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

Last reviewed: 2026-08-16

In Delaware, Skilled Nursing Services delivered in the home under physician orders are regulated and licensed under the category of Skilled Home Health Agencies. These services encompass comprehensive patient assessments, medication administration, wound care, and other skilled treatments provided by Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) directly in the patient's residence.

The single biggest structural barrier to entry for a new Medicaid skilled nursing provider in Delaware is securing network contracts with the state's Managed Care Organizations (MCOs) under the Diamond State Health Plan (DSHP) and DSHP-Plus programs. While Delaware does not require a Certificate of Need (CON) for home health agencies, simply obtaining a state license and enrolling in the Delaware Medical Assistance Program (DMAP) does not guarantee patient volume; providers must successfully navigate MCO credentialing, which can be restricted based on network adequacy needs.

1. Service Definition and Scope

Delaware defines and regulates in-home skilled nursing under its Skilled Home Health Agencies licensure framework. This service model is designed to deliver medical care to individuals who require professional nursing interventions in their homes, preventing institutionalization and supporting community-based recovery or long-term care.

The scope of practice is strictly governed by state nursing board regulations and home health licensure rules, requiring all care to be delivered under a physician-approved plan of care.

• Regulatory Citation: 16 DE Admin. Code 3350 governs Skilled Home Health Agencies.
• Covered Personnel: Services must be delivered by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) operating within their state scope of practice.
• Core Services: Includes initial and ongoing patient assessments, medication administration, wound care, and specialized skilled treatments.
• Physician Orders: All skilled nursing services must be explicitly ordered by a physician or allowable provider.
• Care Plan Requirement: Agencies must maintain an individualized plan of care that is regularly reviewed and revised based on patient progress.

2. Regulatory and Oversight Agencies

The licensing of home health agencies in Delaware is managed by the Department of Health and Social Services (DHSS), specifically through its Division of Health Care Quality (DHCQ). This division conducts initial surveys, issues licenses, and investigates complaints.

Medicaid enrollment and claims processing are overseen by the Delaware Medical Assistance Program (DMAP), while the overarching Medicaid policy and managed care contracts are managed by the Division of Medicaid and Medical Assistance (DMMA).

• Licensing Authority: DHSS Division of Health Care Quality (DHCQ) (https://dhss.delaware.gov/dhcq) issues licenses and conducts surveys.
• Medicaid Enrollment: Delaware Medical Assistance Program (DMAP) (https://medicaid.dhss.delaware.gov) processes fee-for-service provider enrollment.
• Medicaid Policy: DHSS Division of Medicaid and Medical Assistance (DMMA) (https://dhss.delaware.gov/dmma) oversees the Diamond State Health Plan waivers.
• Background Checks: DHSS Background Check Center (BCC) (https://dhss.delaware.gov/dhcq/dhcq/background-checks/) processes mandatory criminal and abuse registry checks.

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware presents a relatively open market for initial licensure, as it explicitly does not require a Certificate of Need (CON) for home health agencies. Any entity that meets the structural, financial, and policy requirements can apply for a state license.

However, the primary gatekeeping mechanism for Medicaid reimbursement is managed care contracting. Providers must secure contracts with the MCOs administering the Diamond State Health Plan (DSHP) and DSHP-Plus, which may close their networks if they determine they have adequate home health coverage in a specific county.

• Certificate of Need (CON): None required; Delaware does not subject home health agencies to CON review.
• MCO Contracting: Required; providers must secure network agreements with DSHP MCOs (e.g., Delaware First Health, Highmark Health Options) to serve most Medicaid beneficiaries.
• Medicare Certification: Highly recommended and frequently required by MCOs for skilled nursing providers to bill for dual-eligible (Medicare/Medicaid) patients.
• Physical Location: Applicants must establish a physical office location capable of maintaining records and directing care for Delaware residents.
• Operating History: No minimum operating history is required to apply for an initial provisional license in Delaware.

