Delaware - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The Delaware Division of Health Care Quality (DHCQ) licenses Assisted Living Facilities under 16 DE Admin. Code 3225, while Medicaid reimbursement flows exclusively through the Diamond State Health Plan Plus (DSHP-Plus) 1115 demonstration waiver. Facilities must secure a state license before applying for Medicaid enrollment through the Delaware Medical Assistance Portal (DMAP) and subsequently contracting with the state's managed care organizations.

Approval requires passing a comprehensive physical plant inspection, submitting a detailed 4-week menu cycle approved by a dietitian, and demonstrating compliance with life-safety standards. Medicaid participation mandates an MCO-Only Provider Enrollment Application to conduct federally mandated screening before executing contracts with Highmark Health Options or AmeriHealth Caritas Delaware.

1. Service Definition and Scope

In Delaware, Assisted Living is defined under 16 Del.C. Ch. 11 as a special combination of housing, supportive services, supervision, personalized assistance, and health care designed to respond to the individual needs of those requiring help with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs). The service is intended for medically stable persons who do not require continuous skilled nursing services.

The state strictly differentiates assisted living from skilled nursing care. Facilities must operate within their licensed scope and cannot retain residents whose medical needs exceed the facility's capacity unless specific temporary waivers are granted by the state.

• Regulatory Definition: 16 DE Admin. Code 3225 defines it as housing and care for medically stable individuals needing ADL/IADL support.
• Excluded Populations: Facilities cannot admit individuals requiring continuous skilled nursing care, ventilators, or those with stage III or IV pressure ulcers unless a specific 90-day waiver is granted.
• Dementia Care: Facilities providing direct healthcare to residents with Alzheimer's or dementia must provide annual dementia-specific training to staff.
• Hospice Exception: Residents requiring excluded skilled care may remain in the ALF if under the care of a licensed Hospice program that provides written assurance of safety.

2. Regulatory and Oversight Agencies

The primary regulatory body for Assisted Living Facilities in Delaware is the Division of Health Care Quality (DHCQ) within the Department of Health and Social Services (DHSS). DHCQ handles initial licensure, physical plant inspections, and ongoing compliance surveys.

Medicaid enrollment is managed by the Division of Medicaid and Medical Assistance (DMMA) via the Delaware Medical Assistance Portal (DMAP), while actual service authorization and payment are administered by the DSHP-Plus Managed Care Organizations (MCOs).

• Licensing Agency: Division of Health Care Quality (DHCQ) https://dhss.delaware.gov/dhss/dhcq/
• Medicaid Authority: Division of Medicaid and Medical Assistance (DMMA) https://dhss.delaware.gov/dhss/dmma/
• Enrollment Portal: Delaware Medical Assistance Portal (DMAP) https://medicaid.dhss.delaware.gov/
• Managed Care Plan: Highmark Health Options https://www.highmarkhealthoptions.com/
• Managed Care Plan: AmeriHealth Caritas Delaware https://www.amerihealthcaritasde.com/

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware does not require a Certificate of Public Review (CPR) or Certificate of Need for Assisted Living Facilities, unlike skilled nursing facilities. The primary structural prerequisite is obtaining the physical facility and passing local zoning and fire marshal approvals before DHCQ will process a licensure application.

For Medicaid reimbursement, Delaware operates a closed-network managed care system under DSHP-Plus. Providers must successfully contract with at least one of the state's MCOs after completing the DMAP MCO-Only Provider Enrollment Application.

• Certificate of Need: None exists for Assisted Living Facilities in Delaware; applicants may proceed directly to licensure.
• Facility Control: Applicants must have physical control of the proposed site and local zoning approval before DHCQ physical plant review.
• Fire Marshal Approval: Written approval from the Delaware State Fire Marshal is required prior to DHCQ licensure issuance.
• MCO Contracting: Medicaid participation requires executing a network contract with Highmark Health Options or AmeriHealth Caritas Delaware; MCOs may restrict networks based on regional capacity.

4. Licensure and Certification Requirements

Licensure is governed by 16 DE Admin. Code 3225. Applicants must submit a comprehensive application to DHCQ, including architectural plans, policies and procedures, and proof of financial viability.

The state issues a provisional license for the first 90 days or up to one year, followed by an annual license upon demonstrating substantial compliance during the initial survey.

• Application Submission: Requires a written statement of intent to DHCQ describing services to request the official application form.
• Menu Cycle: Applicants must submit a 4-week menu cycle documented and approved by a registered dietitian or nutritionist.
• Physical Plant Review: Architectural plans must be submitted to and approved by DHCQ to ensure compliance with life-safety and accessibility standards.
• Provisional License: DHCQ issues an initial provisional license, requiring a follow-up survey to achieve full annual licensure.

5. Medicaid Provider Enrollment

Because Delaware's Medicaid LTSS is entirely managed care (DSHP-Plus), ALFs do not bill fee-for-service Medicaid. Instead, they must complete the MCO-Only Provider Enrollment Application through the Delaware Medical Assistance Portal (DMAP).

This streamlined application fulfills the federally mandated 42 CFR Part 455 screening requirements. Once approved in DMAP, the facility receives a Provider ID used to finalize credentialing with the MCOs.

