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DE Medicaid - Pregnant Women, Infants and Children

Delaware has two Medicaid covered groups for pregnant women and infants. One group is in the AFDC-TANF Related Covered Groups; and one group is in the Federal Poverty Level (FPL) Covered Groups. The two programs have different income and resource eligibility criteria. The Division of Social Services (DSS) will evaluate which program is appropriate depending on individual circumstances.

See below for specific rules for FPL Related Pregnant Women groups and AFDC/TANF Pregnant Women:

Presumptive Eligibility: Delaware provides presumptive Medicaid eligibility for pregnant women to provide prenatal care. Presumptive eligibility is a temporary eligibility determination for pregnant women who appear to meet the eligibility requirements before verification of eligibility.

A baby born during the presumptive eligibility period is eligible at birth. However, for the mother and baby to remain eligible, the required verifications must be provided by the deadline date. The newborn is deemed eligible for one year if a final determination of eligibility is made for the mother. This means that using all verifications, the mother is determined eligible for a presumptive month or for any subsequent month during the pregnancy. The pregnant woman must return the required verifications and be found eligible during a month of the pregnancy to receive continued coverage for the post partum period and for the baby to remain eligible for the first year of life.

If the verifications show that the mother was over the income limit during each month of pregnancy, there is no deemed eligibility for the newborn. A separate determination must be made for the newborn.

FPL Related Covered Group for Pregnant Women, Infants and Children

Pregnant women and infants up to age 1 are eligible for Medicaid under this group if their countable incomes do not exceed 200% of the Federal Poverty Level (FPL). Pregnant women count as 2 family members (or more if twins, triplets or more are expected).

NOTE: There is a special income disregard for pregnant teens. One-half of the gross parental income (includes earned and unearned income) is excluded in the income-eligibility determination for the pregnant teen.

Children age 1 through age 5 (under age 6) must have family income at or below 133% FPL in order to be Medicaid eligible under this group.

Children age 6 through age 18 (under age 19) must have family income at or below 100% of poverty.

There are no resource limits for this group.

AFDC-TANF Related Covered Group for Pregnant Women and Infants.

Because the financial eligibility rules for this group are more restrictive than those for the FLP-Related group, most pregnant women and infants in Delaware are covered under the FLP-Related group described above.

Pregnant women are eligible under the AFDC-TANF Related covered group if they would be eligible for TANF if the child were born and living with her. This means that the TANF Income Eligibility and TANF Resource Eligibility rules apply.

Pregnancies must be verified by a physician, nurse or lab technician authorized to make such determinations.

Women remain eligible through the last day of the month of the 90-day postpartum period regardless of increases in family income.

NOTE: Women who are closed in Medicaid for non-fraudulent reasons may be found eligible for Family Planning services for 24 months after the closing. There is no income test during the first year. Effective January 1, 2007, a woman eligible for Family Planning must have income at or below 200% of poverty at the 12-month re-determination. Women who are open and in the second year of Family Planning are subject as of 01/01/2007 to the 200% FPL income limit. Prior to 01/01/2007, the income limit was 300% FPL.

Assistance Unit: The determination of Medicaid eligibility must take into account the needs, income, and resources that would be taken into account under Delaware's TANF Program if the child were born and living with her. Therefore, include the needs, income, and resources of:

·      The pregnant woman;

·      The unborn child (or children when it is medically verified that there is more than one unborn);

·      The unborn child's father (if living in the household); and

·      Siblings who would otherwise be eligible.

See also:

DE Medicaid - Eligibility

DE Medicaid - Application Procedures

DE DSS - Change Reporting Requirements

DE DSS - Contact Information

Source:

DSS Policy Manual (Sects. 15130, 15130.1-4 16100.1-5, 16250)

Administrative Notice DMMA-02-2006, January 27, 2006

Administrative Notice DMMA-09-2007 with Addendum, January 26, 2007

Back to:

DE Medicaid - Covered Groups

DE Medicaid - Overview

DE Division of Social Services - Overview

DE Benefit Information System Overview

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