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TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 5 A child, who was not receiving SSI on August 22, 1996, is not protected by Section 4913. A child who loses SSI after August 22, 1996, for a nondisability reason is also not protected by Section 4913. If either of these two situations occur, a redetermination of Medicaid eligibility for the child under another eligibility group will be done.

17170.2 Disability Determination The redetermination of disability will follow the rules in 20 CFR 416.924-924e as in effect on April 1, 1996. A contractor who is competent to perform the redetermination of disability will be used.

17170.3 Continuing Disability Reviews The rules in 20 CFR 416.994a as published on April 1, 1996 will be used with the following modifications to the frequency of review:

(a)Review disability after, at most, 18 months if medical improvement is expected.

(b)Review disability after, at most, 3 years if disability is not permanent but medical improvement cannot be predicted.

(c)Review disability after, at most, 7 years if disability is permanent. A contractor who is competent to perform the continuing disability reviews will be used. 17170.4 Financial Eligibility

Follow the SSI income and resource standards and methodologies.

17170.5 Continued Eligibility Medicaid eligibility for children covered under this provision continues until the earlier of:

·the child reaches age 18

·the child no longer meets the criteria of the SSI program for payment of benefits (other than the post August 22, 1996, definition of disability for children). A child who ceases to meet the non-disability SSI eligibility criteria can recover coverage under Section 4913 if the child again meets the non-disability SSI criteria. However, a determination that the child is no longer disabled under the pre-PRWORA disability criteria will permanently bar the child from protected coverage under Section 4913.

·the child is not eligible under another Medicaid eligibility group.

17170.6 Redetermination of Eligibility

A redetermination of the non-disability criteria is required at least every 12 months.

17200 Disabled Children - Program Renamed (See 25000 Section) 17300 Qualified Medicare Beneficiaries

A Qualified Medicare Beneficiary (QMB) is someone who is entitled to hospital insurance benefits under Part A Medicare and whose income does not exceed the Federal Poverty Level. All resources of the applicant and spouse are excluded when determining eligibility.

QMB's qualify for Medicaid to pay their Medicare Part A and B premiums, deductibles, and co-insurance expenses. They do not receive any Medicaid services.

This category of eligibles is mandated for coverage by the Medicare Catastrophic Coverage Act of 1988 (MCCA). Delaware Medicaid implemented the program effective 1/1/90. The eligibility and benefits are not retroactive.

17300.1 Application Process

The individual and his spouse, if married, must complete an application and provide the necessary verifications before a determination of eligibility can be made.

17300.2 Medicare Entitlement

Applicants must be entitled to Medicare Part A.

17300.3 Financial Eligibility

A Qualified Medicare Beneficiary must have countable income that does not exceed 100% of the official poverty line. The revised poverty levels for QMB's with title II income (Social Security) will be effective April 1. If the QMB does not have title II income, the revised poverty levels will be effective February 1.

17300.3.1 COLA Disregard

Social Security COLA increases will be excluded in determining the eligibility of recipients during the first three months of a calendar year.

17300.3.2 Income

The definition of income is the same definition used by the SSI program. In determining countable income take into account those income exclusions and disregards used by the SSI program. Eligibility for SSI (and QMB Program) is dependent in part upon the amount of income available, and since the program is need- oriented, those who have substantial income cannot receive benefits. Income is considered in the period in which it becomes available to meet the needs of the individual. Income includes anything received by the individual, in cash or in kind, that can be used to meet needs for food, clothing, or shelter.

17300.3.2.1 Excluded Income