Delaware - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-15

Becoming a Skilled Respite Service provider in Delaware means stepping into a mandatory managed care environment where clinical acuity dictates your business model. Skilled respite is distinct from companion or attendant care; it is short-term relief for unpaid primary caregivers provided specifically to individuals with complex, ongoing medical needs—such as tracheostomy care, G-tube feeding, or suctioning—that can only be safely managed by a licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN). Services are primarily funded through the Diamond State Health Plan Plus (DSHP-Plus) 1115 Waiver for physical disabilities and the elderly, or the Division of Developmental Disabilities Services (DDDS) Lifespan 1915(c) Waiver for individuals with intellectual and developmental disabilities.

The single biggest structural barrier to entry in Delaware is that the state does not recognize or license 'Skilled Respite' as a standalone business entity. To deploy RNs and LPNs to a patient's home, your agency must first survive the rigorous, months-long process of obtaining a full Home Health Agency (HHA) license from the Delaware Division of Health Care Quality (DHCQ). Even after securing this license and enrolling in Medicaid, providers face a second formidable gate: Delaware's Medicaid system is heavily managed care, meaning state enrollment only creates baseline eligibility. You cannot bill a single claim until you successfully navigate credentialing and secure a network contract with one of the state's contracted Managed Care Organizations (MCOs), who reserve the right to deny new contracts if their provider networks are already full.

1. Service Definition and Scope

Skilled Respite in Delaware is defined as short-term, temporary relief for a primary unpaid caregiver (such as a parent or guardian) when the Medicaid member’s condition requires clinical oversight. Because the individual's needs exceed what an unlicensed personal care attendant can provide, the service must be delivered by a licensed nurse. It can be planned (maintenance) or unplanned (emergency).

• Scope: In-Home Respite: Delivered in the member's private residence or the home of a family member.
• Scope: Out-of-Home Respite: Delivered in a community setting or licensed facility, such as a Prescribed Pediatric Extended Care (PPEC) center or nursing facility.
• Limitation: Benefit Caps: Under DSHP-Plus pediatric benefits, planned respite is typically capped at 15 days or 285 hours per waiver year.
• Limitation: Emergency Respite: Authorized for unplanned crises (e.g., caregiver hospitalization) for up to 72 hours per episode, typically capped at six episodes per waiver year without counting against standard benefit limits.
• Restriction: Routine Care: Respite cannot be used to supplant routine care, such as substituting for routine before/after-school care or normal daycare.
• Restriction: Room and Board: Federal Financial Participation (FFP) regulations strictly prohibit Medicaid from paying for room and board costs during respite, unless provided in a designated licensed facility.

2. Regulatory and Oversight Agencies

Delaware delegates the management of HCBS waivers, licensure, and provider oversight across several specific divisions under the Department of Health and Social Services (DHSS), alongside private MCOs.

• Agency: Division of Medicaid and Medical Assistance (DMMA): The state Medicaid authority that oversees the DSHP-Plus 1115 Waiver and sets overarching provider policy.
• Agency: Division of Developmental Disabilities Services (DDDS): The operating agency for the Lifespan 1915(c) Waiver; manages the provider network for individuals with IDD.
• Agency: Division of Health Care Quality (DHCQ), Office of Health Facilities Licensing and Certification (OHFLC): The regulatory body that licenses Home Health Agencies and facilities in Delaware.
• Entity: Delaware Medical Assistance Program (DMAP): The operational Medicaid enrollment and screening portal, managed by the state's fiscal agent, Gainwell Technologies.
• Entities: Managed Care Organizations (MCOs): Highmark Health Options, AmeriHealth Caritas Delaware, and Delaware First Health. They hold the contracts, authorize services, and pay claims for DSHP-Plus members.

3. Gatekeeping Prerequisites: Who Can Even Apply

Delaware utilizes structural gates to control the quality and volume of clinical providers. Before you can submit a Medicaid application to be a skilled respite provider, you must clear these absolute preconditions.

