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

Last reviewed: 2026-09-10

Utah’s Division of Services for People with Disabilities (DSPD) and the Division of Integrated Healthcare administer Respite Care Services across multiple 1915(c) waivers, including the Community Supports, Aging, Acquired Brain Injury (ABI), and Medically Complex Children's waivers. Respite provides short-term relief to unpaid primary caregivers, allowing them to step away while ensuring the waiver participant's health, safety, and supervision needs are met.

To bill Medicaid for this service, prospective agencies and independent contractors must first navigate the state's procurement and contracting apparatus. Approval requires responding to an active state solicitation through the Utah Public Procurement Place (U3P) to secure a contract with DSPD or enrolling as a participating provider under the specific waiver operating agency, followed by credentialing in the Provider Reimbursement Information System for Medicaid (PRISM). Facility-based respite requires an underlying state license from the Division of Licensing and Background Checks (DLBC), while in-home providers must meet personal care agency standards or specific waiver-contractor qualifications.

1. Service Definition and Scope

Respite Care Services in Utah provide short-term, intermittent relief to a primary caregiver who lives with and provides daily unpaid support to a Medicaid waiver participant. The service ensures the participant’s safety, supervision, and routine daily living needs are met in the caregiver's absence.

Utah allows respite to be delivered in the participant's home, the provider's home, or a licensed facility. The scope varies slightly by waiver; for example, the Aging Waiver permits both in-home and facility-based respite, while DSPD waivers allow individuals to hire independent respite contractors (self-directed or agency models) as outlined in the participant's Person-Centered Support Plan (PCSP).

• In-Home Respite: Delivered in the participant's primary residence, focusing on routine care, supervision, and emergency response during the caregiver's absence.
• Out-of-Home Respite: Provided in a licensed residential facility, adult day care, or the home of a certified respite provider.
• Routine Respite: Planned relief, typically scheduled in advance, capped at a specific number of hours or days annually per the waiver appendix.
• Emergency Respite: Unplanned relief necessitated by a crisis, such as the sudden illness or hospitalization of the primary caregiver.
• Room and Board: Specifically excluded from Medicaid reimbursement for in-home respite, but may be bundled into the facility rate for overnight out-of-home respite per waiver guidelines.

2. Regulatory and Oversight Agencies

Respite Care Services are managed under the umbrella of the Utah Department of Health and Human Services (DHHS). Oversight is bifurcated between the Medicaid financing arm, the operating divisions that manage the waivers, and the licensing division that surveys facilities and agencies.

Providers must maintain active compliance with both the programmatic rules of the operating division and the general Medicaid conditions of participation.

• Utah Department of Health and Human Services (DHHS): The umbrella agency governing health, Medicaid, and human services in Utah (https://dhhs.utah.gov).
• Division of Integrated Healthcare: The state Medicaid authority responsible for the PRISM enrollment portal and overall waiver administration (https://medicaid.utah.gov).
• Division of Services for People with Disabilities (DSPD): The operating agency for the Community Supports, ABI, and Physical Disabilities waivers; dictates provider contracting and qualifications (https://dspd.utah.gov).
• Division of Aging and Adult Services (DAAS): Oversees the Aging Waiver, contracting with local Area Agencies on Aging (AAAs) to administer respite for older adults (https://daas.utah.gov).
• Division of Licensing and Background Checks (DLBC): Inspects and licenses facility-based respite settings and processes mandatory Direct Access Clearance System (DACS) background checks (https://dlbc.utah.gov).
• Utah Public Procurement Place (U3P): The state's procurement portal where prospective DSPD providers must submit responses to open solicitations (https://purchasing.utah.gov/for-vendors/).

3. Gatekeeping Prerequisites: Who Can Even Apply

Utah does not allow any willing provider to simply submit a Medicaid application to bill for HCBS Respite. The state utilizes a strict contracting and procurement gate for agency providers and independent contractors serving DSPD waivers.

To provide respite under DSPD waivers, applicants must secure a state contract by responding to the Division of Purchasing's Open Enrollment solicitations on the U3P portal. For the Aging Waiver, providers must secure a subcontract with the specific regional Area Agency on Aging (AAA). There is no Certificate of Need (CON) required for in-home respite, but facility-based respite must secure local zoning approvals prior to licensure.

