Benefits: Applying for Benefits and Appealing Decisions

Delaware Division of Social Services (DSS) and Division of Medicaid and Medical Assistance (DMMA)

You can apply for certain benefits through the Division of Social Services which is a state agency.  The “Delaware ASSIST” website – https://assist.dhss.delaware.gov/ – acts as a one-stop shop to make it easy for you to find if you are eligible for lots of different programs, and to also apply.  You can use Delaware Assist to apply for:

  • Long Term Care Medicaid
  • Health Care Coverage through Medicaid
  • Food Supplement Program (“Food Stamps”)
  • Cash Assistance
  • Child Care Assistance
  • National School Lunch Program
  • Low Income Home Energy Assistance Program
  • Food Bank

You can also apply for benefits at your local DSS office.

  • You can call the DSS helpline at 211 to find your DSS office.
  • If you cannot apply on-line or by visiting the DSS office in-person, you can request that DSS assist you through the application and other processes via mail and telephone.

You should be aware that you have a right to file an application even if DSS staff tell you that they think you will be denied.

Appeals of Decisions about DSS and DMMA Benefits, including decisions by your Medicaid Managed Care Organization

If your application for Division of Social Services benefits is denied, you have a right to receive a written denial, and you also have a right to appeal that decision.  If you are receiving benefits from the Division of Social Services and you find out that your benefits are being reduced, suspended, or terminated, you also have the right to appeal.

You have the right to appeal decisions about your medical assistance, including Medicaid.  This includes decisions made by your Medicaid Managed Care Organization “MCO” (the private insurance company that manages your Medicaid – in 2015 the two MCOs in Delaware are United Healthcare and Highmark), or the Division of Medicaid and Medical Assistance.  Examples of decisions you can appeal include: a decision to deny coverage for something, to decide not to cover as much of a service as your healthcare provider is requesting, or to reduce or terminate a service you already receiving.  For example, if your doctor requests that you receive 16 hours of home health aide services and you are only approved for 8, you can appeal that decision.  Or, if your doctor prescribes you a medical device and that device is not covered, you can appeal that decision.

Timing is very important for appeals.  Your appeal – called a request for a Fair Hearing – must be received by the DSS Fair Hearing Office within 90 days of the date on your notice. Sometimes your MCO may offer you an “internal” or “informal” appeal.  You may use this procedure to try to resolve your problem without a hearing; however, it is essential that you be sure that you allow yourself time to request a Fair Hearing before your 90 days (using the date on your original notice) are up.  Legal assistance with your appeal may be available from Community Legal Aid Society, Inc. (contact information is on the last page of this guide).  However, you should apply for legal assistance as soon as possible as it can take time for your case to be evaluated.

To request a Fair Hearing, you can complete and return the form that is typically on the last page of your notice, or, you can send a written request to:

Fair Hearing Office

1901 N. duPont Highway

P.O. Box 906, Lewis Bldg.

New Castle, DE 19720

Medicaid Programs for Persons with Disabilities

Medicaid Waiver Programs

In Delaware, we have two Medicaid waiver programs to assist people with higher level of care needs.  One, the “DD Waiver” is operated by the Division of Developmental Disabilities Services (DDDS).  DD Waiver services may include residential services (neighborhood homes – aka group homes, shared living providers, etc.), day habilitation, prevocational services, supported employment, nursing, and behavioral services.  To be eligible for the DD Waiver you must be eligible for DDDS services (you must have a qualifying disability that begins before you turn 22.  Some of the eligible diagnoses include autism, Asperger’s, intellectual disability, Prader Willi Syndrome, and brain injuries/neurological conditions that result in intellectual disability). You can contact DDDS’s Applicant Services at (302) 744-9700 or Toll Free – 1-866-552-5758.

Another waiver, called Diamond State Health Plan – Plus (DSHP+), operated by the Division of Medicaid and Medical Assistance, is for individuals with disabilities who require a higher level of care, but can be served in the community, including family homes and apartments or assisted living facilities, with the correct services.  Services can include home modifications, nursing services, attendant care services, cognitive services, day habilitation, home delivered meals (up to one a day) and more.  To apply, individuals may contact the Division of Medicaid and Medical Assistance’s Long Term Care Programs office at (302) 368-6610 (NCC) or (302) 424-7172 (Kent and Sussex Counties).

Medicaid for Workers with Disabilities

Delaware also has a program called Medicaid for Workers with Disabilities.  This program helps individuals with disabilities by allowing them to work without losing their Medicaid.  To find out more or to apply, contact (302) 857-5045 or 1-800-464-4357.

