- Medicaid Program Overview: The Federal Entitlement
- Medicaid Eligibility Criteria
- Poverty Level-Related Groups
- SSI-Related Groups
- Traditional Fee-For-Service Medicaid
- Medicaid Waivers
- The Delaware Medicaid Managed Care Program
Medicaid is a medical assistance insurance program authorized under federal law in Title XIX of the Social Security Act of 1965. It is an income or "means" tested program, so eligibility always depends in some way on a person's income and resource level. Each state has the option to participate. Once a state decides to participate, it must submit a State Plan to the Federal Government. The State Plan is a contract that the state makes with the federal government. This plan describes how the state intends to follow the rules and how medical assistance program services will be administered locally. Then, the federal government pays a percentage of the cost for the medical assistance services the state provides. The federal share may vary anywhere from 50 percent to approximately 75 percent. In Delaware, the federal match is 50 percent. In addition to mandatory services that a state must cover, a state may also elect to cover optional groups and services.
Delaware Medicaid covers certain AT devices—the Medicaid term is durable medical equipment (DME)—and AT-related services when they are:
- Medically necessary
- Covered under the state plan
- Prescribed by a physician.
NOTE: The state plan requirement has one exception. It is called the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, and involves the 0 to 21 age group (see the Medicaid for Children segment).
As state medical assistance programs go, Delaware Medicaid is very consumer-friendly. In fact, there are times when the agency will provide or pay for certain services (such as Medicare insurance premiums) when the person has no actual Medicaid coverage. So the best approach is this: even when eligibility seems unlikely, check with your local Medicaid unit office about what services may be available to you.
In Delaware, income level formulas and other program eligibility criteria are very complex; they differ with each program category (and subcategory). The following sections offer a basic overview of the two main eligibility categories: Poverty Level-Related Groups, and SSI-Related Groups. Each of these has several subcategories; some examples are mentioned below.
In order to qualify for Medicaid benefits in this category, a person's income must be below a certain level, usually expressed as a percentage of the federal poverty level. First, the 2004 federal poverty levels expressed in terms of annual income are:
- $9,310 for a single person
- $12,490 for a family of 2
- $15,670 for a family of 3
- $18,850 for a family of 4
- $22,030 for a family of 5
Generally, add approximately $3,000 for each additional person*.
*This poverty level information was published on the U.S. Department of Health and Human Services' Website, http://www.aspe.dhhs.gov/poverty/04computations.shtml .
Several subgroups are included in the poverty-level category, and the required family income cut-off is different for each subgroup. For example:
- Pregnant women and infants under the age of one may have family income up to 200 percent of the poverty level.
- Children up to age six qualify at or below 133 percent of the poverty level.
- Children up to age 19 qualify at or below 100 percent of the poverty level.
- Uninsured adults in the expanded population qualify at or below 100 percent of the poverty level.
- Families eligible for Transitional Medicaid qualify at or below 185 percent of the poverty level.
- The Poverty-Related category also includes Medicare-related groups such as:
- Qualified Medicare Beneficiaries (QMBs) for whom, under certain circumstances, Medicaid will pay Medicare Part B premiums, co-insurance and deductible amounts. QMB's must have income at 100 percent of the poverty level or less.
- Qualified Disabled Working Individuals (QDWIs) - These are working people with disabilities who lost Medicare benefits because their incomes exceeded a specified cut-off.
- Specified Low Income Medicare Beneficiaries (SLIMBs) - These individuals are at or below 120 percent of the poverty level, and are not eligible for any regular Medicaid services, but Medicaid will pay their Medicare Part B premiums (but not co-payments or deductibles).
Any individual age 65 or over or who is blind or otherwise permanently disabled may be eligible for Supplemental Security Income (SSI). In the state of Delaware, such persons are eligible for Medicaid automatically. Here again though, there are SSI-related groups whose members may not be receiving SSI benefits, but who are eligible for Medicaid. For example, a 1981 amendment to the Social Security Act [Section 1619(b)] allows some workers with severe disabilities to keep their Medicaid coverage in spite of their loss of SSI benefits due to employment. There are also instances when certain types of income can be excluded from the Medicaid eligibility determination, so the eligibility picture may not be what it seems. Never assume. Always ask.
Again, the best way to ascertain your eligibility for Medicaid services is to check with your local unit office.
The Delaware Medical Assistance Program (DMAP) is the official name of our state Medicaid program. DMAP operates out of Delaware's Department of Health & Social Services (DHSS) and administers the traditional Medicaid system. Under that system, the state directly reimburses Medicaid-authorized providers for covered services. This traditional Medicaid program applies today to only a small percentage of Medicaid recipients in Delaware:
- those in Long Term Care institutions (e.g. nursing homes, ICF/MR, ICFs/IMD)
- dual Medicaid/Medicare recipients
- those who require for their care a physician specialist who is not associated with any available managed care plan
- and those eligible for one of the five Home and Community Based Services (HCBS) Medicaid waivers.
Contact information for fee-for-service Medicaid is:
Delaware Medicaid Office
Lewis Building, Division of Social Services, DHSS Campus
P.O. Box 906, 1901 N. DuPont Highway
New Castle, DE 19720
(302) 255-9500 or (800) 372-2022 (voice)
(302) 577-4150 (TTY)
The Medicaid Waiver system allows states to request "waivers" of federal Medicaid requirements for certain target populations. These groups are comprised of those who would otherwise require an institutional level of care but, with medical and support services, are able to remain in their own homes or other community setting. Those covered by one of the Home and Community Based Services (HCBS) Waiver programs are often able to obtain services, including DME, that are not available either to other fee-for-service members or to MCO members.
In addition to the Medicaid institutional criteria, those applying for services under a HCBS waiver must have incomes at or below 250 percent of the 2004 SSI level of $564 monthly income and must have less than $2,000 in resources. Those covered by waivers are eligible for services in addition to those already covered under the State Plan. The contacts for determining waiver eligibility are detailed below.
DDDS has a waiver for individuals with mental retardation/developmental disabilities receiving residential services from the Division. Services included in the waiver are case management, respite care, residential services, day habilitation services, prevocational services, supported employment services, adult day health services, transportation, clinical support, and environmental adaptations and modifications. The Division’s waiver was renewed in 2004 to 2009. For more information, call the Division of Developmental Disabilities Services (DDDS) at (302) 744-9600 or the Delaware Helpline at (800) 464-4357 (in-state), (800) 273-9500 (out-of-state) or visit the Division’s Website http://www.state.de.us/dhss/ddds/index.html.
Those covered by this Waiver are eligible for case management, homemaker services, medical and social day care, respite care, orthotics and prosthetics (including hearing aids), and participation in the emergency response system.
For more information, call the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) in New Castle County at (302) 453-3820, in Kent and Sussex Counties at (302) 422-1386, or at the Delaware Helpline.
Those covered by this Waiver are eligible for case management, homemaker services, respite care, mental health services, and supplemental nutrition.
For more information, call the Division of Social Services (Medicaid) at (302) 255-9625.
Those covered by this Waiver are eligible for personal services/assistance with activities of daily living (e.g., bathing, dressing, eating, and bathing), nursing services, meal services, and social/emotional services.
For more information, call DSAAPD at (302) 255-9390 or (800) 223-9074.
This waiver is currently under development. Eligible persons are those between 18 and 64 years of age who have a primary or secondary diagnosis of acquired brain injury. Those persons with either a traumatic or a non-traumatic brain injury will be covered under this Waiver. Among those services being considered for inclusion are case management, personal care services, respite care, adult day health, habilitation, environmental accessibility, specialized medical equipment and supplies, adult residential care, and assisted living and cognitive/behavior services.
Call Linda Heller of DSAAPD at (302) 255-9370.
Since 1996, DMAP has provided services to most of its beneficiaries through a Medicaid managed care (HMO-type) health insurance program called the Diamond State Health Plan (DSHP). Currently, two managed care organizations (MCO), First State Health Plan and Diamond State Partners, are employed by the State/DMAP to provide Medicaid managed care services throughout the state. First State Health Plan, which is owned by Christiana Care, receives State funding for each recipient, establish its own network of authorized providers, and makes approval or denial decisions on services covered by the DSHP. Diamond State Partners is a relatively new MCO administered by DMAP. Contact is as follows:
First State Health Plan
11 Read's Way, New Castle, DE 19720
Customer Service: (302) 327-7600 or (800) 362-4214 (voice)
(302) 327-7699 or (800) 855-1155 (TDD)
Client Advocate: (800) 362-4214 or (302) 327-7630
Administration: (800) 362-4214
Diamond State Health Plan
1901 N. DuPont Highway, P.O. Box 906, Lewis Building, New Castle, DE 19720
Provider Relations Unit: (302) 454-7154 or (800) 999-3371
Member Service: (800) 390-6093
Each MCO has customer service and/or case management staff who will answer questions and issue replacement health insurance cards, and Client Advocates with whom to discuss disputes about equipment/service eligibility. However, outreach to members and information on program enrollment options may also be handled through yet another of Medicaid's service contractors called a Health Benefits Manager (HBM). Electronic Data Systems (EDS) is Delaware's current provider of HBM services. EDS can explain plans and enroll beneficiaries in them as well as teach beneficiaries how to use managed care. EDS also enrolls providers and members, helps members find physicians, and processes claims for equipment and services.
The phone number for EDS is (800) 996-9969. Their TTY number is (800) 232-5470.
Careful selection of an MCO is important, not only because one's primary care physician must be a member of the MCO, but also because the benefits package offered by an MCO is not compatible with certain types of needs. An MCO, for example, may offer services beyond those required by the Medicaid contract. Prospective applicants should request information from the MCO and/or EDS prior to enrollment to review its plan. Once a person enrolls with a MCO, s/he is generally required to stay for at least one year. The State Medicaid office may make an exception if the member presents good reasons to justify the request for a change of MCO.
An MCO may request that the State disenroll or terminate a member from the plan for “good cause." However, before doing so, the MCO is required to attempt to resolve the problem with the member. An example of circumstances leading to disenrollment would be if a member habitually uses emergency room services instead of going to an MCO-authorized facility. If disenrolled, the person is not permitted to leave the DSHP program, but would be enrolled in another MCO.