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

Last reviewed: 2026-09-10

The New Jersey Division of Developmental Disabilities (DDD) and the Division of Medical Assistance and Health Services (DMAHS) fund Respite Care Services through the Supports Program, the Community Care Program, and Managed Long-Term Services and Supports (MLTSS). Providers deliver short-term relief to unpaid primary caregivers, billing either hourly or daily codes depending on the duration of the service event.

Approval requires completing the Combined Application to Become a Medicaid/DDD Approved Provider and enrolling through the NJMMIS portal managed by Gainwell Technologies. Agencies providing in-home respite must first obtain licensure as a Health Care Service Firm (HCSF) from the Division of Consumer Affairs and secure accreditation from a recognized body like CAHC before Medicaid enrollment is permitted.

1. Service Definition and Scope

In New Jersey, Respite Care provides short-term relief to an unpaid primary caregiver, ensuring the participant receives continuous supervision and support. The service is delivered in the participant's home, a licensed group home, or a community setting, and is categorized into hourly and daily increments.

The service is designed strictly for caregiver relief and cannot be used as a substitute for routine day programs or standard employment support.

• Hourly Respite: Billed for services lasting less than 8 hours in a single 24-hour period.
• Daily Respite: Billed when the same provider delivers 8 or more hours of care in a 24-hour period.
• Setting Limitations: Cannot be provided simultaneously with Day Habilitation or Community Based Supports.
• Excluded Activities: Room and board costs are not covered unless provided in a licensed facility.

2. Regulatory and Oversight Agencies

Multiple divisions within the New Jersey Department of Human Services (DHS) oversee respite services depending on the target population. The Division of Consumer Affairs (DCA) regulates the underlying agency licensure for in-home care providers.

• Division of Developmental Disabilities (DDD): Approves providers for the Supports and Community Care Programs (https://www.nj.gov/humanservices/ddd/).
• Division of Medical Assistance and Health Services (DMAHS): Administers NJ FamilyCare and oversees the NJMMIS portal (https://www.nj.gov/humanservices/dmahs/).
• Division of Consumer Affairs (DCA): Issues Health Care Service Firm (HCSF) licenses required for in-home care agencies (https://www.njconsumeraffairs.gov/).
• Gainwell Technologies: Operates the NJMMIS provider enrollment portal and processes claims (https://www.njmmis.com/).

3. Gatekeeping Prerequisites: Who Can Even Apply

New Jersey does not utilize a Certificate of Need or closed network moratorium for standard HCBS respite care. However, structural prerequisites dictate that an agency cannot simply enroll as a Medicaid respite provider without first securing the appropriate underlying operational authority.

• HCSF Licensure: Agencies providing in-home respite must hold an active Health Care Service Firm license from the DCA before applying to Medicaid.
• Accreditation Mandate: HCSFs must obtain accreditation from the Commission on Accreditation for Home Care (CAHC) or another state-recognized accrediting body.
• MCO Contracting: For MLTSS respite, providers must successfully credential and contract with at least one of the five NJ FamilyCare managed care plans.
• NPI Requirement: Applicants must obtain a Type 2 National Provider Identifier (NPI) for their administrative office location prior to submitting the DDD Combined Application.

4. Licensure and Certification Requirements

New Jersey does not issue a specific Respite Care License. Instead, providers must obtain a Health Care Service Firm (HCSF) license if delivering care in the participant's home, or operate as a licensed community residence under N.J.A.C. 10:44A for facility-based respite.

• HCSF Registration: Requires submission of an application to the DCA with a $500 initial registration fee.
• Director of Nursing: HCSFs must employ a registered nurse (RN) as the Director of Nursing to oversee clinical policies and caregiver competency.
• Community Residence License: Facility-based respite requires a license under N.J.A.C. 10:44A, involving physical plant inspections by the Department of Community Affairs.
• DDD Certification: Providers must sign the Attestation for Providers of Individual Supports if delivering residential or in-home respite under DDD waivers.

5. Medicaid Provider Enrollment

Enrollment is processed through the New Jersey Medicaid Management Information System (NJMMIS), operated by Gainwell Technologies. DDD providers must submit a Combined Application that bridges DDD program approval and Medicaid fee-for-service enrollment.

