Delaware
Delaware’s Medicaid agency and its state plan are the official source for these rules. This page summarizes them as researched in October 2026; check the state’s own documents, listed under Sources, before relying on them.
At a glance
- Rate method
- Hybrid
- Case-mix level
- Resident-level
- Classification
- State index
- Rate updates
- Once a year
- Managed care (LTC)
- Yes
- Quality program
- None
- Paid outside the rate
- Small
- Bed hold
- Hospital and leave
- Published rates
- Not published
- Assisted living
- Covered
- Personal needs allowance
- $75 / month
Overview
- Delaware's state plan (Attachment 4.19-D) still describes the 2007 'Patient Index Reimbursement System'.
- A peer-group nursing (primary care) rate for each patient class is set from the 75th-percentile nurse wage x standard nursing time.
- Four facility-specific cost components (secondary care, support, administration, capital) are added, each limited by peer-group ceilings.
- Since 4/1/2009 per diems have been held at the 12/31/2008 rates, with 'future rate adjustments suspended until further notice'.
- Since then, money has been added only through the provider-tax rate add-on (from 6/1/2012) and budget-funded increases and directed payments.
What matters in Delaware
- Posted state plan still holds per diems at 12/31/2008 levels; increases since then come from the provider tax and the yearly budget.
- Nursing home stays are paid by the DSHP-Plus managed care plans; plans pay the state rate unless they negotiate another.
- Case mix is Delaware's own ADL-based patient classes, scored by Medicaid nurses and paid per resident, not MDS/PDPM.
- Provider tax is capped at $35 per non-Medicare day ($19 for homes with 44,000+ Medicaid days); CCRCs and homes with 46 or fewer beds are exempt.
- Homes must spend 100% of Medicaid nursing (primary care) pay on nursing, or repay the shortfall at cost settlement.
- Budget money for rate increases: $10M one-time in FY2024 (directed payment), plus up to $10M from the hospital tax for private homes in CY2026.
Frequently asked
Does Delaware Medicaid use MDS or PDPM to set nursing home case mix?
No. The state plan uses Delaware's own patient classes. Medicaid review nurses score four ADLs (eating, mobility, transfer, toileting) plus clinical care items, and each resident's class sets the nursing part of their per diem.
Are Delaware nursing home Medicaid rates still frozen at 2008 levels?
On paper, yes. Attachment 4.19-D holds per diems at 12/31/2008 rates and suspends future adjustments. Since then, money has been added only through the 2012 provider-tax add-on and budget-funded increases or directed payments.
Do Delaware managed care plans have to pay nursing homes the state Medicaid rate?
Only by default. The MCO contract says plans must use the state FFS rate unless they negotiate a different arrangement with that nursing facility. It is not a hard floor.
How much is paid outside the posted rate in Delaware?
Small: occasional budget-funded directed payments to private homes ($10M in FY2024; up to 12.5% of hospital-tax revenue one-time in FY2026).
What does Delaware Medicaid pay on Medicare coinsurance days?
Lesser-of: crossover payments are limited to state plan rates, so homes usually get $0 of the day 21-100 coinsurance.
Does Delaware require a minimum share of spending on care?
Yes; 100% of Medicaid primary-care (nursing) money must be spent on nursing, with under-spending repaid at cost settlement (16 Del. C. 1166).
How is the Delaware nursing home provider tax charged?
Per non-Medicare day, up to $35 (or $19 for homes with 44,000+ Medicaid days); CCRCs, homes with 46 or fewer beds and public homes exempt.
