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

Last reviewed: 2026-09-10

Agency-directed Respite Care Services in Virginia are funded through the Commonwealth Coordinated Care Plus (CCC Plus), Family and Individual Supports (FIS), and Community Living (CL) waivers, and are governed jointly by the Department of Medical Assistance Services (DMAS) alongside either the Virginia Department of Health (VDH) or the Department of Behavioral Health and Developmental Services (DBHDS). The service provides short-term substitute care for individuals when their unpaid primary caregiver is absent or needs relief, ensuring the waiver enrollee's health and safety remain continuously supported in their home or community.

Before a provider can bill for this service, they must secure either a VDH Home Care Organization (HCO) license or a DBHDS provider license, depending on the target population. For providers intending to serve the CCC Plus waiver population, obtaining a Medicaid provider ID is only the midpoint of the process; providers must subsequently secure credentialing and network contracts with the Cardinal Care Managed Care Organizations (MCOs) that administer the benefits regionally.

1. Service Definition and Scope

Respite care in Virginia Medicaid offers temporary, substitute support for individuals who rely on an unpaid primary caregiver residing in the same home. The service covers assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and supervision normally provided by the family member or unpaid caregiver.

Virginia divides this service into Agency-Directed (where a licensed agency employs the direct care staff) and Consumer-Directed (where the individual or their Employer of Record hires the worker directly using a fiscal employer agent). This guide focuses on Agency-Directed Respite Care, which can be delivered in the individual’s home, the home of a temporary caregiver, or a licensed facility.

• Service Limit: 480 hours per individual per state fiscal year (July 1 - June 30) across all Medicaid waivers.
• Excluded Settings: Cannot be provided in a nursing facility, assisted living facility, or group home where the facility is already paid to provide comprehensive care.
• Caregiver Residency Requirement: The unpaid primary caregiver must reside in the home with the waiver enrollee.
• Permitted Activities: Assisting with personal hygiene, meal preparation, medication administration (if properly certified), and protective supervision.
• Prohibited Billing: Providers cannot bill for respite care during hours the individual is attending school or receiving another waiver service like day support.

2. Regulatory and Oversight Agencies

Authority over Respite Care Services is split between the state's Medicaid authority, which sets reimbursement and waiver rules, and the state's licensing bodies, which regulate the provider entities. Providers generally interact with one of two licensing agencies depending on whether they operate as a traditional home care agency or an agency specializing in developmental disabilities.

Acentra Health (formerly Maximus) handles the front-end Medicaid provider enrollment processes on behalf of DMAS.

• Virginia Department of Medical Assistance Services (DMAS): Administers the Medicaid program, holds the federal 1915(c) waivers, and sets service policies and rates. https://www.dmas.virginia.gov
• Virginia Department of Health (VDH) Office of Licensure and Certification (OLC): Licenses Home Care Organizations (HCOs) that provide personal care and respite to the general or aging populations. https://www.vdh.virginia.gov/licensure-and-certification/
• Department of Behavioral Health and Developmental Services (DBHDS): Licenses providers specifically serving individuals with developmental disabilities under the FIS and CL waivers. https://dbhds.virginia.gov/quality-management/Office-of-Licensing/
• Medicaid Enterprise System (MES) Provider Portal: The central portal operated by Acentra Health where providers submit their Medicaid enrollment applications. https://vamedicaid.dmas.virginia.gov/provider
• Cardinal Care Managed Care: The mandatory managed care program through which all CCC Plus waiver services (including respite) are authorized and paid. https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-managed-care/

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia does not impose a Certificate of Need (CON) or population-based moratorium on new respite care agencies. However, distinct structural prerequisites gate the initial application process depending on which licensing path the provider takes and which waivers they intend to serve.

Providers must complete the appropriate licensing prerequisite steps before DMAS will process a Medicaid provider enrollment application.

• DBHDS Mandatory Training Gate: Applicants seeking DBHDS licensure must register for and complete the DBHDS Prospective Provider Training and submit a letter of intent before gaining access to the CONNECT licensing portal.
• VDH HCO Exemption Gate: If an agency is Medicare-certified as a Home Health Agency, they are exempt from the VDH HCO state licensure requirement but must submit proof of Medicare certification to DMAS.
• MCO Contracting Gate: For the CCC Plus waiver, DMAS enrollment is insufficient to receive authorizations. Providers must apply to and be credentialed by at least one (and practically all) of the Cardinal Care MCOs (e.g., Anthem HealthKeepers Plus, Aetna Better Health, Sentara Community Plan). MCOs may claim network adequacy and close enrollment to new providers in specific regions.
• Local Human Rights Committee (LHRC) Gate: DBHDS-licensed applicants must affiliate with an LHRC and submit human rights policies for review as part of the initial conditional license application.

