Page 32

TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 32 Qualifying prior coverage includes coverage under a group health plan, an individual health plan, Medicare, or Medicaid. The concept behind qualifying prior coverage is that individuals should be given credit for previous insurance when moving from one group plan to another. Medicaid must send certificates of coverage to individuals upon request. The certificate must be sent to individuals who request one regardless of the status of the case (open or closed). We must also issue certificates automatically when an individual loses Medicaid coverage. The certificate will show time periods of Medicaid eligibility back to 7/1/96. 14950 Guaranteed Eligibility All guaranteed eligibility will end effective 9/30/2002. Individuals who lose eligibility effective 4/30/2002 may receive up to five more months of guaranteed eligibility. Individuals who lose eligibility 5/31/2002 or after will not receive a period of guaranteed eligibility 14950.1 Coverage Under the DSHP Benefits Package The service package and wrap around services are described in the General Policy Section of the Delaware Medical Assistance Program Provider Services Manual. 14960 Cost Sharing Section 1902(a)(14) of the Social Security Act permits states to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges. 14960.1 Co-Payment Requirement Effective January 10, 2005, clients have a nominal co-payment for generic and brand name prescription drugs as well as over-the-counter drugs prescribed by a practitioner. The co-payment is based upon the cost of the drug as follows: The co-payment is imposed for each drug that is prescribed and dispensed. 9 DE Reg. 569 (10/01/05) 149601.1 Cumulative Maximum Monthly Co-payment Effective July 1, 2005, there is a cumulative maximum monthly co-payment amount equal to $15.00 for each recipient. Any prescriptions dispensed after the cumulative maximum monthly co-payment amount is met are not subject to a co- payment. 9 DE Reg. 569 (10/01/05) 14960.2 Exclusions from Co-payment Requirement The following individuals and services are excluded from the co-payment requirement: a. individuals under age 21 b. pregnant women, including the postpartum period c. individuals eligible under the long term care nursing facility group or the acute care hospital group d. emergency services Medicaid Payment for the Drug Co-payment $10.00 or less $.50 $10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $3.00