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| 2007-10-01 | Earlier Delaware patient-index system (SP 413) | Patient Index Reimbursement System: peer-group nursing rates by ADL-based patient class plus capped facility-specific secondary, support, administration and capital components | SPA 07-004 restated the five-component prospective system with three peer groups and median-based caps. | Five-component patient index system restated | https://dhss.delaware.gov/wp-content/uploads/sites/11/2026/06… |
| 2009-04-01 | Annual rate recalculation under the patient index system | Per diems for all but state-run homes reset to the 12/31/2008 rates; future rate adjustments suspended until further notice | Delaware froze NF rates at 2008 levels (SPA 09-002), and the freeze is still in the posted plan. | Nursing facility rates frozen at 2008 levels | https://dhss.delaware.gov/wp-content/uploads/sites/11/2026/06… |
| 2012-04-01 | Fee-for-service NF payment by DMMA | DSHP-Plus managed LTSS: MCOs pay nursing facilities, by default at the state FFS rate | Delaware moved nursing home and HCBS long-term care into managed care under the DSHP 1115 waiver. | Nursing home care moved into managed care | https://delcode.delaware.gov/title16/c011/sc08/index.html |
| 2012-06-01 | No provider tax | Nursing Facility Quality Assessment per non-Medicare day with a per-diem Quality Assessment Rate Adjustment | A provider tax was created, and its proceeds are returned through a uniform per-diem add-on plus each home's own Medicaid tax share (SPA 12-009). | Nursing facility provider tax created | https://delcode.delaware.gov/title30/c065/index.html |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
Delaware Medicaid Long-Term Care Facilities' Statement of Reimbursement Costs (state cost report), filed annually for the state fiscal year ending June 30, plus an annual nursing wage survey. Medicare HIM-15 principles apply. Cost reports are examined by the State Auditor (FY2021 exams published 2025).
- Base year and rebasing
As written: the primary (nursing) component is rebased every year from the prior-June-30 wage survey and cost report. Non-primary caps are rebased every fourth year and inflated in between. Capital floor/ceiling are rebased every year. In practice, since 4/1/2009, per diems for non-state homes have been set back to the rates in effect 12/31/2008, and 'Future rate adjustments will be suspended until further notice' (4.19-D p.1-1a, SPA 12-009/12-012). No later SPA lifting the freeze appears in the posted plan.
- Components
Component Method Notes Primary patient care (nursing) 75th-percentile hourly wage for RNs, LPNs and aides in each peer group (with fringe and training) x standard nursing time factors for each patient class. Same schedule for every home in a peer group. Peer groups: A = private homes in New Castle County; B = private homes in Kent and Sussex plus the Delaware Veterans Home; C = state-run DHSS homes. Agency nurse cost above a yearly cap is excluded. Add-ons: +20% for an approved rehabilitative/preventive program, +10% for frequent disruptive behaviors, +32% for both. Secondary patient care Facility cost per day up to 115% of the peer-group median. Clinical consultants, social services, raw food, medical supplies, OTC drugs, activities. Support services Facility cost per day up to 110% of the peer-group median. Efficiency incentive: 25% of the gap below the cap, up to 5% of the cap. Dietary, plant operation and maintenance, housekeeping, laundry. Administration Facility cost per day up to 105% of the peer-group median. Efficiency incentive: 50% of the gap below the cap, up to 10% of the cap. Includes home office costs. Capital Actual cost per day between a 20th-percentile floor and an 80th-percentile ceiling. Below the floor: lower of the floor or cost +25%. Above the ceiling: higher of the ceiling or 95% of cost. No revaluation of assets on sale. Quality Assessment Rate Adjustment Per day add-on from 6/1/2012 = the home's own per-day assessment (Medicaid share) + a uniform per-day amount funded from 90% of the statewide assessment, grossed up at FMAP, less the Medicaid share, divided by statewide Medicaid days. Excluded: government-owned homes, children-only homes, homes with no Medicaid residents, homes in tax penalty, out-of-state homes. - Inflation
State-chosen 'recognized source' index (examples listed: University of Delaware Health Care Index, CPI, CMS SNF input price index) for caps in interim years. Not applied while the 2009 rate freeze stands; increases since have been budget-set amounts.
Verified October 11, 2026
Case mix
- System
State index
- Applied at
Resident-level
- How it works
The program pays 'the individual Medicaid recipient's days of care multiplied by the applicable per diem for that patient's classification' (4.19-D p.2), so each resident's class sets their own rate.
