Delaware Long-Term Care Medicaid Application Packet (DSHP-Plus)

DELAWARE LONG-TERM CARE MEDICAID APPLICATION PACKET (DSHP-Plus)

TABLE OF CONTENTS

1. Applicant Identification and Filing Office
2. Program Selection (DSHP-Plus Track)
3. Categorical Eligibility
4. Income Eligibility (2026 Limits)
5. Resource (Asset) Eligibility (2026 Limits)
6. Spousal Impoverishment Calculations
7. Primary Residence and Home Equity
8. 60-Month Look-Back and Transfer Penalty
9. Spend-Down Plan
10. Level of Care (NFLOC) Determination
11. Required Documentation Checklist
12. Authorized Representative and HIPAA
13. Applicant Verification and Signature
14. Cover Letter to DMMA Central Intake Unit
15. Delaware Practice Notes
16. Sources and References

1. APPLICANT IDENTIFICATION AND FILING OFFICE

Filing office. Application is submitted to the Delaware Division of Medicaid and Medical Assistance (DMMA) Central Intake Unit (CIU):

• DMMA Central Intake Unit, 1901 N. DuPont Highway, New Castle, DE 19720
• Toll-free: 1-866-940-8963
• Online portal: ASSIST (Delaware) — https://assist.dhss.delaware.gov

2. PROGRAM SELECTION (DSHP-PLUS TRACK)

Applicant is applying for (check one):

• ☐ DSHP-Plus Nursing Facility Program (skilled nursing facility / institutional care)
• ☐ DSHP-Plus Long-Term Care Community Services (LTCCS) (home and community-based services, including in-home personal care, adult day services, assisted living, and PACE)

3. CATEGORICAL ELIGIBILITY

Applicant qualifies under (check all that apply):

• ☐ Aged (65 or older)
• ☐ Blind (as determined under SSA criteria)
• ☐ Disabled (Title II/Title XVI determination or DDDS/DMMA disability determination)

Documentation attached: [ ☐ SSA award letter ☐ Disability determination ☐ Birth certificate ☐ Other: ____________ ]

4. INCOME ELIGIBILITY (2026 LIMITS)

Delaware income cap (DSHP-Plus): $2,485 per month gross per applicant (250% of the 2026 Federal Benefit Rate). Confirm current figure with DMMA before filing.

Income above the cap. If applicant's gross monthly income exceeds the DSHP-Plus income cap, applicant must establish a Qualified Income Trust ("Miller Trust") under 42 U.S.C. § 1396p(d)(4)(B). Trust documentation is attached at [ ☐ Tab _____ ].

5. RESOURCE (ASSET) ELIGIBILITY (2026 LIMITS)

Asset limits (DSHP-Plus, 2026):

• Single applicant: $2,000
• Married, both spouses applying: $3,000
• Married, one spouse applying: $2,000 (applicant) + Community Spouse Resource Allowance (CSRA) up to $162,660 (community spouse), with a CSRA floor of $32,532

6. SPOUSAL IMPOVERISHMENT CALCULATIONS

Complete this section ONLY if applicant is married and the community spouse resides outside an institution.

7. PRIMARY RESIDENCE AND HOME EQUITY

Primary residence is EXEMPT for eligibility if any of the following apply (check all that apply):

• ☐ Applicant resides in the home OR intends to return (intent is presumed unless rebutted)
• ☐ Community spouse resides in the home
• ☐ Minor, blind, or disabled child of applicant resides in the home
• ☐ Sibling with equity interest who has resided in the home for at least one year prior to institutionalization
• ☐ Caretaker child who resided in the home and provided care for at least two years prior to institutionalization (relevant to transfer rules; see § 8)

8. 60-MONTH LOOK-BACK AND TRANSFER PENALTY

Look-back period. Delaware applies a 60-month look-back to all non-exempt transfers for less than fair market value made before the application date or the date of institutionalization (whichever is later). 42 U.S.C. § 1396p(c).

Transfer penalty divisor (Delaware, 2026). Approximately $11,200 per month (the average statewide private-pay nursing facility rate published by DMMA). A $100,000 uncompensated transfer therefore yields approximately 8.93 months of ineligibility. Confirm the current divisor with DMMA before filing.

Total uncompensated transfers within look-back: [$________]

Calculated penalty period: [$________] ÷ [$11,200] = [____] months of ineligibility, beginning the date applicant is otherwise eligible.

