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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsAugust 2013

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16 DE Admin. Code 14000, 15000, 16000 & 18000
14000 Common Eligibility Information General Eligibility Requirements
14100.1 Application Filing Date Authorized Representative
14100.3 Face-to-Face Interview Requirement for Some Programs Eligibility Groups
14100.5 Timely Determination of Eligibility
14100.8 Coordination of Eligibility and Enrollment with Other Insurance Availability Programs
14100.8.1 Transfer from Other Insurance Affordability Programs to the State Agency
14100.8.2 Evaluation of Eligibility for Other Insurance Affordability Programs
14100.8.3 Individuals Undergoing a Medicaid Eligibility Determination on a Basis Other than MAGI
14105.1 Exception for Infants to Furnish a Social Security Number
14110.1 14110.1 Capable of Indicating Intent to Reside in Delaware and 14110.2 Incapable of Indicating Intent to
14110.2 14110.3 Placement by State in an Out-of-State Institution
14110.3 14110.4 Actions which do not Constitute State Placement
14110.4 14110.5 Lack of Appropriate Facility
14110.5 14110.6 Criteria Specific to Individuals under Age 21
14110.6 14110.7 Criteria Specific to Individuals Age 21 and Over
14110.7 14110.8 Specific Prohibitions and Exceptions and 14110.8.1 Prohibitions Specific Prohibitions for Denial or
14110.8 14110.8.2 Exceptions to General Residency Rules
14800 Verifications of Factors of Eligibility
14810 Continuously Eligible Newborns RESERVED
14820 Reporting Changes in Circumstances
SECTION 14000 – General Eligibility Requirements: DMMA proposes to reformat, renumber, rename and reorganize its general eligibility rules. Proposed for adoption are the following specific rule changes in Section 14000 identified and detailed below. The rule name is italicized and substantive changes noted.
The name and content of this section details General Eligibility Requirements.
The content of this rule, which details General Application Information, is revised to describe the single streamlined application process to ensure a coordinated eligibility and enrollment system for all insurance affordability programs in accordance with the requirements under the Affordable Care Act. The application processes must be accessible for all individuals and maximize the submission options for individuals being evaluated for eligibility under a modified adjusted gross income (MAGI) category and a non-MAGI category.
This content of this rule is moved to 14100. This section is renamed Authorized Representative with new content. This rule details the minimum requirements for authorized representative acting on behalf of individual applicants.
The content of this rule, which details the requirements of the Protected Filing Date, is revised to delete language about the receipt of an application in a Division of Social Services (DSS) office or in the mail. The submission modes for an application are described in section 14100, General Application Information. The examples are deleted as they are procedural depictions.
Language in this rule, Interview Requirement for Some Eligibility Groups, referring to face-to-face requirement is being updated to add the prohibition of an in-person interview requirement for individuals whose eligibility is based on the financial methodology, modified adjusted gross income (MAGI). The rule is also revised to rephrase the in-person interview requirement for some Long Term Care eligibility determinations.
The content of this rule, which details the Disposition of Applications, is revised to delete language about the verification process. The verification process is described in section 14800, Verifications of Factors of Eligibility. New content is added to comply with the requirement for the reinstatement of a withdrawn application in cases where the individual submits an application via the Federally Facilitated Marketplace (FFM.
This rule is renamed Determination of Eligibility with new content and moves the existing content to revised section 14100.5.1, Timely Determination of Eligibility. The new content details the requirement to make a modified adjusted gross income (MAGI) based eligibility determination for each applicant and beneficiary.
This rule, Timely Determination of Eligibility, is renumbered with new content to include time standards for a determination of eligibility when an application is submitted via the Federally Facilitated Marketplace (FFM).
The number and content of this rule, Coordination of Eligibility and Enrollment with Other Insurance Affordability Programs, is new and addresses the requirement for a coordinated eligibility and enrollment system for insurance affordability programs in accordance with the Affordable Care Act. The content of this rule provides definitions for “coordinated content”, “electronic account” files, “insurance affordability program”, and “secure electronic interface”.
The number and content of this rule, Transfer from Other Insurance Affordability Programs to State Agency, is new and addresses the requirement to accept the electronic account for an individual who has been assessed by the Federally Facilitated Marketplace (FFM) as potentially eligible for Medicaid; to promptly complete a determination of eligibility without requiring another application; and, to notify the FFM of the individual’s eligibility or ineligibility.
