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TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 29 14910 Restricted Recipients Certain recipients who are exempt from the Diamond State Health Plan are restricted or locked-in when it has been determined that they are engaged in abusive or fraudulent practices such as overutilization of emergency room services or prescription drugs, lending a Medical Assistance card to an unauthorized person, etc. In general, restriction means that fee for service payments are limited to one primary physician and one primary pharmacy. Women are also permitted one obstetrician/gynecologist. Upon referral from the primary physician, any recipient with a special medical condition is permitted to have a specialist as an additional caretaker. If the restricted recipient visits other doctors or has prescriptions filled at other pharmacies, the Delaware Medical Assistance Program will not pay for these unauthorized claims and the recipient can be held responsible for such claims. Refer to the Delaware Medical Assistance Provider Manual for more information about restricted recipients. 14920 Retroactive Coverage 42 CFR 435.915 The agency must make eligibility for Medicaid effective no later than the third month before the month of application if the individual: Received Medicaid services, at any time during that period, of a type covered under the plan; and Would have been eligible for Medicaid in one of the below retroactive eligibility groups at the time the individual received the services if the individual had applied (or someone had applied on their behalf) regardless of whether the individual is alive when application for Medicaid is made; and Individuals eligible under the Delaware Healthy Children's Program (DHCP) are not eligible for retroactive Medicaid. Effective April 1, 2012, those that may be found eligible for retroactive Medicaid coverage, if general financial and technical eligibility requirements are met, include: a. Individuals entitled to or eligible for 1 of the following Medicare Savings Programs (excludes QMB): i. Specified Low Income Medicare Beneficiaries (SLMB) ii. Qualifying Individuals (QI) iii. Qualified and Disabled Working Individuals (QDWI) b. Individuals residing in a nursing facility c. Individuals residing in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) or for individuals with mental disease (ICF/IMD) d. Individuals in need of only the 30-day Acute Care Hospital Program (in no case should the effective date be earlier than the first day of hospitalization) e. Women eligible under the Breast and Cervical Cancer Treatment Group f. Individuals eligible under the Medicaid for Worker’s with Disabilities Group (provided premium requirements are met) Effective August 1, 2019, the groups that may be found eligible for retroactive Medicaid, if general financial and technical eligibility requirements are met, was expanded to coverage include: a. Pregnant and Postpartum Women b. Infants under age 1 c. Individuals under the age of 19 Effective January 1, 2025, the groups that may be found eligible for retroactive Medicaid coverage, if general financial and technical eligibility requirements are met, was expanded to all eligible DSHP and DSHP-Plus Medicaid participants, with some exceptions, as described in DSSM 14920.1 Retroactive Coverage Limitations. 15 DE Reg. 1717 (06/01/12) 26 DE Reg. 952 (05/01/23) 28 DE Reg. 387 (11/01/24) 14920.1 Retroactive Coverage Limitations