# Presentation: 111809

## Medicaid Support of ACT Programs in Delaware

- Financing Strategies
- Cathy McKay
- October 2004

## The Delaware Experience 

- 1989 State MA Plan Amendment added Community Support Services under Rehabilitation Option Covered Services, including
- Medical/psychosocial evaluation
- Physician services
- Emergency services
- Counseling and psychotherapy
- Psychiatric rehabilitation services

## The Delaware Experience

- Bundled rate for services delivered by an ACT team with specific interdisciplinary staff
- Physician
- Clinician (MSW, PhD, PsyD, MC, MSN)
- Associate Clinician (BA Case Manager, RN)
- Assistant Clinician (LPN, AA Case Management Assistant)
- Same rate regardless of who delivers the service

## The Delaware Experience

- Some limitations/exclusions were built into the initial Plan Amendment
- Required physician to certify medical necessity
- Excluded vocational training services
- Excluded recreational services
- Covered services include only face-to-face contacts with participant
- Services in IMDs and correctional facilities excluded

## The Delaware Experience

- Required program compliance with provider manual based on adaptation of Wisconsin PACT program
- Programs were required to be self-contained, with no subcontracting of service components
- Providers are monitored by State licensure unit to ensure compliance

## Rate Setting and Payment Methodology

- Program-specific prospective rate-setting based on
- Total allowable costs
- Expected clinical billing hours (approximately 55% of all available hours—allows for required meetings and other non-billable activity)
- Allowable costs/billable hours = rate/hour
- 10 minute fee-for-service billing units

## The Delaware Experience

- Same rate for all covered services (bundled) with caps on monthly/annual totals
- Annual review and approval by Rate Setting Committee
- Rate adjustment for new programs over a 4-year sliding scale
- Extensive review of methodology with HCFA/CMS prior to submission of initial 1989 Plan Amendment

## Delaware’s 1991 and 1993 MAP Amendments

- Removed monthly and annual caps per recipient
- Softened specificity of staff qualifications
- HCFA/CMS asked questions about the bundled rate, but did not require changes
- Added facility-based psychosocial rehabilitation center and residential rehabilitation as covered services

## ACT Program Growth Resulting from Medicaid Plan Amendment

- 1990–2 certified programs serving120 persons
- 1996–16 certified programs (3 substance abuse specific) serving 1,300 persons
- 2001–16 certified programs (4 substance abuse specific) serving 1,400 persons

## Delaware’s 2004 MAP Amendment

- Significantly revised rate setting and payment methodology for ACT-type services
- Added rehabilitative services assistant as least-credentialed eligible staff
- Switched from fee-for-service unit of service to per diem rate

## Delaware’s 2004 Change in Rate Setting Methodology

- Simple Rate-Setting Methodology:
- Used actual Medicaid paid claims for ACT services FY 2000–2002
- Service month data extracted
- Service month days converted to ACT days
- Average cost per day calculated
- Linear regression analysis to project cost per day through 2007
- Proposed rate = mean monthly per diem

## Delaware’s 2004 Amendment 

- Per diem rate is paid for all days of service month in which at least one documented face-to-face service is provided
- Excludes days during which participant is in IMD, corrections, or long-term care facility
- Same per diem rate for all providers

## Delaware’s 2004 Program Modifications

- Moved from ACT to Community Continuum of Care (CCC) Program
- Discontinued substance abuse specific ACT teams and replaced with day treatment programs
- Reduced number of discrete certified programs from 16 to 4
- Eliminated State-operated teams

## Delaware’s 2004 Program Modifications

- Maintained ACT services within a broader continuum of care including intensive and targeted case management and outpatient
- Established ‘clinical home’
- Requires use of LOCUS for placement within CCC program
- Future consideration of incentive payments (non-Medicaid participants only)

## Delaware’s 2004 Program Modifications

- Anticipated Benefits
- Leveling of month-to-month fluctuations in funding
- Increased predictability of cash flow
- Flexibility in service delivery
- Teams can focus on engaging hard-to-reach participants without negative revenue impact
- Participants retain ‘clinical home’ and consistency of care as needs change

## Delaware’s Current Status

- 4 certified Community Continuum of Care programs serving 1,250 participants statewide
- 3 substance abuse-specific day treatment programs serving 100 participants
- Per diem rates in effect since April 1, 2004