Delaware Medicaid / Diamond State Health Plan Plus Long Term Care Programs, Benefits & Eligibility Requirements
Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Delaware Medicaid Long Term Care for seniors. This is different from regular Medicaid, which is for low-income people of all ages. In Delaware, Medicaid is a managed care program and is also called Diamond State Health Plan, and Delaware’s long term care Medicaid program is often called Diamond State Health Plan Plus. Delaware Medicaid recipients can receive long term care benefits in a nursing home, in their home, the home of a loved one, an adult foster care home, a residential care home or an assisted living facility and through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid.
Table of Contents
Last Updated: Dec 19, 2022
Delaware Medicaid Long Term Care Programs
Nursing Home / Institutional Medicaid
Delaware Medicaid will cover the cost of long term care in a nursing home for eligible Delaware residents who require a Nursing Facility Level of Care. Nursing home coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with the Activities of Daily Living (eating, bathing, moving, dressing, toileting).
Some of the things Delaware Medicaid won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.
Nursing Home Medicaid is an entitlement. This means that eligible Delaware residents who apply are guaranteed by law, aka “entitled,” to receive Nursing Home Medicaid benefits once their application has been approved.
Any Delaware Medicaid beneficiary who receives nursing home coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $50 / month, as of 2023. This can be spent on personal items such as clothes, snacks, books, haircuts, cell phones, etc. It can not be spent on any item that Delaware Medicaid covers, including hygiene basics like a toothbrush, soap, deodorant, razors and incontinence supplies, unless the beneficiary wants a specific brand that is not covered by Medicaid. In this case, they could spend their personal needs allowance on the item.
Home and Community Based Service (HCBS) Waivers
Home and Community Based Service (HCBS) Waivers will pay for long term care services and supports that help Delaware Medicaid recipients who are at risk of being placed in a nursing home remain living “in the community.” The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long term care services for Delaware residents who live in their home, the home of a loved one, an adult foster care home, a residential care home or an assisted living facility.
Delaware residents can receive HCBS benefits through the state’s Long Term Care Community Services (LTCCS) program.
Long Term Care Community Services
Delaware’s Long Term Care Community Services (LTCCS) program provides services and supports to Delaware Medicaid recipients who live “in the community” but are at risk of nursing home placement. LTCCS program participants can live in their own home, the home of a loved one, an adult foster care home, a residential care home or an assisted living facility. While LTCCS will cover services and supports in those settings, it will not pay for room and board costs.
LTCCS program long term care benefits include adult day care, home modifications, housekeeping services, specialized medical equipment and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). The state will supply a licensed caregiver to provide these benefits, but the program participant can also self-direct some of the LTCCS benefits (like personal care assistance and housekeeping services) by hiring caregivers of their choice, including friends, spouses and other family members.
These benefits will be made available depending on each individual’s needs and circumstances, and they are intended to delay nursing home placement. Any Delaware resident who receives LTCCS benefits will also be enrolled in Diamond State Health Plan Plus (DSHP+). This is a mandatory managed care program that will also provide all of the Delaware Medicaid beneficiary’s medical and behavioral health benefits.
Unlike most HCBS Waivers, Delaware’s Long Term Care Community Services (LTCCS) program is an entitlement. This means that all eligible applicants are guaranteed by law, aka entitled, to be accepted into the program and to receive benefits.
Aged Blind and Disabled / Regular Medicaid
Delaware’s Aged, Blind and Disabled Medicaid, which is also called Regular Medicaid or the Diamond State Health Plan, provides healthcare and long term care services and supports to low-income Delaware residents who are aged (age 65+), blind or disabled and and live “in the community.” Living “in the community” can mean living in in their home, the home of a loved one, an adult foster care home, a residential care home or an assisted living facility. While ABD Medicaid will cover services in all of those settings, it will not cover room and board costs. ABD Medicaid can sometimes be referred to as regular Medicaid for Seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages.
ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait.
1) Standard ABD Benefits
In addition to medical care, ABD Medicaid benefits can include non-medical services and supports such as in-home personal care, adult day care, home modifications and Personal Emergency Response Systems (PERS). ABD Medicaid beneficiaries qualify for these benefits and services one at a time, which is different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. Instead, ABD Medicaid recipients will be evaluated by the state to determine what kind of long term care benefits they need and will receive.
