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Delaware - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

Delaware requires providers of in-home skilled nursing services to obtain a Home Health Agency license under 16 DE Admin. Code § 3350 through the Department of Health and Social Services (DHSS), Division of Health Care Quality. Services are funded primarily through the Diamond State Health Plan Plus (DSHP-Plus) 1115 demonstration waiver and the Division of Developmental Disabilities Services (DDDS) Lifespan Waiver.

Before a provider can bill Delaware Medicaid for skilled nursing, they must first secure a 90-day probationary license from the state, pass an initial on-site survey, and subsequently complete the MCO-Only Provider Enrollment Application to contract with the state's managed care organizations.

1. Service Definition and Scope

In Delaware, skilled nursing services delivered in the home are regulated under the Home Health Agency (HHA) licensure category. These services consist of part-time or intermittent clinical care provided by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) under the direction of a physician's order.

The scope of practice includes comprehensive nursing assessments, medication administration, wound care, and other skilled treatments necessary to maintain the participant safely in their home and community, preventing institutionalization under the DSHP-Plus and Lifespan waivers.

2. Regulatory and Oversight Agencies

The Delaware Department of Health and Social Services (DHSS) is the umbrella agency managing both licensure and Medicaid funding. Within DHSS, distinct divisions handle facility licensing, Medicaid policy, and waiver operations.

Providers must interact with the licensing division for their operating authority and the Medicaid division (and its contracted MCOs) for enrollment and reimbursement.

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware does not require a Certificate of Need (CON) for home health agencies, making it an open-market state for new entrants. There are no moratoria or regional procurement limits currently blocking new applications for skilled nursing providers.

The primary structural precondition is that an applicant must submit a written statement of intent to the Department describing the services to be offered before they are even permitted to request a licensure application. Furthermore, to serve the majority of Medicaid clients, providers must successfully contract with one or more of Delaware's Medicaid Managed Care Organizations (MCOs) after obtaining their license.

4. Licensure and Certification Requirements

Agencies providing skilled nursing must be licensed as a Home Health Agency under 16 DE Admin. Code § 3350. The state issues a 90-day probationary license initially, during which an on-site survey is conducted.

If the agency demonstrates substantial compliance during the probationary period and survey, a full license is granted for a period of one year (12 months).

5. Medicaid Provider Enrollment

Once licensed, providers must enroll in the Delaware Medical Assistance Program (DMAP). Because most HCBS are managed through DSHP-Plus, providers typically use the MCO-Only Provider Enrollment Application.

This streamlined application conducts federally mandated screening activities in compliance with 42 CFR Part 455 and allows the provider to register with Delaware MCOs (such as Highmark Health Options or AmeriHealth Caritas).

6. Staffing, Training and Background Checks

Skilled nursing services must be delivered by licensed professionals. The agency must designate a qualified director responsible for management and ensure all clinical staff hold active Delaware credentials.

All owners, administrators, and direct care workers must undergo state and federal criminal background checks prior to employment.

7. Documentation, Policies and Records

Delaware requires comprehensive policy manuals to be submitted and reviewed during the licensure process. These must cover client rights, emergency preparedness, and clinical recordkeeping.

Patient records must include physician orders for all skilled nursing interventions, detailed nursing assessments, and a compliant plan of care.

8. Billing, Rates and Claims

Reimbursement for skilled nursing under DSHP-Plus is negotiated with and billed directly to the contracted MCOs. For fee-for-service populations (such as certain DDDS waiver participants), claims are submitted through the DMAP MMIS.

Rates for waiver services are periodically reviewed by DHSS, but MCO contracted rates may vary based on network agreements.

9. Approval Sequence and Timeline

The process begins with a written statement of intent to DHCQ, followed by the submission of the application and $500 fee. DHCQ reviews the policies and issues a 90-day probationary license.

During the 90 days, the agency begins operations and undergoes an on-site survey. Following full licensure, the agency applies for Medicaid enrollment and MCO contracting, a process that typically takes 6 to 9 months total.

10. Common Denials and Survey Findings

Applications are frequently delayed if the submitted policies and procedures do not strictly align with 16 DE Admin. Code § 3350 or if the designated director lacks required credentials.

During the initial 90-day survey, surveyors commonly cite agencies for failing to properly document physician orders, inadequate background check files, or operating outside the approved service area.

11. Key Contacts and Resources

Providers should rely on the Division of Health Care Quality for all licensure inquiries and the DMAP portal for enrollment tracking.

Waiver-specific questions can be directed to the Division of Medicaid and Medical Assistance or the Division of Developmental Disabilities Services.

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