Home care billing in Delaware

Managed care. CMS's 2024 state tables describe Diamond State Health Plan and Diamond State Health Plan Plus as a statewide MCO plus MLTSS program under 1115(a) authority, started January 1, 1996 and approved through December 31, 2028, with aged, blind or disabled members and full duals enrolled on a mandatory basis. Its benefits include home health, state plan personal care, HCBS waiver services, private duty nursing, nursing facility services and hospice, and the participating plans are Highmark Health Options of Delaware, AmeriHealth Caritas of Delaware and Delaware First Health.² Non-emergency transportation runs outside the plans as a separate Modivcare program, and PACE is the voluntary alternative for those who choose it. Medicaid.gov's record of the Diamond State Health Plan demonstration, cited below, shows it first approved on May 17, 1995 and lists an HCBS amendment approved on June 28, 2023.

A state system with a third-party option. Since December 30, 2022, in-home personal care and home health services for Medicaid members must be verified with either the state-provided EVV solution, Sandata, or an alternate EVV solution that meets state and federal standards, and every provider of those services, on either route, must register through the Sandata provider self-registration portal.⁴ CMS's November 2, 2023 letter, cited below, found Delaware compliant for home health EVV in the 1905(a)(7) benefit, the 1915(c) waivers, the 1915(i) option and the 1115 demonstrations, and CMS lists the state compliant as of January 1, 2023. For personal care, CMS's March 25, 2021 letter found the 1915(c), 1915(i) and 1115 authorities out of compliance while the state-operated system was delayed, and the 1905(a)(24) state plan benefit compliant.

Services under EVV⁴

• In-home personal care services (PCS) for Medicaid members, verified since December 30, 2022
• Home health services (HHS) for Medicaid members, verified since December 30, 2022

Through the member's plan. In Delaware First Health's manual, LTSS services require approval and prior authorization by the plan, the LTSS case manager sends service authorizations to providers once the member's needs assessment is complete and the person-centered service plan is agreed with the member, caregivers and interdisciplinary team, and the provider is responsible for receiving an authorization from the LTSS case manager for every service it delivers.¹ Home health has its own steps in Delaware First Health's quick reference guide, cited below: standard requests go in at least 5 calendar days before the service start date, the plan approves up to the first six visits (an evaluation and five visits) when the order is submitted within 5 days of start of care, private duty nursing and hourly aide requests are reviewed for 60 days at first and 180 days on continuation, and LTSS HCBS requests carry a 14-calendar-day decision timeframe. Those figures come from one of the three plans, so the member's plan is checked before they are applied.

To the member's plan. Delaware First Health requires every first-time claim within 120 calendar days of the date of service; when the provider is pursuing a third party, the clock starts on the date that party documented its resolution, and for a retroactive enrollment it starts when the plan receives the state's notice of the member's eligibility.⁸ The same billing manual sets EVV units: each visit is rounded to the nearest 15-minute or hourly increment according to the code billed, using its unit charts. Its payment policy DE.PP.005, cited below, pays up to three agencies for the same member on the same date of service for its listed personal care, respite, private duty nursing and aide codes, limits the total to the units authorized, and asks an agency serving more than one member in the same home to bill each member on a separate claim with the modifier for the number of members seen.

CGS Administrators handles Medicare home health and hospice claims for Delaware under its Jurisdiction 15 contract, the same HH+H workload that covers Colorado, the District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming.¹⁰ On the Medicaid side, home health is a covered DSHP and DSHP Plus benefit and a prior authorization item at Delaware First Health, which wants a physician order with the initial request and a recent plan of care for ongoing visits. CMS lists Delaware compliant with the Cures Act home health EVV requirement as of January 1, 2023.