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

Last reviewed: 2026-08-16

In Montana, Skilled Respite Service provides short-term, intermittent relief to unpaid caregivers of Medicaid members whose medical needs require the oversight of a licensed nurse. This service is funded through Montana Department of Public Health and Human Services (DPHHS) Home and Community-Based Services (HCBS) programs, including the Big Sky Waiver, the Severe and Disabling Mental Illness (SDMI) Waiver, and the Developmental Disabilities Program (DDP) Comprehensive Waiver.

The single biggest structural barrier to entry for this service is that Montana does not issue a standalone "Skilled Respite" license. To bill for skilled respite, an agency must first secure a full Home Health Agency (HHA) license or a Nursing Facility license from the DPHHS Quality Assurance Division (QAD) before any Medicaid waiver enrollment application will be accepted. This prerequisite forces applicants to meet the stringent, comprehensive regulatory standards of a home health agency or facility just to provide intermittent skilled respite.

1. Service Definition and Scope

Skilled Respite in Montana is defined as temporary, short-term care provided to waiver participants to relieve the non-paid caregiver, specifically when the participant requires assistance with medical needs that exceed the scope of an unlicensed personal care assistant. It must be delivered by a Registered Nurse (RN) or Licensed Practical Nurse (LPN).

The service can be provided in the member's private residence or in an approved licensed facility. When skilled respite is utilized, the provision of other duplicative waiver services, such as Adult Day Care or standard Personal Assistance Services, is precluded during those specific hours.

• Target Population: Individuals enrolled in the Big Sky, SDMI, or DDP waivers who require a nursing facility level of care.
• Allowed Settings: The participant's residence, another private residence, or a licensed nursing facility.
• Staffing Requirement: Must be delivered by an RN or LPN licensed in Montana.
• Service Limitation: Cannot be billed concurrently with duplicative HCBS services like Adult Day Care.
• Caregiver Status: Only authorized to relieve a primary, non-paid caregiver.
• Authorization: Must be explicitly documented and approved in the member's Person-Centered Service Plan (PCSP).

2. Regulatory and Oversight Agencies

Oversight of skilled respite providers in Montana is divided between the agency that issues the foundational facility license and the divisions that manage the specific Medicaid waivers. The Department of Public Health and Human Services (DPHHS) is the umbrella agency for both functions.

Professional licensing for the nursing staff delivering the actual care is managed separately by the Montana Department of Labor & Industry.

• DPHHS Quality Assurance Division (QAD): Conducts surveys and issues the foundational Home Health Agency or Nursing Facility license required to operate.
• DPHHS Senior and Long Term Care Division (SLTC): Administers the Big Sky Waiver for elderly and physically disabled individuals.
• DPHHS Behavioral Health and Developmental Disabilities (BHDD): Administers the SDMI and DDP waivers and approves providers for these specific populations.
• Montana Board of Nursing (DLI): Regulates and issues licenses for the RNs and LPNs providing the skilled respite care.
• Conduent: Acts as the state's fiscal agent, managing the Montana Access to Health Web Portal (MPATH) for Medicaid provider enrollment and claims.
• Montana Department of Justice (DOJ): Processes mandatory state background checks for all healthcare personnel.

3. Gatekeeping Prerequisites: Who Can Even Apply

Montana repealed its Certificate of Need (CON) program entirely in 2021, meaning there is no longer a need-review approval required to open a health care facility in the state. Furthermore, there are no closed networks or RFP-only procurement windows for HCBS waiver respite providers.

However, the absolute structural precondition that blocks an applicant is the licensure prerequisite. Because DPHHS does not recognize "Skilled Respite" as a standalone business entity, you cannot apply for Medicaid enrollment for this service without first holding an active Montana Home Health Agency (HHA) license or Nursing Facility license issued by DPHHS QAD. The MPATH enrollment system will automatically reject any application for skilled respite that does not include this foundational license.

• Licensure Prerequisite: Must possess an active Home Health Agency or Nursing Facility license from DPHHS QAD before applying to Medicaid.
• Certificate of Need (CON): None required; Montana abolished its CON program in 2021.
• Network Status: Open enrollment; there are no moratoria or closed managed care networks for this specific waiver service.
• NPI Requirement: Must obtain a Type 2 (Organization) National Provider Identifier (NPI) matching the exact legal name on the QAD license.
• Waiver Matrix Approval: Must meet the criteria as a qualified provider authorized to deliver the service as specified in the DPHHS Provider Requirements Matrix.

