1. 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.
2. 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.
3. 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.
4. 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.
5. You have the right to present witnesses, to be represented by someone else, and to present your case at the hearing.
6. If you lose your case at the hearing, you have the right to appeal the decision against you.

Common Questions
*These questions are pulled from various sources*


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.
Hospitalization
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?

Guide to Finding Health Insurance

Setting the Record Straight on Medicaid and Access

Delawareans with special needs