Arkansas Medicaid Managed Care: ARHOME, PASSE, and Appeals

Arkansas Medicaid managed care operates through two programs: ARHOME, which uses Medicaid dollars to buy private Marketplace coverage for most expansion-eligible adults, and PASSE, which coordinates care for beneficiaries with serious behavioral health conditions or intellectual and developmental disabilities. The Division of Medical Services inside the Department of Human Services oversees both.¹ Which program you land in depends on your age, income, and clinical needs, and each comes with its own rules for plan selection, cost-sharing, and appeals.

ARHOME: Private Coverage Paid for by Medicaid

The Arkansas Health and Opportunity for Me program is authorized by a federal Section 1115 waiver and uses a premium assistance model.² Rather than paying providers directly, the state uses Medicaid funds to buy you coverage through a Qualified Health Plan sold on the Health Insurance Marketplace.³ You remain a Medicaid beneficiary, but your insurance card comes from either Blue Cross Blue Shield or Ambetter (Centene’s plan brand).⁴

QHPs cover the ten essential health benefit categories under the Affordable Care Act. Medicaid layers certain wraparound benefits on top through fee-for-service, including non-emergency medical transportation, and 19- and 20-year-olds also get Early and Periodic Screening, Diagnosis, and Treatment benefits as a wraparound.⁵

PASSE: Coordinated Care for Complex Needs

The Provider-Led Arkansas Shared Savings Entity program uses a different model. PASSEs are full-risk managed care organizations built for Medicaid beneficiaries with complex behavioral health or developmental disability needs, authorized under the Medicaid Provider-Led Organized Care Act.⁶ Each PASSE receives a fixed monthly payment per member and takes on responsibility for all medical, behavioral health, and specialized developmental disability services that person needs.

Care coordination is the program’s core feature. Every member is assigned a coordinator who helps build a person-centered service plan, manages referrals and prior authorizations, and keeps providers talking to one another.⁷ For someone juggling multiple specialists, therapists, and support workers, that role is often the most tangible piece of the program.

Who Belongs in Which Program

ARHOME

ARHOME enrollment is mandatory for adults aged 19 to 64 whose income is above 16 percent and below 138 percent of the federal poverty level, provided they aren’t on Medicare.⁸ If you fit that description, you get a QHP unless you qualify for an exemption.

The main exemption is “medically frail” status. If your health care needs make private QHP coverage impractical or would disrupt continuity of care, you stay in fee-for-service Medicaid.⁹ You can self-identify as medically frail during enrollment. Medically frail members receive an Alternative Benefit Plan that adds services like personal care assistance and other long-term supports not sold through QHPs.⁵

PASSE

PASSE applies to Medicaid beneficiaries of any age who need more intensive behavioral health or developmental disability services. You may qualify if you receive services through the Community and Employment Support waiver (or sit on its wait list), live in a private Intermediate Care Facility for individuals with intellectual or developmental disabilities, or have a behavioral health diagnosis requiring services beyond basic counseling and medication management.¹⁰

Eligibility is confirmed through an independent assessment that produces a tier score. Tier 2 qualifies you for intensive non-residential community-based services; Tier 3 qualifies you for the highest level of services, including around-the-clock residential support.¹¹

Some people are excluded from PASSE even with a qualifying condition: residents of a Human Development Center or a skilled nursing facility, people enrolled in the ARChoices home and community-based services waiver, and beneficiaries fully dual-eligible for both Medicare and Medicaid.

Picking a Plan or Getting Assigned One

ARHOME

Once you’re determined eligible for ARHOME, you have 42 days to choose between the available Blue Cross Blue Shield and Ambetter options. Miss that window and DHS auto-assigns you.⁵

Federal managed care rules give you a way out if you’re unhappy with the assignment. You can switch plans without a reason during the 90 days after initial enrollment or after the date the state sends you enrollment notice, whichever is later. After that window, you’re generally locked in until the next annual open enrollment. You can still request a change for cause any time — for example, if you move out of the plan’s service area, the plan won’t cover a service you need for moral or religious reasons, or you lack adequate access to covered services in the network.¹²

PASSE

You don’t pick your PASSE. DHS assigns you using an attribution formula based on your Medicaid claims history over the previous 12 months. The system looks at which specialty providers, primary care providers, and pharmacists you’ve used, then places you with the PASSE whose network best matches those relationships. The formula weights behavioral health and developmental disability specialty providers most heavily, since preserving those relationships matters most for continuity.¹³

What ARHOME Members Pay

ARHOME members in a QHP may owe small copays for services and prescriptions, but only if their income is above 20 percent of the federal poverty level. Copays are $4.70 or $9.40 depending on the service, and each quarter has a cap. Once you hit it, you owe nothing more for that three-month period.¹⁴

Some services are always copay-free: emergency care, preventive services, family planning, inpatient hospitalization, and pregnancy-related care. Some groups never owe copays either, including people below 20 percent of the federal poverty level, hospice patients, medically frail individuals, pregnant women, 19- and 20-year-olds, and American Indian or Alaska Native members.¹⁴

PASSE members have no cost-sharing at all. Medically frail members in fee-for-service Medicaid are also exempt.⁵

Fighting a Denial or a Service Cut

Managed care plans sometimes deny, reduce, or terminate services. You have the right to challenge those decisions, but the deadlines are short and one detail catches people off guard.