4. Licensure and Certification Requirements

To meet the prerequisite for skilled respite, agencies must apply for licensure through the DPHHS QAD Health Care Facility Licensure Bureau. This involves submitting a comprehensive application, policies and procedures, and passing an initial on-site survey.

Providers must comply with the Administrative Rules of Montana (ARM) Title 37, Chapter 106, which outlines the Minimum Standards for All Healthcare Facilities, as well as the specific subchapters for Home Health Agencies or Nursing Facilities.

• Regulatory Citation: Must comply with ARM 37.106 (Minimum Standards for All Healthcare Facilities).
• Application Submission: Initial application submitted directly to the DPHHS QAD Health Care Facility Licensure Bureau.
• Fire Marshal Approval: Facility-based respite requires a passed inspection by the State Fire Marshal or local authority having jurisdiction.
• On-Site Survey: QAD is authorized to conduct an initial on-site survey to verify compliance with health and safety standards before issuing the license.
• Policy Manual: Must submit comprehensive policies covering patient rights, infection control, and medication administration.
• License Renewal: Licensure must be renewed annually through the QAD portal.

5. Medicaid Provider Enrollment

Once the QAD license is secured, providers must enroll in Montana Healthcare Programs via the Montana Access to Health Web Portal (MPATH). The state contracts with Conduent as its fiscal agent to process these applications and maintain the Medicaid Management Information System (MMIS).

Providers must enroll under the specific HCBS provider type and submit all required ownership disclosures and tax documents. Out-of-state providers are permitted but must still meet Montana's strict licensure and enrollment criteria.

• Enrollment Portal: Applications must be submitted electronically through the MPATH provider portal.
• Provider Type: Must enroll using HCBS Provider Type 28 or the specific Home Health Agency provider type.
• Required Form: A completed W-9 form must be uploaded for physical address and tax ID verification.
• Fiscal Agent: Conduent processes the enrollment, verifies the QAD license, and screens against federal exclusion lists.
• Revalidation: Providers must revalidate their Medicaid enrollment information every five years, or upon request by DPHHS.
• Status Changes: Changes in ownership, address, or licensure must be reported in writing to Provider Relations within 30 days.

6. Staffing, Training and Background Checks

Because this is a skilled service, all direct care must be provided by nurses who hold active, unencumbered licenses in Montana. Agencies are responsible for verifying credentials prior to hire and maintaining proof of ongoing training.

Montana law requires strict background checks for any personnel providing direct care to vulnerable populations in HCBS waiver programs.

• Professional Licensure: Direct care staff must hold an active RN or LPN license issued by the Montana Board of Nursing.
• Background Checks: Mandatory name-based and fingerprint-based criminal background checks processed through the Montana Department of Justice (DOJ).
• Exclusion Screening: Staff must be screened monthly against the OIG LEIE and SAM.gov exclusion lists.
• CPR and First Aid: All direct care staff must maintain current CPR and First Aid certification.
• Mandatory Reporting Training: Staff must complete training on identifying and reporting abuse, neglect, and exploitation to Montana Adult Protective Services.
• Supervision: LPNs providing skilled respite must be supervised by an RN in accordance with Montana Nurse Practice Act rules.

7. Documentation, Policies and Records

Providers must maintain rigorous clinical and administrative records that align with both QAD licensure standards and DPHHS waiver manuals (such as SDMI HCBS 200). Documentation must clearly justify the need for skilled nursing interventions during the respite period.

All services must be directly tied to the member's Person-Centered Service Plan (PCSP) developed by their Case Management Team (CMT).

• Care Plan Alignment: Services delivered must strictly match the authorized hours and interventions in the member's PCSP.
• Clinical Notes: Nurses must document vital signs, assessments, and interventions for every respite shift.
• Medication Administration Records (MAR): Must maintain accurate MARs for any medications administered during the respite period.
• Timesheets: Must keep detailed timesheets signed by the nurse and the member/representative verifying the exact hours of service.
• Incident Reporting: Critical incidents must be reported to the DPHHS operating division (SLTC or BHDD) within 24 hours.
• Record Retention: All medical and billing records must be retained for a minimum of five years from the date of service.

