Vol. 4, No. 2, March/April 1996	Previous Issues Subscribe to AT Messenger Download PDF Viewer
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Financing Assistive Technology
The New Delaware Medicaid Managed Care System

Ron Sibert, DATI Funding Specialist

The Delaware Medical Assistance Program (DMAP) is the official name of our state Medicaid program. DMAP, which operates out of Delaware's Department of Health & Social Services (DHSS), recently launched its new Medicaid managed care (HMO-type) health insurance program called the Diamond State Health Plan (DSHP). In theory, all of the services that had been available to Medicaid beneficiaries under the old program are still covered, but the process of accessing those services is now very different.

Probably the most obvious change is that the DSHP services are provided by subcontractors, currently four managed care organizations (MCOs). These agencies have been employed by the State/DMAP to provide Medicaid managed care services; a list of MCOs and their contact information can be found at the end of this article. Anticipating the inevitable confusion about enrollment and service access, the State has also contracted with an agency to provide coordination and support services. This agency is called a Health Benefits Manager (HBM). Electronic Data Systems (EDS) is Delaware's current provider of HBM services (1-800-996-9969). These services include client outreach, assisting beneficiaries with MCO selection and enrollment, and resolving problems with claims on the client's behalf. The latter service is part of a new grievance resolution process discussed in more detail below.

There have also been some changes in Medicaid program and service eligibility. All regular/"categorically eligible" Medicaid beneficiaries are required to enroll in the DSHP. However, certain groups are NOT required to enroll. Those exempt groups include:

• Medicaid recipients in long term care institutions (e.g., nursing homes, ICF/MRs, & ICF/IMDs)
  
• Those who are eligible for home and community-based services through Medicaid Waivers for people who are elderly, disabled, have AIDS/HIV, or mental retardation
  
• Medicaid recipients who also have Medicare
  
• Medicaid eligibles who have other accessible managed care insurance.

Covered services (including equipment) for these exempt groups are to be reimbursed on a "fee for service" basis, which just means that for the exempt groups, claims will be processed the same as they've always been.

One frequently cited benefit of the new system is that a significant number of people who were previously uninsured and not eligible for Medicaid benefits are now qualified. In DMAP's general policy, this newly eligible group is called "the expanded population," and its members qualify for Medicaid benefits at a slightly higher income level compared to the traditional group. However, the state-authorized benefits packages for the two groups are not the same. The categorically eligible group's coverage is slightly more comprehensive. Even so, both groups (that is the expanded population, and all nonexempt categorically eligible beneficiaries) MUST enroll in DSHP and select an MCO. Careful selection of a good compatible MCO is also important; not only because one's physician(s) must be a member(s) of the MCO, but because the benefits packages provided by the individual MCOs are not necessarily identical. Some, for example, may offer services not required by the State (DHSS) in the Medicaid subcontract. I would advise prospective applicants to call the MCOs to do some pre-enrollment comparison shopping before and/or after contacting the HBM. Once a person enrolls with an MCO, s/he is generally required to stay for at least one year. Switching to another plan is only permitted once per year during the open enrollment period. However, an MCO may "disenroll" or drop a person from the plan for "cause." The MCO has the right, for instance, to disenroll a member who habitually uses emergency room services instead of going to an MCO-authorized facility. If disenrolled, the person is still not allowed to leave the DSHP program, but would have to work with the HBM to select and enroll in another managed care plan.

Assistive technology devices are still generally covered as durable medical equipment (DME), but They are now provided through the MCOs. However, the DME providership picture is a bit different. Each MCO maintains a list of its preferred/contracted equipment suppliers. They will only furnish equipment through suppliers with which they have a relationship. However, there is also some flexibility. Each of the MCOs has a mechanism for handling "unusual" equipment claims. For instance, if the device is judged to be a covered item, MCO administrators have expressed a willingness to recruit the suppliers of such equipment to be included on their list of preferred suppliers. Even so, we can probably expect to see at least a few delays and incorrect denials until the MCOs have progressed further along the learning curve (although I've recently been made aware of two MCO-approved claims for augmentative communication devices!).

In any case, a denial should not be taken as the final word. Instead, it should be treated merely as a request for additional information, e.g., from the prescribing physician and/or other involved health care professionals. Denied claims are quite often reversed on appeal, which brings me to yet another set of changes in the system-the new grievance procedure.

For DSHP Medicaid beneficiaries, the complaint/appeal process starts with the HBM. Recall that the HBM is responsible for handling disputes between the beneficiary and the MCO; that includes equipment claim denials and coverage disputes. DMAP, however, still monitors MCO operations and provides some level of oversight. To illustrate, let's say that the MCO and HBM fail to resolve an equipment claim denial, and the device in question has customarily been covered as DME under the Medicaid state plan. Let's also assume that the MCO has never encountered a claim for this type of equipment, does not consider it DME, and refuses to provide it. In this case, DMAP would either intercede and compel the MCO to provide the equipment, or provide the equipment itself as a fee for service claim.

Of course, it is possible for DMAP to deny the claim as well. However, the beneficiary is still entitled to due process (appeal, fair hearing, administrative law judge, etc.) protections under the law, and may exercise those if necessary. Based on my discussions with MCO and DMAP administrators, it appears likely that such disputes will be resolvable at the first (MCO/HBM) level.

Delaware's MCOs and their service areas are:

AMERIHEALTH FIRST
Serving Kent, Sussex, and New Castle Counties
Customer Service:1-800-573-4100
Provider Services: (302) 777-6400, ext. 0956
Administration: (215) 241-3376

DELAWARE CARE
Serving Kent, Sussex, and New Castle Counties
Customer Service: 1-800-713-5095
Administration: (302) 576-8200

FIRST STATE HEALTH CARE
Serving New Castle County
Customer Service: (302) 576-7600
Administration: (302) 576-7605

BLUE CROSS & BLUE SHIELD OF DELAWARE
Serving Kent & Sussex Counties
Customer Service: 1-800-297-6603
Administration: (302) 421-3293