If you have questions or issues with your health care insurance, whether private or Medicaid, Delaware Family Voices can help. We can also keep you updated and answer questions about the Health Care Reform’s Affordable Care Act. Please contact us directly with your questions.
Medicare and Other Benefits: Your Guide To Who Pays First
From the Center for Medicare and Medicaid Services
Compassionate Allowances Conditions
From the Social Security Administration.
What the Insurance Jargon Means for Families
From the Affordable Care Act (ACA). Helping families understand key insurance words and how they affect them.
Your Health Insurance: Questions & Answers
Helping you understand how to use and keep your health insurance.
Children’s Community Alternative Disability Program
Providing Medicaid coverage to severely disabled children who do not qualify for Supplemental Security Income (SSI) or other Medicaid qualifying programs because of parents’ income and/or resources.
Find information about and program details for government benefits in Delaware, Delaware Medicaid and Delaware Healthy Children Program (SCHIP):
The Catalyst Center is a national center dedicated to improving health care insurance and financing for Children and Youth with Special Health Care Needs (CYSHCN).
Public Insurance Programs And Children With Special Health Care Needs – Providing a broad overview of Medicaid and CHIP, the many different populations these programs serve, and the changes they are undergoing with health care reform.
Centers for Medicare and Medicaid Services (CMS)
Website: CMS.Gov – Centers for Medicare and Medicaid Services
Children’s Health Insurance – Delaware Healthy Children Program (DHCP)
Delaware Health Children’s Program (DHCP) provides low-cost health insurance for children under the age of 19, who are currently uninsured and do not qualify for Medicaid.
Website: Benefits.Gov – Delaware Healthy Children Program (DHCP)
Choose Health Delaware
The free official State of Delaware program to help you understand health insurance reform and the Health Insurance Marketplace.
Website: Choose Health Delaware
Delaware Department of Insurance
Protecting Delawareans through regulation and education while providing oversight of the insurance industry to best serve the public.
Website: Delaware Department of Insurance
Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Benefit
EPSDT is the child health component of Medicaid and is designed to improve the health of low-income children, by financing appropriate and necessary pediatric services.
Helping all Americans find high-quality, comprehensive and affordable health care.
Website: Families USA
First Smile Delaware
Providing information about dental services available in Delaware that will help individuals and families find and access dental resources.
Get Started with Healthcare.gov with this one page guide to the Health Insurance Marketplace. Learn tips on how to enroll for health coverage. View health plans and prices before applying.
Conexion: Comenzar con Cuidado De Salud
Insure Kids Now.Gov – Delaware
Connecting Kids to Coverage. Learn about children’s health coverage programs in Delaware.
Website: Insure Kids Now – Delaware
National Website: Insure Kids Now.Gov
Contact: 1-877-543-7669 to learn more about Health Coverage in Delaware or any other state.
Medicaid – Access to Care for Children
Setting the record straight on access to care for children in Medicaid. From the Center for Children and Families.
MCO & Mental/Behavioral Health Monthly Call
A monthly call-in for families with children and youth with special health care needs to address their questions and concerns regarding their Medicaid Managed Care and Mental Health Care benefits.
Link: Flyer – 2017 MCO Call Dates
Link: Medicare Physician Compare – Helping find physicians and other healthcare professionals.
Medigap: Choosing a Policy
A guide to health insurance for people with Medicare. From Centers for Medicare and Medicaid Services.
Social Security Administration
Learn more about and how to apply for social security disability benefits and SSI for your child. Link to how to appeal a decision.
Link: Appeal A Decision – Social Security Administration – Online application
TriCare – Health Plans For Military Families
An additional TriCare Prime option available though networks of community based, not-for-profit health care systems in the United States. The US Family Health Plan provides minimum essential coverage under the Affordable Care Act.
Link: US Family Health Plans
Link: All Tricare Health Plans
Medicaid Managed Care Plan
Medicaid: What if I Am Denied Coverage for Something That I Need?
