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

Last reviewed: 2026-09-10

Texas Health and Human Services (HHSC) regulates Skilled Respite as a nursing service delivered under the Home and Community Support Services Agency (HCSSA) license, funded through Medicaid waivers like the Home and Community-based Services (HCS) program and STAR+PLUS. The service provides temporary relief for primary caregivers of individuals whose medical needs require a licensed nurse.

Before applying for a Medicaid waiver contract to bill for skilled respite, an agency must first obtain an HCSSA license with a Home Health (Skilled Nursing) category from HHSC and complete the Provider Enrollment and Management System (PEMS) process through the Texas Medicaid & Healthcare Partnership (TMHP).

1. Service Definition and Scope

In Texas, Skilled Respite is not a standalone license but a service category provided by licensed home health agencies. It delivers short-term, temporary relief to primary caregivers of individuals with complex medical needs.

The service must be ordered by a physician and delivered by licensed nursing staff when the individual's care needs exceed what an unlicensed caregiver can safely provide.

• Service Category: Home Health (Skilled Nursing) Care delivered under an HCSSA license.
• Target Population: Individuals with complex medical needs in programs like the Medically Dependent Children Program (MDCP) or HCS waiver.
• Allowable Tasks: Medication administration (including IV), acute illness care, sterile wound care, and periodic nursing assessments.
• Duration Limits: Typically capped at 30 days or a specific cost limit per Individual Service Plan (ISP), requiring Managed Care Organization (MCO) approval for extensions.

2. Regulatory and Oversight Agencies

The Texas Health and Human Services Commission (HHSC) is the primary state agency responsible for licensing providers and managing Medicaid waiver contracts. The Texas Medicaid & Healthcare Partnership (TMHP) acts as the state's claims and enrollment administrator.

Providers must interact with both HHSC for licensure and contracting, and TMHP for Medicaid enrollment and billing.

• Licensing Agency: Texas Health and Human Services Commission (HHSC) (https://www.hhs.texas.gov/providers/long-term-care-providers/home-community-support-services-agencies-hcssa)
• Enrollment Broker: Texas Medicaid & Healthcare Partnership (TMHP) (https://www.tmhp.com/topics/provider-enrollment)
• Enrollment System: Provider Enrollment and Management System (PEMS) (https://secure.tmhp.com/pems/)
• Rule Promulgation: Texas Administrative Code (TAC) Title 26, Part 1, Chapter 558

3. Gatekeeping Prerequisites: Who Can Even Apply

Texas does not issue a standalone "Skilled Respite" license. Providers must hold an active HCSSA license with the appropriate skilled nursing designation before they can enroll to provide this service under Medicaid waivers.

Additionally, specific waiver programs impose their own structural prerequisites, such as mandatory training and verified operational experience, before a contract application is accepted.

• Base Licensure: Active HCSSA license with a Home Health (Skilled Nursing) category from HHSC.
• Training Prerequisite: Completion of the Provider Applicant Training (PAT) course and in-person competency exam per 26 TAC §52.31 for HCS contracts.
• Experience Requirement: At least three years of experience planning and providing similar services to individuals with intellectual disabilities (for HCS applicants).
• Medicaid Enrollment: Active enrollment in Texas Medicaid via TMHP PEMS before a waiver contract application is accepted.

4. Licensure and Certification Requirements

To provide skilled respite, an agency must meet the comprehensive licensing standards for Home and Community Support Services Agencies (HCSSAs) in Texas.

This includes paying initial licensing fees and employing qualified administrative and clinical leadership.

• Licensure Rule: 26 TAC Chapter 558 (Licensing Standards for Home and Community Support Services Agencies).
• Application Fee: $1,750 initial HCSSA license fee.
• Administrator Qualifications: Must designate an administrator and alternate administrator meeting 26 TAC §558.244 requirements.
• Nursing Director: Must employ a Supervising Nurse (RN) to oversee skilled nursing services.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed through TMHP's Provider Enrollment and Management System (PEMS). Once enrolled in Medicaid, providers apply for specific waiver contracts through HHSC.

