16 Del. Admin. Code § 14000-14900

Current through Register Vol. 28, No. 7, January 1, 2025

Section 14000-14900 - Enrollment In Managed Care

On May 17, 1995, Delaware received approval from the Health Care Financing Administration (HCFA) (on June 14, 2001, HCFA was renamed Centers for Medicare and Medicaid Services [CMS]) for a Section 1115 Demonstration Waiver that is known as the Diamond State Health Plan. The basic idea behind this initiative is to use managed care principles and a strong quality assurance program to revamp the way health care is delivered to Delaware's most vulnerable populations. The Diamond State Health Plan is designed to provide a basic set of health care benefits to current Medicaid beneficiaries as well as uninsured individuals in Delaware who have income at or below 100% of the Federal Poverty Level (FPL). The demonstration waiver will mainstream certain Medicaid recipients into managed care to increase and improve access to medical service while improving cost effectiveness and slowing the rate of growth in health care costs.

Program Expansions

Effective July 1, 2002, a State operated managed care organization, Diamond State Partners, was implemented. Individuals may enroll in either the Diamond State Health Plan or Diamond State Partners

Effective April 1, 2012, the Diamond State Health Plan is expanded to include Long Term Care Medicaid and other full-benefit dual eligibles. This Long Term Care Managed Care Program is called Diamond State Health Plan Plus. Long Term Care Medicaid recipients and other full-benefit dual eligibles must enroll in Diamond State Health Plan Plus.

Managed Care Eligibility

The majority of the Medicaid population receiving Medicaid services will be enrolled into the Diamond State Health Plan, Diamond State Health Plan Plus, or Diamond State Partners. The following individuals cannot enroll in Diamond State Health Plan, Diamond State Health Plan Plus, or Diamond State Partners:

a. Individuals entitled to or eligible for a Medicare Savings Program (QMB, SLMB);

b. Individuals residing in an intermediate care facility for the developmentally disabled (ICF/MR);

c. Individuals covered under the Developmentally Disabled waiver program;

d. Individuals that choose to participate in the Program of All-inclusive Care for the Elderly (PACE);

e. Non lawful and non qualified non citizens (aliens);

f. Individuals eligible under the Breast and Cervical Cancer Treatment Group;

g. Presumptively eligible pregnant women;

h. Individuals in need of only the 30-Day Acute Care Hospital program.

16 Del. Admin. Code § 14000-14900

12 DE Reg. 446 (10/01/08)
15 DE Reg. 1717 (06/01/12)