- Classification
Delaware patient classes from ADL dependency scores (0-3) in eating, mobility, transfer and toileting plus Clinical Care Items, assigned by Department (Medicaid review) nurses, not by MDS. The number of classes and the time factors were not found in the posted plan.
- Applies to
Primary (nursing) component only; secondary, support, administration and capital are the same for every class in a home.
- Acuity measured from
Not a facility average. Initial class from pre-admission screening (PAE). Reviewed by Department nurses 31-45 days later, then at least twice a year. Facilities are notified of class changes and effective dates.
- Updated
Per resident at each Department classification review (at least semiannual).
- Move to PDPM
None found. Delaware never used RUG/MDS for Medicaid NF payment, so the October 2023 end of CMS OBRA RUG support did not force a change.
Verified October 11, 2026
Low-acuity residents
None found after checking 4.19-D. The lowest-resource residents are placed in the lowest patient class and paid that class's nursing rate plus the home's full base rate. There is no flat or reduced carve-out rate.
Verified October 11, 2026
Capital
Actual cost with a 20th-percentile floor and 80th-percentile ceiling (see cost_basis). No fair rental value. Costs per day use the greater of actual days or 90% occupancy.
Verified October 11, 2026
Budget adjustment factor
Rate freeze: from 4/1/2009, per diems for all but state-run homes were reset to the 12/31/2008 rates, and future rate adjustments were suspended (4.19-D p.1-1a). Since then, increases have been set by appropriation, not by the formula: $10M one-time in FY2024 (state directed payment approved December 2023), a $5.0M structural NF rate increase in the FY2025 Governor's Recommended Budget, and up to 25% of a $40M hospital-tax appropriation for CY2026 private NF rates (FY2026 budget act, sec. 157).
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
small
- Estimate
Probably under 5% of base in most years, by judgment. The only payments outside the per diem found are occasional one-time MCO directed payments funded by appropriations ($10M state in FY2024; a possible FY2026 one-time payment from hospital-tax revenue). The provider-tax return is inside the per diem. Total Delaware NF Medicaid spending was not found, so the share is not computed.
- Components
FY2024 NF directed payment: $10M state one-time (plus federal match). FY2026 optional one-time directed payment: up to 12.5% of hospital-tax revenue (amount not stated). No IGT/UPL programs found.
Verified October 11, 2026
Payments by owner type
- Applies
yes
- Detail
The three DHSS-operated homes (Peer Group C) are paid under a separate group whose wage surveys and cost reports are pooled as one facility, and whose per diem can include ancillaries. They are outside the provider tax and its rate add-on and were exempt from the 2009 freeze. The Delaware Veterans Home is in Peer Group B and outside the tax. The CY2026 increase is limited to private, non-pediatric homes. There is no IGT-funded supplemental payment that only public homes can draw.
- Funding
State appropriations for state-run homes; Veterans Home funded through the Department of State. No IGT or lease arrangements found.
Verified October 11, 2026
Quality program
- Active
No
- Notes
No quality pay-for-performance program found in 4.19-D, the MCO contract or the budget acts. The only incentives are cost-efficiency payments (support and administration below the caps) and the +20% rehabilitative/preventive add-on. The 'Quality Assessment' name refers to the provider tax, not a quality program.
Verified October 11, 2026
Provider tax
- Charged
per non-Medicare day
- Standard amount
Up to $35 per non-Medicare resident day for assessment periods from 6/1/2016 (30 Del. C. 6502(b)(3)). The actual amount is set each year by May 1 and was not found.