8. Billing, Rates and Claims

Skilled respite claims are submitted electronically to the Montana MMIS via the MPATH portal. Providers are reimbursed according to the published DPHHS Medicaid fee schedules for the specific waiver (Big Sky, SDMI, or DDP).

Services cannot be billed unless they have been prior-authorized by the member's case manager. Billing for skilled respite while simultaneously billing for another waiver service for the same member will result in a denial.

• Billing System: Claims are submitted electronically through the MPATH portal.
• Prior Authorization: All skilled respite hours must be prior-authorized by the Case Management Team (CMT) before services are rendered.
• Procedure Codes: Billed using specific HCPCS codes designated for skilled respite (e.g., T1005 or waiver-specific modifiers).
• Timely Filing: Claims must be submitted within 365 days of the date of service to be eligible for reimbursement.
• Rate Setting: Reimbursement rates are fixed and published annually on the DPHHS Medicaid Provider website.
• Duplication of Services: Claims will be denied if billed concurrently with Adult Day Care or standard Personal Assistance Services.

9. Approval Sequence and Timeline

Becoming a skilled respite provider in Montana is a sequential process that cannot be expedited. You must fully establish your business and obtain your facility license before Medicaid will even look at your enrollment application.

The entire process typically takes 4 to 6 months, heavily dependent on the QAD surveyor's schedule for the initial licensure inspection.

• Step 1: Establish the legal business entity and obtain a Type 2 NPI and EIN (1-2 weeks).
• Step 2: Submit the Home Health Agency or Nursing Facility application to DPHHS QAD (30-60 days for document review).
• Step 3: Pass the QAD initial on-site survey and receive the formal license (30-60 days depending on surveyor availability).
• Step 4: Submit the Medicaid Provider Enrollment application via MPATH (30-45 days for Conduent processing).
• Step 5: Receive the welcome letter from Montana Provider Relations confirming active enrollment status.
• Step 6: Receive authorizations from waiver Case Management Teams to begin accepting members.

10. Common Denials and Survey Findings

Applications for Medicaid enrollment are most frequently denied or delayed because the provider attempts to enroll as a generic "respite" provider without uploading the mandatory QAD Home Health or Nursing Facility license. MPATH requires exact matching of legal names and NPIs.

During QAD licensure surveys, deficiencies are commonly cited in personnel files and medication management protocols, which can delay the issuance of the prerequisite license.

• Missing Prerequisite License: MPATH applications are automatically denied if the QAD HHA or NF license is not attached.
• Taxonomy Mismatch: Delays occur if the NPI taxonomy code does not align with the Provider Type 28 (HCBS) selection.
• Incomplete Personnel Files: QAD frequently cites agencies for missing DOJ background checks or lapsed CPR certifications.
• Medication Errors: Surveyors commonly issue deficiencies for incomplete Medication Administration Records (MARs).
• Signature Deficiencies: Claims are recouped during audits if timesheets lack the required member or nurse signatures.
• Unapproved Settings: Billing for respite provided in an unlicensed facility setting results in immediate claim denial.

11. Key Contacts and Resources

Navigating the dual requirements of QAD licensure and MPATH enrollment requires direct communication with state agencies. Providers should bookmark the MPATH portal and the DPHHS QAD website.

For specific billing or enrollment portal issues, Conduent's Provider Relations call center is the primary point of contact.

• DPHHS Quality Assurance Division (QAD): Manages facility licensure; contact for HHA/NF application status.
• Montana Access to Health (MPATH): The web portal (mtaccesstohealth.portal.conduent.com) for Medicaid enrollment and claims.
• Provider Relations (Conduent): Call (800) 624-3958 (Option 7) for MPATH enrollment and billing assistance.
• Montana Board of Nursing: Portal (ebiz.mt.gov/pol) for verifying RN and LPN licenses.
• DPHHS SLTC Division: Oversees the Big Sky Waiver program rules and provider matrix.
• DPHHS BHDD Division: Oversees the SDMI and DDP waiver program rules and provider matrix.

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