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

Last reviewed: 2026-09-10

The Pennsylvania Department of Human Services (DHS) funds Skilled Respite through the Office of Developmental Programs (ODP) Consolidated, Community Living, and Person/Family Directed Support (P/FDS) waivers, as well as the Office of Long-Term Living (OLTL) Community HealthChoices (CHC) program. The service provides temporary relief to primary caregivers by utilizing licensed nursing staff (RNs or LPNs) to support participants with complex medical needs that exceed the scope of standard, unlicensed respite care.

Before a provider can bill for this service, they must pass the ODP New Provider Qualification process administered by a regional Administrative Entity (AE) or secure a network contract with a CHC Managed Care Organization (MCO). Pennsylvania does not issue a distinct facility license for "Skilled Respite"; instead, agencies typically operate under a Department of Health (DOH) Home Care Agency or Home Health Agency license and enroll their nursing staff through the PROMISe Medicaid portal.

1. Service Definition and Scope

In Pennsylvania, Skilled Respite is defined as short-term nursing support provided to individuals whose medical conditions require the clinical expertise of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). It is designed to relieve the primary unpaid caregiver while ensuring the participant's health and safety needs are met.

The service can be delivered in the participant's home, a licensed respite facility, or a community setting, depending on the specific waiver authorization. It is strictly limited to tasks that fall under the state's Nurse Practice Act and cannot be used for routine companion care.

2. Regulatory and Oversight Agencies

Multiple state agencies oversee the delivery of Skilled Respite in Pennsylvania. The Department of Human Services (DHS) manages the Medicaid waivers, while specific program offices handle day-to-day policy and provider qualification.

The Department of Health (DOH) is responsible for the underlying licensure of the agencies employing the nurses, ensuring compliance with state health and safety regulations.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania requires providers to clear specific structural hurdles before an enrollment application is accepted. For ODP waivers, providers must undergo the New Provider Qualification process, which requires sponsorship and review by a county-level Administrative Entity (AE).

For the OLTL Community HealthChoices program, providers face a closed-network managed care environment. Enrollment in the state Medicaid system does not guarantee the ability to bill; providers must successfully negotiate and execute a contract with one of the regional MCOs.

4. Licensure and Certification Requirements

Because Pennsylvania does not have a specific "Skilled Respite" license category, agencies must hold an appropriate overarching license to deploy nursing staff. Most commonly, this is a Home Care Agency license or a Home Health Agency license issued by the DOH.

Agencies must comply with 55 Pa. Code Chapter 6100 regulations for ODP services, which dictate administrative, training, and incident management standards.

5. Medicaid Provider Enrollment

Once qualified by ODP or contracted with an MCO, providers must enroll in the Pennsylvania Medicaid program through the PROMISe portal. This process assigns a 13-digit Master Provider Index (MPI) number.

Providers must submit an electronic application, pay the required application fee (if applicable), and undergo categorical risk screening.

6. Staffing, Training and Background Checks

Staffing for Skilled Respite is strictly limited to Pennsylvania-licensed RNs and LPNs. Unlicensed direct support professionals (DSPs) cannot deliver this specific service tier.

All staff and individuals with significant ownership interest must pass rigorous background checks, including FBI fingerprinting, due to the high-risk classification of the service.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records. For Skilled Respite, this includes detailed nursing notes that justify the medical necessity of the skilled intervention during the respite period.

Agencies must also have approved policies for incident management, quality management, and grievance procedures as dictated by ODP and DOH regulations.

8. Billing, Rates and Claims

Billing for Skilled Respite is processed through the PROMISe system for fee-for-service ODP waivers, or through the respective MCO's clearinghouse for CHC participants. Rates are established by DHS and vary based on whether an RN or LPN provides the service.

Services are typically billed in 15-minute units. Providers must ensure they do not exceed the authorized units on the participant's service plan.

9. Approval Sequence and Timeline

The timeline to become a fully approved Skilled Respite provider in Pennsylvania can take 6 to 12 months. The process is sequential and cannot be expedited.

Providers must first secure their DOH license, then pass ODP qualification or secure MCO contracts, and finally complete the PROMISe enrollment.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete background checks or failure to meet the strict Program Administrator qualifications under Chapter 6100.

During audits, the most common citations involve billing for skilled respite when the documentation only supports standard, non-skilled companion care.

11. Key Contacts and Resources

Prospective providers should utilize the official DHS portals and regional Administrative Entities for guidance. The PROMISe portal contains all necessary enrollment forms and manuals.

For MCO contracting, providers must reach out directly to the provider relations departments of the active CHC plans in their specific geographic zone.

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