The Medicaid application must be made in writing on the prescribed DSS form. This request for assistance can be made by an individual, agency, institution, guardian or other individual acting for the applicant with his knowledge and consent. If the applicant is a minor (under age 18) and living with his or her parents or guardian, the parent or guardian must sign the application. An emancipated minor is permitted to complete and sign the application.

Medicaid will consider an application without regard to race, color, age, sex, handicap, religion, national origin or political belief as per Title VI of the Civil Rights Act of 1964.

Filing an application gives the applicant the right to receive a written determination of eligibility and the right to appeal the written determination.

The application filing date is used to determine the earliest date for which Medicaid can be effective. The Medicaid effective date is affected by the application filing date and the date the applicant meets all factors of eligibility. Medicaid eligibility is effective the first day of the month if the individual was eligible at any time during that month and providing the individual was a Delaware resident on the first of the month. If not a Delaware resident on the first of the month, Medicaid will be effective the date the individual became a Delaware resident.

An individual’s Medicaid application filing date may be established based on either a written statement or an oral inquiry about Medicaid eligibility. An oral inquiry is a discussion about Medicaid eligibility for a specific person that results in a request for Medicaid. An oral inquiry must be documented when received. An oral inquiry or a written statement protects the filing date if a written application is completed and received in a DSS office within 30 days from the date of inquiry. When an application is received in the mail, the date of the postmark is considered the date of receipt. A postmark is the U.S. Postal Service mark stamped on a piece of mail canceling the postage stamp and recording the date and place of sending.

Examples

Protected Filing Date - Oral Inquiry

Ms. Jones telephones the Medicaid office on Friday, January 5, at 4:20 p.m. to inquire about coverage for her children. The receptionist completes a screening form to document the inquiry. An application is mailed to Ms. Jones on Monday, January 8. Ms. Jones must return the signed application by February 5 (February 3 is a Saturday) to establish an application filing date of January 5. The 45-day application processing time standard begins on January 5. If the application is returned after February 5, the filing date will be the date of receipt and the 45-day application processing time standard begins on the date of receipt.

Protected Filing Date - Walk in at DSS Office

Mrs. Watson arrives at the Northeast Medicaid office on February 21 to apply for Medicaid. She decides to take an application home with her to complete. The receptionist documents the walk-in as an oral inquiry. Mrs. Watson must return the application by March 21 to ensure an application filing date of February 21.

Protected Filing Date - DPH Clinic

Ms. Williams has an appointment at the DPH Clinic on Thursday, March 7. Medicaid staff is outstationed there every Wednesday. She has no health insurance and asks the nurse about Medicaid. The nurse documents the oral inquiry and faxes a referral form to a DSS office that same day. The nurse could also call or email a DSS office to document the request for Medicaid. The date the email is sent is considered the date of request. Ms. Williams must complete and return a signed application by April 5 to ensure an application filing date of March 7.

Face to face interviews are required in some programs such as nursing home and home and community based waiver. SEE SECTION 20101 - Application Process - Long-Term Care Services. For these applications the date of the application is the date of the interview. The interview requirement may be waived due to extenuating circumstances on a case by case basis by supervisor approval. If face to face interview is waived, the date of receipt in DSS-LTC office is application date.

The agency must include in each applicant's case record facts to support the agency's decision on his application. The agency must dispose of each application by a finding of eligibility or ineligibility, unless:

a) there is an entry in the case record that the applicant voluntarily withdrew the application, and that the agency sent a notice confirming his decision;

b) there is a supporting entry in the case record that the applicant has died; or

c) there is a supporting entry in the case record that the applicant cannot be located.

d) Certain factors of eligibility must be verified according to specific eligibility groups. If all information requested is not received, DSS cannot determine or redetermine eligibility. This may result in denial of the application or the termination of eligibility. Verifications received and/or provided may reveal a new eligibility issue not previously realized and this may require additional verifications. Failure to provide additional requested verifications may result in denial or termination of eligibility. all verification requested is not received by the due date given to the applicant. If all verification requested is not received by the due date, an eligibility determination cannot be made. This will result in denial of the application. Verification that is received and/or provided may reveal a new eligibility issue not previously realized that requires additional verification. If the additional verification requested is not received by the due date given, this will result in denial of the application.

All applicants will receive a notice of acceptance or denial.

9 DE Reg. 774 (11/01/05)

The following Federal standards have been established for determining eligibility and informing applicants of the decision:

a. Ninety days for applicants who apply for Medicaid on the basis of disability. This includes long term care and Disabled Children.

b. Forty-five days for all other applicants.

These standards equal the period from the application filing date or stamping of application to the date that the notice of decision is mailed. The standards must be met except in unusual circumstances, such as:

a. A decision cannot be made because the applicant, his representative or his physician delays or fails to take a required action.

b. There is an administrative or other emergency beyond the Division's control.

The time standards must not be used as a waiting period before determining eligibility or as a reason for denying eligibility (because a decision has not been reached within the required time). Decision on applications should be made as quickly as possible, but if the final determination does not fall within the prescribed limits, the record must have documentation of the reasons for delay.

Eligibility for continued Medicaid coverage must be redetermined at least annually. A redetermination is a re-evaluation of a recipient's continued eligibility for medical assistance. In a redetermination, all eligibility factors are re-examined to ensure that the recipient continues to meet eligibility requirements. When a redetermination is due, the recipient is required to complete and return a new DSS application form. Failure to complete and return a DSS application form will result in termination of eligibility. A redetermination is complete when all eligibility factors are examined and a decision regarding continued eligibility is reached. Eligibility must be promptly redetermined when information is received about changes in a recipient's circumstances that may affect his eligibility. Some changes in circumstances can be anticipated. A redetermination of eligibility must be made at the appropriate time based on those changes. Examples are: Social Security changes, receipt of child support, return to work, etc.

Medicaid coverage should not terminate without a specific determination of ineligibility. The individual may be eligible under another category of Medicaid. For example, when an individual loses eligibility because of termination from cash assistance, such as SSI, we must make a separate determination of Medicaid eligibility. Medicaid must continue until the individual is found to be ineligible.

Medical assistance will be terminated when DSS is notified by the recipient that he or she no longer wants coverage.

9 DE Reg. 774 (11/01/05)

A fair hearing is an administrative hearing held in accordance with the principles of due process. An opportunity for a fair hearing will be provided, subject to the provisions in policy at DSSM Fair Hearing Section. Any individual who is dissatisfied with a decision of the Division of Social Services may request a fair hearing. See DSSM Fair Hearing Section for policies covering fair hearings.