Delaware Medicaid Fee Schedule 2026

Last Updated: January 31, 2026

The Delaware Medicaid fee schedule for 2026 includes major provider reimbursement updates approved by CMS.

Most services are paid through the Delaware Medical Assistance Program (DMAP) fee schedule or Managed Care Organizations (MCOs).

The state approved a 5% uniform rate increase for personal care services starting January 1, 2026.

The 2026 fee schedule affects providers and members across the state. Here’s what changed this year and what you need to know.

Quick Summary:

• HCBS personal care services got a 5% uniform rate increase
• New $750 institutional provider enrollment fee effective Jan 1, 2026
• Hospital Quality and Health Equity Fund distributes $40 million
• Dental fee schedule remains effective from April 2025
• Behavioral health physicians paid at 98% of Medicare rates
• Personal care payment level increased from 70.2% to 73.8% of the benchmark

2026 Key Rate Updates

Delaware Medicaid made several significant rate changes in 2026. These updates affect how providers get paid. They also impact long-term care cost calculations and enrollment requirements.

The fee schedule is published in the Delaware Register of Regulations.

All rates are also available on the DMAP website at medicaidpublications.dhss.delaware.gov.

Home and Community-Based Services (HCBS)

CMS approved a 5% uniform percentage increase for personal care service claims. This State Directed Payment (SDP) runs from January 1, 2026 through December 31, 2026.

The increase applies to both DSHP and DSHP Plus managed care programs. MCOs must pass through this rate increase to providers for eligible personal care claims.

Financial Impact:

• Total program impact: $14,563,263
• Federal share: $8,652,035
• State share: $5,911,228

The base payment level was 70.2% of the benchmark. After the 5% increase, the total payment reaches 73.8% of the benchmark.

This helps raise wages for Direct Support Professionals (DSPs) and stabilizes the home care workforce.

The increase was based on a 2024 provider fee study. Mercer Health & Benefits LLC conducted the analysis.

The state legislature appropriated the non-federal share to fund this directed payment.

Provider Enrollment Fee Change

Starting January 1, 2026, institutional providers must pay a $750 application enrollment fee. This applies to initial applications, reactivations, and revalidations.

Individual providers and group practices have different fee structures. Check the DMAP Provider Portal for your specific category. Budget for this fee when planning enrollment or revalidation.

Hospital Quality and Health Equity Fund

Delaware operates a Hospital Quality and Health Equity Fund. This fund uses provider assessments to draw down federal matching dollars. For 2026, the fund includes approximately $40 million in hospital provider assessment revenue.

Inpatient Payment Pool Distribution:

• 90% – Uniform payment increase for acute care inpatient days (Medicaid managed care)
• 6% – Uniform payment increase for inpatient rehabilitation days
• 4% – Uniform payment increase for behavioral health days

Outpatient Payment Pool Distribution:

• 99.5% – Uniform payment increase for outpatient hospital visits
• 0.5% – Uniform payment increase for partial hospitalization program services

Overall Fund Allocation:

• 66% of total funds increase payments to hospitals
• 34% for other approved uses including administrative expenses and managed care reimbursement

This structure ensures hospitals receive additional Medicaid payments. It also helps offset the cost of caring for Medicaid beneficiaries.

Dental Services

The dental fee schedule effective April 1, 2025 remains in effect for 2026 until updated. Providers should continue using these rates. Updates typically post in the spring.

Selected Maximum Allowable Rates:

• D1206 (Topical Fluoride Varnish): $37.82
• D1351 (Dental Sealant per tooth): $51.85
• D5110 (Complete Maxillary Denture): $2,039.23
• D5120 (Complete Mandibular Denture): $2,052.30

Adult dental coverage is limited to specific populations. This includes pregnant women (including the 90-day postpartum period), individuals in long-term care facilities, hospice patients, and those under 21.

Behavioral Health Services

Behavioral health reimbursement varies by provider type. The methodology comes from the 2016 manual and still applies for 2026 rate development.

This tiered structure ensures qualified mental health professionals receive appropriate reimbursement. Physicians and psychologists get the highest rates at 98% of Medicare.

Licensed clinical social workers and therapists receive 75% of the physician rate. This still provides competitive compensation while controlling costs.

Provider Reimbursement Schedules

Most Delaware Medicaid services are reimbursed through the Delaware Medical Assistance Program (DMAP) fee schedule. Some services go through Managed Care Organizations like Highmark Health Options and AmeriHealth Caritas Delaware.

The core payment principle is simple. Medicaid fee schedule rates are set equal to or less than the maximum allowable under Medicare rates. This applies where comparable Medicare rates exist.

Cost-Based Modeling

Delaware develops rates using provider cost modeling. This includes staffing assumptions, wages, and benefits like FICA, unemployment, and workers compensation. Program expenses, overhead, and billable units are all factored in.

Room and board costs are explicitly excluded from the fee schedule. This is standard practice across most state Medicaid programs.

