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

Last reviewed: 2026-08-16

In Montana, Respite Care is a critical Home and Community-Based Services (HCBS) waiver benefit designed to provide short-term relief to unpaid primary caregivers. The service ensures that individuals with developmental disabilities, severe mental illness, or age-related frailties continue to receive necessary supervision and support while their primary caregiver steps away. Funding is primarily channeled through the Big Sky Waiver, the Severe and Disabling Mental Illness (SDMI) Waiver, and the Developmental Disabilities Program (DDP) 0208 Comprehensive Waiver.

The single biggest structural barrier to entry is that Montana does not issue a standalone "Respite Care Agency" license. To bill Medicaid for respite services, an entity must first hold an underlying state license (such as a Home Health Agency, Adult Day Care, or Assisted Living Facility issued by the DPHHS Quality Assurance Division) or be explicitly approved as a specialized Developmental Disabilities Program (DDP) provider. This means applicants must secure regional office endorsement or facility licensure before the Montana Provider Access to Health (MPATH) system will even accept a Medicaid enrollment application.

1. Service Definition and Scope

Respite care in Montana provides temporary, substitute support to individuals enrolled in HCBS waivers, allowing their primary, unpaid caregiver a period of rest. Services are strictly tied to the participant's Individualized Service Plan (ISP) and can be delivered in the participant's home, a provider's home, or a licensed facility.

The scope of respite is limited to supervision, basic personal care, and behavioral support during the caregiver's absence. It is not a substitute for continuous nursing care, nor can it be used to subsidize daycare while a caregiver is at work.

• In-Home Respite: Care delivered directly in the waiver participant's primary residence.
• Facility-Based Respite: Short-term, out-of-home stays provided in licensed settings such as Assisted Living Facilities or Adult Day Care centers.
• Prohibited Providers: Respite cannot be provided by a spouse, legal guardian, or legally responsible person.
• Service Limitations: Authorized hours are strictly capped by the participant's ISP and the specific waiver's annual budget limits.
• Duplication of Services: Respite cannot be billed simultaneously with Adult Day Care, Supported Employment, or standard Personal Assistance Services.

2. Regulatory and Oversight Agencies

Oversight of respite care in Montana is divided among several divisions within the Department of Public Health and Human Services (DPHHS), depending on the target population and the setting of care.

Facility licensure is handled centrally, while waiver operations and service authorizations are managed by specific population-focused divisions.

• Montana DPHHS Quality Assurance Division (QAD): Licenses the underlying facilities and home health agencies required to provide formal respite (https://dphhs.mt.gov/qad).
• Montana DPHHS Senior and Long Term Care Division (SLTC): Operates the Big Sky Waiver for the elderly and physically disabled (https://dphhs.mt.gov/sltc).
• Montana DPHHS Developmental Disabilities Program (DDP): Manages the 0208 Comprehensive Waiver and approves specialized DDP providers (https://dphhs.mt.gov/dsd/developmentaldisabilities).
• Montana DPHHS Addictive and Mental Disorders Division (AMDD): Oversees the SDMI Waiver for individuals with severe mental illness (https://dphhs.mt.gov/amdd).
• Montana Healthcare Programs (MPATH): Manages the centralized Medicaid provider enrollment portal and MMIS claims system (https://medicaidprovider.mt.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Montana does not utilize a Certificate of Need (CON) program for home-based services, but it heavily restricts waiver provider enrollment through structural prerequisites. You cannot simply enroll as a generic "Respite Provider" in a vacuum.

Before applying for Medicaid enrollment, an agency must secure the appropriate underlying operational authority. Without one of the following structural approvals, an MPATH application will be immediately rejected.

• No Standalone Respite License: The state does not recognize "Respite Agency" as a distinct corporate licensure category; applicants must qualify under another established provider type.
• Underlying Licensure Requirement: Applicants must already hold an active QAD license (e.g., Home Health Agency, Assisted Living, Adult Day Care) unless operating as an independent consumer-directed provider.
• DDP Regional Office Endorsement: For the 0208 Comprehensive Waiver, agencies must be selected, vetted, and endorsed by a DDP Regional Office before applying for Medicaid enrollment.
• Case Management Contracting: For the Big Sky Waiver, providers must establish referral relationships and receive service authorizations from contracted regional case management teams (e.g., Area Agencies on Aging or Mountain Pacific Quality Health).
• Medicaid Exclusion Verification: Owners and managing employees must clear the federal OIG LEIE and Montana Medicaid exclusion lists prior to application submission.

4. Licensure and Certification Requirements

Because there is no specific respite license, providers must meet the Administrative Rules of Montana (ARM) for their specific facility or agency type. The DPHHS Quality Assurance Division (QAD) conducts the surveys and issues these licenses.

Providers must maintain compliance with both their base license regulations and the overarching federal HCBS Settings Rule.

• Home Health Agency License: Required if providing skilled nursing respite; issued by DPHHS QAD under ARM Title 37, Chapter 106.
• Assisted Living Facility License: Required for out-of-home overnight facility respite; issued by QAD and subject to specific category endorsements (Category A, B, or C).
• Adult Day Care License: Required for out-of-home daytime respite; issued by QAD under ARM Title 37, Chapter 106, Subchapter 26.
• DDP Provider Certification: Non-licensed agencies providing DDP waiver respite must pass a DDP readiness review and sign a specific provider agreement with the division.
• Business Registration: The operating entity must be registered and in good standing with the Montana Secretary of State.

5. Medicaid Provider Enrollment

All Medicaid enrollment in Montana is processed electronically through the MPATH (Montana Provider Access to Health) system. Providers must enroll under the specific waiver program they intend to serve.

Enrollment requires submitting proof of the underlying QAD license or DDP approval, along with standard federal disclosures.

