CurrentDelaware Department of Health and Social ServicesPolicy A-04-2026

Retroactive Eligibility Clarification for Assisted Living

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Governs Delaware Medicaid eligibility and service coverage for Assisted Living services classified as Long Term Care Community Services. Coverage cannot begin retroactively and requires MCO enrollment plus completion of required HCBS assessment and Person-Centered Service Plan steps.

Policy Summary

PayerDelaware Department of Health and Social Services

PolicyRetroactive Eligibility Clarification for Assisted Living

Policy CodePolicy A-04-2026

Change TypeMaterial coverage clarification

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDo not authorize or provide retroactive Assisted Living coverage; begin coverage no earlier than MCO enrollment and completion of all federal HCBS requirements.

SourceLink

POLICY UPDATE CHANGES

Delaware Medicaid no longer permits retroactive Medicaid eligibility or coverage for Assisted Living services.

The policy distinguishes Assisted Living retroactive eligibility from prior retroactive eligibility practices used for Nursing Facility services.

Staff must issue a manual denial notice for requested retroactive LTCCS eligibility until the ASSIST Worker Web system is updated.

0Retroactive Assisted Living coverage permitted

2HCBS authorities identified

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CurrentDelaware Department of Health and Social ServicesPolicy A-04-2026

Retroactive Eligibility Clarification for Assisted Living

Customize your policy alerts

Sign up for Delaware Department of Health and Social Services Policy A-04-2026 alerts

Get alerted when Policy A-04-2026 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDelaware Department of Health and Social Services

PolicyRetroactive Eligibility Clarification for Assisted Living

Policy CodePolicy A-04-2026

Change TypeMaterial coverage clarification

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDo not authorize or provide retroactive Assisted Living coverage; begin coverage no earlier than MCO enrollment and completion of all federal HCBS requirements.

SourceLink

POLICY UPDATE CHANGES

Delaware Medicaid no longer permits retroactive Medicaid eligibility or coverage for Assisted Living services.

The policy distinguishes Assisted Living retroactive eligibility from prior retroactive eligibility practices used for Nursing Facility services.

Staff must issue a manual denial notice for requested retroactive LTCCS eligibility until the ASSIST Worker Web system is updated.

0Retroactive Assisted Living coverage permitted

2HCBS authorities identified

Assisted Living Coverage Rules

Prospective Assisted Living Coverage Criteria

Assisted Living services are covered prospectively under LTCCS when all applicable enrollment and federal HCBS requirements are satisfied.

ALL of the following

The individual is determined eligible for LTCCS, including Assisted Living services, and enrolls in a Managed Care Organization (MCO).
LTCCS is authorized under the Diamond State Health Plan (DSHP) 1115 Demonstration and requires MCO enrollment for service coverage.
The effective date of MCO enrollment has occurred.
All federal HCBS requirements are met, including completion of the assessment and implementation of the Person-Centered Service Plan (PCSP) with informed written consent.

Retroactive Assisted Living Coverage Exclusion

Effective May 1, 2026, Medicaid eligibility for Assisted Living services cannot be applied retroactively. The retroactive eligibility period means the month or months before the month in which the individual applies for services.

Coverage exclusion

Assisted Living services are not covered for any period before the effective date of MCO enrollment.
Assisted Living services are not covered before completion of the assessment and implementation of the PCSP with informed written consent.
Coverage does not begin on the date of Medicaid eligibility determination and cannot be applied to prior months.

Coverage Start Date

Coverage Start

Earliest coverage startThe later of the effective date of MCO enrollment or the date all federal HCBS requirements are met.

Required Staff and Enrollment Actions

Prior Authorization

Apply prospective coverage start requirements

Do not authorize or provide retroactive Assisted Living coverage. Coverage may begin no earlier than the later of the effective date of MCO enrollment and the date all federal HCBS requirements are met, including completion of the assessment and implementation of the Person-Centered Service Plan with informed written consent.

Denial Risk

Issue manual denial for retroactive requests

For applicants requesting retroactive eligibility for LTCCS, complete a manual denial notice until the ASSIST Worker Web system is updated. The notice must state that federal regulations require the Person-Centered Service Plan to be completed and signed before Home and Community Based Services can be provided, and that services cannot be approved before PCSP completion.

Use the required rationale citing 42 CFR §441.301(c)(2) and 42 CFR §441.725(b).

Key Terms

Definitions

Retroactive eligibility periodThe month or months before the month in which the individual applies for services.

Definitions

Person-Centered Service Plan (PCSP)A plan that must be developed, finalized, and completed with the individual's informed written consent before HCBS service delivery.

Definitions

LTCCSLong Term Care Community Services, including Assisted Living services.