Pennsylvania - I/DD Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Pennsylvania Department of Human Services (DHS), through its Office of Developmental Programs (ODP), authorizes intellectual and developmental disability services under the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) Waivers. This service array spans 24-hour residential habilitation in licensed community homes, life sharing, community participation support, and in-home supports, governed primarily by 55 Pa. Code Chapter 6100.

Before submitting a Medicaid enrollment application to the state, prospective agencies must complete the mandatory ODP Provider Applicant Orientation and secure qualification from their designated county Administrative Entity (AE) within a strict 120-day window before the orientation certificate expires. Facilities proposing residential or day services must also pass an ODP location review to prove the site is not adjacent to another human service location serving primarily persons with disabilities.

1. Service Definition and Scope

Pennsylvania's ODP waivers provide a continuum of care for individuals with intellectual disabilities and autism. The services are designed to support individuals in their own homes, family homes, or licensed community settings, ensuring compliance with the federal HCBS Settings Rule.

The scope of services varies by waiver, with the Consolidated Waiver offering the most comprehensive array, including 24/7 residential habilitation, while the Community Living and P/FDS waivers provide capped funding for non-residential supports.

• Consolidated Waiver: Provides services to individuals requiring an ICF/IID level of care, including uncapped residential habilitation and life sharing.
• Community Living Waiver: Provides services up to a specific annual funding cap, excluding 24/7 residential habilitation.
• P/FDS Waiver: Provides capped funding for individuals living in their own or family home, focusing on supported employment and community participation.
• Residential Habilitation: 24-hour support provided in licensed community homes governed by 55 Pa. Code Chapter 6400.
• Life Sharing: Services provided in the private home of a host family, governed by 55 Pa. Code Chapter 6500.
• Community Participation Support: Facility-based and community-based day services, with facilities licensed under Chapters 2380 or 2390.

2. Regulatory and Oversight Agencies

The Pennsylvania Department of Human Services (DHS) is the single state Medicaid agency. Within DHS, the Office of Developmental Programs (ODP) operates the ID/A waivers and sets provider qualification standards.

Local oversight and initial provider qualification are delegated to county-level Administrative Entities (AEs). Facility licensure is managed by the DHS Bureau of Human Services Licensing (BHSL).

• Department of Human Services (DHS): The overarching state Medicaid agency. https://www.dhs.pa.gov
• Office of Developmental Programs (ODP): The DHS program office that administers the Consolidated, Community Living, and P/FDS waivers. https://www.myodp.org
• Bureau of Human Services Licensing (BHSL): The DHS division responsible for inspecting and licensing community homes and day facilities. https://www.dhs.pa.gov/providers/Providers/Pages/Licensing.aspx
• Administrative Entities (AEs): County mental health/intellectual disability (MH/ID) programs that act as ODP's designees to review and approve new provider qualifications.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania utilizes a decentralized, county-based qualification process that strictly gates Medicaid enrollment. A provider cannot apply directly to the state Medicaid portal for ODP services without first passing through the local Administrative Entity (AE).

The most rigid structural precondition is the ODP Provider Applicant Orientation and its associated timeline. Furthermore, ODP enforces strict location restrictions for facility-based services to comply with integration mandates.

• Provider Applicant Orientation: The CEO or Executive Director must complete this mandatory training and receive a Certificate of Completion before submitting any qualification documents.
• 120-Day Expiration: The orientation Certificate of Completion expires if the provider applicant is not fully qualified by the AE within 120 days of the certificate date.
• Administrative Entity (AE) Sponsorship: Providers must submit their qualification application and self-assessment to the specific county AE where they intend to render services.
• Location Adjacency Restriction: Proposed Residential Habilitation, Life Sharing, or Community Participation Support locations will be rejected if they are adjacent to another human service residential or day location serving primarily persons with a disability.
• Self-Assessment Validation: Applicants must complete and pass the ODP provider self-assessment tool, demonstrating compliance with Appendix C of the waivers, validated by the AE.

4. Licensure and Certification Requirements

Provider requirements for ODP waivers are codified in 55 Pa. Code Chapter 6100. This chapter establishes the overarching rules for HCBS providers, including training, incident management, and quality management.

If a provider offers facility-based services, they must obtain the specific license for that service model from BHSL before they can be qualified to bill Medicaid.

• Chapter 6100: The foundational HCBS provider regulations detailing monitoring, compliance, and pre-enrollment training requirements.
• Chapter 6400 Licensure: Required for agencies operating Community Homes for Individuals with an Intellectual Disability (Residential Habilitation).
• Chapter 6500 Licensure: Required for agencies operating Life Sharing homes.
• Chapter 2380 Licensure: Required for agencies operating Adult Training Facilities.
• Chapter 2390 Licensure: Required for agencies operating Vocational Facilities.
• Provisional License Prohibition: Per 55 Pa. Code § 6100.81(c)(1), an applicant possessing only a provisional license for a specific HCBS is prohibited from enrolling in the HCBS program for that service.

5. Medicaid Provider Enrollment

Once qualified by the AE and licensed by BHSL (if applicable), the provider must enroll in the Pennsylvania Medical Assistance program via the DHS Provider Enrollment Electronic Portal.

Enrollment grants the provider a PROMISe ID, which is required to interface with the state's authorization and claims systems.

• PROMISe System: The Provider Reimbursement and Operations Management Information System, Pennsylvania's MMIS. https://promise.dpw.state.pa.us/
• DHS Provider Enrollment Portal: The electronic system used to submit the initial Medicaid enrollment application. https://provider.enrollment.dhs.pa.gov/
• Provider Type 51: The standard PROMISe provider type designation for Home and Community Based Waiver Providers.
• Ownership and Control Interest Form: A mandatory form requiring disclosure of all managing employees and individuals with 5% or more ownership interest.
• Application Fee: Institutional providers must pay the ACA-mandated application fee (approximately $731) unless they provide proof of payment to Medicare or another state's Medicaid program.

