DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 2

Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN'S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:

DELAWARE

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b))

Thomas R. Carper, Governor

June 30, 1998

(Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the State Child Health Plan, the requirements of Titles XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state official(s) are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Vincent P. Meconi Secretary Delaware Health and Social Services

Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The State will use funds provided under Title XXI primarily for (Check appropriate box):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2 Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3

A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date (date State incurs costs):

Initial Plan Submission effective October 1, 1998 SPA #1 effective July, 1, 1999 SPA #2, as amended, effective October 1, 2001 (to convert infants with incomes between 185% - 200% FPL to a Medicaid expansion) SPA #3 withdrawn June 12, 2003

SPA #4 effective January 1, 2007 SPA #5 effective April 1, 2009

Implementation date (date services begin):

SPA #2 - August 1, 2001 SPA #3 - Withdrawn - June 12, 2003 SPA #4 - October 1, 2006 SPA #5 – April 1, 2009

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102(a)(1)-(3) and Section 2105(c)(7)(A)-(B))

2.1 Describe the extent to which, and manner in which, children in the State including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (see Section 10 for annual report requirements). (42 CFR 457.80(a))

The population of Delaware was estimated to be 724,773 in 1996. There were 183,895 children in the 0 - 18 age group or 25% of the State population. Based on the Center for Applied Demography and Survey Research, University of Delaware, approximately 23,432 children (or 13% of the children in Delaware) are uninsured. Of the 23,432 uninsured children in the 0 - 18 age group, 14,581 (or 2.0% of the State’s population) are ≤ 200% FPL; 8,851 (4.8% of the State’s population) are > 200% FPL. It is assumed that approximately 4,068 uninsured children age 0 - 18 ≤ 100% FPL are eligible for Medicaid/Title XIX. Therefore, DHCP will target approximately 10,513 children between 100% - 200% FPL.

Of the 183,895 children 0 - 18 in Delaware, 89.5% have some form of health insurance: 112,135 (or 61.0%) have private insurance; 48,328 (or 26.3%) currently have health care coverage through Title XIX Medicaid; 4,068 (or 2.2%) are eligible for, but not receiving Medicaid. In essence, Title XXI will increase the number of insured children in the 0 - 18 group by 10,513 (or 5.7%), thereby bringing the total of insured children in Delaware to 95.2%. The remaining 8,851 (or 4.8%) or the 0 - 18 population comprises uninsured children above 200% FPL.

According to a published report by the Center for Applied Demography and Survey Research, University of Delaware (U of D), Blacks are twice as likely to be without health insurance compared to Caucasians. Hispanics have a higher risk, almost 5% higher, than Blacks of being without insurance. 51% of the uninsured are male, 69% are White, 8% are Hispanic.

The major reason cited by the U of D report for lack of insurance among 0 - 18 year olds are: poverty, lack of education, lack of work experience, and no family responsibility (i.e., unmarried and without children). Parents of these children are likely to be single-parent households with low-income jobs.

2.2 Describe the current State efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102(a)(2)) (42 CFR 457.80(b))

2.2.1 The steps the State is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

The State of Delaware expanded coverage for children to age 18 and to 100% of the Federal poverty level in 1992, in tandem with plans to develop an 1115 waiver. This waiver was in conjunction with the duPont Hospital for Children a.k.a. the Nemours Foundation. Nearly 7,000 newly eligible children were added in the first year of increased eligibility which constituted a 31.3% increase in the number of children served by Medicaid. When the State received approval for the 1115 waiver that authorized the Diamond State Health Plan, this population of children was rolled into the Diamond State Health Plan and duPont became a provider with all MCOs.

Effective October 1, 2001, all children under the age of 1 enrolled in the Delaware Healthy Children Program were transferred to a Medicaid expansion with no interruption in coverage.

Pursuant to an initiative by the State, the Nemours Foundation also provides free primary health care services in physician clinics to uninsured children up to 175% of poverty and charges a fee on a sliding scale basis to those above 175% of poverty. Since its inception in 1993, the Nemours initiative has resulted in the creation of ten (10) new primary care facilities providing physician services to over 6,200 non- Medicaid children annually.

The Division of Social Services, Medical Assistance Program, the Division of Public Health and the Department of Education work closely together to identify uninsured children and route them to Medicaid for eligibility determination. We have developed an early identification program with the largest hospitals in the State to notify us immediately of the birth of a child to a Medicaid eligible mother. The State’s Enrollment Broker (Health Benefits Manager) provides multiple outreach programs to bring the Diamond State Health Plan and Medicaid to the attention of possibly eligible persons. The State will amend the HBM contract to include these same services for the Title XXI population.

The enrollment process through the Health Benefits Manager worked very well and prevented direct marketing and adverse selection by managed care plans.

The WIC program also participates with the State and the MCOs to identify children in the WIC program who may also be eligible for Medicaid.

2.2.2 The steps the State is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

The State’s relationship with its managed care companies and the Health Benefits Manager (Enrollment Broker) are public-private partnerships. The outreach and education programs are provided in a public-private environment with the State working with each of these entities to identify and enroll eligible persons into the Medicaid program.

In addition, the Nemours Clinics provide services for the Medicaid Children, primarily through contracts with the Managed Care Organizations. They also provide services to uninsured children up to approximately 175% for no charge. These primary care clinics are supported primarily by the Nemours Foundation, a private philanthropical organization, whose trust requires investments in the health of Delaware’s children.

2.3 Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

The public and private entities, which provide health care to children in the State, are already in partnership with Delaware’s Department of Health and Social Services, which will be administering this program. The State is entering discussions with the Nemours Foundation, which provides primary care services to low-income and underinsured children who are not eligible for Medicaid to obtain their agreement to alter their income cap to cover children above 200% of FPL on a more generous basis since the State will assume coverage for uninsured children below 200% of the FPL who meet eligibility criteria.

