DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Division of Medicaid and Medical Assistance
FINAL
ORDER
Case Management of High-Risk Pregnant Women
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 to remove case management of high-risk pregnant women 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 March 2023 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by March 31, 2023, 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, 2023, DHSS/DMMA is to amend XIX Medicaid State Plan to remove case management of high-risk pregnant women as an option from the Delaware Medicaid State Plan.
Background
There is growing evidence that increased stress from social factors such as food insecurity, as well as poverty and social exclusion, can have a major impact on health and can lead to premature death as well as poor birth outcomes for pregnant women and infants. As DMMA' s mission is to "Improve health outcomes by ensuring that the highest quality medical services are provided to the vulnerable populations of Delaware in the most cost-effective manner," addressing social factors and ensuring our most vulnerable populations receive the most effective health care coverage has become imperative to improving health outcomes.
DMMA has provided case management of high-risk pregnant women as an optional Medicaid State Plan service since 1987. Since that time, many evidenced-based home visiting models for pregnant and post-partum women have been developed, researched, and proven effective in improving maternal and child health outcomes. Therefore, effective for services provided on January 1, 2023, DMMA has amended its Diamond State Health Plan (DSHP) 1115 Waiver to include coverage of two models of evidenced-based home visiting for pregnant women and children under the age of two who meet enrollment criteria established by the Nurse Family Partnership and Healthy Families of Delaware, and therefore, the optional state plan service will be sunset.
Statutory Authority
1902(a)(23) of the Social Security Act
42 CFR 440.169 -- Case management services
Social Security Act §1115, Demonstration projects
Purpose
The purpose of this notice is to remove the optional service, case management of high-risk pregnant women, from the Delaware Medicaid State Plan as these services will now be provided via an evidence-based home visiting model under 1115 Waiver authority.
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 March 31, 2023.
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
No comments were received during the public comment period.
FINDINGS OF FACT:
The Department finds that the proposed changes as set forth in the March 2023 Register of Regulations should be adopted.
THEREFORE, IT IS ORDERED, that the proposed regulation to amend Title XIX Medicaid State Plan to remove case management of high-risk pregnant women service as an option from the Delaware Medicaid State Plan, is adopted and shall be final effective May 11, 2023.
4/12/2023
Date of Signature
Molly Magarik, Secretary, DHSS
Revision: HCFA-PM-87-4 (BERC) Supplement 1 to Attachment 3.l-A
March 1987 Page 1
OMB No. 0939-0193
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE/TERRITORY: DELAWARE
CASE MANAGEMENT SERVICES
A. Target Group:
B. Areas of State in which services will be provided:
Entire State.
Only in the following geographic areas (authority of section 1915(g)(1) of Act is invoked to provide services less than Statewide:
C. Comparability if Services
Services are provided in accordance with section 1902(a)(10)(B) of the Act.
Services are not comparable in amount, duration, and scope. Authority of section 1915(g)(1) of the Act is invoked to provide services without regard to the requirements of section 1902(a)(10)(B) of the Act.
D. Definition of Services:
E. Qualification od Providers:
Supplement 1 to Attachment 3.l-A
Page 1a
D. Definition of Services:
Case management of high risk pregnant women must include at least the following
components:
NUTRITION
- nutrition assessment and counseling
- WIC - Food Stamps application assistance
- infant feeding, breast feeding, child care information classes
SOCIAL WORKER
- counseling, access to needed services to resolve problems such as with education,
creditors, mental health;
- referrals to child watch, child abuse help groups; parenting skills
- long-term planning for self sufficiency through
employment/training/education/referrals following delivery;
- substance abuse counseling;
- stop smoking clinic referral and assistance in attending;
- referral to genetic screening and counseling services.
NURSING
- weekly/monthly health assessment by RN with report of suspected problem to
attending physician;
- Education on appropriate pregnancy topics; childbirth, newborn care (anticipating
guidance).
OUTREACH
- contact client prior to pre-natal visit (phone/home visit);
- arrange transportation and babysitting, especially to assure all medical appointments
are kept;
- accompany client to meetings, appointments as necessary;
- follow up to reschedule missed appointments;
- act as translator;
- facilitate implementation of goals of the care plan as directed by professional staff.
POST PARTUM
Continue services and resolve problems in 60 day post partum period including pregnancy
prevention, infant care, assisting clients to plan for self sufficiency through referral to
appropriate employment and training counseling services.
Supplement 1 to Attachment 3.l-A
Page 1b
E. Qualification of Providers:
Qualified providers of case management services for high risk pregnant women will be
those that can provide all of the service components described in item D on page 1a, and
who have staff or contractual arrangements to make up a case management team as
defined below:
Qualifications of Case Management Team Members
NUTRITION
shall be a Registered Dietitian of Nutritionist.
SOCIAL WORKER
shall be an employee with a Bachelors of Arts or Bachelors of Science degree in social work,
counseling or related social services field.
NURSING
shall be a Registered Nurse licensed to practice in the State of Delaware.
OUTREACH
these members shall be experienced para-professionals operating under the supervision of
the professional staff.
CLERICAL/SUPPORT
contractor shall have adequate clerical support staff to track, file, type, etc. all necessary
documentation required to the case management team.
Revision: HCFA-PM-87-4 (BERC) Supplement 1 to Attachment 3.l-A
March 1987 Page 2
OMB No. 0939-0193
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE/TERRITORY: DELAWARE
F. The State assures that the provision of case management services will not restrict an
individual's free choice of providers in violation of section 1902(a)(23) of the Act.
1. Eligible recipients will have free choice of the providers of case management services.
2. Eligible recipients will have free choice of the providers of other medical care under the
plan.
G. Payment for case management services under the plan does not duplicate payments made to
public agencies or private entities under other program authorities for this same purpose.
