Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

Members eligible for SDAC services must have a prior authorization on file for either home health aide services or private duty nursing.

Authority for a self-direction option for parents on behalf of children up to age 21, receiving State Plan personal care services. Self-directed personal care/attendant care services for children includes assistance with ADLs (e.g., bathing, dressing, personal hygiene, transferring, toileting, skin care, eating and assisting with mobility).

This service includes assistance with instrumental activities of daily living (IADLs) (e.g., light housekeeping chores, shopping, meal preparation). Assistance with IADLs must be essential to the health and welfare of the participant based on the assessment of the Case Manager, provided to only the member and not for general utility within the household. A parent/guardian or other representative designated by the parent/guardian shall direct this service on behalf of the member (Delaware Health and Social Services, 2022).

To be eligible to receive self-directed personal care/attendant care services a child must have a chronic medical condition, intellectual/developmental disability, or behavioral health condition which results in the need for assistance with age-appropriate ADLs/IADLS (Delaware Health and Social Services, 2022).

Assessment

The HHO case manager shall inform and educate members and member representatives about the option to self-direct their attendant care services. As part of this discussion the HHO case manager shall obtain from the member a signed statement regarding the member’s decision to participate or not participate in SDAC.

If a member elects SDAC, the HHO care coordinator will assess the member. The assessment instrument shall be completed by the member with assistance from the HHO care coordinator as appropriate. The HHO care coordinator shall file the completed assessment in the member’s electronic case record.

If, based on the results of the assessment, the HHO care coordinator determines that a member requires assistance to direct his/her attendant care services, the HHO care coordinator will inform the member that he/she needs to appoint a representative to perform the employer responsibilities on his/her behalf (Employer Representative). The HHO care coordinator will ensure that an Employer Representative agreement is completed and signed by the Employer Representative and the member, but also that the Employer Representative is not the self-directed care employee for that member.

For SDAC for Children, the care coordinator shall ensure that an Employer Representative agreement is completed and signed by the Employer Representative and that the Employer Representative is not a Self-Directed Employee for that member.

Financial Management Services

The provider of support for SDAC shall be an IRS-approved Fiscal/Employer Agent that functions as the member’s agent in performing payroll and other employer responsibilities that are required by Federal and State law.

At a minimum, the provider of support for SDAC conduct the following FMS functions:

• Assist members in verifying Attendant Care Employees’ citizenship status;
• Collect and process Attendant Care Employees’ timesheets;
• Assist members in ensuring that workers compensation insurance is purchased and maintained;
• Process payroll, withholding, filing and payment of applicable Federal, State and Local employment-related taxes and insurance;
• Execute and hold Medicaid provider agreements; and
• Receive funds from the Contractor and disburse funds for payment of Attendant Care Employees.

Supports Brokerage Functions

The provider of support for SDAC shall perform, at a minimum, the following supports brokerage functions:

• Coordinate with the member’s HHO care coordinator to develop, sign, and update the member’s plan of care to include SDAC;
  
• Recruit Attendant Care Employees;
• Maintain a roster of Attendant Care Employees;
• Assist with developing and posting job descriptions for Attendant Care Employees;
• Secure and pay for background checks on prospective Attendant Care Employees on behalf of members;
• Assist with hiring, supervising, evaluating, and discharging Attendant Care Employees;
• Assist with completing forms related to employers;
• Assist with approving timesheets;
• Provide information on employer/employee relations;
• Provide training to members and Attendant Care Employees;
• Provide assistance with problem resolution;
• Maintain member files; and
• Provide support to the member as an employer in executing the member’s back-up plan for SDAC.

Self-Directed Employee Qualifications

Financial management services delegated by HHO will verify that potential self-directed employees meet all applicable qualifications prior to delivering services including the following minimum qualifications: at least 18 years of age, have the skills necessary to perform the required services, possess a valid Social Security number and willing to submit to a criminal record check.

For each potential self-directed employee, HHO (or delegate), shall conduct a criminal history check pursuant to 16 DE Admin Code 3110, a check of the Delaware’s Adult Abuse Registry (see 11 DE Admin Code 8564; registry is available on the DHSS website), a check of the national and the Delaware sex offender registry and a check of the excluded provider list.

The financial management services provider will notify the member of the findings of the checks as applicable to his/her potential self-directed employee(s).

