DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Statutory Authority: 31 Delaware Code Section 505 (31 Del.C. 505)
BEFORE THE DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DMAP 301.25 Federal Poverty Level Related Programs
IN THE MATTER OF: |
|
REVISION OF THE REGULATIONS |
OF THE MEDICAID/MEDICAL |
ASSISTANCE PROGRAM |
270.10, 301.25, , 307.60, 301.25C |
NATURE OF THE PROCEEDINGS:
The Delaware Department of Health and Social Services (“Department”) initiated proceedings to update client eligibility policy manual as follows: a specific rule for certain eligibility denials and terminations, revise policy on excluded income, new eligibility group of mandatory low income Medicare beneficiaries, and revise definition of uninsured for the adult expansion population. 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 June 1998 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by July 1, 1998 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
No written or verbal comments were received relating to this proposed rule.
FINDINGS OF FACT:
The Department finds that the proposed changes as set forth in the June 1998 Delaware Register of Regulations should be adopted as written.
THEREFORE, IT IS ORDERED, that the proposed regulations of the Medicaid/Medical Assistance Program are adopted and shall be final effective August 10, 1998.
August 11, 1998
Gregg C. Sylvester, M.D.
Secretary
Revision:
Eligibility Manual
270.10 Eligibility Decision
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, except under the following circumstances:
1. 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;
2. There is a supporting entry in the case record that the applicant has died.
3. There is a supporting entry in the case record that the applicant cannot be located.
4. 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
Section 301.25 Federal Poverty Level Related Programs
Excluded Income
• Earned Income Tax Credits (EITC)
• First $50 of the total child support payments
• Governmental (federal, state, or local) rent and housing subsidies, including payments made directly to the applicant/recipient for housing or utility costs, e.g., HUD utility allowances
• Income owned by or received for the benefit of the siblings not included in the budget unit
• Financial Assistance received from school grants, scholarships, vocational rehabilitation payments, Job Training Partnership Act payments, educational loans, and other loans that are expected to be repaid. Also exclude other financial assistance received that is intended for books, tuition, or other self-sufficiency expenses
• One half of the gross parental income for minor pregnant teens
• Payments made by a third party directly to landlords or other vendors
• SSI benefits
• Wages of an individual (under age 19) who is a full-time student or a part-time student but not a full-time employee attending a school, college, university, or a course of vocational or technical training
• Earned income of a minor child regardless of student status
• Earned income of an 18 year old or an emancipated minor who is a full time student or a part time student but not a full time employee attending a school, college, university, or a course of vocational or technical training
307.60 Qualifying Individuals
Section 4732 of the Balanced Budget Act of 1997 establishes a capped allocation for each of five years beginning January 1998, to states for payment of Medicare Part B premiums for two new mandatory eligibility groups of low-income Medicare beneficiaries, called Qualifying Individuals or QIs. This provision amends section 1902(a)(10)(E) of the Social Security Act concerning Medicare cost-sharing for Qualified Medicare Beneficiaries (QMBs) and Specified Low Income Medicare Beneficiaries (SLMBs). It also amends section 1905(b) of the Social Security Act concerning the Federal Medical Assistance Percentage (FMAP) by incorporating reference to and establishing a new section 1933, for QIs.
QIs are individuals who would be QMBs but for the fact that their income exceeds the income levels established for QMBs and SLMBs. This means that QIs must meet all the technical and financial eligibility requirements of the QMB program except for the income limits.
Unlike QMBs or SLMBs, who may be determined eligible for Medicaid benefits in addition to their QMB/SLMB benefits, QIs cannot be otherwise eligible for Medicaid.
Qualifying Individuals 1
Individuals in the first group of QIs, called QI-1s, must have income that exceeds 120% of the Federal Poverty Level (FPL) but the income must be at or below 135% of the FPL. The benefit for QI-1s consists of payment of the full Medicare Part B premium. They do not receive any Medicaid services.
