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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJanuary 2018

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16 DE Admin. Code 5000 & 70000
Delaware Health and Social Services ("Department") / Division of Medicaid and Medical Assistance initiated proceedings to amend the Division of Social Services Manual regarding Medicaid Managed Care Final Rule, specifically, to align DMMA Medicaid Managed Care Policy with new Federal Requirements. 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 November 2017 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by December 1, 2017 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
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 proposed regulation. Comments were to have been received by 4:30 p.m. on December 1, 2017.
Agency Response: DMMA agreed and replaced 42 CFR 438.208(f)(2) with 42 CFR 438.408(f)(2).
Agency Response: All of the requirements in 42 CFR Part 438, subpart F, Grievance and Appeal System, apply to Delaware effective January 1, 2018. DMMA's intends to amend the DSSM consistent with all of the applicable requirements of subpart F (per CMS guidance, because Delaware's MCO contracts and rates are on a calendar year basis, all requirements identified in the rule as effective "no later than the rating period for Medicaid managed care contracts starting on or after July 1, 2017" are effective as of January 1, 2018.)
THEREFORE, IT IS ORDERED, that the proposed regulation to amend the Division of Social Services Manual regarding Medicaid Managed Care Final Rule, specifically, to align DMMA Medicaid Managed Care Policy with new Federal Requirements, is adopted and shall be final effective January 11, 2018.
Any kind of assistance, payments or benefits made by TANF, GA, Medicaid, Delaware Healthy Children Program (DHCP), Delaware Prescription Assistance Program (DPAP), Chronic Renal Disease Program (CRDP), Child Care, Refugee, Emergency Assistance or Food Supplement programs.
7 CFR 273.15 (g), 42 CFR 431.221, 45 CFR 205.10, [42 CFR 438.208(f)(2) 42 CFR 438.408(f)]
E. For recipients enrolled in a MCO, 120 days from the date of the MCO's notice of resolution of the appeal [or the MCO's failure to adhere to the notice and timing requirements in 42 CFR 438.408].
1.A. Timely Notice Period
Exception: Benefits may be reduced or terminated if the conditions in DSSM 5308 are met.
2.B. Ninety Days from the Effective Date of Action
3.C. More than Ninety Days from the Effective Date of Action
4.D. Food Supplement Program Households
E. Recipients enrolled in a MCO
A hearing is granted if the request is received within 120 calendar days from the date of the MCO's notice of an appeal resolution upholding an adverse benefit determination. If the request is not received during the timely notice period, the adverse benefit determination is to take effect. [If the MCO fails to adhere to the notice and timing requirements in 42 CFR 438.408, the recipient is deemed to have exhausted the MCO's appeals process and may initiate a State fair hearing within 120 calendar days].
3. For recipients enrolled in a MCO the request is not received within 120 calendar days from the date of the MCO's notice of an appeal resolution upholding an adverse benefit determination [or the MCO's failure to adhere to the notice and timing requirements in 42 CFR 438.408].
1.2 Pursuant to Section 1902(a)(4) of Title XIX of the Social Security Act (42 U.S.C. §1396a(4)) and 42 C.F.R. §438.1 et. seq., the states are authorized to administer Medicaid through Medicaid managed care organizations (each an “MMCO”).
1.5 Pursuant to 18 Del.C. §7931(c), the Division of Medicaid and Medical Assistance (“DMMA”), which is under the direction and control of the Secretary of the Department of Health and Social Services (“DHSS”), is responsible for the performance of all of the powers, duties, and functions specifically related to Medicaid, which includes certification of MMCOs.
2.1.5 An opinion of Delaware counsel to the MMCO will be prima facie evidence that the criteria in this Section 2 are satisfied.
4.1.1 The person or persons responsible for preparing the MMCO’s financial statements in U.S. generally accepted accounting principles and generally accepted auditing standards format and for preparing any financial reporting required under the Contract. Such person shall have accounting or finance training and experience, and shall have experience in the preparation of financial statements for health plans.
5.1 Prior to certification, the MMCO shall obtain a performance bond from a surety licensed to write surety business in Delaware and rated A- (Excellent) or better by A.M. Best and Company. The performance bond shall be restricted to the Contract.
8.1.3 Maintain a uniform accounting system that adheres to generally accepted accounting principles and generally accepted auditing standards for charging and allocating to all funding resources the MMCO’s costs incurred hereunder including, but not limited to, the American Institute of Certified Public Accountants Statement of Position 89-5 “Financial Accounting and Reporting by Providers of Prepaid Health Care Services.”
11.2 In the event of such decertification, DHSS shall notify the MMCO of the proposed decertification in accordance with 29 Del.C. §§10122 and 10131. If the MMCO requests a hearing on the proposed decertification, DHSS shall appoint a hearing officer to preside over the hearing.
11.3.7 If the MMCO fails to appear at the decertification hearing after receiving the notice required by 29 Del.C. §10122 and 10131, the hearing officer may proceed to hear and determine the validity of the proposed decertification.
Last Updated: December 31 1969 19:00:00.
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