Contract applications for programs like HCS are submitted via the Contract Application and Management for Providers (CAMP) portal.

• Portal: Provider Enrollment and Management System (PEMS).
• Contract Application: Contract Application and Management for Providers (CAMP) portal for HCS contracts.
• Required Form: Form 5873 (Waiver and Community-based Programs and Services Contract Application Packet Checklist).
• Entity Documentation: Form 2031 (Governing Authority Resolution - Business Organization).

6. Staffing, Training and Background Checks

Because skilled respite involves complex medical care, it must be delivered by licensed nursing professionals.

Agencies must ensure all staff meet state licensing board requirements and pass mandatory criminal history checks.

• Direct Care Staff: Must be a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) licensed in Texas.
• Background Checks: Copies of receipts for criminal history records requests must be submitted for all required individuals.
• Competency: HCS program provider applicants must pass the HHSC provider competency examination.
• Supervision: LVNs must practice under the supervision of an RN or physician.

7. Documentation, Policies and Records

Providers must maintain strict clinical and administrative records to justify the medical necessity of skilled respite.

Failure to maintain these records can result in contract sanctions or recoupment of funds.

• Plan of Care: Services must be provided according to an established plan of care reviewed by the prescribing physician every 60 days.
• Medical Necessity: Documentation must show the service is prescribed by a physician and medically necessary.
• Privacy Compliance: Submission of the Texas HHS Information Security and Privacy Initial Inquiry (SPI) form.
• Data Agreement: Signed Data Use Agreement (DUA) with HHSC.

8. Billing, Rates and Claims

Claims for skilled respite are submitted to TMHP or the respective Managed Care Organization (MCO) for STAR+PLUS members.

Services must be prior-authorized and fit within the member's Individual Service Plan (ISP) cost limits.

• Claims System: TMHP Claims Management System or LTC Online Portal.
• Paper Claims: UB-04 CMS-1450 form required if billing on paper; superbills are not accepted.
• Coding: HCPCS/CPT codes subject to National Correct Coding Initiative (NCCI) relationships.
• Prior Authorization: Services must be authorized in the member's Individual Service Plan (ISP) and remain within the ISP cost limit.

9. Approval Sequence and Timeline

The approval process is sequential, requiring licensure before Medicaid enrollment, and Medicaid enrollment before waiver contracting.

HHSC accepts applications for programs like HCS year-round through an open enrollment process with no deadline.

• Step 1: Obtain HCSSA license with Home Health (Skilled Nursing) category from HHSC Regulatory Services.
• Step 2: Complete Provider Applicant Training (PAT) and competency exam.
• Step 3: Enroll in Texas Medicaid via TMHP PEMS.
• Step 4: Submit waiver contract application via the CAMP portal.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to administrative errors or failure to meet strict documentation standards.

During surveys, agencies are often cited for failing to adhere to nursing standards or exceeding authorized service limits.

• Application Denial: Using correction tape or fluid on HHSC application forms.
• Licensure Sanctions: Failure to deliver health-care items in full accordance with 1 TAC §371.1659.
• Documentation Errors: Missing physician signatures on the 60-day plan of care review.
• Unapproved Extensions: Exceeding the 30-day respite maximum without written MCO approval for extenuating circumstances.

11. Key Contacts and Resources

Prospective providers should utilize official state portals and contact centers for guidance on licensure and enrollment.

The TMHP Contact Center and HHSC operations mailboxes are the primary points of contact.

• TMHP Contact Center: 800-925-9126 (Option 3) (https://www.tmhp.com)
• HHSC HCSSA Page: (https://www.hhs.texas.gov/providers/long-term-care-providers/home-community-support-services-agencies-hcssa)
• CAMP Portal: Contract Application and Management for Providers (https://camp.hhs.texas.gov/)
• HCS Contracting Operations: [email protected]

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