DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Statutory Authority: 16 Delaware Code, Section 133 (16 Del.C. §133)
16 DE Admin. Code 4203
4203 Cancer Treatment Program
The Department Health and Social Services is proposing revisions to the State of Delaware Regulations Governing the Cancer Treatment Program. Originally adopted on July 10, 2004, these regulations establish medical insurance coverage for Delawareans for treatment of cancer. The proposed revisions extend treatment coverage from 12 months to 24 months after the date that cancer treatment is initiated for each primary cancer diagnosis.
NOTICE OF PUBLIC HEARING
Health Promotion and Disease Prevention Section, under the Division of Public Health, Department of Health and Social Services (DHSS), will hold a public hearing to discuss the proposed revisions to the State of Delaware Regulations Governing the Cancer Treatment Program. The public hearing will be held on September 26, 2007 at 10:00 a.m. in the Health Promotion and Disease Prevention Conference Room, Second Floor, located in the Thomas Collins Bldg, 540 S. Dupont Highway, Dover, Delaware.
Copies of the proposed regulations are available for review by calling the Health Promotion and Disease Prevention Section at (302) 744-1040.
Anyone wishing to present his or her oral comments at this hearing should contact Mr. David Walton at (302) 744-4700 by September 25, 2007. Anyone wishing to submit written comments as a supplement to or in lieu of oral testimony should submit such comments by October 1, 2007 to:
David Walton, Hearing Officer
Division of Public Health
417 Federal Street
Dover, DE 19901
Summary of Changes to Regulations Governing the Cancer Treatment Program
• Extends treatment coverage from 12 months to 24 months after the date that cancer treatment is initiated for each primary cancer diagnosis.
• Clarifies that eligibility of treatment for individuals who has a recurrence of cancer is made by the treating physician.
• Clarifies the period of eligibility for enrollees receiving treatment for cancer.
4200 Health Promotion and Disease Prevention
4203 Cancer Treatment Program
The Cancer Treatment Program (CTP) is a program of Delaware Health and Social Services (DHSS), Division of Public Health (DPH) intended to provide medical insurance coverage to Delawareans for the treatment of cancer.
8 DE Reg. 1144 (2/1/05)
2.0 Availability Of Funds
2.1 Benefits will be available to enrollees provided that funds for this program are made available to DHSS.
2.2 In the event that funds are not available, DHSS will notify enrollees and providers.
3.0 General Application Information
3.1 The application must be made in writing on the prescribed CTP form. An individual, agency, institution, guardian or other individual acting can make this request for assistance for the applicant with his knowledge and consent. The CTP will consider an application without regard to race, color, age, sex, disability, religion, national origin or political belief as per State and Federal law.
3.2 Each individual applying for the CTP is requested, but not required, to furnish his or her Social Security Number.
3.3 Filing an application gives the applicant the right to receive a written determination of eligibility and the right to appeal the written determination.
4.0 Technical Eligibility
4.1 The following for an adult applicant are required to receive benefits under this program. The adult applicant must:
4.1.1 Need treatment for cancer in the opinion of the applicant’s licensed physician of record. Cancer treatment will not include routine monitoring for pre-cancerous conditions, or monitoring for recurrence during or after remission.
4.1.2 Be a Delaware resident.
4.1.3 Have been a Delaware resident at the time cancer was diagnosed.
4.1.4 Have no health insurance.
126.96.36.199 Examples of health insurance include comprehensive, major medical and catastrophic plans, Medicare, and Medicaid.
188.8.131.52 Excepted are the following types of insurance plans, which do not exclude eligibility for the CTP: dental, vision, dismemberment, drug, mental health, nursing home, blood bank, workman’s compensation, accident, family planning, the Delaware Prescription Assistance Program, the Delaware Chronic Renal Disease program, and non-citizen medical coverage.
184.108.40.206 The CTP is the payer of last resort and will only provide benefits to the extent that they are not covered by the plans listed in 220.127.116.11.
4.1.5 Be over the age of 18 years.
4.1.6 Be diagnosed with any cancer on or after July 1, 2004, or be receiving benefits for the treatment of colorectal cancer through the Division of Public Health’s Screening for Life program on June 30, 2004.
4.2 The following are required for a minor (child under 18 years of age) to receive benefits under this program. The minor applicant must:
4.2.1 Need treatment for cancer in the opinion of the applicant’s licensed physician of record. Cancer treatment will not include routine monitoring for pre-cancerous conditions, or monitoring for recurrence during or after remission.
4.2.2 Be a Delaware resident
4.2.3 Have been a Delaware resident at the time cancer was diagnosed.
4.2.4 Be diagnosed with any cancer on or after July 1, 2004. Coverage shall be retroactive up to 3 months prior to date of application, provided applicant meets medical requirements and applicant’s parent(s) or legal guardian(s) meet financial eligibility requirements under 5.1. In no case will the minor applicant be eligible for benefits under this program before July 1, 2004.
