16 Del. Admin. Code § 14000-14100
The application will be the single, streamlined application for all insurance affordability programs developed by the Centers for Medicare and Medicaid Services (CMS) or an alternative single, streamlined application for all insurance affordability programs as approved by CMS.
For individuals applying, or who may be eligible, on a basis other than a determination based on the modified adjusted gross income (MAGI) methodologies described in Section 16000, the agency will use:
* a single, streamlined application and supplemental forms to collect the additional information needed, or
* an application designed specifically to determine eligibility on a basis other than MAGI.
The application may be submitted via the Internet web site established by the Federally Facilitated Marketplace (FFM), via the agency's Application for Social Service and Internet Screening Tool (ASSIST) self-service Internet web site, by telephone, via mail, in person with reasonable accommodations for those with disabilities, as defined by the Americans with Disabilities Act (ADA), and through other commonly available electronic means.
The FFM is a competitive marketplace for individuals and small employers to directly compare available health insurance options. The FFM will conduct basic screening and an assessment for potential Medicaid eligibility and transmit the information provided on the application to the agency for an eligibility determination as described in Section 14100.8 Coordination of Eligibility and Enrollment with Other Insurance Affordability Programs.
The application must be signed under penalty of perjury. Electronic, including telephonically recorded, signatures and handwritten signatures transmitted via any other electronic transmission are accepted.
When an application is completed online, the date of application is the date the application is submitted online. The date of application for a paper application will be the date of receipt in an agency office or the date of the postmark if received via the United States Postal Service (USPS). The application filing date is used to determine the earliest date for which Medicaid can be effective. Medicaid eligibility is effective the first day of the month if the individual was eligible at any time during that month provided the individual was a Delaware resident on the first of the month. If not a Delaware resident on the first of the month, Medicaid will be effective the date the individual became a Delaware resident.
Assistance will be provided to any individual seeking help with the application or renewal process in person, over the telephone, online, and in a manner that is accessible to individuals with disabilities and those who are limited English proficient.
Applicants and beneficiaries are permitted to designate an individual or organization to act responsibly on their behalf in assisting with the individual's application and renewal of eligibility and other ongoing communications with the agency. The designation must be in writing, including the applicant's signature, and is permitted at the time of application and at other times.
Legal documentation of authority to act on behalf of an applicant or beneficiary under state law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of written authorization by the applicant or beneficiary. The authorized representative must agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency.
The agency will accept electronic, including telephonically recorded, signatures and handwritten signatures transmitted by facsimile or other electronic transmission. Designation of authorized representatives will be accepted via ASSIST self-service web site, by telephone, via mail, in person, and through other commonly available electronic means.
Representatives may be authorized to:
* assist the individual in completing and submitting an application, verification, or other documentation;
* sign an application on the applicant's behalf;
* complete and submit a renewal form;
* receive copies of the applicant or beneficiary's notices and other communications from the agency; and/or
* act on behalf of the applicant or beneficiary in any other matters with the agency.
The power to act as an authorized representative is valid until the applicant or beneficiary modifies the authorization or notifies the agency the representative is no longer authorized to act on his or her behalf, or there is a change in the legal authority upon which the individual or organization's authority was based. This notification to the agency must be in writing and should include the individual's or authorized representative's signature as appropriate.
As a condition of serving as an authorized representative, a provider or staff member or volunteer of an organization must sign an agreement that he or she will adhere to the regulation in:
* 42 CFR part 431, subpart F (relating to confidentiality of information);
* 45 CFR 155.260(f) (relating to confidentiality of information);
* 42 CFR 447.10 (relating to the prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility's behalf); and
* other relevant State and Federal laws concerning conflicts of interest and confidentiality of information.
An individual's application filing date may be established based on either a written statement or an oral inquiry about Medicaid eligibility. An oral inquiry is a discussion about Medicaid eligibility for a specific person that results in a request for Medicaid. An oral inquiry must be documented when received. An oral inquiry or a written statement protects the filing date if a written application is completed and received in a DSS office within 30 days from the date of inquiry. When an application is received in the mail, the date of the postmark is considered the date of receipt. A postmark is the U.S. Postal Service mark stamped on a piece of mail canceling the postage stamp and recording the date and place of sending. An oral inquiry or written statement protects the filing date if an application is received within 30 days from the date of the inquiry.
An in-person interview is not required for any eligibility group subject to the modified adjusted gross income (MAGI)-based methodologies described in Section 16000.
An in-person interview is not required for Long Term Care eligibility determinations. SEE SECTION 20101 - Application Process - Long-Term Care Services.
The agency must include in each applicant's case record facts to support the agency's decision on the individual's application. The agency must dispose of each application by a finding of eligibility or ineligibility, unless there is:
An application must be reinstated effective as of the date the application was first received by the Federally Facilitated Marketplace (FFM) in cases where the individual:
All applicants will receive a notice of acceptance or denial.
A determination of eligibility includes:
Each applicant or beneficiary who meets the non-financial eligibility requirements will have a determination of financial eligibility based on MAGI methodology. For an applicant or beneficiary found not eligible based on MAGI methodology and who has been identified on the application or renewal form as potentially eligible on a MAGI-excepted basis, a determination of eligibility will be made on such basis. In addition, an individual may request a determination of eligibility on a basis other than MAGI.
