Delaware - Respite Care Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-15

In Delaware, Respite Care Services provide essential short-term relief to unpaid primary caregivers of individuals enrolled in Medicaid Home and Community-Based Services (HCBS) programs. Funded primarily through the Division of Developmental Disabilities Services (DDDS) Lifespan Waiver and the Diamond State Health Plan Plus (DSHP+) managed care program, this service ensures the Medicaid member receives continuous, safe supervision in their home or a community setting while their regular caregiver steps away.

The single biggest structural barrier to entry for this service is that Delaware does not issue a standalone "Respite Provider" license. To bill Medicaid for respite care, an agency must first undergo the rigorous process of obtaining a Personal Assistance Services Agency (PASA) or Home Health Agency (HHA) license from the Division of Health Care Quality (DHCQ). Furthermore, licensure does not guarantee Medicaid enrollment; providers must subsequently secure authorization from DDDS or win a network contract with one of Delaware's Managed Care Organizations (MCOs) before the state will accept their Medicaid enrollment application.

1. Service Definition and Scope

Respite care in Delaware is defined as short-term, temporary relief provided to an unpaid primary caregiver. It is designed to prevent caregiver burnout and institutionalization of the Medicaid member by ensuring the member's health, safety, and supervision needs are met during the caregiver's absence.

The service can be delivered in the member's private home, a licensed facility, or an approved community setting like a specialized camp. It is strictly a relief service and cannot be billed for routine childcare or during hours when the primary caregiver is at their regular place of employment.

• Duration Limits: Non-waivered respite must be a minimum of 1 hour in duration, but no more than 10 hours per day.
• Caregiver Presence: The primary caregiver must not be required to be present during service delivery, nor can they be the one providing the billed service.
• Waiver Coverage: Respite is a core service under the DDDS Lifespan Waiver (1115/1915c concurrent) and the DSHP+ managed care program.
• Delivery Settings: Can be provided by a PASA or HHA in the client's home, in a neighborhood group home, or via a specialized camp.
• Self-Direction Option: Under the DDDS waiver, respite may be self-directed, allowing the family to identify and hire their own provider through a fiscal intermediary.

2. Regulatory and Oversight Agencies

Oversight of respite services in Delaware is distributed across several divisions within the Department of Health and Social Services (DHSS). Providers must navigate a matrix of licensing, program authorization, and financial oversight entities.

While one division handles the physical licensure of the agency, others manage the specific waiver programs, authorize the provider networks, and process Medicaid claims.

• Division of Health Care Quality (DHCQ): The DHSS division responsible for licensing and surveying the underlying PASA or HHA entities that provide respite.
• Division of Medicaid and Medical Assistance (DMMA): Administers the overarching Delaware Medicaid program and oversees the MCOs operating DSHP+.
• Division of Developmental Disabilities Services (DDDS): Manages the Lifespan Waiver and authorizes providers to deliver services to individuals with intellectual and developmental disabilities.
• Division of Services for Aging and Adults with Physical Disabilities (DSAAPD): Manages non-Medicaid respite grants (NFCSP) and coordinates aging services.
• Managed Care Organizations (MCOs): AmeriHealth Caritas Delaware, Highmark Health Options, and Delaware First Health manage the DSHP+ provider networks and credentialing.

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware does not utilize a Certificate of Need (CON) program for home-based respite services, but it enforces strict structural prerequisites that block applicants from enrolling in Medicaid. You cannot simply apply to be a Medicaid respite provider; you must first hold a specific facility or agency license.

Additionally, Medicaid enrollment is gated by network authorization. Even with a DHCQ license, the Delaware Medical Assistance Program (DMAP) will reject your enrollment if you do not have prior approval from DDDS or an active MCO contract.

• Underlying Licensure Prerequisite: Applicants must already hold or concurrently obtain a Personal Assistance Services Agency (PASA) or Home Health Agency (HHA) license from DHCQ; there is no standalone respite license.
• DDDS Provider Authorization: For the Lifespan Waiver, agencies must pass the DDDS Provider Enrollment process and be officially added to the Authorized Provider list before DMAP will accept their application.
• MCO Network Adequacy: For DSHP+, providers must secure a contract with at least one of the three MCOs. MCOs operate closed networks and will deny credentialing if they determine adequate geographic capacity already exists.
• Medicare Enrollment Mandate: High-risk providers must successfully enroll in Medicare prior to enrolling with the Delaware Medical Assistance Program (DMAP).
• Physical Location Requirement: Providers must maintain a physical business office in or accessible to Delaware that can be inspected by DHCQ during the initial licensure survey.