- Tiers
Who Test Amount Homes with 44,000 or more annual Medicaid resident days (latest cost report) medicaid_utilization Up to $19 per non-Medicare day Continuing care retirement communities (AL+IL beds at least 2x NF beds on a contiguous campus) ccrc exempt Homes with 46 or fewer beds size exempt Delaware Veterans Home and state, federal or other public government-owned homes public not subject (outside the definition of nursing facility) Homes with an average daily census of 80%+ children under 21 other not subject - Lower for high-Medicaid homes
yes
- Returned in the rate
Quality Assessment Rate Adjustment on every per diem (4.19-D p.1-1a): (a) the home's own per-day assessment amount, plus (b) a uniform per-day amount = (90% of the statewide assessment x FMAP gross-up - the Medicaid share of the assessment) / statewide Medicaid days. Paid by DMMA and the MCOs (16 Del. C. 1183). Current dollar amounts were not found.
Verified October 11, 2026
Provider tax notes
Nursing Facility Quality Assessment (30 Del. C. ch. 65, since 6/1/2012): quarterly, per non-Medicare resident day (bed-hold days count), at amounts set each year by the Secretaries of Finance and DHSS by May 1. Capped at $35, or $19 for high-Medicaid homes. 90% goes to the NF Quality Assessment Fund (16 Del. C. 1181), 10% to the General Fund. The fund repays the Medicaid share of the tax and a uniform per-diem add-on. FY2026 budget ASF authority: $26.0M.
Verified October 11, 2026
Supplemental payments
(1) MCO state directed payments funded by one-time appropriations: FY2024 $10M one-time for NF rate increases, SDP approved December 2023 (DMMA FY2025 JFC hearing). (2) FY2026 budget act (HB 225, sec. 157): up to 25% of the $40M Hospital Quality Assessment appropriation 'to further enhance rates for private, non-pediatric skilled nursing facilities during the Calendar Year 2026', from 1/1/2026 and annually after. Up to 12.5% of hospital-tax revenue may be used as a one-time directed payment in FY2026. (3) No IGT or UPL payments to public homes found.
Verified October 11, 2026
Other add-ons
Patient-level add-ons to the primary (nursing) component: +20% for an approved rehabilitative/preventive program, +10% for frequent disruptive psychosocial behaviors, +32% for both. Nurse aide training and certification costs are reimbursed directly, outside the per diem (billed quarterly). No COVID-era add-on was found in the plan.
Verified October 11, 2026
Units paid separately
(1) 'Super Skilled' care: residents needing more skilled care than the standard classes are placed by bid. Interested NFs bid a per diem, and DMMA picks the lowest bid that meets the need (4.19-D sec. V). (2) Pediatric NFs: three levels (Pediatric Skilled, Advanced Pediatric Skilled, Advanced Pediatric Skilled Plus for ventilator-dependent children). Prospective all-inclusive rates set from prior-year reasonable cost, capped in aggregate at Medicare children's-hospital payment (sec. IX). FY2026 budget adds $200K for pediatric NF 'bridge unit' beds. (3) Out-of-state homes: lesser of their home-state rate or Delaware's highest comparable rate. (4) State-run homes (Peer Group C) are paid a cost-based rate that includes ancillaries.
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
yes
- Detail
DSHP-Plus, Delaware's MLTSS program added to the DSHP 1115 waiver in 2012, enrolls nursing facility residents, children in pediatric NFs and dual eligibles (1115 extension application 2024-2028). Under 16 Del. C. 1183(b), 'effective April 1, 2012, nursing facilities are paid for services rendered to Medicaid patients directly by DHSS as well as by managed care companies under contract to the Medicaid agency'. MCOs collect patient liability through the facility and pay net of it (2023 MCO MSA 3.11.3.6).
Verified October 11, 2026
Who pays
managed_ltss (Diamond State Health Plan Plus, DSHP-Plus, 1115 demonstration since April 2012). Nursing home residents are enrolled in an MCO (AmeriHealth Caritas Delaware, Delaware First Health, Highmark Health Options), which pays the nursing facility. DMMA still sets the FFS rate schedule the MCOs use.
