According to Delaware Online, fewer than 40 Delawareans have enrolled in the plan thus far. Federal Officials have been visiting healthcare clinics in recent weeks to help promote the plan that an estimated 4 million people nationally are eligible for. According to HealthCare.gov, Delaware and 22 other states have opted to have the US Department of Health and Human Services administer the plan. For Delaware residents that means that you apply for coverage directly from the federal government.

It is important to note that there are criteria that must be met in order to be eligible to purchase the plan, and the monthly premiums can still be significant. To qualify you must:

1. Be a citizen or national of the United States or lawfully present in the United States.
2. Have been uninsured for at least the last six months before you apply.
3. Have a pre-existing condition or have been denied coverage because of your health condition.

If you qualify (and can afford the premiums), the plan covers a broad range of benefits including primary care, hospital care, prescription medications, testing, and specialty care. Three types of plans are offered, the standard option, the extended option, and the HSA option. The difference between the plans are the monthly premium and the deductible before benefits begin. A detailed summary of the benefits is available from the Pre-Existing Condition Insurance Plan website.

The current monthly rates for the Pre-Existing Condition Insurance Plan for Delaware Residents are summarized below (please note that these rates may be adjusted in the future):

The standard and extended options both have separate deductibles for medical and prescription costs. Under the standard plan, the medical deductible for in-network care is $2,000 and the prescription deductible is $500. The extended plan has a $1,000 deductible for in-network care and a $250 deductible for prescription costs. The HSA option has a combined deductible of $2,500 for in-network medical and prescription costs. Copay and co-insurance benefits do not begin until after the calendar year deductible is spent. The maximum out-of-pocket medical costs under these plans is $5,950 for in-network care and $7,000 for out of network care.

Coverage under these plans begin based on when the application is completed. If your application is completed on or before the 15th of the month, coverage begins no later than the first day of the following month, if your application is completed after the 15th of the month, your coverage may not begin until the first day of the second calendar month after you apply.

To apply for benefits in States that the plan is administered by the US Department of Health and Human Services, you may complete and submit a paper application or apply online at https://www.pcip.gov/Apply.html. The following documentation is needed when applying for the federally administered program:

1. Denial letter from an insurance company licensed in your state that is dated within the past 12 months, or a letter in the past 12 months from an insurance agent or broker that shows that you are not eligible for one or more health insurance plans because of your medical condition; or,
2. Offer of individual insurance coverage within the past 12 months that you did not accept that has an exclusion for a pre-existing medical condition; or,
3. If you are under 19 (or you live in Massachusetts or Vermont), an offer of individual insurance coverage within the last 12 months that show a premium that is at least twice as much as the Pre-Existing Condition Plan premium for the Standard Option in your State.

To determine the Pre-Exisiting Condition Insurance Plan requirements for your State, visit http://www.pcip.gov or http://www.healthcare.gov.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Effective March 1, 2001, Delaware extended Medicaid eligibility to certain individuals that were approved for SSDI. The program was named “Medical Assistance During Transition to Medicare” or “MAT” and was codified as part of the Delaware Administrative Code. (See Title 16 Sec. 17800 of Delaware Administrative Regulations).

Beginning March 1, 2001, individuals in Delaware who were already receiving Medicaid and were approved for at least one month of Supplemental Security Income payments (SSI is the Social Security Administration’s poverty based disability program) no longer lost their eligibility for Medicaid because of the receipt of SSDI. The only requirements were that 1) the individual lost Medicaid because of receipt of SSDI, and 2) they were not yet eligible for Medicare. This was an important change, because previously these same individuals would lose eligibility for Medicaid if their SSDI payments were above the State income limits. Since Medicare does not begin until 24 months after eligibility for the first SSDI payment, before MAT, it was common for individuals to lose Medicaid and have to go months or even as long as 2 years without government provided medical coverage, despite being found disabled by the Social Security Administration.

Unfortunately, MAT did not extend Medicaid coverage in every situation. Only individuals that were approved for SSDI and had at least one month of SSI eligibility qualified for this program. The result was that anyone in Delaware that was receiving Medicaid and approved for SSDI, but was not approved for SSI (or never applied for SSI), still lost their Medicaid eligibility and had no government provided medical insurance coverage until Medicare began.

Effective September 1, 2008, Delaware extended MAT to any individual that was 1) not yet eligible for Medicare and 2) lost eligibility for Medicaid on or after January 1, 2008 due to the receipt of SSDI. As a result, even if an individual never met the requirements for SSI, they became eligible to retain Medicaid as long as they were receiving Medicaid before their SSDI claim was approved. This change in the Administrative Regulations closed a loophole that was causing many individuals in Delaware to lose all government provided medical coverage once they were approved for SSDI until they were finally eligible for Medicare.

In effect, this now means that no Delaware resident who is receiving Medicaid should lose government provided medical insurance just because of being found disabled by the Social Security Administration. Unfortunately, the regulations are not being applied consistently by the Delaware Division of Social Services. Many of my clients have had Medicaid benefits terminated after being approved for SSDI benefits, even though they should still qualify under MAT. I have found that several employees of the Delaware Division of Social Services are still not aware of these changes, and need reminders on how to properly apply the MAT Regulations.

I recommend that individuals that receive a notice that their Medicaid coverage has been terminated because of receipt of SSDI (who are not yet eligible for Medicare), print out copies of the applicable regulations and provide them to their Social Worker. Additionally, the individual should provide the Social Worker with the Notice of Approval from the Social Security Administration to prove that the source of their new income is SSDI benefits.

In order to implement this Medicaid gap coverage, individuals that fall within these limited categories are made eligible for $5.00 in an optional Delaware SSI State Supplement program regardless of the amount of their earned or unearned income. A Medicaid redetermination may be necessary after qualifying for SSDI, but the Administrative Regulations provide that eligibility for Medicaid continue until Medicare eligibility begins.

Remember, both of these extensions of Medicaid only apply if you were already receiving Medicaid before you were approved for SSDI. If you did not qualify for Medicaid before being found disabled under the SSDI program, you will still need to wait 24 months from the date of your first SSDI payment until you are eligible for Medicare Coverage. If you have not yet been approved for SSDI, and do not have medical insurance, you can use the Delaware Division of Social Services online Application for Social Services and Internet Screening Tool to determine if you qualify for State Assistance while waiting for your disability determination.

If you were represented by an attorney for your Social Security disability claim, and your Medicaid is terminated before you are eligible for Medicare, I would recommend that you ask your attorney to write a letter to your Social Worker describing the applicable regulations and explaining why you should retain your eligibility. If you live outside of Delaware, it is important that you determine if your State has a similar MAT program.

Relevant Links

Applicable Medical Assistance during Transition to Medicare Regulations

• Delaware Administrative Code Title 16, Section 17800 Medical Assistance during Transition to Medicare
• Delaware Administrative Code Title 16, Section 17801 Status Eligibility
• Delaware Administrative Code Title 16, Section 17802 Financial Eligibility
• Delaware Administrative Code Title 16, Section 17803 Eligibility Determination
• Delaware Administrative Code Title 16, Section 13434 Recipients of Optional State Supplement Payments

Delaware Medicaid

• Delaware Division of Medicaid & Medical Assistance
• Work World/Delaware Benefit Information System
• Work World Section on Delaware Medicaid MAT Program
• Delaware Application for Social Services and Internet Screening Tool

Medicare

• United State Medicare

Sample Letter

• Sample Letter Requesting Redetermination of Medicaid Termination

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.