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Delaware General AssemblyDelaware RegulationsAdministrative CodeTitle 16Department of Health and Social ServicesDivision of Social ServicesDelaware Social Services Manual

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This program was formerly known as the Disabled Children’s Program and is based on 42 CFR §435.225.

 

25050 PURPOSE

The Children’s Community Alternative Disability Program (CCADP) is a Delaware Medicaid option that is designed to serve children with significant disabilities. Such children would otherwise qualify to be cared for in an institutional setting. The State desires that this program serve as many children as possible at home or in non-institutional settings as long as it can be done safely, efficiently and economically. The best care for children who would be eligible for this program is with the support and direction of involved parents or guardians. This care will generally result from the active collaboration of DSS, and multidisciplinary providers, and parents or guardians.

In general, any child whose disability profile meets a designated level of care may be eligible for Medicaid without regard to parental income, resources, or other health insurance. Given the State’s commitment to promoting children’s access to basic health care, any benefit of the doubt concerning program qualification should be resolved in favor of eligibility. To the extent eligibility is jeopardized by safety concerns, DSS will act affirmatively to eliminate or reduce unsafe conditions to an acceptable level through Departmental and community resources. DSS recognizes its responsibility to make a referral to a protective agency if conditions so warrant.

 

25100 ELIGIBILITY

Medicaid eligibility is available to children who meet ALL of the following seven (7) criteria established by Federal regulation (42 CFR §435.225):

1.

The child must be 18 years of age or younger (under age 19).

2.

The child’s countable resources do not exceed the SSI limit for a single individual described in DSSM §20300.

3.

The child’s countable income does not exceed 250% of the SSI benefit level.

4.

The child’s profile is consistent with the level of care of a hospital, Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), Intermediate Care Facility for Mental Retardation (ICF/MR), or Intermediate Care Facility Institution for Mental Disease (ICF/IMD).

5.

The child must meet Supplemental Security Income (SSI) medical disability standards codified at 42 U.S.C. § 1382c(a) (presumptively met if child with chronic condition qualifies for SNF, ICF, ICF/MR, or ICF/IMD level of care).

6.

It is appropriate to provide a comparable level of care in an alternative setting (e.g. natural family home).

7.

The estimated Medicaid cost of care in the alternative setting is no higher than the estimated cost of the comparable facility-based level of care.

 

25110 Managed Care Enrollment Requirements

Individuals who are found eligible must enroll with a managed care organization. The Health Benefits Manager (enrollment broker) will be responsible for the enrollment process.

15 DE Reg. 1716 (06/01/12)

 

25150 APPROVAL DURATION AND REVIEW TIMETABLE

Approval of an initial application is generally effective for a period not to exceed one year. Subject to DSSM 14950 (6 month guaranteed eligibility) if the Division is aware of the likelihood of a material change in financial or medical status, initial approval may be for a shorter period.

Redetermination of eligibility is expected to occur on at least an annual basis and may otherwise be prompted by notice of a material change in financial or medical status. Redetermination shall include a reassessment of whether the child meets all seven eligibility criteria (DSSM 25100). If a child manifests a chronic profile, the Division may utilize abbreviated reassessment forms and rely on previous evaluations that remain clinically valid.

 

25200 CAREGIVER QUALIFICATIONS

The primary person in charge of the care of a child, usually a family member or a designated health care professional meeting the following qualifications:

The individual must be willing to accept the responsibility of the care of the child.

The individual must be trained and/or display competence in the medical skill required by the child.

 

25250 GENERAL LEVEL OF CARE FACTORS

1. The assessment of whether a child’s profile is consistent with a qualifying level of care is influenced by multiple considerations. Material criteria include the following mental, physical, familial, and environmental factors:

a. chronological and developmental age of child;

b. nature and severity of disease or medical condition(s);

c. symptomatology or functional limitations attributable to disease or medical condition (s);

d. stability of disease process or medical condition(s);

e. physical environment;

f. availability and profile of primary caregiver(s);

g. potential for harm, regression, or developmental delay in absence of services;

h. extent of assistance necessary for child to engage in activities of daily living (“ADLs”)

i. extent of monitoring or supervision necessary to minimize potential for harm due to mental or physical health risks (e.g. suicide; elopement; self injurious behaviors; seizure); and

j. extent to which professional or specialized personnel (e.g. nurse; therapist) are necessary to provide monitoring, assistance, or services.

