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

Last reviewed: 2026-08-16

Respite Care Services in Pennsylvania provide temporary, short-term relief to primary unpaid caregivers of individuals enrolled in Medicaid Home and Community-Based Services (HCBS). These services are primarily administered through the Office of Developmental Programs (ODP) for individuals with intellectual disabilities and autism, and the Office of Long-Term Living (OLTL) under the Community HealthChoices (CHC) managed care program.

The single biggest structural barrier to entry for new respite providers in Pennsylvania is securing network contracts with CHC Managed Care Organizations (MCOs) or obtaining initial provider qualification through a county Administrative Entity (AE) for ODP waivers. Because OLTL utilizes a managed care model, MCOs frequently enforce closed networks based on regional adequacy, meaning a fully qualified provider may still be blocked from receiving CHC referrals if the MCO determines no additional respite capacity is needed in that county.

1. Service Definition and Scope

In Pennsylvania, Medicaid Respite Care is defined as a service provided to participants unable to care for themselves, furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care. It is not a standalone program but a service line item within specific 1915(c) waivers, including the ODP Consolidated, Community Living, and Person/Family Directed Support (P/FDS) waivers, as well as the OLTL CHC waiver.

The service can be delivered in the participant's home (unlicensed) or out-of-home in a licensed facility, camp, or host home. It is authorized in 15-minute increments for short durations or on a per-diem basis for overnight stays, strictly governed by the participant's Individual Support Plan (ISP) or Person-Centered Service Plan (PCSP).

• In-Home Respite: Provided in the participant's private residence to relieve the primary caregiver.
• Out-of-Home Respite: Provided in licensed settings such as Chapter 6400 Community Homes or Chapter 6500 Life Sharing homes.
• Emergency Respite: Unplanned coverage authorized due to sudden caregiver illness, crisis, or absence.
• Camp Respite: Out-of-home respite provided at a licensed camp facility during summer or day programs.
• Unit of Service: Billed in 15-minute increments (hourly) or a 24-hour per-diem rate.
• Service Limitations: Capped at a specific number of days or units per fiscal year depending on the specific waiver (e.g., 30 days per year for certain ODP populations).

2. Regulatory and Oversight Agencies

Respite care in Pennsylvania is bifurcated based on the target population. The Department of Human Services (DHS) is the overarching state Medicaid agency. Under DHS, the Office of Developmental Programs (ODP) oversees services for individuals with intellectual disabilities and autism, while the Office of Long-Term Living (OLTL) oversees aging and physical disability waivers.

Providers must interact with state-level portals and regional entities. ODP utilizes county-level Administrative Entities (AEs) for local oversight, while OLTL relies on contracted Managed Care Organizations (MCOs) to administer the Community HealthChoices (CHC) program.

• Pennsylvania Department of Human Services (DHS): The single state Medicaid agency overseeing all HCBS programs (https://www.dhs.pa.gov).
• Office of Developmental Programs (ODP): Administers waivers for intellectual disabilities and autism (https://www.dhs.pa.gov/about/DHS-Information/Pages/Office-of-Developmental-Programs.aspx).
• Office of Long-Term Living (OLTL): Administers the Community HealthChoices (CHC) managed care waiver (https://www.dhs.pa.gov/about/DHS-Information/Pages/Office-of-Long-Term-Living.aspx).
• PROMISe Provider Portal: The state's Medicaid Management Information System used for enrollment and fee-for-service claims (https://promise.dhs.pa.gov).
• Home and Community Services Information System (HCSIS): The ODP portal for provider qualification, incident management, and ISPs (https://www.hcsis.state.pa.us).
• Community HealthChoices MCOs: Designating entities like UPMC for You (https://www.upmchealthplan.com/chc/) and PA Health & Wellness (https://www.pahealthwellness.com) that manage OLTL networks.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania does not utilize a Certificate of Need (CON) for HCBS respite, but it enforces strict structural prerequisites before an application is accepted. For ODP waivers, a prospective provider cannot simply enroll in Medicaid; they must first complete the mandatory ODP Applicant Orientation and secure sponsorship and qualification from a county Administrative Entity (AE).

For OLTL's Community HealthChoices, the gatekeeper is the MCO. Providers must submit a network participation request to one of the three regional CHC MCOs. If the MCO determines their network is adequate for respite providers in that county, they will reject the application (a closed network moratorium), blocking the provider from serving CHC participants regardless of their qualifications.

• ODP Applicant Orientation: Mandatory prerequisite training that must be completed before initiating the ODP New Provider Qualification process.
• Administrative Entity (AE) Qualification: ODP providers must be reviewed and approved by the local county MH/ID office (the AE) before PROMISe enrollment is permitted.
• MCO Network Adequacy Closures: CHC MCOs (e.g., AmeriHealth Caritas, UPMC) restrict new contracts based on regional need; closed networks act as a hard barrier to entry.
• Business Registration: Must be registered with the Pennsylvania Department of State with an active EIN and Type 2 NPI prior to application.
• Service Location Requirement: Must have a physical commercial or established business address in Pennsylvania or a border state; virtual offices are rejected.