Pathways to Employment

This is a new program for eligible people with disabilities ages 14-25.  Through the Pathways to Employment program you can receive services such as:

  • Employment navigator
  • Career exploration and assessment
  • Supported employment (individual and small group)
  • Benefits counseling
  • Financial coaching
  • Non-medical transportation
  • Personal care (including a self-directed component)
  • Orientation, mobility, and assistive technology

Find out more at: http://dhss.delaware.gov/dhss/dsaapd/pathways.html

PROMISE Program

This is a new program for eligible individuals with behavioral health needs.  Through the PROMISE program you can receive services such as:

  • Care management
  • Individual employment supports & short-term small group supported employment
  • Financial coaching & benefits counseling
  • Peer support
  • Non-medical transportation
  • Community-Based residential supports (not assisted living)
  • Nursing
  • Community psychiatric support and treatment
  • Psychosocial rehabilitation
  • Respite
  • Independent activities of daily living/chore
  • Personal care
  • Community Transition Services

Find out more at: http://dhss.delaware.gov/dhss/dsamh/promise.html

You can appeal decisions by these Medicaid programs, including eligibility decisions and service authorizations, like you would a decision by DSS or a Medicaid  MCO; see the discussion, above, in the section on Appeals of Decisions about DSS Benefits.

Social Security Administration (SSA) Benefits

The SSA handles benefits applications for the following disability related programs:

  • Supplemental Security Income (SSI)
  • Supplemental Security Disability Income (SSDI)
  • Medicare

Introduction to SSA Programs

A brief description of each and instructions on how to apply are provided below:

  • Supplemental Security Income (SSI)
    • The Supplemental Security Income (SSI) program pays benefits to individuals with disabilities (adults and children) who have limited income and resources.
    • Online application – not available
    • Office application – schedule an appointment with a local Social Security office to file an application by calling 1-800-772-1213 (TTY 1-800-325-0778) or by contacting your local Social Security office. If you cannot go in person to apply you can call the same phone numbers to set up a telephone or mail based application.
  • Social Security Disability Insurance (SSDI)
    • SSDI is a monthly payment for you (and sometimes certain other family members) if you worked enough previously and paid Social Security taxes. It is available to people who are unable to work because of a medical condition that is expected to last at least 12 months or result in death.[1]
    • Online application:
    • Office application – schedule an appointment with a local Social Security office to file an application by calling 1-800-772-1213 (TTY 1-800-325-0778) or by contacting your local Social Security office. If you cannot go in person to apply you can call the same phone numbers to set up a telephone or mail based application.
  • Medicare
    • Medicare is a health insurance program. The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care. You may buy a Medicare supplement policy (called Medigap) from a private insurance company to cover some of the costs that Medicare does not.  Some people can qualify for Medicaid in addition to Medicare, which would cover many of the costs not covered by Medicare.  There are also some other government programs to help with some of the Medicare costs.
    • People most commonly know that Medicare is health insurance for seniors over 65. However, it is also available to some people under 65:
      • Once you have been receiving SSDI for two years – you will automatically become enrolled in Medicare.
      • You are receiving SSDI for Lou Gehrig’s Disease (amyotrophic lateral sclerosis)
      • You have permanent kidney failure and you receive maintenance dialysis or a kidney transplant and meet additional requirements described on page 7 of this document: http://www.ssa.gov/pubs/EN-05-10043.pdf
      • You are the child or widow(er) age 50 or older, including a divorced widow(er), of someone who has worked long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social Security disability program.
    • You can apply for Medicare online at http://www.ssa.gov/medicare/apply.html
      • Tips for applying:
        • Make sure you meet the requirements to apply online – you can learn more at http://www.socialsecurity.gov/medicare/apply.html#a0=0
        • Gather the information you need to complete the application process which can take 10 – 30 minutes – you can find a checklist here: http://www.socialsecurity.gov/hlp/isba/10/isba-checklist.pdf
      • Office application – schedule an appointment with a local Social Security office to file an application by calling 1-800-772-1213 (TTY 1-800-325-0778) or by contacting your local Social Security office. If you cannot go in person to apply you can call the same phone numbers to set up a telephone or mail based application.

Appealing SSI, SSDI & Medicare Decisions

SSI & SSDI

You have the right to appeal both SSI and SSDI decisions.  See the link below for more information on the appeals process, or contact your local Social Security Office for more information on how to appeal a decision you disagree with: http://www.socialsecurity.gov/pubs/EN-05-10041.pdf

Timing is very important for appeals.  Generally, your appeal must be received within 60 days of the date on your notice. Legal assistance for your appeal may be available.  However, you should apply for legal assistance as soon as possible as it can take time for your case to be evaluated.

Medicare

Learn how to appeal your Medicare Income-Related Premium: http://www.socialsecurity.gov/pubs/EN-05-10125.pdf

Information – on how to appeal coverage or payment decisions made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan – can be found at http://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html.

[1] The medical eligibility criteria for SSI and SSDI are the same.