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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsDecember 2015

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The Department published its notice of proposed regulation changes pursuant to 29 Del.C §10115 in the September 2015 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by September 30, 2015 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
Section 1905(a)(11) of the Social Security Act, includes physical therapy and related services in the definition of medical assistance
42 CFR §440.110 defines physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders
42 CFR §447.205, Public notice of changes in statewide methods and standards for setting payment rates
In accordance with the federal public notice requirements established at Section 1902(a)(13)(A) of the Social Security Act and 42 CFR 447.205 and the state public notice requirements of Title 29, Chapter 101 of the Delaware Code, Delaware Health and Social Services (DHSS)/Division of Medicaid and Medical Assistance (DMMA) gives public notice and provides an open comment period for thirty (30) days to allow all stakeholders an opportunity to provide input to the requirements and reimbursement provisions governing private duty nursing services. Comments must be received by 4:30 p.m. on September 30, 2015.
1.1.6. Therapists that provide Hippotherapy must be certified by the American Hippotherapy Certification Board as a Hippotherapy Professional Clinical Specialist (HCPS). [Given the low number of Delaware therapists with HCPS certification, a therapist enrolled as an American Hippotherapy Association "member therapist" may bill the DMAP for Hippotherapy provided through December 31, 2016.]
Agency Response: DMMA acknowledges your endorsement, thank you. The American Hippotherapy Certification Board (AHCB) specifically recognizes AHCB Certified Therapist as an entry level certification. This certification includes a minimum requirement of one year or 2,000 hours experience in the practice of physical, occupational or speech and language pathology. AHCB also requires a minimum of 25 hours of one on one direct patient treatment using Hippotherapy, prior to the application. The therapist must be experienced and comfortable with horses, riding safely at the walk and trot.
Apart from the obvious grammatical problems with this subsection, its substance is inconsistent with federal regulation and the DMMA medical necessity regulation. It literally limits OT to "medical improvement". In contrast, 42 C.F.R. 440.110(b) (reproduced on p. 165) authorizes OT for both "medical improvement" AND restoration of function. The DMMA "medical necessity" regulation does not require services to result in medical improvement, i.e. services can "restore" or "prevent worsening" of function. See attached regulatory definition [2 DE Reg. 1249 (1/1/99)]. See also attached correspondence from Delaware Medicaid Director disapproving an MCO denial notice based on a "chronic" condition which would "not significantly improve... with occupational therapy". Section 3.3.1 literally bars coverage of OT which would restore or prevent the worsening of effects of a condition. The entire subsection could be deleted since it is grammatically infirm, substantively incorrect, and superfluous (other sections define the scope of covered OT). The Division is authorized to informally correct this section pursuant to Title 29 Del.C. §10113(b)(4)(5).
Agency Response: DMMA agrees and will remove this policy statement. [Bracketed bold stricken through] indicates language deleted in the final order regulation.
Physical and occupational therapists and speech/language pathologists who are individually enrolled with the Delaware Medical Assistance Program (DMAP) are reimbursed at a rate using Healthcare Common Procedure Coding System (HCPCS) procedure codes. Reimbursement rates shall be based on the Medicare Relative Value (RVU).
When billing for PT, OT, and Speech/language pathology services, providers shall use the appropriate Physical Medicine and Rehabilitation CPT Procedure codes and specify the diagnosis with accurate ICD-9-CM codes. When billing for physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders, providers shall use the appropriate Physical Medicine and Rehabilitation Current Procedural Terminology (CPT) codes and specify the diagnosis with accurate International Classification of Diseases, Clinical Modification (ICD-CM) codes.
1.1.5 Therapists who bill the DMAP for services provided to eligible Medicaid clients beneficiaries are required to verify that they actually rendered the service which is being billed. The following are the documentation requirements to verify the identity of the performing provider: A performing therapist in a group practice is required to initial the entry in the client's Medicaid beneficiary’s medical record at the time of service. Any system that a particular office may have in place that identifies the performing provider for each service will be acceptable.
1.1.6 Therapists that provide Hippotherapy must be certified by the American Hippotherapy Certification Board as a Hippotherapy Professional Clinical Specialist (HCPS). Hippotherapy – is a form of physical, occupational and speech-language therapy in which a therapist uses the multidimensional movements of a horse to provide carefully graded motor and sensory input. A foundation is established to improve neurological function and sensory processing, which can be generalized to a wide range of daily activities. Hippotherapy involves therapeutic exercise, neuromuscular education, kinetic activities, therapeutic activities, sensory integration activities and individual speech therapy. This treatment strategy utilizes the movement of the horse as part of an integrated rehabilitation plan of care to achieve functional outcomes.
[3.3 Services Not Covered
Last Updated: December 31 1969 19:00:00.
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