Hawaii - Respite Care Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Hawaii, Respite Care Services provide short-term, temporary relief to unpaid primary caregivers of Medicaid participants, ensuring the individual continues to receive necessary supervision and support. Because Hawaii does not issue a standalone "Respite Care Agency" license, providers typically must first become licensed as a Home Care Agency or an Adult Residential Care Home (ARCH) through the Department of Health before they can enroll to provide these services.

The single biggest structural barrier to entry for a new respite provider in Hawaii is the mandatory managed care contracting requirement under the QUEST Integration (QI) program. Simply obtaining a state license and enrolling in Hawaii Medicaid (Med-QUEST) is insufficient to receive clients or payment; a provider must successfully secure a network contract with one or more of the designated QUEST Integration health plans (MCOs) or be awarded a contract through a Developmental Disabilities Division (DDD) procurement solicitation. If the MCO networks are closed to new home care or respite providers, the applicant will be structurally blocked from operating.

1. Service Definition and Scope

Respite care in Hawaii is defined as a service provided to individuals unable to care for themselves, furnished on a short-term basis because of the absence or need for relief of those unpaid persons normally providing the care. It is a critical component of Hawaii's Home and Community-Based Services (HCBS) designed to prevent institutionalization.

The service can be delivered in various settings depending on the participant's waiver and authorized care plan. It is strictly a relief service and cannot supplant the routine care provided by paid staff or be used for the provider's own childcare needs.

• Service Locations: May be provided in the individual's home, a licensed foster home, an expanded-care adult residential care home (ARCH), a Medicaid-certified nursing facility, or a licensed respite day care facility.
• Authorization Requirement: Respite care services must be explicitly authorized by the member's Primary Care Provider (PCP) or MCO Service Coordinator as part of the individualized care plan.
• Excluded Providers: Respite may be provided by a relative, but cannot be provided by a legal guardian, legally responsible person, or an individual serving as a designated representative for a consumer-directed waiver participant.
• Delivery Models: Services can be agency-directed (delivered by staff of a licensed home care agency) or self-directed by the participant using a fiscal intermediary.

2. Regulatory and Oversight Agencies

Oversight of respite services in Hawaii is divided between the agency that manages the Medicaid funds and the agency that licenses the healthcare facilities and home care agencies. Providers must interact with both departments to maintain compliance.

Medicaid enrollment and managed care oversight are handled by the Department of Human Services, while clinical licensure and safety surveys are conducted by the Department of Health.

• Med-QUEST Division (MQD): The division of the Department of Human Services that administers the Hawaii Medicaid program and manages the HOKU provider enrollment portal (https://medquest.hawaii.gov).
• Office of Health Care Assurance (OHCA): The Department of Health division responsible for licensing Home Care Agencies, ARCHs, and conducting state licensing surveys (https://health.hawaii.gov/ohca).
• Developmental Disabilities Division (DDD): The Department of Health division that manages the 1915(c) waiver for individuals with I/DD and oversees specialized waiver provider approvals (https://health.hawaii.gov/ddd).
• Hawaii Criminal Justice Data Center (HCJDC): The state agency responsible for processing required fingerprint-based state and federal background checks (https://ag.hawaii.gov/hcjdc).

3. Gatekeeping Prerequisites: Who Can Even Apply

Hawaii operates its Medicaid program under the QUEST Integration (QI) 1115 demonstration waiver, meaning almost all services are managed by Managed Care Organizations (MCOs). The most significant gatekeeping prerequisite is that providers must secure a network contract with a QUEST Integration health plan.

For providers targeting the I/DD population, access is restricted by state procurement rules. Providers cannot simply enroll; they must wait for and win a solicitation bid.

