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

Last reviewed: 2026-08-15

In Delaware, an Assisted Living Facility (ALF) provides a congregate residential setting that combines housing, personalized supportive services, supervision, and personal care for adults who require assistance with activities of daily living (ADLs) but do not need 24-hour skilled nursing care. Under Delaware Medicaid, this service is authorized through the Diamond State Health Plan-Plus (DSHP-Plus) Section 1115 managed long-term services and supports (MLTSS) waiver.

The single biggest structural barrier to entry for a prospective Medicaid ALF provider in Delaware is securing a network contract with the state’s Managed Care Organizations (MCOs). While Delaware does not restrict ALF development through a Certificate of Need process, Medicaid operates under a mandatory managed care model. Simply obtaining a state license and enrolling in the Medicaid portal does not guarantee the ability to bill; facilities must successfully navigate the closed-network credentialing and contracting processes of the designated DSHP-Plus MCOs.

1. Service Definition and Scope

Assisted Living in Delaware is strictly defined by state licensure regulations to serve medically stable individuals who need help with routine daily tasks but do not require round-the-clock skilled nursing supervision. Under the DSHP-Plus waiver's Long Term Care Community Services (LTCCS) program, Medicaid covers the cost of personal care, medication management, and supervision provided within the facility. However, Medicaid strictly prohibits paying for the resident’s room and board, which remains the financial responsibility of the resident.

• Service Scope: Personalized assistance with ADLs (bathing, dressing, transferring), instrumental ADLs, and medication administration.
• Excluded Services: 24-hour continuous skilled nursing care, and room and board charges (strictly private pay).
• Resident Profile: Medically stable elderly individuals or adults with physical disabilities who require supervision to safely reside in the community.
• Regulatory Citation: Governed by 16 Del. Admin. Code § 3225 (Assisted Living Facilities).
• Memory Care Extension: Facilities providing specialized dementia care must adhere to additional environmental and training standards under § 3225-7.0.

2. Regulatory and Oversight Agencies

Delaware consolidates most regulatory and Medicaid functions under a single umbrella department, though facility licensing and Medicaid enrollment are handled by distinct divisions. Providers must interact with state licensure boards, centralized background check hubs, and private managed care plans.

• Delaware Department of Health and Social Services (DHSS): The primary umbrella agency overseeing health regulations and Medicaid.
• Division of Health Care Quality (DHCQ): The DHSS division responsible for inspecting, licensing, and surveying ALFs in Delaware.
• Division of Medicaid and Medical Assistance (DMMA): The DHSS division that manages the DSHP-Plus waiver and Medicaid program integrity.
• Gainwell Technologies: The fiscal agent that operates the Delaware Medical Assistance Portal (DMAP) for centralized provider screening and enrollment.
• DSHP-Plus MCOs: Highmark Health Options, AmeriHealth Caritas Delaware, and Delaware First Health (Centene)—the private entities that authorize services and pay claims.
• Board of Long-Term Care Resident Protection: State entity overseeing the certification and training requirements of facility administrators.

3. Gatekeeping Prerequisites: Who Can Even Apply

This is the most critical section for market entry. Prospective providers must understand exactly which structural constraints exist in Delaware and which do not. Unlike hospitals or skilled nursing facilities, ALFs bypass certain state planning boards, but they face absolute barriers regarding Medicaid managed care access.

• Certificate of Public Review (CPR) Exemption: Delaware’s Health Resources Board requires a CPR (Certificate of Need) for nursing homes and hospitals under 16 Del. C. § 9301. Assisted Living Facilities are categorically exempt and do not require a CPR to build or expand.
• Managed Care Contracting: Delaware Medicaid operates via the DSHP-Plus waiver. A facility cannot bill Medicaid unless it successfully negotiates a contract with AmeriHealth Caritas, Highmark Health Options, or Delaware First Health. MCOs may deny contracts based on network adequacy (closed networks).
• Sequential Precondition: DMMA requires providers to hold a fully approved DHCQ ALF license before an application can be accepted into the DMAP system.
• Local Zoning and Fire Approvals: DHCQ will not accept a licensing application without prior approved architectural plans and clearance from the State or local Fire Marshal.