4. Licensure and Certification Requirements

Pennsylvania does not issue a distinct "Respite Care License" for in-home services. In-home respite is an unlicensed service governed by ODP or OLTL provider qualification standards. Providers must meet the regulatory requirements outlined in 55 Pa. Code Chapter 6100 (for ODP) or the CHC agreement (for OLTL) to be certified as a qualified provider.

If a provider intends to offer out-of-home respite, they must obtain a specific facility license from the DHS Bureau of Human Services Licensing (BHSL). Operating an out-of-home respite program without the corresponding residential or day facility license is strictly prohibited.

• In-Home Respite Authority: Unlicensed; authorized via ODP Provider Qualification under 55 Pa. Code Chapter 6100 or OLTL CHC credentialing.
• Chapter 6400 Community Homes: Required license for out-of-home respite provided in a community residential setting for individuals with intellectual disabilities.
• Chapter 6500 Life Sharing Homes: Required license for out-of-home respite provided in a host home or family living setting.
• Chapter 3800 Child Residential: Required license if providing out-of-home respite to children in a facility setting.
• BHSL Licensure Application: Facility licenses must be obtained through the DHS Bureau of Human Services Licensing prior to Medicaid enrollment.
• Provider Qualification (DP 1059): The specific ODP form and process required to certify an unlicensed in-home respite agency.

5. Medicaid Provider Enrollment

Once qualified by ODP or licensed by BHSL, providers must enroll in the Pennsylvania Medical Assistance program via the PROMISe portal. This step is mandatory to receive a 13-digit PA Medicaid Provider Number, which is required to bill fee-for-service or contract with CHC MCOs.

The enrollment process requires submitting an electronic application, paying the federal application fee (if applicable to the provider type), and uploading required attachments. DHS screens all applications against federal databases for exclusions and verifies state licensure or qualification status.

• PROMISe Portal Application: The electronic enrollment system used to submit the initial application, reactivations, and revalidations.
• Provider Type 59 (HCBS): The typical PROMISe provider type used for ODP waiver services, requiring specific specialty codes for respite.
• Application Fee: Subject to the CMS-mandated fee (approximately $709), though some HCBS in-home provider types may qualify for waivers or exemptions.
• Required Attachments: W-9, IRS EIN confirmation, ODP qualification letter or BHSL license, and ownership disclosure forms.
• Out-of-State Providers: Must be licensed in their home state and provide proof of Medicaid enrollment in that state to enroll in PA PROMISe.
• Revalidation: Federal rules require PA Medicaid providers to revalidate their PROMISe enrollment every five years.

6. Staffing, Training and Background Checks

Direct Support Professionals (DSPs) and respite aides must meet strict state requirements before providing care. Pennsylvania mandates comprehensive background checks, including child abuse clearances, to protect vulnerable waiver participants.

Training requirements are dictated by the specific waiver. ODP requires all staff to complete the state-mandated incident management and mandatory reporter training, while OLTL requires specific competencies in personal care and aging support.

• Age and Education: Respite staff must be at least 18 years of age and possess a high school diploma or GED.
• Criminal Background Check: Mandatory Pennsylvania State Police (PATCH) criminal history record check prior to client contact.
• Child Abuse Clearance: Required via the PA Child Abuse History Clearance system if serving participants under 18.
• FBI Fingerprinting: Required if the staff member has lived outside of Pennsylvania within the past two years.
• CPR and First Aid: All direct care staff must hold valid, in-person CPR and First Aid certification.
• ODP Required Training: Must complete the ODP Annual Pre-Service Training, including Chapter 6100 regulations and Incident Management.
• Medication Administration: Staff must complete the ODP Medication Administration Training Program if they will be assisting with medications.

7. Documentation, Policies and Records

Respite providers must maintain a comprehensive Policy and Procedure Manual that aligns with DHS regulations. For ODP, this means strict adherence to 55 Pa. Code Chapter 6100, which dictates how incidents are reported, how quality is managed, and how records are retained.

Service documentation must support every unit billed. Providers must maintain daily logs that detail the start and end times of respite, the specific activities provided, and the signature of the caregiver or participant verifying the service was delivered.

• Quality Management (QM) Plan: A mandatory ODP document outlining how the provider will evaluate and improve service delivery.
• Incident Management Policy: Must align with the Enterprise Incident Management (EIM) system protocols for reporting abuse, neglect, or critical events within 24 hours.
• Emergency Disaster Plan: Documented protocols for handling medical emergencies, natural disasters, and caregiver crises.
• Service Notes: Daily documentation requiring date, start/end times, location of service, description of respite activities, and staff signature.
• Record Retention: Pennsylvania requires Medicaid providers to retain all service and billing records for a minimum of five years.
• HIPAA Compliance: Written policies safeguarding Protected Health Information (PHI) and participant confidentiality.