• MPATH Portal: Applications must be submitted via the Conduent-managed MPATH Provider Services portal (https://mtaccesstohealth.portal.conduent.com).
• NPI Requirement: Agencies must obtain a Type 2 NPI (Organization) from NPPES, while independent contractors must obtain a Type 1 NPI.
• Provider Type Selection: Applicants must select the appropriate Provider Type (e.g., Provider Type 74 for HCBS Waiver) and the specific specialty codes for Respite Care.
• Application Fee: Institutional providers are subject to the ACA application fee (approximately $709) unless waived or already paid to Medicare or another state's Medicaid program.
• Revalidation: Enrolled providers must revalidate their Medicaid enrollment every 3 to 5 years through the MPATH system.

6. Staffing, Training and Background Checks

Direct care workers providing respite must meet baseline health, safety, and background standards mandated by DPHHS. Agencies are responsible for maintaining these records in the employee's personnel file.

Training requirements vary slightly depending on which waiver funds the participant's care, with DDP waivers requiring the most specialized behavioral training.

• Criminal Background Checks: Required through the Montana Department of Justice (DOJ) and FBI fingerprinting for all patient-facing staff prior to independent client contact.
• Basic Training: Staff must hold current CPR and First Aid certification before providing unsupervised care.
• DDP-Specific Training: Staff serving the 0208 Waiver must complete the College of Direct Support modules and state-approved behavioral intervention training (e.g., Mandt System).
• Age Requirement: Direct care workers providing respite must be at least 18 years of age.
• Competency Verification: The employing agency must document that the worker is capable of meeting the specific medical and behavioral needs outlined in the participant's ISP.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and billing records subject to audit by DPHHS QAD and the Medicaid Program Integrity unit.

Policies must explicitly address participant rights, emergency procedures, and compliance with federal community integration standards.

• Service Logs: Must document the exact date, start time, end time, specific activities performed, and the signature of the caregiver for every respite shift.
• Individualized Service Plan (ISP): A current copy of the participant's ISP must be maintained in the provider's file to guide care delivery.
• HCBS Settings Compliance: Facility-based policies must demonstrate compliance with the CMS HCBS Final Rule, ensuring participant privacy, autonomy, and community access.
• Incident Reporting: Mandatory policies must be in place for reporting abuse, neglect, or exploitation to Montana Adult Protective Services (APS) or Child and Family Services.
• Record Retention: All Medicaid billing, personnel, and clinical records must be retained for a minimum of 5 years (60 months).

8. Billing, Rates and Claims

Respite is billed as a fee-for-service claim through the MPATH portal. Rates are established by the Montana Legislature and published in division-specific DPHHS fee schedules.

Providers cannot bill for services until a prior authorization is loaded into the MMIS by the participant's case manager.

• Billing Codes: Typically billed using HCPCS codes S5150 (unskilled respite, 15-minute increments) or S5151 (per diem), depending on the waiver and setting.
• Prior Authorization: All respite hours must be prior-authorized by the participant's Case Manager; claims submitted without a matching authorization will deny.
• Claim Submission: Claims are submitted electronically via the MPATH Provider Portal or via standard 837P EDI transactions.
• Rate Variations: Reimbursement rates differ between the Big Sky Waiver, SDMI Waiver, and DDP Comprehensive Waiver; providers must consult the specific division's current fee schedule.
• Timely Filing: Claims must be submitted within 365 days of the date of service to be eligible for Medicaid reimbursement.

9. Approval Sequence and Timeline

The end-to-end process requires securing the underlying license or regional approval before touching the Medicaid enrollment portal.

Prospective providers should expect the entire process to take several months, largely dependent on QAD survey schedules or DDP review timelines.

• Step 1: Business Formation: Register with the Montana Secretary of State and obtain an EIN and NPI (1-2 weeks).
• Step 2: Underlying Licensure/Approval: Obtain QAD licensure (e.g., Home Health, Assisted Living) or DDP Regional Office endorsement (3-6 months).
• Step 3: MPATH Application: Submit the Medicaid enrollment application via the MPATH portal (30-60 days for processing).
• Step 4: Case Management Contracting: Establish referral relationships with local Case Management agencies (e.g., Area Agencies on Aging).
• Step 5: Service Authorization: Receive the first prior authorization from a case manager before delivering or billing for care.

10. Common Denials and Survey Findings

DPHHS QAD and Medicaid Program Integrity frequently cite providers for documentation lapses and unapproved service delivery during routine audits.

Financial recoupment is common when providers fail to strictly align their billing with the authorized ISP.

• Missing Start/Stop Times: Claims are frequently denied or recouped because service logs lack exact times or caregiver signatures.
• Exceeding Authorized Hours: Billing for more respite hours than were explicitly approved in the participant's ISP.
• Lapsed Background Checks: Citations issued for allowing staff to provide care before the DOJ background check fully clears.
• Unapproved Settings: Providing out-of-home respite in a facility that has not been validated for HCBS Settings Rule compliance.
• Duplication of Services: Billing for respite on the same day and time as Adult Day Care or supported employment services.

11. Key Contacts and Resources

Prospective respite providers must interact with multiple state portals and divisions to achieve full compliance and enrollment.

The following official Montana resources provide the necessary manuals, fee schedules, and application portals.

• Montana Medicaid Provider Enrollment (MPATH): https://mtaccesstohealth.portal.conduent.com
• DPHHS Quality Assurance Division (QAD): https://dphhs.mt.gov/qad
• DPHHS Developmental Disabilities Program (DDP): https://dphhs.mt.gov/dsd/developmentaldisabilities
• DPHHS Senior and Long Term Care (SLTC): https://dphhs.mt.gov/sltc
• Montana Medicaid Provider Information: https://medicaidprovider.mt.gov

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