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

Last reviewed: 2026-09-09

The Idaho Department of Health and Welfare (DHW) Division of Medicaid funds Respite Care Services primarily through the Aged and Disabled (A&D) Waiver and the 1915(i) State Plan HCBS for Children with Serious Emotional Disturbance (SED). The service provides short-term or temporary relief for unpaid primary caregivers, delivered in the participant's home, a private residence, or non-institutional community locations.

Approval to deliver this service requires structural affiliation with an existing credentialed entity rather than standalone enrollment. For the SED population, applicants must be affiliated with a Medicaid-enrolled behavioral health agency credentialed under the Idaho Behavioral Health Plan (IBHP) contractor, while A&D waiver providers must operate as employees of record or fact for an enrolled agency unless DHW explicitly grants an exception.

1. Service Definition and Scope

In Idaho, Respite Care is defined under IDAPA 16.03.10.329 and SPA 17-0013 as short-term or temporary care provided in the least restrictive environment that provides relief for the usual caretaker. For children with SED, it is specifically aimed at the de-escalation of stressful situations.

The scope of service delivery varies by the target population. Respite may be provided in the participant's home, another private residence, a credentialed agency facility, or community locations such as parks and activity centers, provided they are not institutional in nature.

• A&D Waiver Scope: Relief care for caregivers of aged and disabled adults, requiring adherence to the provider training matrix.
• SED 1915(i) Scope: Temporary care for youth with serious emotional disturbance aimed at crisis prevention and caregiver relief.
• Institutional Respite: Skilled Nursing Facilities (SNFs) may offer respite under IDAPA 16.03.02.301 with specific physician authorization.
• Setting Limitations: Services cannot be delivered in nursing facilities, institutions for mental diseases (IMD), or ICF/IIDs unless specifically admitted for institutional respite.
• Delivery Method: Can be provider-managed or participant-directed depending on the specific waiver authorization.
• Allowable Tasks: Must align with the standards for direct care staff and allowable tasks in the DHW-approved waiver appendix.

2. Regulatory and Oversight Agencies

The Idaho Department of Health and Welfare (DHW) serves as the State Medicaid Agency and holds primary regulatory authority over HCBS waivers and provider standards. DHW's Division of Medicaid directly manages provider enrollment, policy formulation, and waiver compliance.

Gainwell Technologies operates the Idaho Medicaid Management Information System (MMIS) and the provider enrollment portal. For behavioral health respite, the Idaho Behavioral Health Plan (IBHP) contractor manages network credentialing and specific training requirements.

• Idaho Department of Health and Welfare (DHW): https://healthandwelfare.idaho.gov
• DHW Division of Medicaid: https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/provider-enrollment
• Gainwell Technologies (Idaho Medicaid Portal): https://www.idmedicaid.com
• Idaho Behavioral Health Plan (IBHP) Contractor: https://healthandwelfare.idaho.gov/services-programs/medicaid-health/idaho-behavioral-health-plan

3. Gatekeeping Prerequisites: Who Can Even Apply

Idaho does not enroll independent, standalone Respite Care agencies for HCBS waivers. Instead, the state requires applicants to operate under the umbrella of an established, credentialed agency. There is no Certificate of Need (CON) required for HCBS respite, but the agency affiliation acts as a strict structural precondition.

For the SED 1915(i) program, providers must be affiliated with a Medicaid-enrolled, credentialed behavioral health agency that is contracted with the IBHP. For the A&D waiver, IDAPA 16.03.10.329 mandates that individual service providers must be an employee of record or fact of an agency, unless DHW determines no agency or fiscal intermediary is available.

• Agency Affiliation Requirement: Applicants must be employees of record or fact of an enrolled agency (e.g., Residential Habilitation or Home Health).
• IBHP Network Credentialing: SED respite providers must be affiliated with an agency credentialed by the IBHP contractor.
• Standalone Enrollment Prohibition: Independent practitioners cannot enroll directly to provide A&D waiver respite without DHW exception.
• HCBS Settings Self-Assessment: Agencies must complete a DHW-approved self-assessment form verifying compliance with 42 CFR 441 Subpart M before approval.
• No Certificate of Need: Idaho does not require a CON for community-based respite services.

