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

Last reviewed: 2026-08-16

In Pennsylvania, Skilled Respite Service is not licensed as a standalone category. Instead, it is delivered under the state's Medicaid Home and Community-Based Services (HCBS) waivers by agencies holding a Pennsylvania Department of Health (DOH) Home Care Agency or Home Health Agency license. This service provides temporary relief to primary caregivers of participants with complex medical needs, utilizing licensed nursing staff (RNs or LPNs) when the participant's care requirements exceed the scope of an unlicensed direct support professional.

The single biggest structural barrier to entry in Pennsylvania depends on the target waiver population. For aging and physical disability waivers under the Office of Long-Term Living (OLTL), the barrier is Managed Care Organization (MCO) network contracting; the state operates under the Community HealthChoices (CHC) managed care model, and MCOs frequently close their networks to new providers. For intellectual and developmental disability waivers under the Office of Developmental Programs (ODP), the primary barrier is the County Administrative Entity (AE) Provider Qualification (PQ) process, which acts as a strict gatekeeper that must approve your agency before you can even submit a Medicaid enrollment application.

1. Service Definition and Scope

Skilled Respite in Pennsylvania provides short-term, temporary relief to unpaid primary caregivers of individuals enrolled in Medicaid HCBS waivers. Because the participant requires continuous or complex medical interventions (such as ventilator management, tracheostomy care, or complex medication administration), the service must be delivered by licensed nursing personnel.

The service is authorized through the participant's Individual Support Plan (ISP) or Person-Centered Service Plan (PCSP). It can be delivered in the participant's home or in a licensed out-of-home setting, but it cannot be billed simultaneously with other direct care services like Community Participation Support or standard Residential Habilitation.

2. Regulatory and Oversight Agencies

Medicaid in Pennsylvania is administered by the Department of Human Services (DHS). Within DHS, two distinct program offices manage the waivers that fund Skilled Respite: the Office of Developmental Programs (ODP) for intellectual/developmental disabilities, and the Office of Long-Term Living (OLTL) for aging and physical disabilities.

Because Pennsylvania does not have a specific "Respite License," the physical licensure of the agency providing the nurses falls under the jurisdiction of the Pennsylvania Department of Health (DOH). Local oversight and initial provider qualification for ODP waivers are handled by county-level Administrative Entities (AEs).

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania does not require a Certificate of Need (CON) for home care or respite agencies. However, the state imposes strict structural barriers that block applicants from enrolling in Medicaid depending on the waiver system they intend to serve.

For OLTL's Community HealthChoices (CHC), the absolute barrier is MCO network contracting; if the MCOs have closed networks due to regional adequacy, you cannot receive referrals or payment. For ODP, the barrier is the County Administrative Entity (AE) Provider Qualification (PQ) process, which must be passed in the Home and Community Services Information System (HCSIS) before a PROMISe Medicaid enrollment application is even permitted.

4. Licensure and Certification Requirements

To provide Skilled Respite in a participant's home, the agency must be licensed by the Pennsylvania Department of Health (DOH) as a Home Care Agency or a Home Health Agency. This licensure ensures the agency meets state standards for hiring, supervising, and deploying clinical staff.

The application process is managed through the DOH Enterprise Provider Registry (EPR) / State Agency Information System (SAIS). Providers must submit policies, ownership disclosures, and an application fee, followed by a state survey.

5. Medicaid Provider Enrollment

Once licensed by DOH and qualified by the AE (for ODP) or contracted with an MCO (for OLTL), the agency must enroll in Pennsylvania's Medicaid Management Information System, known as PROMISe. Enrollment is conducted entirely online.

Providers use the DHS Provider Electronic Enrollment Portal (PEEP) to submit their application. The agency must enroll under the specific Provider Type and Specialty codes that correspond to the waivers they are authorized to bill.

6. Staffing, Training and Background Checks

Because this is a skilled service, direct care must be provided by nurses licensed by the Pennsylvania State Board of Nursing. The agency must also appoint administrative leadership that meets state regulatory standards.

Pennsylvania enforces strict background check requirements under the Child Protective Services Law (CPSL) and Older Adults Protective Services Act (OAPSA). All clearances must be obtained prior to the staff member's first day of patient contact.

7. Documentation, Policies and Records

Providers must maintain a comprehensive Policy & Procedure Manual that aligns with DOH Chapter 611 and DHS Chapter 6100 regulations. Documentation must prove that the skilled services delivered match the exact frequency and duration authorized in the ISP.

Incident management is highly scrutinized in Pennsylvania. Providers must use the state's Enterprise Incident Management (EIM) system to report critical incidents within strict timeframes.

8. Billing, Rates and Claims

Billing procedures depend on the waiver. ODP claims are billed directly to PROMISe based on authorizations generated in HCSIS. OLTL CHC claims are billed to the specific MCO's clearinghouse (e.g., Change Healthcare, Availity).

Pennsylvania requires Electronic Visit Verification (EVV) for all in-home personal care and home health services, which includes in-home respite. Providers must use the DHS Sandata system or an approved alternate EVV vendor.

9. Approval Sequence and Timeline

Becoming a Skilled Respite provider in Pennsylvania is a sequential process that typically takes 6 to 9 months from business formation to billing the first claim. Steps cannot be taken out of order, as each subsequent agency requires the approval of the previous one.

The longest delays usually occur during the DOH licensure phase and the MCO contracting phase, both of which are subject to state and corporate backlogs.

10. Common Denials and Survey Findings

Both DOH and DHS conduct routine and unannounced surveys. Initial applications are frequently delayed due to incomplete policy manuals or failure to properly map policies to the specific Pennsylvania Code citations.

Post-enrollment, the most common audit findings result in payment retractions. These usually stem from EVV non-compliance or gaps in mandatory staff background checks.

11. Key Contacts and Resources

Navigating Pennsylvania's dual-waiver system requires utilizing specific state portals and help desks. Providers should bookmark the DHS and DOH resource pages for the most current regulatory bulletins.

The PROMISe Provider Service center and the DOH Resource Accounts are the primary points of contact for technical assistance during the enrollment and licensure phases.

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