Verified October 11, 2026
Managed care rate floor
Default, not a hard floor: 'If the Contractor has not negotiated a different payment arrangement with a particular nursing facility, the Contractor must use the State's Medicaid FFS rate to pay Medicare/Medicaid certified DMAP-enrolled nursing facilities for DSHP Plus LTSS members' (2023 MCO Master Service Agreement 3.11.3.6). MCOs must load FFS rate changes on the same effective date (3.11.1.3). 16 Del. C. 1183 also requires the provider-tax per diem adjustments to be paid by MCOs.
Verified October 11, 2026
Included in the daily rate
Private homes (A, B): the per diem excludes prescription drugs, Medicare Part B services, physician, hospital, dental, lab, radiology and certain therapies, which are billed by the practitioner. Oxygen, PT, OT and speech therapy are paid fee-for-service at the lower of cost or a median-based cap, re-surveyed every 3 years. DME not in the per diem is covered by the MCO. State-run homes (C): lab, radiology, drugs, physician, dental and therapies may be in the per diem. Pediatric NFs: all-inclusive except custom DME and legend drugs.
Verified October 11, 2026
Bed hold
- Hospital stays
Paid for up to 7 days per hospitalization in a 30-day period (14 days for ICF/IID). Rate is presumably the full per diem (percentage not stated).
- Leave days
Paid for up to 18 days per calendar year if in the plan of care. More days can be approved by the Title XIX Medical Consultant when the resident's emotional need for a family setting affects their condition.
- Occupancy rule
None stated.
- Notes
The MCO contract repeats the 7-day/30-day and 18-day limits for DSHP-Plus members (2023 MSA). Held days count as resident days for the provider tax.
Verified October 11, 2026
Personal needs allowance
- Per month
75
- Notes
DMMA: 'A Medicaid nursing facility resident may keep $75.00 of his monthly income for his personal needs.' The rest goes to the facility unless protected for a community spouse or medical expenses. Effective date and any indexing were not found.
Verified October 11, 2026
Medicare coinsurance days
- Method
lesser_of
- Rule
Supplement 1 to Attachment 4.19-B (SP 302, eff. 7/1/1992): for Medicare Part A and B deductibles and coinsurance, payments 'are limited to State plan rates and payment methodologies' ('SP') for all groups (QMBs, other Medicaid recipients, QMB Plus duals). Medicare Advantage cost-sharing treatment was not found.
- Effect
Medicare's SNF payment is far above Delaware's Medicaid per diem, so for days 21-100 the home usually receives $0 of the coinsurance from Medicaid.
Verified October 11, 2026
Required care spending
- Applies
yes
- Rule
16 Del. C. 1166(b): 'The Department shall ensure that 100% of Medicaid funds paid for primary care are expended by the residential health facility for primary care purposes.' Under-spending in any annual cost report period must be repaid through cost settlement. 1166(c) applies the rule regardless of payment method, including managed care. This goes with the minimum staffing law (16 Del. C. 1162: 3.67 direct-care hours per resident per day, subject to appropriation, plus shift ratios). Whether DMMA currently enforces the cost settlement under the rate freeze was not confirmed.
Verified October 11, 2026
Occupancy rules
- Applies
yes
- Rule
For the base-rate components (secondary, support, administration, capital), allowable cost is divided by the greater of actual patient days or days at 90% occupancy of Medicaid-certified beds. New facilities use 75%. The nursing (primary) component is not affected (4.19-D sec. II.E).
Verified October 11, 2026
MDS accuracy penalties
Not applicable in MDS form: patient classes are assigned and reviewed by Department nurses. Cost report and wage survey field audits recover overpayments, and late cost reports or wage surveys can lead to fines or suspension (4.19-D sec. VI).
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
As written, the rate year is January 1-December 31 for peer groups A and B and October 1-September 30 for the state-run group C. In practice, the formula has been frozen since 4/1/2009, and changes come from the yearly provider-tax add-on and budget-funded increases (e.g., 1/1/2026). Per resident, the rate changes when Department nurses reclassify the resident (reviews at least twice a year).