4. Licensure and Certification Requirements

Idaho does not issue a distinct license category for "Respite Care Agencies." Providers are approved based on their primary agency licensure or certification, such as a Residential Habilitation Agency certification under IDAPA 16.04.17, a Home Health Agency license, or designation as a credentialed behavioral health agency.

Facilities providing institutional respite, such as Skilled Nursing Facilities, must maintain their SNF licensure and comply with IDAPA 16.03.02.301, which allows modified admission and care plan documentation for short-term respite stays.

• Primary Agency Certification: Must hold active certification or licensure appropriate to the overarching agency type (e.g., ResHab, Home Health).
• Behavioral Health Credentialing: SED providers must maintain credentialed status as a behavioral health agency.
• Facility-Based Respite: SNFs providing respite must maintain state SNF licensure and meet IDAPA 16.03.02.301 standards.
• HCBS Settings Compliance: All non-institutional settings must pass the DHW HCBS setting quality requirements under IDAPA 16.03.10.311 through 318.
• Out-of-State Providers: Must meet equivalent licensure in their home state and enroll through Gainwell if serving Idaho Medicaid members.

5. Medicaid Provider Enrollment

Provider enrollment is processed through the Idaho Medicaid Health PAS OnLine portal managed by Gainwell Technologies. Agencies must submit a complete application, including the Medicaid Provider Enrollment Agreement and a signed W-9.

The effective date of enrollment is deemed to be the date the completed and acceptable application is received by DHW or Gainwell. Exceptions for retroactive enrollment are typically limited to emergency services or specific specialist coverage.

• Enrollment Portal: Applications are submitted via www.idmedicaid.com.
• Required Forms: Medicaid Provider Enrollment Agreement and W-9 must be signed and attached.
• Effective Date Policy: Enrollment is effective the date the acceptable application is received, not the date of submission initiation.
• Provider Type Selection: Agencies enroll under their primary taxonomy (e.g., Adult Residential Care, Agency-Professional) and add respite as a service code.
• Application Assistance: Providers can contact Gainwell support at 866-686-4272 for enrollment portal issues.

6. Staffing, Training and Background Checks

Direct care staff providing respite must meet specific qualifications outlined in IDAPA 16.03.10.329 and the respective waiver appendices. All respite care providers must complete a criminal history and background check and receive clearance under IDAPA 16.05.06 before delivering services.

For the SED 1915(i) program, staff must be at least 21 years old, hold a high school diploma or GED, and have at least six months (1,040 hours) of experience working with children experiencing SED. They must also complete IBHP-developed training on behavior management, crisis de-escalation, and basic First Aid.

• Background Checks: Mandatory clearance under IDAPA 16.05.06 for all direct care staff prior to service delivery.
• A&D Waiver Qualifications: Staff must receive care-giving instructions specific to the participant, demonstrate ability to follow the service plan, and be free of communicable disease.
• SED Age and Education: Must be at least 21 years of age with a high school diploma or GED.
• SED Experience Requirement: Minimum of 1,040 hours (6 months) full-time work or volunteer experience with SED children and families.
• SED Training: Must complete classroom or on-the-job training covering SED characteristics, crisis management, confidentiality, and First Aid.
• Relative Providers: Waiver providers cannot be a relative of the participant except under extraordinary circumstances defined by DHW.

7. Documentation, Policies and Records

Agencies must maintain comprehensive records demonstrating compliance with person-centered service plans and provider qualifications. Under 45 CFR 74.53, written copies or electronic facsimiles of service plans must be maintained for a minimum period of three years.

For institutional respite in SNFs, IDAPA 16.03.02.301 allows for abbreviated documentation. A complete history and physical is not required if sufficient care information is provided, and care plans may be limited to short-term goals unless the stay exceeds four weeks.

• Record Retention: Service plans and delivery records must be kept for at least 3 years.
• Verification of Qualifications: Credentialed agencies must verify staff qualifications at initial hire, at least every two years, and as needed.
• SNF Admission Orders: Institutional respite requires physician authorization and signed medication/treatment orders.
• SNF Care Plans: Activity assessments and long-term goals are not required for SNF respite stays under 4 weeks.
• Quality Control Reviews: Agencies must conduct at least annual participant satisfaction or quality control reviews available to DHW.
• HCBS Assurances: Providers must maintain documentation proving settings are not institutional in nature.