Exempt transfers (no penalty) include transfers to: (a) a spouse, or to another for the sole benefit of the spouse; (b) a blind or disabled child; (c) a trust solely for the benefit of a disabled individual under 65; (d) a sibling with equity interest residing in the home for one year prior; (e) a caretaker child residing in the home and providing care for two years prior. 42 U.S.C. § 1396p(c)(2).

9. SPEND-DOWN PLAN

If countable resources exceed the applicable limit, applicant proposes the following spend-down (must be for fair market value or on exempt purposes):

Permissible spend-down categories (non-exhaustive):

• Pre-paid irrevocable funeral and burial contracts (within DMMA limits)
• Outstanding medical and dental bills
• Home repairs, accessibility modifications (community spouse)
• Replacement of one vehicle for the community spouse
• Pay-off of mortgage, real estate taxes, homeowner's insurance on exempt residence
• Personal effects, household goods of reasonable value
• Medicaid-compliant single-premium immediate annuity for community spouse (with state as remainder beneficiary to extent of Medicaid paid)

10. LEVEL OF CARE (NFLOC) DETERMINATION

Both DSHP-Plus tracks require a Nursing Facility Level of Care (NFLOC) determination. Applicant requests evaluation by:

• ☐ DMMA Pre-Admission Screening unit (institutional)
• ☐ DSAAPD/DMMA Long-Term Care Community Services assessor (HCBS)

Functional impairments documented (check all that apply):

• ☐ Bathing
• ☐ Dressing
• ☐ Toileting
• ☐ Transferring
• ☐ Continence
• ☐ Eating/feeding
• ☐ Medication management
• ☐ Meal preparation
• ☐ Mobility
• ☐ Cognitive impairment / dementia (specify diagnosis: [___________])
• ☐ Behavioral/psychiatric needs requiring supervision

Attached medical documentation: [ ☐ Physician statement ☐ Recent H&P ☐ Discharge summary ☐ Cognitive assessment (MMSE/MoCA) ☐ Other ]

11. REQUIRED DOCUMENTATION CHECKLIST

The following must be attached. Mark each item.

• ☐ Photo identification (driver's license / state ID / passport)
• ☐ Social Security card or SSA verification
• ☐ Birth certificate (or proof of age)
• ☐ Marriage certificate (if applicable)
• ☐ Divorce decree / separation order (if applicable)
• ☐ Death certificate of deceased spouse (if applicable)
• ☐ Citizenship/immigration documentation
• ☐ Medicare card (Parts A/B/D) and supplemental insurance cards
• ☐ Five years of bank statements (all institutions, all account types)
• ☐ Five years of brokerage / IRA / 401(k) statements
• ☐ Most recent tax returns (federal and Delaware)
• ☐ Deeds for all real property owned within five years
• ☐ Vehicle titles and registrations
• ☐ Life insurance policies (face/cash value statements)
• ☐ Burial contracts and trust documents
• ☐ Trust instruments (revocable and irrevocable)
• ☐ Annuity contracts
• ☐ Promissory notes and loan documents
• ☐ Pension/retirement award letters
• ☐ VA award letter (if applicable)
• ☐ Long-term care insurance policy
• ☐ Power of attorney / advance directive
• ☐ Guardianship orders (if applicable)
• ☐ Physician statement / NFLOC assessment
• ☐ Spend-down receipts and supporting documentation

12. AUTHORIZED REPRESENTATIVE AND HIPAA

Applicant designates the following authorized representative for this Medicaid application and any redetermination, fair hearing, or appeal:

Applicant authorizes DMMA, the Social Security Administration, financial institutions, healthcare providers, and other custodians of records to release information necessary to determine Medicaid eligibility and to communicate directly with the authorized representative under HIPAA (45 C.F.R. § 164.502).

13. APPLICANT VERIFICATION AND SIGNATURE

I, [APPLICANT NAME], declare under penalty of perjury under the laws of the State of Delaware that the information provided in this application packet is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information is a violation of 31 Del. C. § 1004 and federal law (42 U.S.C. § 1320a-7b) and may result in denial of benefits, recoupment, civil penalties, and criminal prosecution.

