DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Division of Medicaid and Medical Assistance
FINAL
ORDER
Assertive Community Integration Support Team (ACIST)
NATURE OF THE PROCEEDINGS:
Delaware Health and Social Services ("Department") / Division of Medicaid and Medical Assistance initiated proceedings to amend Title XIX Medicaid State Plan regarding Health Home Services, specifically, to remove the Assertive Community Integration Support Team (ACIST) health home service as an option from the Delaware Medicaid State Plan. The Department's proceedings to amend its regulations were initiated pursuant to 29 Del.C. §10114 and its authority as prescribed by 31 Del.C. §512.
The Department published its notice of proposed regulation changes pursuant to 29 Del.C. §10115 in the November 2021 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by December 2, 2021 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
SUMMARY OF PROPOSAL
Effective for services provided on and after January 1, 2022 Delaware Health and Social Services (DHSS)/Division of Medicaid and Medical Assistance (DMMA) proposes to amend Title XIX Medicaid State Plan regarding Health Home Services, specifically, to remove the Assertive Community Integration Support Team (ACIST) health home service as an option from the Delaware Medicaid State Plan.
Background
The Division of Developmental Disabilities Services (DDDS) in partnership with DMMA amended the 1915 (c) Home and Community Based Services Lifespan waiver to allow enrollees to also be enrolled in Managed Care for their acute medical care needs, where in previous years they had been carved out into Fee for Service Medicaid. This change became effective July 1, 2019. At approximately the same time, DDDS decided to do a thorough evaluation of the services and supports the MCOs were providing. As a result of that review it was determined that the ACIST program was no longer the best way to meet the service needs of those enrolled in the program, and in fact, they would receive very similar support through the MCO carve in. DDDS decided to discontinue this specialized program in order for service recipients to receive supports in the most integrated manner, which is through the MCOs. The ACIST Home Health program is currently closed and no provider is actively providing this State Plan service.
Statutory Authority
1902(a)(10)(D) of the Social Security Act, Home health services
Purpose
The purpose of this proposed regulation is to remove the Assertive Community Integration Support Team (ACIST) health home service as an option from the Delaware Medicaid State Plan.
Public Notice
In accordance with the federal public notice requirements established at Section 1902(a)(13)(A) of the Social Security Act and 42 CFR 440.386 and the state public notice requirements of Title 29, Chapter 101 of the Delaware Code, DHSS/DMMA gave public notice and provided an open comment period for 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 2, 2021.
Centers for Medicare and Medicaid Services Review and Approval
The provisions of this state plan amendment (SPA) are subject to approval by the Centers for Medicare and Medicaid Services (CMS). The draft SPA page(s) may undergo further revisions before and after submittal to CMS based upon public comment and/or CMS feedback. The final version may be subject to significant change.
Provider Manuals and Communications Update
Also, there may be additional provider manuals that may require updates as a result of these changes. The applicable Delaware Medical Assistance Program (DMAP) Provider Policy Specific Manuals and/or Delaware Medical Assistance Portal will be updated. Manual updates, revised pages or additions to the provider manual are issued, as required, for new policy, policy clarification, and/or revisions to the DMAP program. Provider billing guidelines or instructions to incorporate any new requirement may also be issued. A newsletter system is utilized to distribute new or revised manual material and to provide any other pertinent information regarding DMAP updates. DMAP updates are available on the Delaware Medical Assistance Portal website: https://medicaid.dhss.delaware.gov/provider
Fiscal Impact Statement
There is no anticipated fiscal impact.
Summary of Comments Received with Agency Response and Explanation of Changes
The following summarized comments were received:
Comment: DHSS needs to ensure that the mental health service and support needs of individuals with SPMI and I/DD receiving services from DDDS are being met. The Council endorses strengthening the coordination of care efforts for individuals being served by both DDDS and the Division of Substance Abuse and Mental Health (DSAMH) to better meet the unique needs of this population
Agency Response: DDDS Response: DDDS representatives have been meeting with DSAMH staff who manage the PROMISE program to discuss coordination of supports and services for dually eligible individuals. DDDS is currently participating in the "988 workgroup" with DSAMH and other community agencies to coordinate crisis supports. The DSAMH Mobile Crisis Team is a critical component of the 988 initiative in Delaware and DDDS has been vocal in our advocacy to extend DSAMH Mobile Crisis supports to DDDS service recipients living in provider-managed settings. DSAMH has been agreeable to including this with the other 988 enhancements. DDDS has also discussed improvements to other crisis supports utilized by our service recipients with the 988 workgroup members, such as cross training of emergency personnel, including but not limited to first responders and hospital staff, as well as increasing ease of access to inpatient psychiatric services when necessary. DDDS will continue to partner with DSAMH to address the needs of dually eligible service recipients. DDDS has also established a close working relationship with both MCOs to ensure that the individuals who coordinate care across all these service delivery networks are aligned with regard to meeting the need for mental health services for DDDS's population.
Comment: The Council recommends that DDDS complete a comprehensive evaluation of the behavioral health needs of their service recipients as compared to what they are receiving from the MCOs.
Agency Response: DDDS did complete an evaluation of the behavioral health needs of individuals supported by the Division in 2019 when the contracted vendor that was delivering the ACIST services ended their contract with minimum notice. DDDS and the Managed Care Organizations (MCOs) immediately partnered to identify mental health practitioners for impacted DDDS service recipients to ensure there was no interruption of necessary services and supports during the transition. After ensuring continuity of care for those service recipients, DDDS conducted a comprehensive evaluation of the behavioral and mental health services and supplemental benefits available through the MCOs and concluded that the MCOs enabled DDDS service recipients to access a more robust network of behavioral health providers than what was previously available when these services could only be accessed outside of the MCO network as fee for service. The MCO care coordination of these benefits and physical health benefits also filled a gap that was previously experienced by DDDS service recipients that led DDDS to create the ACIST program. Prior to the development of ACIST, DDDS waiver enrollees were carved out of Managed Care and received their acute medical Medicaid benefits through a fee for service arrangement. At the point that DDDS and DMMA partnered to carve this population into Managed Care through an amendment to the DDDS 1915 (c) Lifespan Waiver and the Diamond State Health Plan 1115 Waiver, service recipients gained access to a wider network of service providers as well as supplemental benefits offered by the MCOs such as a Behavioral Health Coordinator to ensure timely referral and access to necessary behavioral health services.
DMMA is pleased to provide the opportunity to receive public comments and greatly appreciates the thoughtful input given by: Governor's Advisory Council for Exceptional Citizens (GACEC)
FINDINGS OF FACT:
The Department finds the proposed changes as set forth in the November 2022 Register of Regulations should be adopted.
THEREFORE, IT IS ORDERED, that the proposed regulation to amend Title XIX Medicaid State Plan regarding Health Home Services, specifically, to remove the Assertive Community Integration Support Team (ACIST) health home service as an option from the Delaware Medicaid State Plan is adopted and shall be final effective March 11, 2022.
2/14/2022 Molly K. Magarik, Secretary, DHSS
Date of Signature
*Please Note: Due to the size and formatting requirements of the regulation, it is being attached here as a PDF document:
