District of Columbia - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The District of Columbia Department of Health Care Finance (DHCF) does not recognize "Skilled Respite" as a distinct, standalone Medicaid waiver service category, instead funding these nursing-level relief hours through the Elderly and Persons with Physical Disabilities (EPD) Waiver and the Individual and Family Support (IFS) Waiver under broader skilled nursing or home health authorizations. Providers must first obtain a Home Care Agency (HCA) license from DC Health and secure a Certificate of Need (CON) from the State Health Planning and Development Agency (SHPDA) before applying for Medicaid enrollment.

Approval requires navigating a strict sequencing of local regulatory approvals followed by DHCF's mandatory pre-enrollment steps. Prospective agencies must attend a mandatory quarterly Provider Information Session, submit a formal Letter of Intent (LOI) within 10 business days, and pass a pre-enrollment site visit conducted by Maximus, DHCF’s enrollment vendor, before gaining access to the Provider Data Management System (PDMS).

1. Service Definition and Scope

Because the District of Columbia does not operate a standalone "Skilled Respite" waiver service, these interventions are authorized as skilled nursing services utilized for caregiver relief. The service provides temporary, short-term nursing care for waiver participants whose complex medical needs exceed the scope of a standard home health aide or personal care aide.

Care is delivered by licensed nursing professionals in the participant's natural home or a licensed community setting to ensure medical stability while the primary unpaid caregiver is unavailable.

• Service Category: Skilled Nursing / Home Health (utilized for respite purposes).
• Target Population: EPD and IDD waiver participants requiring continuous nursing assessment, ventilator management, or complex medication administration.
• Delivery Setting: The participant's natural home or a licensed community setting.
• Excluded Settings: Hospitals, nursing facilities, or intermediate care facilities (ICFs).
• Staffing Level: Registered Nurse (RN) or Licensed Practical Nurse (LPN) operating under RN supervision.

2. Regulatory and Oversight Agencies

Multiple District of Columbia agencies oversee the licensure, need-approval, and Medicaid enrollment of agencies providing skilled nursing respite. Providers must maintain compliance with both health regulation standards and Medicaid waiver rules.

DHCF manages the financial and enrollment aspects, while DC Health handles clinical licensure and facility standards.

• Licensing Authority: DC Health, Health Regulation and Licensing Administration (HRLA) (https://dchealth.dc.gov).
• Medicaid Authority: Department of Health Care Finance (DHCF), Long-Term Care Administration (LTCA) (https://dhcf.dc.gov).
• Waiver Operating Agency (IDD): Department on Disability Services (DDS) (https://dds.dc.gov).
• Need Review Authority: State Health Planning and Development Agency (SHPDA) (https://dchealth.dc.gov/shpda).
• Enrollment Vendor: Maximus (conducts site visits and processes PDMS applications).

3. Gatekeeping Prerequisites: Who Can Even Apply

The District of Columbia imposes strict structural preconditions before a Medicaid provider application is accepted. A provider cannot simply enroll to provide skilled respite; they must hold specific facility licenses and pass mandatory DHCF pre-screening.

Failure to secure the necessary health planning approvals or missing the tight windows for the LOI submission will result in an immediate block from the enrollment portal.

• Certificate of Need (CON): Required from SHPDA for establishing a new Home Health Agency before licensure can be initiated.
• Licensure Prerequisite: Must hold an active Home Care Agency (HCA) license from DC Health.
• Mandatory Information Session: Prospective providers must register via the TA & T portal and attend a quarterly DHCF/LTCA session.
• Letter of Intent (LOI): Must be submitted via the official Smartsheet link within 10 business days of attending the information session.
• Corporate Registration: Proof of incorporation in the District of Columbia via the Department of Consumer and Regulatory Affairs (DCRA).

4. Licensure and Certification Requirements

Agencies must comply with the District of Columbia Municipal Regulations (DCMR) for Home Care Agencies to deliver skilled nursing services. This licensure ensures the agency has the clinical oversight necessary for complex care.

DC Health conducts initial and routine surveys to verify compliance with physical office requirements and clinical governance.

• Regulation Citation: 22-B DCMR Chapter 39 (Home Care Agencies).
• Operating Office: Must maintain a physical operating office within the District of Columbia, staffed at least eight hours per day, Monday through Friday.
• Administrator: Must employ a qualified agency administrator to oversee daily operations.
• Director of Nursing: Must employ a Registered Nurse as the Director of Nursing to oversee all skilled services.
• Plan of Care: Must be approved and signed by a physician within 30 days of the start of care.

5. Medicaid Provider Enrollment

After LOI approval, providers have a strict 90-day window to submit their application through the Provider Data Management System (PDMS). Maximus conducts the initial desk review and site visits.

The updated provider enrollment framework includes a rigorous Financial Viability Assessment and structured pre- and post-enrollment site visits.