• Prerequisite: DHCQ Home Health Agency (HHA) Licensure: Because skilled respite requires deploying nurses, you cannot apply to Medicaid as a 'respite agency.' You must first apply for, be surveyed for, and obtain a Delaware Home Health Agency license from the OHFLC.
• Prerequisite: Mandatory MCO Contracting: Delaware operates under a mandatory managed care model for DSHP-Plus. Enrolling in DMAP FFS/MCOP does not guarantee you any patients or revenue. You must obtain a network contract from Highmark, AmeriHealth, or Delaware First Health. MCOs can and do impose closed networks based on geographic need—if they have enough HHAs providing skilled respite in your county, they will deny your credentialing request.
• Prerequisite: DDDS Provider Network Qualification: If you intend to serve the IDD population under the Lifespan Waiver, you cannot simply bill DDDS. You must formally apply to the DDDS Office of Provider Services, pass their internal qualification review, and be admitted to the authorized DDDS Provider Directory.
• Absence of Gate: Certificate of Need (CON): Delaware does not require a Certificate of Need (CON) to open a Home Health Agency. You may proceed directly to DHCQ licensure without a CON review board hearing.

4. Licensure and Certification Requirements

To operate legally and deploy nurses for skilled respite in Delaware, the agency must adhere to the state’s Home Health Agencies regulations (16 DE Admin. Code 4406).

• Requirement: Initial Licensure Application: Must be submitted to DHCQ/OHFLC with all required organizational documents, a detailed business plan, and the licensing fee.
• Requirement: Director of Nursing (DON): The agency must employ a qualified RN as the Director of Nursing to oversee all clinical services, nurse supervision, and care plan development.
• Requirement: Governing Body: The agency must establish a formal governing body assuming full legal authority and responsibility for the operation of the agency.
• Requirement: State Survey: Before a permanent license is issued, OHFLC will conduct an on-site initial survey to verify compliance with Title 16 requirements, facility standards, and policy implementation.
• Requirement: Clinical Policies: You must submit a comprehensive policy and procedure manual specific to Delaware regulations, including infection control, emergency preparedness, and patient rights.

5. Medicaid Provider Enrollment

Once licensed by OHFLC, providers must formally enroll with the state via the Delaware Medical Assistance Portal (DMAP), operated by Gainwell Technologies.

• System: Gainwell DMAP Portal: All applications are submitted electronically through the DMAP portal. Paper applications are not accepted.
• Application Type: Managed Care Only Provider (MCOP): Providers targeting DSHP-Plus must complete the streamlined MCOP enrollment application. This fulfills federal screening mandates and allows the provider to legally proceed to MCO contracting.
• Application Type: Fee-For-Service (FFS): Providers targeting DDDS waivers or remaining state-plan carve-outs must complete the FFS Enrollment Application.
• Requirement: Categorical Risk Screening: Because home health and nursing services carry higher federal fraud risk, agencies must undergo moderate to high-risk screening, which includes site visits and an application fee (set annually by CMS, approx. $700+).
• Requirement: Disclosure of Ownership: You must accurately disclose any individual or entity with a 5% or greater direct or indirect ownership interest in the agency. Missing or placeholder data here triggers an auto-denial in DMAP.

6. Staffing, Training and Background Checks

Nurses delivering skilled respite must meet stringent professional, training, and background standards mandated by both Delaware law and Medicaid waiver requirements.

• Standard: Clinical Licensure: The individual rendering the service must hold an active, unencumbered RN or LPN license issued by the Delaware Board of Nursing (or a multi-state compact license).
• Standard: CPR and First Aid: All direct care staff must hold current, valid CPR and First Aid certifications.
• Standard: Criminal Background Checks: Providers must secure a State Bureau of Identification (SBI) criminal background check for every employee prior to patient contact.
• Standard: Registry Checks: Mandatory screening against the Delaware Adult Abuse Registry and Child Abuse Registry is required.
• Standard: Client-Specific Training: The RN or LPN must be trained and demonstrably competent in the specific skilled needs of the child or adult (e.g., ventilator management, seizure protocols) before taking a shift.

7. Documentation, Policies and Records

Providers are subject to routine audits by DHCQ, DDDS, and the MCOs. Your documentation must prove that the service was medically necessary and delivered as authorized.

