Medicaid of Delaware
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- Medicaid for Children – the EPSDT Program
- EPSDT and Managed Care
- The Right to Appeal
- Medicaid County Offices
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Medicaid for Children - The EPSDT Program
EPSDT is Medicaid's Early and Periodic Screening, Diagnosis, and Treatment program for individuals 0 to 21 years of age. It is the most comprehensive health care insurance available today. Under this program, Medicaid must provide any type of AT, related service, or treatment if:
- It is shown to be medically necessary for a Medicaid beneficiary in this age group
- It is the least costly and most appropriate alternative available
- It is a federally approved item or service.
This is true regardless of whether the device or service is included in the Delaware Medicaid State Plan. For example, hearing aids are covered for those between the ages of 0-21, but not for those ages 21 and over. Specialized equipment that is not generally covered by Medicaid may be covered through the EPSDT program but, as mentioned earlier, the process may need to be handled a bit differently from that of standard DME claims.
Under the traditional Medicaid fee-for-service program, the physician prescribing the specialized item(s) is required to submit a letter to Medicaid's Medical Review Team. The letter must document the patient's diagnosed medical condition and how the prescribed item(s) will benefit the patient medically. If the physician's recommendation is approved for coverage through the EPSDT program, a letter will be forwarded to the physician with instructions to give a copy of the approval letter along with the prescription to the recipient's parent or guardian. The parent/guardian should present the prescription and approval letter to an enrolled DME supplier. The supplier may then order and provide the specialized equipment when presented with the approval letter and prescription. A CMN, signed by the physician, must be submitted to Medicaid along with the approval letter so an authorization can be assigned for billing purposes.
EPSDT & Managed Care
Again, the approach changes significantly under managed care. The process of obtaining equipment through a MCO may be much simpler, at least in theory. The nature and complexity of the process is determined by the internal policies of the particular MCO to which an individual belongs. Generally, a member-physician (or MCO approved-physician) must prescribe the equipment, and a MCO preferred provider must supply it upon approval.
The Right to Appeal
Any Delaware Medicaid applicant or recipient who is dissatisfied with a Medical Assistance Program decision about program eligibility or service eligibility, or who has experienced undue delay in action, may appeal that decision. An MCO member has the option of challenging the action through the MCO's internal appeal process as well as through the State Fair Hearing system.
State Fair Hearing Appeal System
Those members covered by traditional fee-for-service Medicaid have the right to request a State Fair Hearing. The request must be submitted in writing within 90 days of the disputed action or decision. Prior to the hearing, the member has the right "to examine all documents and records to be used by State agency or its agent at the hearing and to examine the claimant's case records." There is no charge to the member for copies of documents. The contact information is:
Delaware Health and Social Services—Medicaid
1901 N. Dupont Highway
P.O. Box 906
New Castle, DE 19720
(302) 255-9500
(800) 372-2022
In response to any correctly submitted Fair Hearing request, Medicaid staff must complete a summary of the factual and legal reasons for the action/decision being appealed, and submit that summary to an impartial Fair Hearing officer within five working days of the request. The officer must in turn mail a copy of the summary to the person requesting the appeal.
The agency must notify the applicant/recipient in writing about the date, time, and location of the hearing no less than 10 days before it is to take place. At the hearing, the applicant/recipient has the right to examine case records and relevant agency documents, present and cross-examine witnesses, and present arguments. The member bears the burden of proof in cases where there is an initial denial of eligibility or where there is a request for services. The State (or MCO) bears the burden of proof in cases involving termination of eligibility or terminations/reductions of services. The hearing officer must notify the applicant/recipient in writing of the decision, and must provide information about eligibility for judicial review if applicable.
If the Hearing Officer denies the member's appeal, the member has the right to appeal that decision within 30 days to the Delaware Superior Court.
Medicaid Managed Care & Appeals
For Medicaid beneficiaries served by an MCO, the complaint/appeal process usually starts with the MCO. The beneficiary may want to try to resolve a dispute with an MCO decision through that MCO's review/appeal process before taking further steps. The Health Benefits Manager (HBM) as well as the MCO's Client Advocate may help access this process. DMAP also monitors MCO operations and may assist the member.
In addition, the United States Supreme Court recently upheld a lower court's ruling that patients have the right to seek an independent review of denials of care by their MCOs.