6. Staffing, Training and Background Checks

Staff qualifications are strictly defined in Appendix C of the approved ODP waivers and 55 Pa. Code Chapter 6100. Providers must maintain documentation of all clearances and training prior to staff having direct contact with participants.

ODP requires standardized incident management training and annual continuing education for all direct support professionals (DSPs).

• Criminal History Clearances: A Pennsylvania State Police criminal history record check is required for all staff prior to client contact.
• Child Abuse History Clearance: Required under the Child Protective Services Law for staff serving individuals under age 18.
• FBI Fingerprint Check: Required for any staff member who has resided outside of Pennsylvania within the past two years.
• Annual Training Requirement: Chapter 6100 mandates 24 hours of annual training for DSPs, covering person-centered planning, HCBS principles, and specific individual needs.
• EIM Training: Staff must complete training on ODP's Enterprise Incident Management (EIM) system for reporting critical incidents.

7. Documentation, Policies and Records

Providers must adhere to ODP Bulletin 00-17-02, which outlines the strict claim and service documentation requirements necessary to justify Federal Financial Participation (FFP).

Services must be delivered and documented exactly as authorized in the individual's Individual Support Plan (ISP).

• ODP 00-17-02 Requirements: Every claim must be supported by documentation showing the date, recipient name, MA ID, provider name, units of service, and place of service.
• Individual Support Plan (ISP): The person-centered plan that dictates the exact frequency, duration, and scope of authorized services.
• Eligibility Verification System (EVS): Providers must document that they verified the individual's Medicaid eligibility via EVS prior to rendering services.
• Quality Management Plan: Chapter 6100 requires providers to develop and implement a written quality management plan, updated at least every three years.
• Progress Notes: Contemporaneous documentation must describe the nature and extent of the service provided, linking directly to ISP goals.

8. Billing, Rates and Claims

ODP services are reimbursed primarily through a statewide fee schedule established by DHS and published in the Pennsylvania Bulletin. Claims are adjudicated through the PROMISe system.

Service authorizations are managed in the Home and Community Services Information System (HCSIS), which interfaces with PROMISe to validate claims against approved ISP units.

• PROMISe Billing: Claims must be submitted electronically to PROMISe using standard HIPAA 837 transactions or the PROMISe internet portal.
• HCSIS Authorization: Claims will deny in PROMISe if the service, date, or units do not match an active authorization in HCSIS.
• Fee Schedule Rates: DHS publishes standard rates for services like In-Home and Community Support and Community Participation Support.
• Needs Group Tiering: Residential habilitation rates are often tiered based on the individual's assessed Needs Group, determined by the Supports Intensity Scale (SIS).
• 180-Day Timely Filing: Claims must generally be received by PROMISe within 180 days of the date of service to be eligible for payment.

9. Approval Sequence and Timeline

The path to becoming an ODP provider is strictly sequenced. Medicaid enrollment cannot occur without AE qualification, and AE qualification cannot begin without the orientation certificate.

Because the orientation certificate expires in 120 days, providers must have their policies, self-assessment, and AE relationships prepared before taking the orientation.

• Step 1: Register for and complete the ODP Provider Applicant Orientation to obtain the Certificate of Completion.
• Step 2: Submit the completed ODP self-assessment and required policy documentation to the local county AE within the 120-day window.
• Step 3: Apply for and obtain the appropriate BHSL facility license (e.g., Chapter 6400 or 2380) if proposing facility-based services.
• Step 4: Submit the PROMISe enrollment application via the DHS Provider Enrollment Portal, attaching the AE qualification letter and BHSL license.
• Step 5: Receive the PROMISe Provider ID and request access to HCSIS to begin receiving service authorizations.

10. Common Denials and Survey Findings

Initial applications are frequently denied due to timing errors or failure to meet the HCBS Settings Rule location requirements. ODP and AEs strictly enforce the 120-day qualification window.

During ongoing licensure and AE reviews, citations often stem from missing staff training documentation or failure to implement corrective action plans.

• 120-Day Timeout: Applications are rejected by the AE because the provider failed to submit all required, compliant documentation before the orientation certificate expired.
• Location Adjacency Denials: Proposed residential or day facilities are denied qualification because ODP determines they are adjacent to another disability-specific human service location.
• Provisional License Rejections: PROMISe enrollment applications are denied because the provider submitted a provisional BHSL license instead of a regular license.
• Incomplete Ownership Disclosures: Enrollment is delayed or denied because the Ownership and Control Interest Form lacks required managing employee details for each service location.
• Training Documentation Citations: Providers are cited during Chapter 6100 reviews for failing to document the mandatory 24 hours of annual DSP training.

11. Key Contacts and Resources

Prospective providers must utilize ODP's dedicated training portal and the DHS enrollment systems to navigate the qualification process.

County Administrative Entities serve as the primary point of contact for initial qualification questions and local needs assessments.

• MyODP Training and Resource Portal: The central hub for ODP communications, training, and the Provider Applicant Orientation. https://www.myodp.org
• DHS Provider Enrollment Portal: The system for submitting the PROMISe Medicaid application. https://provider.enrollment.dhs.pa.gov/
• PA Code Chapter 6100 Regulations: The official text of the HCBS provider requirements. https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/055/chapter6100/chap6100toc.html
• PROMISe Provider Service Center: For technical assistance with Medicaid enrollment and claims. 1-800-537-8862
• Bureau of Human Services Licensing (BHSL): For questions regarding Chapter 6400, 6500, 2380, and 2390 facility licensure. https://www.dhs.pa.gov/providers/Providers/Pages/Licensing.aspx

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