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

Last reviewed: 2026-09-10

The New Mexico Health Care Authority (HCA) funds skilled respite services primarily through the Medically Fragile and Developmental Disabilities (DD) waivers, requiring providers to first obtain licensure as a Home Health Agency through the Division of Health Improvement (DHI) before applying to the Developmental Disabilities Supports Division (DDSD). New Mexico does not issue a distinct "Skilled Respite" facility or agency license; instead, agencies must meet the overarching home health regulations (8.370.22 NMAC) and the specific waiver service standards for nursing respite.

Approval requires submitting a Letter of Intent to DHI for agency licensure, followed by Medicaid enrollment through the YES.NM portal and waiver-specific credentialing through the Provider Enrollment Relations Unit (PERU). Applicants must secure local business licenses for every county of operation and demonstrate full compliance with HCBS Settings Requirements prior to receiving any waiver allocations or executing a Provider Agreement.

1. Service Definition and Scope

In New Mexico, skilled respite is defined as short-term nursing care provided to waiver participants whose medical conditions require the clinical assessment and intervention of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). This service provides temporary relief to the primary unpaid caregiver and is authorized when the participant's care needs exceed the scope of what an unlicensed direct support professional can safely manage.

Because New Mexico does not have a standalone skilled respite license, this service is delivered by licensed Home Health Agencies or specialized nursing agencies enrolled under the DD or Medically Fragile waivers. The service may be delivered in the participant's home or in an approved facility setting, provided the setting complies with all state and federal regulations.

• Service Category: Respite care requiring nursing-level intervention under the DD and Medically Fragile waivers.
• Licensure Vehicle: Home Health Agency license (8.370.22 NMAC) issued by the Division of Health Improvement.
• Delivery Setting: Participant's home or a licensed facility meeting HCBS settings criteria.
• Scope of Practice: Must align with the New Mexico Nursing Practice Act for RNs and LPNs.
• Exclusions: Cannot be billed concurrently with other waiver nursing services or during typical school hours for school-aged children.

2. Regulatory and Oversight Agencies

The New Mexico Health Care Authority (HCA) is the single state Medicaid agency, having absorbed the former Department of Health and Human Services Department functions in 2024. Within the HCA, multiple divisions coordinate to oversee skilled respite providers.

The Division of Health Improvement (DHI) handles the physical licensure and compliance surveys, while the Developmental Disabilities Supports Division (DDSD) manages the waiver programs and provider network. Medicaid enrollment and claims are processed through the YES.NM portal.

• New Mexico Health Care Authority (HCA): Umbrella agency for Medicaid and health regulation (https://www.hca.nm.gov/).
• Division of Health Improvement (DHI): Conducts licensing, surveys, and incident investigations (https://www.hca.nm.gov/division-of-health-improvement/).
• Developmental Disabilities Supports Division (DDSD): Manages waiver policies and provider network (https://www.hca.nm.gov/developmental-disabilities-supports-division/).
• Provider Enrollment & Relations Unit (PERU): Handles waiver-specific credentialing and provider agreements (https://www.hca.nm.gov/provider-enrollment-relations/).
• YES.NM Portal: The state's consolidated Medicaid enrollment and business license verification system (https://yes.nm.gov/nmhr/s/provider).

3. Gatekeeping Prerequisites: Who Can Even Apply

New Mexico does not require a Certificate of Need (CON) for home health or respite agencies, nor does it utilize closed network procurements for standard waiver providers. However, strict structural preconditions must be met before an application is accepted.

The state mandates that all prospective waiver providers secure local business licenses for every city or county in which they intend to operate prior to Medicaid enrollment. Additionally, agencies must pass an HCBS Settings Requirement review and secure a $1,000,000 liability insurance policy naming the HCA as an additional insured.