4. Licensure and Certification Requirements

To operate as a Skilled Home Health Agency in Delaware, providers must submit a comprehensive application to the DHCQ. The state utilizes a provisional licensing model to allow new agencies to begin operations and demonstrate compliance before receiving a full annual license.

Agencies must submit detailed operational policies, proof of insurance, and ownership disclosures. The initial license is granted for 90 days, during which the state will conduct an on-site survey.

• Application Fee: A non-refundable fee of $500 must accompany the initial licensure application.
• Annual Licensure Fee: A $300 fee is required for the annual renewal of the license.
• Provisional License: A 90-day probationary license is issued to applicants whose policies and procedures demonstrate compliance on paper.
• On-Site Survey: DHCQ mandates an on-site survey during the first 90 calendar days of operation under the provisional license.
• Required Documentation: Applicants must submit a complete policies and procedures manual, ownership identity (officers, directors, managing members), and management credentials.
• Insurance Requirements: Agencies must maintain and provide proof of professional liability, general liability, and workers' compensation insurance.

5. Medicaid Provider Enrollment

Once licensed by DHCQ, agencies must enroll in the Delaware Medical Assistance Program (DMAP) to receive a Medicaid provider number. This process is managed through the DMAP Provider Portal operated by Gainwell Technologies.

Enrollment in DMAP is a prerequisite for credentialing with Delaware's Medicaid MCOs. Providers must ensure their taxonomy codes and service locations exactly match their state license and MCO contracts.

• Enrollment Portal: Applications are submitted via the DMAP Provider Portal (https://medicaid.dhss.delaware.gov/provider).
• Application Tracking: Providers receive an Application Tracking Number (ATN) to monitor the status of their submission.
• Application Fee: Subject to the standard CMS institutional provider application fee, unless the provider is already enrolled in Medicare or another state's Medicaid program and paid the fee there.
• Revalidation: DMAP requires providers to revalidate their enrollment information at least every five (5) years.
• MCO Credentialing: After DMAP enrollment, providers must separately credential with MCOs such as Delaware First Health (https://www.delawarefirsthealth.com).

6. Staffing, Training and Background Checks

Delaware enforces strict background check and drug testing requirements for all direct care workers in home health agencies. These checks are centralized through the DHSS Background Check Center (BCC).

Agencies must also designate qualified administrative leadership and ensure that all nursing staff hold active, unencumbered Delaware or compact state nursing licenses.

• Agency Director: Must designate a qualified individual responsible for the day-to-day management of the home health agency.
• Nursing Supervision: An RN must be available to supervise LPNs and any home health aides employed by the agency.
• Criminal Background Checks: Mandatory fingerprint-based criminal history checks via the DHSS BCC for all owners, administrators, and direct care workers.
• Abuse Registry: Mandatory pre-employment checks against the Delaware Adult Abuse Registry.
• Drug Testing: Mandatory pre-employment drug screening processed through the DHSS Drug Testing Center.
• Continuing Education: Agencies must submit and execute a plan for providing continuing education and training for personnel during the first year of operation and annually thereafter.

7. Documentation, Policies and Records

Recordkeeping standards for Delaware Skilled Home Health Agencies are explicitly detailed in 16 DE Admin. Code 3350. Agencies must maintain comprehensive clinical records that justify the medical necessity of the skilled nursing services provided.

In addition to clinical documentation, agencies must maintain administrative records, including a disaster preparedness plan and an advance directive policy compliant with Delaware law.

• Admission Records: Must capture patient name, birth date, address, Medicaid/Medicare IDs, and emergency contact information.
• Clinical Records: Must include initial assessments, reassessments, and chronological, timely progress notes for every visit.
• Plan of Care: Must maintain an individualized plan of care, including initial orders, reviews, and revisions signed by a physician.
• Advance Directives: Must include an advance health-care directive form compliant with 16 Del.C. Ch. 25, or a statement that one was requested.
• Disaster Preparedness: Must maintain a comprehensive disaster preparedness plan to ensure continuity of care during emergencies.
• Policy Manual: Must maintain a DHCQ-approved policies and procedures manual covering patient rights, quality improvement, and infection control.

