Medicaid Costs and Coverage in Delaware

“How much is Medicaid in Delaware?” is often one of the first questions applicants and new recipients of Medicaid benefits ask. But, “How much does Medicaid cost?” cannot be answered with a single, consistent figure. Medicaid cost estimates range widely and can be influenced by many factors. Similarly, what services are covered by Medicaid differ depending on how an applicant qualified for coverage, his or her household size and income and personal characteristics such as age and disability status. Certain benefits are covered under alltypes of Medicaid insurance, while others are available only to specifically qualifying recipients. Medicaid recipients in Delaware are encouraged to fully review all of the materials that they receive upon enrollment to help them better understand the benefits to which they are entitled.

Medicaid Managed Care Plans in Delaware

To provide Medicaid coverage and benefits to qualifying state residents effectively and efficiently, Delaware requires that nearly all Medicaid recipients enroll in a Diamond State Health managed care plan. Under these types of Medicaid insurance plans, Medicaid-eligible recipients are allowed to select a participating primary care physician. These physicians ensure that recipients receive all services covered by Medicaid for which they are eligible, including appropriate primary and preventative care, and that their medical needs are met.

Medicaid coverage recipients may choose from two different managed care organizations with whom Delaware’s DMMA holds contracts. Under these contracts, most health services are covered by Medicaid but provided and administered by the selected MCO. A few services, such as prescription medication and non-emergency medical transportation, are handled and paid for by Delaware’s Medicaid program directly. In all cases, Medicaid coverage recipients should present their Medicaid card to providers when receiving services to ensure services covered by Medicaid are properly accounted for and correctly billed. Recipients newly enrolled in Medicaid coverage are encouraged to review the Medicaid information they receive to see if the physician in whose practice they are already enrolled participates in any of the available MCO plans. If so, then it is often in the patient’s best interest to select that plan to maintain continuity of care. Enrolling in an MCO is an essential part of accessing services covered by Medicaid in Delaware and recipients who decline, neglect or fail to select an MCO by the deadline provided to them will be assigned to an MCO by Medicaid.

Some categories of Medicaid insurance recipients may be exempt from the managed care plan mandate. Recipients who also qualify for or who are enrolled in Medicare are not required to select a Diamond State Health managed care plan. Medicaid coverage recipients living in qualifying nursing or intermediate care facilities and those with waivers under Medicaid’s home and community-based care programs are also exempt. Enrollment is not required for recipients with military health insurance, who are participating in or eligible for the Medicaid Breast and Cervical Cancer program or women who are pregnant. Download our national Medicaid guide for more information about eligibility requirements to obtain insurance coverage from the program.

Services Covered by Medicaid in Delaware

All types of Medicaid insurance in Delaware pay some or all of the costs associated with routine primary and preventative health care, such as sick and well-patient doctor’s visits for adults and children. Well-patient visits covered by Medicaid are authorized to include the taking of a patient’s personal and family medical histories, physical examination, blood work and urine testing, age-appropriate vaccinations and behavioral health screenings. Under Medicaid coverage, children may additionally be screened for growth concerns and oral health and may be provided with essential health and safety education. Adults can be screened for issues related to blood pressure and cholesterol levels, may be given hearing exams and receive consultations regarding alcohol, tobacco and substance use. Medicaid covers some forms of inpatient and outpatient hospital care and associated costs to include the following:

  • Laboratory tests

  • X-rays

  • Ambulance services

Adult patient education may be covered by Medicaid if it is in regards to heart health, nutrition or physical activity. Medicaid coverage also pays for women’s health care associated with family planning, pregnancy and maternity care. These services and standards were informed by and conform to national recommendations for all citizens made by the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention (CDC).

Medicaid coverage also covers certain home health care services, hospice care and qualifying medical equipment and supplies. Dental health services are available to Medicaid recipients 21 years of age or younger. Dental services may be covered by Medicaid for adult recipients in particular circumstances. Some recipients may qualify for supplemental transportation assistance to and from medical appointments, which will be organized and administered by their MCOs. All recipients have access to a suite of behavioral health and substance abuse services as needed and appropriate. Children receiving benefits under Medicaid coverage may be eligible to receive additional benefits and services if they also qualify for support under the Delaware Healthy Children Program. Find out more about services covered by Medicaid and the Children’s Health Insurance Program (CHIP) by downloading our detailed national guide.

How much does Medicaid cost in Delaware?

General Medicaid cost estimates in Delaware are difficult to provide with accuracy due to the fact that they are determined and affected by a variety of independent and personalized factors. The type of Medicaid insurance a recipient qualifies for and his or her household size and income all have an impact on which services covered by Medicaid that recipient can expect to access and at what cost. For example, households that qualify solely due to income-eligibility may qualify for different copayments or services than households that were eligible for coverage due to disability status. Households with children or legally elderly members may have different rates than households composed solely of adults between 18 and 64 years of age. After the completing the Medicaid application process in Delaware, beneficiaries will know if and how they qualify for coverage and what out-of-pocket expenses they can expect.

How much Medicaid costs can also change over time with changes in the amount or types of care that a household accesses. For example, recipients relying on services covered by Medicaid for just routine preventative and primary care will likely have lower Medicaid expenses than recipients who use their benefits to pay for hospital visits or ongoing behavioral health care services. How much Medicaid costs is often directly impacted by household income. In part, this is because the types of Medicaid insurance for which a recipient qualifies is influenced by household income levels. It is also partly due to the expectation that households with higher incomes can afford, and are therefore assigned, higher levels of cost-sharing in the form of co-pays and other expenses.

What does Medicaid not cover in Delaware?

“What does Medicaid not cover in Delaware?” is a question many newly enrolled Medicaid recipients are quick to ask. Medicaid coverage is available for most essential health care services. However, elective, optional or cosmetic procedures are typically not covered by Medicaid. Some limitations on medical equipment and supplies may apply as well unless a recipient’s physician properly and specifically requests them.

The most important Medicaid information for recipients of all types of Medicaid insurance to understand is that where and how they receive services is as important to determine if that service will be covered than the type of service they are requesting. With the exception of exempt groups, Medicaid coverage policies require that all recipients’ care must be approved and delivered by their Diamond State Health managed care plan and its participating providers. Except in rare cases, Medicaid does not cover services delivered by providers who are not enrolled in and approved by MCO. This remains true even if the service would have been fully paid for under Medicaid coverage if an in-network provider had delivered it.