Qualifying Individuals 2
Individuals in the second group of QIs , called QI-2s, must have income that exceeds 135% of the FPL, but the income must be at or below 175% of the FPL. The benefit for QI-2s consists only of the portion of the Medicare Part B premium that is attributable to the shift of some home health benefits from Part A to Part B. The amount of this benefit in 1998 is $1.07 per month. This is equivalent to 1/7 of the cost of the home health shift. The amount will increase by an additional 1/7 in each of the following years.
COLA Disregard
Social Security COLA increases will be excluded in determining the eligibility of recipients during the first three months of a calendar year.
Retroactive Coverage
Retroactive eligibility does apply to this group unlike the QMB program. Benefits may begin with the month of application. Retroactive coverage is available for the three months prior to the month of application. Coverage cannot be effective prior to January 1, 1998.
Capped Allocation
This provision is effective for premiums payable beginning with January 1998 and ending with December 2002. Each state will receive a specific capped allocation for QIs.
Because of the capped allocation, we must limit the number of QIs selected in a calendar year so that the amount of benefits provided to these individuals does not exceed our state allocation. QIs will be selected on a first-come, first-served basis. This means the QIs are selected in the order in which they apply for benefits.
Once a QI is approved, the QI is entitled to receive assistance for the remainder of the calendar year, provided the individual meets the eligibility requirements. However, the fact that an individual receives assistance at any time during the year does not necessarily entitle the individual to continued assistance for any succeeding year. We will give preference to individuals who were QIs, QMBs, SLMBs, or QDWIs in the last month of the previous year.
Redetermination of Eligibility
A redetermination of eligibility must be completed at least every 12 months. We will promptly redetermine eligibility when information is received about changes in circumstances that may affect eligibility.
301.25 C. Adult Expansion Population: Non Categorically Related Individuals
Section 1902(a)(10)(A)(i) of the Social Security Act requires states to provide medical assistance to certain mandatory categories of individuals and allows states to cover optional categories. On May 17, 1995, HCFA approved a Section 1115 Demonstration Project, entitled Diamond State Health Plan. This demonstration waiver extends Medicaid coverage to uninsured individuals age 19 or over with income at or below 100% of the FPL who are not categorically eligible. Individuals who receive long term care services (nursing facility and home and community based waivers), who have accessible managed care coverage, or who are entitled to Medicare are excluded from this category of assistance created under the demonstration waiver. Medicaid coverage for this new group is effective March 1, 1996. Adults are not eligible for Medicaid benefits until the first of the month in which they are enrolled in a Managed Care Organization (MCO). Enrollment in a MCO is a technical eligibility requirement for these clients under the demonstration waiver. Adults will not receive Medicaid services until they are enrolled in a MCO.
Individuals who receive long term care services (nursing facility and home and community based waivers), who have comprehensive health insurance as defined in this section, who are entitled to or eligible to enroll in Medicare, or who have coverage through CHAMPUS are excluded from this eligibility group created under the demonstration waiver. Medicaid coverage for this group is effective March 1, 1996.
Adults are not eligible for Medicaid benefits until the first of the month in which they are enrolled in a Managed Care Organization (MCO). Enrollment is a technical eligibility requirement for adults in the expanded population.
D. General Assistance (GA) Recipients
General Assistance is a cash assistance program available to families and unemployable individuals who meet certain financial and technical eligibility requirements.
An individual age 18 and under who receives GA is categorically eligible for Medicaid. An individual between age 18 and 19 who receives GA is categorically eligible under the poverty level related program for children. An individual age 19 or over who receives GA must be uninsured as defined in this section in order to be found eligible for Medicaid. Enrollment in a MCO is a technical eligibility requirement for individuals age 19 and over who receive GA. GA recipients who are age 19 or over will not receive Medicaid benefits until the first of the month in which they are enrolled in a MCO.
[All GA adults must be enrolled in a MCO effective March 1, 1996. Enrollment in a MCO is a technical eligibility requirement for GA adults under the demonstration waiver. GA adults will not receive Medicaid services unless they are enrolled in a MCO as of March 1, 1996.]
