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TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 22 14630 Cooperation In Establishing Paternity And Obtaining Support The individual is required to cooperate in establishing the paternity of a child born out of wedlock for whom the individual can legally assign rights and in obtaining medical care support and medical care payments for himself/herself, as well as for any other person for whom the individual can legally assign rights. Exception: Pregnant and Post Partum women do not have to cooperate in establishing paternity and obtaining medical support. 14640 Identifying and Providing Third Party Information The individual is required to cooperate in identifying and providing information to assist the state in pursuing any third party which may be liable to pay for care and services available under the state plan. 14650 Good Cause For Noncooperation The requirements for cooperation may be waived if there is a determination of good cause. The determination of whether good cause exists is based on the factors established by the TANF/AFDC child support enforcement program at 45 CFR 232.40 - 232.49. Use similar procedures to make a determination of good cause for individuals other than a child excluding those applicable only to children. 14660 Denial Or Termination Of Eligibility Individuals who fail to meet the assignment provisions including assignment of rights to benefits and cooperation must be denied Medicaid eligibility or have eligibility terminated if already receiving Medicaid. This includes individuals who refuse to assign his or her own rights or those of any other individual for whom he or she can legally make an assignment. Pregnant and postpartum women do not have to cooperate in establishing paternity and obtaining medical support. Medicaid must be provided to any individual who cannot legally assign his or her own rights and is otherwise eligible for Medicaid, when the person who has the legal authority refuses to assign the eligible individual’s rights. For example, if a mother refuses to assign benefits for herself and her children, only the mother becomes ineligible for Medicaid. The children remain eligible. However, if a mother with a newborn refuses to assign rights or to cooperate, both the mother and the newborn are ineligible, since the newborn’s eligibility is dependent upon the mother’s eligibility. An application must be filed on behalf of the newborn to establish eligibility on his or her own behalf as a child. 14670 Payor Of Last Resort Because other insurance is commonly available, the Federal Government as a way of saving taxpayers’ monies, has required by law THAT Medicaid be a payor of last resort. Because Medicaid is a payor of last resort, it is especially important to screen patients for the existence of other health insurance coverage. Keep in mind that other insurance will usually pay more for the incurred charges than Medicaid, hence it is beneficial to always inquire thoroughly. Although the Medicaid Program attempts to collect this information when a recipient becomes eligible, additional efforts in this area at redetermination should not only increase provider's payments, but decrease the expenditures of taxpayers' monies. The usual elements that a financial social worker will need to obtain are: name, address, policy number of the insurance company, as well as the policy holders name, address, Social Security number, employer number and effective dates of coverage. Medicaid will only pay a designated amount (which is usually lower than the amount billed) no matter what the provider charges. This payment has to be accepted in full by the provider and the client cannot be billed for any balance. Providers agree to accept our payment as payment in full when they sign a contract to enroll in the Medicaid Program. Any violations should be referred to the Surveillance and Utilization Review unit. Clients can report loss of coverage or a change in benefit directly to the TPL unit via phone call. This unit also investigates and verifies potential coverage for Medicaid recipients.