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Division of Medicaid and Medical Assistance

Statutory Authority: 42 U.S.C. §1396a (a)(13) and 42 CFR §447.205




In accordance with the requirements of 42 U.S.C. §1396a (a)(13) and 42 CFR §447.205, Delaware Health and Social Services (DHSS), Division of Medicaid and Medical Assistance (DMMA) gives notice related to an amendment to the Pathways to Employment Home and Community Based State Plan Amendment authorized under 1915 (i) of the Social Security Act.


In 2015, the Centers of Medicare & Medicaid Services (CMS) approved Delaware's application for Pathways to Employment, a 1915(i) Medicaid Home and Community Based State Plan Option. CMS recently approved the Pathways SPA for another five years. The Pathways HCBS SPA serves individuals aged 14 to 25 who have intellectual disabilities/autism spectrum disorders, physical disabilities or visual impairment who require support to attain and sustain competitive employment. Pathways to Employment is currently limited to transition-aged youth and young adults to address the needs, identified by this age group, that were not being met through existing programs and services.

At the time of program development, it was determined that supports available through the other Medicaid authorities and the Division of Vocational Rehabilitation were sufficient to meet the needs of adults over the age of 25. Delaware has since discovered there is a small subset of the disability population who in fact have a gap in employment-related services. This subset includes young adults aging out of Pathways to Employment who are enrolled in the Diamond State Health Plan Plus and who need continued employment support.


The purpose of this posting is to provide public notice and elicit public input regarding Delaware's proposed amendment to its current Pathways to Employment program.

Overview and Summary of the Pathways to Employment Amendment

Delaware proposes to amend the Pathways to Employment 1915 (i) State Plan Amendment (SPA) to modify the targeting criteria which limits participation to only those who are between the ages of fourteen (14) and twenty-five (25). The proposed amendment would maintain the minimum age as fourteen (14) but would remove the maximum age of twenty-five (25).

Removing the maximum age requirements will address the service gap experienced by a small subset of Medicaid eligible individuals who require certain supports that they cannot receive from other programs to enable them to obtain or maintain competitive employment. These are individuals who have chosen to enroll in the Diamond State Health Plan Plus program to receive long term services and supports.

Currently, individuals must choose between the DDDS Lifespan waiver or the Diamond State Health Plan Plus program to receive long term services and supports based on which program better meets their needs. Individuals are not permitted to concurrently enroll in the Diamond State Health Plan Plus and the DDDS Lifespan Waiver. The DSHP Plus program does not contain any employment supports.

Because Pathways to Employment is a Medicaid State Plan HCBS Option, individuals may be concurrently enrolled in Pathways and either the DSHP Plus Program or the DDDS Lifespan HCBS Waiver. Removing the upper age limit from the Pathways to Employment program will enable individuals who have chosen to enroll in the DSHP Plus program but who want to work to be able to access needed employment supports.

In addition to the change outlined above, Delaware desires to make other changes to the Pathways SPA, most of which are technical in nature:

Amend the reimbursement methodology for personal care and respite services provided by either a Home Health Agency (HHA) or Personal Attendant Service Agency (PASA) to be consistent with rates for the same service under the DDDS Lifespan Waiver. The current Pathways methodology is based on the DMMA fee schedule for Home Health Agency rates that was in place at the time CMS initially approved Pathways. CMS then later directed DMMA to change the reimbursement methodology for the Home Health Agency services. However, when DMMA made changes to the rate methodology, the Pathways methodology was not updated to reflect those changes. The DDDS Lifespan rate methodology for personal care and respite from Home Health and PASA agencies was updated during the July 2019 renewal. This change to Pathways aligns the reimbursement methodology for respite and personal care delivered by Home Health and PASA Agencies across the Lifespan 1915 (c) Home and Community Based waiver, and the Pathways to Employment 1915 (i) State Plan Amendment.
Amend the "needs based" criteria and institutional "level of care" criteria for the target group of individuals with visual impairment (change requested by CMS).
Amend the chart of "Projected Number of Unduplicated Individuals To Be Served Annually" to change from a state fiscal year basis to a calendar year basis (change requested by CMS) to be consistent with the SPA renewal approval period.
Remove the provider qualification for Supported Employment: Individual and Group that requires providers to be contracted with the Division of Vocational Rehabilitation to contract with the Pathways program. The intent of this requirement was to facilitate continuity of providers for individuals transitioning from DVR services under the Rehab Act to Pathways services but DDDS is concerned that this requirement may have the unintended consequence of limiting the pool of providers enrolled to deliver these Pathways services.

Fiscal Impact

Delaware anticipates no additional cost to the general fund for this amendment if it is approved by CMS because funds are already budgeted under the assumption that these individuals would be able to access Supported Employment under the DDDS Lifespan HCBS Waiver.

Public Comment Submission Process

As required by 42 CFR Part 441.304, DHSS/DMMA must establish and use a public input process for any changes in the services or operation of the waiver. Per Del. Code, Title 29 §10118 (a), the opportunity for public comment shall be held open for a minimum of 30 days. The public is invited to review and comment on the proposed Pathways to Employment renewal. Comments must be received by 4:30 p.m. on August 31, 2021. Comments may be submitted in the following ways:

By Mail: Planning, Policy and Quality Unit

Division of Medicaid and Medical Assistance

1901 North DuPont Highway

P.O. Box 906

New Castle, Delaware 19720-0906

By Email:

By Fax: 302-255-4413

(Please identify in the subject line: Pathways to Employment Amendment #1)

The hardcopy renewal will be available at the following locations from August 1, 2021 through August 31, 2021.

DDDS Fox Run Office at: 2540 Wrangle Hill Road, Suite 200, Bear, DE 19701
Thomas Collins Building at: 540 South Dupont Hwy, 1st Floor, Dover, DE 19901
At the Woodbrook Office at: 1056 S. Governors Ave, Dover, DE 19904
On the Stockley Center campus at: 26351 Patriots Way, Georgetown, DE 19947 - 101 Lloyd Lane and 101 Boyd Blvd.

Any public feedback received will be summarized including any changes that will be made as a result of the public comment to the proposed Pathways to Employment Renewal that will be submitted to CMS.

7/12/2021 12:39 PM EDT

Stephen M. Groff Date


Division of Medicaid and Medical Assistance

25 DE Reg. 203 (08/01/21) (Gen. Notice)