This section describes the eligibility requirements under Delaware’s CHIP program - the Delaware Healthy Children Program (DHCP).
The Balanced Budget Act of 1997, enacted on Augusts 5, 1997, established the Children’s Health Insurance Program (CHIP) under Title XXI of the Social Security Act. The purpose of this program is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.
This program does not create any entitlement on the part of children to child health assistance. CHIP creates a capped allotment to the funds on the part of the states. Enrollment will be stopped when total expenditures are projected to equal the available funding level.
18100 Definitions
“Comprehensive health insurance” means a benefit package comparable in scope to the "basic" benefit package required by the State of Delaware's Small Employer Health Insurance Act at Title 18, Chapter 72 of the Delaware Code. This package covers hospital and physician services as well as laboratory and radiology services. The term "comprehensive" does not mean coverage for benefits normally referred to as "optional," e.g., prescription drugs.
“Inmate of a public institution” means a person living in a public institution. A public institution is an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. An inmate is serving time for a criminal offense or confined involuntarily in State or Federal prisons, jail, detention facilities, or other penal facilities. A person living in a detention center after his case has been adjudicated and other living arrangements are being made (such as a transfer to a community residence) is not an inmate of a public institution.
“Institution for Mental Disease” means a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care, and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for Individuals with Intellectual Disabilities is not an institution for mental diseases.
18200 Delaware Healthy Children Program General Eligibility Requirements
An individual must meet the general eligibility requirements described in Section 14000.
Exceptions: DHCP does not provide coverage of emergency services and labor and delivery only for illegally residing nonqualified aliens. Retroactive coverage is not available under DHCP.
18300 Technical Eligibility
Age: The child must be under age 19.
Uninsured: The child must be uninsured. Children cannot be found eligible for DHCP if they:
A child who has a family member who works for a public agency within Delaware and is eligible to participate in the State health benefits plan with an employer premium subsidy is not eligible for DHCP. Family member is defined as the parent of the child or the individual who has legal custody of the child. The State health benefits plan is the plan that is offered or organized by the State of Delaware on behalf of State employees or other public agency employees within the state. The State health benefits plan does not include separately run county plans, city plans, or other municipal plans.
Residents of Institutions: A child who is a patient in an institution for mental disease (IMD) or who is an inmate of a public institution is not eligible. Exception: If a child enrolled in DHCP subsequently requires inpatient services in an IMD, the receipt of inpatient services will not make the child ineligible during a period of continuous eligibility.
28 DE Reg. 45 (07/01/24)
18400 Financial Eligibility
Financial eligibility is determined using the MAGI methodologies described in Section 16000.
Household income may not exceed 212% of the Federal Poverty Level (FPL).
18500 Protection of Former Medicaid Children
Children who are enrolled in Medicaid on December 31, 2013, and who lose eligibility for Medicaid at their first renewal due to the application of MAGI methodologies, must be covered under DHCP until the next scheduled 12-month renewal. Children are not subject to the uninsured requirement or the income limit during this 12-month protected period. The other requirements under DHCP are applicable during this 12-month protected period.
18600 Managed Care Enrollment Requirements
Children who are found eligible must enroll with a managed care organization to receive coverage of medical services. The Health Benefits Manager (enrollment broker) will be responsible for the enrollment process.
28 DE Reg. 45 (07/01/24)
18700 Premium Requirements
Effective January 1, 2024, premiums are no longer required.
18 DE Reg. 375 (11/01/14)
20 DE Reg. 639 (02/01/17)
22 DE Reg. 299 (10/01/18)
26 DE Reg. 323 (10/01/22)
28 DE Reg. 45 (07/01/24)
18800 Continuous Eligibility
Statutory Authority
42 CFR 435.926
42 CFR 435.118
18800.1 Continuous Eligibility for Target Low-Income Children
Continuous eligibility for targeted low-income children provides coverage to children in DHCP for a full 12-month period regardless of changes in circumstance, with certain exceptions. Continuous eligibility is based on the effective date of the child's last eligibility determination at application or renewal.
The continuous eligibility period begins:
A child's eligibility may not be terminated during a period of continuous eligibility for changes in circumstance, unless 1 of the following allowable exceptions applies. These exceptions have been revised effective January 1, 2024.
(1) The child attains age 19, unless the child is in a 12-month postpartum period;
(2) The child or child's representative requests a voluntary termination of eligibility;
(3) The child ceases to be a resident of the State;
(4) The agency determines that eligibility was erroneously granted at the most recent determination, or renewal of eligibility, because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative;
(5) The child dies; or
(6) The child becomes eligible for Medicaid.
Children who have been determined eligible based on self-attested information are entitled to the 12-month continuous eligibility period. Coverage may not be terminated for such children during a continuously eligible period if, in conducting post-enrollment verification, the state obtains information that indicates that the child does not meet all the eligibility requirements unless the information indicates that 1 of the limited exceptions to continuous eligibility above applies.
If the self-attested information indicates that the child is eligible, the state is not considered to have made an erroneous determination, even if there is an inconsistency between the attested information and information subsequently obtained from family or electronic data sources after enrollment. The receipt of information is considered a change in circumstance. See Section 14800 Verifications of Factors of Eligibility.
Children whose citizenship or satisfactory immigration status is not verified have not been determined eligible. Continuous Eligibility does not apply to children who are receiving benefits under a reasonable opportunity to provide (ROP) period if the child's status cannot be verified. See Section 14390.1 Reasonable Opportunity to Provide Documentation of Citizenship and Identity or Alien Status.
28 DE Reg. 45 (07/01/24)
18800.2 12-month Postpartum Continuous Eligibility
The 12-month postpartum period is a mandatory extension of coverage for DCHP members who were determined eligible in the month the pregnancy ends or in a month prior to the month the pregnancy ends (while still pregnant). A targeted low-income child cannot apply and be found eligible for the postpartum period alone.
The 12-month postpartum period begins on the date a pregnancy ends, extends 12 months, and ends on the last day of the month in which the 12-month period ends.
Once it has been determined that a DHCP member is eligible for the 12-month postpartum continuous eligibility, they will transfer to the Pregnant Woman Medicaid group and remain continuously eligible throughout the 12-month postpartum period, regardless of changes in income.
13 DE Reg. 1540 (06/01/10)
14 DE Reg. 1361 (06/01/11)
17 DE Reg. 503 (11/01/13)
26 DE Reg. 323 (10/01/22)
28 DE Reg. 45 (07/01/24)
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