The number and content of this rule, Evaluation of Eligibility for Other Insurance Affordability Programs, is new and addresses the requirement to assess eligibility for another insurance affordability program for individuals determined to be ineligible for Medicaid; to transfer the individual’s electronic account to the Federally Facilitated Marketplace (FFM) as appropriate; to notify the individual of the electronic transfer.
The number and content of this rule, Individuals Undergoing a Medical Eligibility Determination on a Basis other than MAGI, is new and addresses the requirement to assess an individual’s eligibility for another insurance affordability program and to transfer an individual’s electronic account to the Federally Facilitated Marketplace (FFM) while the individual is undergoing a Medicaid eligibility determination on a basis other than modified adjusted gross income (MAGI).
The content of this rule, Social Security Number, which details social security number requirements, is revised to comply with the requirement to verify the Social Security number of an applicant with the Social Security Administration via the Federal Data Services Hub (FDSH) in accordance with the Affordable Care Act.
The name and content of this rule, Exceptions to SSN, details the following exceptions to the social security number (SSN) requirements: the individual: is not eligible to receive a SSN; does not have a SSN and may only be issued a SSN for a valid non-work reason; or, refuses to obtain a SSN because of well-established religious objections; or is an infant under age one.
This rule, State Residency, is revised to rephrase the requirement that an individual must be a Delaware resident.
This rule, previously numbered 14110.3, addresses Placement by State in an Out-of-State Institution, is renumbered as 14110.2.
This rule, previously numbered 14110.4, details Actions which do not Constitute State Placement, is renumbered as 14110.3.
This rule, previously numbered 14110.5, explains Lack of Appropriate Facility and is renumbered 14110.4.
This rule (previously numbered 14110.6), which details eligibility criteria specific to Individuals Under Age 21, is renumbered 14110.5 to reflect the above-referenced numbering changes. The content is revised to strike the references to the SSI and AFDC programs and the cross-reference to 45 CFR 233.40(a); to strike the note about an institution which is now included in 14110.1; to align the residency rules for individuals who are emancipated or married with the residency rules for adults; and, to combine and consolidate the residency rules for un-emancipated individuals under age 21.
This rule (previously numbered 14110.7), which details eligibility criteria specific to Individuals Age 21 and Over, is renumbered to reflect the above-referenced numbering changes. The content is revised to base the residency for a non-institutionalized adult upon where the individual is living and has intent to reside. The content for an institutionalized individual who became incapable of indicating intent before age 21 and an institutionalized individual who became of indicating intent at or after age 21 are not being changed. The content is revised to base the residency of any other institutionalized individual on the state where the individual is living.
This rule, which addresses criteria specific to prohibitions, is renumbered to reflect the above-referenced numbering changes and renamed Specific Prohibitions for Denial or Termination of Eligibility. This rule combines content located in previous sections 14110.8 and 1410.8.1.
This rule, which addresses verifications, is renamed Verification of Factors of Eligibility with new content. The content is revised to accept attestation of most of the information needed to determine eligibility and accept such attestation by the individual, an adult in the individual’s household, an authorized representative, or someone acting responsibly for a minor or an incapacitated individual.
This rule, Continuously Eligible Newborns, is deleted and its contents moved to new section 15210. The content of this rule regarding “retroactive coverage” is deleted here and described in current section 14920, Retroactive Coverage. The number 14810 remains in place as “RESERVED”.
The name and content of this rule, which addresses Changes in Circumstances, is revised to require the agency to accept the reporting of changes via the agency’s self-service web site, by telephone, via mail, in person, and through other commonly available electronic means, and to add language about the existing procedures to redetermine eligibility promptly when information about a change in circumstances is received.
This proposed section includes the new net income limits for eligibility groups that are subject to the modified adjusted gross income (MAGI) methodology described in Section 16000, Financial Methodologies - Application of Modified Adjusted Gross Income (MAGI). Provisions under the ACA require states to convert current net income limits to MAGI-equivalent income limits.