Publication and Transparency

All rates are published in the Delaware Register of Regulations. They’re also available on the DMAP website at medicaidpublications.dhss.delaware.gov.

By July 1, 2026, federal rules require complete transparency. States must publish full fee schedules online. They must also provide formal comparisons between Medicaid and Medicare payment rates.

Providers should expect increased rate transparency after this deadline. This makes it easier to verify reimbursement amounts and compare rates.

Fee-for-Service vs. Managed Care

Fee-for-Service (FFS) uses published DMAP fee schedules. Managed Care (DSHP and DSHP Plus) allows MCOs to negotiate rates with providers.

However, MCOs must comply with state-directed payments. The 5% personal care increase is mandatory. MCOs must pass through these payments to providers.

Telehealth Services

Delaware Medicaid covers telehealth services with specific billing rules. These rules help ensure proper reimbursement while preventing fraud.

Originating Site Facility Fee:

• Billable using HCPCS code Q3014
• Covered unless the originating site is the patient’s home
• One fee per provider per day

Distant Site Providers:

• Bill usual and customary charges
• Follow standard billing procedures for your specialty

Limitations:

• Up to 3 different consulting practitioners per date of service
• Up to 3 originating site providers per date (one fee per provider per day)

Non-Covered Services:

• Chart reviews conducted remotely
• Email, fax, or internet consultations
• Online medical evaluations without real-time interaction

Documentation is critical for telehealth claims. You must document medical necessity, visit type, patient location, and consent. Missing documentation leads to audit disallowances.

Multiple Surgery Payment Rules

Delaware follows specific payment guidelines when billing multiple surgeries. Understanding these rules prevents claim denials and underpayment.

Multiple Major Related Procedures (through one incision):

• Full fee for primary procedure only
• Secondary procedures bundled into primary

Major Unrelated Procedures:

• Full fee for primary procedure
• Half fee (50%) for secondary procedures

Minor Unrelated Procedures:

• Full fee for primary procedure
• Half fee (50%) for secondary procedures

Bilateral Procedures:

• Use modifier 50 with one unit
• Only if designated as bilateral by DMAP
• Check fee schedule for bilateral designation

Ensure proper use of modifiers. Incorrect modifier usage is a common reason for claim denials. When in doubt, contact the provider services line before submitting.

Comparison to Medicare Benchmarks

Delaware Medicaid rates are generally benchmarked against Medicare. However, they typically reimburse at lower levels. This is standard across most state Medicaid programs.

Current Payment Levels (2026):

• Personal Care Services: 73.8% of benchmark midpoint (up from 70.2%)
• Behavioral Health Physicians: 98% of Medicare
• Mid-level Behavioral Health Providers: Equivalent to physician rates (≈98% of Medicare)
• Behavioral Health Specialists (LCSW, LMFT): 75% of physician rates

National Context: Medicaid typically pays 30-40% less than Medicare across all states. Delaware’s rates are relatively competitive within this national landscape.

The 5% increase for personal care services represents progress. However, significant disparity remains between Medicaid and Medicare rates. Providers should monitor legislative sessions for future rate increases.

For comparison across states, see Medicaid fee schedule in 2026 and the Medicaid income limits by state in 2026.

FY2026 Budget Context

The Delaware FY2026 budget includes significant Medicaid provider payment investments. These investments show the state’s commitment to improving access and quality.

Key Budget Allocations:

• $85.5 million increase in state funds for Medicaid inflation, volume, and new benefits
• $1.5 million one-time hospital provider contingency funds
• $1,131,300 for Direct Support Professional rate adjustments in developmental disability services
• $40 million anticipated from hospital provider assessment revenue (Senate Bill 13)

These investments supplement the 5% personal care rate increase. They also support hospital reimbursement through the Quality and Health Equity Fund.

Providers should monitor the Joint Finance Committee hearings this spring. Additional rate proposals may emerge as the budget process continues.

Collaborative Care Management (CoCM)

Delaware covers Collaborative Care Management codes for behavioral health integration. These include CPT codes 99492-99494 and G2214.

However, as of January 2026, specific rates are not publicly listed on the Medicaid fee schedule. Fee schedule comparisons list these as “Undetermined” relative to Medicare rates.

Providers offering CoCM services should contact the DMAP Provider Services line. Request current reimbursement rates before submitting claims. Rates may be available on a case-by-case basis pending formal publication.

Juvenile Justice Initiative

Delaware has a targeted program for eligible juveniles in the justice system. State Plan Amendment (SPA 25-0001) is effective through December 31, 2026.

This initiative provides targeted case management and screening services. Coverage begins 30 days pre-release and continues 30 days post-release from public institutions.

Reimbursement uses standard DMAP fee schedules. Providers must verify eligibility and document services carefully. This population requires specialized care coordination.

Practical Guidance for Providers

Providers should take several steps to ensure smooth billing in 2026. Staying updated on rate changes and system maintenance is critical.