4. Licensure and Certification Requirements

A provider must possess an active, appropriate license to deliver Agency-Directed Respite Care. Most general personal care and respite agencies obtain a Home Care Organization (HCO) license from VDH, specifically under the "Personal Care Services" classification.

Agencies exclusively targeting individuals with developmental disabilities under the FIS/CL waivers typically obtain a Supportive In-Home Services or Center-Based Respite license from DBHDS.

• VDH Regulatory Citation: VDH Home Care Organizations are licensed under 12VAC5-381.
• VDH HCO Application Fee: $500 initial application fee submitted to the VDH Office of Licensure and Certification.
• DBHDS Regulatory Citation: DBHDS providers are licensed under 12VAC35-105 (Rules and Regulations for Licensing Providers by DBHDS).
• DBHDS Initial License: Issued as a "Conditional License" valid for six months, during which the provider must admit individuals and demonstrate compliance before receiving a standard annual or triennial license.
• Administrator Qualifications (VDH): An HCO administrator must have at least one year of supervisory or management experience in healthcare or a related field.
• Nursing Supervision: Both licensing tracks require the provider to employ or contract with a Registered Nurse (RN) to conduct initial assessments and periodic supervisory visits of the direct care workers.

5. Medicaid Provider Enrollment

Once licensed by VDH or DBHDS, the provider applies to DMAS via the Provider Registration and Servicing System (PRSS) within the Virginia Medicaid Enterprise System (MES). Providers must enroll under specific provider types and specialties tied to the waivers they serve.

Providers must keep their licensure information updated in PRSS; if a VDH or DBHDS license expires, PRSS automatically suspends the provider's Medicaid enrollment.

• System: Provider Registration and Servicing System (PRSS) portal.
• Provider Type/Specialty (CCC Plus): Enrolled as Provider Type 75 (Personal Care/Respite).
• Application Fee: Subject to the federally mandated Medicaid application fee (currently $731 for 2024/2025) unless proof of payment to Medicare or another state's Medicaid program is provided.
• Required Documentation: W-9, National Provider Identifier (NPI), copy of VDH HCO or DBHDS license, and a voided check for EFT enrollment.
• Revalidation: Providers must revalidate their Medicaid enrollment in PRSS every 5 years.
• MCO Enrollment: Following PRSS approval, providers must initiate separate contracting and credentialing applications with each Cardinal Care MCO operating in their target region.

6. Staffing, Training and Background Checks

Direct care staff providing respite services must meet strict training and background screening requirements. Virginia defines the minimum competencies for Personal Care Aides (PCAs) and Direct Support Professionals (DSPs), and prohibits hiring individuals with specific barrier crimes.

Supervisory oversight by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) under RN direction is mandatory for agency-directed services to ensure the health and safety of the individual during the primary caregiver's absence.

• Background Checks: Mandatory Virginia State Police criminal history check and Virginia Department of Social Services Child Protective Services (CPS) registry check (if serving minors). Barrier crimes found in Code of Virginia § 32.1-162.9:1 permanently disqualify applicants.
• PCA Qualifications (VDH/CCC Plus): Must successfully complete a 40-hour state-approved PCA training program, or be a Certified Nurse Aide (CNA), or have completed a nursing education program.
• DSP Qualifications (DBHDS/DD Waivers): Must complete the DBHDS DSP Orientation training and pass the accompanying competency testing within 30 days of hire.
• Nursing Supervision Frequency: The RN supervisor must conduct a supervisory visit at least every 90 days for respite-only cases to evaluate the aide's performance and the individual's status.
• CPR/First Aid: All direct care staff must hold current, standard certification in CPR and First Aid (online-only certifications without in-person skills demonstrations are not accepted).

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records that justify the billing of respite services. Documentation must clearly link the hours provided to the absence or need for relief of the primary unpaid caregiver.

Failure to maintain signed, contemporaneous records is a primary cause for payment retractions during DMAS Program Integrity audits.

• Plan for Supports/Care Plan: The provider's RN must develop a customized plan detailing the specific tasks to be performed during respite hours, based on the waiver enrollee's assessment.
• DMAS-90 Form: The Personal Care/Respite Aide Record (DMAS-90) or an electronic equivalent must be used to document the specific dates, arrival/departure times, and tasks performed during every shift.
• Caregiver Verification: Documentation must verify that the unpaid primary caregiver resides in the same home as the waiver enrollee.
• Signatures: Each shift record must be signed and dated by the direct care worker and the individual or their representative. Electronic Visit Verification (EVV) data satisfies this requirement if fully compliant.
• EVV Requirement: Agency-directed respite is subject to the federal 21st Century Cures Act; providers must use an EVV system to capture the date, time, location, individual receiving, and person providing the service.
• Record Retention: All clinical and billing records must be retained for a minimum of six years from the date of service or discharge.