• Combined Application: Submitted to the Gainwell Technologies Provider Enrollment Unit in Trenton, NJ.
• Application Fee: Providers must pay the federal Medicaid application fee unless waived by prior Medicare enrollment.
• Form CMS-1513: Ownership and Control Interest Disclosure Statement must be completed to identify all individuals with 5 percent or more ownership.
• NJMMIS Portal: Approved providers receive a Medicaid ID and must register on https://www.njmmis.com/ to manage their profile and claims.

6. Staffing, Training and Background Checks

Direct support professionals (DSPs) delivering respite must meet strict background and training standards mandated by DHS. Training must be completed through state-approved vendors, notably The Boggs Center on Developmental Disabilities.

• Age and Education: DSPs must be at least 18 years old and possess a high school diploma or GED.
• Background Checks: Mandatory fingerprinting through the Criminal History Record Information (CHRI) system and checks against the Central Registry of Offenders Against Individuals with Developmental Disabilities (CARI).
• CPR and First Aid: Staff must hold current, in-person certification in CPR and Standard First Aid prior to delivering services unsupervised.
• DDD Mandatory Training: Completion of the College of Direct Support (CDS) modules, including Abuse and Neglect prevention, within 90 days of hire.

7. Documentation, Policies and Records

Providers must maintain comprehensive administrative and client records in compliance with N.J.A.C. 10:49. Electronic Visit Verification (EVV) is mandatory for all in-home respite services to capture the exact time and location of care.

• EVV Compliance: Agencies must use the state's EVV aggregator or an integrated third-party system to record clock-in and clock-out times.
• Service Plans: Respite delivery must align exactly with the authorized hours and goals specified in the participant's Individualized Service Plan (ISP).
• Record Retention: All Medicaid billing and clinical records must be retained for a minimum of five years from the date of service.
• Deficit Reduction Act: Agencies receiving over $5 million annually must establish written policies detailing the Federal False Claims Act for all employees.

8. Billing, Rates and Claims

Respite claims are submitted either to Gainwell Technologies for DDD fee-for-service participants or directly to the participant's MCO for MLTSS beneficiaries. Rates are established by DHS and published in the DDD Rate Schedule.

• Hourly Code: S5150 is typically used for in-home respite care lasting less than 8 hours per day.
• Daily Code: S5151 is used for daily respite care exceeding 8 hours in a single 24-hour period.
• Prior Authorization: All respite services require prior authorization from the Support Coordinator or MCO care manager before billing.
• Claim Submission: Fee-for-service claims are submitted via the NJMMIS portal or via EDI 837P transactions.

9. Approval Sequence and Timeline

The pathway to becoming a billable respite provider involves sequential approvals from DCA, DDD, and DMAHS. The entire process typically spans 6 to 9 months from initial entity formation to final MCO contracting.

• Step 1: Obtain NPI and establish the business entity (1 to 2 weeks).
• Step 2: Apply for HCSF licensure through DCA and secure provisional accreditation (3 to 5 months).
• Step 3: Submit the Combined Application to Become a Medicaid/DDD Approved Provider to Gainwell Technologies (60 to 90 days for review).
• Step 4: Complete MCO credentialing for MLTSS network inclusion (90 to 120 days post-Medicaid enrollment).

10. Common Denials and Survey Findings

Applications and claims are frequently delayed or denied due to administrative omissions or failure to adhere to EVV mandates. State auditors heavily scrutinize staff training records and background check completion dates.

• Application Denial: Failure to submit the Attestation for Providers of Individual Supports with the Combined Application.
• EVV Mismatches: Claims denied because the EVV recorded time does not match the billed units or lacks GPS location validation.
• Training Lapses: Survey citations for DSPs providing care before completing mandatory CPR/First Aid or Boggs Center modules.
• Background Check Violations: Allowing staff to work prior to receiving cleared CARI and CHRI results.

11. Key Contacts and Resources

Providers should utilize the official DHS portals and helpdesks for application status and policy clarification. The Boggs Center is the primary resource for mandatory staff training registration.

• DDD Provider Helpdesk: [email protected] for Combined Application inquiries.
• NJMMIS Provider Enrollment: 609-588-6036 or https://www.njmmis.com/ for Medicaid ID and portal access.
• Division of Consumer Affairs (HCSF): https://www.njconsumeraffairs.gov/hcsf/ for licensure applications.
• The Boggs Center on Developmental Disabilities: https://rwjms.rutgers.edu/boggscenter/ for DSP training and orientation schedules.
• Horizon NJ Health Provider Portal: https://www.horizonnjhealth.com/ for MLTSS credentialing and claims.

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