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

Last reviewed: 2026-09-10

In Utah, Skilled Respite Care is funded through 1915(c) Home and Community-Based Services (HCBS) programs like the Technology Dependent Waiver and New Choices Waiver, requiring providers to first hold a Home Health Agency license from the Department of Health and Human Services (DHHS). Because Utah does not issue a standalone license for skilled respite, agencies must meet the comprehensive clinical and operational standards of a home health agency before they can apply to deliver this specific waiver service.

Approval to bill Medicaid for this service mandates enrollment through the Provider Reimbursement Information System for Medicaid (PRISM) and specific waiver program authorization. Agencies must employ licensed nursing staff (RNs or LPNs) to deliver care for participants whose medical needs exceed the scope of standard personal care respite, ensuring continuity of complex care when primary caregivers require temporary relief.

1. Service Definition and Scope

Skilled Respite provides temporary relief to primary caregivers of individuals with complex medical needs. In Utah, this service is heavily utilized in programs like the Technology Dependent Waiver for individuals under 21 who require skilled nursing or rehabilitative services at least five days per week.

Unlike standard respite, which can be performed by unlicensed direct care workers, skilled respite must be delivered by licensed nurses. The service is designed to maintain the participant's health and safety in their home or community setting during the caregiver's absence.

• Target Population: Individuals requiring skilled nursing or rehabilitative services at least five days per week, such as those on the Technology Dependent Waiver.
• Service Delivery: Delivered in the participant's home or an approved community-based setting.
• Provider Qualifications: Must be delivered by a licensed nurse (RN or LPN) employed by an approved agency.
• Waiver Programs: Available through the Technology Dependent Waiver, New Choices Waiver, and Acquired Brain Injury Waiver.
• Exclusions: Cannot be provided or billed simultaneously with other skilled nursing services.

2. Regulatory and Oversight Agencies

Oversight for skilled respite providers in Utah is divided between facility licensing and Medicaid waiver enrollment. The Department of Health and Human Services (DHHS) manages both the baseline agency licensure and the administration of HCBS waiver programs.

Medicaid enrollment and claims processing are handled through the state's PRISM system, while background clearances are processed through the state's criminal identification bureau.

• Licensing Authority: Utah DHHS Division of Licensing and Background Checks (https://dhhs.utah.gov)
• Medicaid Agency: Utah Medicaid Provider Enrollment (https://medicaid.utah.gov/become-medicaid-provider/)
• Waiver Administration: Utah DHHS Long-Term Care and Waiver Programs (https://medicaid.utah.gov/ltc-2/)
• Background Checks: Utah Bureau of Criminal Identification (BCI) (https://bci.utah.gov)

3. Gatekeeping Prerequisites: Who Can Even Apply

Utah does not issue a standalone "Skilled Respite" license. To provide this service, an entity must first obtain a Home Health Agency license from the DHHS Division of Licensing and Background Checks.

There is no Certificate of Need requirement for home health agencies in Utah, but the agency must be fully licensed and operational before submitting a Medicaid waiver provider enrollment application through PRISM.

• Base Licensure: Must hold an active Utah Home Health Agency license from DHHS DLBC prior to Medicaid enrollment.
• Business Registration: Must be legally registered as a business entity with the Utah Division of Corporations.
• Settings Rule Compliance: Must complete a Settings Rule self-attestation and survey prior to waiver approval.
• Insurance: Must carry general liability, professional liability, and workers' compensation insurance meeting DHHS minimums.

4. Licensure and Certification Requirements

Obtaining a Home Health Agency license involves submitting a comprehensive application to DHHS DLBC and passing an initial on-site survey. The agency must demonstrate compliance with state health and safety codes, including strict protocols for nursing supervision.

The licensure process requires the designation of qualified leadership, including an administrator and a clinical director to oversee all skilled nursing activities.

• Application Form: Submit the Home Health Agency initial licensing application to DHHS DLBC.
• Policies and Procedures: Must submit operational policies including client rights, grievance processes, and incident reporting.
• Initial Survey: Must pass an on-site health and safety inspection by DHHS surveyors.
• Administrator Qualifications: Must designate a qualified agency administrator to manage daily operations.
• Clinical Director: Must employ a registered nurse (RN) to oversee and direct all clinical services.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed entirely through the Provider Reimbursement Information System for Medicaid (PRISM) portal. Providers must ensure their PRISM profile accurately reflects their licensed services and target counties.

For specific waivers, such as the New Choices Waiver, providers must submit distinct attachments for each service they intend to offer, uploading the final signature pages directly into PRISM.

• Enrollment Portal: PRISM (Provider Reimbursement Information System for Medicaid) (https://medicaid.utah.gov/become-medicaid-provider/)
• NPI Requirement: Must obtain a National Provider Identifier (NPI) prior to initiating PRISM enrollment.
• Waiver Documentation: Submit a separate Attachment B for each distinct New Choices Waiver service offered.
• Tax Documentation: Submit a completed IRS W-9 form for tax verification.
• Specialty Designation: Must select the appropriate HCBS waiver specialties in the PRISM provider profile.