• Managed Care Contracting: Mandatory affiliation with at least one QUEST Integration MCO (e.g., AlohaCare, HMSA, Kaiser Permanente, Wellcare, UnitedHealthcare) is required to receive authorizations and payment; MCOs may close their networks if they deem access adequate.
• DDD Waiver Solicitations: For I/DD waiver services, providers must respond to specific procurement solicitations via the Hawaii State eProcurement (HIEPRO) system; open enrollment is not continuous.
• Underlying Licensure: Applicants must obtain a Home Care Agency license (HAR 11-700) or appropriate facility license from OHCA before a Medicaid enrollment application will be approved.
• Business Registration: The entity must be registered, active, and in good standing with the Hawaii Department of Commerce and Consumer Affairs (DCCA) prior to applying.

4. Licensure and Certification Requirements

Because Hawaii does not have a specific "Respite Provider" license, agencies providing in-home respite must obtain a Home Care Agency license from OHCA. Residential respite requires an Adult Residential Care Home (ARCH) or Nursing Facility license.

The licensure process involves a detailed review of the agency's policies, procedures, and administrative structure, followed by an initial on-site survey to verify compliance with state administrative rules.

• Licensing Authority: Department of Health, Office of Health Care Assurance (OHCA) State Licensing Section.
• Rule Citation: Hawaii Administrative Rules (HAR) Title 11, Chapter 700 governs the licensure of Home Care Agencies providing non-medical personal care and respite.
• Application Process: Providers must submit an initial application, comprehensive policies and procedures, and licensing fees to OHCA for review prior to the initial on-site survey.
• Licensing Fees: Fees are paid into the OHCA special fund as required by HRS § 321-1.4; exact fees vary based on agency size and scope.
• Survey Requirement: OHCA conducts initial and renewal licensure inspections, as well as complaint investigations; deficiencies require formal corrective action plans.

5. Medicaid Provider Enrollment

Once licensed by OHCA, providers must enroll in Hawaii Medicaid through the Med-QUEST Division's HOKU (Hawaii Online Kahu Utility) system. HOKU is the mandatory electronic portal for all new enrollments, revalidations, and updates.

While a paper option (Form DHS 1139) exists for certain updates, initial enrollments are heavily directed through the HOKU portal to ensure faster processing and document tracking.

• Enrollment Portal: HOKU Provider Enrollment System (https://hoku.medicaid.hawaii.gov).
• Paper Form Alternative: DHS 1139 (Provider Enrollment Application), though electronic submission is preferred.
• Application Fee: A $500 enrollment fee (or the current CMS institutional fee) is required for agency enrollments, unless the provider has already paid the fee to Medicare or another state's Medicaid program.
• Required Documents: Must upload IRS EIN confirmation, NPI confirmation, DCCA business license, and proof of general and professional liability insurance.
• Provider Agreement: A signed Provider Participation Agreement must accompany all applications, legally binding the provider to Med-QUEST rules.

6. Staffing, Training and Background Checks

Respite staff must meet the qualifications of the underlying license (e.g., Home Care Agency) and specific waiver requirements. Hawaii enforces strict background check mandates to protect vulnerable populations.

Agencies are responsible for ensuring all direct care workers complete required training and health clearances before their first day of client contact.

• Criminal Background Checks: Fingerprint-based state and federal checks via the Hawaii Criminal Justice Data Center (eCrim) are mandatory for all direct care staff.
• Abuse Registries: Mandatory clearance through the Adult Protective Services (APS) and Child Welfare Services (CWS) registries prior to employment.
• Health Clearance: Staff must have documented Tuberculosis (TB) clearance before providing any in-home services.
• Basic Training: CPR, First Aid, and bloodborne pathogens training are required, along with agency-specific orientation on client rights and emergency procedures.
• Supervision: Home Care Agencies must provide RN supervision for any delegated nursing tasks or personal care assistance performed during the respite period.

7. Documentation, Policies and Records

Providers must maintain comprehensive records compliant with HAR 11-700 and Med-QUEST requirements. Records must be accessible for OHCA surveys, MCO audits, and state quality assurance reviews.

Documentation must clearly demonstrate that the respite care provided aligns exactly with the authorized care plan and that the primary caregiver was actually relieved.