8. Billing, Rates and Claims

Respite care in Virginia is billed in 15-minute increments or per diem, depending on the length of the authorization and the waiver. For the CCC Plus waiver, claims are submitted directly to the member's Cardinal Care MCO rather than to DMAS fee-for-service, meaning providers must navigate multiple MCO clearinghouses.

Rates are established by DMAS and generally feature a geographical differential, paying slightly higher rates in Northern Virginia (NOVA) to account for the higher cost of living.

• Procedure Code: T1005 (Respite care services, 15 minutes).
• Modifier: Often requires a modifier (e.g., U4) to designate agency-directed vs consumer-directed, or TD for nursing respite, as defined in the current DMAS manual.
• Current Rate Range: Approximately $5.00 to $6.50 per 15-minute unit for agency-directed PCA respite, varying by NOVA vs. Rest of State (rates update annually; providers must consult the DMAS rate schedule).
• EVV Claims Integration: Claims submitted for T1005 will deny if matching EVV data (capturing clock-in/clock-out and location) is not successfully transmitted to the MCO or DMAS aggregator.
• Billing Limit: Hard cap of 480 hours per fiscal year. Providers must track utilization carefully, as claims exceeding the 480-hour limit will deny.
• Timely Filing: Fee-for-service claims must be submitted within 365 days of the service date; MCO timely filing limits vary by contract but are often shorter (e.g., 90 to 180 days).

9. Approval Sequence and Timeline

Becoming a fully operational agency-directed respite provider is a sequential process that typically takes 6 to 9 months from initial business formation to billing the first claim. Licensing is the longest phase, followed by state Medicaid enrollment and finally MCO contracting.

Providers cannot initiate Medicaid enrollment until the licensing certificate is physically issued and effective.

• Phase 1: Licensing Preparation (1-2 months): Develop policies, secure a commercial office space (required by VDH/DBHDS), and hire the RN supervisor.
• Phase 2: Licensure Review (3-5 months): Submit application to VDH or DBHDS. Includes a desk review of policies and an on-site initial inspection of the agency office.
• Phase 3: MES/PRSS Enrollment (30-45 days): Submit application to DMAS via Acentra Health. Includes credentialing verification and application fee processing.
• Phase 4: MCO Credentialing (90-120 days): Submit rosters and applications to Cardinal Care MCOs. Often involves completing CAQH profiles for the agency and negotiating contract terms.
• Phase 5: Authorization Transfer: Once contracted, the provider coordinates with the MCO care coordinator to receive authorizations for specific members before scheduling shifts.

10. Common Denials and Survey Findings

Both licensing surveyors and Medicaid program integrity auditors heavily scrutinize agency-directed respite providers. Common citations revolve around the failure to strictly adhere to personnel qualification rules and inadequate documentation of the caregiver's absence.

Auditors will recover funds if the service was provided but the aide lacked the required credentials at the exact time of the shift.

• EVV Non-Compliance: Claims denied because the EVV data lacked GPS coordinates or failed to match the exact billed units on the claim form.
• Missing 90-Day RN Visits: Survey citations and payment retractions because the supervising RN failed to conduct and document the required 90-day face-to-face supervisory visit.
• Background Check Timing: Citations for direct care workers providing services before the Virginia State Police criminal history check results were fully returned and reviewed by the agency.
• School Hour Billing: Program Integrity retractions for respite shifts billed during hours the child was attending public school or receiving another funded service.
• Policy Deficiencies: Initial VDH/DBHDS applications rejected or delayed because emergency preparedness or human rights policies were generic templates not customized to the agency's actual operations.
• Overbilling the Annual Cap: Claims denied for exceeding the 480-hour annual limit because the agency failed to verify how many respite hours the member had already used with a previous provider in the same fiscal year.

11. Key Contacts and Resources

Providers must rely on the official portals and provider manuals published by DMAS and the respective licensing agencies to maintain compliance and submit accurate applications.

• DMAS Provider Portals (MES): Access PRSS for enrollment and the EVV aggregator information. https://vamedicaid.dmas.virginia.gov/provider
• VDH Office of Licensure and Certification (OLC): Handles Home Care Organization licensure applications and regulations. https://www.vdh.virginia.gov/licensure-and-certification/
• DBHDS Office of Licensing: Manages the CONNECT portal for providers serving the DD waivers. https://dbhds.virginia.gov/quality-management/Office-of-Licensing/
• DMAS Provider Manuals: The official source for the "Commonwealth Coordinated Care Plus Waiver" and "Developmental Disabilities Waivers" provider manuals. https://vamedicaid.dmas.virginia.gov/manuals/provider-manuals
• Cardinal Care Managed Care: Directory and contracting information for the MCOs administering waiver services. https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-managed-care/

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