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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsDecember 2016

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Delaware Health and Social Services (“Department”) / Division of Medicaid and Medical Assistance initiated proceedings to amend Delaware’s Title XIX Medicaid State Plan regarding Targeted Case Management, specifically, to establish coverage and reimbursement methodologies for targeted case management services for individuals with intellectual disabilities. The Department’s proceedings to amend its regulations were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.
The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the October 2016 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by October 31, 2016 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
Delaware’s Title XIX Medicaid State Plan regarding Targeted Case Management, specifically, to establish coverage and reimbursement methodologies for targeted case management services for individuals with intellectual disabilities.
42 CFR §440.169, Case management services, general provisions
42 CFR §441.18, Case management services, specific requirements
42 CFR §441.301(c)(1)(2)(3), Contents of a waiver request, Person-Centered Services
42 CFR §441.301(c)(4), Contents of a waiver request, Home and Community-Based Settings
42 CFR §447.205, Public notice of changes in statewide methods and standards for setting payment rates
§1902(a)(23) of the Social Security Act, Freedom of choice of qualified providers
§1903(c) of the Social Security Act, FFP for case management included in an individualized education program or individualized family service plan
§1915(c) of the Social Security Act, Home and community-based services
§1915(g)(1) of the Social Security Act, location and comparability of case management services
On July 25, 2000, the Center for Medicare and Medicaid Services (CMS) issued a State Medicaid Director Letter (SMDL) providing policy changes and clarification giving states more flexibility to serve people with disabilities in different settings. This SMDL provided clarification regarding the use of Case Management to assist states to overcome barriers to community transition. Case management services are defined under section 1915(g)(2) of the Social Security Act (the Act) as "services which will assist individuals, eligible under the plan, in gaining access to needed medical, social, educational, and other services." Case management services are often used to foster the transitioning of a person from institutional care to a more integrated setting or to help maintain a person in the community. There are several ways that case management services may be furnished under the Medicaid program. Home and Community-Based Services (HCBS) Case Management may be furnished as a service under the authority of section 1915(c) when this service is included in an approved HCBS waiver. Persons served under the waiver may receive case management services while they are still institutionalized, for up to 180 consecutive days prior to discharge. This case management service may be provided under the optional Targeted Case Management (TCM) authority of section 1915(g)(2) of the Social Security Act. TCM, defined in section 1915(g) of the Act, may be furnished as a service to institutionalized persons who are about to leave the institution, to facilitate the process of transition to community services and to enable the person to gain access to needed medical, social, educational and other services in the community. TCM may be furnished during the last 180 consecutive days of a Medicaid eligible person's institutional stay if provided for the purpose of community transition. States may specify a shorter time period or other conditions under which TCM may be provided.
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. Comments must be received by 4:30 p.m. on October 31, 2016.
Agency Response: The set of minimum credentials of both the Community Navigators and the Support Coordinators is the same as the current State of Delaware Merit System requirements for the classification of Senior Social Worker/Case Manager which is also the classification of the current Division of Developmental Disability Services (DDDS) case managers. State agencies do not have the authority to change the minimum qualifications for state Merit classifications. Because this is the standard currently used to establish the minimum credentials for individuals performing the work that is contemplated under the TCM State Plan Amendment (SPA), DDDS believes it appropriate to use this standard for both types of case managers. Nothing in the SPA or the RFP for the TCM service for individuals living in the family home will prohibit the provider from establishing higher standards. DDDS will closely monitor the performance of the TCM provider(s) against established quality metrics. The minimum required credentials for the contracted TCM will be reevaluated in the future after the state has the ability to assess the provider’s performance. There was no change as a result of this comment.
Agency Response: This response will address both the second and third comments together. The expected level of involvement of the Community Navigators is based on a required caseload ratio of 1:60 staff to consumer. The caseload ratio of 1:60 will be specified in the RFP for the TCM provider. This ratio is roughly double the current desired caseload ratio of 1:35 for individuals living in a waiver residential setting but is less than the current caseload ratio of approximately 1:100 for individuals supported in the family home by the Family Support Specialists. In establishing a caseload ratio and minimum contact schedule, DDDS was mindful of the need to maintain costs within existing budget allocations. The TCM provider will be responsible for supervising and monitoring the performance of individual Community Navigators and assuring that they provide high quality case management. DDDS has designated two positions within the Division to be the liaison between the TCM provider and the state. These positions will also have responsibility for monitoring the performance of the TCM provider and reporting back to the contract manager. There was no change as a result of these comments.
Agency Response: The current Administration has enforced a policy of not expanding the state workforce. Therefore, using state employees to provide TCM for individuals living at home was not an option. To maintain a caseload ratio of 1:60, given current DDDS caseloads, we anticipate that the vendor will need to hire 54 Community Navigators and 5 supervisors. The budget proposals included as part of the vendor bids will be carefully scrutinized as part of the evaluation process to assure that proposed costs are reasonable. There was no change as a result of this comment.
Agency Response: DDDS acknowledges this comment and has adopted the alternative language as follows:
Agency Response: DDDS acknowledges this comment. However, as long as the nursing facility benefit is available under the State Plan, the state must allow Medicaid eligible individuals who meet the nursing facility criteria to receive this benefit. As council points out, individuals must go through the Preadmission Screening and Resident Review (PASRR) process, prior to actual admission to a nursing facility. This process is designed to ensure that alternatives are considered before nursing facility admission is approved. DDDS has revised the language to indicate that alternatives to nursing facility placement must be considered and exhausted prior to consideration of a nursing facility. The revised language is as follows:
THEREFORE, IT IS ORDERED, that the proposed regulation to amend Delaware’s Title XIX Medicaid State Plan regarding Targeted Case Management, specifically, to establish coverage and reimbursement methodologies for targeted case management services for individuals with intellectual disabilities, is adopted and shall be final effective December 11, 2016.