Section Eligibility Group
To accurately reflect the revised content of revised section 15000, AFDC-TANF Related Programs is renamed Family and Community Medicaid Eligibility Groups.
SECTION 15000 - Family and Community Medicaid Eligibility Groups: The following table presents the assignment of new numbers and shorter names for each rule, section, and subsection in the renamed section 15000, Family and Community Medicaid Eligibility Groups. The rule name is italicized and substantive changes noted.
This rule describes the Parent/Caretaker Relative Group, formerly section 15120, Low Income Families with Children Under Section 1931.
This rule, Definitions, provides definitions for the following words and terms: “caretaker relative” and “dependent child”.
This rule describes Parent/Caretaker Relative General Eligibility Requirements.
This rule describes Parent/Caretaker Relative Technical Eligibility requirements.
This rule describes Parent/Caretaker Relative Financial Eligibility requirements using MAGI-based financial methodologies.
This rule describes the Transitional Group eligibility requirements. In the second paragraph, language referring to the “twelve-month extension period”, which is based on federal authorization/federal funding, is added.
This rule describes the Transitional Group General Eligibility Requirements
This rule describes the Three out of Six Months Requirement for the Transitional Group.
This rule describes eligibility criteria based on Increase in Earned Income or Hours of Employment.
This rule describes the Child Living in the Home (as defined in section 15100.1) criteria.
This rule describes the criteria for household Composition of a Transitional Group Family Unit.
This rule describes the criteria First Month of Transitional Group Eligibility.
This rule describes Transitional Group Eligibility during First Six-Month Period.
This rule describes Transitional Group Eligibility during Second Six-Month Period.
This rule, Child Living in the Home, describes the requirement that a dependent child must be living in the home during the second six-month period.
This rule, Employment of Caretaker Relative, describes “good cause” exceptions to the requirement that a parent/caretaker relative must be employed.
This rule describes the Limit on Gross Monthly Earned Income.
This rule describes the criteria for Twelve-Month Period of Transitional Group Eligibility.
This new rule describes the criteria for Four-Month Period of Transitional Group Eligibility.
This rule describes the eligibility requirements for the Prospective Group. Language in this rule referring to child support extension is being eliminated because income from child support is not counted under MAGI-based financial methodologies.
This rule describes Prospective Group General Eligibility Requirements.
This rule describes Three out of Six Months Requirement for the Prospective Group.
This rule describes the Collection of Spousal Support requirement for the Prospective Group.
This rule, Child Living in the Home, describes the requirement that a dependent child must be living in the home, as defined in 15100.1.
This rule, First Month of Prospective Group Eligibility, describes when prospective group eligibility begins.
This rule describes the criteria for household Composition of Prospective Group Family Unit.
This new rule, Definitions, provides a definition for “pregnant woman” which mirrors the definition of pregnant woman in the Affordable Care Act.
This rule describes Pregnant Woman Group General Eligibility Requirements.
This rule describes Pregnant Woman Group Technical Eligibility requirements.
This rule describes Pregnant Woman Group Financial Eligibility requirements using MAGI-based financial methodologies.
This rule describes Continuous Eligibility throughout the pregnancy and the postpartum period.
This rule describes the Postpartum Period which includes a change from 90-days of postpartum coverage to 60-days of postpartum coverage. NOTE: The authorization for 90-day postpartum coverage was in the 1115 Demonstration Waiver.
This rule describes Deemed Newborn Group General Eligibility Requirements.
This rule describes Deemed Newborn Group Financial Eligibility requirements.
This rule describes Children Group General Eligibility Requirements.
This rule describes Children Group Technical Eligibility requirements.
This rule describes Children Group Financial Eligibility requirements using MAGI-based financial methodologies.
This rule describes Mandatory Continuation of Eligibility for Children.
This new rule describes eligibility requirements for the low-income Adult Group. NOTE: The uninsured adults at 100% of the Federal Poverty Level (FPL) are moving from the 1115 Demonstration Waiver to the Medicaid state plan as the new 133% FPL adult group.
This new rule, Definitions, provides a definition for the following term: “minimum essential coverage”.
This new rule describes Adult Group General Eligibility Requirements.
This new rule describes Technical Eligibility for the Adult Group.
This new rule describes Financial Eligibility requirements for the Adult Group using MAGI-based financial methodologies.
