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TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 3 Each applicant or beneficiary who meets the non-financial eligibility requirements will have a determination of financial eligibility based on MAGI methodology. For an applicant or beneficiary found not eligible based on MAGI methodology and who has been identified on the application or renewal form as potentially eligible on a MAGI-excepted basis, a determination of eligibility will be made on such basis. In addition, an individual may request a determination of eligibility on a basis other than MAGI. The agency will consider all categories of eligibility prior to a termination of eligibility. For individuals determined ineligible for Medicaid, the agency will determine potential eligibility for other insurance affordability programs in accordance with Section 14100.8 Coordination of Eligibility and Enrollment with Other Insurance Affordability Programs. 17 DE Reg. 503 (11/01/13) 14100.5.1 Timely Determination of Eligibility The following Federal standards have been established for determining eligibility and informing applicants of the decision: a. Ninety days (90) for applicants who apply for Medicaid on the basis of disability. This includes long term care and Children’s Community Alternative Disability Program. b. Forty-five (45) days for all other applicants. The standards cover the period from the date of application with the agency or the date the application is transferred via the Federally Facilitated Marketplace (FFM) to the date the agency notifies the applicant of its decision. The standards must be met except in unusual circumstances, such as: a. A decision cannot be made because the applicant, his representative or his physician delays or fails to take a required action. b. There is an administrative or other emergency beyond the Division's control. The time standards must not be used as a waiting period before determining eligibility or as a reason for denying eligibility (because a decision has not been reached within the required time). Decision on applications should be made as quickly as possible, but if the final determination does not fall within the prescribed limits, the record must have documentation of the reasons for delay. 17 DE Reg. 503 (11/01/13) 17 DE Reg. 731 (01/01/14) 14100.6 Annual Renewal of Eligibility 42 CFR 435.916 The eligibility of Medicaid beneficiaries must be renewed once every 12 months and no more frequently than once every 12 months. The agency will redetermine eligibility without requiring information from the individual if able to do so based on reliable information contained in the individual’s record or other more current information available to the agency. Information available to the agency includes but is not limited to information accessed through the electronic data sources described in DSSM 14800 - Verifications of Factors of Eligibility. If the agency is able to renew eligibility based on the available information, the agency will notify the individual of: • The eligibility determination and the information used for the determination; and • The individual’s responsibility to inform the agency if any of the information contained in the agency’s notice is inaccurate. The individual may report this information via the agency’s Application for Social Service and Internet Screening Tool (ASSIST) self-service Internet web site, by telephone, via mail, in person with reasonable accommodations for those with disabilities as defined by the Americans with Disabilities Act (ADA), and through other commonly available electronic means. If the agency cannot renew eligibility as described above, the agency will provide the individual with a pre-populated renewal form. The pre-populated renewal form will contain information available to the agency about factors of eligibility. The renewal form will also include basic screening questions necessary to indicate potential eligibility on a basis other than modified adjusted gross income (MAGI). The individual will be given 30 days from the date of the renewal form to respond. The individual must provide any additional information requested and sign and return the renewal form. The request for additional information from the individual will be limited to only the information needed to renew eligibility. The individual may return the additional information and the renewal form through any of the submission modes described above. If the individual does not respond to the renewal form and provide the additional information requested and eligibility is terminated on that basis, eligibility can be reconsidered if the individual responds within 90 days after the date of termination. The individual is not required to submit a new application. Coverage may extend back to the date of termination provided the individual is found eligible as described in DSSM 14920 - Retroactive Coverage.