• Local Business Licenses: Required for each county/city of operation and must be uploaded annually to the YES.NM portal.
• HCBS Settings Compliance: New agencies must demonstrate compliance with CMS settings rules in their application policies before approval.
• Liability Insurance: Minimum $1,000,000 per occurrence policy naming the State of New Mexico Health Care Authority as an additional insured.
• Letter of Intent (LOI): DHI will not issue a licensure application packet until a formal LOI is submitted and approved.
• Board of Directors: Agencies must establish and submit an active Board of Directors roster to PERU.

4. Licensure and Certification Requirements

To obtain the underlying Home Health Agency license required to provide skilled respite, applicants must navigate the DHI Health Facility Licensing and Certification process. This begins with submitting a Letter of Intent (LOI) and a detailed Program Narrative to the DHI licensing bureau.

Once the LOI is approved, DHI issues the application packet. The application, policies and procedures, and fee are valid for one year. If the agency plans to provide facility-based respite, architectural plans must be submitted for Life Safety Code review, and a temporary license is only issued after a successful initial health survey.

• Letter of Intent: Must be emailed to [email protected] with a designated contact person to initiate the process.
• Program Narrative: Required document detailing the scope of services, target population, and operational plan.
• Application Fee: Non-refundable fee submitted via certified check, money order, or the new HCA e-payment system.
• Life Safety Code Inspection: Required for facility-based respite prior to temporary licensure, necessitating local fire and certificate of occupancy approvals.
• Initial Health Survey: Conducted by DHI to verify policy implementation and staff credentialing before an annual license is issued.

5. Medicaid Provider Enrollment

After securing DHI licensure, the agency must enroll as a New Mexico Medicaid provider. This process is managed entirely online through the YES.NM portal, where providers submit their NPI, taxonomy codes, and licensure documentation.

Simultaneously, agencies must execute a Provider Agreement with the HCA through the Provider Enrollment Relations Unit (PERU). PERU requires annual submissions of business licenses, insurance certificates, and subcontractor credentials to maintain active status.

• YES.NM Portal: The mandatory online system for submitting Medicaid enrollment applications and reverifications (https://yes.nm.gov/nmhr/s/provider).
• Provider Administrator: Organizations must designate an administrator in YES.NM to manage enrollment activities.
• Provider Agreement: The formal contract with HCA, requiring adherence to Article 25 insurance mandates.
• Annual Reverification: Business licenses and insurance policies must be submitted annually to [email protected] or via the portal.
• Taxonomy Code: Must align with home health or nursing agency classifications as directed by the DDSD billing matrix.

6. Staffing, Training and Background Checks

Skilled respite requires delivery by nurses licensed by the New Mexico Board of Nursing. Agencies must maintain current copies of all RN and LPN licenses and submit them annually to PERU.

All staff with direct participant contact must undergo the New Mexico Caregiver Criminal History Screening Program (CCHSP) background checks. Additionally, clinical staff must maintain current CPR certification and provide proof of tuberculosis (TB) screening at the time of the initial DHI survey.

• Nursing Licensure: Active, unencumbered RN or LPN license issued by the New Mexico Board of Nursing.
• Background Checks: Mandatory fingerprint-based screening through the DHI Caregiver Criminal History Screening Program.
• TB Testing: Purified Protein Derivative (PPD) skin test certificates or chest x-ray results required for all direct-care staff.
• CPR/First Aid: Current certification required for all nursing staff delivering respite.
• Subcontractor Reporting: New subcontractor licenses and start dates must be reported to PERU immediately.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records in accordance with DDSD waiver standards and DHI licensing rules. This includes detailed nursing assessments, medication administration records (MARs), and individualized service plans.

Agencies are also subject to strict incident reporting requirements. Any instances of abuse, neglect, or exploitation must be reported to the DHI Incident Management Bureau within mandated timeframes, and internal policies must reflect these state-specific protocols.

