Delaware’s Medicaid Managed Care Program
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.
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’s Current – DSHP 1115 Waiver August 2019 to December 2023[MOU1]Delaware’s Proposed – DSHP 1115 Waiver Amendment 2022Delaware’s Proposed – DSHP Waiver Amendment Public Notice May 2022
As required by 42 CFR 431.408, DMMA must provide an opportunity for public comment on proposed DSHP 1115 Waiver amendments, extensions, and renewals.
Delaware’s DSHP 1115 Waiver Approval Letter 2023Delaware’s Proposed – DSHP 1115 Waiver Extension Public Notice November 2022Delaware’s Final – DSHP 1115 Waiver Extension 2022Delaware’s DSHP 1115 Demonstration Interim Evaluation 2022Delaware’s DSHP 1115 SUD Demonstration Interim Evaluation 2022
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.
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_dataast reports or can archive?
