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Medical Benefits

Many of the health care services and benefits for AmeriHealth Caritas Delaware members are listed below. For some benefits, you have to be a certain age or have a certain need for the service.

You must use an AmeriHealth Caritas Delaware network provider to get these benefits and services, unless:

The services are emergency services.

You get prior authorization (preauthorization) to use a provider who is not in our network.

You are a new AmeriHealth Caritas Delaware member, are pregnant, and already get treatment from an OB or midwife who is not in our network. You can keep getting treatment from that provider until your postpartum care for that delivery ends up to 60 days following delivery of the baby.

To learn more about all of your benefits, see your member handbook. Or call AmeriHealth Caritas Delaware Member Services, 24 hours a day, seven days a week, at:

  • Diamond State Health Plan: 1-844-211-0966 (TTY 1-855-349-6281).
  • Diamond State Health Plan-Plus: 1-855-777-6617 (TTY 1-855-362-5769).

Your benefits

Which coverage do you have?

Diamond State Health Plan (DSHP)
  • Routine doctor office visits, checkups, and sick visits.
  • Well-baby visits, well-child visits, and immunizations.
  • Tests and studies, laboratory work, and X-rays.
  • Preventive services, including mammogram, colonoscopy, and well visits for adults.
  • Radiology services, including invasive and non-invasive imaging, when medically necessary.
  • OB/GYN exams and annual Pap tests.
  • Prenatal and postpartum care, including delivery, birthing center admission, newborn care, and early discharge home visits for new mothers.
  • Family planning.
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, including periodic preventive health screenings and other necessary diagnostic and treatment services for members under age 21.
  • Pharmacy.
  • Care management and care coordination services.
  • Vision services: routine eye exams — covered every 12 months.
  • Vision services: eye glasses or contact lenses — covered every 12 months.
  • Dental services for adults (ages 21 and over): routine exams and cleanings — covered once every 12 months.
  • Dental services for adults (ages 21 and over): X-rays.
    • Bite-wing: one set every 12 months; full mouth: one set every 36 months.
  • Behavioral health and substance use disorder services.
    • Covered for adult members ages 18 and over.
    • Children (ages 17 and under): 30 outpatient visits per year; visits above 30 are provided through DSCYF.
  • Visits to specialists.
  • Organ transplants when medically necessary and with proper documentation.
  • Chiropractic services.
    • Maximum of one manual manipulation per member per day up to 20 manual manipulations per member per calendar year.
  • Federally qualified health center services.
  • Hospital: inpatient and/or outpatient care.
  • Inpatient behavioral health services in a general hospital or psychiatric hospital:
    • Covered for members ages 18 and over.
    • Services provided by Department of Services for Children, Youth, and Their Families (DSCYF) for members 17 and under.
  • Ambulatory service center services.
  • Surgery: inpatient and/or outpatient.
  • Ambulance rides when medically necessary.
  • Private-duty nursing and home health care services — when medically necessary.
  • Durable medical equipment when medically necessary.
  • Physical, speech, and occupational therapy when medically necessary.
  • Skilled nursing facility services when medically necessary, up to 30 days per year.
  • Hospice services.

