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

Last reviewed: 2026-08-16

In Texas, Respite Care Services provide short-term relief to unpaid primary caregivers of individuals enrolled in Medicaid Home and Community-Based Services (HCBS) waivers. Texas does not issue a standalone "Respite Care License." Instead, providers typically must obtain a Home and Community Support Services Agency (HCSSA) license to provide in-home respite, or hold an appropriate facility license (such as an Assisted Living Facility) for out-of-home respite, before applying for certification under specific waiver programs like HCS, CLASS, or STAR+PLUS.

The single biggest structural barrier to entry is that Medicaid respite cannot be billed as an independent fee-for-service line item; it requires securing a Medicaid waiver contract through the Texas Health and Human Services Commission (HHSC) Open Enrollment process or obtaining network contracts with regional Managed Care Organizations (MCOs) under the STAR+PLUS program. These MCOs frequently enforce closed networks based on regional adequacy, meaning even fully licensed and Medicaid-enrolled providers may be blocked from serving clients if the MCO determines it has enough existing respite providers in that Service Delivery Area.

1. Service Definition and Scope

Respite care in Texas is defined as temporary relief provided to an unpaid primary caregiver of an eligible Medicaid waiver participant. The service ensures the participant's health, safety, and supervision needs are met while the primary caregiver is temporarily unavailable or taking a break.

Services can be delivered in the individual's private home, in a foster home, or in licensed out-of-home settings. The scope, duration, and setting of the respite care are strictly dictated by the participant's Individual Service Plan (ISP) as authorized by their waiver case manager or MCO service coordinator.

• In-Home Respite: Delivered in the participant's private residence by an attendant or Direct Support Professional (DSP).
• Out-of-Home Respite: Provided in licensed facilities such as an Assisted Living Facility, adult day care, or a certified waiver group home.
• Duration Limits: Under the STAR+PLUS HCBS waiver, respite is generally limited to 30 days (720 hours) per year unless the MCO authorizes an extension.
• Provider Exclusions: The respite care provider must not be the primary caregiver and must not live in the same household as the waiver member, per STAR+PLUS Handbook Section 7300.
• Emergency vs. Planned: Respite can be scheduled on a routine basis to prevent caregiver burnout or authorized on an emergency basis for unforeseen caregiver absences.

2. Regulatory and Oversight Agencies

The Texas Health and Human Services Commission (HHSC) is the primary umbrella agency that regulates HCBS waivers, licenses healthcare facilities, and manages the state Medicaid program. HHSC's Long-Term Care Regulation (LTCR) division is specifically responsible for surveying and inspecting agencies.

The Texas Medicaid & Healthcare Partnership (TMHP) acts as the state's Medicaid claims and enrollment administrator. Providers must interact with TMHP for enrollment and fee-for-service billing, while interacting directly with MCOs for managed care billing.

• Texas Health and Human Services Commission (HHSC): Oversees waiver contracts, facility licensing, and Medicaid policy (https://www.hhs.texas.gov).
• HHSC Long-Term Care Regulation (LTCR): Conducts initial and ongoing surveys, inspections, and enforces HCSSA and waiver compliance (https://www.hhs.texas.gov/providers/long-term-care-providers).
• Texas Medicaid & Healthcare Partnership (TMHP): Administers the Provider Enrollment and Management System (PEMS) for all Medicaid enrollment (https://www.tmhp.com).
• HHSC Provider Finance Department (PFD): Establishes and publishes the rate enhancement and attendant compensation fee schedules (https://pfd.hhs.texas.gov).
• Texas Department of Public Safety (DPS): Processes mandatory criminal history background checks for all direct care staff (https://www.dps.texas.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Texas does not utilize a Certificate of Need (CON) program for HCBS or respite services. However, significant structural prerequisites exist depending on the delivery model. A provider cannot simply enroll in Medicaid and begin billing for respite; they must secure access through specific waiver contracts or managed care networks.

For managed care programs like STAR+PLUS, providers face strict network adequacy barriers. For fee-for-service waivers like HCS, providers must pass a rigorous state Readiness Review before a contract is awarded.

