Indiana - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-15

In Indiana, Skilled Respite is delivered under the state's Home and Community-Based Services (HCBS) waivers to provide temporary relief to primary caregivers of individuals with complex medical needs. Because this service requires licensed nursing staff (RNs or LPNs) to perform tasks that exceed the scope of an unlicensed caregiver, Indiana does not utilize a standalone "respite agency" license. Instead, providers must be fully licensed as a Home Health Agency (HHA) through the Indiana Department of Health (IDOH) before they can enroll to provide skilled respite.

The single biggest structural barrier to entry for this service is the strict sequencing of the IDOH Home Health Agency licensure process combined with the Family and Social Services Administration's (FSSA) periodic HCBS provider enrollment moratoria. An applicant cannot even submit a Medicaid HCBS waiver enrollment application until they have successfully passed a rigorous pre-licensure state survey and secured their HHA license, and they must carefully time their Medicaid application to avoid active state moratoria on new waiver providers.

1. Service Definition and Scope

Skilled Respite provides temporary, substitute care for waiver participants whose medical needs exceed the capabilities of an unlicensed caregiver or a standard Personal Services Agency (PSA). It is authorized under Indiana's HCBS waivers, such as the Community Integration and Habilitation (CIH) Waiver and the Family Supports Waiver (FSW), to ensure caregiver relief while maintaining participant safety.

Because the service is "skilled," it must be delivered by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). The scope of practice is strictly governed by the Indiana Nurse Practice Act and the participant's individualized care plan.

• Service Modality: In-home or facility-based temporary relief for primary caregivers.
• Clinical Scope: Includes medication administration, wound care, tube feeding, and ventilator management during the respite period.
• Care Plan Requirement: Skilled tasks must be explicitly detailed in the participant's Person-Centered Individualized Support Plan (PCISP) and supported by physician orders.
• Excluded Activities: Cannot be utilized for routine childcare, while the primary caregiver is at work, or overlapping with other skilled nursing waiver services.
• Duration Limits: Authorized in 15-minute increments or daily rates, subject to the annual financial or unit caps of the specific HCBS waiver.

2. Regulatory and Oversight Agencies

Oversight of skilled respite in Indiana is bifurcated between health regulation and Medicaid administration. The clinical and facility standards are regulated by the state's health department, while the funding and waiver rules are managed by social services.

Providers must maintain compliance with both entities simultaneously, responding to health surveyors for clinical matters and waiver auditors for billing and service plan adherence.

• Indiana Department of Health (IDOH): The Acute and Continuing Care Division licenses Home Health Agencies (HHAs) and conducts clinical compliance surveys.
• Family and Social Services Administration (FSSA): The umbrella state agency overseeing Indiana Medicaid and all HCBS waiver programs.
• Bureau of Disabilities Services (BDS): A division within FSSA that manages the CIH and FSW waivers and oversees provider compliance for developmental disability services.
• Office of Medicaid Policy and Planning (OMPP): Administers the Indiana Health Coverage Programs (IHCP) and sets Medicaid reimbursement rates.
• Gainwell Technologies: The fiscal agent contracted by the state to operate the IHCP Provider Healthcare Portal for enrollment, EVV, and claims processing.

3. Gatekeeping Prerequisites: Who Can Even Apply

Indiana strictly gates the provision of skilled respite through its Home Health Agency licensure requirement and active enrollment management. You cannot enroll as an HCBS waiver provider for skilled respite without first holding an active IDOH HHA license.

Furthermore, the state actively manages provider network capacity. FSSA periodically enacts HCBS Waiver Provider Enrollment Moratoria, which act as absolute blocks on new applications during the specified windows.

• Licensure Prerequisite: Applicants must possess an active Indiana Home Health Agency (HHA) license from IDOH before the IHCP Medicaid enrollment portal will accept an application for skilled services.
• HCBS Moratoria: FSSA periodically enacts enrollment moratoria (e.g., 6-month pauses) blocking new waiver provider applications; applicants must verify that the enrollment window is open before applying.
• Business Registration: The operating entity must be registered and in good standing with the Indiana Secretary of State.
• NPI Requirement: The agency must obtain a Type 2 National Provider Identifier (NPI) specific to the organizational entity prior to licensure and enrollment.
• Physical Location: The agency must maintain a physical office in Indiana or a designated border county to house clinical records and facilitate state surveys.