4. Licensure and Certification Requirements

DHCQ issues assisted living licenses based on strict physical plant, policy, and life-safety standards. Facilities must pass comprehensive pre-licensure surveys that evaluate the building's readiness and the provider's operational policies.

• Regulatory Authority: Licenses are issued under 16 Del. Admin. Code § 3225-4.0 (Licensing Requirements and Procedures).
• License Scope: The Secretary of DHSS issues either a provisional or annual license for a specifically approved number of beds.
• Separate Locations: Distinct licenses are required for agencies maintained in separate geographical locations, even if operated by the same management entity.
• Change of Ownership (CHOW): Licenses are non-transferable. Under any condition of assignment or transfer of ownership, a new DHCQ license application must be initiated.
• Waiver for Retained Residents: Under § 3225-6.0, ALFs must apply for a resident-specific waiver from DHCQ to retain a resident whose condition deteriorates to require skilled nursing care.
• Facility Closure Rules: Facilities must notify DHCQ and all residents at least 90 days prior to any planned closure, arranging relocation based on resident preference.

5. Medicaid Provider Enrollment

Even though providers will bill the MCOs, they must first pass federal Affordable Care Act (ACA) screening by the state. This is done via DMAP, Delaware’s centralized provider portal managed by Gainwell Technologies.

• Portal System: Delaware Medical Assistance Portal (DMAP) operated by Gainwell Technologies.
• Enrollment Category: ALFs must submit a Managed Care Organization-Only Provider (MCOP) Enrollment Application.
• Application Tracking Number (ATN): Issued when an application is saved in DMAP, required to resume and track the submission.
• Disclosure of Ownership: DMMA mandates a complete Disclosure Statement detailing any individual or parent company holding a 5% or greater controlling interest or serving as a managing employee.
• Required Attachments: Current DHCQ license, W-9, and a letter of intent to contract with a DSHP-Plus MCO.
• Revalidation Cycle: Providers are required to revalidate their DMAP enrollment every five years. Gainwell mails a notification letter 60 days prior to the deadline.

6. Staffing, Training and Background Checks

Delaware imposes stringent background check requirements integrated into a centralized state system. Staffing minimums are flexible based on resident acuity, but specific leadership and nursing qualifications are strictly defined.

• DHSS Background Check Center (BCC): Facilities must process all prospective employees through the BCC, which cross-references the Delaware Bureau of Identification, FBI federal history, and the Delaware Adult Abuse Registry.
• Mandatory Drug Testing: Facilities must comply with Delaware's mandatory drug testing law for all direct-care employees prior to independent work.
• Administrator Qualifications: Must oversee daily operations and either possess a post-secondary degree with administrative experience in residential care or hold a current Delaware Registered Nurse (RN) license.
• Director of Nursing / RN Oversight: The facility must employ or contract with a Registered Nurse to perform resident assessments and delegate medication administration.
• Dementia Training: If the facility provides care to residents with Alzheimer’s or dementia, state law dictates mandatory annual dementia-specific continuing education for staff.
• Orientation Requirements: Temporary and regular resident assistants must complete a formalized orientation program before providing direct care.

7. Documentation, Policies and Records

DHCQ and DMMA require exhaustive documentation ranging from the initial resident admission agreements to daily medication logs. Records must be immediately available during unannounced state surveys or MCO audits.

• Resident Agreements: Prior to admission, the facility must execute a contract detailing all financial charges, ancillary fees, rate-change policies, and non-financial resident rights.
• Service Agreements: Must be developed based on the RN's resident assessment, specifically delineating the personal care, nursing, and supervision services the facility will provide.
• Medication Policies: Facilities must maintain written protocols differentiating assistance with self-administration versus actual medication administration by authorized licensed personnel (per 24 Del. C. § 1902).
• Infection Control: Must include documented tuberculin (TB) testing for all new employees and newly admitted residents, mirroring CDC guidelines.
• Wandering Protocols: Facilities must develop and adhere to specific written policies to prevent residents with memory impairment from wandering away from safe areas.
• Record Retention: Records must be maintained and open to inspection and copying by authorized DHSS representatives under 16 Del. C. Ch. 11, Subchapter I.