This rule describes Title IV-E Foster Children Group General Eligibility Requirements.
This rule describes Technical Eligibility requirements for the Title IV-E Foster Children Group.
This rule explains that the Eligibility Determination for the Title IV-E Foster Children Group is the responsibility of the Delaware Department of Services for Children, Youth, and their Families (DSCYF).
This rule describes Foster Children Group General Eligibility Requirements.
This rule describes Technical Eligibility requirements for the Foster Children Group.
This rule describes the Financial Eligibility requirements for the Foster Children Group using MAGI-based financial methodologies.
This rule describes the Effective Date of Coverage for the Foster Children Group.
This rule describes the Adoption Assistance Group General Eligibility Requirements.
This rule describes the Technical Eligibility requirements for the Adoption Assistance Group.
This rule explains that Eligibility Determination for the Title IV-E Foster Children Group is the responsibility of the Delaware Department of Services for Children, Youth, and their Families (DSCYF).
This rule describes the Adoption Subsidy Group General Eligibility Requirements.
This rule describes the Technical Eligibility requirements for the Adoption Subsidy Group.
This rule, Financial Eligibility, explains that there is no income or resource test for the Adoption Subsidy Group.
This rule describes Infants Awaiting Adoption Group General Eligibility Requirements.
This rule describes the Technical Eligibility requirements for the Infants Awaiting Adoption Group.
This rule describes Financial Eligibility for the Infants Awaiting Adoption Group using MAGI-based financial methodologies.
This rule describes the Effective Date of Coverage for the Infants Awaiting Adoption Group.
This rule explains that Termination of Eligibility for Infants Awaiting Adoption Group occurs when the infant is placed with the prospective adoptive parents even if the adoption is not final.
This new rule describes the Former Foster Children Group General Eligibility Requirements.
This new rule describes the Technical Eligibility requirements for the Former Foster Children Group.
This new rule, Financial Eligibility, explains that there is no income or resource test for the Former Foster Children Group.
This rule, Definitions, provides a definition for the following Breast and Cervical Cancer Group term: “comprehensive health insurance”.
This rule describes the Breast and Cervical Cancer Group General Eligibility Requirements.
This rule describes the Technical Eligibility requirements for the Breast and Cervical Cancer Group.
This rule, Financial Eligibility, explains that there is no income or resource test for the Breast and Cervical Cancer Group.
This rule describes the Presumptive Eligibility criteria for the Breast and Cervical Cancer Group.
This rule describes the Eligibility Period for the Breast and Cervical Cancer Group.
This rule, Benefits, explains that a woman eligible under the Breast and Cervical Cancer Group is entitled to full Medicaid coverage and that coverage is not limited to breast and cervical cancer.
This rule describes Termination of Eligibility under the Breast and Cervical Cancer Group.
This rule describes the Family Planning Group General Eligibility Requirements.
This rule describes the Technical Eligibility requirements for the Family Planning Group.
This new rule describes the Financial Eligibility for the Family Planning Group using MAGI-based financial methodologies.
This rule, Benefits, explains that Medicaid coverage is limited to family planning and related services only.
This rule explains that Termination of Eligibility occurs at the end of the 24-month period.
To accurately reflect the revised content of section 16000, Federal Poverty Level Related Programs is renamed Financial Methodologies – Application of Modified Adjusted Gross Income (MAGI).
This section, Pregnant Women, Infants and Children, is moved to 15200.
This rule, Presumptive Eligibility for Pregnant Women, and its subsections, Application Procedures, Initial Eligibility Determination, Final Eligibility Determination and Limitations, are being eliminated because attestation will be accepted for verification of pregnancy and income. Managed care enrollment will occur earlier with better birth outcomes.
This section, Continuously Eligibility for Newborns, is moved to 15210.
This section, Adult Expansion Population, is redefined and becomes the new eligibility group, Adult Group. See section 15400.
This section, General Assistance (GA) Recipients, becomes the new eligibility group, Adult Group, and is moved to 15400.
This rule, Application Process, is deleted because its content is covered by revised rule 14100.
This rule, Protected Filing Date, is deleted because its content is covered by revised rule 14100.2.
This rule, Limitations on Retroactive Coverage, is deleted because its content is covered by current rule 14920.
