Diamond State Health Insurance Plan The Diamond State Health Plan is Delaware's Medicaid managed care program (DSHP). Diamond State Health Plan Plus is Delaware's long-term care Medicaid program (DSHP Plus). Delaware's Medicaid program is administered by the Delaware Division of Medicaid & Medical Assistance (DMMA).
The DSHP provides health coverage for adults and children with limited income and resources who are eligible for Medicaid but cannot afford medical care. It does this by assigning them to a primary care provider or "PCP" who agrees to accept a reduced rate of payment from the state agency.
PCPs are required to see patients within 90 days of being assigned one, so it's important that you find a doctor who will take part in this plan. They must be licensed in the state where they practice and may not charge any fees to patients or their families for services rendered. However, some practices may have financial relationships with hospitals or other healthcare providers and may receive additional compensation for referrals made through these channels.
It is important to understand that while this is an insurance program, it has many similarities to a private health plan in that it provides benefits such as hospitalization, physician visits, prescription drugs, and vision care. In addition, like any insurance policy, premiums are based on your income and family size. There are also limitations on what can be charged for services under this plan.
Some Medicaid beneficiaries in Delaware do not receive their medical treatment through a managed care company, including those who simultaneously receive Medicare and those in long-term care Medicaid programs such as the Nursing Facility program. DMMA offers a variety of managed care organizations from which to choose the MCO plan that is ideal for you and your family. An MCO pays a fixed monthly premium to DMMA for the right to manage claims against any Medicaid account. If an MCO fails to meet quality standards or misses its budget allocation, it can be removed from the program. A new MCO then takes its place.
When an MCO accepts a patient into its network, that individual becomes eligible for benefits under the plan. Patients must meet certain eligibility requirements to be accepted into a plan. For example, one must be age 65 or older, a resident of Delaware, and unable to work because of a disability to be accepted into a retirement plan. Those younger than 65 may still be accepted into a health maintenance organization (HMO) plan.
An MCO typically provides coverage for doctors' visits, hospitalization, prescription drugs, preventive services, and emergency room visits. Some plans also cover lab tests, X-rays, and other services. The amount patients must pay out of pocket varies depending on the plan they select. Some plans require patients to pay a copayment for each service received while others have a set limit on how much they will pay in total per year.
A Medicaid State Plan is an official document that specifies the structure and extent of the Medicaid program in a state. As required by Section 1902 of the Social Security Act (the Act), each state designs its own plan, which is subsequently authorized by the federal Department of Health and Human Services (DHHS).
States must comply with certain requirements in order to receive federal funds under Medicaid. For example, states must provide medical assistance to individuals who are below the federal poverty level. They also need to take into account an individual's income from all sources when determining whether they are eligible for Medicaid. If an individual's income is greater than some specified amount, they will not be eligible for Medicaid unless they qualify for an exemption or exclusion.
Further, states must establish a process to review their plans periodically. This process may include having an independent party conduct a compliance audit of the plan. If a state fails to comply with any requirement of the Act or its regulations, it can be subject to a penalty. These penalties can be as high as 10% of the total amount of funding that the state received in that year. However many times have been noted on plans that if the state agency fails to comply within 30 days after notice from DHHS then the plan is approved for such period/months. After these periods end the state must either comply or remove itself from the Medicaid program.
Medicaid provides medical assistance to eligible low-income families as well as qualified elderly, blind, and/or handicapped individuals whose income is inadequate to cover the cost of required medical care. The Delaware Healthy Children Program (CHIP) provides high-quality coverage comparable to that of some of the top commercial insurance plans. In addition, CHIP reduces the financial burden on parents by covering most of the costs of doctor visits, prescriptions, and other health services.
Eligibility for Medicaid varies depending on an individual's age and situation. Generally, if a person was born after January 1, 1950 and has been declared disabled by the Social Security Administration (SSA), he or she is automatically eligible for Medicaid. If you were not born into disability, are under 19 years old, or any other condition prevents you from working, you will still be able to get health coverage through CHIP.
To be eligible for CHIP, your family must meet certain income requirements. Your annual income cannot exceed $50,400 for an individual or $100,800 for a couple. These figures include one wage earner who is not a spouse or a partner. If your income is above these limits, you will not be eligible for CHIP.
Additionally, anyone who was previously eligible for Medicare but has lost eligibility because they started earning more than $85,000 annually will not be able to re-enroll in this program.