Additionally, in the State's Division of Public Health, Maternal and Child Health program activities are funded under the Maternal and Child Health Block Grant program, Title V of the Social Security Act. This funding is intended to improve the health of all mothers and children and must be equally divided on prevention and primary care services for children, pregnant women, mothers and infants, and children with special health care needs. Referral processes are in place with the DPH and FQHCs, which aid in the identification and referral of uninsured children in the appropriate program. Applicants who do not qualify for Medicaid or the DHCP are referred to FQHCs.

All applicants will be screened by staff employed by the State of Delaware Division of Social Services to assure that they are potentially eligible targeted low income children. The screening document will determine:

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

1. If the child(ren) has Medicaid coverage or is potentially eligible. If the child has Medicaid, the Social Services staff will cease screening for The Delaware Healthy Children Program. If potentially eligible because family income appears to be less than the Medicaid limit, a Medicaid application will be processed.

2. If the child is not Medicaid eligible, the social worker will screen for family income, credible coverage within last six months, residency, citizenship, Social Security Numbers, and age.

3. If child appears to qualify based on passing those screens, an application will be mailed or handed to the family.

4. Other State and private agencies serving potentially eligible targeted low-income children will be encouraged to refer such children for screening.

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Section 3. Methods of Delivery and Utilization Controls (Section 2102(a)(4))

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4.

3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42 CFR 457.490(a))

The Delaware Healthy Children Program (DHCP) is targeted to children under age 19 with income at or below 200% of the Federal Poverty Level (FPL). The service package will include all of those basic benefit services provided under the State’s Medicaid Managed Care program as it was structured during 1998. Services will be provided by the same fully capitated managed care organizations (MCOs) participating with Medicaid. In addition, participants in the DHCP will receive pharmacy services comparable to the Medicaid population. They will also receive all medically necessary mental health and substance abuse treatment services (any treatment modality) which exceed the basic MCO benefit of 30 outpatient visits for mental health. The mental health/substance abuse services will be provided through the State's Department of Services for Children, Youth, and Families. For children actively case managed by the Department's Division of Child Mental Health Services (a JCAHO-certified public mental health managed care provider), a monthly encounter rate will be billed to the DHCP. Children receiving mental health or substance abuse services by the Department's Division of Family Services or the Division of Youth Rehabilitation Services will have their care paid on a fee-for-service basis. Beyond the 31 days of additional coverage of inpatient care, children will become eligible for Medicaid long- term care services. Thus the DHCP will provide very high quality mental health and substance abuse coverage - coverage which is better by far than most private sector coverage. Services will be provided statewide with no variations based on geography.

Children are eligible under Title XXI (DHCP) only after enrollment with a MCO. Delaware assures that it will spend no more than 10% of actual or estimated Federal expenditures for outreach and administrative costs in accordance with Section 2105(a)(2)). The plan does not currently include any initiative to provide services through any options other than through MCO capitated arrangements with the two “wrap-around” services listed above.

Dental Benefits will be provided on a fee-for-service basis.

3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102(a)(4)) (42 CFR 457.490(a))

Delaware will use the same utilization control procedures as are used for the Diamond State Health Plan (also see Section 7). These are:

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Utilization Management

The MCO must have written utilization management policies and procedures that include protocols for denial of services, prior approval, hospital discharge planning, physician profiling, and retrospective review of claims. As part of its utilization management function the MCO must also have processes to identify utilization problems and undertake corrective action.

The MCO will develop and maintain a Utilization Management Committee to oversee utilization management decisions. The committee must include membership by individuals representative of the organization's provider network. The committee must also participate in the development of utilization management policies and procedures. The MCO must also ensure that it has sufficient/appropriate staff and resources to perform utilization management functions.

In addition, the State operates a Drug Utilization Review system that provides for prospective and retrospective reviews with oversight provided by a nine- member board. The prospective review generates alerts for medication problems at the time that the prescription is dispensed. The retrospective review monitors beneficiary compliance and overall prescribing/dispensing patterns.

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Section 4. Eligibility Standards and Methodology (Section 2102(b))

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 5.

4.1 The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102(b)(1)(A)) 42 CFR 457.305(a) and 457.320(a))

4.1.1

Geographic area served by the Plan: All of Delaware

4.1.2

Age: Children from ages 1 to 19. This amendment moves infants previously covered into a Medicaid expansion.

4.1.3

Income: Eligibility will be established using gross income of all immediate family* members living in the same household with a standard $90 disregard per earner, a disregard for the amount of actual child care expenses up to $175 for children age 2 and above and $200 for children under age two. In addition, there will be a disregard of the first $50 of child support for any potentially eligible children. The resultant countable income will be compared to 200% of the FPL for a family the size of those in the immediate family with one exception (a pregnant woman will count as two [2] people for determining the FPL level to use). Income less than or equal to 200% of the FPL will qualify the children for eligibility for The Delaware Healthy Children Program. (The State is considering allowing a buy-in for families with incomes between 200% and 300% of the FPL with payment of the full capitation amount as their premium as part of a State-supported initiative.) * ”Immediate family” is defined a unit (living in the same household) comprised of various adults who are legally/financially responsible for each other, and various children (related or unrelated) for whom the adults have legal responsibility or for whom the adults have accepted parental-like responsibility. This is the same definition that is used for Medicaid eligibility.

All wages paid by the U. S. Census Bureau for temporary employment related to Decennial Census activities are excluded in years in which there is a federal census.

4.1.4 Resources (including any standards relating to spend downs and disposition of resources):

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

4.1.5

Residency (so long as residency requirement is not based on length of time in state): Must be current Delaware resident with intent to remain.

4.1.6

Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7

Access to or coverage under other health coverage: Must be uninsured for at least 6 previous months (see exceptions in section 4.4.4.1).

4.1.8 Duration of eligibility: 12 months of guaranteed eligibility

4.1.9

Other standards (identify and describe): must be (1) a citizen of the United States or must have legally resided in the US for at least 5 years if their date of entrance into the US is 8/22/96 or (2) meet the Personal Responsibility and Work Opportunity Reconciliation Act of 1997 (PRWORA) definition of qualified alien; and (3) ineligible for enrollment in any public group health plan; and, (4) a social security number is required for an applicant child, effective August 24, 2001.