• DSPD Procurement Requirement: Agencies must submit an application through the U3P portal under an active Request for Statement of Qualifications (RFSQ) or Open Enrollment for HCBS providers. Without a resulting DSPD contract, PRISM enrollment for these waivers is blocked.
• AAA Subcontracting: Providers seeking to serve the Aging Waiver must contact their regional AAA and secure a vendor agreement; Medicaid does not enroll independent Aging Waiver respite providers directly without this affiliation.
• Business Registration: Applicants must hold an active registration and Certificate of Existence with the Utah Department of Commerce, Division of Corporations and Commercial Code.
• DACS Registration: The applicant agency must register with the Direct Access Clearance System (DACS) to initiate background checks before hiring any direct-care respite staff.
• Local Zoning Clearance: Out-of-home (facility-based) respite providers must obtain a conditional use permit or zoning clearance from their city or county planning department before DLBC will accept a facility license application.

4. Licensure and Certification Requirements

The licensure required depends entirely on the setting in which the respite is delivered. Utah does not have a standalone "Respite Provider License." Instead, providers obtain the license corresponding to their service model or operate under certification standards set by the waiver operating agency.

In-home agency providers typically operate under a Personal Care Agency or Home Health Agency license, governed by Utah Administrative Code R432. Individual contractors (Self-Administered Services model) do not require a facility license but must meet DSPD certification standards.

• Personal Care Agency License: Governed by UAC R432-700; required for agencies dispatching staff to provide non-medical respite and personal care in the participant's home.
• Adult Day Care License: Governed by UAC R432-270; required if providing daytime, facility-based respite to multiple adults simultaneously.
• Residential Support License: Required for community-based residential settings offering overnight, out-of-home respite.
• Self-Administered Services (SAS) Certification: Individual independent contractors hired directly by families must pass DSPD qualification reviews, including CPR/First Aid certification and DACS clearance, but are exempt from DHHS facility licensure.
• Licensure Fees: The base fee for a Personal Care Agency license is typically $1,000, plus additional fees for initial inspections, payable to DLBC.

5. Medicaid Provider Enrollment

Once the required license is obtained (if applicable) and the DSPD contract or AAA affiliation is secured, the provider must enroll in Utah Medicaid via the Provider Reimbursement Information System for Medicaid (PRISM).

PRISM is a fully electronic enrollment and credentialing system. Providers must link their NPI, state license, and waiver operating agency contract to their Medicaid provider file to activate the necessary HCBS billing codes.

• PRISM Portal: The state's online MMIS and provider enrollment system used for all Medicaid credentialing and maintenance (https://medicaid.utah.gov/prism/).
• Provider Type Selection: Agencies typically enroll under Provider Type 38 (Home and Community Based Services) with the specific specialty code for Respite.
• NPI Requirement: Agencies must obtain a Type 2 National Provider Identifier (NPI) from NPPES prior to initiating the PRISM application.
• Application Fee: Institutional and agency providers are subject to the federally mandated Medicaid application fee (approximately $731 in 2024, updated annually), unless enrolled in Medicare or another state's Medicaid program where the fee was already paid.
• FC-22 Form: Providers may need to submit form FC-22 (Provider Agreement) electronically within PRISM to finalize their enrollment conditions.

6. Staffing, Training and Background Checks

Direct care respite staff must meet baseline health, safety, and training requirements before interacting with waiver participants. Utah relies heavily on its centralized background check system to vet all HCBS personnel.

Staff must complete both state-mandated baseline training and participant-specific training detailing the individual's emergency plans and specific behavioral or medical needs as outlined in their PCSP.

• DACS Clearance: All employees, volunteers, and contractors with direct patient access must pass a fingerprint-based background check through the Direct Access Clearance System (DACS) before their first shift.
• Age and Education: Direct care respite workers must be at least 18 years of age and possess a high school diploma or equivalent.
• CPR and First Aid: All respite staff must maintain current, hands-on (not strictly online) certification in CPR and First Aid.
• DSPD Basic Training: Staff serving DSPD waivers must complete required online modules covering incident reporting, rights and protections, and abuse/neglect prevention within 30 days of hire.
• Participant-Specific Training: Before providing respite, the worker must be trained on the participant's PCSP, including specific dietary restrictions, behavioral support plans, and emergency contacts.

7. Documentation, Policies and Records

Providers are subject to routine audits by both the Medicaid Office of Program Integrity and the operating divisions (DSPD, DAAS). Documentation must clearly prove that the primary caregiver was absent and that the services billed align with the authorized PCSP.

Agencies must maintain comprehensive administrative policies, personnel files, and daily service logs.