4. Licensure and Certification Requirements

Because skilled respite requires nursing staff, providers must comply with Indiana Administrative Code Title 410 IAC 17 for Home Health Agencies. This involves a formal application, a non-refundable fee, and a rigorous pre-licensure survey by IDOH.

The state survey evaluates the agency's clinical policies, the qualifications of the designated Nursing Supervisor, and the agency's readiness to safely deliver skilled care in a home setting.

• Application Form: Must submit State Form 4008 (Application for License to Operate a Home Health Agency) to IDOH.
• Licensure Fee: A $250.00 licensure fee must accompany the initial application and subsequent renewals.
• Regulatory Citation: Providers must demonstrate strict compliance with 410 IAC 17 (Home Health Agencies) rules.
• Pre-Licensure Survey: IDOH conducts an on-site initial survey to verify clinical policies, administrator qualifications, and operational readiness before issuing the license.
• Accreditation Alternative: For license renewals, a comprehensive survey by an approved accrediting body (like CHAP or ACHC) can often be utilized as proof of compliance in lieu of a state survey.

5. Medicaid Provider Enrollment

Once the HHA license is secured, the agency must enroll in the Indiana Health Coverage Programs (IHCP) as a Waiver Provider. This process is conducted entirely online through the IHCP Provider Healthcare Portal.

Providers must carefully select the specific HCBS waivers they intend to serve (e.g., FSW, CIH) and link their HHA license to their Medicaid profile to authorize skilled billing codes.

• Enrollment Portal: Applications are submitted via the IHCP Provider Healthcare Portal operated by Gainwell Technologies.
• Provider Type: Agencies must enroll as Provider Type 32 (Waiver Provider) with the appropriate specialty code for Respite Care.
• Application Fee: Must pay the federal Medicaid institutional application fee (or provide proof of prior payment to Medicare or another state's Medicaid program) unless explicitly exempt.
• Waiver Selection: The application requires the provider to explicitly select the waivers they are applying for (e.g., Family Supports Waiver, Community Integration and Habilitation Waiver).
• Supporting Documentation: Must upload the active IDOH HHA license, a signed W-9, and proof of general and professional liability insurance.

6. Staffing, Training and Background Checks

Skilled respite mandates licensed nursing personnel. Agencies must strictly adhere to both IDOH clinical staffing rules and FSSA/BDS waiver provider qualifications.

Indiana requires rigorous background screening for all direct care staff, and agencies must maintain detailed personnel files proving that nurses meet both clinical and waiver-specific training mandates.

• Clinical Qualifications: Direct care must be provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) operating under the direct supervision of an RN.
• Background Checks: Must obtain a limited criminal history check through the Indiana Central Repository prior to hire (subject to specific emergency waiver exceptions).
• OIG Exclusion: Mandatory monthly screening of all staff against the federal OIG List of Excluded Individuals/Entities (LEIE).
• Mandatory Training: Staff must complete BDS HCBS Provider Mandatory Training, which covers incident reporting, participant rights, and abuse/neglect prevention.
• CPR/First Aid: All direct care nursing staff must maintain active, hands-on CPR and First Aid certifications.
• TB Testing: Staff must undergo tuberculosis screening upon hire and annually thereafter per IDOH regulations.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records compliant with 410 IAC 17 and IHCP waiver manuals. Documentation must bridge the gap between medical necessity and waiver service plans.

State surveyors and FSSA auditors frequently review these records to ensure that skilled tasks were performed exactly as ordered and that caregiver relief was actually provided.

• Policy Manual: Must include comprehensive protocols for intake, caregiver relief planning, emergency response, and infection control.
• Clinical Records: Must maintain a Plan of Care (POC) signed by a physician detailing the specific skilled nursing tasks required during the respite period.
• Service Notes: Daily documentation must record exact start and stop times, specific skilled tasks performed, and the signature of the attending nurse.
• Incident Reporting: Policies must dictate the reporting of critical incidents to the BDS Incident Reporting System within 24 hours of occurrence.
• Record Retention: IHCP requires providers to retain all Medicaid service, clinical, and billing records for a minimum of seven years.