4.2 The State assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b) (1) (B)) (42 CFR 457.320(b))

4.2.1 These standards do not discriminate on the basis of diagnosis.

4.2.2 Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income.

4.2.3 These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3 Describe the methods of establishing eligibility and continuing enrollment (Section 2102(b)(2)) (42 CFR 457.350)

Eligibility and redeterminations of eligibility will be conducted by staff under the administration of the Title XIX / Medicaid program consistent with those activities for Medicaid applicants / recipients.

Individuals will be enrolled with MCOs using the same Health Benefits Manager and the same process of enrollment as is used by Delaware’s Diamond State Health Plan. Individuals will be given a time frame to choose an MCO, and then, in the absence of any indication of choice, will be automatically assigned to an MCO based on location and availability of providers.

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

The application form for Delaware’s Title XXI program will be incorporated into the Medicaid application so that there is no need to apply separately after a determination of Medicaid eligibility is completed.

Eligibility will always be determined, as defined in the remainder of this section, by staff under the administration of the Title XIX/Medicaid program, using abbreviated, mail-in applications and outstationing eligibility staff at various sites. On a daily basis, the information on all Title XIX and Title XXI clients will be electronically transferred to the State’s Health Benefits Manager and the State’s Fiscal Agent. The Health Benefits Manager will mail information regarding all available MCO choices to the client. As with Title XIX, clients eligible under Title XXI will have an enrollment application that pre-selects an MCO for them. If written or verbal contact is not made by the client to the HBM within thirty (30) days of their eligibility start date, they will be assigned to the pre-assigned MCO. The HBM does a follow-up telephone contact 20 days after the first notice. All information from the HBM to the Title XXI eligible will carry the name of the Title XXI program and will be separate and distinct from Title XIX information.

Applicants who have been uninsured less than 6 months will be given a time when their pending application for the program can be approved. Families who do not pay the premiums may re-enroll at any time without penalty, with the re-enrollment period starting with the first month for which the premium is paid.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any) (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

4.4 Describe the procedures that assure that:

4.4.1 Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan; (Section 2102(b)(3)(A)) (42 CFR 457.350(a)(1) and 457.80(c)(3)

The Delaware Client Information System (DCIS) and the Medicaid Management Information System (MMIS) will be used to monitor and control eligibility. The DCIS will contain edits that assure that income and age limitations are not exceeded and that action is taken when a child is about to turn age 19. Likewise, the MMIS will contain edits that

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

assure that aid category codes for this population are limited to individuals under age 19.

4.4.2 The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102(b)(3)(B)) (42 CFR 457.350(a)(2))

The eligibility for Title XXI, Delaware Healthy Children Program, will be done in conjunction with a Medicaid application. Policy will require that Medicaid / Title XIX be the primary program for coverage for children. Since the benefits for the Medicaid population with “wrap around” services is a slightly richer package than for Title XXI, staff will be assuring that the Medicaid package has priority. The State’s DCIS II system includes this population to assure that Medicaid is first in the priority level for establishment of eligibility. (See Section 2.3)

4.4.3 The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42 CFR 431.636(b)(4))

Delaware uses a joint application form for Medicaid and Title XXI. Our automated eligibility system, DCIS II, incorporates a set of eligibility rules that explore the most beneficial and comprehensive benefits for applicants and recipients. Applicant and recipient data is evaluated through a "cascade" of Medicaid programs. If the applicant or recipient is found ineligible for Medicaid, the system automatically explores eligibility for Title XXI.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

The Delaware Title XXI program is targeted to uninsured children and is not expected to supplant any health insurance currently provided to any applicant. Delaware’s approach to crowd out is:

The joint application asks whether the applicant has had health insurance within the last six months. Children are not eligible for the Delaware Title XXI program unless they have been without health coverage for at least the six preceding months. Exceptions to this would be made if coverage is lost due to:

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

• death of parent, • disability of parent, • termination of employment, • change to a new employer who does not cover dependents, • change of address so that no employer-sponsored coverage is available, • expiration of the coverage periods established by COBRA • employer terminating health coverage as a benefit for all employees.

The recommendation for enforcement of this provision is:

Simple declaration at the time of application and during each redetermination.

The joint application asks whether the applicant currently has health insurance. The Third Party Liability Unit verifies this information.

Delaware will monitor the data collected from the application on private coverage, looking for trends on substitution of coverage over time.

4.4.4.2

Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: Describe how substitution is monitored and identify specific strategies in place to prevent substitution.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

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American Indian and Alaska Native children are eligible for the Delaware Healthy Children Program on the same basis as any other children in Delaware. All children in Delaware who may be eligible will be targeted through outreach efforts specifically outlined in Section 5.

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the State to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1) (42 CFR 457.90)

The State plans a multi-pronged approach to finding, notifying and assisting eligible children to enroll in DHCP such as:

• The State plans to replicate the simplified application process in place for Medicaid and continue to outstation staff to complete Medicaid and DHCP applications. Staff will coordinate the application so families can be screened and apply for both programs with a single application by mail without a face to face interview.

• During the Public Hearing process we will elicit partners who can help outreach to children in their communities, service area, client base etc. We will ask for their suggestions for outreach strategies. Delaware will supplement this process by considering the schools as an outreach point, because the Title XXI program targets children.

• Non-traditional outreach strategies, which have been used successfully in other States, such as adding a check off box to the reduced/free lunch application in schools, will be considered. The sentence will ask parents if they would like their child’s name referred to Medicaid for an application for benefits. Other non-traditional strategies may include fliers on pizza boxes and fast food trays, temporary agency employees paycheck inserts, article in the American Association of Retire Persons newsletter to reach grandparents raising their grandchildren.

• Delaware plans to search out other states’ initiatives that have been successful and replicate those in Delaware if feasible.