4.2.5 The CTP is payer of last resort and will only provide benefits to the extent that they are not covered by other plans.
4.3 An inmate of a public institution shall be eligible for the CTP, provided that the benefits of the CTP are not otherwise provided in full or in part.
4.3.1 For the purposes of the CTP, the definitions of public institution and inmate shall be the same as used by the Delaware Medicaid program.
4.4 The Medical Assistance Card is the instrument used to verify an individual’s eligibility for benefits. Prior to rendering services, medical providers are required to verify client eligibility using the client’s identification number by accessing one of the Electronic Verification Systems (EVS) options. Instructions for accessing EVS are described in the EVS section of the billing manual.
8 DE Reg 1144 (2/1/05)
5.0 Financial Eligibility
5.1 To be eligible for the CTP the applicant must have countable household income that is less than 650% of the Federal Poverty Level (FPL).
5.2 Income is any type of money payment that is of gain or benefit to an individual. Income is either counted or excluded for the eligibility determination.
5.3 Countable income includes but is not limited to:
5.3.1 Social Security benefits – as paid after deduction for Medicare premium
5.3.2 Pension – as paid
5.3.3 Veterans Administration Pension – as paid
5.3.4 U.S. Railroad Retirement Benefits – as paid
5.3.5 Wages – net amount after deductions for taxes and FICA Senior Community Service Employment – net amount after deductions for taxes and FICA
5.3.6 Interest/Dividends – gross amount
5.3.7 Capital Gains – gross amount from capital gains on stocks, mutual funds, bonds.
5.3.8 Credit Life or Credit Disability Insurance Payments – as paid
5.3.9 Alimony – as paid
5.3.10 Rental Income from entire dwelling – gross rent paid minus standard deduction of 20% for expenses
5.3.11 Roomer/Boarder Income – gross room/board paid minus standard deduction of 10% for expenses
5.3.12 Self Employment – countable income as reported to Internal Revenue Service (IRS)
5.3.13 Unemployment Compensation - as paid
5.4 Excluded income includes but is not limited to:
5.4.1 Annuity payments
5.4.2 Individual Retirement Account (IRA) distributions
5.4.3 Payments from reverse mortgages
5.4.4 Capital gains from the sale of principal place of residence
5.4.5 Conversion or sale of a resource (i.e. cashing a certificate of deposit)
5.4.6 Income tax refunds
5.4.7 Earned Income Tax Credit (EITC)
5.4.8 Vendor payments (bills paid directly to a third party on behalf of the individual)
5.4.9 Government rent/housing subsidy paid directly to individual (i.e. HUD utility allowance)
5.4.10 Loan payments received by individual
5.4.11 Proceeds of a loan
5.4.12 Foster care payments made on behalf of foster children living in the home
5.4.13 Retired Senior Volunteer Program (RSVP)
5.4.14 Veterans Administration Aid and Attendance payments
5.4.15 Victim Compensation payments
5.4.16 German reparation payments
5.4.17 Agent Orange settlement payments
5.4.18 Radiation Exposure Compensation Trust Fund payments
5.4.19 Japanese-American, Japanese-Canadian, and Aleutian restitution payments
5.4.20 Payments from long term care insurance or for inpatient care paid directly to the individual
5.5 Determination of the household income will be based on the family budget group, which is the total number of persons whose income is budgeted together. This will always include the following:
5.5.1 Married couples if they live together; and,
5.5.2 Unmarried couples who live together as husband and wife.
5.5.3 Couples will be considered as living together as husband and wife if:
18.104.22.168 They say they are married, even if the marriage cannot be verified; or,
22.214.171.124 They are recognized as husband and wife in the community; or,
126.96.36.199 One partner uses the other's last name; or,
188.8.131.52 They state they intend to marry.
5.6 In households that include a caretaker, the caretaker's children and other children that are the caretaker's responsibility, the caretaker's income and those of his/her children are always budgeted together. The income of any other children in the home will be considered separately. In these situations, the separate budget groups can be combined to form a single family budget group only when the following conditions are met:
5.6.1 CTP benefits would be denied to any of the recipients by maintaining separate budget groups.
5.6.2 The caretaker chooses to have his/her income and those of his/her children considered with the income of any other people in the home.
6.1 A Delaware resident is an individual who lives in Delaware with the intention to remain permanently or for an indefinite period, or where the individual is living and has entered into a job commitment, or seeking employment whether or not currently employed.
6.2 Factors that may be taken into account when determining residency are variables such as the applicant’s age, location of dwellings and addresses, location of work, institutional status, and ability to express intent.
6.3.1 Will not be denied to an otherwise qualified resident of the State because the individual's residence is not maintained permanently or at a fixed address.
6.3.2 Will not be denied because of a durational residence requirement.
6.3.3 Will not be denied to an institutionalized individual because the individual did not establish residence in the community prior to admission to an institution.