Uninsured Individual: This is a separate technical eligibility requirement for the non categorically related adults (GE, GF, GG) who have income at or below 100% FPL. The individual must be uninsured. An uninsured individual is defined as an individual who does not have Medicare or accessible managed care coverage. An adult who is entitled to Medicare or who has accessible managed care cannot be eligible for Medicaid under the demonstration waiver. The Third Party Liability Unit will determine if an individual has accessible managed care coverage.
A managed care organization (MCO) is an organization that is licensed as an HMO, Health Services Corporation, or "like entity" and that requires the insured to go to a primary care provider who manages medical care for the insured. Payment to the primary care provider by the MCO can be fee for service or a capitated rate. An individual who is enrolled in a Delaware MCO but not through the Diamond State Health Plan is in an accessible managed care plan provided the MCO is licensed to do business in the insured's county of residence. See Section 600 for more information on managed care.
Uninsured Individual: This is a separate technical eligibility requirement for non categorically related adults age 19 or over, including those who receive General Assistance. The individual must be uninsured. An uninsured individual is defined as an individual who does not have Medicare, CHAMPUS, or other comprehensive health insurance. An adult who is entitled to or eligible to enroll in Medicare or who has CHAMPUS or who has any comprehensive health insurance, cannot be eligible for Medicaid as a non categorical adult under the demonstration waiver. The Third Party Liability Unit will determine if an individual has comprehensive health insurance.
Comprehensive Health Insurance: 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. This package covers hospital and physician services as well as laboratory and radiology services. The term "comprehensive" does not mean coverage for benefits normally referred to as "optional," e.g., prescription drugs.
Enrollment in Managed Care: Medicaid eligible individuals (with a few exceptions) must enroll with a managed care organization. Individuals entitled to Medicare, receiving Medicaid long term care services, or who already have accessible managed care cannot enroll in the Diamond State Health Plan.
Enrollment in a managed care organization is a separate technical eligibility requirement for the non categorically related adults (GE, GF, GG) with income at or below 100% FPL. An adult in this non categorical group, who is otherwise eligible, cannot receive Medicaid until he or she is enrolled in a Diamond State Health Plan MCO.
Enrollment in Managed Care: Medicaid eligible individuals, with a few exceptions, must enroll with a MCO in the Diamond State Health Plan. The following individuals cannot enroll in the Diamond State Health Plan:
• individuals entitled to or eligible to enroll in
Medicare
• individuals who have CHAMPUS
• individuals who are receiving Medicaid long term care services, and
• individuals who already have accessible managed care coverage.
A managed care organization (MCO) is an organization that is licensed as an HMO, Health Services Corporation, or "like entity" and that requires the insured to go to a primary care provider who manages medical care for the insured. Payment to the primary care provider by the MCO can be fee for service or a capitated rate. An individual who is enrolled in a Delaware MCO but not through the Diamond State Health Plan is in an accessible managed care plan provided the MCO is licensed to do business in the insured's county of residence.
Enrollment in a Diamond State Health Plan MCO is a separate technical eligibility requirement for the non categorically related adults including adults who are receiving General Assistance. The adult must join a MCO before the 20th day of the approval month in order for Medicaid coverage to begin the first day of the next month. If the adult joins a MCO after the 20th day of the approval month, Medicaid coverage will start the second month following the approval month. The approval month is the month in which the notice to approve Medicaid is sent to the applicant.
Certain individuals, who are excluded from the Diamond State Health Plan, may be found eligible for retroactive Medicaid. Individuals who may be found eligible for retroactive Medicaid are:
• those entitled to Medicare those entitled to Medicare or eligible to enroll in Medicare(e.g., a pregnant woman who has Medicare),
• those who have accessible managed care coverage,
• those receiving long term care services (nursing facility and the home and community based waivers), and
• those living out-of-state but considered Delaware residents, such as a child placed out-of-state by DSCYF.