Verified October 11, 2026
When rates change
January 1 (peer groups A and B); October 1 (state-run peer group C); provider-tax amounts set by May 1 for the year starting June 1.
Verified October 11, 2026
Posted rates
- Home-level rates published
No
- Where
Not found on the DMMA Forms and Publications page (https://dhss.delaware.gov/dmma/home/forms-and-publications/), which posts only the statewide average Nursing Home Private Pay Rate (2021-2026) used for transfer penalties.
- Format
none
Verified October 11, 2026
Rate build-ups
- Published
No
- Where
Not found. Per-facility State Auditor examinations of the Medicaid cost reports are public (auditor.delaware.gov) and show cost-center adjustments, but not rate build-ups.
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2023-12 | FY2024 one-time appropriation of $10 million for nursing facility rate increases, paid through an MCO state directed payment that CMS approved in December 2023. | One-time $10M nursing facility directed payment | increase | $10 million one-time (state appropriation) | https://dhss.delaware.gov/wp-content/uploads/2025/12/dmma2025… |
| 2024-07-01 | The FY2025 Governor's Recommended Budget included $5.0 million in structural (ongoing) funding for nursing facility rate increases; the enacted amount and how it was applied were not confirmed. | FY2025 budget proposes $5M nursing facility increase | increase | $5.0 million (recommended) | https://dhss.delaware.gov/wp-content/uploads/2025/12/dmma2025… |
| 2026-01-01 | FY2026 budget act lets DMMA use up to 25% of a $40M Hospital Quality Assessment appropriation to raise rates for private, non-pediatric nursing facilities in CY2026 and later. Up to 12.5% of hospital-tax revenue may also be used for a one-time directed payment in FY2026. | Hospital tax funds private nursing home rate increase | increase | up to $10M (25% of $40M ASF) plus federal match | https://legis.delaware.gov/json/BillDetail/GetPdfDocument?fil… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
yes
- Program
DSHP-Plus (Diamond State Health Plan Plus) 1115 demonstration; assisted living is a listed DSHP-Plus HCBS benefit, delivered through the MCOs (formerly the 1915(c) Elderly and Disabled waiver).
- What is paid
Services; the resident pays room and board. MCOs delegate patient-liability collection to the assisted living facility and pay net of it (2023 MSA 3.11.3.6).
- Limits
NF level of care required (or 'at-risk' group). No waitlist found; MLTSS enrollment is not capped like a 1915(c) slot program.
Verified October 11, 2026
Sources
- Delaware Medicaid State Plan, Attachments 4.11-A to 7.7.c (incl. Attachment 4.19-B Supp. 1, 4.19-C bed hold, 4.19-D NF reimbursement, SPAs 07-004, 09-002, 12-009, 12-012) · state plan
- 30 Del. C. ch. 65, Nursing Facility Quality Assessments · statute
- 16 Del. C. ch. 11 subch. VIII, Nursing Facility Quality Assessment Fund (1180-1183) · statute
- 16 Del. C. ch. 11 subch. VII, Minimum Staffing Levels (1162, 1166 Medicaid reimbursement) · statute
- 2023 DSHP/DSHP-Plus MCO Master Service Agreement (sec. 3.11 provider payment, 3.11.3.6 LTSS facilities) · agency page
- DSHP 1115 Waiver 2024-2028 Extension Application · agency page
- DMMA Diamond State Health Plan Plus page · agency page
- DMMA Long-Term Care Medicaid Programs page · agency page
- DMMA FY2025 Joint Finance Committee hearing remarks · agency page
- HB 225 (153rd GA), FY2026 Appropriations Act, sec. 157 (hospital quality assessment funds for SNF rates) · statute
- DMMA Forms and Publications (no NF rate files; private pay rate notices 2021-2026) · agency page
- Delaware Office of Auditor of Accounts, Newark Manor Nursing Home Medicaid cost report examination FY21 · agency page
- MACPAC 2019 compendium, Delaware tab (baseline only) · secondary
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