8. Billing, Rates and Claims

Medicaid billing for skilled nursing services in Delaware is primarily routed through the MCOs, as the vast majority of HCBS recipients are enrolled in the Diamond State Health Plan. Fee-for-service claims are rare and processed directly through the DMAP portal.

Providers must comply with federal Electronic Visit Verification (EVV) mandates for in-home services, ensuring that the time, location, and personnel delivering the service are electronically captured at the point of care.

• Billing System: Fee-for-service claims are submitted via the DMAP Provider Portal; managed care claims go through the respective MCO clearinghouses.
• Prior Authorization: Skilled nursing visits require prior authorization from the MCO based on the physician-signed plan of care.
• Coding: Services are typically billed using standard HCPCS codes (e.g., G0299 for RN services, G0300 for LPN services) or applicable revenue codes.
• Electronic Visit Verification (EVV): Mandatory for home health services under the 21st Century Cures Act to validate visit data.
• Rate Structure: Reimbursement rates are negotiated directly with the MCOs, though they are generally benchmarked against the DMAP fee schedule.

9. Approval Sequence and Timeline

The pathway to becoming a fully billing Medicaid skilled nursing provider in Delaware involves sequential approvals from DHCQ, DMAP, and the MCOs. Providers cannot skip steps; licensure must precede Medicaid enrollment.

The entire process from initial application compilation to active MCO contracts typically takes 6 to 9 months, heavily dependent on the agency's readiness for the initial DHCQ survey.

• Step 1: Compile and submit the licensure application, policies, and $500 fee to DHCQ (1-2 weeks).
• Step 2: DHCQ reviews the application and issues a 90-day provisional license (typically 30-60 days).
• Step 3: Agency begins operations and undergoes the mandatory DHCQ on-site survey within the first 90 days.
• Step 4: Upon successful survey, DHCQ issues the full 12-month Skilled Home Health Agency license.
• Step 5: Submit the DMAP Medicaid enrollment application via the Provider Portal (30-60 days for processing).
• Step 6: Apply for network inclusion and credentialing with Delaware's Medicaid MCOs (90-120 days).

10. Common Denials and Survey Findings

New agencies frequently face delays or denials due to administrative oversights during the application phase or compliance failures during the initial 90-day provisional survey.

DHCQ surveyors strictly enforce background check compliance and clinical documentation standards. Failure to adhere to these regulations can result in the revocation of the provisional license.

• Incomplete Policies: Licensure applications are frequently delayed because the submitted policies and procedures manual lacks required Delaware-specific regulatory language.
• Background Check Violations: Survey citations for allowing staff to provide patient care before BCC and Adult Abuse Registry clearances are fully finalized.
• Care Plan Deficiencies: Citations for failing to update the individualized plan of care or operating without current physician signatures.
• MCO Network Closures: Denial of Medicaid participation because an MCO determines its home health network is currently adequate and closed to new providers.
• Insurance Lapses: Application rejection for failing to provide certificates of insurance for professional liability and workers' compensation.

11. Key Contacts and Resources

Providers should rely on the official Delaware state portals and regulatory codes for the most current requirements. The DHSS websites provide access to all necessary forms, fee schedules, and portal logins.

Maintaining direct contact with the MCO provider relations departments is essential for navigating the final credentialing and contracting phases.

• DHSS Division of Health Care Quality (DHCQ): https://dhss.delaware.gov/dhcq
• Delaware Medical Assistance Program (DMAP) Portal: https://medicaid.dhss.delaware.gov/provider
• DHSS Background Check Center (BCC): https://dhss.delaware.gov/dhcq/dhcq/background-checks/
• Delaware First Health (MCO): https://www.delawarefirsthealth.com
• 16 DE Admin. Code 3350 (Skilled Home Health Regulations): https://regulations.delaware.gov/AdminCode/title16/3350

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