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

Last reviewed: 2026-09-10

Virginia funds Skilled Respite Care Services through the Commonwealth Coordinated Care (CCC) Plus Waiver and Developmental Disabilities (DD) waivers, requiring providers to first hold a Home Care Organization (HCO) license from the Virginia Department of Health (VDH) or a provider license from the Department of Behavioral Health and Developmental Services (DBHDS). The service reimburses RNs and LPNs for temporary care when an unpaid primary caregiver is absent and the waiver individual's needs—such as ventilator assistance or tube feedings—exceed the scope of unlicensed personal care aides.

Approval requires completing the state licensure process before submitting a Medicaid enrollment application through the Medicaid Enterprise System (MES) Provider Resources System (PRSS). Providers must document the specific medical necessity for skilled nursing respite in the individual's plan of care and ensure all LPNs are directly supervised by an RN.

1. Service Definition and Scope

Skilled Respite Care in Virginia provides temporary, episodic nursing care to waiver individuals who require routine skilled interventions that cannot be safely delegated to unlicensed personnel. The service is designed to relieve the unpaid primary caregiver while ensuring continuity of complex medical care.

Providers must ensure that the licensed nurses delivering this service also handle all standard aide duties during their shift, preventing the need for overlapping staff.

• Target Population: Waiver individuals with documented needs for routine skilled care, such as ventilator management or gastrostomy feedings.
• Service Trigger: Absence or need for relief of the unpaid primary caregiver when no other support system can provide the skilled care.
• Provider Scope: The RN or LPN providing skilled respite must also perform all standard respite services normally provided by an aide during the shift.
• Supervision Requirement: An RN must provide ongoing supervision of all LPNs delivering skilled respite services.

2. Regulatory and Oversight Agencies

Oversight is split between the licensing bodies that authorize the agency to operate and the Medicaid authority that funds the waiver services. Providers must maintain compliance with both their specific licensing authority and Medicaid participation standards.

Because skilled respite spans medical and behavioral waivers, the exact licensing body depends on the agency's primary target population.

• Medicaid Authority: Virginia Department of Medical Assistance Services (DMAS) (https://www.dmas.virginia.gov) administers the waivers and sets provider rules.
• Licensing Agency (Medical): Virginia Department of Health (VDH) Office of Licensure and Certification (https://www.vdh.virginia.gov/licensure-and-certification/) licenses Home Care Organizations.
• Licensing Agency (Behavioral/DD): Virginia Department of Behavioral Health and Developmental Services (DBHDS) (https://dbhds.virginia.gov/) licenses providers serving the DD waiver population.
• Enrollment Portal: Medicaid Enterprise System (MES) (https://vamedicaid.dmas.virginia.gov) processes all provider enrollments and claims.

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia does not require a Certificate of Need (CON) or Facility Need Review to open a home care or skilled respite agency. However, Medicaid enrollment is strictly gated by prior licensure.

Applicants cannot bypass the state licensing queue; DMAS will automatically reject any MES enrollment application that does not include an active, finalized state license.

• Licensure Prerequisite: Applicants must hold an active, unencumbered Home Care Organization (HCO) license from VDH or a DBHDS license before DMAS will accept a Medicaid enrollment application.
• NPI Requirement: Agencies must obtain a National Provider Identifier (NPI) from NPPES prior to initiating the MES enrollment process.
• Network Affiliation: Virginia does not restrict skilled respite to closed networks or require pre-existing MCO contracts to apply for Medicaid enrollment.
• Operating History: No minimum operating history is required to apply for initial VDH licensure or DMAS enrollment.

4. Licensure and Certification Requirements

Virginia does not issue a standalone "Skilled Respite" license. Instead, agencies must obtain a Home Care Organization (HCO) license from VDH with a skilled nursing designation, or a DBHDS license if operating under DD waivers.

The licensure process involves a comprehensive review of the agency's clinical policies, administrative structure, and nursing leadership.

• Regulatory Authority: Licensure standards are governed by 12VAC30-120-935 and VDH/DBHDS specific administrative codes.
• Application Submission: VDH HCO applications require submission of organizational policies, nursing supervisor credentials, and a non-refundable fee.
• Initial Survey: VDH conducts an initial on-site survey to verify compliance with state home care regulations before issuing the permanent license.
• Deemed Status: VDH accepts accreditation from CHAP or ACHC in lieu of a standard state survey for HCO licensure.

5. Medicaid Provider Enrollment

Once licensed, agencies enroll as Medicaid providers through the Virginia Medicaid Enterprise System (MES) portal. Skilled respite is typically enrolled under the broader waiver services provider type.

DMAS utilizes a risk-based screening model, meaning home health and waiver agencies must undergo specific database checks before approval.

