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DE Medicaid - Covered Groups

The Division of Social Services (DSS) uses the general eligibility criteria (called Common criteria by DSS) listed in Medicaid -Eligibility - General to determine basic eligibility for all Delaware Medicaid programs.

But to be eligible for Medicaid in Delaware you must also meet current income limits, and in some cases resource limits, and other criteria for one of the Medicaid Covered Groups listed below.

Certain eligibility groups have requirements that include age, household composition/filing unit, and medical eligibility/disability.

The effects of employment on Medicaid eligibility depend largely on which of the following types of covered group you are enrolled in:

·      SSI-Related Covered Groups; or

·      Medicare Related Covered Groups; or

·      AFDC-TANF Covered Groups; or

·      Federal Poverty Level Related Groups.

For more information on the relationship between employment and Medicaid eligibility, see: DE Medicaid - Employment.

SSI-Related Medicaid Covered Groups

SSI Recipients: Any individual aged 65 years or over, blind, or permanently disabled receiving a benefit through the Supplemental Security Income (SSI) program, is automatically eligible for Medicaid in Delaware. (For eligibility details, see Medicaid - SSI Recipients.)

SSI State Supplement Recipients: Delaware provides a state supplement payment (SSP) to elderly and disabled SSI recipients who live in Residential Care Facilities. The amount of payment generally relates to the level of assistance provided. These individuals qualify for Medicaid. (For eligibility details, see Medicaid - SSI State Supplement Recipients.)

1619(b) Eligibles: Prior to 1981, some severely disabled individuals lost SSI and Medicaid due to employment. The loss of Medicaid often meant that the individuals could no longer afford their medical care and were forced to quit their jobs and go back on SSI to assure Medicaid coverage. An amendment to the Social Security Act, Section 1619(b), was passed to allow these individuals to retain their Medicaid coverage while they continued working. These clients are referred to as 1619(b)s. (For details, see 1619(b) SSI Work Incentive.)

Adult Disabled Children: Individuals eligible under this category are over age 18 and became disabled before the age of 22. They lost SSI due to income drawn from the SSA account of an aged, blind disabled or deceased parent. Eligibility is the same as for SSI except that the SSA benefit is disregarded for Medicaid. (For eligibility details, see Medicaid - Adult Disabled Child.)

NOTE: DAC or ADC? The Social Security Administration (SSA) uses the terminology "Disabled Adult Child (DAC)" rather than the "Adult Disabled Child (ADC)" terminology used by Delaware. WorkWORLD uses both terms, depending on the context -- DAC for federal topics, and ADC for Delaware state topics.

MAT Medicaid: Medical Assistance during Transition to Medicare is available to SSI recipients who lose SSI eligibility due to receiving SSDI but are not yet eligible to receive Medicare. (For eligibility details, see Medicaid - MAT.)

Disabled Children: Disabled children under age 19 who require institutional level of care, but can be cared for cost-effectively at home, may be covered. (Contact DSS for more information.)

Home and Community Based Waivers: States may request waivers of some federal Medicaid requirements in order to provide needed medical and support services to people who need an institutional level of care but who can, with those additional services, remain in their own homes. Delaware currently has four approved waivers. (For more information see: Medicaid - HCB Waivers.)

Pickle Amendment - Loss Of SSI Due To SSA Increases: Individuals who lose their SSI due to an increase in Social Security benefits are referred to, by Delaware Medicaid staff, as Public Laws or Pickle People. They continue to be eligible for Medicaid as long as their combined income, disregarding all SSA increases since they lost SSI, does not exceed the current SSI standard. (Contact DSS for more information.)

SSI Except for OASDI Increase: These are individuals who were receiving Old Age, Survivors, and Disability Insurance (OASDI) and would be SSI recipients now if the July 1972 increase in OASDI were deducted from their incomes. (Contact DSS for more information.)

NOTE: OASDI is now called RSDI (Retirement, Survivors and Disability Insurance).

Widows/Widowers - Age 60-64: Individuals eligible under this category are over age sixty and under age 65. They lost SSI due to income drawn from a deceased spouse’s SSA account. Medicaid coverage continues until individuals become eligible for Part A Medicare when they reach age 65. (Contact DSS for more information.)

Disabled Widows/Widowers - Age 50-59: These are certain disabled widow(er)s who lose SSI/SSP because they began receiving Title II Social Security disabled widows benefits. They are deemed to be SSI recipients for Medicaid purposes until they are entitled to Medicare Part A. (Contact DSS for more information.)