6.3.4 Will not be terminated due to temporary absence from the State, if the person intends to return when the purpose of the absence has been accomplished.
6.4 When 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.
7.0 Verification Of Eligibility Information
7.1 The CTP may verify information related to eligibility. Verification may be verbal or written and may be obtained from an independent or collateral source.
7.2 Documentation shall be date stamped and become part of the CTP case record.
7.3 Verifications received and/or provided may reveal a new eligibility issue not previously realized. Additional verifications may be required.
7.4 Failure to provide requested documentation may result in denial or termination of eligibility.
8.0 Disposition Of Applications
8.1 The CTP will dispose of each application by a finding of eligibility or ineligibility, unless:
8.1.1 There is an entry in the case record that the applicant voluntarily withdrew the application, and that the CTP sent a notice confirming the applicant’s decision;
8.1.2 There is a supporting entry in the case record that the applicant is deceased; or
8.1.3 There is a supporting entry in the case record that the applicant cannot be located.
9.0 Changes In Circumstances And Personal Information
9.1 Enrollees are responsible for notifying the CTP of all changes in his circumstances that could potentially affect eligibility for the CTP. Failure to do so may result in overpayments being processed and legal action taken to recover funds expended on his/her behalf during periods of ineligibility.
9.2 Enrollees are responsible for notifying the CTP of changes in the enrollee’s name, address and telephone number.
10.0 Termination Of Eligibility
10.1 Eligibility terminates:
10.1.1 When the enrollee attains other medical insurance, including Medicare, Medicaid, and the Medicaid Breast and Cervical Cancer treatment program.
10.1.2 When the enrollee is no longer receiving treatment for cancer as defined in 4.1.1.
10.1.3 When the enrollee no longer meets the technical or financial eligibility requirements.
12 Twenty-four months after the date that cancer treatment is initiated for each primary cancer diagnosis.
10.2 If eligibility is terminated, it may only be renewed for an individual who is diagnosed with
another cancer for which coverage has not been previously provided a new primary cancer. An individual who has a recurrence of cancer for which coverage has been previously provided is not eligible for additional coverage. The determination of a new primary cancer or recurring cancer is made by the treating physician.
11.0 Coverage And Benefits
11.1 Coverage is limited to the treatment of cancer as defined by DHSS.
11.2 There is no managed care enrollment.
11.3 Benefits will be paid at rates equivalent to Medicaid under a fee for service basis. If a Medicaid rate does not exist for the service provided, the CTP will determine a fair rate.
11.4 Benefits will only be paid when the provider of the cancer treatment services is a Delaware Medicaid Assistance Provider.
11.5 Benefits for patients enrolled prior to September 1, 2004 (or whatever date is established by DHSS as having an operational benefits management information system), may not be paid until after that date.
11.6 The CTP is the payer of last resort and will only provide benefits to the extent that they are not otherwise covered by another insurance plan.
11.7 Eligibility may be retroactive to the day that cancer treatment was initiated provided that the application is filed within one year of that day. In such circumstances, covered services will only be provided for the time period that the applicant is determined to have been eligible for the CTP.
11.8 In no case will eligibility be retroactive to a time period prior to July 1, 2004, except if the enrollee was receiving benefits for the treatment of colorectal cancer through the Division of Public Health’s Screening for Life program on June 30, 2004. If this exception occurs, eligibility will be retroactive only to the date the enrollee was receiving benefits for colorectal cancer treatment through the Screening for Life program.
11.9 Enrollees receiving treatment for cancer as defined in 4.1.1 as of July 1, 2007, are able to extend their initial 12 month coverage to a maximum of 24 months after the date cancer treatment is initiated for each primary cancer diagnosis, provided that the enrollee continues to meet the technical and financial eligibility requirements.
12.0 Cancer Treatment Services Which Are Not Covered
12.1 The cost of nursing home or long-term care institutionalization is not covered. (The cost of cancer treatment services within a nursing home or long term care institution is a covered benefit.)
12.2 Services not related to the treatment of cancer as determined by DHSS are not covered.
12.3 Cancer treatment services for which the enrollee is eligible to receive by other health plans as listed in 184.108.40.206 are not covered.
13.0 Changes In Program Services
13.1 When changes in program services require adjustments of CTP benefits, the CTP will notify enrollees who have provided an accurate and current name, and address or telephone number.
14.1 The CTP will maintain the confidentiality of application, claim, and related records as required by law.
15.0 Review Of CTP Decisions
15.1 Any individual who is dissatisfied with a CTP decision may request a review of that decision.
15.2 Such request must be received by the CTP in writing within 30 days of the date of the decision in question.
15.3 The CTP will issue the results of its review in writing. The review will be final and not subject to further appeal.
8 DE Reg. 107 (7/1/04)
11 DE Reg. 278 (09/01/07) (Prop.)