6. Staffing, Training and Background Checks

Skilled respite requires clinical staff, specifically RNs or LPNs, who must maintain active, unencumbered Utah nursing licenses. Unlicensed assistive personnel cannot deliver skilled respite.

All staff must clear comprehensive background checks through the state system before having any direct patient contact or providing billable services.

• Clinical Staff: Must employ Licensed Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) for service delivery.
• Background Checks: All direct care staff must undergo a Utah Bureau of Criminal Identification (BCI) criminal history check.
• Disqualification Registry: Staff must be checked against state disqualification lists prior to hire.
• Orientation: New providers must attend mandatory Medicaid Waiver provider training covering billing and incident reporting.
• CPR/First Aid: Clinical staff must maintain current CPR and First Aid certifications.

7. Documentation, Policies and Records

Agencies must maintain comprehensive records to satisfy both DHHS licensing standards and Medicaid waiver compliance. Service delivery plans must strictly align with the participant's waiver care plan authorized by the case management agency.

Providers must utilize state-approved forms for information sharing and maintain detailed personnel files demonstrating ongoing staff credentialing.

• Service Delivery Plans: Must outline how the agency will provide services aligned with Utah's waiver guidelines and the Notice of Decision.
• Personnel Files: Must contain copies of nursing licenses, BCI background check clearances, and training certificates.
• Incident Reporting: Must maintain written policies for reporting critical incidents to DHHS and the waiver case manager.
• Release of Information: Must utilize forms such as the NCW Release of Information (ROI) when coordinating care.
• Record Retention: Must retain clinical and billing records as mandated by Utah Medicaid policy for audit purposes.

8. Billing, Rates and Claims

Claims for skilled respite are submitted electronically through the PRISM MMIS system. Services must be prior-authorized in the participant's care plan before any billing can occur.

Rates and specific procedure codes are published and updated in the Utah Medicaid Information Bulletin and Provider Manuals.

• Billing System: Claims are processed electronically through the PRISM portal.
• Procedure Codes: Respite care is typically billed using codes such as S5150 (15 Minute), with specific modifiers required for skilled nursing levels.
• Rate Publication: Current fee schedules and rate limits are located in the Utah Medicaid Provider Manuals.
• Prior Authorization: Services must be authorized via a Notice of Decision from the Case Management Agency before billing.
• Claim Format: Must use standard electronic claim formats (e.g., 837P) for professional services.

9. Approval Sequence and Timeline

The approval process is strictly sequential, beginning with business registration and culminating in PRISM enrollment. An agency cannot apply for waiver enrollment until the base Home Health Agency license is secured.

Timelines vary based on the agency's readiness for the initial DHHS survey and the current processing queues within the PRISM system.

• Step 1: Register the business entity with the Utah Division of Corporations.
• Step 2: Apply for and obtain a Home Health Agency license from DHHS DLBC, including passing the initial survey.
• Step 3: Complete the HCBS Settings Rule self-attestation and survey.
• Step 4: Submit the provider enrollment application and required waiver attachments (e.g., Attachment B) via PRISM.
• Step 5: Attend mandatory Medicaid Waiver provider orientation and receive the Provider Identification Number (PID).

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete PRISM profiles or failure to upload required waiver-specific attachments. Discrepancies between the PRISM profile and actual business operations will halt enrollment.

During surveys, agencies are commonly cited for inadequate personnel files, specifically regarding lapsed background checks or expired nursing licenses.

• Incomplete Profiles: Failure to match the PRISM provider profile with existing waiver enrollment records or selected counties.
• Missing Attachments: Neglecting to upload the final signature page of Attachment B to PRISM for New Choices Waiver.
• Background Check Lapses: Allowing staff to provide care before BCI clearance is fully processed and documented.
• Settings Rule Non-Compliance: Failing to submit the required Settings Rule self-attestation prior to the deadline.
• Care Plan Deviations: Providing and billing for services outside the scope or authorized hours of the case manager's Notice of Decision.

11. Key Contacts and Resources

Providers should rely on official DHHS resources, the PRISM portal, and published Medicaid Information Bulletins to maintain compliance and track regulatory changes.

The waiver-specific program pages provide essential forms, such as the Notice of Decision and Release of Information templates.

• Utah Medicaid Provider Enrollment: (801) 538-6155 or [email protected] (https://medicaid.utah.gov/become-medicaid-provider/)
• New Choices Waiver Program: https://medicaid.utah.gov/ltc-2/nc/
• Technology Dependent Waiver: https://medicaid.utah.gov/ltc-2/tech
• Utah DHHS Division of Licensing and Background Checks: https://dhhs.utah.gov
• Utah Medicaid Official Publications: https://medicaid.utah.gov/utah-medicaid-official-publications

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