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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsFebruary 2017


Regulatory Flexibility Act Form

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42 CFR §441.530; Home and Community-Based Settings
42 CFR §441, Subpart G; Home and Community-Based Services, Waiver Requirements
§1915(c) of the Social Security Act; Home and Community-Based Services
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 on the revision of the Elderly and Disabled Waiver Provider Policy Manual. Comments must be received by 4:30 p.m. on March 3, 2017.
Health care services are provided to the majority of Medicaid clients Long Term Care Community Services (LTCCS) recipients through a Managed Care Organization (MCO). Elderly and Disabled Waiver (E and D) Waiver services are included in the MCO benefits package. All Elderly and Disabled Waiver clients who are enrolled with an MCO must receive E and D Waiver services through the MCO. Enrollment in a MCO is required in order for clients to receive services through the LTCCS program.
1.1 Waiver LTCCS Objectives
1.1.1 The LTCCS program provides for home and community-based services in integrated community settings for individuals aged 18 and above recipients who are elderly, or who have physical disabilities (including acquired brain injuries), certain diagnoses (including Acquired Immune Deficiency Syndrome (AIDS) or HIV-Related Diseases), or reside in Assisted Living (AL) facilities and who have limited ability to perform activities of daily living and would otherwise require care in a nursing facility be "at risk" of requiring nursing facility placement in the absence of LTCCS.
1.1.2 The goal of the waiver is to provide services to persons in a manner which responds to each participant's abilities, assessed needs, and preferences, and ensures maximum self-sufficiency, independent functioning, and safety in the most integrated community-based settings while preserving recipient dignity, respect and privacy. This goal is accomplished through the delivery of a range of home and community-based long-term care services which target the special needs of the population.
1.2.1 The Elderly and Disabled (E&D) Waiver is a LTCCS program is operated and administered by the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD). The Division of Medicaid and Medical Assistance (DMMA). has oversight responsibilities, DSAAPD and DMMA share responsibilities for determining eligibility for waiver program applicants DMMA contracts with Managed Care Organizations (MCOs) which are responsible for delivery of LTCCS to eligible and enrolled program participants.
2.0 Program/Contractual Responsibilities Qualities of LTCCS Provider Settings
2.1 Elderly & Disabled Waiver Provider Responsibilities Overview
2.2 Division of Services for Aging & Adults with Physical Disabilities (DSAAPD) Responsibilities Requirements for LTCCS Provider Settings
2.2.1 DSAAPD agrees to furnish the E&D provider with administrative and program guidance. The setting is integrated in and supports full access of LTCCS recipients to the greater community, including:
2.2.2 DSAAPD agrees to identify a Community Services Program (CSP) contact for the service area of the waiver provider. The setting must optimize, but not regiment, recipient initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.
2.2.3 If the applicant or participant requests a fair hearing, DSAAPD agrees to make arrangements to provide such a hearing through its normal fair hearing procedures. The setting must ensure a recipient's rights of privacy, dignity and respect, and freedom from coercion and restraint.
2.3 Responsibilities of Both Parties Requirements Specific to Provider-Owned or Controlled Residential Settings
2.3.1 Formal communication concerning the contract, program activities, treatment methods, and reports, etc. will be made via written correspondence between the E&D waiver provider and the DSAAPD. In addition to the requirements listed above in 2.1 and 2.2, provider-owned or controlled residential settings must also meet the following conditions:
3.0 Program Eligibility Criteria/Contractual Responsibilities
3.1 Criteria LTCCS Provider Responsibilities
3.1.1 In order to participate in the E&D waiver program, an individual must meet medical and financial criteria as established in Appendix B of the approved E&D waiver application. The LTCCS provider must agree to all terms and conditions listed in the Delaware Medical Assistance Program (DMAP) contract, the MCO contract, and the policies and procedures of the DMAP and the MCO.
4.0 Application Program Eligibility Criteria
4.1 Application Instructions Criteria
4.1.1 An individual wishing to apply for the E&D Waiver must contact the appropriate DSAAPD Community Services Program Unit to initiate the application. Refer to Section 9.0 of this manual for the appropriate Community Service Program Unit address and phone number. In order to participate in the LTCCS program, an individual must meet medical and financial criteria as established by DMMA.
5.0 Content/Description of Services Application
5.1 Limitations Application Instructions
5.1.1 The services provided to eligible persons may be limited in duration or amount as documented in Appendix C of the E&D Waiver application. An individual who wishes to apply for the LTCCS program must contact the DMMA CIU to initiate the application. Refer to Section 7.0 of this manual for the DMMA CIU contact information.
56.1.2 Service limitations imposed by DSAAPD staff will be consistent with the medical necessity of the patient's condition, as determined by the DSAAPD Case Manager and DSAAPD Nurse Consultant with the assistance of the attending physician or other practitioner. This determination will be made in accordance with standards generally recognized by licensed health professionals and promulgated through the DSAAPD. MCO determinations of amount, duration and scope of covered services shall be guided by the considerations contained in Section 13.0-Appendix H (Medical Necessity Definition) of DMMA's General Policy Manual.