8. Billing, Rates and Claims

Billing procedures depend on the waiver authority. ODP respite services are billed fee-for-service through the PROMISe system, utilizing authorizations generated in HCSIS. OLTL CHC respite is billed directly to the participant's contracted MCO using their specific clearinghouse or portal.

Rates are established by DHS and published in the Pennsylvania Bulletin. Respite is typically billed using specific HCPCS codes with modifiers indicating the waiver and staffing ratio.

• ODP Billing System: Claims are submitted directly to PROMISe based on authorized units in the HCSIS system.
• CHC MCO Billing: Claims must be submitted to the specific MCO (e.g., UPMC, PA Health & Wellness) via their designated clearinghouse (e.g., Change Healthcare, Availity).
• HCPCS Codes: Commonly utilizes S5150 (Unskilled Respite Care, 15 minutes) or S5151 (Unskilled Respite Care, per diem).
• Rate Schedule: ODP publishes a standardized fee schedule annually; MCO rates are negotiated but generally align with the DHS fee schedule.
• Prior Authorization: 100% of respite services require prior authorization in the participant's ISP/PCSP before services can be rendered or billed.
• Electronic Visit Verification (EVV): In-home respite requires the use of the DHS EVV system (Sandata) or an approved alternate EVV vendor to capture shift start/end times.

9. Approval Sequence and Timeline

Becoming a fully approved respite provider in Pennsylvania is a multi-step process that typically takes 4 to 8 months. The sequence must be followed exactly, as PROMISe enrollment cannot occur without prior ODP qualification or BHSL licensure.

For CHC providers, the timeline is extended by the MCO credentialing and contracting phase, which can take an additional 90 to 120 days after PROMISe enrollment is complete.

• Step 1: Business Setup (Weeks 1-4): Register with PA Dept of State, obtain EIN, NPI, and secure commercial liability insurance.
• Step 2: ODP Orientation (Weeks 4-6): Complete the mandatory ODP Applicant Orientation and prepare the qualification packet.
• Step 3: AE Qualification / BHSL Licensure (Months 2-4): Submit DP 1059 to the local AE for in-home, or apply for a BHSL facility license for out-of-home.
• Step 4: PROMISe Enrollment (Months 4-6): Submit the electronic application via the PROMISe portal and await DHS screening and approval.
• Step 5: MCO Contracting (Months 6-8): For OLTL/CHC, apply for network participation with regional MCOs and complete credentialing.
• Step 6: HCSIS Registration (Month 8): Finalize HCSIS access to receive ODP service authorizations and begin accepting referrals.

10. Common Denials and Survey Findings

Applications are frequently denied at the PROMISe enrollment stage due to mismatched data between the IRS, NPPES (NPI registry), and the DHS application. Additionally, ODP qualification packets are often rejected by AEs if the Quality Management Plan or Incident Management policies lack required state-specific language.

During post-enrollment audits or BHSL surveys, providers are commonly cited for staffing and documentation failures. Missing EVV data or incomplete background checks can result in immediate claim recoupments and suspension of referrals.

• Mismatched Identifiers: PROMISe denials caused by the legal business name or address not matching exactly across the W-9, NPI, and state registration.
• Closed MCO Networks: CHC applications rejected outright because the MCO has determined they have sufficient respite providers in the requested county.
• Incomplete Clearances: Survey citations for allowing staff to provide care before the PA State Police or Child Abuse clearances are fully processed.
• EVV Non-Compliance: Claim denials or recoupments due to staff failing to log in/out using the mandated Sandata EVV system.
• Missing Service Notes: Recoupment of funds during audits because daily logs lack specific descriptions of respite activities or required signatures.
• Policy Deficiencies: AE qualification delays due to generic, non-PA-specific policy manuals that fail to reference 55 Pa. Code Chapter 6100.

11. Key Contacts and Resources

Providers must utilize official state resources for accurate regulations, fee schedules, and portal access. The DHS website and the MyODP training portal are the primary hubs for policy updates and mandatory training.

For technical assistance, providers should contact the PROMISe Provider Enrollment hotline or their regional AE/MCO provider relations representatives.

• PA Department of Human Services (DHS): Official state agency portal (https://www.dhs.pa.gov).
• PROMISe Provider Portal: Medicaid enrollment and claims system (https://promise.dhs.pa.gov).
• MyODP Training Resource: Hub for ODP Applicant Orientation and mandatory staff training (https://www.myodp.org).
• HCSIS Portal: System for ODP authorizations and incident management (https://www.hcsis.state.pa.us).
• DHS Provider Enrollment Hotline: 1-800-537-8862 (Option 1) for PROMISe application status and technical support.
• PA Health & Wellness (CHC MCO): Provider network contracting (https://www.pahealthwellness.com/providers/become-a-provider.html).
• UPMC for You (CHC MCO): Provider network contracting (https://www.upmchealthplan.com/chc/providers/).

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