Skip to Page Content  |  Text OnlyGovernor | General Assembly | Courts | Elected Officials | State Agencies
 Photo: Featured Delaware Photo
 Phone Numbers Mobile Help Size Print Email

Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsAugust 2013

Table of Contents Previous Next

Authenticated PDF Version

The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the May 2013 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by June 12, 2013 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
42 U.S.C. §1315, Demonstration projects
Social Security Act §1115, Demonstration projects
42 CFR 431 Subpart G, Section 1115 Demonstrations
Agency Response: DMMA appreciates and will consider your recommendations. However, no changes to the waiver are needed at this time.
Generations Home Care encourages a partnership between Generations and the Delaware Department of Health and Social Services to fund a new Residential Supported Living Service, referred to as Adult Foster Care Level II. This program is not a new option for most states. Adult Foster Care Level II, in most states, is a Medicaid-funded home and community-based service for adults with physical disabilities and older adults who can no longer live alone and who otherwise would have no option but to be placed in a nursing facility for lack of alternative community options. All services are provided in a licensed residential home - a home with less than four (4) adults.
Adult Foster Care Level II is not a group home model, nor is it Assisted Living. Adult Foster Care Level II assists an adult with Activities of Daily Living (i.e. toileting, bathing, feeding, walking, grooming) and/or Instrumental Activities of Daily Living (i.e., shopping, managing medications, budgeting, preparing meals, handling transportation). In addition, the program provides coordination with social activities.
Elderly and disabled adults accepted into the program require Long Term Care support, which makes this population appropriate for the Diamond State Integrated Long Term Care Delivery System, which began April 1, 2012.The Diamond State Health Plan Plus already includes this service population: aged and/or disabled individuals over age 18 who meet Nursing Facility level of care, but who prefer to receive home and community-based services as an alternative. Program participants are maintained in the most integrated setting appropriate for their needs. Adult Foster Care Level II affords choice in remaining in an alternative residential setting versus entering or remaining in an institution. Plus, it is consistent with the demonstration waiver’s objective of controlling expenditures while honoring the preferences of individuals who want to remain in a homelike setting and out of more costly and restrictive institutional settings.
Adult Foster Care Level II services are provided under the direction of a licensed Home Health Agency and supervised by a Registered Nurse and Masters prepared staff with degrees in social work, rehabilitation, psychology or a related field. Further, all Level II sponsors and resident managers have high school diplomas and receive specialized training to meet the needs of the at-risk adult. To assure safety and quality, this program can and should be licensed by DHSS. The process exists today to make this happen and should be included in this application.
Generations Home Care avidly agrees with DHSS, the provider community, and at -risk individuals, and their families, that it is critical to Delaware to continue the successful implementation of programs and services that rebalance Long Term Care resources. The Adult Foster Care Level II program respects individual choice by offering quality, cost-effective, humane, non-institutional alternatives. Would any one of us want anything less for our loved ones and for ourselves?
Adult Foster Care or rest residential homes with fewer than four unrelated individuals should be a community based option. According to the Kaiser Family Foundation, individuals in the Money Follows the Person Program most often transitioned to an apartment setting; Delaware has a shortage of housing settings appropriate for this population. AFC Tier II offers an additional housing setting with support services.
Housing remains the biggest challenge facing states in the year ahead. States have repeatedly cited the lack of safe affordable and accessible housing as the biggest barrier to MFP transitions since the demonstration program began in 2008 (The Kaiser Commission on Medicaid and the Uninsured).
(2) Transparency regarding comments made during the public comment period and how these comments were addressed by the State. How were public comments considered in the Waiver Demonstration extension? Will the state ask for an amendment to the demonstration, etc.?
(7) Access to the State’s summary of types of grievances and appeals, trends discovered and actions taken or to be taken.
Agency Response: Thank you for your comments and support. DMMA concurs with your support of diverse long term service options and the critical role of safe, affordable, and accessible housing. In response to your specific question regarding compliance with federal regulations, DMMA has adhered to the federal requirements for transparency by publishing the renewal request for public comment, holding public hearings and, publishing the comments received and the agency’s response on the DMMA website at
First, the Public Notice is inconsistent with the “Extension Request”. The Notice [16 DE Reg. 1140 (May 1, 2013)] recites that the extension is sought “for an additional three years”. In contrast, the Extension Request is for five years. At pp. 4 and 61.
Agency Response: Thank you for pointing out the discrepancy. The Extension Request is correct. DMMA is requesting an extension for five (5) years.
Second, the Division of Prevention and Behavioral Health Services (DPBHS), formerly the Division of Child Mental Health Services, was identified as a distinct MCO under the original DSHP. See attachments. If it still enjoys that status, its role should be described in the Extension Request. The Extension Request (p. 15) indicates that “extended mental health” benefits “are covered under the traditional Medicaid system.” To the contrary, my impression is that the DPBHS provides extended mental health benefits for children enrolled in the DSHP requiring more than a certain threshold of services.
