Delaware - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The Delaware Division of Developmental Disabilities Services (DDDS) and the Division of Medicaid and Medical Assistance (DMMA) authorize Case Management under specific waiver authorities, including the Pathways to Employment 1915(i) program where it is designated as Employment Navigation (Case Management), and the Long Term Care Community Services (LTCCS) program. Prospective providers must secure approval from the DDDS Provider Authorization Committee (PAC) for developmental disability waivers or secure a network contract with a Delaware Managed Care Organization (MCO) for LTCCS before Medicaid enrollment is permitted.

Delaware does not issue a standalone state facility license for case management agencies. Instead, approval is structurally gated by the state's waiver operating agencies and managed care delivery system, requiring applicants to complete a multi-phase authorization process through DDDS or enroll as an MCO-Only Provider (MCOP) through the state's Gainwell-operated Medicaid portal.

1. Service Definition and Scope

In Delaware, Case Management is defined distinctly depending on the waiver program. Under the Pathways to Employment 1915(i) State Plan Amendment, it is titled Employment Navigation (Case Management) and focuses on assisting participants in gaining access to needed employment, coordinating between employment supports, State plan services, and medical or social services.

Under the Long Term Care Community Services (LTCCS) program, case management involves developing the person-centered service plan, offering informed choices regarding services and settings, and monitoring the participant's health and safety in the most integrated community-based setting.

• Service Title (1915i): Employment Navigation (Case Management)
• Service Title (LTCCS): Case Management
• Core Function: Assessment and person-centered service plan development
• Coordination Scope: Medical, social, educational, and employment supports
• Setting Requirement: Must ensure maximum self-sufficiency and integration
• Service Limits: LTCCS case management prior authorizes certain services, such as exceptions to the 14-day per year limit for specific supports

2. Regulatory and Oversight Agencies

The Division of Medicaid and Medical Assistance (DMMA) serves as the Single State Medicaid Agency and oversees the LTCCS program and MCO contracts. The Division of Developmental Disabilities Services (DDDS) operates the Lifespan 1915(c) Waiver and the Pathways to Employment 1915(i) program.

Provider enrollment and the Medicaid Management Information System (MMIS) are managed by Gainwell Technologies through the Delaware Medical Assistance Portal for Providers.

• Single State Agency: Division of Medicaid and Medical Assistance (DMMA) (https://dhss.delaware.gov/dmma/)
• Operating Agency: Division of Developmental Disabilities Services (DDDS) (https://dhss.delaware.gov/ddds/)
• Enrollment Portal: Delaware Medical Assistance Portal for Providers (https://medicaid.dhss.delaware.gov/provider)
• Managed Care Oversight: DMMA Managed Care Operations (https://dhss.delaware.gov/dmma/)
• Authorization Body: DDDS Provider Authorization Committee (PAC) (https://dhss.delaware.gov/ddds/homepage/providers)

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware restricts direct Medicaid enrollment for case management based on the delivery system. For LTCCS, services are delivered exclusively through Managed Care Organizations (MCOs); an applicant must secure a network contract with a Delaware MCO and enroll as an MCO-Only Provider (MCOP).

For DDDS-operated waivers, applicants must pass the Provider Authorization Committee (PAC) review. DDDS accepts applications on an open and continuous basis, but requires completion of a mandatory Information Gathering phase (Phase 1A and 1B) before an application is accepted.

• LTCCS Prerequisite: Executed contract with a Delaware Managed Care Organization
• DDDS Prerequisite: Completion of 10 mandatory Information Gathering Sessions
• DDDS Submission Gate: Approval by the DDDS Provider Authorization Committee (PAC)
• Enrollment Designation: MCO-Only Provider (MCOP) screening for managed care networks
• Provisional Status: DDDS may issue Provisional Authorization based on state need

4. Licensure and Certification Requirements

Delaware does not require a specific Department of Health facility license for case management agencies. Instead, providers must meet the DDDS Provider Standards for Home and Community-Based Services or the credentialing standards of the contracting MCO.

Agencies must also demonstrate compliance with the CMS HCBS Settings Final Rule, ensuring that case management practices do not isolate participants and that they offer informed choices among generic and waiver settings.

• State Licensure: No distinct facility license required for case management
• DDDS Standards: Must comply with DDDS Provider Standards for HCBS
• Settings Compliance: Must pass the state's HCBS Settings Required Reporting self-assessment
• MCO Credentialing: Must meet individual MCO credentialing requirements for LTCCS
• Compliance Plan: Must submit an Essential Elements to a Medicaid Compliance Plan document

5. Medicaid Provider Enrollment

Once authorized by DDDS or contracted with an MCO, providers must enroll through the Delaware Medical Assistance Portal for Providers operated by Gainwell. The state utilizes a web-based system for all screening and enrollment activities.