The agency will consider all categories of eligibility prior to a termination of eligibility. For individuals determined ineligible for Medicaid, the agency will determine potential eligibility for other insurance affordability programs in accordance with Section 14100.8 Coordination of Eligibility and Enrollment with Other Insurance Affordability Programs.
The following Federal standards have been established for determining eligibility and informing applicants of the decision:
The standards cover the period from the date of application with the agency or the date the application is transferred via the Federally Facilitated Marketplace (FFM) to the date the agency notifies the applicant of its decision.
The standards must be met except in unusual circumstances, such as:
The time standards must not be used as a waiting period before determining eligibility or as a reason for denying eligibility (because a decision has not been reached within the required time). Decision on applications should be made as quickly as possible, but if the final determination does not fall within the prescribed limits, the record must have documentation of the reasons for delay.
42 CFR 435.916
The eligibility of Medicaid beneficiaries must be renewed once every 12 months and no more frequently than once every 12 months. The agency will redetermine eligibility without requiring information from the individual if able to do so based on reliable information contained in the individual's record or other more current information available to the agency. Information available to the agency includes but is not limited to information accessed through the electronic data sources described in DSSM 14800 - Verifications of Factors of Eligibility.
If the agency is able to renew eligibility based on the available information, the agency will notify the individual of:
* The eligibility determination and the information used for the determination; and
* The individual's responsibility to inform the agency if any of the information contained in the agency's notice is inaccurate. The individual may report this information via the agency's Application for Social Service and Internet Screening Tool (ASSIST) self-service Internet web site, by telephone, via mail, in person with reasonable accommodations for those with disabilities as defined by the Americans with Disabilities Act (ADA), and through other commonly available electronic means.
If the agency cannot renew eligibility as described above, the agency will provide the individual with a pre-populated renewal form. The pre-populated renewal form will contain information available to the agency about factors of eligibility. The renewal form will also include basic screening questions necessary to indicate potential eligibility on a basis other than modified adjusted gross income (MAGI).
The individual will be given 30 days from the date of the renewal form to respond. The individual must provide any additional information requested and sign and return the renewal form. The request for additional information from the individual will be limited to only the information needed to renew eligibility. The individual may return the additional information and the renewal form through any of the submission modes described above.
If the individual does not respond to the renewal form and provide the additional information requested and eligibility is terminated on that basis, eligibility can be reconsidered if the individual responds within 90 days after the date of termination. The individual is not required to submit a new application. Coverage may extend back to the date of termination provided the individual is found eligible as described in DSSM 14920 - Retroactive Coverage.
The agency will consider all categories of eligibility prior to a termination of eligibility as described in DSSM 14100.5 - Determination of Eligibility.
A fair hearing is an administrative hearing held in accordance with the principles of due process. An opportunity for a fair hearing will be provided, subject to the provisions in policy at DSSM Fair Hearing Section. Any individual who is dissatisfied with a decision of the Division of Social Services may request a fair hearing. See DSSM Fair Hearing Section for policies covering fair hearings.
The following words and terms, when used in the context of these policies, will have the following meaning unless the context clearly indicates otherwise.
"Coordinated content" means information included in an eligibility notice regarding the transfer of the individual's or households' electronic account to the Federally Facilitated Marketplace (FFM) for a determination of eligibility for another insurance affordability program.
"Electronic account" means an electronic file that includes all information collected and generated by the agency regarding each individual's Medicaid eligibility and enrollment including any information collected or generated as part of the agency fair hearing process or the FFM appeals process.
"Insurance affordability program" means a program that is one of the following:
"Secure electronic interface" means an interface which allows for the exchange of data between Medicaid and other insurance affordability programs and adheres to the requirements in 42 CFR Part 433 subpart C.
For individuals who have been assessed by the FFM (including as a result of a decision made by the FFM appeals entity) as potentially Medicaid eligible the agency must:
* accept, via secure electronic interface, the electronic account for the individual and notify the FFM of the receipt of the electronic account;
* not request information or documentation from the individual provided in the individual's electronic account;
* promptly and without undue delay, determine the Medicaid eligibility of the individual without
* requiring submission of another application; and
* notify the FFM of the final determination of the individual's eligibility or ineligibility for Medicaid
For individuals who submit an application; return a renewal form; or whose eligibility is being redetermined due to a change in circumstances; and who are found ineligible for Medicaid, the agency will:
* promptly and without undue delay, determine potential eligibility for, and as appropriate, transfer via a secure electronic interface the individual's electronic account to the FFM, and
* include coordinated content in the notice of denial or termination of Medicaid eligibility.
For individuals with household income greater than the applicable MAGI standard and for whom the agency is determining eligibility on another basis, the agency must promptly and without undue delay:
* determine potential eligibility for, and as appropriate, transfer via secure electronic interface the individual's electronic account to the FFM;
* notify the FFM that the individual is not eligible based on MAGI, but a final determination on a non-MAGI basis is still pending; and
* notify the FFM of the agency's final determination of eligibility or ineligibility.
16 Del. Admin. Code § 14000-14100
17 DE Reg. 503 (11/1/2013)
17 DE Reg. 731 (1/1/2014)
22 DE Reg. 66 (7/1/2018)
28 DE Reg. 387 (11/1/2024) (Final)