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

Last reviewed: 2026-09-10

The Pennsylvania Department of Human Services (DHS) Office of Long-Term Living (OLTL) funds Respite services through the Community HealthChoices (CHC) and OBRA waivers to provide short-term relief for unpaid caregivers. Approval to bill Medicaid for in-home respite requires an applicant to first obtain a Home Care Agency license from the Pennsylvania Department of Health under 28 PA Code Chapter 611 before submitting a fee-for-service enrollment application through the DHS Provider Enrollment portal.

Because the majority of Pennsylvania's adult HCBS population is enrolled in the mandatory CHC managed care program, securing a Medicaid PROMISe provider ID is only an intermediate step. Providers must successfully negotiate and execute network contracts with the regional CHC Managed Care Organizations (CHC-MCOs) to receive participant authorizations and reimbursement.

1. Service Definition and Scope

Respite services in Pennsylvania support individuals on a short-term basis due to the absence or need for relief of unpaid caregivers normally providing care. The service ensures the participant's health and safety while the primary caregiver is unavailable.

Under OLTL waiver specifications, in-home respite is strictly delineated from other daily living supports and cannot be billed concurrently with similar services.

2. Regulatory and Oversight Agencies

Oversight of Respite providers is split between the Department of Health (DOH) for agency licensure and the Department of Human Services (DHS) for Medicaid enrollment and waiver administration.

Managed care organizations provide the direct oversight of service authorizations and claims for the majority of waiver participants.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania requires structural prerequisites before a provider can bill for Respite under OLTL waivers. The state utilizes a mandatory managed care delivery system for most adult HCBS, meaning fee-for-service enrollment does not guarantee business.

Providers must clear both state licensure hurdles and managed care network adequacy reviews.

4. Licensure and Certification Requirements

In-home respite providers must be licensed as Home Care Agencies by the Pennsylvania Department of Health.

This licensure ensures the agency meets baseline health, safety, and administrative standards before interacting with the Medicaid system.

5. Medicaid Provider Enrollment

After obtaining DOH licensure, agencies must enroll in Pennsylvania Medical Assistance via the DHS Provider Enrollment Electronic Portal.

The state has streamlined the portal to verify DOH licenses directly from primary sources, reducing the need for manual document uploads.

6. Staffing, Training and Background Checks

Direct care workers providing respite must pass comprehensive background checks and meet competency standards before providing care.

Additional clearances are strictly enforced if the provider will be operating in homes where children are present.

7. Documentation, Policies and Records

Providers must maintain strict documentation to support claims and demonstrate compliance with waiver standards.

Auditors frequently review personnel files and service logs to ensure alignment with the participant's authorized service plan.

8. Billing, Rates and Claims

Respite is billed according to the OLTL Home and Community Based Waiver Services fee schedule, though CHC-MCO contracted rates may dictate final payment.

Claims for the majority of participants are routed through managed care clearinghouses rather than the state's fee-for-service system.

9. Approval Sequence and Timeline

The path to becoming a billing provider involves sequential approvals from DOH, DHS, and MCOs.

Providers cannot skip steps; Medicaid enrollment will be rejected without an active DOH license.

10. Common Denials and Survey Findings

Applications and claims are frequently delayed or denied due to missing prerequisites or documentation errors.

State and MCO auditors heavily scrutinize overlapping service times and missing background clearances.

11. Key Contacts and Resources

Primary resources for prospective respite providers in Pennsylvania include state licensing divisions and managed care portals.

Providers should monitor OLTL bulletins for updates to waiver definitions and rate schedules.

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