2. Since some debilitating diseases and medical conditions (quadriplegia; profound mental retardation) are highly correlated with a qualifying level of care, the Division may adopt presumptive eligibility guidelines to expedite processing of such applications.

 

25300 SPECIFIC LEVEL OF CARE STANDARDS

 

25300.1 DEFINITION OF INSTITUTIONAL SETTING

An institutional setting is a residential placement that provides room board and health related services, which are supervised by a licensed practitioner. The setting has the necessary professional personnel, equipment and facilities to meet the health and functional needs of the child on a continuing or repetitive basis and is authorized under State law to provide such care.

 

25300.2 DEFINITION OF HOSPITAL LEVEL OF CARE

A hospital is an institutional setting that provides medical, nursing and allied health care for acute or chronic illnesses. Such a setting includes at least daily physician intervention and the availability of around the clock professional nursing care. A hospital may provide general medical care or specialized care (e.g. psychiatric or rehabilitative).

 

25300.3 DEFINITION OF SKILLED NURSING FACILITY LEVEL OF CARE

Skilled nursing facility (SNF) is an institutional setting, which provides skilled nursing or rehabilitation, services for mental or physical conditions. Such a setting includes availability of around the clock professional nursing observation, assessment or intervention.

 

25300.4 DEFINITION OF INTERMEDIATE NURSING FACILITY LEVEL OF CARE

Intermediate care nursing facility (ICF) is an institutional setting in which nursing and allied health care and support services are provided. Such services are supervised by but not necessarily given by a licensed nurse.

 

25300.5 DEFINITION OF ICF/IMD LEVEL OF CARE

An intermediate care facility for mental disease (ICF/IMD) is a residential setting which offers comprehensive clinical and support services to persons with significant behavioral health disorders. Children who qualify for an ICF/IMD level of care exhibit a severe, complex, or chronic behavioral health disorder. Such disorder must compromise age-appropriate functioning in multiple areas and require frequent or intensive medical or behavioral interventions (e.g. drug therapy; professional counseling; behavior management techniques). Subject to full consideration of factors itemized in Section DSSM 25250), the presence of the following disability-related personal characteristics supports qualifications under an ICF/IMD level of care:

a.

impaired judgment or insight

b.

disorientation to time, place, or person

c.

memory impairment

d.

perceptual or thinking disturbance

e.

lack of self-regulation or impulse control

f.

diminished capacity to focus, concentrate, or maintain attention

g.

propensity to engage in verbal or physical aggression towards others

h.

marked changes in mood or affect

i.

marked withdrawal, isolation, or depression

j.

sleep disturbance

k.

appetite disturbance with change in weight

l.

marked difficulty in maintaining interpersonal relationships

m.

propensity to elope

 

25300.6 DEFINITION OF ICF/MR LEVEL OF CARE

An intermediate care facility for the mentally retarded (ICF/MR) is a residential setting which offers comprehensive habilitative and support services to persons with mental retardation or related conditions. Children who qualify for an ICF/MR level of care exhibit significant deficits in age-appropriate functioning in multiple domains. As a consequence, they require frequent assistance or supervision to competently or safely engage in activities of daily living (ADLs). Subject to full consideration of factors itemized in Section DSSM 25200, the presence of adaptive behavior deficits in the following contexts supports qualification under an ICF/MR level of care:

 

25400 APPROPRIATENESS OF COMMUNITY-BASED SETTING

Program eligibility is contingent upon a finding that non-institutional care is appropriate and services are available (DSSM 25100). The community-based setting must meet the child’s needs safely and effectively to be appropriate. To fulfill this requirement, the Division will assess both the physical and social environment within the community–based setting. Given the State’s strong preference for non-institutional care of children, denial of eligibility based on environmental deficits is disfavored. If eligibility is jeopardized by environmental deficits, the division will affirmatively attempt to eliminate or reduce such deficits to an acceptable level through Departmental and community resources.