Agency Response: DPBHS does not operate as a Managed Care Organization specified under the requirements in 42 CFR 438. DPBHS does coordinate and provide the extended mental health benefits for children enrolled in the DSHP requiring more than the identified threshold of services.
Agency Response: The waiver document has been corrected with the word “through”.
Fourth, effective July 1, 2014, DMMA “plans to terminate the state-operated primary case management entity, Diamond State Partners (DSP).” See Extension Request, p. 12. The DSHP originally had four MCOs. By 2002, it had only one MCO left. See Extension Request, pp. 22-23. Given the need for “choice”, DMMA essentially established a State MCO, Diamond State Partners (DSP). From 2007 to the present, DMMA has had two private MCOs. DMMA implies that enrollment in DSP has declined dramatically due to the attractiveness of the two private MCOs:
Section II.1: This section recites that “(t)he State wishes to have a maximum of two Contractors to provide a statewide managed care service delivery system...”. This is apart from the State-run MCO, Diamond State Partners (DSP) which DHSS notes is closed to new members. See also §II.3.3. There are multiple “concerns” with this approach.
b. Allowing only the 2 current private MCOs to implement the DSHP Plus severely limits participant freedom of choice. The original DSHP had four (4) MCOs - Amerihealth, Blue Cross, First State, and Delaware Care. This provided real competition and an incentive to offer supplemental services (e.g. eyeglasses) to attract participants. Although the current plan authorizes MCOs to offer supplemental services (§§II.7.3.1.a; 7.3.3; and 7.5, final bullet), the prospects for MCOs offering such services are marginal given the non-competitive system adopted by DHSS. The prospects for “conscious parallelism”, “price fixing”, and collusion are enhanced with only 2 MCOs. No RFP was issued to invite competitive bids to serve as an MCO. Moreover, DHSS eschews any negotiating leverage with the 2 approved MCOs which are quite aware of the burden faced by DHSS if 1 of the MCOs withdraws. The Concept Paper contains the following recitation:
The Councils strongly oppose the discontinuation of the DSP. We recommend that DMMA provide satisfaction survey results on DSP to permit comparison with satisfaction survey results from the two private MCOs described at p. 38 of the Extension Request. If satisfaction results for the DSP are high, this would provide additional support for not diminishing “choice” by terminating the DSP.
Agency Response: DMMA appreciates your comments regarding DSP. DMMA endorses freedom of choice. As the commenter points out, however, experience has shown that the small population in Delaware does not support the viability of multiple managed care organizations. We are confident that two managed care organizations effectively and efficiently serve the existing DSHP population without limiting access to services. It is no longer cost-effective to cover services through the State managed program, DSP. Please note that CMS requirement of “choice” is satisfied as long as the State contracts with two MCOs.
Agency Response: The DMMA addressed the Councils’ concerns previously and revised the case management qualifications to ensure that case managers were not treated as fungible, therefore all case managers must have knowledge or experience in:
Sixth, the planned expansion of eligibility to individuals with countable income at or below 133% of the FPL merits endorsement. See Extension Report at p. 12. However, it would also be preferable if the benefits menu could be enhanced to cover adult dental services. Such services are currently excluded. See Extension Request at p. 16. Such expansion has some legislative support. See S.B. 56, introduced on April 30, 2013.
Agency Response: Thank you for your endorsement of the expansion. We recognize the importance of dental services. However, at this time there is no funding available to expand coverage to the adult population.
Agency Response: DMMA’s decision to encourage family members to select the same MCO is based on the benefits to the family including, but not limited to: better navigation of the healthcare system and provider availability. Participants always have the option to select an alternative MCO within 90 days of enrollment.
Agency Response: We cannot respond to this comment because we do not know what revisions the commenter wants.
Agency Response: Both attachments “D” and “E” break out specifics for satisfaction levels. Additionally, the QMS provides more details concerning the MCOs’ satisfaction levels.
Agency Response: “Good Cause” exceptions are incorporated as outlined in 42 CFR 438.56.
Agency Response: DMMA appreciates the comment noting that our currently approved 1115 waiver permits the State to begin providing services to certain population groups upon enrollment in an MCO. As part of this waiver renewal, DMMA proposes to begin providing medical services to all applicable populations beginning with their month of application.
Agency Response: DMMA appreciates and has considered the recommendations expressed and thank you for your comments. However, we have not proposed any changes to the waiver as a result of this comment.
Agency Response: DMMA appreciates and has considered the recommendations expressed and thank you for your comments. However, we have not proposed any changes to the waiver as a result of this comment.
Agency Response: Thank you for your comments. DMMA continues to support efforts to move individuals from institutional settings to community based settings.
Agency Response: Thank you for your comment. DMMA appreciates the opportunity to work with you in serving the Medicaid population of Delaware.
THEREFORE, IT IS ORDERED, that the proposed regulation to renew the Diamond State Health Plan 1115 Demonstration Waiver for the period January 1, 2014 through December 31, 2018 is adopted and shall be final effective August 10, 2013.
Last Updated: December 31 1969 19:00:00.
site map   |   about this site   |    contact us   |    translate   |