Title 16
16000 Federal Poverty Level Related Programs
16100 Pregnant Women, Infants and Children
The Omnibus Budget Reconciliation Act (OBRA) of 1986 established a categorically needy eligibility group of pregnant women, infants, and children. Coverage was expanded by OBRA '87 and the Medicare Catastrophic Coverage Act (MCAA) of 1988.
16100.1 Presumptive Eligibility for Pregnant Women
Effective January 1, 1997, the Delaware Medical Assistance Program established presumptive eligibility for pregnant women to provide prenatal care. Presumptive eligibility is a temporary eligibility determination for pregnant women who appear to meet the eligibility requirements before verification of eligibility. Presumptive eligibility will provide expedited Medicaid coverage to pregnant women during the application processing period. This special application processing procedure will provide pregnant women with access to prenatal care through Medicaid earlier in their pregnancy. Early prenatal care has a positive effect on birth outcomes and the health of the mother.
16100.1.1 Application Procedures
Pregnant women must complete an application that will be used to determine both presumptive eligibility and final eligibility for Medicaid benefits. Women applying after the birth of the baby are not eligible for presumptive Medicaid, but may be found eligible using all required verifications. The application filing date is established as described under "Application Process" in this section. (See DSSM 16200 )
16100.1.2 Initial Eligibility Determination
The two criteria for finding an applicant presumptively eligible are: a medically verified pregnancy and self-reported family income at or below 200% of the Federal Poverty Level. Countable family income is determined using the rules in this section including the $90 earned income deduction and any self-reported dependent care expenses. State residency is established for presumptive eligibility by the applicant writing a home address on the application that is a Delaware residence.
Note: Women who are nonqualified aliens or illegally residing in the U.S. are not eligible for presumptive Medicaid.
Verifications of all other factors of eligibility are postponed. Postponed verifications must be provided within 30 days from the date of receipt of the application. Under unusual circumstances, the deadline date for postponed verifications may be extended. The reason for the extension must be documented in the case record. The verifications that were postponed are required to determine final eligibility for Medicaid benefits. Presumptive eligibility continues until a final eligibility determination is completed. If the required verifications are not provided, eligibility under the presumptive period ends.
16100.1.3 Final Eligibility Determination
The final eligibility determination for Medicaid may be completed using:
• the circumstances which exist at the time the pregnant woman became presumptively eligible, regardless of any changes that may have occurred in the interim; or
• the circumstances that exist during any month in the application processing period. Any month may be used beginning with the protected filing month.
This means that an eligibility determination can be completed using the family size and income that exists during the month of the presumptive application or during any subsequent month until a final eligibility determination is made.
16100.1.4 Limitations
There is only one presumptive period of eligibility per pregnancy. If the pregnant woman does not return the required verifications within 30 days from the date the application is received, the case will be closed. If the woman reapplies during the same pregnancy, she must provide the required verifications to be determined eligible for Medicaid. She cannot be found eligible for another presumptive period.
16100.1.5 Continuous Eligibility for Newborns
A baby born during the presumptive eligibility period is eligible at birth. However, for the mother and baby to remain eligible, the required verifications must be provided by the deadline date. The newborn is deemed eligible for one year if a final determination of eligibility is made for the mother. This means that using all verifications, the mother is determined eligible for a presumptive month or for any subsequent month during the pregnancy. The pregnant woman must return the required verifications and be found eligible during a month of the pregnancy to receive continued coverage for the post partum period and for the baby to remain eligible for the first year of life.
If the verifications show that the mother was over the income limit during each month of pregnancy, there is no deemed eligibility for the newborn. A separate determination must be made for the newborn.