Date: [__/__/____]

Signature of applicant (or authorized representative): [________________________________]

Print name: [________________________________]

Capacity: [________________________________]

14. COVER LETTER TO DMMA CENTRAL INTAKE UNIT

[DATE]

DMMA Central Intake Unit
1901 N. DuPont Highway
New Castle, DE 19720

Re: Application for DSHP-Plus Long-Term Care Medicaid
Applicant: [NAME]
DOB: [__/__/____]
SSN: [XXX-XX-XXXX]

Dear DMMA:

Enclosed please find the completed DSHP-Plus Long-Term Care Medicaid application packet for the above-named applicant, requesting [ ☐ Nursing Facility ☐ LTCCS ] coverage with a requested effective date of [__/__/____].

The packet includes (i) the completed application; (ii) supporting financial and identity documentation; (iii) a transfer disclosure and, where applicable, a spend-down plan; (iv) medical documentation in support of the NFLOC determination; and (v) a HIPAA-compliant authorized representative designation.

Please direct all correspondence and requests for additional documentation to the undersigned authorized representative. We respectfully request notice of any verification deadline at least seven (7) days in advance.

Respectfully submitted,

[________________________________]

[AUTHORIZED REPRESENTATIVE NAME]

[FIRM / RELATIONSHIP]

[ADDRESS / PHONE / EMAIL]

15. DELAWARE PRACTICE NOTES

• Income cap. Delaware uses a 250%-of-FBR income cap for DSHP-Plus, which is lower than the 300%-of-FBR cap used in most "income cap" states. Applicants between 250% and 300% of FBR who would qualify in another state may still need a Qualified Income Trust here. 42 U.S.C. § 1396p(d)(4)(B).
• No statewide HCBS waitlist. Delaware eliminated its HCBS waiver waitlist when DSHP-Plus absorbed the legacy waivers in 2014. LTCCS is therefore an entitlement once eligibility is established.
• Transfer penalty divisor. Delaware uses a single statewide private-pay rate (approximately $11,200/month for 2026) — confirm the current figure with DMMA before quoting penalty periods.
• Estate recovery (MERP). Delaware actively pursues estate recovery against the probate estate of LTC recipients age 55 or older under 42 U.S.C. § 1396p(b) and 16 Del. Admin. C. § 14920. Hardship waivers and undue-hardship exceptions are available in narrow circumstances.
• Snapshot timing. The CSRA "snapshot" is taken on the first day of the first continuous 30-day period of institutionalization. Asset levels in the months following the snapshot do not reset the snapshot.
• Fair hearing rights. A denial, reduction, or termination triggers the right to a fair hearing within 90 days under 16 Del. Admin. C. § 5000. Aid pending appeal may be available if the request is filed within 10 days.
• Patient pay calculation. For institutional applicants, post-eligibility income is offset by (a) a $50 personal needs allowance; (b) Medicare and supplemental premiums; (c) MMNA to the community spouse; and (d) certain incurred medical expenses. The remainder is the "patient pay" amount owed to the facility.
• Annuities. Delaware enforces the DRA-2005 annuity rules: applicants must name the State of Delaware as remainder beneficiary up to the amount of Medicaid benefits paid, or the annuity may be deemed an uncompensated transfer.

16. SOURCES AND REFERENCES

• 42 U.S.C. § 1396 et seq. (Title XIX) — https://www.ssa.gov/OP_Home/ssact/title19/1900.htm
• 42 U.S.C. § 1396p (transfers, liens, estate recovery)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• Delaware Division of Medicaid and Medical Assistance — https://dhss.delaware.gov/dmma/
• DMMA Long-Term Care Medicaid programs — https://dhss.delaware.gov/dmma/ltcmedicaid/
• DSHP-Plus program overview — https://dhss.delaware.gov/dmma/dshpplus.html
• DMMA Administrative Notices — https://dhss.delaware.gov/dmma/admin_notices/
• Delaware Social Services Manual (DSSM) — 16 Del. Admin. C. § 14000 et seq.
• ASSIST Delaware online application portal — https://assist.dhss.delaware.gov
• Centers for Medicare & Medicaid Services (Medicaid Eligibility) — https://www.medicaid.gov/medicaid/eligibility/

Disclaimer: This packet is a working template and not a substitute for legal advice. Medicaid figures (income cap, asset limits, CSRA, MMMNA, home equity cap, transfer-penalty divisor) change at least annually. A Delaware-licensed elder law attorney must verify all figures and review the applicant's full financial history before submission.