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

Last reviewed: 2026-08-16

In Texas, "Skilled Respite" is not a standalone license or distinct provider type. Instead, it is a service delivered under Medicaid managed care waivers (such as STAR+PLUS and STAR Kids) by licensed nurses (RNs or LVNs) to provide temporary relief for primary caregivers of individuals with complex medical needs. To deliver these skilled nursing tasks in a home setting, providers must be licensed as a Home and Community Support Services Agency (HCSSA).

The single biggest structural barrier to entry is the prerequisite to obtain an HCSSA license with a Licensed Home Health Services (LHHS) category from the Texas Health and Human Services Commission (HHSC) before Medicaid enrollment can even begin. This requires paying a $1,750 fee, passing an initial unannounced on-site survey, and subsequently securing closed-network contracts with regional Managed Care Organizations (MCOs) to receive client referrals.

1. Service Definition and Scope

Skilled Respite in Texas provides temporary, short-term relief to an unpaid primary caregiver of a Medicaid waiver participant whose medical needs exceed what an unlicensed personal care attendant can safely manage. The service must be ordered by a physician and is strictly limited to the hours and scope defined in the individual's Individual Service Plan (ISP).

Because Texas does not issue a specific "respite license," agencies provide this service under their broader authority to deliver skilled nursing. The care must be performed by a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) and typically includes tasks like ventilator management, tracheostomy care, and complex medication administration.

• Service Category: In-home skilled respite care under Medicaid waivers.
• Target Population: Participants in STAR Kids, STAR+PLUS, or Home and Community-based Services (HCS) waivers requiring skilled nursing.
• Provider Qualifications: Must be delivered by an RN or LVN licensed by the Texas Board of Nursing.
• Setting: Typically delivered in the member's private residence, though facility-based respite exists under separate facility licenses.
• Limitations: Authorized hours are strictly capped by the specific waiver's annual cost limits and the member's approved ISP.

2. Regulatory and Oversight Agencies

The Texas Health and Human Services Commission (HHSC) is the umbrella agency governing both licensure and Medicaid policy. Within HHSC, distinct divisions handle the physical licensing of agencies, the oversight of managed care plans, and the investigation of fraud.

Medicaid enrollment and claims processing are outsourced to the state's fiscal agent, Texas Medicaid & Healthcare Partnership (TMHP). Providers must interact with both HHSC for regulatory compliance and TMHP for financial enrollment.

• Licensing Authority: HHSC Long-Term Care Regulation (LTCR) (https://www.hhs.texas.gov/providers/long-term-care-providers/home-community-support-services-agencies-hcssa).
• Medicaid Enrollment: Texas Medicaid & Healthcare Partnership (TMHP) (https://www.tmhp.com).
• Managed Care Oversight: HHSC Medicaid and CHIP Services (MCS) (https://www.hhs.texas.gov/services/health/medicaid-chip).
• Fraud and Abuse: Texas HHSC Office of Inspector General (OIG) (https://oig.hhs.texas.gov).
• Nursing Regulation: Texas Board of Nursing (BON) (https://www.bon.texas.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Texas strictly prohibits standalone enrollment for "Skilled Respite." An applicant cannot even access the Medicaid enrollment portal for this service without first holding an active Home and Community Support Services Agency (HCSSA) license with the Licensed Home Health Services (LHHS) category.

Furthermore, because the vast majority of Texas Medicaid HCBS is carved into managed care, obtaining a Medicaid provider number is only the halfway point. Providers must then secure network contracts with regional Managed Care Organizations (MCOs), which frequently utilize closed networks or moratoria based on regional network adequacy.

• Licensure Prerequisite: Active HCSSA license (LHHS category) required before TMHP PEMS enrollment is permitted.
• Business Registration: Must be registered and in good standing with the Texas Secretary of State.
• Managed Care Contracting: Must secure network contracts with STAR+PLUS or STAR Kids MCOs (e.g., Superior HealthPlan [https://www.superiorhealthplan.com], Texas Children's Health Plan [https://www.texaschildrenshealthplan.org]) to receive authorizations.
• NPI Requirement: Must obtain a Type 2 National Provider Identifier (NPI) matching the exact legal business name prior to application.
• Physical Location: Must maintain a physical operating location in Texas; virtual offices or P.O. boxes are prohibited for licensure.