Extra services provided by AmeriHealth Caritas Delaware

  • Access to our Community Wellness Center.
  • Free weight management classes in our Community Wellness Center through community collaboration.
  • Gift cards incentivize members to perform healthy behaviors resulting in improved health outcomes.
  • Disease management programs with incentives for healthy outcomes.
  • Digital home scale. Provided to members with heart failure.
  • Free phone program through SafeLink. Available to members who qualify.
Delaware Healthy Children Program (DHCP)
  • Routine doctor office visits, checkups, and sick visits.
  • Well-baby, well-child visits, and immunizations.
  • Tests and studies, laboratory, and X-rays.
  • Radiology services, including invasive and non-invasive imaging when medically necessary.
  • OB/GYN exams and annual Pap tests.
  • Prenatal and postpartum care, including delivery, birthing center, newborn care, and early discharge home visits for new mothers.
  • Family planning.
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, including periodic preventive health screens and other necessary diagnostic and treatment services for members ages under 21.
  • Pharmacy.
  • Case management and care coordination services.
  • Routine eye exams — covered annually and more often if medically necessary.
  • Eye glasses or contact lenses — eye glasses or contact lenses every 12 months.
  • Behavioral health and substance use disorder services.
    • Children (ages 17 and under): 30 outpatient visits per year; visits above 30 are provided through DSCYF.
  • Visits to specialists.
  • Hospital — inpatient or outpatient care.
  • Federally qualified health center services.
  • Ambulatory service centers.
  • Organ transplants when medically necessary.
  • Surgery: inpatient or outpatient.
  • Ambulance when medically necessary.
  • Private-duty nursing, home health care when medically necessary.
  • Durable medical equipment when medically necessary.
  • Physical, speech, and occupational therapy when medically necessary.
  • Skilled nursing facility when medically necessary, up to 30 days per year.
  • New member comprehensive risk assessment program.
Diamond State Health Plan-Plus (DSHP-Plus)
  • Routine doctor office visits, checkups, and sick visits.
  • Tests and studies, laboratory work, and X-rays.
  • Pharmacy.
  • Case management and care coordination services.
  • Visits to specialists.
  • Hospital inpatient and/or outpatient care.
  • Ambulatory surgery centers.
  • Surgery inpatient and/or outpatient.
  • Behavioral health and substance use disorder services.
  • Hospice services.
  • Ambulance when medically necessary.
  • Private-duty nursing when medically necessary.
  • Durable medical equipment when medically necessary.
  • Physical, speech, and occupational therapy when medically necessary.
  • Skilled nursing facility up to 30 days per year, when medically necessary.
  • Vision services: routine eye exams — covered every 12 months.
  • Vision services: eye glasses or contact lenses — covered every 12 months.
  • Dental services for adults (ages 21 and over): routine exams and cleanings — covered once every 12 months.
  • Dental services for adults (ages 21 and over): X-rays.
    • Bite-wing: one set every 12 months; full mouth: one set every 36 months.

Managed care organization (MC) provided extra services

  • Access to our Community Wellness Center.
  • Free weight management classes in our Community Wellness Center through community collaboration.
  • Gift cards incentivize members to perform healthy behaviors resulting in improved health outcomes.
  • Disease management programs with incentives for healthy outcomes.
  • Digital home scale provided to members with heart failure.
  • Free phone program through SafeLink available for members who qualify.
Diamond State Health Plan-Plus long-term services and supports (DSHP-Plus LTSS)
  • Routine doctor office visits, checkups, and sick visits.
  • Tests and studies, laboratory work, and X-rays.
  • Pharmacy.
  • Case management and care coordination services.
  • Visits to specialists.
  • Hospital — inpatient and/or outpatient care.
  • Ambulatory surgery centers.
  • Surgery — inpatient and/or outpatient.
  • Behavioral health and substance use disorder services.
  • Hospice services.
  • Ambulance when medically necessary.
  • Private-duty nursing when medically necessary.
  • Durable medical equipment when medically necessary.
  • Physical, speech, and occupational therapy when medically necessary.
  • Skilled nursing facility when medically necessary.
  • Vision services: routine eye exams — covered every 12 months.
  • Vision services: eye glasses or contact lenses — covered every 12 months.
  • Dental services for adults (ages 21 and over): routine exams and cleanings — covered once every 12 months.
  • Dental services for adults (ages 21 and over): X-rays.
    • Bite-wing: one set every 12 months; full mouth: one set every 36 months.

Managed care organization (MCO) provided extra services

  • Access to our Community Wellness Center.
  • Disease management programs with incentives for healthy outcomes.
  • Digital home scale provided to members with heart failure.
  • Free phone program through SafeLink available for members who qualify.