Rate Verification

Monitor the Delaware Medical Assistance Portal regularly. Visit medicaid.dhss.delaware.gov/provider for the most current fee schedules.

Rates are updated periodically. All changes are published in the Register of Regulations. Set a weekly reminder to check for Provider Notices.

Enrollment Costs

Budget for the new $750 enrollment fee if you’re an institutional provider. This applies to initial applications, reactivations, and revalidations starting January 1, 2026.

Individual providers have different fee structures. Verify your provider category before submitting payment.

Personal Care Providers

Expect the 5% rate increase to apply to claims dated January 1, 2026 and later. MCOs must pass through this increase for eligible personal care claims.

If you don’t see the increase reflected in remittance, contact your MCO immediately. Retroactive adjustments should be applied for applicable managed care claims.

Multiple Surgery Billing

Use proper modifiers and bundling rules. This prevents claim denials. Bilateral procedures require Modifier 50. Multiple surgeries receive 50% payment for secondary procedures.

Review the fee schedule for specific procedure bundling rules. Some procedures cannot be billed together on the same date.

Telehealth Documentation

Document medical necessity clearly. Include visit type, patient location, and consent in your records. Missing documentation is the top reason for telehealth audit disallowances.

Store telehealth records for at least 7 years. Delaware may audit claims years after service delivery.

July 1, 2026 Transparency Deadline

Expect increased transparency in rate comparisons after July 1, 2026. Federal rules require states to publish Medicaid-to-Medicare rate comparisons.

This will make it easier to verify you’re receiving correct reimbursement. You’ll be able to compare Delaware rates to Medicare directly.

How to Apply for Delaware Medicaid

If you need help paying for health care or long-term care, you can apply for Delaware Medicaid. The application process is straightforward. Assistance is available at every step.

Online Application

Visit the Delaware ASSIST portal at assist.dhss.delaware.gov. Create an account and complete the application online. You’ll need to upload documents like proof of income and identity.

The system saves your progress if you need to take a break. Most people complete the application in 20-30 minutes.

In-Person Application

You can apply at your local Division of Social Services (DSS) office. Bring your ID, proof of income, and asset statements. A caseworker will help you fill out the forms.

Appointments are recommended but walk-ins are accepted. Call ahead to check current wait times.

Application Timeline

Most applications are processed within 45 days. Long-term care applications may take up to 90 days due to additional asset verification.

You’ll receive a written notice of the decision. If approved, coverage often starts the month you applied. Retroactive coverage may be available for up to 3 months.

Need Help?

Call the Medicaid Helpline at 1-800-372-2022. Representatives are available Monday through Friday, 8 AM to 5 PM. You can also contact a local community health center.

Many offer free application assistance. They can help gather documents and submit your application.

Frequently Asked Questions

What is the Delaware Medicaid fee schedule for 2026?

The Delaware Medicaid fee schedule sets provider reimbursement rates. For 2026, HCBS personal care services received a 5% uniform rate increase effective January 1. Behavioral health physicians are paid at 98% of Medicare rates. Institutional providers pay a $750 enrollment fee.

How much is the new provider enrollment fee?

Institutional providers must pay $750 at initial application, reactivation, and revalidation starting January 1, 2026. This fee is required before enrollment is processed. Individual providers and group practices have different fee structures based on provider category.

What is the HCBS rate increase for 2026?

CMS approved a 5% uniform percentage increase for personal care service claims. The total program impact is $14.6 million. This raises the payment level from 70.2% to 73.8% of benchmark. The increase supports higher wages for direct care workers.

How are behavioral health services reimbursed?

Physicians and psychologists receive 98% of Medicare rates. Clinical nurse specialists, nurse practitioners, and physician assistants receive 100% of Delaware Medicaid physician rates (approximately 98% of Medicare). Licensed clinical social workers and therapists receive 75% of the physician rate.

When will dental rates be updated?

Delaware typically releases dental fee schedule updates in the spring. The current schedule from April 2025 remains in effect until the new one is posted. Providers should check the DMAP portal for announcements expected around March or April 2026.

What is the hospital provider assessment for 2026?

The Hospital Quality and Health Equity Fund includes approximately $40 million from hospital provider assessments. This draws down federal matching funds. 66% of total funds increase hospital payments. 90% of inpatient payments go to acute care services. 99.5% of outpatient payments support hospital visits.

Additional Resources

For more information about Delaware Medicaid, visit these official sources:

• Delaware Division of Medicaid and Medical Assistance (DMMA)
• DMAP Provider Portal
• Delaware Medicaid Publications: medicaidpublications.dhss.delaware.gov
• Compare eligibility across the country: Medicaid fee schedule 2026

Stay informed about policy changes and rate updates. Check official sources regularly to ensure you have the most current information. The July 1, 2026 transparency deadline will make rate comparisons easier for all providers.