Long Term Care Services & Supports from Delaware’s Diamond State Health Plan – Plus (DSHP-Plus)

Last updated: February 21, 2024

 

Overview of Delaware Medicaid DSHP-Plus

Delaware’s Diamond State Health Plan Plus (DSHP-Plus, DSHP Plus, or DSHP+) Program is a mandatory managed care Medicaid program that provides long-term care services and supports for DE residents who are elderly or physically disabled. While nursing home facility care is available via this program, so is a variety of home and community based services (HCBS) to prevent and / or delay nursing home admissions. Examples of potential HCBS include adult day care, home meal delivery, personal care assistance, personal emergency response systems, and respite care.

In addition to long-term care, DSHP-Plus program participants receive medical and behavioral health benefits via a single Medicaid health plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. DSHP-Plus program participants have a choice of long-term care managed care health plans.

There is, however, some flexibility of providers for persons receiving long-term care services via DSHP Plus. Some benefits, such as attendant care services, can be participant-directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. Friends and relatives, including spouses and adult children, can be hired. A financial management services agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.

DSHP-Plus program participants can reside in a variety of settings. This includes one’s home, the home of a loved one, an adult foster care home (rest residential care home), an assisted living facility, or a nursing home.

The Diamond State Health Plan (DSHP) is the state’s Medicaid managed care program for persons who do not need long-term care services and supports (LTSS). The DSHP-Plus Program is the managed care program through which state benefits, nursing facility care, and home and community based services are provided. Formally, the DSHP-Plus Program is broken into two programs: The Nursing Facility Program and the Long Term Care Community Services (LTCCS) Program. DSHP and DSHP-Plus Programs both operate under the Diamond State Health Plan Section 1115 Waiver Demonstration Waiver. They are entitlement programs; meeting eligibility requirements equates to immediate receipt of program benefits.

 What is Medicaid Managed Care?
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.

 

Benefits of Delaware Medicaid DSHP-Plus

In addition to medical benefits, such as doctor’s appointments, laboratory services, x-rays, and hospitalization, dental, behavioral health benefits, and nursing facility care, a variety of home and community based services (HCBS) are available via DSHP Plus. While all program participants receive case management, an individualized service plan determines which other HCBS a program participant receives. Potential benefits are as follows. Those marked with an asterisk can be participant-directed.

– Adult Day Care
– Chore Services* – preparing meals, light housecleaning, laundry, shopping for essentials
– Cognitive Services – counseling / therapy for program participants and their families
– Community Based Residential Services – services (i.e., personal care, homemaker, meal preparation) provided in assisted living facilities / adult foster care homes
– Day Habilitation
– Home Delivered Meals
– Minor Home Modifications – i.e., installation of wheelchair ramps, hand rails, and grab bars
– Nutritional Supports – for persons diagnosed with AIDS
– Personal Care / Attendant Care* – assistance with daily living activities (i.e., bathing, dressing, eating, mobility, meal preparation, light housekeeping)
– Personal Emergency Response Systems
– Respite Care* – in-home and out-of-home short-term care to alleviate a primary caregiver
– Specialized Medical Equipment / Supplies
– Support for Participant-Directed Care – information, counseling, training, and assistance with self-directing one’s care
– Transitional Services – assistance for persons moving from a nursing home facility back into the community

While program participants can reside in an adult foster care home or an assisted living residence, DSHP+ does not cover the cost of room and board.

 

Eligibility Requirements for Delaware Medicaid DSHP-Plus

The DSHP-Plus Program is for Delaware residents who are elderly (65+ years old), physically disabled, or have specific diagnosis, such as AIDS. Additional eligibility criteria follows and is relevant for seniors who require long-term home and community based services.

 The American Council on Aging provides a Delaware Medicaid Eligibility Test for seniors that require long-term care. Start Here

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is $2,358 / month. This figure is equivalent to 250% of the Federal Benefit Rate (FBR) for 2024. When both spouses of a married couple are applicants, each spouse is considered as a single applicant and is permitted income up to $2,358 / month. When only one spouse is an applicant, the $2,358 / month income limit applies to the applicant spouse, and the income of the non-applicant spouse is disregarded. Furthermore, in some cases, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance.

In Delaware, there is a minimum income allowance, which is set at $2,465 / month (eff. 7/1/23 – 6/30/24). This allows the applicant spouse to transfer up to $2,465 / month to their non-applicant spouse in order to bring the non-applicant’s total monthly income up to $2,465. In 2024, the state also sets a maximum income allowance of $3,853.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount they can receive is dependent on their shelter and utility costs. However, a Spousal Income Allowance can never push a non-applicant’s total monthly income over $3,853.50.

Assets
In 2024, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can retain up to $2,000 in assets, while the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment.

The CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If 50% of the couple’s assets falls under $30,828, the non-applicant spouse can keep all of the couple’s assets, up to this amount.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Medicaid Spend Down Calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, Medicaid in Delaware considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has Intent to Return, and their home equity interest is no greater than $713,000 (in 2024). Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child living in the home.
– The applicant has a disabled or blind child of any age living in the home.

While the home is likely exempt while one is receiving Medicaid benefits, it may not be safe from Medicaid’s Estate Recovery Program. Learn more about the potential of Medicaid taking the home here.

 

Medical Criteria: Functional Need

An applicant must be “at risk” of requiring a Nursing Facility Level of Care (NFLOC). To make this determination, a level of care (LOC) screening (functional assessment) is completed by DE’s Division of Medicaid & Medical Assistance Pre-Admission Screening (PAS) team. To be considered “at risk” one must require assistance with 1 of the Activities of Daily Living (ADLs). This includes activities such as bathing, dressing, mobility, toileting, eating, and transitioning from one position to another. While persons with Alzheimer’s Disease or a related dementia can meet the level of care criteria, a diagnosis in and of itself does not mean one will automatically meet it.

 Learn more about long-term care Medicaid in Delaware.

 

Qualifying When Over the Limits

Having income and / or assets over Delaware’s Medicaid limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of Medicaid planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

When persons have income over the limits, Miller Trusts, also called Qualified Income Trusts, can help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs), are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on medical bills, household furnishings and appliances, or even a vacation. Another option, although it must be implemented well in advance of the need for Medicaid-funded long-term care, is the Long Term Care Partnership Program. In DE, this is specifically called the Delaware Long-Term Care Insurance Partnership Program. Not only does it allow some assets to be exempt from Medicaid’s asset limit, but it also protects them from Medicaid’s Estate Recovery Program. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Delaware to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. These strategies often violate Medicaid’s 60-month Look-Back Rule, and therefore, should be executed years prior to the need for long-term care. However, there are some workarounds, such as the Modern Half a Loaf Strategy, and DE Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.

 

How to Apply for Delaware Medicaid DSHP-Plus

Before You Apply

Prior to applying for the DSHP-Plus Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

Persons can begin the process of applying for the Delaware State Health Plan – Plus Program by requesting an application packet from the Division of Medicaid & Medical Assistance (DMMA) Central Intake Unit (CIU). DMMA CIU can be reached at 866-940-8963.

Although not necessarily intended for a consumer audience, additional information about the DSHP-Plus Program can be found here. Persons can also call Medicaid Customer Relations at 866-843-7212 or the DMMA Central Intake Unit at 866-940-8963.

The Division of Medicaid & Medical Assistance (DMMA) and the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) within the Delaware Health and Social Services (DHSS) administers DSHP-Plus.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.

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