• The State will use all media types, which are cost effective, such as traditional mailings, newspaper, buses, and Public Service Announcements on radio and television for different ethnic/racial/demographic/age markets.

• The State will target children within the State programs who are known to be potentially eligible like children receiving food stamps, WIC, subsidized child care, etc. for a special “invitation” to join with a simplified application process since income/technical requirements are stored in common shared computer eligibility file.

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

• The State will periodically reevaluate and revise outreach strategies so enrollment is successful.

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1 The state elects to provide the following forms of coverage to children: (Check all that apply.) (42 CFR 457.410(a))

6.1.1. Benchmark coverage; (Section 2103(a)(1)) and 42 CFR 457.420)

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.)

6.1.1.2.

State employee coverage; (Section 2103(b)(2)). (If checked, identify the plan and attach a copy of the benefits description.) See Attachment A

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2)) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3)) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania]. Please attach a description of the benefits package, administration, date of enactment. If “existing comprehensive state-based coverage” is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for “existing comprehensive state- based coverage.”

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

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Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

6.1.4.1. Coverage the same as Medicaid State plan

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population

6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

6.1.4.5. Coverage that is the same as defined by “existing comprehensive state-based coverage”

6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done)

6.1.4.7. Other (Describe)

6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42 CFR 457.490)

The following services marked with an are covered by the Delaware Healthy Children Program either as part of a basic MCO benefit package when medically necessary or as a “wrap-around” service - exceptions/limitations noted:

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) - included as a “wrap-around” service with the same limitations as the Title XIX program. 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) - included as a “wrap-around” and limited to drug categories where the over- the-counter product may be less toxic, have fewer side effects, and be less costly than an equivalent legend product. 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

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6.2.10.

Inpatient mental health services, other than services described in 6.2.18, but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) - inpatient mental health and/or substance abuse treatment services will be provided as “wrap-around” services by the DSCYF. Inpatient services will be provided with limits based on medical necessity. Children who need inpatient services beyond this will convert to Medicaid Long-Term Care. 6.2.11. Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) - 30 days of outpatient care included in the basic MCO benefit. Additional days of outpatient mental health and/or substance abuse treatment services, with limitations based on medical necessity, will be provided by the DSCYF. See note in 6.2.10. 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) - limited to medically necessary home health services provided by the MCOs as part of the basic benefit. Does NOT include personal care, chore services, day care, respite care, or home modifications. Home health

aide services are covered as medically necessary according to the State’s published definition. 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) - there is a limit of 28 hours of Private Duty Nursing Services per week in the basic benefit; no additional hours available. 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) – included as “wrap- around” services with the same limitations as the EPSDT dental program. The SCHIP dental benefit is comprehensive in nature and consists of the following services: Diagnostic, Preventive, Restorative, Endodontics, Periodontics, Prosthodontics, Oral Surgery, and adjunctive services (such as, anesthesia, behavior management, occlusal guard, and treatment of dental pain). Orthodontic services are covered for diagnosed conditions considered to be handicapping malocclusions. 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) - see note in 6.2.10.

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6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) - see note in 6.2.10. 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) Emergency transportation only as provided in the basic benefit package. 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe:

6. 4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42 CFR 457.1005(a)):

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6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42 CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; and Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42 CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42 CFR 457.1005(a))

6.4.2. Purchase of Family Coverage. Describe the plan to provide family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low-income children.) (Section 2105(c)(3)(A)) (42 CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42 CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42 CFR 457.1010(c))

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Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(A)(7)(A)) 42 CFR 457.495(a))

Quality Assurance Structure

The MCO's utilization management and quality assurance program will consist of internal monitoring by the MCOs, oversight by DSS and the federal government, and evaluation by an independent, external review organization (EQRO). These programs are in place for the MCOs currently contracting for Title XIX clients and the same programs will be used for Title XXI. Future RFPs for Managed Care Organizations will include the need to provide services for both the Title XIX and the Title XXI programs. All MCOs must have a quality assurance structure composed of:

(a) An internal system of monitoring services;

(b) Designated staff with expertise in quality assurance; and

(c) Written policies and procedures for quality assurance and utilization management.

Quality Assurance System

As with Title XIX, MCOs are required to establish, implement, and adhere to the Quality Assurance and Utilization Management review systems approved by the Department and based on the current HCFA guidelines (A Health Care Quality Improvement System for Medicaid Managed Care issued July 6, 1993) or subsequent revisions thereof, and shall:

(a) Ensure that health care is provided as medically necessary in an effective and efficient manner;

(b) Assess the appropriateness and timeliness of care provided;

(c) Evaluate and improve, as necessary, access to care and quality of care with a focus on improving patient outcomes;

(d) Focus on the clinical quality of medical care rendered to enrollees; and

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(e) Incorporate all the "Minimum Quality Assurance and Utilization Management Requirements."

MCOs will be held accountable for monitoring, evaluating, and taking action as necessary to improve the health of its members under contract with DSS. MCOs will also be held accountable for the quality of care delivered by sub- contractors, which must comply with all quality management procedures and requirements of this RFP.

Quality Assurance Policy and Procedures

NOTE: These policies and procedures are already in place for Title XIX. MCOs must distinguish between Title XIX and Title XXI for reporting.

Internal policies and procedures must:

(a) Assure that the utilization management and quality assurance committee has established parameters for operating and meets on a regular schedule which is at least quarterly; committee members must be clearly identified and representative of the MCO's providers, accountable to the medical director and governing body, and must maintain appropriate documentation of the committee's activities, findings, recommendations, and actions;

(b) Provide for regular utilization management and quality assurance reporting to the MCO management and MCO providers, including profiling of provider utilization patterns;

(c) Be developed and implemented by professionals with adequate and appropriate experience in quality assurance;

(d) Provide for systematic data collection and analysis of performance and patient results;

(e) Provide for interpretation of this data to practitioners;

(f) Provide for making appropriate changes when problems in quality of care are found; and

(g) Clearly define the roles, functions, and responsibilities of the quality assurance committee and medical director.