• If a member wants to employ a person who does not pass the criminal history check, the financial management service provider shall educate the member of the risk. If the member insists on hiring a person who does not pass the criminal history check, the financial management services provider shall have the member sign a waiver of liability stating that they understand the risks and want to hire the person despite his/her failure to pass the criminal history check and will hold the State and HHO harmless from any claims or responsibility for any injury, loss, or damage because of hiring the person.
• A person who is listed on the Delaware Adult Abuse Registry, the national or Delaware sex offender registry or the excluded provider list shall not provide SDAC services.

Members have the flexibility to hire persons with whom they have a close personal relationship to serve as a Self-Directed Employee, such as a neighbor, friend, or family member including legally responsible family members. 

The financial management service provider will ensure that each member has an employment agreement with a Self-Directed Employee prior to services being provided by that Self-Directed Employee. HHO will not pay a Self-Directed Employee for the provision of Self-Directed HCBS/Self-Directed Attendant Care for Children unless the Self-Directed Employee has a signed employment agreement with the member. 

The financial management service provider will ensure that employment agreements are updated anytime there is a change in any of the terms or conditions specified in the agreement. The financial management service provider will ensure employment agreements are signed by the new Employer Representative when there is a change in Employer Representative.

The financial management service shall provide a copy of each employment agreement to the member and/or Employer Representative. The case manager will also give a copy of the employment agreement to the Self-Directed Employee and shall maintain a copy for its files.

Monitoring

The HHO care coordinator will monitor the quality-of-service delivery and the health, safety and welfare of members electing Self-Directed Attendant Care for Children.

The HHO care coordinators will verify that Self-Directed Attendant Care for Children services are provided in accordance with the member’s plan of care, including the amount, frequency, duration, and scope of each service, in accordance with the member’s service schedule. This shall include, but not be limited to, reviewing EVV information and asking the member is they are receiving the services they need.

The HHO care coordinator will monitor implementation of the back-up plan by the member or Employer Representative.

The HHO care coordinator will also monitor a member’s participation in Self-Directed Attendant Care for Children to determine, at a minimum, the success, and the viability of the service delivery model for the member. The HHO care coordinator shall note any patterns, such as frequent turnover of Employer Representatives that may warrant intervention by the HHO care coordinator. If problems are identified, an HHO care coordinator should also ask a member to complete a self-assessment to determine what additional supports, if any (such as designating an Employer Representative), could be made available to assist the member. 

Disenrollment from Self-Directed Attendant Care Services

The  HHO care coordinator will ensure that members are informed of their right to voluntarily disenroll from Self-Directed Attendant Care for Children at any time and return to the traditional service delivery system. To the extent possible, the member shall provide their Self-Directed Employee ten calendar days advance notice regarding their intent to disenroll from Self-Directed Attendant Care for Children. The HHO care coordinator will educate and assist the member in providing such disenrollment.

A member may be involuntarily disenrolled from Self-Directed Attendant Care for Children for the following for cause reasons:

• Continued participation in Self-Directed Attendant Care for Children would not permit the member’s health, safety or welfare needs to be met;
• The member demonstrates the consistent inability to carry out the tasks needed to self-direct services and refuses to appoint an Employer Representative;
• There is fraudulent use of Medicaid funds such as substantial evidence that a member has falsified documents related to Self-Directed Attendant Care for Children.
• If a member is disenrolled voluntarily or involuntarily from Self-Directed Attendant Care for Children, the HHO case manager will transition the member to the traditional service delivery system and have safeguards in place to ensure continuity of services.

Overtime

Workers/caregivers who provide Medicaid self-directed attendant care services will receive overtime pay for hours worked over 40 hours in a work week:

• Overtime will be paid at a rate of 1.5 times the worker/caregiver’s regular rate of pay.
• Overtime will be paid beginning July 31, 2022, and forward. Overtime hours must be submitted on the same claim as non-overtime hours for the same service period.

Worker/caregiver hours will not be counted across MCOs, financial management services (FMS) entities (e.g., Easter Seals/JEVS/GT Independence), or members.

• Workers/caregivers living in the same home as the member will not receive overtime. These workers/caregivers will need to complete a form provided by the FMS indicating they reside with the member.

Overtime does not require a separate prior authorization.

Limitations

• The respite benefit may not be substituted for additional attendant hours
• Sharing of funds from the attendant to the member are prohibited
• Legally responsible family members who provide Self-Directed Attendant Care for Children must designate another person to serve as the Employer Representative
• Legally responsible family members will be limited to providing 40 hours a week of care

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Place of Service: Outpatient

Reimbursement: Participating facilities will be reimbursed per their Highmark Health Options contract.