This includes evaluating medication prescription, administration, monitoring, and supervision; and informing beneficiaries regarding medication(s) and its potential effects and side effects. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Collateral Intervention, Mental Health Paraprofessional DEFINITION: A face-to-face contact by a mental health paraprofessional with caregivers, family members, other community-based service providers or other Participants on behalf of and with the expressed written consent of an identified beneficiary in order to obtain or share relevant information

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

necessary to the enrolled beneficiary's assessment, master treatment plan, and/or rehabilitation. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. The identified beneficiary does not have to be present for this service.

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Crisis Stabilization Intervention, Mental Health Professional

Please refer to Provider Qualifications on page 5d18.

· SERVICE: Crisis Stabilization Intervention, Mental Health Paraprofessional

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

Please refer to Provider Qualifications on page 5d18.

Services may include:

A. Goal compliance,

B. Problem solving,

C. Patient Safety

D. Task completion

E. Pharmaceutical supervision and/or

G. Health monitoring.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

The providers are licensed mental health professionals and paraprofessionals under their supervision.

Please refer to Provider Qualifications on page 5d18.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

Revised: September 1, 2010

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

B. Provider Qualifications

Providers for each specific RSPMI service are licensed by the State and must practice within the scope of Arkansas licensure. Individuals providing RSPMI services must be:

1. Licensed in the State of Arkansas as a mental health professional .;

2. Medical records librarian;

4. Licensed Psychologist or Licensed Psychological Examiner

5. Licensed Physician or

6. Certified Mental Health Paraprofessional, under the direct supervision of a Licensed Mental Health Professional

Qualified professionals must be present to furnish all medically necessary RSPMI services, including all services in each patient's care plan

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

1. Rehabilitative Services for Persons with Mental Illness (RSPMI)(continued)

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

October 1, 2012

MEDICALLY NEEDY

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (Continued)

2. Rehabilitative Services for Persons with Physical Disabilities (RSPD)

a. . Extended Rehabilitative Hospital Services

The following services are included in the global coverage of an Extended Rehabilitative Hospital:

1) Restorative Therapies

2) Behavioral Rehabilitation

3) Life Skills Training

4) Individual and Group Counseling

5) Assessment Services

6) Nursing Care

Service delivery is delivery is the same as inpatient hospital services described in Attachment 3.1-A, Page 1a, Item 1, minus the room and board component.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)

A. Scope

DMS has set forth in policy the settings in which each individual service may be provided. Each service shown below includes the place of service allowable for that procedure.

B. Services

i .: Individual Behavioral Health Counseling*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

B. Services

ii. Group Behavioral Health Counseling*

DEFINITION: Group Behavioral Health Counseling, including tobacco cessation, is a face-to-face treatment provided to a group of beneficiaries. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support his/her rehabilitation effort, and to minimize relapse. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

iii. Marital/Family Behavioral Health Counseling with Beneficiary Present (continued)*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

iv. Marital/Family Behavioral Health Counseling without Beneficiary Present*

DEFINITION: Marital/Family Behavioral Health Counseling without Beneficiary Present, including tobacco cessation, is a face-to-face treatment provided to one or more family members outside the presence of a beneficiary for the benefit of the beneficiary. Services must be congruent with the age and abilities of the beneficiary or family member(s), client-centered and strength- based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

v. Group Psychoeducation*

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

v. Group Psychoeducation (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children. Dyadic treatment must be prior authorized.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the Provider must have Arkansas State Infant Mental Health Certification.

vi. Multi-Family Behavioral Health Counseling*

DEFINITION: Multi-Family Behavioral Health Counseling, including tobacco cessation, is a group therapeutic intervention using face-to-face verbal interaction between two (2) to a maximum of nine (9) beneficiaries and their family members or significant others. Services are a more cost-effective alternative to Family Behavioral Health Counseling, designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services may pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

vii. Mental Health Diagnosis*

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

vii. Mental Health Diagnosis (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

iii. Interpretation of Diagnosis*

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

viii. Interpretation of Diagnosis (continued)*

-Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; and For Beneficiaries Under the Age of 4 the provider must have Arkansas State Infant Mental Health Certification.

ix. Substance Abuse Assessment*

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician;

* All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS) (continued)

x. Psychological Evaluation*

Allowable Performing Provider - Licensed Psychologist, Licensed Psychological Examiner and a Licensed Psychological Examiner - Independent

xi: Pharmacologic Management*

Allowable Performing Provider - Advanced Practice Nurse or a Physician

xii: Psychiatric Assessment*

Allowable Performing Provider - Advanced Practice Nurse or a Physician

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xiii. Treatment Plan*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; and Physician

xiv. Crisis Stabilization Intervention*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Crisis Stabilization Intervention is a scheduled face-to-face treatment activities provided to a beneficiary who has recently experienced a psychiatric or behavioral crisis that are expected to further stabilize, prevent deterioration and serve as an alternative to 24-hour inpatient care. Services can include interventions, stabilization activities, coping strategies and other various activities to assist the beneficiary in crisis. The services provided are expected to reduce or eliminate the risk of harm to the person or others in order to stabilize the beneficiary. Services are to be congruent with the age, strengths, needed accommodation for any disability and cultural framework of the beneficiary and his/her family.

Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non- Independently Licensed Clinicians - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xv: Partial Hospitalization*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider - Must be certified by the Department of Human Services as a Partial Hospitalization provider.

xvi: Behavioral Assistance*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider -Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xvii. Family Support Partners*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider - Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

xviii: Peer Support*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider - Certified Peer Support Specialist; and a Certified Youth Support Specialist

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xix. Individual Pharmacologic Counseling*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider -Registered Nurse

xx: Group Pharmacologic Counseling*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider - Registered Nurse

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxi. Intensive Outpatient Substance Abuse Treatment*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider - Behavioral Health Agency that is certified by the Department of Human Services as an Intensive Outpatient Substance Abuse Treatment provider The Intensive Outpatient Substance Abuse Treatment provider shall have practitioners who are able to and appropriate to deliver Intensive Outpatient Substance Abuse Treatment.

xxii: Individual Life Skills Restoration*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

Allowable Performing Provider -Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY

July 1, 2017

13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan. (Continued)

d. Rehabilitative Services (continued)

3. Outpatient Behavioral Health Services (OBHS)(continued)

xxiii. Group Life Skills Restoration*

Eligibility for this service is determined by an Independent Assessment and must be prior authorized.

DEFINITION: Group Life Skills Restoration is a service that provides support and training for beneficiaries in a group setting of up to six (6) beneficiaries with one staff member or up to ten (10) beneficiaries with two staff members. This service includes behavioral modeling to restore a beneficiary's skills needed to support an independent lifestyle and restore a strong sense of self-worth. This service should be a strength-based, culturally appropriate process that integrates the youth into their community as they develop their recovery plan. In addition, it aims to restore the ability of youth in setting and achieving goals, and restoring independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living.