8. Billing, Rates and Claims

Medicaid ALFs in Delaware do not bill Gainwell/DMAP directly for daily care; all HCBS claims flow through the managed care network.

• Payer Authority: Claims are submitted to the specific DSHP-Plus MCO (Highmark, AmeriHealth, or Delaware First Health) with which the resident is enrolled.
• Room and Board: Must be segregated on all ledgers. Medicaid strictly prohibits billing the MCO for housing or food; these costs are paid out of the resident’s personal income (e.g., SSI).
• Service Authorization: The MCO care coordinator must formally authorize the LTCCS package before the facility can bill for Medicaid services.
• Patient Pay Liability: Providers are responsible for collecting the resident's "Patient Pay Amount" (their monthly income minus a state-allowed personal needs allowance) to cover room and board.
• Billing Systems: Claims must be formatted to the specifications of the contracted MCO's clearinghouse, typically utilizing institutional/per-diem HCBS billing codes.

9. Approval Sequence and Timeline

Becoming an active Medicaid ALF provider in Delaware is a linear process that spans local, state, and private corporate reviews.

• Step 1: Local Approvals: Secure local zoning, building permits, and fire marshal occupancy clearance for the physical facility.
• Step 2: DHCQ Licensure: Submit the ALF application and fees to the Division of Health Care Quality and pass the initial pre-licensure inspection.
• Step 3: State License Issuance: Receive the official provisional or annual ALF license specifying the approved bed count.
• Step 4: Gainwell DMAP Enrollment: Submit the MCOP application via the Delaware Medical Assistance Portal, complete ownership disclosures, and clear ACA risk screening.
• Step 5: MCO Credentialing: Apply to the provider networks of Highmark Health Options, AmeriHealth Caritas, and Delaware First Health.
• Step 6: Contracting and Authorization: Execute MCO contracts, receive care coordinator authorizations for eligible members, and commence billing.

10. Common Denials and Survey Findings

Failure to meticulously follow Delaware’s strict administrative and clinical protocols results in enrollment rejections from Gainwell or citations/license actions from DHCQ.

• DMAP Application Rejection: Utilizing N/A or placeholder data on the Gainwell Disclosure Statement, or failing to list parent companies with 5% or more controlling interest.
• MCO Credentialing Denial: Attempting to join an MCO network before obtaining a finalized DMAP ID, or applying when an MCO has closed its network to new ALFs.
• DHCQ Survey Finding: Allowing uncertified or unauthorized staff to administer medications, violating 24 Del. C. § 1902.
• BCC Compliance Failure: Allowing new employees to provide direct care before the DHSS Background Check Center confirms fingerprint and abuse registry clearance.
• Improper Resident Retention: Retaining residents who require continuous skilled nursing care without formally securing a resident-specific waiver (§ 3225-6.0) from DHCQ.

11. Key Contacts and Resources

Familiarity with Delaware's specific digital portals and divisions is required to initiate and manage enrollment.

• Division of Health Care Quality (DHCQ): Oversees ALF licensure and facility inspections. Phone: 302-255-9040.
• Gainwell Technologies / DMMA Provider Services: Manages DMAP portal technical support and FFS/MCOP enrollment. Phone: 1-800-999-3371 (Option 0, then 4).
• Delaware Medical Assistance Portal (DMAP): The official Gainwell hub for applications: medicaid.dhss.delaware.gov.
• DHSS Background Check Center (BCC): The mandatory state portal for processing employee criminal background and abuse registry checks.
• Highmark Health Options: MCO Provider Services line for DSHP-Plus contracting. Phone: 1-844-325-6251.
• AmeriHealth Caritas Delaware: MCO Provider Services and credentialing for DSHP-Plus. Phone: 1-855-707-5818.
• Delaware First Health (Centene): MCO Provider Services line for DSHP-Plus credentialing and authorizations. Phone: 1-877-236-1341.

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