Frequently Asked Questions
What is Delaware First Health?
Delaware First Health is a Medicaid Managed Care health plan that will begin offering services on January 1, 2023 to children, adults, pregnant women, families with children, elderly, children and adults with disabilities.
What is a Managed Care Organization (MCO)?
An MCO is an insurance company that contracts with providers and medical facilities to provide health care services to its members.
What services are covered under Delaware First Health?
Delaware First Health services include physical health, behavioral health, pharmacy, long-term services and supports, and home and community benefits.
How do I know if my doctors are contracted with a Delaware Medicaid MCO?
Ask your doctors if they are contracted with Delaware First Health.
You can check the Find a Provider webpage on our website to view our online provider directory or consult our Provider Directory.
If you have questions about our doctors, contact Delaware First Health Member Services at 1-877-236-1341 (TTY: 711).
Can I change my Primary Care Provider (PCP)?
Yes. You can change your PCP at any time.
I need to see a specialist, what do I need to do?
Delaware First Health does not require a referral from your PCP to see a specialist for covered services. The Provider specialist may still need a referral or additional information from your PCP. This helps them give you the right treatment. They will tell you if they need a referral. If you would like additional information, you may contact Delaware First Health Member Services at 1-877-236-1341 (TTY: 711).
What is a Home and Community Benefit?
The “Home and Community Benefit” is the name given to a set of services that help to keep people in their homes and communities. Some of these services include adult day health, respite care, and personal care services.
What services are not covered?
- Services that are not medically necessary
- Abortion unless the pregnancy is the result of rape or incest, or if the woman suffers a life-endangering physical condition caused by, or arising from, the pregnancy itself per Section 508 of PL 110-161 (the Hyde Amendment). The Contractor shall have information on file to demonstrate that any abortions performed were in accordance with Federal law
- Sterilization of a mentally incompetent or institutionalized individual
- Except in an emergency, inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practice, who is responsible for the diagnosis or treatment of a particular patient’s condition
- Infertility treatments
- Cosmetic services, unless the Contractor determines the service is medically necessary
- Christian Science nurses and sanitariums
- Pharmacy-related services such as
- Any drug or device marketed by a manufacturer who does not participate in the Medicaid Drug Rebate Program
- Any drug, device, or classes of drugs listed in Section 1927(d)(2)(B), (C), (H), or (K) of the Social Security Act
- All Drug Efficiency Study Implementation (DESI) drugs, as defined by the FDA
- Drugs that are lifestyle drugs or that are not medically necessary
How do I dis-enroll from Delaware First Health?
All new members have the opportunity to change MCOs during the 90-day calendar period immediately following the initial enrollment into Delaware First Health. Call the Health Benefits Manager to request to change MCO’s: 1-800-996-9969. The State will also provide an opportunity for members to change MCOs during an Annual Open Enrollment Period.
What is the service area covered by Delaware First Health?
Delaware First Health currently offers Managed Care services statewide in Delaware.