• Care Plan Alignment: Respite hours delivered must strictly match the MCO Service Coordinator's authorized care plan; overages will not be reimbursed.
• Service Logs: Must document start and stop times, date, location, the specific caregiver providing relief, and a brief narrative of the shift.
• Personnel Files: Must contain background check clearances, TB clearance, training certificates, and annual performance evaluations.
• Policy Manuals: Agencies must maintain written policies on client rights, grievance procedures, infection control, and emergency preparedness.
• Record Retention: Medicaid records must generally be retained for a minimum of 10 years per state and federal guidelines.

8. Billing, Rates and Claims

Respite care is typically billed in 15-minute increments or per diem rates, depending on the setting and the specific MCO authorization. Claims are submitted directly to the contracted QUEST Integration MCO, not to Med-QUEST fee-for-service, for the vast majority of members.

Providers must utilize Electronic Visit Verification (EVV) for in-home respite services to comply with the federal 21st Century Cures Act.

• Billing Increments: Typically billed using HCPCS codes (e.g., S5150 for 15-minute increments or S5151 for per diem) as specified by the authorizing MCO.
• Claims Submission: Submitted via the specific MCO's provider portal or clearinghouse (e.g., HMSA, Wellcare, AlohaCare).
• Prior Authorization: 100% of respite services require prior authorization from the MCO or DDD before service delivery; retroactive authorizations are rarely granted.
• Electronic Visit Verification (EVV): In-home respite services are subject to EVV mandates; providers must use the state's EVV system or an approved alternate system that integrates with the state aggregator.

9. Approval Sequence and Timeline

The process to become a fully operational respite provider in Hawaii is sequential and can take 6 to 12 months. Licensure must precede Medicaid enrollment, which in turn precedes MCO contracting.

Delays at the OHCA licensing stage or during MCO credentialing are common, so providers should plan their operational budgets accordingly.

• Step 1: Business Registration: Register with Hawaii DCCA and obtain NPI/EIN (1-2 weeks).
• Step 2: OHCA Licensure: Apply for a Home Care Agency license, submit policies, and pass the initial on-site survey (3-6 months).
• Step 3: Med-QUEST Enrollment: Submit the provider application via the HOKU portal with the approved OHCA license (30-90 days).
• Step 4: MCO Contracting: Apply to join QUEST Integration health plan networks and complete credentialing (90-120 days).

10. Common Denials and Survey Findings

Applications and surveys frequently fail due to incomplete documentation or failure to adhere to strict background check timelines. OHCA surveyors are particularly strict regarding personnel file compliance.

At the enrollment stage, the most common barrier is rejection by MCOs due to network adequacy, leaving the provider licensed but without a payer.

• HOKU Rejections: Missing or expired DCCA business registration, or failure to upload current general and professional liability insurance certificates.
• Survey Deficiencies: Failure to complete APS/CWS registry checks and TB clearances before a caregiver's first day of client contact.
• Care Plan Mismatches: Billing for respite hours that exceed the MCO's prior authorization limit, resulting in immediate claim denials.
• MCO Network Closures: Denials from health plans stating their provider network for respite or home care is currently adequate (closed network).
• EVV Non-Compliance: Claim denials due to missing or mismatched Electronic Visit Verification data for in-home shifts.

11. Key Contacts and Resources

Prospective providers should utilize these official state resources for the most current applications, fee schedules, and regulatory updates.

Always verify current MCO contracting windows directly with the health plans before beginning the OHCA licensure process.

• Med-QUEST Provider Enrollment: HCSBInquiries@dhs.hawaii.gov, 808-692-8099 (https://medquest.hawaii.gov).
• HOKU Portal: Hawaii Online Kahu Utility for Medicaid enrollment (https://hoku.medicaid.hawaii.gov).
• DOH OHCA State Licensing Section: 601 Kamokila Blvd, Room 361, Kapolei, HI 96707, 808-692-7400 (https://health.hawaii.gov/ohca).
• DOH Developmental Disabilities Division (DDD): For I/DD waiver provider information and HIEPRO solicitations (https://health.hawaii.gov/ddd).
• Hawaii State eProcurement (HIEPRO): For DDD waiver solicitations (https://hiepro.ehawaii.gov).

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