Internal Quality Assurance Program

The MCO must have an internal written quality assurance plan (QAP) that monitors, assures, and improves the quality of care delivered over a wide

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range of clinical and health service delivery areas. Emphasis must be placed on, but need not be limited to, clinical areas relating to well baby care, well child care, pediatric and adolescent development, as well as on key access or other priority issues for [Title XXI] patients such as teen age pregnancy and immunizations.

All MCOs are to structure their internal QAPs in a manner consistent with the standards as outlined in the Federal Government's "Quality Assurance Reform Initiative Guide for States" (QARI) or subsequent revisions thereof, for internal and external quality assurance reviews.

Provider Profiling

The MCO must have written credentialing and re-credentialing policies and procedures for determining and assuring that all providers under contract to the plan are licensed by the State and qualified to perform their services according to CMS's "A Health Care Quality Improvement System for Medicaid Managed Care: A Guide for the States", or subsequent revisions thereof. The MCO also must have written policies and procedures for monitoring its providers and for disciplining providers who are found to be out-of-compliance with the MCO's medical management standards.

Quality Assurance Report

As with the existing Title XIX program, plans will also be required to submit periodically to DSS reports regarding results of their internal monitoring. This will include the reporting of The Health Plan Employer Data and Information Set (HEDIS), version 3.0 or subsequent revisions, and other targeted health indicators that shall be monitored by DSS as well as other specific quality data periodically requested by the federal government. The MCO must agree to submit a quality assurance report six (6) months after the contract effective date and semi-annually thereafter. These reports will distinguish clearly between the Title XIX and the Title XXI programs.

Outcomes Objectives

The State, in conjunction with the MCOs, will develop a system of incentives for reaching outcome objectives in certain key areas to be defined by the State and MCOs. These outcome objectives will include, at a minimum, childhood immunizations, well baby and well child care pediatric asthma, and behavioral health care. MCOs will be required to submit on a periodic basis objective numerical data and/or narrative reports describing clinical and related information on health services and outcomes of health care for the Title XXI and Title XIX enrolled populations. Each program will be handled as separate programs for reporting.

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Internal Staff

The State’s enrolled populations for the Title XIX and the Title XXI programs are too small to require separate internal programs for the MCOs. Therefore, internal staff and internal committees may serve both populations. A clear definition will be made during reporting.

The MCO must designate a quality assurance and utilization management coordinator, who is either the MCO's medical director or a person who directly reports to the medical director. This individual is responsible for the development and implementation of the quality assurance program. The coordinator must have adequate and appropriate experience in successful utilization management and quality assurance programs and be given sufficient time and support staff to carry out the MCO's utilization management and quality assurance functions. This person, or persons, will also be responsible for assuring the interface and support of the EQRO and State quality assurance functions as necessary.

Quality Assurance Committee

MCOs must have a quality assurance committee that assists the coordinator in carrying out all quality assurance functions. This committee must satisfy the DSS's requirements and, at a minimum:

(a) Demonstrate that the Committee will have oversight responsibility and input on all quality assurance and utilization management activities;

(b) Demonstrate that the committee has accountability to the MCOs governing board;

(c) Ensure membership on the committee and active participation by individuals representative of the MCOs provider community; and

(d) Demonstrate that the contractor will secure adequate insurance for members of the committee and subcommittees.

Quality Assurance and Utilization Management Coordinator

The coordinator and the quality assurance committee must be accountable to the MCO's governing body.

The qualifications and responsibilities must include but need not be limited to what follows below. Specifically, the coordinator must:

(a) Be licensed to practice medicine in the United States and be board- certified or board-eligible in his or her field of specialty;

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(b) Be responsible for developing the MCO's annual written quality assurance description including areas and objectives, scope, specific activities, and methodologies for continuous tracking, provide review and focus on health outcomes;

(c) Be responsible for the MCO's utilization management and quality assurance committee, direct the development and implementation of the MCO's internal quality assurance plan and utilization management activities, and monitor the quality of care that MCO members receive;

(d) Oversee the development of clinical care standards and practice guidelines and protocols for the MCO;

(e) Review all potential quality of care problems and oversee development and implementation of continuous assessment and improvement of the quality of care provided to members;

(f) Assure that adequate staff and resources are available for the provision of proper medical care and health education to members;

(g) Specify clinical or health service areas to be monitored;

(h) Specify the use of quality indicators that are objective, measurable, and based on current knowledge and clinical experience for priority areas selected by DSS as well as for areas the MCO selects; current Health Plan Employer Data and Information Set standards must be used;

(i) Oversee the MCO's referral process for specialty and out-of-plan services; all denied services must be reviewed by a physician, physician assistant, or advanced nurse practitioner; the reason for the denial must be documented and logged; all denials must identify appeal rights of the member;

(j) Be involved in the MCO's recruiting and credentialing activities;

(k) Be involved in the MCO's process for prior authorization and denying services;

(l) Be involved in the MCO's process for ensuring the confidentiality of medical records and member information;

(m) Be involved in the MCO's process for ensuring the confidentiality of the appointments, treatments, and required State reporting of adolescent sexually transmitted diseases;

(n) Work with the special programs coordinator to assure that reports of disease and conditions are made to DSS in accordance with all

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applicable State statutes, rules, guidelines, and policies and with all metropolitan ordinances and policies;

(o) Assure that control measures for tuberculosis, sexually transmitted diseases, and communicable disease are carried out in accordance with applicable laws and guidelines and contained in each provider manual;

(p) Serve as a liaison between the MCO and its providers and communicate regularly with the MCO's providers, including oversight of provider education, in-service training, and orientation;

(q) Be available to the MCO's medical staff for consultation on referrals, denials, complaints, and problems;

(r) Attend State medical director's meetings;

(s) Maintain current medical information pertaining to clinical practice and guidelines; and

(t) Attend grievance committee meetings when necessary.

External Quality Assurance Reviews

DSS will contract with independent, external evaluators to examine the quality of care provided by MCOs. The State will amend the existing contract with its EQRO for the Title XIX program. The amendment will clearly define the need to keep the populations and associated reporting separate.

