16 Del. Admin. Code § 17000-17170
Section 4913 of the Balanced Budget Act (BBA) provides that children who were receiving SSI payments on August 22, 1996, and who but for the enactment of the new disability definition under §211(a) of the Personal Responsibility and Work Opportunity Act of 1996 (PRWORA), would continue to be paid SSI, are mandatory categorically eligible for Medicaid. This provision is effective for those children who lose their SSI payment on or after July 1, 1997.
15 DE Reg. 202 (08/01/11)
The child must meet all of the following requirements:
| (a) | The child was being paid SSI on August 22, 1996. This includes children who, as of August 22, 1996, were in current pay status, had received favorable or partially favorable administrative decisions, or had a Zebley appeal pending. |
| (b) | The child's SSI payment stopped on or after July 1, 1997. |
| (c) | The decision to stop SSI payments was due to a determination that the child does not met the definition of disability enacted on August 22, 1996, at §211(a) of the Personal Responsibility and Work Opportunity Act of 1996. |
| (d) | The child would, except for the disability determination described in (c), continue to be paid SSI. |
A child, who was not receiving SSI on August 22, 1996, is not protected by Section 4913. A child who loses SSI after August 22, 1996, for a nondisability reason is also not protected by Section 4913. If either of these two situations occur, a redetermination of Medicaid eligibility for the child under another eligibility group will be done.
The redetermination of disability will follow the rules in 20 CFR 416.924-924 e as in effect on April 1, 1996. A contractor who is competent to perform the redetermination of disability will be used.
The rules in 20 CFR 416.994a as published on April 1, 1996 will be used with the following modifications to the frequency of review:
| (a) | Review disability after, at most, 18 months if medical improvement is expected. |
| (b) | Review disability after, at most, 3 years if disability is not permanent but medical improvement cannot be predicted. |
| (c) | Review disability after, at most, 7 years if disability is permanent. |
A contractor who is competent to perform the continuing disability reviews will be used.
Follow the SSI income and resource standards and methodologies.
Medicaid eligibility for children covered under this provision continues until the earlier of:
| · | the child reaches age 18 |
| · | the child no longer meets the criteria of the SSI program for payment of benefits (other than the post August 22, 1996, definition of disability for children). A child who ceases to meet the non-disability SSI eligibility criteria can recover coverage under Section 4913 if the child again meets the non-disability SSI criteria. However, a determination that the child is no longer disabled under the pre-PRWORA disability criteria will permanently bar the child from protected coverage under Section 4913. |
| · | the child is not eligible under another Medicaid eligibility group. |
A redetermination of the non-disability criteria is required at least every 12 months.
16 Del. Admin. Code § 17000-17170