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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsFebruary 2018

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16 DE Admin. Code 20620
Delaware Health and Social Services ("Department") / Division of Medicaid and Medical Assistance initiated proceedings to amend the Delaware Social Services Manual (DSSM) regarding Prior Medical Costs, specifically, to add a reasonable limit on the timeframe for the submission of requests for the protection of prior medical costs. The Department's proceedings to amend its regulations were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.
The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the December 2017 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by January 2, 2018, at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
In accordance with the federal public notice requirements established at Section 1902(a)(13)(A) of the Social Security Act and 42 CFR 447.205 and the state public notice requirements of Title 29, Chapter 101 of the Delaware Code, Delaware Health and Social Services (DHSS)/Division of Medicaid and Medical Assistance (DMMA) gives public notice and provides an open comment period for thirty (30) days to allow all stakeholders an opportunity to provide input on the proposed regulation. Comments were to have been received by 4:30 p.m. on January 2, 2018.
I. Processing of Insurance Claims
First, if the individual has multiple forms of insurance (e.g. Medicare; Medicaid; private insurance), sequential claims may have to be submitted and processed based on the order of financial responsibility. This process can easily take several months to complete for even "clean" claims. Second, a medical provider may not issue a bill in timely fashion which delays the processing of insurer claims and identification of the individual's final financial responsibility. Third, if the individual has invoked internal and/or external appeals of insurer denials that process could easily take several months to resolve. Consider the following timetables for health insurer determinations covered by the Delaware Department of Insurance: 1) the health insurer can delay issuing a claim decision by requesting more information (18 DE Admin. Code 1310.6.0; 2) once a patient eventually receives the "final" insurer decision, the patient can request mediation or, within 4 months of the final insurer decision, request IHCAP review which takes another 45 days (18 DE Admin. Code 1301.4.0, 5.1, and 5.7); and 3) in lieu of IHCAP review, the patient can opt for arbitration with the Insurance Department within 60 days of an insurer's final decision and, subject to continuances, expect a decision within 45 days (18 DE Admin. Code 1315.3.1 and 13.15.6.1).
II. Beneficiary Capacity
Agency Response: DMMA appreciates the comments on the Processing of Insurance Claims. However, DMMA is proposing to establish a provision that implements a one (1) year limit on the submission of requests for the protection of prior medical costs for institutionalized individuals. This proposal is an entirely separate issue from our existing policy relating to the one (1) year limit on the timely submission of medical claims by providers.
THEREFORE, IT IS ORDERED, that the proposed regulation to amend the Delaware Social Services Manual (DSSM) regarding Prior Medical Costs, specifically, to add a reasonable limit on the timeframe for the submission of requests for the protection of prior medical costs is adopted and shall be final effective February 11, 2018.
Last Updated: December 31 1969 19:00:00.
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