• MCO Network Contracting: To provide STAR+PLUS respite, agencies must be credentialed and contracted with regional MCOs (e.g., Superior HealthPlan https://www.superiorhealthplan.com, Molina Healthcare https://www.molinahealthcare.com), which can and do deny entry if their network is deemed adequate.
• Waiver Open Enrollment: HCS and TxHmL providers must apply through HHSC's Open Enrollment process and pass a mandatory Readiness Review before receiving a Medicaid waiver contract.
• Licensure Prerequisite: Out-of-home respite providers must hold an active, appropriate facility license (e.g., Assisted Living Facility) before applying for a Medicaid waiver contract.
• HCSSA Prerequisite: Agencies providing in-home respite must typically obtain a Home and Community Support Services Agency (HCSSA) license before they can contract with MCOs.
• Business Registration: Applicants must be registered and in good standing with the Texas Secretary of State and obtain a Type 2 NPI and EIN prior to any application.

4. Licensure and Certification Requirements

Because Texas does not have a specific "Respite License," agencies providing in-home respite typically must obtain a Home and Community Support Services Agency (HCSSA) license under the Personal Assistance Services (PAS) category. This is governed by Texas Administrative Code (TAC) Title 26, Part 1, Chapter 558.

All licensing applications, renewals, and changes of ownership are processed through the Texas Unified Licensure Information Portal (TULIP). Out-of-home respite requires the facility to hold its own specific license, such as an Assisted Living Facility (ALF) license.

• HCSSA License: Required for most in-home care agencies, governed by TAC Title 26, Chapter 558.
• Application Portal: HCSSA applications must be submitted electronically through TULIP (https://tulip.hhs.texas.gov).
• Licensing Fee: The initial HCSSA license fee is $1,750, and the license is valid for two years.
• Administrator Qualifications: HCSSA administrators and alternate administrators must complete 24 hours of initial educational training in administration and agency operations before the agency can be licensed.
• Initial Survey: After receiving a provisional license, the agency must admit at least one client and pass an initial on-site health and safety survey by HHSC LTCR to receive a full license.

5. Medicaid Provider Enrollment

All Medicaid providers in Texas must enroll through the Texas Medicaid & Healthcare Partnership (TMHP) using the Provider Enrollment and Management System (PEMS). Enrollment at the state level grants billing rights but does not guarantee MCO credentialing.

Providers must ensure their legal business name, EIN, and NPI exactly match across the IRS, the Texas Secretary of State, and the National Plan and Provider Enumeration System (NPPES) before starting the PEMS application.

• System Access: Providers must create an account via TMHP IAMOnline to access PEMS (https://www.tmhp.com/topics/provider-enrollment/pems/start-application).
• Application Type: Agencies enroll as a Facility/Agency/Organization (FAO) using their Type 2 NPI.
• Application Fee: Subject to the federal Medicaid/Medicare institutional application fee (approximately $709 for 2024/2025) unless waived by proof of prior Medicare enrollment.
• Required Documents: Must upload the HCSSA license, IRS CP575 (EIN confirmation), and a completed HHSC signature authority designation form.
• Revalidation: Texas requires Medicaid providers to revalidate their enrollment through PEMS every 3 to 5 years to maintain active status.

6. Staffing, Training and Background Checks

Direct Support Professionals (DSPs) and attendants providing respite must meet strict background and training standards set by HHSC. Agencies are strictly liable for verifying these credentials prior to any client contact.

Texas maintains specific state registries for abuse and misconduct. Clearing a standard criminal background check is not sufficient; providers must also check state-specific misconduct registries.

• Age and Education: Respite attendants must be at least 18 years old and hold a high school diploma, GED, or pass a written competency evaluation.
• Criminal Background Checks: Agencies must conduct pre-employment criminal history checks through the Texas Department of Public Safety (DPS).
• Registry Clearances: Mandatory pre-employment and annual checks against the Texas Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR).
• Required Training: Staff must maintain current CPR/First Aid certification and complete HHSC-mandated training on Abuse, Neglect, and Exploitation (ANE) prevention.
• Individual-Specific Training: Attendants must be trained on the specific health, safety, and behavioral needs outlined in the participant's Individual Service Plan (ISP) before providing care.

7. Documentation, Policies and Records

HHSC and MCOs require comprehensive documentation to justify respite billing and ensure participant safety. Providers must maintain a detailed Policy and Procedure Manual that complies with TAC Chapter 558.

Failure to maintain accurate, contemporaneous service logs is the leading cause of Medicaid recoupment in Texas. All service delivery must be verifiable.