4. Licensure and Certification Requirements

HCSSA licensure is governed by 26 Texas Administrative Code (TAC) Chapter 558. Applicants must submit HHSC Form 2021 and demonstrate compliance with all state minimum standards for home health agencies.

Texas utilizes a two-step initial survey process. Agencies receive an initial license to begin operating, but must admit at least one client and pass an unannounced on-site survey by HHSC LTCR within the first license period to maintain their operating authority.

• Governing Statute: Texas Health and Safety Code Chapter 142.
• Regulatory Code: 26 TAC Chapter 558 (Minimum Standards for HCSSAs).
• Application Form: HHSC Form 2021 (Home and Community Support Services Agency License Application).
• Licensure Fee: $1,750 for an initial two-year HCSSA license.
• Training Prerequisite: The designated Administrator and Alternate Administrator must complete an HHSC-approved 8-hour pre-survey training course.
• Initial Survey: Unannounced on-site survey conducted by HHSC LTCR after the agency has admitted its first client.

5. Medicaid Provider Enrollment

Once licensed, agencies must enroll in Texas Medicaid through the TMHP Provider Enrollment and Management System (PEMS). Providers typically enroll as a Comprehensive Care Program (CCP) provider or under specific waiver provider types depending on their target demographic.

Because HCSSAs provide in-home services, they are categorized as Moderate or High risk by the HHSC OIG. This triggers mandatory fingerprint-based background checks for owners and unannounced pre-enrollment site visits.

• Enrollment Portal: TMHP PEMS (https://www.tmhp.com/topics/provider-enrollment/pems/start-application).
• Application Fee: $750 CY 2026 Federal Application Fee (required for institutional provider types).
• Risk Category: Moderate/High risk, requiring site visits before a new practice location is approved to render services.
• Required Documentation: Active HCSSA license, IRS CP575/W-9, and ownership disclosure meeting the 5% threshold per 42 CFR §455.104.
• Fingerprinting: All owners with 10% or more interest must submit fingerprints upon receiving the TMHP link.
• Revalidation: Required every 3 to 5 years depending on the specific enrollment track.

6. Staffing, Training and Background Checks

Because this service is explicitly "skilled" respite, all direct care must be provided by licensed nursing staff. HCSSAs must strictly adhere to Texas Board of Nursing delegation rules and HHSC background check mandates.

Texas law is unforgiving regarding background checks: agencies must clear staff through multiple state registries before any direct patient contact occurs. Failure to do so is an automatic survey deficiency.

• Direct Care Qualifications: Must hold an active, unencumbered Texas RN or LVN license.
• Administrator Qualifications: Must be a licensed physician, RN, or hold at least a high school diploma/GED with one year of management experience in health care.
• Background Checks: Mandatory criminal history checks through the Texas Department of Public Safety (DPS).
• Registry Checks: Must verify staff are not listed on the HHSC Employee Misconduct Registry (EMR) or the Texas Nurse Aide Registry (NAR) prior to hire and annually.
• OIG Exclusion Check: Monthly screening against the Texas HHSC OIG and federal LEIE exclusion lists.
• Orientation: Staff must complete agency-specific orientation covering the individual's ISP, emergency procedures, and abuse reporting.

7. Documentation, Policies and Records

HCSSAs must maintain comprehensive clinical records and administrative policies as dictated by 26 TAC §558.281. For skilled respite, the documentation must clearly justify the medical necessity of the nursing tasks performed during the caregiver's absence.

Agencies are also required to maintain robust emergency preparedness plans, detailing how waiver participants dependent on skilled nursing will be supported during natural disasters or power outages.

• Plan of Care: Must have a physician-ordered plan of care detailing the specific skilled nursing tasks required during the respite period.
• Clinical Records: Must document all nursing notes, medication administration records (MAR), and exact shift start/stop times.
• Emergency Preparedness: Must maintain a written emergency preparedness and response plan per 26 TAC §558.256.
• Abuse and Neglect Policy: Written policies for preventing, identifying, and reporting abuse, neglect, and exploitation (ANE) to the Texas Department of Family and Protective Services.
• Record Retention: Clinical records must be retained for at least five years after the discharge date.