Diamond State Partners
Complaints and appeals for Diamond State Partner members are handled identically to the process used for those persons in fee-for-service Medicaid.
First State Health Plan
First State has an informal complaint process. If a member's call to First State does not yield the desired result, the next step is to file a Formal Grievance. Formal Grievances need to be in writing and must be sent to First State within 90 days of the problem. Their Member Service Department, at (302) 327-7600 or (800) 362-4214, offers to assist those having trouble writing their grievance. A Formal Grievance should include the following:
- A description of the problem
- What the member did about the problem before filing the grievance
- How the member wants the problem to be settled
- Notification to First State if the member wants to attend and participate in the Grievance Meeting
- Identification of any representative(s) who will attend the Grievance Meeting with the member or the member's request that a First State employee represent him/her.
The Grievance Committee meets within 30 days after receiving the Grievance. Members will be notified of the meeting date 10 days before it takes place. A decision is made within 30 days after the Grievance Committee meeting. (Under new federal regulations effective June 14, 2002, an expedited appeal (where a delay could seriously jeopardize the person's life or health) must be decided within three working days.) If the member is dissatisfied with the decision, s/he can pursue the appeal through the State Fair Hearing system within 90 days of the Grievance Committee decision. (Of course, MCO members have the same appeal rights to Delaware Superior Court as do fee-for-service members.)
DHSS regulations require a uniform appeal procedure in cases of MCO decisions involving medical necessity. Essentially, these regulations call for a three stage appeal process:
- Stage 1 - an internal review by the carrier
- Stage 2 - a subsequent internal carrier review involving at least two physicians or other health care professionals who had no role in the matter
- Stage 3 - an External Review under the DHSS Independent Health Care Appeals Program.
These regulations also establish timeframes for the various appeals and other procedural safeguards.
Medicaid County Offices
New Castle County:
Service Areas & Alphabetical References: 19720,19801,19804
Office Location: DHSS Campus, 1901 N. DuPont Hwy.,
New Castle, DE 19720
(302) 577-4448
Service Areas & Alphabetical References: 19703, 19707, 19710, 19732, 19735, 19736, 19802, 19803, 19805, 19806, 19807, 19809, 19810, 19899
Office Location: Northeast State Service Center, 1624 Jessup
Street, Wilmington, DE 19802
(302) 577-3630
Service Areas & Alphabetical References: 19701, 19702, 19706, 19708, 19709, 19711, 19712, 19713, 19714, 19730, 19731, 19733, 19734, 19808 and all NC County long term care applications
Office Location: Robscott Building, 153 Chestnut Hill Road, Newark,
DE 19713
(302) 368-6610
Kent County:
Service Areas & Alphabetical References: Dover service area with last names beginning with A-D and all of Milford service area. (The Dover Service Area includes: Camden-Wyoming, Cheswold, Clayton, Dover, Felton, Hartly, Kenton, Little Creek, Magnolia, Marydel, Smyrna, Viola, and Woodside. The Milford Service Area includes: Bowers Beach, Ellendale, Farmington, Frederica, Greenwood (Kent County side), Harrington, Houston, Lincoln, Little Heaven, and Milford (Kent County side).
Office Location: 32 Loockerman Square, Suite 106, Dover, DE 19901
(302) 739-6924
Service Areas & Alphabetical References: Dover service area with last names beginning with E-Z
Office Location: Williams State Service Center, 805 River Road,
Dover, DE 19901
(302) 739-3716
Service Areas & Alphabetical References: All Long Term Care applications for both Kent & Sussex
Office Location: Milford State Service Center, 11-13 Church Avenue,
Milford, DE 19963
(302) 422-1555
Sussex County:
Service Areas & Alphabetical References: 19931, 19933, 19940, 19941, 19950, 19956, 19960, 19963, 19966, 19973
Office Location: Georgetown State Service Center, 546 S. Bedford
Street, Georgetown, DE 19947
(302) 856-5501
Service Areas & Alphabetical References: 19930, 19939, 19944, 19945, 19947, 19951, 19958, 19966, 19968, 19969, 19970, 19971, 19975
Office Location: Georgetown State Service Center, 546 S. Bedford Street, Georgetown,
DE 19947
(302) 856-5349
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