The MCO will be required to cooperate with any external quality, independent assessment of its performance, which has been duly authorized by DSS. Independent assessments shall include, but not be limited to, the federally required reviews of (1) access to care, quality of care, cost effectiveness, and the effect of case management; (2) the contractor's quality assurance procedures, implementation of the procedures, and the quality of care provided; and (3) consumer satisfaction surveys.

The MCO agrees to assist in the identification and collection of any data or medical records to be reviewed by the independent assessors and/or DSS. The contractor shall ensure that the data, medical records, and workspace are available to the independent assessors or DSS at the contractor's work site.

DSS will monitor each MCO's adherence to QARI standards through one or more of the following mechanisms:

(a) Review of each MCO's written QAP prior to contract execution;

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(b) Periodic review of numerical data and/or narrative reports describing clinical and related information on health services and outcomes of health care for the enrolled population;

(c) On-site monitoring by DSS of QAP implementation to ensure compliance with all standards; such monitoring will take place at least once every six (6) months;

(d) Independent, external review of the quality of services furnished by each MCO, conducted by an entity under contract to DSS; such reviews will be conducted at least once each year; the MCO must agree to make available to DSS's external evaluator medical and other records (subject to confidentiality constraints) for review as requested;

(e) On-site visits and inspections of facilities;

(f) Staff and enrollee interviews;

(g) Review of appointment scheduling logs, emergency room logs, denial of services, and other areas that will indicate quality of care delivered to enrollees;

(h) Medical records reviews;

(i) All quality assurance procedures, reports, committee activities and recommendations, and corrective actions;

(j) Review of staff and provider qualifications;

(k) Review of grievance procedures and resolutions; and

(l) Review of requests for transfers between primary care providers within each MCO.

The MCO shall submit a corrective action plan to resolve any performance or quality of care deficiencies identified by the independent assessors and DSS as determined necessary by DSS.

Fraud and Abuse Protections

The MCO may not knowingly:

(a) have a person who has been debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non procurement activities under regulations issued pursuant to Executive Order 12549 or under guidelines implementing such order, as a Director, officer,

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partner, or person with beneficial ownership of more than 5% of the entity’s equity, or

(b) have an employment, consulting, or other agreement with a person described above for the provision of items and services that are significant and material to the entity’s obligations under its contract with the State.

The MCO may not distribute directly or indirectly or through any agent or independent contractor marketing materials within the state:

(a) without prior approval of the State, and,

(b) that contains false and materially misleading information.

The MCO shall develop marketing materials specially for the Title XXI program. These materials will be provided to the State’s HBM. The HBM will include these materials in all mailings to the eligible population.

The MCO shall distribute marketing materials to entire service areas covered under this contract.

The MCO or its subcontractors may not seek to influence an individual’s enrollment with the MCO in conjunction with the sale of any other insurance.

The MCO shall comply with such procedures and conditions as the State prescribes in order to ensure that before a member is enrolled with the MCO, the individual is provided accurate oral and written information sufficient to make an informed decision.

The MCO shall not directly or indirectly, conduct door-to-door, telephonic or other “cold-call” marketing of enrollment.

The MCO shall require each professional providing services to members eligible for the program to have a unique provider identifier, the method of which will be approved by the State.

The MCO shall report any fraudulent or abusive practices by subcontractors or providers to DSS for investigation or referral to other appropriate authorities and must cooperate with any subsequent investigation. The MCO and its providers are subject to review or investigation by DSS and other State agencies for quality of care, fraud or abuse, and must cooperate fully in the provision of requested information to offices, including but not limited to, DHSS, the Department of Justice, the State Auditor, the Insurance Department, and the appropriate licensing agencies within the Department of Administrative Services.

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Member Satisfaction Report

MCOs must survey their members on at least an annual basis to determine satisfaction with MCO's services.

The MCO must agree to collect and assist DSS in collecting annual member satisfaction data through application of a uniform instrument to a randomly selected sample of its members The State will design a questionnaire to measure satisfaction and include measures of out-of-plan use, to include use of emergency rooms; average waiting time for appointments, including physician office visits; average time and distance to reach providers; access to special providers; and the number and causes of disenrollment; and coordination with other health programs. This member satisfaction survey will be based on the Consumer Assessment of Health Plan Survey (CAHPS). To ensure comparability of results, all members will receive the same survey. DSS will consider suggestions from the MCO for questions to be included in this survey. DSS will tally the results of these surveys, which will be published.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1. Quality standards 7.1.2. Performance measurement 7.1.3. Information strategies 7.1.4. Quality improvement strategies

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42 CFR 457.495)

NOTE: These policies and procedures are already in place for Title XIX. MCOs must distinguish between Title XIX and Title XXI for reporting.

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

MCO's must have an internal written quality assurance plan (QAP) that monitors, assures, and approves the quality of care delivered over a wide range of clinical and health service delivery areas to include, but are not limited to:

• Well baby care; • Well child care; • Pediatric and adolescent development; and, • Immunizations.

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Plans are also required to report semi-annually results of their internal monitoring. This will include the reporting of the above-referenced HEDIS indicators.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR §457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Delaware will expect its contracting Medicaid MCOs to use existing provider panels to provide services to the DHCP. The State requires a 1:2500 patient to primary care provider ratio for DSHP and expects the MCOs to maintain that ratio for the DHCP. The MMIS provides weekly reports on MCO capacity. These reports are monitored by DSHP staff. The MCOs are notified of access issues and the need to add providers. Delaware Medicaid's contracting MCOs have contracts with all of the State's hospitals for outpatient and emergency care. A majority of Delaware’s physician providers also contract with the Medicaid MCOs. The State’s contracting MCOs report percentage of primary providers with open panels on a quarterly basis to DSHP.

The state requires the "prudent layperson" language for emergency services as defined by the BBA of 1997. This regulation also restricts the use of prior authorizations for emergency care and the denial of emergency care provided by non-network providers.