• System: Applications are submitted electronically via the MES Provider Resources System (PRSS).
• Screening Risk Level: Home health and waiver agencies are subject to limited or moderate risk screening, requiring database checks for exclusions.
• Required Documentation: Providers must upload their active VDH or DBHDS license, W-9, and proof of NPI during the PRSS application.
• Revalidation: DMAS requires providers to revalidate their enrollment at least every five years through the MES portal.

6. Staffing, Training and Background Checks

Skilled respite must be delivered by licensed nurses who also meet the baseline qualifications of personal care aides. Agencies must maintain strict supervisory hierarchies and background check compliance.

Virginia law strictly prohibits the employment of individuals with specific barrier crimes in direct care roles.

• Direct Care Qualifications: Must employ an RN or LPN with an active Virginia nursing license.
• Age Requirement: All staff, including nurses acting in an aide capacity, must be at least 18 years of age.
• Supervision: An RN must conduct a home supervisory visit with the LPN on or before the start of care for episodic respite.
• Background Checks: Providers cannot be reimbursed for services provided by staff convicted of any barrier crime under Section 19.2-392.02 of the Code of Virginia.

7. Documentation, Policies and Records

DMAS requires granular documentation to justify the higher reimbursement rate of skilled respite over standard respite. Records must explicitly detail the medical necessity and the absence of the primary caregiver.

Failure to maintain these specific records is a primary driver of Medicaid clawbacks during post-payment reviews.

• Medical Necessity Documentation: The individual's record must document the specific circumstances (e.g., ventilator care) requiring an LPN or RN.
• Plan of Care: The respite services plan of care must be reviewed every six months or when half of the approved respite hours are used, whichever comes first.
• Supervisory Notes: RN supervisory visits must be documented; if delayed, the reason must be recorded and completed within 15 days of availability.
• Service Logs: Nurses must document all skilled interventions performed as well as any standard aide tasks completed during the shift.

8. Billing, Rates and Claims

Skilled respite is billed to DMAS or the individual's Medicaid Managed Care Organization (MCO) using specific HCPCS codes. Claims must accurately reflect the nursing level provided.

Because most waiver individuals are enrolled in managed care, providers must secure contracts with the CCC Plus MCOs to bill for the majority of their census.

• Billing System: Fee-for-service claims are submitted through the MES portal; managed care claims go directly to the contracted MCO.
• Procedure Codes: Billed using waiver-specific HCPCS codes designated for skilled respite as defined in the CCC Plus manual.
• ORP Requirement: The NPI of the Ordering, Referring, or Prescribing (ORP) provider must be included on all claims to ensure adjudication.
• Service Limitations: Reimbursement is strictly limited to periods when the unpaid primary caregiver is absent or needs relief.

9. Approval Sequence and Timeline

The critical path to billing skilled respite in Virginia is sequential: entity formation, state licensure, Medicaid enrollment, and finally MCO credentialing.

Providers cannot overlap these steps; DMAS will not process an enrollment without a license, and MCOs will not credential without an active DMAS enrollment.

• Step 1: Establish corporate entity and obtain NPI (1-2 weeks).
• Step 2: Submit VDH HCO or DBHDS license application and pass initial survey (typically 3-6 months).
• Step 3: Submit Medicaid enrollment application via MES PRSS (30-60 days for processing).
• Step 4: Complete credentialing and contracting with Virginia CCC Plus MCOs (90-120 days post-Medicaid enrollment).

10. Common Denials and Survey Findings

State surveyors and DMAS auditors frequently cite providers for failing to justify the skilled level of care or for lapses in RN supervision.

Auditors look closely at the overlap between skilled respite and standard personal care to ensure the state is not overpaying for unskilled tasks.

• Justification Failure: Billing skilled respite when the individual's needs could have been met by an unlicensed personal care aide.
• Supervision Lapses: Missing the required RN supervisory visit on or before the start of episodic care, or failing to document the delay within 15 days.
• Background Check Violations: Employing staff with disqualifying barrier crimes under Section 19.2-392.02.
• Incomplete Care Plans: Failing to review the respite plan of care at the six-month mark or when half the hours are exhausted.

11. Key Contacts and Resources

Providers must utilize official state portals and manuals to maintain compliance with Virginia's evolving waiver regulations.

The MES portal and agency websites are the primary sources for manual updates, provider bulletins, and enrollment tracking.

• Virginia Medicaid Enterprise System (MES): https://vamedicaid.dmas.virginia.gov
• DMAS Provider Appeals: https://www.dmas.virginia.gov/appeals/
• VDH Office of Licensure and Certification: https://www.vdh.virginia.gov/licensure-and-certification/
• DBHDS Licensing Information: https://dbhds.virginia.gov/licensing-information-for-providers

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