A. Target Group - Services shall be provided to participants[, regardless of age,] who (42 CFR §441.18(a)(8)(i) and §441.18(a)(9)):
1. Meet the eligibility requirements set forth in 16 DE Admin. Code 2100 Division of Developmental Disabilities Services (DDDS) Eligibility Criteria [which requires a diagnosis of an intellectual developmental disability (including brain injury), autism spectrum disorder or Prader Willi Syndrome with functional limitations]; and,
X Target group includes individuals transitioning to a community setting. Case management services will be made available for up to 180 consecutive days of a covered stay in a medical institution. The target group does not include individuals between the ages of [22 21] and 64 who are served in Institutions for Mental Disease (IMD) or individuals who are inmates of public institutions (State Medicaid Directors Letter 072500b, July 25, 2000).
i) [Collecting Obtaining client histories and other] information necessary for evaluating and/or reevaluating and recommending community based supports and services that may address individual or family needs;
2. Development (and periodic revision) of a person-centered plan in accordance with 42 CFR §441.301(c)(1) through 42 CFR §441.301(c)(4). This activity may be conducted through direct and collateral contacts. The plan must reflect what is important to the individual to lead the life they want to lead. The plan must also identify and reflect the services and supports that are important for and to the individual to [reach specified goals, to] achieve desired outcomes and to meet needs identified through an assessment of functional need. The plan must also reflect the individual's preferences for the delivery of such services and supports. Individuals and families may focus on their current situation and stage of life but may also find it helpful to look ahead to start thinking about what they can do or learn now that will help build an inclusive productive life in the future.
xi) Informs and assists an individual or his or her family [to obtain guardianship or other surrogate decision making capability with surrogate decision making and assistance options, including supported decision-making agreements, powers of attorney, and guardianship.]
xii) Facilitates referral to a nursing facility when appropriate [and when other available options have been fully considered and exhausted]
Page [78]
Targeted case management for Individuals Meeting Delaware DDDS Eligibility Criteria Living In their Own Home or their Family's Home will be reimbursed at a [prospective monthly unit cost] rate. The initial rate [was will be] established using reasonable estimates for the following [projected] costs based on OMB Uniform Guidance on Cost Principals:
Employment Related Expenses including [such elements as] fringe benefits and taxes, paid time off and training
Program Indirect Expenses [necessary for the provision of TCM services] including [such elements as] supervision, technology, quality assurance and allowance for non-productive time
Practitioner Transportation costs [(not to include transportation of consumers)]
General and Administrative Cost [necessary for the provision of TCM services] limited to 12%
After the initial rate is established [using a negotiated TCM budget], an annual cost report will be completed by the provider each year and will be used by the state to compute each subsequent annual rate.
Each year a carry forward adjustment will be made to the next year's [prospective provisional] rate to account for differences between projected and actual cost for the rate period. [The carry forward adjustment computation will be performed within three months of the close of the cost reporting period.]
A. Target Group - Services shall be provided to participants[, regardless of age,] who (42 CFR §441.18(a)(8)(i) and §441.18(a)(9)):
1. Meet the eligibility requirements set forth in 16 DE Admin. Code 2100 Division of Developmental Disabilities Services (DDDS) Eligibility Criteria [which requires a diagnosis of an intellectual developmental disability (including brain injury), autism spectrum disorder or Prader Willi Syndrome with functional limitations]; and,
2. Have been approved to receive residential habilitation under [an the Delaware] HCBS waiver [program DE 0009] administered by the Delaware Division of Developmental Disabilities Services (DDDS) authorized under Section §1915(c) of the Social Security Act
X Target group includes individuals transitioning to a community licensed and/or certified setting. Case management services will be made available for up to 180 consecutive days of a covered stay in a medical institution. The target group does not include individuals between the ages of [22 21] and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions (State Medicaid Directors Letter 072500b, July 25, 2000) or individuals receiving services and supports while living in their own or family home.
i) [Collecting Obtaining client histories and other] information necessary for evaluating and/or reevaluating and recommending determination of the individual's level of care;
ii) Informs and assists an individual or his or her family [to obtain guardianship or other surrogate decision making capability with surrogate decision making and assistance options, including supported decision-making agreements, powers of attorney, and guardianship.]
iii) Facilitates referral to a nursing facility when appropriate [and when other available options have been fully considered and exhausted]
Targeted case management for Individuals Approved for Funding through the Delaware DDDS HCBS Waiver Program DE 0009 Who Are Receiving Residential Habilitation will be reimbursed at a [prospective monthly unit cost] rate. This rate [was will be] established using an annual cost report that uses OMB Uniform Guidance on Cost Principals and that captures costs for the following cost categories:
Employment Related Expenses including [such elements as] fringe benefits and taxes, paid time off and training
Program Indirect Expenses [necessary for the provision of TCM services] including [such elements as] supervision, technology, quality assurance and allowance for non-productive time
Practitioner Transportation costs [(not to include transportation of consumers)]
General and Administrative Cost [necessary for the provision of TCM services] limited to 12%
The initial rate will be established using projected data for cost, percentage of reimbursable activity and billable units. Each year thereafter, a carry forward adjustment will be made to the next year's [prospective provisional] rate to account for differences between projected and actual cost for the rate period. [The carry forward adjustment computation will be performed within three months of the close of the cost reporting period.]
Last Updated: December 31 1969 19:00:00.
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