4. Licensure and Certification Requirements

Because Delaware does not license "respite" as a distinct category, providers must meet the comprehensive licensure standards for a Personal Assistance Services Agency (PASA) under 16 Del. Admin. C. Section 3345 or a Home Health Agency (HHA) under Section 3350.

This process involves submitting a detailed application to DHCQ, passing an initial on-site survey, and operating under a provisional license before full licensure is granted.

• Application Submission: Submit the DHCQ initial licensure application for a PASA or HHA along with the required state licensure fee.
• Policies and Procedures: Applicants must submit comprehensive operational policies, including emergency preparedness plans, patient rights, and infection control, for DHCQ review.
• Agency Director Qualifications: The agency must designate a Director who meets DHCQ's specific education and administrative experience requirements to oversee daily operations.
• Initial On-Site Survey: DHCQ conducts a mandatory on-site inspection of the agency's office and records prior to issuing any license.
• Provisional Licensure: New agencies are typically issued a provisional license for up to one year, during which they must demonstrate full regulatory compliance to earn a standard license.

5. Medicaid Provider Enrollment

Once licensed by DHCQ and authorized by DDDS or an MCO, providers must enroll in the Delaware Medical Assistance Program (DMAP). This is done through the online Delaware Medical Assistance Portal for Providers, managed by Gainwell Technologies.

Providers contracting exclusively with MCOs must complete a streamlined Managed Care Only Provider (MCOP) application to satisfy federal screening requirements under the 21st Century Cures Act.

• DMAP Portal: All enrollment applications must be initiated and submitted online through the Delaware Medical Assistance Portal.
• MCOP Application: Providers serving only DSHP+ members must complete the mandatory MCOP application for initial enrollment, reenrollment, and revalidation.
• Application Fee: Institutional providers must pay the federal Medicaid application fee (adjusted annually by CMS) unless they have already paid it to Medicare or another state.
• Required Attachments: Applicants must upload their W-9 tax form, DHCQ license, proof of liability insurance, and NPI assignment letter.
• Application Tracking Number (ATN): Upon submission, the portal generates an ATN and password, which the provider must use to check their enrollment status or resume a saved application.

6. Staffing, Training and Background Checks

Direct care workers providing respite must meet strict background and training standards mandated by DHSS. Agencies are strictly liable for ensuring no staff member has independent client contact before all clearances are returned.

Training requirements vary slightly depending on whether the provider is serving the DDDS Lifespan Waiver or the DSHP+ aging population, but baseline safety and emergency response training is universal.

• Criminal Background Check: Mandatory fingerprint-based state and federal background checks must be processed through the Delaware State Bureau of Identification (SBI).
• Registry Clearances: Staff must clear the Delaware Adult Abuse Registry and the Child Protection Registry prior to hire.
• Basic Safety Training: All direct care staff must hold current certification in CPR and First Aid before providing independent care.
• DDDS Specific Modules: Lifespan Waiver providers must complete DDDS-mandated training, including positive behavior supports, rights restrictions, and incident reporting protocols.
• Supervisory Visits: PASA and HHA regulations require periodic on-site supervisory visits by a registered nurse or qualified agency supervisor to evaluate the direct care worker's performance.

7. Documentation, Policies and Records

Providers must maintain meticulous records to justify Medicaid billing and demonstrate compliance during DHCQ surveys. Documentation must clearly establish that the service provided was respite (relief for the caregiver) rather than standard personal care.

Delaware mandates the use of Electronic Visit Verification (EVV) for in-home services, and failure to capture this data will result in automatic claim denials.

• Person-Centered Service Plan (PCSP): Respite hours and frequency must be explicitly authorized in the member's PCSP by their care coordinator or case manager.
• Electronic Visit Verification (EVV): Agencies must use the state-mandated EVV system to log the exact start and end times, location, and caregiver for all in-home respite shifts.
• Caregiver Absence Documentation: Clinical notes must explicitly state that the primary caregiver was relieved of their duties during the billed hours.
• Incident Reporting: Agencies must maintain policies for reporting critical incidents (e.g., falls, abuse allegations) to DHSS within 24 hours via the state's incident reporting system.
• Record Retention: Medicaid and DHCQ regulations require all clinical, personnel, and billing records to be retained for a minimum of five years.

