In Delaware, Medicaid benefits are provided mainly through a managed care organization, or MCO, under contract with the state. Managed care is an organized way to ensure that people receive the quality medical care they need in the most cost-effective manner.
Delaware’s Medicaid Program is called Diamond State Health Plan (DSHP).
If you are approved for Medicaid benefits under the Diamond State Health Plan, you must choose a family doctor who, along with a managed care organization (MCO), will provide or arrange for all your preventive care and medical needs.
DMMA provides a choice of managed care organizations so you can select the MCO plan that is best for you and your family. Delaware contracts with three managed care plans – AmeriHealth Caritas, Delaware First Health and Highmark Health Options.
The Medicaid MCO provides almost all of the care for Medicaid members who join their plan. Prescription and non-emergency medical transportation services are covered directly by Medicaid, not through the MCO. You will need to show your Medicaid card to pharmacies and transportation providers when receiving these services.
Choosing the managed care organization that’s right for you
Once you are notified that you are eligible for Medicaid (or certain other medical assistance programs), you will receive in the mail a packet of information about the different managed care organization (MCO) plan options for receiving your Medicaid benefits. You may choose any plan described in this mailing. If you would like to stay with your current doctor, check to see which of the plans they belong to before selecting an MCO. If you need help making this decision, call the health benefit manager at the phone number provided in the mailing. If your current doctor does not belong to one of the three plans, you will need to choose a new doctor who does in order for your care to be covered under Diamond State Health Plan.
If you do not choose an MCO in the time allotted (usually within 90 days), the Health Benefit Manager will assign you to a plan. However, it is best if you choose your own plan.
Who is not enrolled in an MCO
The following individuals are not enrolled with a MCO:
- Individuals entitled to or eligible to enroll in Medicare
- Individuals residing in a nursing facility or intermediate care facility for Individuals with Intellectual Disabilities (ICF/IID).
- Individuals covered under the Medicaid home and community based waiver programs.
- Non lawful and non qualified non citizens (aliens).
- Individuals who have military health insurance for active duty, retired military, and their dependents.
- Individuals eligible for the Medicaid Breast and Cervical Cancer program.
- Presumptively eligible pregnant women.
Section 1115 Demonstration Waiver
Diamond State Health Plan operates under a Section 1115 demonstration waiver from the Centers for Medicare & Medicaid Services (CMS).
In 2024, the Centers for Medicare & Medicaid Services (CMS) approved Delaware’s request for a five-year extension of the “Diamond State Health Plan (DSHP)” section 1115 demonstration through December 31, 2028. (Project Number 111-W-00036/4), in accordance with section 1115(a) of the Social Security Act (“the Act”).
- Delaware’s DSHP 1115 Waiver Approval Letter 2024
- Delaware DSHP 1115 Waiver 2024-2028 Extension Application
In compliance with the Special Terms and Conditions of the Diamond State Health Plan (DSHP), Section 1115 Demonstration, the State of Delaware (Delaware Health and Social Services/Division of Medicaid and Medical Assistance (DMMA)) publishes this most recently approved Annual Report.
In compliance with the Special Terms and Conditions of the Diamond State Health Plan (DSHP), Section 1115 Demonstration, the State of Delaware (Delaware Health and Social Services/Division of Medicaid and Medical Assistance (DMMA)) publishes this Approved Evaluation Design.
- Diamond State Health Plan 1115 Waiver Approved Interim Evaluation Report April 2024
- Diamond State Health Plan 1115 Waiver Approved Evaluation Design April 2024
Diamond State Health Plan Quality Strategy
The Delaware Quality Strategy 2023 is a comprehensive plan incorporating quality insurance monitoring and ongoing improvement processes to improve the delivery of quality care. The Quality Strategy is an evolving document that undergoes regular reviews and necessary changes by DMMA. Please see the changes and the 2023 Quality Strategy outlined below.
- Summary of Changes from the 2018 Quality Management Strategy to 2023 Quality Strategy
- Evaluation of the 2018 Quality Strategy
Managed Care Program Annual Report (MCPAR)
Centers for Medicare and Medicaid Services (CMS) regulations at 42 CFR § 438.66(e) require states to submit a Managed Care Program Annual Report (MCPAR). Under the regulation, each state must submit to CMS no later than 180 days after each contract year, a report on each managed care program administered by the state.
The annual report is part of CMS’s overall strategy to improve access to services by supporting federal and state access monitoring for Medicaid beneficiaries within a managed care delivery system.
The MCPAR report provides information in the following categories:
- Program enrollment and service area expansions
- Financial performance
- Encounter data reporting
- Grievances, appeals, and state fair hearings
- Availability, accessibility, and network adequacy
- Delegated entities
- Quality and performance measures
- Sanctions and corrective action plans
- Beneficiary support system (BSS)
- Program integrity
Each of the above categories has data indicators (data elements) that are organized by and will be reported at state, program, or plan levels. The blank excel workbook is available on Medicaid.gov and provides the exact indicators reported along with the instructions on how to report. Each MCPAR report for the managed care program is provided below.
- FFY 2023 MCPAR Annual Report for Delaware Diamond State Health Plan
- FFY 2022 MCPAR Annual Report for Delaware Diamond State Health Plan
Diamond State Health Plan & Diamond State Health Plan Plus Managed Care Master Service Agreement
Monthly Enrollment Totals for Medicaid
(Diamond State Health Plan and Diamond State Health Plan Plus) and Children’s Health Insurance Program (CHIP)
https://data.delaware.gov/Health/Medicaid-Enrollment/xhfg-cwx7/about_data