56.2 Available Services
56.2.1 Adult Day Services - Services furnished in a non-institutional, community-based setting, encompassing both health and social services needed to ensure the optimal functioning of the participant. Members with an acquired brain injury (ABI) or traumatic brain injury (TBI), will receive additional prompting and/or intervention as needed, and as indicated in the person-centered service plan. Meals provided as part of these services shall not constitute a "full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care will be furnished as component parts of this service. This service is not available to persons residing in assisted living or nursing facilities.
56.2.2 Personal Care Attendant Services - Personal Attendant care services includes assistance with activities of daily living (ADL's) (bathing, dressing, personal hygiene, transferring, toileting, skin care, eating and assisting with mobility). When specified in the plan of care, this service includes assistance with instrumental activities of daily living (IADL's) (e.g. light housekeeping chores, shopping, meal preparation). Assistance with IADL's must be essential to the health and welfare of the participant. This service does not duplicate a service provided under the state plan as an expanded EPSDT service. Members with an acquired brain injury (ABI) or traumatic brain injury (TBI) will receive additional prompting and/or intervention as needed, and as indicated in the person-centered service plan. This service is not available to persons residing in assisted living or nursing facilities.
56.2.3 Respite - Respite service provides supportive care in assisted living facilities or nursing facilities HCB settings on a short-term basis because of the absence of, or need for relief for, those persons normally providing the care. This service does not duplicate a service provided under the state plan as an expanded EPSDT service.
56.2.4 Personal Emergency Response System (PERS) - A PERS is an electronic device that enables an waiver LTCCS participant to secure help in an emergency. As part of the PERS service, a participant may be provided with a portable "help" button to allow for mobility. The PERS device is connected to the participant's phone and programmed to signal a response center and/or other forms of assistance once the "help" button is activated. The PERS service is available only to participants who live outside of assisted living facilities. This service does not duplicate a service provided under the state plan as an expanded EPSDT service.
56.2.5 Specialized Medical Equipment and Supplies - Specialized medical equipment and supplies include: (a) devices, controls, or appliances, specified in the plan of care, that enable participants to increase their ability to perform activities of daily living; (b) devices, controls, or appliances that enable the participant to perceive, control, or communicate with the environment in which they live; (c) items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items; (d) such other durable and non-durable medical equipment not available under the State plan that is necessary to address participant functional limitations; and, (e) necessary medical supplies not available under the State plan. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the State plan and exclude those items that are not of direct medical or remedial benefit to the participant. All items shall meet applicable standards of manufacture, design and installation. This service does not duplicate a service provided under the state plan as an expanded EPSDT service.
56.2.6 Cognitive Services - Cognitive Services are necessary for the assessment and treatment of individuals who exhibit cognitive deficits or interpersonal conflict, such as those that are exhibited as a result of a brain injury. Cognitive Services include two key components:
56.2.6.1 Multidisciplinary Assessment and consultation to determine the participant's level of functioning and service needs. This Cognitive Services component includes neuropsychological consultation and assessments, functional assessment and the development and implementation of a structured behavioral intervention plan.
56.2.6.2 Behavioral Therapies include remediation, programming, counseling and therapeutic services for participants and their families which have the goal of decreasing or modifying the participant's significant maladaptive behaviors or cognitive disorders that are not covered under the Medicaid State Plan. These services consist of the following elements: Individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law.), services of social workers, trained psychiatric nurses, and other staff trained to work with individuals with psychiatric illness, individual activity therapies that are not primarily recreational or diversionary, family counseling (the primary purpose of which treatment of the individual's condition) and diagnostic services.
56.2.7 Day Habilitation - Day Habilitation service is the includes assistance with the acquisition, reacquisition, retention, or improvement in self-help, socialization and adaptive skills that take place in a non-residential HCB setting separate from the participant's private residence. Activities and environments are designed to foster the acquisition of skills, appropriate behavior, greater independence, and personal choice. Meals provided as part of these services shall not constitute a "full nutritional regiment" (3 meals per day). Day habilitation services focus on enabling the participant to attain or maintain his or her maximum functional level and shall be coordinated with any physical, occupational, or speech therapies in the service plan. In addition, day habilitation services may serve to reinforce skills or lessons taught in other settings. This service is provided to participants who demonstrate a need based on cognitive, social, and/or behavioral deficits such as those that may result from an acquired brain injury. This service does not duplicate a service provided under the state plan as an expanded EPSDT service.
56.2.8 Assisted Living - Assisted Living provides personal care and supportive services (homemaker, chore, attendant services, and meal preparation) that are furnished to waiver LTCCS participants who reside in homelike, non-institutional settings. Assisted living includes a 24-hour on-site response capability to meet scheduled or unpredictable resident needs and to provide supervision, safety and security. Services also include social and recreational programming, and medication assistance (to the extent permitted under State law). As needed, the assisted living service may also include prompting to carry out desired behaviors and/or to curtail inappropriate behaviors. Services that are provided by third parties must be coordinated with the assisted living provider.
56.2.9 Waiver LTCCS clients are also eligible for all services normally covered by the DMAP.
7.0 Obtaining Prior Authorization Contact Information - DMMA and MCO
7.1 Prior Authorization Process DMMA
Last Updated: December 31 1969 19:00:00.
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