8. Billing, Rates and Claims

Billing for skilled respite is submitted to the respective MCO (for STAR+PLUS/STAR Kids) or TMHP (for fee-for-service). Services are typically billed hourly, and rates are established by HHSC but may be negotiated slightly depending on the MCO contract.

Texas mandates the use of Electronic Visit Verification (EVV) for all in-home personal care and respite services. Providers must use state-approved EVV systems to log exact clock-in and clock-out times, and claims will deny if they do not match the EVV data.

• Billing System: TMHP TexMedConnect for FFS, or specific MCO clearinghouses (e.g., Availity, PaySpan) for managed care claims.
• Procedure Codes: Commonly billed using HCPCS code T1005 (Respite care services) with modifiers TD (for RN) or TE (for LVN).
• Prior Authorization: Mandatory prior authorization from the MCO or HHSC before rendering any respite services.
• Electronic Visit Verification (EVV): Mandatory compliance required to log shift times; claims without matching EVV visits are automatically denied.
• Claim Timely Filing: Typically 95 days from the date of service for Texas Medicaid FFS, though MCO contracts may allow up to 120 days.

9. Approval Sequence and Timeline

The end-to-end process from business formation to billing for skilled respite can take 9 to 12 months due to sequential dependencies. You cannot apply for Medicaid until you are licensed, and you cannot bill MCOs until you are enrolled in Medicaid.

Delays at any step—particularly during the HHSC licensure review or the TMHP PEMS enrollment—will push back the entire timeline. Providers should plan for significant operating capital to float the business during this period.

• Step 1: Business formation and NPI acquisition (1-2 weeks).
• Step 2: Submit HCSSA Form 2021 and $1,750 fee to HHSC (45-60 days for initial review).
• Step 3: Receive initial HCSSA license and admit first client (variable timeline).
• Step 4: Submit TMHP PEMS Medicaid enrollment application (90-120 days for processing and OIG screening).
• Step 5: Pass HHSC initial unannounced licensure survey (within the first license period).
• Step 6: Apply for MCO network credentialing and contracting (90-120 days post-Medicaid enrollment).

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to mismatched data between the IRS, the NPI registry, the HCSSA application, and the PEMS portal. Even a slight variation in the legal business name or address will trigger a rejection.

During licensure surveys, HHSC inspectors heavily scrutinize employee files. The most common and severe deficiencies relate to failing to conduct background and registry checks before a nurse's first shift.

• Application Denial: Discrepancies between the physical address on the HCSSA application and the TMHP PEMS portal.
• Survey Deficiency: Failure to run the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) checks prior to the first day of patient contact.
• Survey Deficiency: Incomplete, missing, or expired physician signatures on the skilled nursing plan of care.
• PEMS Rejection: Failure to disclose all owners, board members, or managing employees with 5% or more interest per 42 CFR §455.104.
• Billing Denial: Rendering services before the official MCO contract effective date, without prior authorization, or without matching EVV records.

11. Key Contacts and Resources

Navigating Texas Medicaid requires utilizing the correct state portals and regulatory rulebooks. The HHSC and TMHP websites are the authoritative sources for all forms, fee schedules, and policy manuals.

Providers should subscribe to HHSC GovDelivery alerts to receive immediate notifications regarding changes to HCSSA rules, EVV mandates, and Medicaid waiver amendments.

• HHSC HCSSA Licensing: https://www.hhs.texas.gov/providers/long-term-care-providers/home-community-support-services-agencies-hcssa
• TMHP Provider Enrollment (PEMS): https://www.tmhp.com/topics/provider-enrollment
• Texas Administrative Code (HCSSA Rules): https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=26&pt=1&ch=558
• HHSC OIG Provider Enrollment: https://oig.hhs.texas.gov/resources/providers/provider-enrollment
• Texas Board of Nursing: https://www.bon.texas.gov
• HHSC Managed Care (MCS): https://www.hhs.texas.gov/services/health/medicaid-chip

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