Waiver Consulting Group — Start any program. In any state.

North Dakota - Residential Care Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In North Dakota, 24-hour residential care services delivering habilitation, supervision, and personal care are primarily administered as 'Adult Residential Care' under the HCBS Waiver for the Aged and Disabled, and 'Residential Habilitation' under the Developmental Disabilities (DD) Waiver. These services require providers to operate out of a specifically licensed physical address that meets federal HCBS settings requirements.

The single biggest structural barrier to entry for this service in North Dakota is securing the underlying facility licensure (either a Basic Care Facility license or a DD Provider License under NDCC 25-16) prior to Medicaid enrollment. For DD providers, this is further gatekept by a mandatory Regional Need Approval process, meaning an application for licensure will not even be accepted unless the North Dakota Department of Health and Human Services (ND HHS) Developmental Disabilities Section has authorized the specific regional capacity.

1. Service Definition and Scope

In North Dakota, 24-hour residential care with habilitation and personal care is covered under two distinct paths: Adult Residential Care via the HCBS Waiver for Aged and Disabled, and Residential Habilitation via the Developmental Disabilities (DD) Waiver. Both require the provider to deliver round-the-clock supervision, assistance with activities of daily living (ADLs), and community integration at a specific licensed address.

Providers are responsible for the health and safety of the participants while ensuring the setting complies with the CMS HCBS Settings Final Rule, which mandates community access, privacy, and autonomy for residents.

2. Regulatory and Oversight Agencies

The North Dakota Department of Health and Human Services (ND HHS) is the consolidated umbrella agency responsible for both facility licensing and Medicaid waiver administration. Different divisions within ND HHS handle specific populations and licensing types.

Prospective providers must interact with the Health Facilities Unit for physical plant licensing and the specific waiver division for programmatic approval before enrolling through the state's MMIS portal.

3. Gatekeeping Prerequisites: Who Can Even Apply

North Dakota does not allow open, on-demand enrollment for 24-hour residential habilitation without prior structural approvals. Prospective providers cannot simply submit a Medicaid application; they must first clear regional need and facility licensing hurdles.

If a provider attempts to enroll in the ND Health Enterprise MMIS portal without the underlying facility license and regional authorization, the application will be immediately rejected.

4. Licensure and Certification Requirements

To provide these services, the physical location must be licensed by the state. For DD Residential Habilitation, providers are licensed under NDCC 25-16 and NDAC 75-04-01. For Adult Residential Care, the setting is typically licensed as a Basic Care Facility.

The licensing process requires rigorous physical plant inspections, including Life Safety Code compliance verified by the State Fire Marshal or local jurisdiction.

5. Medicaid Provider Enrollment

Once the facility is licensed and programmatic approval is granted, providers must enroll via the ND Health Enterprise MMIS portal. Enrollment is a mandatory four-step process requiring taxonomy verification and electronic application submission.

Providers must enroll as a Group/Facility and link their specific licensed service locations to their Medicaid profile.

6. Staffing, Training and Background Checks

Direct Support Professionals (DSPs) and facility managers must meet strict ND HHS requirements to ensure resident safety. Background checks are mandatory and must be completed before a staff member has unsupervised contact with residents.

North Dakota requires specific, state-approved training modules for developmental disability providers, often facilitated through university partnerships.

7. Documentation, Policies and Records

ND HHS requires comprehensive policy manuals and individualized documentation for every resident. Records must be retained for a minimum of six years to comply with Medicaid audit standards.

Providers must utilize state-mandated reporting systems for critical incidents and maintain transparent financial ledgers for any resident funds they manage.

8. Billing, Rates and Claims

Residential care is billed on a per-diem (daily) basis. Rates for DD Residential Habilitation are tiered based on the individual's assessed level of need, ensuring higher reimbursement for residents requiring intensive supports.

Providers must ensure that all billed days correspond to actual resident presence or approved therapeutic leave, and that room and board are strictly excluded from Medicaid claims.

9. Approval Sequence and Timeline

The end-to-end process from business formation to billing first claims typically takes 6 to 9 months in North Dakota. This timeline is heavily dependent on facility acquisition, zoning approvals, and Life Safety inspections.

Delays in securing the physical plant or passing the Fire Marshal inspection will pause the entire Medicaid enrollment process.

10. Common Denials and Survey Findings

Applications and ongoing licenses are frequently delayed or cited for life safety code violations and incomplete staff training records. ND HHS conducts regular unannounced surveys to ensure compliance.

Failure to maintain strict adherence to medication administration protocols is a leading cause of citations and potential license suspension.

11. Key Contacts and Resources

Prospective providers should utilize the official ND HHS portals and contact the Developmental Disabilities or Aging Services divisions directly for application packets, regional need assessments, and guidance.

The MMIS portal help desk is available for technical assistance during the Medicaid enrollment phase.

See all North Dakota services · North Dakota Medicaid consulting · book a consultation.