The content of this rule, Technical Eligibility, is deleted and becomes obsolete as requirements for “technical eligibility” are covered in each eligibility group rule in section 15000.
The content of this rule, Waiver of Social Security Number Requirement for Infants, is deleted as this requirement is covered in section 14105.1.
The content of this rule, Age Requirement, is deleted as this requirement is covered in each eligibility group rule in section 15000.
This rule, Adult, is deleted because its content is covered in 15400.3.
The content of this rule, Minor, is deleted and becomes obsolete with adoption of these rule changes.
The content of this rule, Emancipated Minor, is deleted and becomes obsolete with adoption of these rule changes.
This rule, Pregnancy, is deleted because its content is covered by revised rule 15200.3.
This rule, Uninsured Requirement of Adult Expansion Population, is deleted and becomes obsolete with adoption of these rule changes.
This rule, Definition of Comprehensive Health Insurance, is deleted and becomes obsolete with adoption of these rule changes.
This rule, Enrollment in Managed Care – Special Requirement for Adult Expansion Population, is deleted and becomes obsolete with adoption of these rule changes.
These rules, Financial Eligibility, Earned Income, Wages, Self-Employment Income, Roomer/Boarder Income, Deductions from Earned Income, Unearned Income and Excluded Income are deleted and become obsolete with the adoption of MAGI-based financial methodologies.
These rules, Composition of Budget Units, Individuals to Include, Individuals to Exclude and Individuals in Separate Budget Units are deleted and become obsolete with the adoption of MAGI-based financial methodologies.
This rule, Eligibility Determination, is deleted and becomes obsolete as requirements for “determining eligibility” are covered in section 14100.5 and in each eligibility group rule in section 15000.
This rule, Effective Date of Coverage for Adult Expansion Population, is deleted and becomes obsolete with adoption of these rule changes.
This rule, Continuous Eligibility of Pregnant Women, is deleted because its content is covered by revised rule 15200.5.
This rule, Postpartum, is deleted because its content is covered by revised rule 15200.6.
This rule, Deemed Eligibility of Newborns, is deleted because its content is covered by revised rule 15210.
This rule, Continuous Eligibility of Newborns, is deleted because its content is covered by revised rule 15210.2.
This rule, Mandatory Continuation of Coverage for Children, is deleted because its content is covered by revised rules 15300, 15300.2, 15300.3 and 15300.4.
This rule, Redetermination of Eligibility, is deleted because its content is covered by rule 14100.5.
This rule, Termination of Eligibility, is deleted because its content is covered by revised rule 14100.5.
This rule, Pregnant Women, is deleted because its content is covered by revised rules 15200.6 and 15700.2.
This rule, Children, is deleted because its content is covered by revised rules 15300, 15300.2, 15300.3 and 15300.4.
This rule, Adults, is deleted and becomes obsolete with adoption of these rule changes.
This rule, Family Planning, is deleted because its content is covered by revised rules 15700, 15700.1, 15700.2, 15700.3, 15700.4 and 15700.5.
This rule, Eligibility Requirements, is deleted because its content is covered by revised rules 15700, 15700.1, 15700.2, 15700.3, 15700.4 and 15700.5.
This rule, Procedures for Determining Eligibility, is deleted because its content is covered by revised rules 15700, 15700.1, 15700.2, 15700.3, 15700.4 and 15700.5.
This rule, Redetermination of Eligibility, is deleted because its content is covered by revised rules 15700, 15700.1, 15700.2, 15700.3, 15700.4 and 15700.5.
This rule, Benefits, is deleted because its content is covered by revised rules 15700, 15700.1, 15700.2, 15700.3, 15700.4 and 15700.5.
This rule, Termination of Eligibility, is deleted because its content is covered by revised rules 15700, 15700.1, 15700.2, 15700.3, 15700.4 and 15700.5.
This rule, Definitions, provides definitions for the following words and terms used in the context of MAGI-based methodology: “child”, “family size”, “Federal Poverty Level”, “household income”, “modified adjusted gross income (MAGI)”, ”parent”, “sibling”, and “tax dependent”.
This rule describes the Application of MAGI income and household size.
This rule describes MAGI-based Determination of Eligibility.
This rule describes Household Composition.
