Title 16
16000 Federal Poverty Level Related Programs
16300 Redetermination of Eligibility
A redetermination is required at least every 12 months. A redetermination may be necessary before 12 months have gone by because of changes in eligibility criteria such as increased income or change in household size.
16310 Termination of Eligibility
Medicaid eligibility may not be terminated until we determine that the individual is not eligible under any other eligibility group.
This section discusses termination of eligibility under the poverty level related groups of pregnant women, children, and adults.
9 DE Reg. 774 (11/01/05)
16310.1 Pregnant Women
Women remain eligible through the last day of the month of the 90-day postpartum period regardless of increases in family income. Women who are closed in Medicaid for non fraudulent reasons may be found eligible for Family Planning services for 24 months after the closing.
16310.2 Children
Children should be closed the last day of the month in which family income exceeds the applicable limit. Exception: If the child is an inpatient in a hospital or long-term care facility receiving covered services at the time the child reaches the maximum age limit (1, 6 or 19), the child's eligibility can continue until the child is discharged.
16310.3 Adults
Non categorically related adults will remain eligible as long as the family income is at or below 100% FPL. These adults may lose Medicaid eligibility due to disenrollment from a managed care organization because of:
• non-compliance,
• threatening or abusive behavior, or
• falsification of application or enrollment material determined after a fair hearing on the issue.
If the adult becomes entitled to or eligible to enroll in Medicare or acquires Military Health Insurance for Active Duty, Retired Military, and their dependents or comprehensive health insurance, redetermine eligibility promptly. If the adult in not eligible for Medicaid under another eligibility group or if benefits are reduced (e.g. to QMB), terminate or reduce benefits after giving at least 10 days advance notice.
