Medical Billing Services in Delaware.
Delaware is a small but complex billing market dominated by the Diamond State Health Plan managed care program, a duopoly of Aetna Better Health and Highmark Health Options serving the majority of Medicaid beneficiaries, and two major health systems—ChristianaCare and Bayhealth—that define the provider landscape. Happy Billing brings expertise in Delaware Medicaid MCO authorization workflows, ChristianaCare and Bayhealth credentialing, Highmark BCBS commercial billing, and the state’s behavioral health and substance use disorder billing landscape amid Delaware’s ongoing opioid response.
Delaware Medicaid Billing
Delaware Medicaid (known as Diamond State Health Plan for managed care beneficiaries) covers approximately 280,000 residents. Delaware expanded Medicaid under the ACA in 2014. The program is administered by the Delaware Department of Health and Social Services (DHSS) Division of Medicaid and Medical Assistance (DMMA).
Diamond State Health Plan — MCO Managed Care
The Diamond State Health Plan is Delaware’s primary Medicaid managed care program, covering most Medicaid beneficiaries including expansion adults, children, and families. Delaware currently contracts with two MCOs:
- Aetna Better Health of Delaware — one of the two contracted MCOs serving Diamond State Health Plan members across the state
- Highmark Health Options Delaware (formerly Delaware Physicians Care) — the other contracted MCO, with roots in Delaware’s Blue Cross Blue Shield affiliate
Providers serving Diamond State Health Plan members must credential with both MCOs, as beneficiaries may be enrolled in either plan. Each MCO maintains its own provider directory, prior authorization requirements, and claims submission portal.
Diamond State Health Plan Plus — Long-Term Services
Delaware also operates the Diamond State Health Plan Plus for individuals dually eligible for Medicare and Medicaid (D-SNP) and for certain long-term services and supports (LTSS) populations. This program has distinct billing and authorization requirements from the standard Diamond State Health Plan.
CHIP — Delaware Healthy Children Program
Delaware’s CHIP program (Delaware Healthy Children Program) covers children in families with incomes too high for Medicaid but who lack affordable employer coverage. CHIP enrollees are served through the same MCO structure as Medicaid, with Aetna Better Health and Highmark Health Options participating.
Fee-for-Service Carve-Outs
Certain services are carved out of managed care and billed directly to Delaware Medicaid FFS:
- Long-term care and nursing facility services
- Some behavioral health services (though most are MCO-managed)
- Certain waiver services for individuals with disabilities
Major Payers and Health Systems in Delaware
ChristianaCare Health System
ChristianaCare is Delaware’s largest health system and one of the most prominent academic medical centers in the mid-Atlantic region. ChristianaCare operates Christiana Hospital (the state’s largest hospital with over 900 beds) and Wilmington Hospital, along with an extensive network of ambulatory and primary care sites. ChristianaCare is nationally ranked in multiple specialties and serves as the primary referral center for Delaware and surrounding areas. Providers credentialing with ChristianaCare follow the system’s centralized medical staff office processes.
Bayhealth Medical Center
Bayhealth is Delaware’s second major health system, operating Kent General Hospital in Dover and Milford Memorial Hospital in Milford. Bayhealth serves central and southern Delaware and is the primary hospital system for the state’s less densely populated communities. Bayhealth became independent from Christiana Care Health System in 1998 and has since expanded its service lines across Kent and Sussex counties.
Nemours Children's Health
Nemours Children’s Health operates the Alfred I. duPont Hospital for Children in Wilmington, one of the leading pediatric hospitals in the United States. Nemours provides specialized pediatric care across Delaware and the surrounding region and is nationally ranked in multiple pediatric specialties. Pediatric providers must credential separately with Nemours given its distinct medical staff structure.
Commercial Payers in Delaware
- Highmark Blue Cross Blue Shield Delaware — dominant commercial insurer in Delaware; affiliated with the Highmark network covering most of the mid-Atlantic region
- Aetna — significant commercial presence, including employer group and individual market plans
- UnitedHealthcare — active in Delaware’s employer and Medicare Advantage markets
- Cigna — employer group plans for Delaware’s large corporate employer base (DuPont, AstraZeneca, JPMorgan Chase)
- Coventry/First Health — commercial and worker’s compensation plans
Is your Delaware practice leaving revenue on the table?
Specialties We Serve in Delaware
Each specialty page dives into the specific billing challenges and our approach. Visit our Specialties to explore the one most relevant to your practice.
Delaware Medical Billing FAQs
How many MCOs does Delaware Medicaid use?
Delaware Medicaid’s Diamond State Health Plan currently contracts with two MCOs: Aetna Better Health of Delaware and Highmark Health Options Delaware. Providers must credential with both plans to serve the full Medicaid population.