16 Del. Admin. Code § 4203-4.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 4203-4.0 - 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.

4.1.4.1 Examples of health insurance include comprehensive, major medical and catastrophic plans, Veterans Affairs Medical Services, Correctional Healthcare Services, Medicare, and Medicaid.

4.1.4.2 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.

4.1.4.3 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 4.1.4.2.

4.1.5 Meet one of the exemptions listed in the Patient Protection and Affordable Care Act's (PPACA) requirements to buy coverage.

4.1.5.1 Exemptions listed in the PPACA include: applicant is part of a religion opposed to acceptance of benefits from a health insurance policy; applicant is an undocumented immigrant; applicant is incarcerated; applicant is a member of an Indian tribe; applicant's family income is below the threshold for filing a tax return; applicant is required to pay more than 8% of household income for health insurance, after taking into account any employer contributions or tax credits.

4.1.5.2 Applicants will need to show proof of exemption from the PPACA.

4.1.6 Be ineligible for Medicaid.

4.1.7 Be over the age of 18 years.

4.1.8 Be diagnosed with any cancer on or after July 1, 2004, or be receiving benefits for the diagnosis 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.

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 ineligible for the CTP.

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 16 DE Admin. Code 14120.

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.

16 Del. Admin. Code § 4203-4.0

8 DE Reg 1144 (2/1/05)
18 DE Reg. 67( 7/1/2014) (Final)