Grievances vs. Appeals

A grievance is for complaints about things like poor customer service, long wait times, or trouble accessing providers. You have 45 days from the event to file with your PASSE, and the plan must resolve it within 30 days and send you a written explanation.¹⁵

An appeal is what you file when the plan takes an adverse action — denying a service, reducing services you’re already getting, or refusing to pay a claim. You, a guardian, or your provider can file it. Standard appeals must be resolved within 30 calendar days. If waiting could seriously harm your health, you or your provider can request an expedited appeal, which must be resolved within 72 hours.¹⁶

The Detail Most People Miss

If the plan tells you it’s cutting or ending a service you already have, and you file your appeal before the effective date of that action, the plan generally must keep providing the service while the appeal is pending.¹⁵ Wait until after the action takes effect and you lose that protection. The clock starts the day the notice arrives.

State Fair Hearing

If the internal appeal comes back against you, the written decision must tell you how to request a state fair hearing.¹⁵ A fair hearing is an independent proceeding under the Arkansas Administrative Procedure Act, decided by a neutral hearing officer rather than the plan.

Work Requirements Coming in 2026

Starting July 1, 2026, DHS will begin a soft rollout of work and community engagement requirements for ARHOME. Healthy adult members must work, volunteer, or attend school for at least 20 hours per week, or 80 hours per month.¹⁷

Nobody loses coverage in 2026. DHS will run automated checks and send compliance notices so people can adjust. Real penalties begin January 1, 2027: non-exempt beneficiaries who don’t meet the requirement will get 30 days to demonstrate compliance before Medicaid benefits are suspended.¹⁷

Federal law defines community engagement broadly to include work, education, community service, participation in a work program, or a combination.¹⁸ The rule applies only to the adult expansion population. PASSE members, medically frail individuals, and other exempt groups aren’t subject to it. If you’re on ARHOME, watch your mail from DHS closely during the second half of 2026.

What’s Ahead for the ARHOME Waiver

The current ARHOME Section 1115 waiver expires December 31, 2026.² DHS has submitted a renewal application for a new demonstration period starting January 1, 2027. Beyond the work requirement, proposed changes include raising the minimum Medical Loss Ratio for QHP carriers from 80 to 85 percent, requiring QHPs to remit pharmacy rebates to the state, and expanding the Life360 HOME care coordination program to let Federally Qualified Health Centers and other Medicaid providers participate alongside hospitals. Voluntary success coaching, aimed at connecting members at risk of long-term poverty with employment, education, and training, is proposed to launch July 1, 2028, with no penalties for declining.¹⁹ What CMS approves, modifies, or delays will decide how ARHOME looks after 2026.

1
Arkansas Department of Human Services. Division of Medical Services
2
Medicaid.gov. Arkansas Health and Opportunity for Me (ARHOME)
3
Arkansas Department of Human Services. Arkansas Health and Opportunity for Me ARHOME Section 1115 Demonstration Application
4
Arkansas Department of Human Services. ARHOME
5
Arkansas Department of Human Services. Arkansas Health and Opportunity for Me Section 1115 Demonstration Project Application Summary
6
Justia. Arkansas Code 20-77-2701 – Title
7
Arkansas Department of Human Services. Care Coordination and Person Centered Service Plan
8
Arkansas Department of Human Services. Overview of Significant Programs for DHS Beneficiaries
9
Arkansas Department of Human Services. ARHOME Workers With Disabilities Transitional Medicaid Cost Sharing
10
Arkansas Department of Human Services. Provider-Led Arkansas Shared Savings Entity Detailed Fact Sheet
11
Arkansas Department of Human Services. ARIA Behavioral Health Tier Logic – Adults and Children
12
eCFR. 42 CFR 438.56 – Disenrollment Requirements and Limitations
13
Arkansas Department of Human Services. Provider-Led Arkansas Shared Savings Entity (PASSE) Program Medicaid Provider Manual
14
Arkansas Department of Human Services. ARHOME Cost-Sharing Information
15
Arkansas Department of Human Services. Medicaid Administrative Reconsiderations and Appeals
16
eCFR. 42 CFR 438.408 – Resolution and Notification – Grievances and Appeals
17
Arkansas Department of Human Services. DHS to Launch Soft Implementation of Work and Community Engagement Requirement Starting July 1
18
Medicaid.gov. CMCS Informational Bulletin – Section 71119 of the Working Families Tax Cut Legislation
19
Arkansas Department of Human Services. ARHOME Demonstration Project Public Notice – Waiver Renewal