8. Billing, Rates and Claims

Respite is billed in specific time increments, typically 15-minute units or per diem rates, depending on the waiver and the setting. Claims are submitted either to the DMAP MMIS for fee-for-service (DDDS) or directly to the contracted MCO (DSHP+).

Rates are established by DMMA and DDDS, and providers cannot balance-bill Medicaid members for any difference between the Medicaid rate and their private-pay rate.

• Billing Codes: Respite is typically billed using standard HCPCS codes such as S5150 (unskilled respite, 15 minutes) or S5151 (unskilled respite, per diem).
• EVV Claims Matching: Claims submitted for in-home respite will be automatically denied by the MMIS or MCO if they are not supported by matching EVV data.
• MCO Clearinghouses: DSHP+ claims must be submitted through the respective MCO's designated clearinghouse (e.g., AmeriHealth Caritas or Highmark portals).
• Prior Authorization Requirement: All respite hours must be prior-authorized; billing for hours that exceed the annual or weekly limit set in the PCSP will result in denial.
• Rate Structure: Reimbursement rates are fixed by the state and vary based on whether the service is delivered by a PASA (unskilled) or an HHA (skilled nursing respite).

9. Approval Sequence and Timeline

The end-to-end process for becoming a fully enrolled respite provider in Delaware is lengthy, typically taking 6 to 12 months. It requires sequential approvals from DHCQ, the authorizing division (DDDS or MCO), and finally DMAP.

Providers cannot skip steps; for instance, DMAP will not process an enrollment application without the underlying DHCQ license and MCO/DDDS authorization already in hand.

• Step 1: Business Formation and NPI: Register the business in Delaware and obtain a National Provider Identifier (NPI) (1-2 weeks).
• Step 2: DHCQ Licensure Application: Submit the PASA or HHA application, policies, and fee to DHCQ for document review (2-4 months).
• Step 3: DHCQ On-Site Survey: Pass the initial facility inspection to receive a provisional PASA or HHA license (1-2 months).
• Step 4: Program Authorization: Apply for DDDS Authorized Provider status or undergo MCO credentialing and contracting (2-4 months).
• Step 5: DMAP Enrollment: Submit the final application via the Delaware Medical Assistance Portal for MMIS integration (30-60 days).

10. Common Denials and Survey Findings

Applications and claims are frequently delayed or denied due to administrative errors, missing documentation, or failure to meet Delaware's strict background check laws. DHCQ surveys often cite agencies for personnel file deficiencies.

In the DMAP portal, applications that sit idle waiting for provider responses are automatically purged, forcing the agency to start over.

• Incomplete Background Checks: DHCQ frequently issues citations for agencies allowing staff to work before SBI fingerprint and Registry clearances are fully returned and filed.
• Missing EVV Data: Claims are routinely denied because the direct care worker failed to clock in/out using the EVV system, causing a mismatch with the billed hours.
• Lapsed Authorizations: Billing for respite hours after the member's prior authorization has expired or exceeding the annual hour limit.
• Portal Inactivity Purge: DMAP enrollment applications are denied and deleted if the provider fails to respond to requests for missing documents (like a W-9 or license copy) within 30 days.
• Training Deficiencies: Surveyors commonly cite agencies for failing to document mandatory CPR/First Aid renewals or DDDS-specific training in employee personnel files.

11. Key Contacts and Resources

Providers should utilize official State of Delaware portals and division contacts for the most accurate and up-to-date information regarding licensure, waiver rules, and enrollment.

Because the process spans multiple divisions, providers must maintain contact with DHCQ for licensing, DDDS/MCOs for authorization, and Gainwell Technologies for portal support.

• DHCQ Licensure: Division of Health Care Quality, (302) 421-7400, for PASA and HHA regulations, applications, and survey questions.
• DMAP Provider Portal: medicaid.dhss.delaware.gov for initiating Medicaid enrollment, checking ATN status, and accessing the MCOP application.
• DDDS Provider Network: dhss.delaware.gov/ddds for Lifespan Waiver provider authorization requirements and training modules.
• Gainwell Technologies: The fiscal agent managing the DMAP MMIS and provider enrollment helpdesk for technical portal issues.
• MCO Provider Relations: Contact Delaware First Health, Highmark Health Options, or AmeriHealth Caritas Delaware directly for DSHP+ network contracting and credentialing.

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