The State will perform consumer satisfaction surveys and will require the MCOs to perform consumer satisfaction surveys. Issues related to access are an integral part of these surveys. The State uses a modified CAHPs survey for the DSHP and will use the same methodology for the DHCP. The State also uses grievance and complaint records for DSHP to identify MCO panels that may be reaching capacity. These methods have worked well for DSHP and we would expect the same results for the DHCP.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

Benefit procedures exist for members with chronic, complex, or serious conditions. All of the managed care organizations must comply with regulations regarding access to and adequacy of specialists.

During enrollment, the Health Benefits Manager screens enrollees with chronic, complex, or serious medical conditions and refers this information to the MCOs. The MCOs utilize case managers to assure appropriate access to care for children with serious health care needs.

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7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

The state complies with SCHIP requirement of decisions related to the prior authorization of health services within 14 days after receipt of request.

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Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505)

8.1.1. YES 8.1.2. NO, skip to question 8.8.

Describe the amount of cost-sharing and any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) & (c), 457.515(a)&(c))

8.2.1. Premiums: $10 per family per month (PFPM) for families with incomes between 101% and 133% of the FPL, $15 PFPM for families with incomes between 134% and 166% of the FPL, and $25 PFPM for families with incomes between 167% and 200% of the FPL (see Section 4.3 for information on effect of non-payment of premiums). Incentives for pre-payment of premiums will be considered. 8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: $10 per emergency room visit (waived if results in immediate inpatient hospitalization or if a prudent layperson would interpret the need for the visit to the ER to be an emergency) 8.2.4. Other:

8.3 Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)(1)(B)) (42CFR 457.505(b))

The public will be notified of cost sharing requirements and any other aspects of the DHCP through the State’s Administrative Procedures Act which requires publishing everything that has an impact on State citizens and provides an opportunity for public comment. Information is published in the Delaware Register of Regulations monthly as changes or new initiatives occur (www.state.de.us/research/dor/register.htm). Information will also be initially provided at public meetings and through outreach and educational efforts. Delaware will also use the Health Benefits Manager to educate and continue to do outreach similar to the DSHP.

8.4 The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

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8.4.1. Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42 CFR 457.520) 8.4.3. No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. Section 2103(e)(1)(A)) (2CFR 457.515(f))

8.5 Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child's eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Since cost sharing is per family per month (PFPM), rather than per member per month, each family will pay the same amount no matter the number of children in the household. The premium rates are significantly less than those allowed by the Balance Budget Act of 1997 for premiums (see chart below). There is a minimal copayment of $10 per inappropriate use of the emergency room that will be waived if a prudent layperson would deem the visit an emergency or if it results in an inpatient admission. Delaware believes these levels of cost sharing are affordable but, at the same time, provide an incentive for clients to responsibly use health care services and avoid unnecessary emergency room visits.

An analysis of the State's fee schedule suggests that cumulative cost-sharing will rarely exceed 1% of the family's adjusted gross income. However, should families submit evidence that they have reached the aggregate limit on cost- sharing, the State will work with the MCOs on an individual basis to exempt the family from future cost-sharing. Premiums as a percentage of Income % of FPL* Family Size 101% 133% 134% 166% 167% 200% $120 Annual Premium 1 1.47% 1.12%

2 1.09% 0.83%

3 0.87% 0.66%

$180 Annual Premium 1

1.66% 1.35%

2

1.23% 1%

3

0.98% 0.79%

$300 Annual Premium 1

2.23% 1.86%

2

1.65% 1.38%

3

1.32% 1.1% * Based on the 1998 Poverty Limit of $8050 for 1 person, $10,850 for 2, and $13,650 for 3.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

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Delaware's application form asks for race group including American Indian/Alaskan Native and we accept self-declaration. This information is included in the automated record, which enables us to exclude these families from premium requirements. We will add a statement to the approval notices indicating that American Indian/Alaskan Native families are exempt from premium requirements. The approval notices include a toll free contact number. To exclude American Indian/Alaska Native enrollees from any copayments on non-emergent use of emergency room services, the premium and approval notices will include a statement advising families the AI/AN families are exempt. The notices will advise AI/AN families to call the Health Benefits Manager (HBM) at a toll-free number to identify themselves and request an exemption. MMIS has an exemption code that must be manually entered by the HBM.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Coverage will be cancelled when the family is in arrears for two premium payments. The coverage will end the last day of the month when the second payment is due. A notice of cancellation will be sent to the family advising the family to report any change in circumstances, such as a decrease in income that may result in eligibility for Medicaid. If one premium payment is received by the last day of the cancellation month, coverage will be reinstated.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:



State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

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8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

1) to decrease the number of uninsured children and thereby improve their health and chances for life success; 2) to mainstream uninsured children in the health care industry so they receive the same quality of care as insured children; and 3) to go from a clinical base system (fee-for-service/sick care) to a community-base system (managed care/preventive care) which provides genuine access to high quality care.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1) show-rate of uninsured children; 2) percentage increase in wellness visits; and 3) percentage decline in unnecessary emergency room visits.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A), (B)) (42CFR 457.710(d))

The State will use the first year of the DHCP to develop base line information to monitor future years of the program. In addition, the State will expect the same utilization reporting for the DHCP that we currently receive for the DSHP. We will also monitor the experience of the DHCP against the experience for the same age cohorts under the DSHP to look for possible outliers.

The State will require encounter data submission for the DHCP. The State can also identify specific reporting categories and require the MCOs to report that information from their database. The State will be able to report all of the CMS required information identified in section 9.3.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1. The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. The reduction in the percentage of uninsured children. 9.3.3. The increase in the percentage of children with a usual source of care. 9.3.4. The extent to which outcome measures show progress on one or more of the health problems identified by the state.

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9.3.5. HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. Other child appropriate measurement set. List or describe the set used. 9.3.7. If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1.

Immunizations 9.3.7.2.