• Enrollment Portal: Provider Data Management System (PDMS) (https://www.dcpdms.com).
• Application Window: 90 days from the date DHCF acknowledges the complete LOI.
• Financial Viability Assessment: Required review conducted by DHCF-ORRFA as part of the updated enrollment framework.
• Site Visits: Mandatory pre-enrollment and post-enrollment site visits conducted by Maximus.
• Waiver Supplemental Application: Required for adding specific IDD waiver services under an existing provider number.

6. Staffing, Training and Background Checks

Staff delivering skilled respite must hold active DC nursing licenses and pass comprehensive background screenings. Unlicensed personnel cannot deliver this tier of service.

Agencies must maintain personnel files proving continuous compliance with DC Health Board of Nursing requirements.

• RN Qualifications: Active Registered Nurse license issued by the DC Health Board of Nursing.
• LPN Qualifications: Active Licensed Practical Nurse license, practicing under the direct supervision of an RN.
• Background Checks: Mandatory fingerprint-based criminal background check through the DC Metropolitan Police Department and FBI.
• Registry Clearances: Must clear the DC Nurse Aide Abuse Registry and OIG List of Excluded Individuals/Entities (LEIE).
• CPR Certification: All direct care nursing staff must maintain active, in-person CPR/Basic Life Support certification.

7. Documentation, Policies and Records

Providers must maintain clinical records that justify the need for skilled nursing during the respite period. Documentation must clearly link the nursing interventions to the physician's orders.

Agencies must also maintain specific emergency protocols for handling medical crises when the primary caregiver is absent.

• Physician Orders: Written orders detailing the specific skilled interventions required during the caregiver's absence.
• Nursing Assessments: Comprehensive RN assessment completed prior to the initiation of respite services.
• Progress Notes: Shift-by-shift clinical documentation of all nursing interventions, medications administered, and patient status.
• Emergency Protocols: Documented agency policies for handling medical emergencies during respite shifts.
• Coordination of Care: Evidence in the plan of care showing coordination between the respite nurses and the primary care team.

8. Billing, Rates and Claims

Billing is processed through the DC Medicaid Management Information System (MMIS). Since skilled respite is billed under skilled nursing codes, rates align with the DC Medicaid fee schedule for home health services.

Providers must secure prior authorization before initiating shifts to ensure the hours are deducted from the participant's waiver budget.

• Billing System: DC MMIS / Provider Data Management System.
• Prior Authorization: Required from DHCF or the waiver case manager before initiating billable shifts.
• Procedure Codes: Billed using standard HCPCS codes for skilled nursing modified for waiver services.
• Unit Measurement: Typically billed in 15-minute increments or hourly units, depending on the specific waiver authorization.
• Electronic Visit Verification (EVV): Required for in-home nursing shifts to capture start and end times.

9. Approval Sequence and Timeline

The end-to-end process is lengthy due to the sequential nature of CON approval, licensure, and Medicaid enrollment. Providers cannot run these steps concurrently.

Delays in SHPDA review or Maximus site visits can significantly extend the timeline to active billing status.

• Step 1: Obtain Certificate of Need (CON) from SHPDA (can take 3-6 months).
• Step 2: Apply for and receive Home Care Agency license from DC Health (3-6 months).
• Step 3: Register for and attend the quarterly DHCF Mandatory Information Session.
• Step 4: Submit Letter of Intent (LOI) within 10 business days of the session.
• Step 5: Submit PDMS application within 90 days of LOI approval, followed by Maximus site visit.

10. Common Denials and Survey Findings

Applications and surveys frequently fail due to missed deadlines in the LOI/PDMS process or non-compliance with DC's strict physical office requirements.

DHCF strictly rejects informal inquiries or attempts to bypass the structured PDMS enrollment phases.

• Missed Deadlines: Failing to submit the PDMS application within the strict 90-day window after LOI approval.
• Office Requirement: Failing to maintain a DC-based physical office staffed 8 hours a day, Monday-Friday.
• Incomplete LOI: Submitting an LOI that lacks proof of DC incorporation or fails to demonstrate understanding of waiver services.
• Plan of Care Deficiencies: Nursing plans of care not signed by a physician within the required 30-day timeframe.
• Unapproved Informal Inquiries: Attempting to bypass the PDMS system with informal email or phone applications.

11. Key Contacts and Resources

Prospective providers must utilize the official District of Columbia portals for licensure, need-approval, and Medicaid enrollment.

Monitoring the DHCF and DC Health websites for policy updates is essential for maintaining compliance.

• DC Health (Licensing): https://dchealth.dc.gov
• DHCF Provider Enrollment: https://dhcf.dc.gov/page/becoming-epd-waiver-provider
• PDMS Portal: https://www.dcpdms.com
• DDS/DDA (IDD Waiver): https://dds.dc.gov
• SHPDA (Certificate of Need): https://dchealth.dc.gov/shpda

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