• System: Delaware Medical Assistance Portal (DMAP) Provider Enrollment system.
• Application Type: MCO-Only Provider Enrollment Application for DSHP-Plus participation.
• Screening Level: ALFs are subject to federal risk-based screening, which may include site visits and fingerprint-based background checks for owners with 5% or more interest.
• NPI Requirement: Facilities must obtain and link a Type 2 National Provider Identifier (NPI) to their DMAP enrollment.

6. Staffing, Training and Background Checks

16 DE Admin. Code 3225 mandates specific leadership and direct care staffing. Facilities must have a designated Director responsible for daily operations and a Director of Nursing (DON) if providing nursing services.

All staff must undergo rigorous background screening through the Delaware Division of State Police and the state's Adult Abuse Registry before providing direct care.

• Director Qualifications: Must have a baccalaureate degree in a health or human services field, or equivalent experience, and be designated in writing.
• Nursing Oversight: Administration of medication and nursing tasks must be supervised by a Delaware-licensed Registered Nurse (RN).
• Background Checks: Mandatory fingerprint-based state and federal criminal history checks via the Delaware State Bureau of Identification (SBI).
• Registry Checks: Mandatory screening against the Delaware Adult Abuse Registry and the CNA Registry prior to hire.
• Dementia Training: Annual dementia-specific training is required for all healthcare providers in facilities serving Alzheimer's/dementia residents.

7. Documentation, Policies and Records

DHCQ requires ALFs to maintain comprehensive administrative and resident records. Policies must align with 16 DE Admin. Code 3225 and cannot conflict with state regulations.

Resident records must include pre-admission assessments, individualized service agreements, and medication administration records (MARs).

• Service Agreements: Must be developed for each resident detailing how staff will provide care and assistance with ADLs/IADLs.
• Incident Reporting: Reports of incidents, accidents, and medical emergencies must be kept on file at the agency for a minimum of six years.
• Closure Policy: Facilities must notify DHCQ and residents at least 90 days before any planned closure.
• Waiver Documentation: Resident-specific waiver requests for temporary skilled care needs must include physician documentation stating the condition will improve within 90 days.

8. Billing, Rates and Claims

Medicaid reimbursement for Assisted Living in Delaware is negotiated and paid by the DSHP-Plus MCOs, not through a centralized fee-for-service schedule. Facilities submit claims directly to Highmark Health Options or AmeriHealth Caritas Delaware.

Medicaid covers the service component of assisted living, while the resident is responsible for room and board costs, typically paid from their SSI or other income.

• Payer Source: Claims are submitted to the contracted MCO (Highmark or AmeriHealth) via their respective clearinghouses.
• Room and Board: Medicaid does not pay for room and board; facilities must collect this directly from the resident's income up to the state-allowed maximum.
• Rate Setting: Reimbursement rates for the care component are established through contract negotiations between the ALF and the MCOs.
• Authorization: All Medicaid ALF services require prior authorization from the MCO care coordinator before billing.

9. Approval Sequence and Timeline

The process begins with securing a facility and obtaining local approvals, followed by the DHCQ licensure application. Physical plant review and initial surveys are the longest phases of state approval.

After licensure, the DMAP MCO-Only enrollment takes 30-60 days, followed by MCO credentialing and contracting, which can add several months.

• Step 1: Local zoning and Delaware State Fire Marshal approval for the physical plant.
• Step 2: Submission of the DHCQ licensure application, including the 4-week menu cycle and architectural plans.
• Step 3: DHCQ physical plant inspection and issuance of a provisional license (typically 90-120 days from complete application).
• Step 4: Submission of the MCO-Only Provider Enrollment Application via DMAP (30-60 days for state screening).
• Step 5: MCO credentialing and contract execution (60-90 days post-DMAP approval).

10. Common Denials and Survey Findings

DHCQ frequently cites facilities for life-safety code violations during initial physical plant inspections, which halts the licensure process. Operational surveys often identify issues with medication administration and incomplete resident service agreements.

Medicaid enrollment denials typically stem from failing to complete the Medicare enrollment prerequisite (if applicable) or failing the fingerprint-based background check for high-risk owners.

• Physical Plant Deficiencies: Failure to meet Delaware Food Code standards in the kitchen or life-safety code violations.
• Menu Cycle Rejections: Submitting a menu cycle that lacks documented approval from a registered dietitian or nutritionist.
• Scope of Care Violations: Admitting or retaining residents who require continuous skilled nursing without an approved 90-day DHCQ waiver.
• Background Check Lapses: Allowing staff to provide direct care before the SBI fingerprint background check and Adult Abuse Registry results are fully returned.

11. Key Contacts and Resources

Providers must interact with multiple state portals and divisions. The primary regulatory text is 16 DE Admin. Code 3225, and the primary enrollment portal is DMAP.

MCO provider relations departments are the main contacts for billing and contracting questions once licensed.

• DHCQ Assisted Living Regulations: 16 DE Admin. Code 3225 https://regulations.delaware.gov/AdminCode/title16/3225
• Delaware Medical Assistance Portal (DMAP): Provider Enrollment https://medicaid.dhss.delaware.gov/
• Division of Health Care Quality (DHCQ): Licensing Authority https://dhss.delaware.gov/dhss/dhcq/
• Highmark Health Options: DSHP-Plus MCO https://www.highmarkhealthoptions.com/
• AmeriHealth Caritas Delaware: DSHP-Plus MCO https://www.amerihealthcaritasde.com/

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