Medicare-Related Covered Groups - Limited Medicaid Benefits

The four groups in this category are actually a special subset of the SSI-Related Covered Groups. These four groups have four characteristics in common: 1) They are for people who receive Medicare; 2) Income-eligibility is related to the Federal Poverty Level (FPL); 3) resource limits are two times the SSI limits of $2,000 for individuals and $3,000 for couples ($4,000 and $6,000); and 4) the benefits are very limited, paying the Medicare deductible and co-payments and/or Medicare premiums.

The groups are: Qualified Medicare Beneficiaries (QMB); Specified Low income Medicare Beneficiaries (SLMB); Qualified and Disabled Working Individuals (QDWI), and Qualifying Individuals-1 (QI-1).

See: Medicaid - Medicare-Related Medicaid for more information.

AFDC-TANF Related Covered Groups

The Federal law replacing AFDC with TANF removed the automatic entitlement to Medicaid for welfare recipients. Instead, the law created a new Medicaid eligibility group for Low Income Families with Children (Section 1931).

Low Income Families with Children - Section 1931: Families with children who have gross incomes less than or equal to 185% of the TANF Standard of Need and Countable Income less than the TANF Standard of Need. Families who are eligible for Medicaid under Section 1931 may be receiving TANF cash assistance or may be Medicaid-only families. (For eligibility details, see Medicaid - Low Income Families with Children.)

Pregnant Women and Infants: A pregnant woman who would be eligible for AFDC-TANF Related Medicaid if her infant were born may be eligible for Medicaid from the date her pregnancy is verified until at least 90 days post-partum. Infants born to Medicaid eligible mothers are deemed eligible for Medicaid for one year as long as the mother remains eligible and the child remains in the house with the mother. (For eligibility details, see Medicaid - Pregnant Women and Infants - AFDC-TANF Related.

General Assistance (GA) Recipients: GA Recipients who are 1-17 years old may receive Medicaid. They are classified as an AFDC-TANF Related Covered Group even though they are subject to GA Financial Eligibility rules.

Income Deeming Eligibles: When income deemed from a step-parent, grandparent, sibling or the sponsor of an alien makes an individual ineligible for TANF benefits, Medicaid determines eligibility using Section 1931 rules except that deemed income is excluded.

Long-Term Care Institutionalized Individuals: Individuals who would be eligible for TANF if not in a medical institution or nursing facility are eligible for Medicaid under Delaware’s Plan. In addition, institutionalized individuals may qualify for Medicaid based upon a higher income standard than that used for TANF or SSI. Delaware uses an income standard of 250% of the SSI uniform payment. (For eligibility details, see Medicaid - Long Term Care Financial Eligiblity.)

Transitional Medicaid: A family’s eligibility for transitional Medicaid is linked to receipt of Medicaid under Low Income Families with Children under Section 1931. Families who lose Medicaid under Section 1931 because of earnings or loss of earned income disregards, may be eligible for up to 12 months of extended Medicaid coverage. (For eligibility details, see Medicaid - Transitional.)

Prospective Medicaid: Families who lose Medicaid because of new or increased child or spousal support, may be eligible for 4 months of extended Medicaid coverage. Section 1931 financial eligibility rules are used.

Foster Children and Adoption Assistance Children: Children receiving foster care or adoption assistance.

Children In Custody: Children for whom any Division within DSCYF has custody or consent to place and who have been removed from their own home, and are in a medical facility for a temporary planning period prior to placement would fall in this optional coverage category.

Federal Poverty Level (FPL) Related Covered Groups

Pregnant Women, Infants and Children:

·      Pregnant women and infants up to age one are eligible if their Medicaid FPL Countable Income does not exceed 200% of the Federal Poverty Level (FPL).

·      Children aged one through five are eligible at 133% FPL.

·      Children aged six through 18 are eligible at 100% FPL.

For eligibility details, see Medicaid - Pregnant Women, Infants and Children - FPL Related.

General Assistance: Children age 18 who receive General Assistance (GA). (For more information about Medicaid and General Assistance, see Medicaid - General Assistance.)

Adult Expansion Population: Delaware has a Demonstration Project entitled Diamond State Health Plan. This demonstration waiver (under Section 1115) extends Medicaid coverage to uninsured individuals age 19 or over with income at or below 100% of the Federal Poverty Level (FPL) who are not categorically eligible for Medicaid.

See also:

DE Medicaid - Eligibility

DE Medicaid - Application Procedures

DE DSS - Change Reporting Requirements

DE DSS - Contact Information

Source:

DSS Policy Manual (Sects. 13402-462)

Back to:

DE Medicaid - Overview

DE Division of Social Services - Overview

DE Benefit Information System Overview

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