16 Del. Admin. Code § 14000-14920

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

Section 14000-14920 - Retroactive Coverage

The agency must make eligibility for Medicaid effective no later than the third month before the month of application if the individual:

* Received Medicaid services, at any time during that period, of a type covered under the plan; and

* Would have been eligible for Medicaid in one of the below retroactive eligibility groups at the time the individual received the services if the individual had applied (or someone had applied on their behalf) regardless of whether the individual is alive when application for Medicaid is made; and

* Individuals eligible under the Delaware Healthy Children's Program (DHCP) are not eligible for retroactive Medicaid.

Effective April 1, 2012, those that may be found eligible for retroactive Medicaid coverage, if general financial and technical eligibility requirements are met, include:

a. Individuals entitled to or eligible for 1 of the following Medicare Savings Programs (excludes QMB):

i. Specified Low Income Medicare Beneficiaries (SLMB)

ii. Qualifying Individuals (QI)

iii. Qualified and Disabled Working Individuals (QDWI)

b. Individuals residing in a nursing facility

c. Individuals residing in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) or for individuals with mental disease (ICF/IMD)

d. Individuals in need of only the 30-day Acute Care Hospital Program (in no case should the effective date be earlier than the first day of hospitalization)

e. Women eligible under the Breast and Cervical Cancer Treatment Group

f. Individuals eligible under the Medicaid for Worker's with Disabilities Group (provided premium requirements are met)

Effective August 1, 2019, the groups that may be found eligible for retroactive Medicaid coverage, if general financial and technical eligibility requirements are met, was expanded to include:

a. Pregnant and Postpartum Women

b. Infants under age 1

c. Individuals under the age of 19

Effective January 1, 2025, the groups that may be found eligible for retroactive Medicaid coverage, if general financial and technical eligibility requirements are met, was expanded to all eligible DSHP and DSHP-Plus Medicaid participants, with some exceptions, as described in DSSM 14920.1 Retroactive Coverage Limitations.

15 DE Reg. 1717 (06/01/12)

26 DE Reg. 952 (05/01/23)

14920.1Retroactive Coverage Limitations

Effective January 1, 2024, retroactive medical coverage is potentially available, if general financial and technical eligibility requirements are met, for all Medicaid individuals enrolled under the Diamond State Health Plan (DSHP) and Diamond State Health Plan Plus (DSHP-Plus).

Individuals eligible under the Delaware Healthy Children's Program (DHCP) are not eligible for retroactive Medicaid.

Individuals in the following programs are excluded from DSHP and DSHP-Plus, but may be found eligible for retroactive Medicaid coverage, if general financial and technical eligibility requirements are met.

a. Individuals entitled to the following Medicare Savings Programs

i. Specified Low Income Medicare Beneficiaries (SLMB)

ii. Qualifying Individuals (QI)

iii. Qualified and Disabled Working Individuals (QDWI)

b. Individuals residing in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) or for individuals with mental disease (ICF/IMD)

c. Individuals in need of only the 30-Day Acute Care Hospital Program

d. Individuals eligible under the Breast and Cervical Cancer Treatment Group.

e. Individuals eligible for emergency, labor, and delivery coverage only.

f. Incarcerated Medicaid members.

All other individuals in programs excluded from DSHP and DSHP-Plus are not eligible for retroactive Medicaid Coverage. These include, but may not be limited to, individuals enrolled in the following programs:

a. The following Medicare Savings Program - Qualified Medicare Beneficiary.

b. The Chronic Renal Disease Program.

c. The Delaware Prescription Assistance Program.

d. The Delaware Cancer Treatment Program.

e. The Part C Program.

f. The VFC Immunization Program.

15 DE Reg. 1716 (06/01/12)

26 DE Reg. 952 (05/01/23)

14920.2Retroactive Coverage Of Medical Bills Individuals or families who apply for Medicaid and who may be eligible for Diamond State Health Plan or the Diamond State Health Plan Plus may be eligible for retroactive Medicaid coverage of any unpaid medical bills incurred in any of the three months prior to the month in which they applied. However, certain requirements must be met in order for these bills to be paid under Medicaid.

a. The client must have been eligible in all respects for Medicaid in one of the retroactive eligibility categories in the month(s) that the medical services were received (including Delaware residency).

b. The medical bill must be for a service covered by Medicaid.

c. The client did not have any third party coverage that would have been responsible for paying the bill.

d. The medical service must have been given by a provider who was a participant in the Delaware Medicaid program at the time of service. If the provider was not enrolled at the time of the service, the provider may enroll retroactively (up to 12 months).

14920.3Retroactive Coverage Time Limits There is no time limitation on requests for retroactive coverage. They may be processed at any time.

14920.4Retroactive Application Process Requests for retroactive Medicaid are received in various ways as described below:

a. Applicants indicate on the application that they have unpaid medical bills in the three months prior to the month of application.

b. Many requests are received over the telephone from clients who have an unpaid bill.

c. The Medicaid units receive lists from various medical providers such as Division of Public Health, and the school districts requesting assistance with the resolution of an unpaid bill for a Medicaid client.

d. The SSI Medicaid Unit receives data from the Social Security Administration via the SDX regarding individuals who need retroactive coverage.

14920.5Retroactive Eligibility Determination

If the individual is determined to be eligible for retroactive coverage, the worker must confirm that the date of service of the individual's medical bill(s) falls within the 3 months prior to the month of application and that the individual meets the financial, technical, and medical (if applicable) eligibility requirements under Medicaid in 1 of the programs eligible for retroactive coverage during the retroactive period. Verify income and resources, as applicable in accordance with DSSM 14800.

Obtain information about third party liability information and forward to the TPL Unit.

A notice of Retroactive Medicaid Approval or Denial will be used to inform the client of the agency's disposition of the request for retroactive coverage. The client should be aware that even those bills submitted for payment may not be reimbursed by Medicaid (i.e., service not covered by Medicaid, non-participating provider, etc.).

15 DE Reg. 202 (08/01/11)

26 DE Reg. 952 (05/01/23)

14920.6Retroactive Eligibility For Newborns

A baby born to a woman eligible for and receiving Medicaid on the date of the child's birth is deemed to have filed an application. Also, a mother can apply after a child is born and we will determine her eligibility for three month retroactive coverage. If the mother is determined retroactively eligible during her pregnancy or post-partum period, the infant is deemed eligible at birth and remains eligible for 1 year.

16 Del. Admin. Code § 14000-14920

13 DE Reg. 1540 (06/01/10)
15 DE Reg. 202 (08/01/11)
15 DE Reg. 1716 (06/01/12)
26 DE Reg. 952 (5/1/2023)
28 DE Reg. 387 (11/1/2024) (Final)