Delaware - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Delaware, Home Health Services provide intermittent skilled nursing, physical therapy, occupational therapy, and speech therapy to individuals in their residences under a physician-ordered plan of care. These services are designed for patients who require an institutional level of care but can be safely maintained in a home or community setting, and they are heavily regulated to ensure clinical safety and quality.

The single biggest structural barrier to entry for this service in Delaware is the strict sequencing prerequisite for high-risk providers. Before an agency can even submit an application to the Delaware Medical Assistance Program (DMAP) portal, it must first obtain a Skilled Home Health Agency license from the Division of Health Care Quality (DHCQ) and secure Medicare PECOS approval. Attempting to enroll in Medicaid before these two federal and state approvals are finalized will result in an automatic rejection.

1. Service Definition and Scope

Delaware defines Skilled Home Health Agencies under 16 DE Admin. Code § 3350. This licensure category is distinct from Personal Assistance Services Agencies (PASAs), which provide non-medical care. Skilled home health encompasses intermittent nursing care and therapeutic services delivered by licensed professionals.

Services must be medically necessary, ordered by a physician, and delivered according to a formal plan of care. Agencies must be capable of providing at least one skilled service directly, while other services may be provided under contract.

• Regulatory Citation: 16 DE Admin. Code § 3350 - Skilled Home Health Agencies (Licensure).
• Core Services: Intermittent skilled nursing, physical therapy, occupational therapy, speech-language pathology, and medical social services.
• Medical Necessity: All care must be driven by a physician-ordered plan of care that is reviewed and updated at least every 60 days.
• Excluded Services: Standalone non-medical personal care, which requires a separate PASA license under 16 DE Admin. Code § 3345.
• Setting: Services must be delivered in the patient's residence or a community-based setting, not in a hospital or nursing facility.

2. Regulatory and Oversight Agencies

The primary regulatory body for home health licensure in Delaware is the Department of Health and Social Services (DHSS), specifically operating through the Division of Health Care Quality (DHCQ). DHCQ handles initial licensing, provisional surveys, and ongoing compliance.

Medicaid enrollment and claims are managed by the Delaware Medical Assistance Program (DMAP), while federal oversight for Medicare certification is handled by the Centers for Medicare & Medicaid Services (CMS).

• Licensing Department: Delaware Department of Health and Social Services (DHSS) (https://dhss.delaware.gov/)
• Licensing Division: Division of Health Care Quality (DHCQ) (https://dhss.delaware.gov/dhcq)
• Medicaid Authority: Delaware Medical Assistance Program (DMAP) (https://medicaid.dhss.delaware.gov/)
• Federal Oversight: Centers for Medicare & Medicaid Services (CMS) PECOS (https://pecos.cms.hhs.gov/)
• Background Screening: Delaware Background Check Center (BCC) (https://backgroundcheckcenter.dhss.delaware.gov/)

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware does not require a Certificate of Need (CON) for home health agencies, nor does it restrict entry through closed networks or Request for Proposal (RFP) procurements. However, the state enforces rigid structural prerequisites that block applications if not met in the correct order.

An applicant cannot simply apply to be a Medicaid provider. They must first establish their legal and clinical foundation through state licensure and federal Medicare certification, as home health is classified as a high-risk provider type.

• Prior State Licensure: Applicants must secure a Skilled Home Health Agency license from DHCQ before initiating DMAP Medicaid enrollment.
• Medicare Certification: Because home health is a high-risk category, agencies must obtain Medicare PECOS approval prior to applying to Delaware Medicaid.
• Physical Location: The agency must maintain an operational office in Delaware or a border state that complies with DHCQ administrative standards.
• NPI Requirement: The agency must possess an active Type 2 National Provider Identifier (NPI) that maps exactly to the legal entity and NPPES taxonomy.
• MCO Contracting Mandate: Providers must be prepared to contract with Delaware's three Managed Care Organizations (MCOs); standalone fee-for-service Medicaid enrollment yields virtually no patient access.

