16 Del. Admin. Code § 15000-15600
This section describes the eligibility requirements for the Breast and Cervical Cancer Group. This group includes uninsured women who are identified through the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and are in need for treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer.
The following words and terms, when used in the context of these policies, will have the following meaning unless the context clearly indicates otherwise:
"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.
Comprehensive health insurance does not include time periods when there is no coverage for the treatment of breast or cervical cancer. Examples include when coverage is effective only after a waiting period of uninsurance or after the lifetime limits are exhausted.
Comprehensive health insurance does include insurance that has limits on benefits (such as limits on the number of outpatient visits per year) or high deductibles.
A woman must meet the general eligibility requirements described in Section 14000.
Age: The woman must be under age 65. If a woman turns age 65 during her period of coverage, her eligibility terminates. Exception: If the woman is an inpatient in a hospital when she turns 65, eligibility continues until discharge.
Uninsured:
The woman must be uninsured. The woman is not eligible if she has:
Screening:
The woman must have been screened for breast or cervical cancer under the CDC Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act and found to need treatment for either breast or cervical cancer (including a pre-cancerous condition).
A woman is considered to have met the screening requirement if she comes under any of the following categories:
Treatment:
The woman must need treatment for breast or cervical cancer. The woman meets this requirement when it is the opinion of the woman's treating health professional that the diagnostic test following a breast or cervical cancer screen indicates that the woman is in need of cancer treatment services. These services included diagnostic services that may be necessary to determine the extent and proper course of treatment, as well as treatment itself.
Based on the physician's plan-of-care, a woman who is determined to require only routine monitoring services for a pre-cancerous breast or cervical condition (such as breast examination and mammograms), is not considered to need treatment.
There is no income or resource test.
Presumptive eligibility is a temporary eligibility determination that will provide expedited Medicaid coverage to women in this group during the application processing period. This special application processing procedure will facilitate the prompt enrollment and immediate access to services for women who are in need of treatment for breast or cervical cancer. An applicant can be determined presumptively eligible when the agency receives verification that she has been screened for breast or cervical cancer under CDC and needs treatment.
If the information on the application indicates that she may be eligible under one of the mandatory eligibility groups, the agency will first make a determination of presumptive eligibility under this group. Verifications of factors of eligibility for the mandatory group are postponed. Postponed verifications must be provided within 30 days from the date of receipt of the application. The verifications that were postponed are required to determine final eligibility for Medicaid. Presumptive eligibility continues until a final eligibility determination is completed. If the required verifications are not provided, eligibility is terminated.
If the information on the application indicates that the woman is not eligible under one of the mandatory groups, the agency will make a final determination of eligibility under this group provided all verification requirements are met.
Eligibility may begin up to three months prior to the month of application provided the woman meets all eligibility requirements during those prior three months including having been screened and found to need treatment for breast or cervical cancer.
A woman is not limited to one period of eligibility. A new period of eligibility and coverage can begin each time a woman is screened under the CDC program, has been found to need treatment for breast or cervical cancer, and meets the other eligibility requirements.
A woman eligible under this group is entitled to full Medicaid coverage. Coverage is not limited to the treatment of breast and cervical cancer.
Eligibility under this group terminates when the woman:
16 Del. Admin. Code § 15000-15600