• Service Logs: Daily documentation must include start/stop times, specific activities provided, and the signature of the caregiver or participant.
• Care Plan Alignment: Respite hours must strictly align with the authorized hours in the Individual Service Plan (ISP) generated by the MCO or waiver case manager.
• Incident Reporting: Policies must dictate the reporting of critical incidents (e.g., injuries, abuse allegations) to the HHSC Provider Investigations unit within 24 hours.
• Emergency Preparedness: HCSSAs must maintain and annually test a comprehensive emergency preparedness and response plan.
• Record Retention: Texas Medicaid requires providers to retain all clinical, personnel, and billing records for a minimum of five years.

8. Billing, Rates and Claims

Respite care is billed in hourly or daily increments depending on the waiver program and the setting. Claims are submitted either to TMHP for fee-for-service waivers (like HCS) or directly to the contracted MCO for STAR+PLUS.

In-home respite services are subject to the 21st Century Cures Act and require the use of Electronic Visit Verification (EVV) to validate that services were physically delivered.

• Billing Codes: Commonly billed using HCPCS codes such as S5150 (unskilled respite care, per 15 minutes) or S5151 (per diem), modified by waiver-specific modifiers.
• Rate Setting: Base rates are established by the HHSC Provider Finance Department; providers can opt into the Attendant Compensation Rate Enhancement program for higher reimbursement.
• Claims Portal: Fee-for-service claims are submitted via the TMHP TexMedConnect portal.
• Electronic Visit Verification (EVV): In-home respite requires attendants to use a state-approved EVV system (e.g., HHAeXchange) to electronically clock in and out.
• Prior Authorization: Claims will be denied if the provider does not have an active prior authorization on file from the MCO or HHSC before the date of service.

9. Approval Sequence and Timeline

Becoming a fully operational respite provider in Texas is a multi-step process that typically takes 6 to 12 months. It requires sequential approvals from the Secretary of State, HHSC Licensing, TMHP, and finally the MCOs or waiver contract managers.

Providers cannot begin the Medicaid enrollment process until their facility or agency license is issued, and they cannot bill MCOs until credentialing is fully complete.

• Step 1: Business Formation and NPI/EIN acquisition (1-2 weeks).
• Step 2: HCSSA Licensure via TULIP, including the initial application, fee payment, and passing the preliminary desk review (3-6 months).
• Step 3: TMHP PEMS Medicaid Enrollment, requiring submission of the new license and federal fee (60-90 days for processing).
• Step 4: Waiver Contract Application (for HCS/TxHmL) or MCO Credentialing (for STAR+PLUS), involving committee review and network adequacy checks (90-120 days).
• Step 5: Initial HHSC LTCR on-site health and safety survey, required shortly after admitting the first client to secure the full HCSSA license.

10. Common Denials and Survey Findings

Applications and claims are frequently delayed or denied due to administrative errors or failure to meet strict waiver guidelines. HHSC Long-Term Care Regulation (LTCR) surveys often cite providers for documentation and background check lapses.

MCO credentialing is frequently denied simply because the MCO determines it already has enough respite providers in a specific county.

• Enrollment Denials: PEMS applications are immediately rejected if there is a mismatch in the legal business name between the IRS CP575, the NPI registry, and the Texas Secretary of State.
• Survey Citations: A common LTCR citation is the failure to conduct or document annual unannounced supervisory visits for in-home respite attendants.
• Background Check Violations: Agencies are frequently fined for allowing an attendant to provide care before the EMR and NAR registry checks are fully cleared and documented in the personnel file.
• Billing Denials: Claims are routinely rejected because the billed hours exceeded the annual 720-hour STAR+PLUS limit without prior MCO authorization.
• EVV Mismatches: Claims are denied when the EVV clock-in/clock-out data does not perfectly match the billed units submitted to TMHP or the MCO.

11. Key Contacts and Resources

Prospective providers should utilize official state resources for the most current manuals, fee schedules, and enrollment portals. Relying on third-party summaries can lead to compliance failures due to frequent rule changes.

The TMHP help desk and HHSC LTCR regional offices are the primary points of contact for application status and regulatory clarification.

• Texas Health and Human Services Commission (HHSC): https://www.hhs.texas.gov
• TMHP Provider Enrollment (PEMS): https://www.tmhp.com/topics/provider-enrollment
• Texas Unified Licensure Information Portal (TULIP): https://tulip.hhs.texas.gov
• HHSC Provider Finance Department: https://pfd.hhs.texas.gov
• Texas Administrative Code (TAC) Title 26, Chapter 558: https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=26&pt=1&ch=558
• STAR+PLUS Handbook: https://www.hhs.texas.gov/handbooks/starplus-handbook

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