Delaware program
Plan approval for treatment away from home
Help checking coverage and any approvals for planned care away from home.
What it is
Help checking coverage and any approvals for planned care away from home.
Treatment across a state line can involve network rules and written plan approval. Delaware First Health lists prior approval for out-of-network care and transplants. Your child’s own plan confirms its requirements.
Eligibility rules
- This card concerns a Delaware Medicaid health plan. Commercial plans have their own rules.
- Delaware First Health lists prior authorization for planned transplants and out-of-network care. Out-of-state care can be in network. Emergency services have separate protections and cannot be delayed for prior authorization. Your child’s plan confirms its own service rules.
What you get
- Help obtaining a written coverage decision and payment arrangements for planned distant treatment.
What the help includes
- A single-case agreement may be needed to settle payment with the receiving hospital.
If you decide to apply
- Ask the oncology team and your health-plan care manager to review the receiving hospital and planned date.
- Have your member number and the oncologist’s explanation of why that center is needed ready.
- Ask whether the receiving hospital needs a separate payment agreement with the plan.
Child’s health-plan care manager · Official page ↗
What happens next
- If the plan approves care, its written decision identifies the services, dates and scope. A separate payment agreement may be needed; neither document guarantees payment of every receiving-hospital bill.
Good to know
The oncologist’s referral is not the health plan’s approval. The approval’s scope matters for the bill.
Other details
- Crossing a state line does not by itself put a hospital out of network. Emergency care never needs approval first.
Official sources
- Delaware First Health — Prior Authorization and Referrals
- CMS — Delaware Diamond State Health Plan, approved section 1115 extension (May 17, 2024; technical corrections November 22, 2024)
- Delaware First Health, 2026 Diamond State Health Plan member handbook, approved December 8, 2025
- 42 CFR 438.210(d), Medicaid managed-care authorization clocks
- 42 CFR 438.114, emergency and post-stabilization services
- 42 CFR 431.52, out-of-state Medicaid services
- 42 CFR 438.408, resolution, extensions, and hearings
- 42 CFR 438.420, continuation and possible recovery of benefits
“If our child needs treatment away from home, what must the plan approve? What are the benefits and risks of that transfer, and could you help with the request?”
Why I’m asking: I want the receiving hospital and our plan to agree on coverage before a transfer.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask for the authorisation number in writing before you travel, and keep it with the admission papers.
Your social worker
The oncology team and the plan’s care manager open the request and chase it.
The care team
The oncologist documents why the treatment has to happen at that centre.
- Who decides
- The child’s health plan.
- Ask your social worker
- “Before we transfer, can we have the plan’s prior authorisation for out-of-network care and for the transplant in writing, and is a single-case agreement needed?”
How to apply
First step: If you decide to pursue distant care, ask the care manager which services need approval and whether a payment agreement is needed.
- Ask the plan in writing for prior authorisation for the out-of-state admission and for the transplant.
- Ask whether a single-case agreement with the receiving hospital is needed, and who signs it.
- Ask the receiving hospital’s financial counsellor to confirm the approval landed before you travel.
Official application / program page ↗
Where it starts: Ask the oncology team and the plan’s care manager to open the authorisation before the transfer date, and to say in writing whether a single-case agreement is needed.
What to gather
- The receiving hospital and the planned admission date
- The oncologist’s letter saying why it must happen there
- Your plan name and member number
How long: Delaware’s own clock for this was not published. Ask the plan for its deadline and diary it.
What a yes looks like
An authorisation number, the dates it covers and the receiving hospital named on it.
What a no looks like, and the next move
A Medicaid denial uses the plan appeal and, where available, a state fair hearing. Commercial outside review is a separate route.
Watch out
- A referral from the oncologist is not the plan’s authorisation. Ask for both.
- Ask whether a single-case agreement with the receiving hospital is needed, and who signs it.
- The rule quoted here is one plan’s published table. A statewide Delaware pathway was not published, so ask your own plan in writing.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
Written approval before a transfer, so the receiving hospital’s bills are covered rather than argued about afterwards.
Covers: Prior authorisation for out-of-network services · Prior authorisation for transplants
Legal protection: A written authorisation is the record that the receiving hospital and the plan agreed before the transfer
What it costs the family: None to ask.
The eligibility facts, as published
- Coverage
- a Delaware Medicaid health plan; commercial plans have their own equivalent rules
- Condition
- care outside the plan’s network, or a transplant
The trap: An oncology referral is not itself plan approval. Network status and the services decide what approvals or payment agreements are needed. Emergency care has separate protections.
Where I read this
- Delaware First Health — Prior Authorization and Referrals — Delaware First Health (Centene), read September 10, 2026
- CMS — Delaware Diamond State Health Plan, approved section 1115 extension (May 17, 2024; technical corrections November 22, 2024) — Centers for Medicare & Medicaid Services, read September 10, 2026