• Service Logs: Must document the date, start time, end time, location of service, and a description of activities provided, signed (or electronically verified) by both the respite worker and the primary caregiver upon their return.
• Incident Reporting: Providers must submit critical incident reports via the Utah Provider Interface (UPI) system within 24 hours of any event involving injury, elopement, or suspected abuse.
• Personnel Records: Must contain DACS clearance certificates, verified I-9s, copy of driver’s license (if transporting the participant), and documented completion of all required training.
• Emergency Plans: Agencies must maintain a written emergency and disaster response plan, updated annually, detailing how participants will be supported during power outages or natural disasters.
• Record Retention: All clinical and billing records must be retained securely for a minimum of five years from the date of service, or longer if a participant is a minor.

8. Billing, Rates and Claims

Respite is an authorized service that requires prior approval documented in the participant's PCSP. Billing without an active authorization or exceeding the allotted hours will result in claim denial.

Claims for DSPD waivers are often processed through the USTEPS system or billed directly through PRISM, depending on the specific provider contract and model. Rates are established by the Utah Legislature and published on the DHHS rate schedules.

• Procedure Codes: Respite is typically billed using HCPCS codes such as S5150 (Unskilled respite care, not hospice, per 15 minutes) or S5151 (Unskilled respite care, not hospice, per diem).
• Rate Schedules: Current maximum allowable rates are published on the DSPD Provider Rates webpage and the Medicaid Coverage and Reimbursement site.
• USTEPS System: The Utah System for Tracking Eligibility, Planning and Services; used by DSPD providers to view authorizations, track participant budgets, and submit billing data.
• Electronic Visit Verification (EVV): In-home respite providers must utilize an EVV system to capture the time, location, and date of service delivery in compliance with the 21st Century Cures Act.
• Caregiver Exclusion: Medicaid will not reimburse for respite care provided by the participant's spouse, parent (if the participant is a minor), or the designated primary caregiver.

9. Approval Sequence and Timeline

Becoming an approved agency provider of HCBS respite in Utah is a multi-step process that typically spans 4 to 8 months, largely dependent on the state's procurement cycle and background check processing times.

Applicants cannot bill for services until all phases—business registration, procurement/contracting, DACS enrollment, and PRISM activation—are complete and the provider receives a welcome letter from Utah Medicaid.

• Step 1: Entity Formation and Planning (Weeks 1-4): Register the business with the Utah Department of Commerce and obtain an NPI.
• Step 2: State Solicitation/U3P (Weeks 4-12): Respond to the open HCBS vendor solicitation on the U3P portal. Await review and contract award from DSPD.
• Step 3: DACS Registration (Weeks 12-14): Register the agency in the DACS portal to allow for staff background checks.
• Step 4: PRISM Enrollment (Weeks 14-20): Submit the Medicaid enrollment application in PRISM, linking the newly awarded DSPD contract and NPI. Pay the application fee.
• Step 5: EVV Setup and Training (Weeks 20-24): Onboard with the state's EVV aggregator or configure a compliant third-party EVV system before accepting authorized clients.

10. Common Denials and Survey Findings

Utah enforces strict compliance regarding background checks and participant authorizations. Agencies frequently face payment retractions, corrective action plans, or contract suspension for administrative oversights.

Most issues arise from lapses in credentialing or failing to accurately document the duration of the caregiver's absence.

• DACS Lapses: Allowing an employee to work a respite shift before their DACS clearance is fully approved, or failing to renew a clearance, leading to immediate payment retractions for all hours worked by that employee.
• Unauthorized Overages: Billing for respite hours that exceed the annual or monthly cap authorized in the participant's PCSP.
• EVV Non-Compliance: Submitting claims without corresponding EVV data, or relying too heavily on manual EVV edits, triggering pre-payment claim denials.
• Missing Signatures: Failing to obtain the primary caregiver's signature on the service log verifying that the respite was delivered as billed.
• Incomplete Training Records: Surveyors citing agencies for failing to document that a respite worker received training on a participant's specific behavioral support plan prior to their first shift.

11. Key Contacts and Resources

Providers must utilize the specific portals and division resources for their respective waivers.

• Provider Reimbursement Information System for Medicaid (PRISM): https://medicaid.utah.gov/prism/
• Division of Services for People with Disabilities (DSPD) Provider Page: https://dspd.utah.gov/providers/
• Utah Public Procurement Place (U3P): https://purchasing.utah.gov/for-vendors/
• Direct Access Clearance System (DACS): https://dlbc.utah.gov/dacs/
• Utah Administrative Code (DHHS Rules): https://adminrules.utah.gov/public/search/agency/Health%20and%20Human%20Services
• Division of Integrated Healthcare (Medicaid): Provider Enrollment Helpdesk: 1-800-662-9651.

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