• Document: Plan of Care: Skilled respite cannot be delivered ad-hoc. It must be tied to a physician-ordered or MCO-authorized Plan of Care detailing the specific medical interventions required during the respite period.
• Document: Prior Authorization (PA): The agency must secure an approved PA from the member's MCO or DDDS before initiating service, confirming the allotted hours or days.
• Document: Shift Notes/Flowsheets: The RN or LPN must complete concurrent clinical documentation for each shift, detailing vitals, interventions performed, and the patient's response, signed by the rendering nurse.
• Document: Emergency Backup Plan: Agencies must maintain documented protocols outlining how care will be safely managed if the scheduled nurse calls out or a medical crisis occurs during the caregiver's absence.

8. Billing, Rates and Claims

Reimbursement for skilled respite flows through different clearinghouses depending on the member's waiver program.

• System: MCO Clearinghouses: For DSHP-Plus, claims are not sent to Gainwell. They are submitted to the specific MCO (Highmark, AmeriHealth, or Delaware First) via their designated EDI clearinghouse (e.g., Availity).
• System: EVV Mandate: Delaware mandates Electronic Visit Verification (EVV) for in-home personal care and home health services. Skilled respite visits must be logged via the state-sponsored EVV system (AuthentiCare) or a compliant third-party vendor.
• Coding: Claims typically utilize HCPCS code T1005 (Respite care services), appended with specialized modifiers (e.g., TD for RN, TE for LPN) to denote the skilled level of the provider, as dictated by the MCO's billing manual.
• Rule: Third-Party Liability (TPL): Medicaid is the payer of last resort. If the member has commercial insurance that covers in-home skilled nursing, that policy must be billed and a denial received before Medicaid will pay.

9. Approval Sequence and Timeline

Opening a skilled respite agency in Delaware requires executing approvals in a strict chronological order. Attempting to bypass a step will result in immediate rejection.

• Step 1: Entity and Readiness (1-2 months): Form your corporate entity, obtain an EIN, register with the Delaware Division of Revenue, and secure your NPI.
• Step 2: DHCQ HHA Licensure (4-6 months): Submit the Home Health Agency application to OHFLC, write clinical policies, hire your DON, and pass the initial state survey.
• Step 3: DMAP Medicaid Enrollment (30-60 days): Submit the MCOP or FFS application via the Gainwell DMAP portal, uploading your brand-new DHCQ license.
• Step 4: MCO Credentialing & Contracting (90-120 days): Submit Letters of Interest and credentialing applications to the three DSHP-Plus MCOs. Wait for committee approval and contract execution.
• Step 5: DDDS Network Enrollment (Concurrent with Step 4): If serving the IDD population, apply for DDDS Provider Selection concurrently.

10. Common Denials and Survey Findings

Delaware regulators and MCOs frequently delay or deny providers who fail to respect the administrative details of the state's clinical and managed care frameworks.

• DMAP Denial: Missing Attachments: Failing to upload the approved OHFLC Home Health license or inputting 'N/A' in the ownership disclosure section of the Gainwell portal results in automatic DMAP rejection.
• Survey Finding: Inadequate DON Oversight: DHCQ frequently cites agencies if the Director of Nursing fails to document their required supervisory visits or sign off on LPN clinical notes.
• MCO Denial: Out of Network Service: Delivering skilled respite to an MCO member before the specific MCO contract's effective date will result in denied claims that cannot be billed to the patient.
• Audit Failure: Lapsed Credentials: MCO and DDDS auditors will claw back funds if shift notes reveal that the rendering RN or LPN had an expired Delaware nursing license or lapsed CPR certification on the date of service.

11. Key Contacts and Resources

Use the following definitive Delaware resources to initiate the licensure and enrollment processes.

• Home Health Licensure: Delaware Division of Health Care Quality (DHCQ), Office of Health Facilities Licensing and Certification (OHFLC).
• Medicaid Enrollment: Delaware Medical Assistance Portal (DMAP), managed by Gainwell Technologies.
• IDD Waiver Network: Delaware Division of Developmental Disabilities Services (DDDS), Office of Provider Services.
• DSHP-Plus MCOs: Highmark Health Options Delaware, AmeriHealth Caritas Delaware, and Delaware First Health (Provider Relations departments).

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