• Service Plans: Must document the specific nursing interventions required during the respite period.
• Medication Administration Records: Required for all medications administered during the respite shift.
• Incident Reporting: Policies must align with DHI guidelines for reporting abuse, neglect, and exploitation.
• Board Roster: Annual submission of the Board of Directors list (name, address, phone, email) to PERU.
• Policy Review: DHI reviews all clinical and administrative policies during the initial application and subsequent surveys.

8. Billing, Rates and Claims

Skilled respite services are billed to the New Mexico Medicaid MMIS system using specific HCPCS procedure codes outlined in the DDSD and Medically Fragile waiver billing matrices. Rates are established by the HCA and published in the official fee schedules.

Services require prior authorization based on the participant's approved budget and Individual Service Plan (ISP). Providers are notified of participant selection via the Primary Freedom of Choice (PFOC) form, which triggers the authorization process.

• Claims System: Billed through the state's MMIS via the YES.NM portal or approved clearinghouses.
• Procedure Codes: Providers must reference the current DDSD Waiver Billing Matrix for exact HCPCS codes and modifiers for skilled nursing respite.
• Rate Schedule: Fixed fee-for-service rates published on the HCA provider portal; providers cannot balance-bill participants.
• Prior Authorization: Required for all waiver services; tied to the participant's approved ISP.
• PFOC Form: The Primary Freedom of Choice form serves as the official notification that a participant has selected the agency.

9. Approval Sequence and Timeline

The approval process is sequential and can take 6-9 months depending on facility readiness and DHI survey schedules. It begins with the LOI submission to DHI, which is typically reviewed within 30 days.

Once the application is submitted, the agency has one year to complete the process, including the initial health survey. Following DHI licensure, Medicaid enrollment through YES.NM and PERU credentialing adds an additional 30-60 days before the agency can accept waiver allocations.

• Step 1: Submit Letter of Intent and Program Narrative to DHI.
• Step 2: Receive application packet, submit fee and policies (valid for 1 year).
• Step 3: Complete Life Safety Code inspection (if facility-based) and Initial Health Survey.
• Step 4: Receive DHI License and apply for Medicaid enrollment via YES.NM.
• Step 5: Submit Provider Agreement, insurance, and local licenses to PERU for final waiver approval.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete submissions, particularly the failure to secure local business licenses for every jurisdiction of operation. DHI will also halt the process if the Program Narrative lacks sufficient detail regarding nursing oversight.

During initial surveys, common citations include missing TB test results for staff, incomplete background check clearances, and failure to adequately address HCBS Settings Requirements in the agency's operational policies.

• Missing Local Licenses: Failure to upload city/county business licenses to YES.NM results in Medicaid termination or denial.
• HCBS Settings Failures: Policies that do not guarantee participant privacy, dignity, and community integration.
• Incomplete Background Checks: Allowing staff to provide care before CCHSP clearance is finalized.
• Insurance Deficiencies: Policies that fail to name the HCA as an additional insured or fall below the $1M threshold.
• Expired Application: Failing to pass the initial survey within the one-year application window requires starting over.

11. Key Contacts and Resources

Prospective providers should begin by contacting the DHI Health Facility Licensing and Certification bureau for the LOI process. For waiver-specific questions, the DDSD Provider Enrollment Relations Unit (PERU) is the primary resource.

Technical assistance for the Medicaid enrollment portal is handled by the YES.NM helpdesk. Providers should also monitor the HCA website for special announcements and rule changes.

• DHI Licensing Bureau: [email protected] or 505-476-9093 (https://www.hca.nm.gov/health-facility-licensing-and-certification-2/).
• PERU Contact: Tammy Barth at [email protected] or fax 505-476-8894 (https://www.hca.nm.gov/provider-enrollment-relations/).
• YES.NM Provider Portal: For Medicaid enrollment and business license uploads (https://yes.nm.gov/nmhr/s/provider).
• DHI Rule Changes: Email [email protected] to join the regulatory update list.
• Board of Pharmacy: 505-841-9102 (required if the facility will handle or store drugs).

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