4. Licensure and Certification Requirements

Licensure is processed by the DHCQ Office of Health Facilities Licensing and Certification. The process begins with a comprehensive application package, followed by the issuance of a provisional license that allows the agency to begin operations and prepare for an initial survey.

Agencies must demonstrate financial solvency, appropriate insurance coverage, and the employment of qualified clinical leadership before a license is granted.

• Application Fee: A $500 non-refundable initial application fee must be submitted to DHCQ.
• Annual Renewal Fee: A $300 annual licensure renewal fee is required at least 30 days prior to expiration.
• Provisional License: DHCQ typically issues a 90-day provisional license first, followed by an on-site survey to grant full licensure.
• Insurance Requirements: Agencies must provide certificates of insurance for professional liability, general liability, and workers' compensation.
• Administrator Qualifications: The agency must designate an Administrator with specific health care management experience as defined in § 3350-5.0.
• Clinical Leadership: Must employ a Director of Clinical Services (a Registered Nurse) with at least one year of home health and administrative experience.

5. Medicaid Provider Enrollment

Once licensed and Medicare-certified, agencies enroll in Medicaid via the DMAP Provider Portal. Because home health agencies are designated as "High Risk" by CMS, the enrollment process includes enhanced screening.

Providers must submit detailed ownership disclosures and undergo fingerprint-based background checks for all individuals with a 5% or greater ownership interest.

• Enrollment Portal: Delaware Medical Assistance Portal for Providers (https://medicaid.dhss.delaware.gov/provider).
• Risk Classification: Categorized as "High Risk," requiring enhanced CMS screening and fingerprinting.
• Application Fee: Subject to the CMS institutional provider application fee (approx. $709) unless already paid to Medicare during PECOS enrollment.
• Ownership Disclosure: Must submit CMS-1513 forms detailing all managing directors and individuals with 5% or more ownership.
• Tax Documentation: Requires a signed IRS Form W-9 (within the last 12 months) and an IRS CP-575 or LTR 147C confirming the active EIN.
• Revalidation: Enrollment must be revalidated every 5 years in accordance with 42 CFR § 455.414.

6. Staffing, Training and Background Checks

Delaware law imposes strict pre-employment screening requirements for all home care agency staff. No employee may provide direct patient care until these clearances are fully processed.

Clinical staff must hold active Delaware licenses, and home health aides must complete state-approved training and competency evaluations.

• Background Check System: All hires must be processed through the Delaware Background Check Center (BCC).
• Criminal History: Fingerprint-based state and federal criminal background checks are mandatory for all direct care workers, administrators, and owners.
• Drug Testing: Mandatory pre-employment drug testing is required under Delaware law for all home care agency staff.
• Registry Screening: Mandatory screening against the Delaware Adult Abuse Registry and Child Protection Registry prior to hire.
• Clinical Licensing: RNs, LPNs, and therapists must hold current, unrestricted Delaware licenses or valid multi-state compact licenses.
• Aide Qualifications: Home health aides must complete a state-approved training program and pass a competency evaluation before providing care.

7. Documentation, Policies and Records

Agencies must maintain comprehensive policy manuals that align directly with 16 DE Admin. Code § 3350. DHCQ surveyors will review these documents extensively during the initial and annual surveys.

Clinical records must be meticulously maintained, demonstrating that all care provided aligns with the physician's orders and that patient rights are protected.

• Plan of Care: Must maintain a physician-signed plan of care for every patient, reviewed and updated at least every 60 days.
• Clinical Records: Patient clinical records must be retained for a minimum of 5 years after the date of discharge.
• Quality Improvement: Must implement a documented Quality Improvement (QI) program that systematically evaluates patient care and outcomes.
• Disaster Preparedness: Must maintain a comprehensive emergency and disaster preparedness plan per § 3350-10.0.
• Patient Rights: Must provide written notice of patient rights upon admission and maintain signed acknowledgments in the clinical file.
• HIPAA Compliance: Must maintain strict adherence to federal health information privacy regulations and secure electronic record systems.

