How to start a skilled nursing facility in Delaware

Delaware requires a Skilled and intermediate care nursing facility license from Delaware Department of Health and Social Services, Division of Health Care Quality to operate a skilled nursing facility.

License required

Yes

License

Skilled and intermediate care nursing facility license

Issuing agency

Delaware Department of Health and Social Services, Division of Health Care Quality

Renewal

Every year · Renew on the anniversary of initial licensure; file at least 30 days before expiration and pay the applicable fee.

Survey and inspection

Initial licensure requires an on-site physical inspection showing compliance with all applicable regulations.

Certificate of need

Required

Medicare certification

Separate from the state license. The state survey agency runs an unannounced standard health survey, a Life Safety Code survey and an emergency-preparedness survey against 42 CFR Part 483 Subpart B. For a Medicare SNF the state certifies and the CMS Location decides Medicare participation; for a Medicaid-only NF the state's certification is final and the state Medicaid agency decides participation.

Regulation

16 Del. Admin. Code 3201; 16 Del. C. §1104 and §1119C; 16 Del. C. ch. 93 (Certificate of Public Review)

1. Obtain a Certificate of Public Review from the Delaware Health Resources Board if adding more than 10 beds or 10% of licensed capacity (whichever is less) over two years, or for other covered projects
2. Apply to the Division of Health Care Quality and substantiate a satisfactory compliance history
3. Pass the initial physical inspection of the premises
4. For Medicare/Medicaid, complete the federal certification survey and enroll with Delaware Medicaid

Program

Delaware Medical Assistance Program (DMAP) / Diamond State Health Plan

Enrollment portal

DMAP Provider Portal — Provider Enrollment

Fiscal agent

Gainwell Technologies (DMAP provider portal and Provider Relations/enrollment help desk)

Application fee

DMAP states that from January 1, 2026, institutional providers pay $750 at initial application, reactivation, revalidation, re-enrollment and when adding a location. Its screening-level lists mark which taxonomies owe the fee; hardship exceptions go to CMS. Federal rule (42 CFR 455.460): the state must collect the CMS application fee from institutional providers that are newly enrolling or re-enrolling; individual physicians and non-physician practitioners are exempt, as are providers already enrolled in (or that already paid the fee to) Medicare or another state's Medicaid/CHIP. CMS set the fee at $750 for calendar year 2026.

Fingerprinting

DMAP publishes taxonomy screening-level lists (limited/moderate/high) for fee-for-service and managed-care-only providers; the high-risk taxonomies on those lists are subject to fingerprinting. Federal rule (42 CFR 455.434, 455.450(c)): providers the state places in the 'high' categorical risk level, and anyone owning 5% or more of such a provider, must submit fingerprints for a criminal background check.

Site visit

Risk levels for site-visit purposes follow DMAP's published taxonomy screening-level lists. Federal rule (42 CFR 455.432, 455.450(b)-(c)): the state must do site visits before and after enrollment for providers in the 'moderate' or 'high' risk levels, and any enrolled provider must allow unannounced on-site inspections.

Revalidation

DMAP mails revalidation instructions 60 days before the due date and terminates providers who miss it; it warns that CMS is requiring many providers to revalidate within the next 24 months. Federal rule (42 CFR 455.414): every enrolled provider must be revalidated at least once every 5 years.

Full Delaware Medicaid enrollment guide →

For this business

Required (licensing source)

CON program

Yes

Program

Certificate of Public Review (CPR)

Agency

Delaware Health Resources Board, staffed by the Bureau of Health Planning and Resources Management (Department of Health and Social Services)

Services covered

• hospitals
• nursing homes
• freestanding surgical centers
• freestanding birthing centers
• freestanding acute inpatient rehabilitation hospitals
• freestanding emergency centers
• capital expenditures above $5.8 million (inflation-adjusted)
• bed capacity changes of more than 10 beds or 10% (whichever is less) over 2 years
• acquisition of a nonprofit health-care facility

Moratoria

Until July 1, 2028, only charities / not-for-profit entities may apply for a Certificate of Public Review to build, establish or acquire an acute care hospital; the Board may not accept other applicants (16 Del. C. §9304(b), added by 85 Del. Laws c. 350).

Delaware certificate of need details →

State minimum wage

$15.00 an hour

Effective

2025-01-01

Scheduled increases

No scheduled change found in the official sources reviewed.

HCBS 80/20 rule

Federal baseline: 42 CFR 441.302(k) requires the state to show that each provider spends at least 80% of Medicaid payments for homemaker, home health aide and personal care services under 1915(c) waivers on direct care worker pay and benefits. Compliance starts 2030-07-09 (for managed care, the first rating period starting on or after that date); annual payment-adequacy reporting under 441.311(e) starts 2028-07-09. A state may set a lower share for state-defined small providers and exempt providers facing hardship, each only through a public notice-and-comment process. The eCFR text has not changed since 2024-07-09. No state-published 80/20 implementation step (small-provider criteria, hardship exemption or reporting guidance) was found for this state in the official sources reviewed.

Skilled nursing facilities — active organization NPIs (NPPES)

103 (as of Sep 13, 2026)

Medicare/Medicaid-certified nursing homes (CMS Care Compare)

44 (as of Aug 1, 2026)

Total Medicaid and CHIP enrollment (latest reported month)

234,783 (as of Jun 1, 2026)