Providers serving only MCO members must complete the MCO-Only Provider (MCOP) Enrollment Application to comply with 21st Century Cures Act screening mandates.

• System Name: Delaware Medical Assistance Portal for Providers
• Vendor: Gainwell Technologies
• Application Type (Managed Care): MCO-Only Provider (MCOP) Enrollment Application
• Application Type (Fee-for-Service/DDDS): Standard HCBS Provider Enrollment
• Required Identifier: National Provider Identifier (NPI)
• Screening Standard: Subject to 42 CFR Part 455 subparts B and E risk-based screening

6. Staffing, Training and Background Checks

Agencies must ensure that all case managers and employment navigators meet the qualifications outlined in the approved waiver appendices and DDDS Provider Standards. This includes specific educational backgrounds and experience in human services.

Providers must utilize the DDDS Electronic Training System and ensure staff complete required modules on person-centered planning, HCBS settings rules, and abuse/neglect reporting.

• Background Checks: State and federal criminal background checks required for all patient-facing staff
• Training System: Mandatory use of the DDDS Electronic Training System
• Required Training: Charting the Lifecourse Nexus and Community Settings Rule
• Staff Qualifications: Defined in the 1915(i) Pathways and 1915(c) Lifespan waiver appendices
• Registry Checks: Adult Abuse Registry and Child Abuse Registry clearance required

7. Documentation, Policies and Records

Case management providers must maintain comprehensive records in the state's designated Electronic Client Data Management System (e.g., Therap for DDDS). Documentation must clearly link assessed needs to the person-centered service plan.

Under LTCCS policy, providers must ensure access to participant case records by authorized representatives of DHSS, the MCO, and CMS at all times.

• Electronic Record: Mandatory use of Delaware Therap for DDDS waivers
• Core Document: Person-Centered Service Plan
• Policy Requirement: Essential Elements to a Medicaid Compliance Plan
• Audit Access: Must grant immediate record access to DHSS, MCOs, and CMS
• Conflict of Interest: Case managers cannot provide direct care services to the same individual

8. Billing, Rates and Claims

Billing procedures depend on the authorizing program. For LTCCS, claims are submitted directly to the participant's MCO according to the MCO's specific fee schedule and clearinghouse requirements.

For DDDS fee-for-service waivers, claims are processed through the Gainwell MMIS portal. Providers can upload 837 transactions and check claim status directly in the provider portal.

• FFS Portal: Delaware Medical Assistance Portal for Providers (Gainwell)
• MCO Billing: Submitted to the contracted Managed Care Organization
• Transaction Format: 837 electronic claims accepted via portal
• Rate Setting: Established by DMMA and DDDS; published in provider fee schedules
• Prior Authorization: Case management may require prior authorization depending on the MCO

9. Approval Sequence and Timeline

The DDDS approval process follows four distinct phases: Phase 1 (Information Gathering and Sessions), Phase 2 (Application Submission to PAC), Phase 3 (Medicaid Enrollment), and Phase 4 (Contracting and Final Approval).

Applications to the PAC are reviewed quarterly. Providers should expect the entire process, from initial information gathering to final MCO contracting or DDDS authorization, to take several months.

• Phase 1: Review Provider Application Manual and attend 10 recorded sessions
• Phase 2: Submit application to [email protected]
• Phase 3: Enroll via Gainwell Delaware Medical Assistance Portal
• Phase 4: Final contracting and DDDS New Provider Orientation
• Review Frequency: PAC reviews proposals once per quarter

10. Common Denials and Survey Findings

Applications to the DDDS PAC are frequently rejected if they are incomplete or if the provider fails to submit the Requirement Summary Checklist. DDDS explicitly states that incomplete applications will not be accepted.

During ongoing monitoring, providers often face corrective action for failing to properly document person-centered planning choices or for non-compliance with the HCBS Settings Final Rule regarding participant integration.

• Application Denial: Incomplete submissions to the PAC
• Survey Finding: Failure to document informed choice of settings
• Survey Finding: Inadequate person-centered service plan updates
• Enrollment Denial: Failure to complete MCOP screening for managed care
• Audit Finding: Lack of required staff training in the Electronic Training System

11. Key Contacts and Resources

Prospective providers should utilize the DDDS Provider Application Manual and the DMMA provider portal for all official instructions and forms.

The DDDS Provider Authorization Committee handles all initial inquiries and application submissions for developmental disability waivers.

• DDDS Provider Authorization Committee: [email protected]
• Delaware Medical Assistance Portal: https://medicaid.dhss.delaware.gov/provider
• DDDS Provider Page: https://dhss.delaware.gov/ddds/homepage/providers
• DMMA Homepage: https://dhss.delaware.gov/dmma/
• Gainwell Provider Call Center: 1-800-999-3371

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