Living Independence for the Elderly (LIFE)
Delaware residents who are age 55+ and have Aged Blind and Disabled (ABD) Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Living Independence for the Elderly (LIFE) program. The program is also known as Program of All-Inclusive Care for the Elderly (PACE). LIFE/PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community and a LIFE/PACE center must be available in that community. Delaware’s LIFE/PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. LIFE/PACE also administers vision and dental care, and LIFE/PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. The Delaware LIFE/PACE centers are located in Milford (PACE Your LIFE) and Wilmington (Saint Francis LIFE). More.
Eligibility Criteria For Delaware Medicaid’s Long Term Care Programs
To be eligible for Delaware Medicaid and the state’s Long Term Care Community Services (LTCCS) program, a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged, Blind and Disabled (ABD) / Regular Medicaid.
Delaware Nursing Home Medicaid Eligibility Criteria
Financial Requirements
Delaware residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through Delaware Medicaid. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,285 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Delaware Medicaid beneficiaries who reside in nursing homes are only allowed to keep $50 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.
For married applicants with both spouses applying, the 2023 asset limit for nursing home coverage through Delaware Medicaid is $3,000 combined, and the income limit is $4,570 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $ 2,285 / month for the applicant. The income of the non-applicant spouse is not counted.
Delaware Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Delaware has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for nursing home coverage through Delaware Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. The state will administer a functional assessment of applicants to determine if they do require that level of care. An applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning, and laundry), as well as their cognitive function, are taken into consideration.
Delaware Medicaid Home and Community Based Service (HCBS) Waivers Eligibility Criteria
Financial Requirements
Delaware residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2023, the asset limit for HCBS Waivers in Delaware is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,285 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants with both spouses applying, the 2023 asset limit for HCBS Waivers in Delaware is $3,000 combined, and the income limit is $4,570 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $2,285 / month for the applicant. The income of the non-applicant spouse is not counted.
Delaware HCBS Waiver applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Delaware has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers through Delaware Medicaid is being at risk of nursing home placement. To determine if HCBS Waiver applicants are at risk of nursing home placement, Delaware’s Division of Medicaid & Medical Assistance Pre-Admission Screening team will conduct a functional assessment. Applicants who need help with at least one of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) are considered to be at risk and meet the functional criteria for HCBS Waivers in Delaware.
Delaware Aged Blind and Disabled Medicaid Eligibility Criteria
Financial Requirements
Delaware residents have to meet an asset limit and an income limit in order to be financially eligible for Aged, Blind and Disabled (ABD) Medicaid. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $914 / month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.
For married applicants, the 2023 asset limit for Delaware ABD Medicaid is $3,000 combined, and the income limit is $1,371 / month combined. This applies to married couples with both spouses applying or with just one spouse applying.
While Delaware has a “look-back” period of five years for Nursing Home Medicaid and Home and Community Based Service Waivers applicants to make sure they don’t give away their assets to get under the limit, there is no “look-back” period for ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid, or an HCBS Waiver, and those programs will deny or penalize the applicant for giving away assets.
Functional Requirements
The functional requirement for Aged Blind and Disabled (ABD) Medicaid in Delaware is being age 65 or over, blind or disabled. For ABD Medicaid applicants who require in-home services and supports, Delaware Medicaid will conduct an assessment of their ability to perform the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning and taking medications) to determine what kind of services the applicant needs and the state will cover.
One’s home is often their most valuable asset, and if counted toward the asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage / debt) is less than $688,000 (as of 2023) then the home is exempt. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $688,000. These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. More on Medicaid & Homeownership.
Applying For Delaware Medicaid Long Term Care Programs
The first step in applying for Delaware Medicaid Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Service (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid.
The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Delaware Medicaid when not financially eligible will result in the application, and benefits, being denied.
During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Delaware Medicaid applicant. These documents will be needed for the official Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.
After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Delaware residents can apply for Medicaid online at Delaware ASSIST. Or they can begin the application over the phone or in person by contacting their local Delaware Health and Social Services office.
1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid
Choosing a Delaware Medicaid Nursing Home
After an applicant has been approved for nursing home coverage through Delaware Medicaid, they need to choose which Medicaid-approved nursing home they will live in. Even though Delaware Medicaid nursing home coverage is an entitlement, it will only cover stays and care in approved nursing homes. Delaware residents can find a list of licensed nursing homes on this Delaware Health and Social Services webpage. They can also use Nursing Home Compare, which is a federal government website that has information about more than 15,000 nursing homes across the country, to help them find a nursing home. All of the nursing homes on this site are either Medicaid- or Medicare-approved.