department of health and social services

Division of Medicaid and Medical Assistance

PROPOSED

PUBLIC NOTICE

School-Based Wellness Center Clinic Services

In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) with 42 CFR §447.205, and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Medicaid and Medical Assistance (DMMA) is amending the Title XIX Medicaid State Plan to update the reimbursement methodology for School-Based Wellness Center Clinic Services.

Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Planning & Policy Development Unit, Division of Medicaid and Medical Assistance, 1901 North DuPont Highway, P.O. Box 906, New Castle, Delaware 19720-0906 or by fax to (302) 255-4454 by September 30, 2010.

The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.

SUMMARY OF PROPOSAL

The purpose of this proposal is to amend the Title XIX Medicaid State Plan to update the reimbursement methodology for School-Based Wellness Center Clinic Services.

Statutory Authority

Summary of Proposed Amendment

School-Based Wellness Center Clinic (SBWCCs), operated by the Division of Public Health in Delaware schools, provide primary prevention and early intervention services, including physical examinations, treatment of acute medical problems, community referrals, counseling and other supportive services to children in school or educational settings.

The Title XIX Medicaid State Plan is being revised to update the reimbursement methodology for School-Based Wellness Center Clinic Services, as the current rate methodology expires on September 30, 2010.

Effective for dates of service on October 1, 2010 and after, claims for School Based Wellness Center Clinic Services will no longer be reimbursed at a single encounter rate per child per year but will be paid based on billed procedure codes for individual services delivered by SBWCCs at the Delaware Medicaid Physician Fee Schedule rates.

No change will be made to the services provided under the school-based wellness center clinic services benefit.

The provisions of this amendment are subject to approval by the Centers for Medicare and Medicaid Services (CMS).

Fiscal Impact Statement

The proposal imposes no increase in cost on the General Fund.

DMMA PROPOSED REGULATION #10-37

REVISION:

ATTACHMENT 4.19-B

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: DELAWARE

School-Based Wellness Center Clinic Services, operated by the Division of Public Health in Delaware schools, are reimbursed a single rate once each benefit year for any client served in one of the school-based clinics. This rate methodology will sunset on September 30, 2010 using the DMAP physician fee schedule effective for dates of service on or after October 1, 2010. Except as otherwise noted in the plan, State-developed fee schedule rates are the same for both governmental and private providers of this service and the DMAP physician fee schedule is available on the DMAP website. (http://www.dmap.state.de.us/downloads/hcpcs.html)

Payments for clinic services will not exceed the upper payment limits set forth in 42 CFR 447.321:. (1) For services covered by Medicare, payments are not to exceed the Medicare rates or the Medicare aggregate payment amount for those services; and (2) For services not covered by Medicare, aggregate payments are not to exceed an amount that could reasonably be estimated would have been paid under Medicare payment principles. Since the School-Based Wellness Centers will be paid at the DMAP physician fee schedule rates, which is paid as a percentage of the Medicare physician fee schedule, not to exceed 100%, the payments will not exceed what Medicare would have paid.

Payments to School-Based Wellness Centers shall be considered “preventive pediatric services” as per 42 CFR 433.139(b)(3)(i) for the purpose of applying third party billing requirements.