Form DHS-8505 "Arkansas Money Follows the Person Informed Consent for Participation" - Arkansas

What Is Form DHS-8505?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 19, 2017;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-8505 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DHS-8505 "Arkansas Money Follows the Person Informed Consent for Participation" - Arkansas

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Arkansas Money Follows the Person
Informed Consent for Participation
Name_________________________
Social Security Number_______________
Medicaid Number____________________
The Money Follows the Person Rebalancing Demonstration (MFP) is sponsored by the
U. S. Department of Health and Human Services, Centers for Medicare and Medicaid
Services (CMS). CMS awarded an MFP grant to the Arkansas Department of Human
Services (DHS) to operate the program in Arkansas. MFP will support Arkansas in
transitioning residents from institutions and improving Arkansas’s long-term care
systems.
I understand that:
• I don’t have to participate in the MFP program.
• If I don’t participate in MFP, I can still get Medicaid home and community-based
services.
• I have rights and responsibilities, and these have been explained to me.
Benefits of MFP
I will benefit from participating in MFP by:
• Receiving extra help in moving from an institution to a home of my choice. I can
receive extra services for one year after I move from an institution as long as I still
meet the MFP eligibility rules. Extra services may include:
1. 24 Hour Help Line – A 24-Hour Help line will be established to
support individuals transitioning to the community.
2. Telemedicine - The practice of health care delivery, diagnosis,
consultation, treatment, transfer of medical data, or exchange of
medical education information by means of audio, video, or data
communications. Telemedicine is not a consultation provided by
telephone or facsimile machine.
3. Intense Transitional Coordination – Individuals transitioning from
institutions often need more community support than is offered
through traditional waiver services. Intense Transitional Management,
similar to case management, includes activities such as information
and assistance; assistance with linkage with appropriate resource(s),
including contact and follow-up with provider(s); and more frequent
follow-up with the client to ensure expectations are met regarding
outcome of action(s) taken and any need for further services.
• At the end of one year, I will still receive the Medicaid home and community-based
services I enrolled in as long as I am still eligible.
DHS-8505 Rev. 5/19/2017
Arkansas Money Follows the Person
Informed Consent for Participation
Name_________________________
Social Security Number_______________
Medicaid Number____________________
The Money Follows the Person Rebalancing Demonstration (MFP) is sponsored by the
U. S. Department of Health and Human Services, Centers for Medicare and Medicaid
Services (CMS). CMS awarded an MFP grant to the Arkansas Department of Human
Services (DHS) to operate the program in Arkansas. MFP will support Arkansas in
transitioning residents from institutions and improving Arkansas’s long-term care
systems.
I understand that:
• I don’t have to participate in the MFP program.
• If I don’t participate in MFP, I can still get Medicaid home and community-based
services.
• I have rights and responsibilities, and these have been explained to me.
Benefits of MFP
I will benefit from participating in MFP by:
• Receiving extra help in moving from an institution to a home of my choice. I can
receive extra services for one year after I move from an institution as long as I still
meet the MFP eligibility rules. Extra services may include:
1. 24 Hour Help Line – A 24-Hour Help line will be established to
support individuals transitioning to the community.
2. Telemedicine - The practice of health care delivery, diagnosis,
consultation, treatment, transfer of medical data, or exchange of
medical education information by means of audio, video, or data
communications. Telemedicine is not a consultation provided by
telephone or facsimile machine.
3. Intense Transitional Coordination – Individuals transitioning from
institutions often need more community support than is offered
through traditional waiver services. Intense Transitional Management,
similar to case management, includes activities such as information
and assistance; assistance with linkage with appropriate resource(s),
including contact and follow-up with provider(s); and more frequent
follow-up with the client to ensure expectations are met regarding
outcome of action(s) taken and any need for further services.
• At the end of one year, I will still receive the Medicaid home and community-based
services I enrolled in as long as I am still eligible.
DHS-8505 Rev. 5/19/2017
Potential Risks
• Medicaid home and community-based programs are approved by CMS. There is a
slight risk that a program may not be reapproved by CMS. This risk is low because
all these programs are in good standing and meet CMS rules.
• There is a slight risk that I may not continue to be safe in my home of choice because
of changes in my health or medical needs and/or that the cost of my care at home
increases to more than it would be in an institution. I understand that this might result
in the need to move to a more restrictive setting.
• There is a risk that I will lose eligibility for the Medicaid home and community-based
program that I enroll due to changes in my situation, such as: more income, more
assets, changes in my health, etc. I understand that the eligibility rules for Medicaid
home and community-based services are mostly the same as nursing home Medicaid.
Participation in Research
• CMS has chosen Mathematica Policy Research to evaluate MFP. Information about
you will be given to CMS and Mathematica to help them in their evaluation of MFP.
• I have read :
1) Basic goals of the research
2) The types of data that will be collected
3) How the confidentiality of the data is protected
4) The likely benefits/risks associated with the research
5) Whom to contact if I have any questions
Confidentiality
I have been informed that the information provided by DHS to CMS will be used and the
evaluation contractor is confidential and will be protected under the Health Information
Privacy and Portability Act (HIPPA).
Disenrollment
• Death
• End of individual demonstration period
• Reinstitutionalization
• Incident of an extreme nature involving violence, property destruction, arrest or other
incident determined by the review team as necessary to insure the safety of self or
others. (Upon notice of termination of participation the participant will be given
instruction on the appeal process for MFP).
• Voluntary withdrawal.
Consent
My MFP representative has explained to me my rights and responsibilities. I understand I
will be given a signed copy of this consent form to keep. By signing this Informed
Consent, I am agreeing to participate in the MFP Demo and to accept all conditions for
participation.
DHS-8505 Rev. 5/19/2017
Signature-Participant
Date Signed
Address(Street, City, State, Zip Code)
Telephone Number
(
)
-
Signature-Legal Guardian (if applicable)
Date Signed
Address (Street, City, State, Zip Code)
Telephone Number
(
)
-
Care Manager Acknowledgement
I have read the informed consent materials to the applicant, and I believe that he/she (or
the guardian, if signed) understands the materials.
Signature-Care Manager/Service
Date signed
Coordinator
Name- Agency
Telephone Number
(
)
-
OPTION TO FORMALLY DECLINE PARTICIPATION
I was offered the opportunity to participation in the MFP demo and have chosen to
decline. I understand that this will not affect my eligibility for Medicaid or home and
community-based services.
Signature- Participant
Date Signed
Address(Street, City, State, Zip Code)
Telephone Number
(
)
-
Signature- Legal Guardian (if applicable)
Date Signed
Address (Street, City, State, Zip Code)
Telephone Number
(
)
-
Complaints
I understand that if I have any complaints or concerns about my participation in the MFP
Program I can contact:
LaTonya Robinson, DHS Project Director
P.O. Box 1437, Slot S530
Little Rock, AR 72203-1437
501-320-6577
latonya.robinson@dhs.arkansas.gov
DHS-8505 Rev. 5/19/2017
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