 

25500 DETERMINING MEDICAL PLAN OF CARE AND COSTS

During the application and redetermination process, medical and social information is gathered from several sources including the primary caregivers, primary care practitioners, specialists and other health care providers, the schools, Child Development Watch (Part C) and/or other relevant sources. A listing of the services needed or currently being provided is recorded indicating whether there are ongoing costs (such as daily home health aides or one-time costs (durable medical equipment). The cost for each are estimated as closely as possible and, to the extent possible, costs paid or defrayed by other insurance or other means of payment insurance settlement, donations, etc.) are deducted from the cost cap. Since Medicaid is generally payor of last resort [with exception of Individual with Disabilities Education Act (IDEA) services], the assessor may contact other potential payment sources to determine potential coverage especially when it appears the child might exceed the cost cap. Once the medical costs are computed the entire packet of assessment information is reviewed by the medial review team for the cost comparison and final eligibility determination.

 

25600 COST EFFECTIVENESS CALCULATION

A determination of cost effectiveness for the Children's Community Alternative Disability's Program must be made using the following procedures.

 

25625 CALCULATION

A calculation is made of the total actual or projected cost of all significant, recurring medical services (home health aides & nurses, private duty nursing, Prescribed Pediatric Extended Care, supplies, equipment and therapies).

 

25650 ANNUALIZED COSTS CALCULATION

The annualized costs of any significant recurring DME (e.g. specialized wheelchair or lift not included in facility per diem rate) is added to the calculation in DSSM 25625.

 

25675 OTHER COSTS

All other costs, such as physician services, pharmaceuticals, lab tests, x-rays, etc. are not part of medical facility costs, so will not be considered in the cost effectiveness determination except in cases where acute hospitalization is the appropriate comparable level of care.

 

25700 COST DOES NOT EXCEED COMPARABLE MEDICAL FACILITY CARE

The calculated cost in DSSM 25600 must not exceed 100% of comparable medical facility care. Comparable rates to be used are defined in the following subsections.

A. If the child is determined to meet the hospital LOC, the anticipated home services costs will be compared to the current fiscal year inpatient hospital rate of the AI DuPont Hospital for Children or alternate facility rate as determined by the Medicaid Director.

B. If a child is determined to meet the skilled LOC, the anticipated home services costs will be compared to the current averaged rate of participating Delaware nursing facilities that are caring for children under 18. A higher comparative rate based on the current averaged rate for children placed in subacute pediatric facilities may be applied for children determined "superskilled" by the DSS Medical Operation Administrator.

C. If a child is determined to meet ICF/MR/DD LOC, the anticipated home service costs will be compared to the current Stockley Center ICF/MR/DD rate or alternate facility rate as determined by the Medicaid Director.

D. If a child is determined to meet the ICF/IMD LOC, the anticipated home costs would be compared to the current Terry Center rate or alternate facility rate as determined by the Medicaid Director.

E. If a child is determined to meet an ICF LOC the anticipated home services costs will be compared to the current averaged rate of participating Delaware nursing facilities that are caring for children under 18 years of age.

 

25800 COST EFFECTIVENESS EXCEEDS COST OF INSTITUTIONAL CARE

When the cost effectiveness analysis shows that the cost of care in the home will exceed the cost of comparable institutional care, the parent or guardian will be offered a choice of the following options.

A. The use of less costly alternatives (such as privately contracting with LPNs or RNs for private duty nursing at a lower cost than can be obtained through an agency, purchasing refurbished, used equipment, etc.), or

B. The use of fewer units of service with assurances from parent/guardian that the remainder of medically necessary services will be provided by or paid for by other means, or

C. The admission to an appropriate medical facility, or

D. The withdrawal of the application for this program.

Last Updated: June 11 2015 09:17:45.
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