This rule describes the Basic rule for taxpayer not claimed as a tax dependent.
This rule describes the Basic rule for tax dependents.
Rule for married couples is described in this section.
This rule describes MAGI-based Income.
This rule, Counted Income, describes the income calculated to determine MAGI.
This rule, Excluded Income, describes the exceptions to counted income.
This rule, Deductions, describes deductions from income allowed in determining MAGI-based income.
This rule, Income Disregard, describes the five-percent disregard in determining MAGI eligibility.
This rule, Budget Period, explains that the budget period is based on current monthly household income and family size.
This rule, Eligibility Determination, explains that household income must not exceed the income standard for the applicable eligibility group to the individual.
This rule, General Eligibility Requirements, is deleted and its content moved to revised section 18200.
This rule, Alien Status, is deleted and its content is covered by revised rule 18200.
This rule, Limitations on Retroactive Coverage, is eliminated and its content moved to 18200.
This rule, Technical Eligibility, is deleted and its content moved to revised section 18300.
This rule, Age Requirement, is deleted and its content moved to revised section 18300.
This rule, Uninsured Requirement, is deleted and its content moved to revised section 18300. Language about “comprehensive health insurance within the six months preceding the month of application” is deleted.
This rule, Definition of Comprehensive Health Insurance, is deleted and its content moved to revised section 18100.
This rule, Good Cause for Loss of Health Insurance, is deleted because the six-month waiting period for loss of health insurance is being eliminated.
This content of this rule, Children of Public Agency Employees, is deleted and becomes obsolete with adoption of these rule changes. See revised section 18300.
This rule, Residents of Institutions, is deleted and its content is covered by revised rule 18300.
This rule, Patient in an Institution for Mental Disease, is deleted and its content is covered by revised rule 18100.
This rule, Inmate of a Public Institution, is deleted and its content is covered by revised rule 18100.
This rule, Composition of Budget Unit, is deleted and its content is covered by revised 18400.
This rule, Financial Eligibility, is deleted and its content is covered by revised rule 18400.
This rule, Eligibility Determination, is deleted and its content is covered by revised rule 18400.
This rule, Managed Care Enrollment Requirements, is deleted and its content is covered by revised rule 18600.
This rule, Premium Requirements, is deleted and its content is covered by revised rule 18700.
This rule, Initial Premium, is deleted and its content is covered by revised rule 18700.
This rule, Premiums to Continue Coverage, is deleted and its content is covered by revised rule 18700.
This rule, Advance Payment of Premiums, is deleted and its content is covered by revised rule 18700.
This rule, Refund of Premiums, is deleted and its content is covered by revised rule 18700.
This rule, Cancellation of Coverage for Nonpayment of Premiums, is deleted and its content is covered by revised rule 18700.
This rule, Good Cause for Nonpayment of Premiums, is deleted and its content is covered by revised rule 18700.
The name and number of this rule, Continuous Eligibility, remains in place. The content is revised to combine the content of current section 18800.1, Termination of Eligibility, and current section 18800.2, Changes in Family Income.
This rule, Continuously Eligible Newborns, is deleted because its content is covered by revised rule 15210.2.
This rule, Redetermination of Eligibility, is deleted because its content is covered by existing rule 14100.6. NOTE: DSSM 14100.6, Redetermination of Eligibility and DSSM 14100.7, Fair Hearings will be revised in future rulemakings.
This rule, Definitions, provides definitions for the following words and terms: “comprehensive health insurance”, “inmate of a public institution” and “institution for mental disease”.
This rule, General Eligibility Requirements, explains that an individual must meet the general eligibility requirements described in revised section 14000.
This rule describes Technical Eligibility requirements for the Delaware Health Children Program.
This rule describes Financial Eligibility requirements for the Delaware Health Children Program.
The requirements for Protection of Former Medicaid Children are described in this new section.
This rule describes Managed Care Enrollment Requirements.
This rule describes Premium Requirements.
This rule describes Continuous Eligibility.
THEREFORE, IT IS ORDERED, to assure compliance with relevant Federal Medicaid rules, that the proposed revisions to the Division of Social Services Manual (DSSM) aligning Medicaid and Children’s Health Insurance Program (CHIP) eligibility determination rules with the Medicaid eligibility provisions of the Affordable Care Act (ACA), particularly the switch to Modified Adjusted Gross Income (MAGI) methodologies be adopted on an emergency basis without prior notice or hearing.
