New to helping someone in Delaware?
Start with three things from the patient or family:
- Insurance card — shows the carrier and plan name
- Denial letter or explanation of benefits (EOB) — lists appeal rights and deadlines
- Summary of Benefits and Coverage (SBC) — if available
Your first job is to learn what kind of plan this is (Marketplace, job-based, Medicaid, Medicare) and what deadline the letter gives you. Delaware plans use terms like adverse determination, internal review process (IRP), and Independent Health Care Appeals Program (IHCAP) external review.
For steps that work in every state, use these general guides first, then return here for Delaware rules:
What is different in Delaware?
- Choose Health Delaware + HealthCare.gov: Delaware is a partnership exchange—learn about plans at choosehealthde.com, enroll on HealthCare.gov (three Marketplace carriers for 2026: Highmark BCBS, AmeriHealth Caritas, Ambetter/Celtic).
- Delaware Department of Insurance: Regulates most fully insured commercial health coverage and runs IHCAP external review (18 Del. C. § 6416).
- Prior authorization reform (2025): Non-urgent PA often within 5 business days (3 if electronic); urgent within 24–48 hours; missing deadlines can mean services are deemed preauthorized (18 Del. C. Title 18, Ch. 33, Subch. II).
- State external review: After internal review, request external appeal within 4 months of a final coverage decision; IURO decision often within 45 days (72 hours expedited).
- Medicaid (Diamond State Health Plan): MCO internal appeal, then DSS state fair hearing—often 120 days from the MCO appeal resolution notice.
Who is in charge of your plan?
- Delaware Department of Insurance: Fully insured health plans, IHCAP external review, consumer complaints — insurance.delaware.gov. Consumer line: 800-282-8611 (in DE) or 302-674-7310.
- U.S. Department of Labor: Many self-funded employer plans.
- DHSS / Division of Medicaid & Medical Assistance: Medicaid fair hearings — dhss.delaware.gov — fair hearings.
- CMS: Medicare and Medicare Advantage.
For complaints after appeals, see Regulator complaints.