If you have applied for or are receiving Medicaid benefits, you have special appeal rights. If you are in a managed care plan, you have the same grievance rights as those in managed care plans who are not receiving Medicaid. If you are in a managed care plan, you will also want to look at the articles, “How Can I File a Grievance in my Health Plan?” and “Can I Appeal the Health Plan’s Denial to Someone Outside the Plan?”
If you are receiving Medicaid:
- You have a right to receive written notice whenever you are denied Medicaid eligibility, a service or part of a service or coverage for something that you have requested. You must get written notice of an adverse action before it will take effect.
- If you disagree with the denial, you have the right to appeal that decision and ask for a fair hearing in front of an administrative law judge.
- If you ask for your appeal before the action would take effect, you have the right to have your coverage continue while you are appealing the decision.
- Before the hearing, you have the right to review any documents in your case file as well as any documents that the State or county will use at the hearing.
- You have the right to present witnesses, to be represented by someone else, and to present your case at the hearing.
- If you lose your case at the hearing, you have the right to appeal the decision against you.
Have questions about your Medicaid Managed Care plan? Join our Medicaid Managed Care Teleconference. See our events page for the next teleconference and more information.
Common Healthcare Insurance Questions
Consider these questions when evaluating an existing health insurance plan, considering a new health insurance plan, or comparing an existing plan with a new plan.
- Does my plan cover these services?
- Is there an annual deductable?
- What are co-pays?
- Is there an annual upper payment limit/cap or limit/cap on number of visits? What are lifetime limits/caps?
- Is there an annual limit for out-of-pocket expenses?
- What are the differences in cost between using a provider who is part of the plan and one that is not part of the plan?
- Physical examinations and health screenings.
- Care by specialists.
- Emergency care.
- Prescription drugs (see more detailed questions below).
- Vision care.
- Dental services.
- Care and counseling for mental health.
- Services for drug and alcohol abuse.
- Obstetrical-gynecological care and family planning services.
- Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
- Physical therapy and other rehabilitative care.
- Home health, nursing home, and hospice care.
- Chiropractic or alternative health care, such as acupuncture.
- Experimental treatments.
- What preventive care is offered, such as shots for children?
- What health screenings are covered, such as breast exams and Pap smears for women?
- If the plan does not have a certain type of subspecialist in its network who is trained in the care of children, can I see an out of network pediatric specialist at no additional cost?
- What is the plan’s definition of medically necessary? (How/who determines medical necessity of services?)
- Are benefits, costs, etc different if traveling – out of state
Here are questions to ask to better understand a health insurance plan’s pharmacy benefit:
- Does the plan require that doctor to choose drugs from a formulary, or list of covered medicines?
- If so, are the prescriptions that my family needs on the plan’s formulary? If we need a medicine that is not on the formulary, will we have to pay for it myself, or will the plan reconsider its decision based on an appeal?
- What is the process for pursuing an appeal?
- How much are co-payments, or What do I owe the pharmacy when I get a prescription?
- Does the plan use a prescription mail order services? Is there a penalty if I don’t want to use the mail order service? Will the plan require that I use it, or can I choose to get medicines at a local pharmacy?
- Is there a limit to out-of-pocket expenses? Does it include the amount I pay for my medications?
- Is there a cap (limit) on my total benefits? Is it possible that I could use up all my benefits and have to pay full price myself for anything else I need?
- If there is a less expensive medicine than the one my doctor prescribes, will the health plan require that the cheaper one is used first? (This is called step therapy.)
- Does the health plan ever call doctors to ask them to switch patients to a different, cheaper drug? (This is called therapeutic substitution.)
- Does the health plan require approval for certain medicines before it will pay for them? If so, how is this prior authorization obtained?
United Healthcare Children’s Foundation
United Healthcare Children’s Foundation (UHCCF) provides grants for financial help/assistance to families with children that have medical needs not covered or not fully covered by their commercial health insurance plan. The Foundation aims to fill the gap between what medical services/items a child needs and what their commercial health benefit plan will pay for.
First Hand Foundation
The First Hand Foundation strives to change children’s lives by providing funding for clinical necessities such as medication, therapy, and surgery, medical equipment, and travel relate to a child’s care.
Link: Application for First Hand assistance