14000 Medicaid Common General Eligibility Requirements
Section 14000 contains information applicable to all Delaware Medicaid programs. For information and eligibility requirements for specific Medicaid programs see the following:
This section describes the general eligibility requirements for Medicaid.
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.
The application will be the single, streamlined application for all insurance affordability programs developed by the Centers for Medicare and Medicaid Services (CMS) or an alternative single, streamlined application for all insurance affordability programs as approved by CMS.
The application may be submitted via the Internet web site established by the Federally Facilitated Marketplace (FFM), via the agency’s Application for Social Service and Internet Screening Tool (ASSIST) self-service Internet web site, by telephone, via mail, in person with reasonable accommodations for those with disabilities, as defined by the Americans with Disabilities Act (ADA), and through other commonly available electronic means.
14100.1 Application Filing Date Authorized Representatives
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.
Applicants and beneficiaries are permitted to designate an individual or organization to act responsibly on their behalf in assisting with the individual’s application and renewal of eligibility and other ongoing communications with the agency. The designation must be in writing, including the applicant’s signature, and is permitted at the time of application and at other times.
As a condition of serving as an authorized representative, a provider or staff member or volunteer of an organization must sign an agreement that he or she will adhere to the regulation in:
An individual’s 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. An oral inquiry or written statement protects the filing date if an application is received within 30 days from the date of the inquiry.
Examples
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.
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.
14100.3 Face To Face Interview Requirement for Some Programs Eligibility Groups
Face to face interviews are required in some programs such as nursing home and home and community based waiver. An in-person interview is required for some Long Term Care eligibility determinations. 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.
14100.5.1 Timely Determination of Eligibility
The standards cover the period from the date of application with the agency or the date the application is submitted via the Federally Facilitated Marketplace (FFM) to the date the agency notifies the applicant of its decision.
Coordinated content” means information included in an eligibility notice regarding the transfer of the individual’s or households’ electronic account to the Federally Facilitated Marketplace (FFM) for a determination of eligibility for another insurance affordability program.
Electronic account” means an electronic file that includes all information collected and generated by the agency regarding each individual’s Medicaid eligibility and enrollment including any information collected or generated as part of the agency fair hearing process or the FFM appeals process.
Insurance affordability program” means a program that is one of the following:
1) Medicaid
Secure electronic interface” means an interface which allows for the exchange of data between Medicaid and other insurance affordability programs and adheres to the requirements in 42 CFR Part 433 subpart C.
Verification of the SSN, either through IEVS or acceptable documentation, must be obtained by the first redetermination of eligibility.
Each individual applying for Medicaid, except as provided in this section, must furnish his or her Social Security number (SSN) as a condition of eligibility. If the individual cannot furnish a SSN, he or she must provide proof of an application for a SSN with the Social Security Administration (SSA). The agency will assist the applicant with the completion of an application for a SSN.
14105.1 Exception For Infants Exception to Furnish a Social Security Number (SSN)
The requirement to furnish a SSN does not apply to an individual who:
Incapable of Indicating Intent to Reside in Delaware” means one of the following applies to the individual:
Institution” has the same meaning as Institution and Medical Institution as defined in 42 CFR 435.1010. For purposes of state placement, the term also includes foster care homes.
14110.3 14110.2 Placement by State in an Out-Of-State Institution
14110.4 14110.3 Actions which do not Constitute State Placement
14110.5 14110.4 Lack of Appropriate Facility
b) For an individual not residing in an institution and who is not capable of stating intent, the State of residence is the state where the individual is living.