8. Billing, Rates and Claims

The vast majority of Delaware Medicaid beneficiaries are enrolled in managed care. Therefore, home health agencies must contract with and bill the state's three MCOs rather than relying on fee-for-service DMAP billing.

Agencies must navigate MCO-specific prior authorization requirements for skilled nursing and therapy visits, and utilize Electronic Visit Verification (EVV) where mandated.

• MCO Billing: Claims are primarily submitted to Highmark Health Options, AmeriHealth Caritas Delaware, and Delaware First Health.
• Prior Authorization: Most skilled therapy and nursing visits require prior authorization from the respective MCO before services are rendered.
• Billing Formats: Claims are submitted using standard UB-04 (institutional) or CMS-1500 (professional) formats via MCO clearinghouses.
• Electronic Visit Verification (EVV): Required for applicable home health and personal care services under the federal 21st Century Cures Act.
• Rate Structure: MCOs negotiate specific rates with providers, which generally align with or slightly exceed the Delaware Medicaid fee schedule base rates.
• CAQH ProView: Providers must maintain a fully attested CAQH ProView profile to facilitate MCO credentialing and claims payment.

9. Approval Sequence and Timeline

Launching a Medicaid-approved Skilled Home Health Agency in Delaware is a lengthy process due to the sequential nature of the approvals. Agencies should budget 9 to 12 months from initial application to final MCO contracting.

Attempting to run these steps concurrently (e.g., applying to DMAP before Medicare PECOS is approved) will result in application denial and lost fees.

• Step 1 (Licensure Prep): Compile DHCQ application, policies, and $500 fee (1-2 weeks).
• Step 2 (State Licensure): DHCQ review, background checks, and issuance of a 90-day provisional license (typically 6-9 months).
• Step 3 (Medicare PECOS): Submit Medicare enrollment application and undergo CMS screening (90-120 days, often overlapping with the provisional survey).
• Step 4 (DMAP Enrollment): Submit Delaware Medicaid application via the DMAP portal (30-60 days post-Medicare and Licensure approval).
• Step 5 (MCO Credentialing): Contract and credential with the three Delaware MCOs (90-120 days post-DMAP approval).

10. Common Denials and Survey Findings

Applications and surveys frequently fail in Delaware due to administrative sequencing errors or failure to strictly adhere to DHCQ's background check mandates.

Surveyors are particularly strict regarding the timely completion of physician orders and the proper vetting of direct care staff.

• Sequencing Errors: Applying to the DMAP portal before securing Medicare PECOS approval or the final DHCQ license.
• Background Check Failures: Allowing staff to provide patient care before BCC clearance and mandatory drug testing results are finalized.
• Care Plan Lapses: Failing to obtain physician signatures on the 60-day plan of care renewals prior to the expiration of the previous order.
• Incomplete Ownership Disclosure: Failing to list all 5% owners or managing employees on the CMS-1513 form during Medicaid enrollment.
• Policy Deficiencies: Submitting generic, out-of-state policy manuals that do not specifically reference 16 DE Admin. Code § 3350.
• Insurance Gaps: Failing to maintain the required minimum limits for professional liability or workers' compensation insurance.

11. Key Contacts and Resources

Providers should rely on the official Delaware DHSS portals and the specific MCO provider networks for the most current applications, fee schedules, and regulatory updates.

Maintaining active communication with DHCQ during the provisional licensure phase is critical to avoiding survey delays.

• DHCQ Licensing: Division of Health Care Quality (https://dhss.delaware.gov/dhcq)
• Medicaid Portal: Delaware Medical Assistance Portal for Providers (https://medicaid.dhss.delaware.gov/provider)
• Background Checks: Delaware Background Check Center (https://backgroundcheckcenter.dhss.delaware.gov/)
• MCO 1: Highmark Health Options (https://www.highmarkhealthoptions.com/)
• MCO 2: AmeriHealth Caritas Delaware (https://www.amerihealthcaritasde.com/)
• MCO 3: Delaware First Health (https://www.delawarefirsthealth.com/)
• State Regulations: 16 DE Admin. Code § 3350 (https://regulations.delaware.gov/AdminCode/title16/3350)

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