In Delaware:
  • As of July 1, 2011, there were 200,810 beneficiaries enrolled in the state’s Medicaid program, 161, 655 of whom were enrolled in a managed care program known as Diamond State Health Plan. (now known as Diamond State Partners).
  • Physical, behavioral, and dental benefits are provided through two Medicaid-only managed care organizations.
  • Severely disabled children who require a nursing home level of care but do not qualify for Medicaid due to their parents income can receive Medicaid services through the state’s Children’s Community Alternative Disability Program.
As of 2013, 111,655 individuals were eligible for Delaware’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 80% and a participant ratio of 60%. 48,665 children received dental services of any kind, with 46,197 receiving preventive dental services.
Last updated September 2014
Medical Necessity
According to Delaware’s Administrative Code, medical necessity means providing health care services or products that a prudent physician would provide to a patient for the purpose of diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:
  1. in accordance with generally accepted standards of medical practice;
  2. consistent with the symptoms or treatment of the conditions; and
  3. not solely for anyone’s convenience.
Initiatives to Improve Access
Reporting & Data Collection
Delaware’s Medicaid and CHIP Managed Care Quality Strategy details the state’s approach to quality measurement and reporting. The strategy requires managed care organizations (MCOs) to submit quarterly reports that include information on:
  • Total Number of EPSDT Visits
  • Rate of EPSDT Visits vs. Eligible
  • Total Number of Outreach Calls for EPSDT Visits for visits missed within 30 days
  • Total Number of Outreach Calls for EPSDT Visits for visits missed within 60 days
  • Total number of mailers sent to Members for missed EPSDT visits
MCOs also report annually on a variety of HEDIS measures, including metrics pertaining to children:
  • Well-Child Visits in the First 15 months of Life
  • Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
  • Children and Adolescents’ Access to Primary Care Practitioners
  • Childhood Immunization Status
  • Lead Screening in Children
  • Appropriate Treatment for Children with Upper Respiratory Infection
Behavioral Health
Delaware’s Medicaid program encourages managed care organizations (MCOs) to community providers of mental health and substance abuse services. Children through age 18 can receive 30 units of outpatient counseling services per year through their managed care plan; additional services are then provided through the state’s Department of Children Youth and Their Families.
As part of the state’s ABCD Screening Academy, Delaware Medicaid improved the delivery of child development services by promoting awareness of the importance of developmental screening among Medicaid MCOs, implementing the Parents Evaluation of Developmental Status (PEDS) developmental screening tool in all ABCD demonstration sites, and hosting an ABCD Stakeholder Forum to promote structured developmental screening throughout the state.
Support to Providers and Families
Support to Providers
Delaware Medicaid publishes a regularly updated General Policy Manualand Practitioner Provider Specific Policy Manual containing information on the EPSDT program. The manuals include information on periodicity schedules, medical necessity, required services, and other guidelines.
Care Coordination
Medicaid beneficiaries enrolled in the Diamond State Health Plan receive care coordination services that emphasize early intervention and continuity of care through partnerships with providers in the community.
Oral Health
An overview of the state of children’s dental care in Delaware can be found in the report “Delaware Smiles: The Oral Health of Delaware’s Children,”published by the Division of Public Health.
Delaware Oral Health Coalition
In an effort to ensure that all people in Delaware can access affordable oral health services, the state established the Delaware Oral Health Coalition, of which the state Medicaid program is a member. Coalition stakeholders gather to discuss innovative actions that can be taken by the state, potential partnerships to influence change, and collaborative opportunities for service delivery, health promotion, and research.
Department of Public Health Dental Clinics
The Department of Public Health operates dental clinics that provide EPSDT dental screenings. If Medicaid eligible children require services that fall outside of the range of activities provided in these clinics, the Department of Public Health will arrange treatment referrals to private dentists and bills these referrals to the Delaware Medicaid Agency.