Well child care 9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, please list: ER Visits 9.3.8. Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.720)

The State of Delaware has provided quarterly reports and Annual progress reports to CMS for the DSHP. The format and process used has received compliments from the CMS Central office. We expect to use the same format and reporting methodology for the DHCP. This reporting will include all of the CMS requested reports. The reports will contain a short summary review of the Title XXI program over the last quarter, or reporting year. This summary will be supported by back-up attachments that show the information requested in Sections 9.3 and 10.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1. Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) - State general funds for mental health services covered under the SCHIP State Plan are appropriated annually to the Delaware Department

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of Services for Children, Youth and Their Families (DSCYF). Claims for covered behavioral health services are submitted to DMMA by DSCYF during the year as services are provided, and as the claims are processed and paid by DMMA. The State draws down the appropriate federal share and provides it to DSCYF. 9.8.3. Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. Section 1132 (relating to periods within which claims must be filed)

9.9 Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

A Legislative hearing was held on 3/18/98 related to Senate Bill 246, which would authorize the DHCP for Delaware. There were thirty (30) advocates present with testimony from eleven (11) and written testimony from three (3).

The Delaware Health Care Commission (DHCC) hosted public hearings to obtain input on the Title XXI Plan in Kent County (Milford Library) on 3/31/98 and New Castle County (Stanton Middle School) on April 1, 1998.

The major issues raised at all hearings were the imposition of premiums, the six- month waiting period after loss of other insurance, the proposed $25 copay on ER services, and the exclusion of dental benefits for these children. In addition, advocates expressed concern that the State was not pursuing presumptive eligibility.

The DHCC, after deliberating the testimony, supported the Plan as written with modifications/exceptions to the six-month waiting period and the $25 copay on ER services. The recommended changes are reflected in this submission.

Delaware will publish, concurrent with this Plan submission, notice in the State’s Register of Regulations under the requirements of the Administrative Procedures Act (APA). Any changes proposed after the Plan is implemented will be published in accordance with the APA with appropriate periods for comment and review/consideration of comments.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR §457.125. (Section 2107(c)) (42CFR 457.120(c))

Delaware has no federally or State-recognized Indian tribes. Any Delaware resident, including those who are American Indians or Alaska natives, may participate in the review of amendments to State law or regulation and may offer comments on all Program policies, including those relating to provision of child health assistance to American Indian or Alaska native children. The process for review and comment is outlined in 9.9.2 below.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).

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Delaware will publish, concurrent with Plan submission, notice in the State’s Register of Regulations under the requirements of the Administrative Procedures Act (APA). Any changes proposed after the Plan is implemented will be published in accordance with the APA with appropriate periods for comment and review/consideration of comments.

9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

See Attachment 1.

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Section 10. Annual Reports and Evaluations (Section 2108)

10.1 Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1), (2)) (42CFR 457.750)

10.1.1. The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2. The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3. The state assures it will comply all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

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Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1 The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b))

11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents)

11.2.2.

Section 1124 (relating to disclosure of ownership and related information)

11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals)

11.2.4.

Section 1128A (relating to civil monetary penalties)

11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges)

11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

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Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR §457.1120.

Note: Delaware is using Medicaid Fair Hearing Practices and Procedures for review of eligibility and enrollment, as follows:

Timely written notices of agency actions are provided to applicants and recipients that include a statement of the right to a fair hearing, how to request a hearing, and a statement that he or she may represent him or herself or may be represented by counsel or by another person. An opportunity for a fair hearing will be provided to any individual requesting a hearing who is dissatisfied with a decision of the Division of Social Services, (i.e., denial, suspension, reduction, delays, termination, disenrollment for failure to meet premium payment requirements). If the recipient requests a hearing within the timely notice period, enrollment will not be suspended, reduced, discontinued, or terminated until a decision is reached after a fair hearing.

The hearing officer will be an impartial official and may not have been previously involved with the matters raised at the hearing outside his duties as hearing officer. The notice of the hearing informs the applicant or recipient of the hearing procedures and of the opportunity to examine the record prior to the hearing.

The decision of the hearing officer shall be in writing and shall be sent to the appellant as soon as it is made but not more than 90 days after the date the appeal is filed.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR §457.1120.

Note: Delaware is using Medicaid Fair Hearing Practices and Procedures for review of health service matters, as follows:

MCOs must give clients due process rights when it denies, reduces, or terminates a client's health service; it must notify the client or his/her authorized representative in writing of the right to file a complaint/grievance. The notice shall explain: 1) how to file a complaint/grievance with the MCO; 2) how to file a complaint grievance with the State; 3) that filing a

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complaint/grievance through the MCO's complaint grievance process is not a prerequisite to filing for a State hearing; 4) the circumstances under which health services will be continued pending a complaint/grievance; 5) any right to request an expedited complaint/grievance; 6) the right to advised or represented by an ombudsman, lay advocate, or attorney; and, 7) the right to request that a disinterested third party who works for the MCO assist in the writing of the complaint/grievance.

The MCO will notify the client of complaint/grievance resolution or schedule a date for the Grievance Committee non-expedited formal hearing within ten (10) calendar days of receipt of the request for the formal hearing. The complaint/grievance formal hearing must take place within thirty (30) calendar days of receipt of the written complaint/grievance (nonexpedited formal hearing). The MCO must render a decision to the client within thirty (30) calendar days of receipt of the written complaint/grievance (nonexpedited). If the decision affirms denial, reduction, or termination of a client's health service or in any way denies the resolution sought, the client will be informed of the right to apply for a fair hearing.

The MCO must ensure that the MCO's complaint/grievance system cannot be prerequisite to, nor a replacement for, the client's right to appeal to the Division of Social Services and request a fair hearing in accordance with 42 CFR 431, Subpart E.

The MCO must comply with DSS hearing rules and final hearing decisions.

The MCO will provide for an expedited formal complaint/grievance hearing (twenty-four (24) to forty-eight (48) hours) for any action, which seriously jeopardizes the client's health or well-being.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR §457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

N/A for Delaware