8. Billing, Rates and Claims

Idaho Medicaid reimburses respite providers the lower of the billed amount or the maximum allowable fee established by the DHW Division of Medicaid. Fee schedules are published and updated on the IDMedicaid provider portal.

Claims must be submitted to Gainwell Technologies within 365 days from the date of service. The only exception to this timely filing requirement is for Medicare crossover claims, which have a six-month window from the Medicare EOB date.

• Timely Filing Limit: All claims must be submitted within twelve months (365 days) of the date of service.
• Reimbursement Rate: Paid at the DHW maximum allowable fee or the provider's billed amount, whichever is lower.
• Fee Schedule Location: Current rates are published on the Gainwell portal at www.idmedicaid.com.
• Medicare Crossovers: Allowed within six months of the Medicare payment or EOB date.
• Billing System: Claims are processed through the Health PAS OnLine MMIS.
• Prior Authorization: Respite hours must be authorized in the participant's person-centered service plan prior to billing.

9. Approval Sequence and Timeline

The approval sequence begins with the agency securing its primary certification (e.g., Residential Habilitation) and completing the DHW HCBS settings self-assessment. Once the agency is established, it submits the Medicaid provider enrollment application through Gainwell.

For SED respite, the agency must simultaneously complete credentialing with the IBHP contractor. The effective date of Medicaid enrollment is tied to the receipt of a complete application, provided all background checks and agency licenses are active.

• Step 1: Agency Certification: Obtain primary agency licensure or certification from DHW.
• Step 2: Background Clearances: Ensure all direct care staff clear IDAPA 16.05.06 background checks.
• Step 3: HCBS Self-Assessment: Submit the setting compliance form to DHW.
• Step 4: IBHP Credentialing: (SED only) Complete network credentialing with the behavioral health contractor.
• Step 5: Gainwell Enrollment: Submit the Provider Enrollment Agreement and W-9 via IDMedicaid.
• Step 6: Effective Date Assignment: DHW/Gainwell assigns the effective date based on application receipt.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied if the applicant attempts to enroll as an independent respite provider without the required agency affiliation or DHW exception. Failure to submit a signed W-9 or Provider Enrollment Agreement also results in immediate application return.

During compliance surveys, DHW frequently cites agencies for failing to maintain current IDAPA 16.05.06 background check clearances for all direct care staff, or for delivering services in settings that fail to meet the HCBS final rule requirements (e.g., settings that isolate participants).

• Missing Affiliation: Denials for independent applicants lacking an agency employer of record.
• Background Check Lapses: Survey citations for staff providing care before receiving official IDAPA 16.05.06 clearance.
• HCBS Settings Violations: Citations for providing community respite in environments deemed institutional in nature.
• Incomplete Applications: Gainwell rejections due to missing signatures on the Provider Agreement or W-9.
• Training Deficiencies: Failure to document the required 1,040 hours of experience or First Aid training for SED staff.
• Timely Filing Denials: Claims rejected for exceeding the 365-day submission window.

11. Key Contacts and Resources

Providers should utilize the DHW and Gainwell portals for the most current fee schedules, provider handbooks, and enrollment forms. The Gainwell provider support line is the primary contact for application status and portal technical assistance.

For questions regarding the SED 1915(i) waiver and behavioral health credentialing, providers must coordinate directly with the current IBHP contractor.

• Gainwell Provider Enrollment Support: 866-686-4272
• Idaho Medicaid Provider Portal: https://www.idmedicaid.com
• DHW Provider Enrollment Info: https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/provider-enrollment
• Idaho Administrative Code (IDAPA 16): https://adminrules.idaho.gov/rules/current/16/index.html
• Criminal History and Background Checks: https://healthandwelfare.idaho.gov/providers/background-checks/background-checks
• IBHP Contractor Information: https://healthandwelfare.idaho.gov/services-programs/medicaid-health/idaho-behavioral-health-plan

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