14110.8.1 Prohibitions 14110.7 Specific Prohibitions for Denial or Termination of Eligibility
14110.8.2 Exceptions 14110.8 Exceptions to General Residency Rules
a) Exception for individuals An individual receiving a State Supplementary Payment is a resident of, the State of residence is the State making the payment.
b) Exception for individuals of any age who are An individual receiving Federal payments for foster care under title IV-E of the Social Security Act, and individuals an individual for whom there is an adoption assistance agreement in effect under title IV-E of the Social Security Act, the State of residence is the State where the individual is living is a resident of the State where the individual is living.
c) Exception where a State or agency of the State, including an entity recognized under State law as being under contract with the State, arranges for an individual to be placed in an institution in another State, the State arranging that placement is the individual's State of residence. An individual to be placed in an institution in another state is a resident of the State that arranges the placement.
d) Exception when residency is disputed - When two or more States cannot resolve which State is the State of residence, the State in which the individual is physically located is the State of residence.
e) Exception when an institutionalized individual is capable of indicating their intent to return home to their principal place of residence located in another state, the individual will not be considered a Delaware resident since their intent is not to remain in Delaware. An institutionalized individual capable of indicating their intent to return home to their principal place of residence is a resident of the State where their principal place of residence is located.
14800 Verifications of Factors of Eligibility
Attestation will be accepted for most factors of eligibility at application, renewal, and for a change in circumstances. Attestation will be accepted by the individual; an adult who is in the applicant’s household; an authorized representative; or if the individual is a minor or incapacitated someone acting responsibly for the individual. Certain factors of eligibility will be verified post-enrollment, post-renewal, and after a redetermination of eligibility due to a change in circumstances.
Attestation will be accepted without post-enrollment verification for the following factors of eligibility:
Attestation will be accepted with post-enrollment verification for the following factors of eligibility:
Attestation will not be accepted and must be verified via the FDSH for the following factors of eligibility:
When the difference between the attestation of income and the electronic verification is more than 10%, a reasonable explanation will be sought from the applicant or beneficiary. A reasonable explanation may include, but is not limited to, a loss of employment or reduced hours of employment.
14810 Continuously Eligible Newborns RESERVED
14820 Reporting Changes in Circumstances
At the time of application and renewal, individuals will be informed that they are responsible for notifying the agency about changes in circumstances that may affect eligibility. Changes may be reported via the ASSIST self-service web site, by telephone, via mail, in person, and through other commonly available electronic means. Eligibility will be redetermined promptly between regularly scheduled renewals when information about a change in circumstance may affect eligibility.
15000 AFDC-TANF Related Programs Family and Community Medicaid Eligibility Groups
a) report to Medicaid foster child worker any changes in a child's circumstances immediately
1. CDC Title XV funds paid for all or part of the costs of her screening services.
Caretaker relative” means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and who is one of the following:
Dependent Child” means a child who is under age 18 or is age 18 and a full-time student in a secondary school (or equivalent vocational or technical training), and if before attaining age 19, the child may reasonably be expected to compete such school or training.
The parent or caretaker relative must continue to have a dependent child, as defined in Section 15100.1 living in the home.
Prospective Group eligibility begins with the month of ineligibility under the Parent/Caretaker Relative Group due to new or increased spousal support collections. A family who is not timely in reporting the start of new or increased spousal support collections could have the extension period reduced. The family must be notified they are eligible for the Prospective Group and the reasons why Prospective Group coverage could be terminated.
Pregnant Woman” means a woman during pregnancy and the post partum period, which begins on the date the pregnancy ends, extends 60 days, and then ends on the last day of the month in which the 60-day period ends.
Minimum essential coverage” means coverage defined in section 5000A(f) of subtitle D of the Internal Revenue Code, as added by section 1401 of the Affordable Care Act, and implementing regulations of such section issued by the Secretary of the Treasury. Minimum essential coverage includes any of the following:
15530 Adoption Subsidy Group
Medicaid coverage begins on the date of birth if the Consent to Place the Infant for Adoption document is signed within five days of the date of birth or if the mother was receiving Medicaid on the date of birth. If the consent document is not signed within five days of the date of birth, Medicaid coverage will begin on either the date the consent document was signed or the date of placement with the agency.
Comprehensive health insurance” means a benefit package comparable in scope to the "basic" benefit package required by the State of Delaware's Small Employer Health Insurance Act at Title 18, Chapter 72 of the Delaware Code. To be considered comprehensive health insurance, the benefits package must cover hospital and physician services, laboratory and radiology, and must include coverage for the treatment of breast and cervical cancer.
16000 Federal Poverty Level Related Programs Financial Methodologies – Application of Modified Adjusted Gross Income (MAGI) Methodology