8. Billing, Rates and Claims

Skilled respite is billed to IHCP using specific HCPCS codes and modifiers that denote the level of care (RN vs. LPN). Claims are submitted via the IHCP Provider Healthcare Portal or through an approved EDI clearinghouse.

Because this is an in-home service, providers must comply with federal Electronic Visit Verification (EVV) mandates to validate the location and duration of the care provided.

• Billing System: Claims are processed through the Medicaid Management Information System (MMIS) via Gainwell Technologies.
• HCPCS Code: Billed using T1005 (Respite Care - 15 minutes) with specific modifiers (e.g., TD for RN, TE for LPN) as dictated by the current IHCP fee schedule.
• Prior Authorization: Services must be prior-authorized by the waiver case manager and listed on the participant's Notice of Action (NOA) before billing can occur.
• Unit Calculation: Billed in 15-minute increments; providers cannot bill for time overlapping with other authorized waiver services.
• EVV Requirement: Electronic Visit Verification (EVV) is federally mandated, requiring GPS or telephony timestamping integrated with the state's Sandata system or an approved alternate EVV vendor.

9. Approval Sequence and Timeline

The pathway to becoming a billing provider for skilled respite is sequential and lengthy, primarily due to the IDOH survey queue. Agencies should plan for a multi-month startup phase.

Medicaid enrollment cannot begin until the health department has fully signed off on the agency's clinical capabilities.

• Step 1: Corporate formation, obtaining an EIN, and securing a Type 2 NPI (1-2 weeks).
• Step 2: Submit State Form 4008 and the $250 fee to IDOH for HHA licensure (30-60 days for initial document review).
• Step 3: IDOH Pre-Licensure Survey and subsequent license issuance (3-6 months, highly dependent on state surveyor availability).
• Step 4: Submit IHCP Waiver Provider enrollment via the Provider Healthcare Portal (30-45 days for Gainwell and FSSA review).
• Step 5: Receive IHCP Provider ID, complete EVV integration, and begin accepting waiver authorizations (1-2 weeks post-approval).

10. Common Denials and Survey Findings

Applications and surveys frequently fail due to administrative omissions or a lack of clinical readiness. IDOH and FSSA strictly enforce policy completeness and staff credentialing.

Understanding these common pitfalls can save providers months of delays in the licensure and enrollment phases.

• Premature Medicaid Application: Denials occur immediately if the IHCP application is submitted before the IDOH HHA license is fully active and uploaded.
• Moratorium Rejections: Applications submitted during an active FSSA HCBS enrollment moratorium will be summarily rejected without review.
• Survey Failure: IDOH will deny licensure if the agency's designated Nursing Supervisor lacks the required clinical management experience or if policies are generic and not Indiana-specific.
• Background Check Gaps: Citations frequently occur for failing to run the Indiana Central Repository check prior to the employee's first day of patient contact.
• EVV Non-Compliance: Post-enrollment billing denials often stem from failing to properly capture EVV data or failing to link the alternate EVV system to the Gainwell MMIS.

11. Key Contacts and Resources

Providers must interact with multiple state portals and divisions to maintain compliance. It is critical to bookmark the official state resources for the most current manuals, fee schedules, and policy bulletins.

Relying on outdated waiver manuals can lead to immediate recoupment of funds during state audits.

• IDOH Acute and Continuing Care: Manages Home Health Agency licensing, forms, and state surveys (in.gov/health/cshcr).
• IHCP Provider Healthcare Portal: Managed by Gainwell Technologies for Medicaid enrollment, EVV management, and claims submission.
• FSSA Bureau of Disabilities Services (BDS): Oversees CIH and FSW waiver policies, provider compliance, and incident reporting.
• IHCP Provider Reference Modules: The definitive source for HCBS Waiver billing guidelines, modifier rules, and policy updates.
• Indiana Secretary of State: The portal for initial business entity registration and maintaining corporate good standing.

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