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

Last reviewed: 2026-09-10

The Wisconsin Department of Health Services (DHS) funds Respite Care Services through the IRIS (Include, Respect, I Self-Direct), Family Care, and Children's Long-Term Support (CLTS) waiver programs to provide temporary relief for unpaid primary caregivers. Approval to deliver this service requires either establishing a participant-hired worker relationship directly with an IRIS participant or securing a subcontract with a regional Managed Care Organization (MCO) such as Inclusa for the Family Care program.

Providers must enroll through the ForwardHealth Portal and comply with the Training and Documentation Standards for Supportive Home Care. Facility-based respite requires a distinct Division of Quality Assurance (DQA) license, such as a Chapter DHS 83 Community-Based Residential Facility or Chapter DHS 88 Adult Family Home credential, before Medicaid enrollment can proceed.

1. Service Definition and Scope

Respite Care Services in Wisconsin provide short-term relief to ease a member's family or primary caregiver from daily stress and care demands. The service can be delivered in the member's home, the provider's home, or a licensed facility.

This service cannot be used to compensate relief staff for residential service providers who already provide more than eight consecutive hours of care, nor can it be used to fill gaps in standard home care staffing.

• Primary Caregiver Definition: A caregiver providing more than fifty percent of the care and support on the participant's service plan.
• Room and Board: Excluded from reimbursement unless provided in a state-approved facility that is not a private residence.
• Concurrent Services: Receipt of respite precludes billing for Adult Day Care or Supportive Home Care at the exact same time.
• Duration Limits: Respite care stays may not exceed 28 days without prior approval from the authorizing MCO or ICA.

2. Regulatory and Oversight Agencies

The Wisconsin Department of Health Services (DHS) oversees all Medicaid waiver programs, including IRIS and Family Care. Facility-based providers are regulated by the DHS Division of Quality Assurance (DQA).

Individual and agency providers are monitored by the specific Managed Care Organizations (MCOs) or IRIS Consultant Agencies (ICAs) they contract with, while Medicaid enrollment is handled by ForwardHealth.

• Wisconsin Department of Health Services (DHS): Administers the Medicaid program and waivers (https://www.dhs.wisconsin.gov).
• Division of Quality Assurance (DQA): Licenses and certifies residential facilities and agencies (https://www.dhs.wisconsin.gov/dqa/index.htm).
• ForwardHealth: Manages the Medicaid provider enrollment portal and MMIS (https://www.forwardhealth.wi.gov).
• Inclusa (iCare): Example of a regional Managed Care Organization overseeing Family Care subcontracts (https://www.inclusa.org).

3. Gatekeeping Prerequisites: Who Can Even Apply

Wisconsin does not enroll standalone Respite Care agencies into Medicaid without an underlying network connection. To receive authorization and payment, a provider must either be selected by a self-directing participant or secure a network contract.

Facility-based providers face an additional structural barrier, as they must obtain full state licensure for their physical location before the Medicaid enrollment application can even be submitted.

• MCO Contracting: Family Care providers must secure a subcontract agreement with a regional Managed Care Organization before rendering services.
• Participant-Hired Worker Status: IRIS providers must be directly hired by a waiver participant exercising employer authority.
• Facility Licensure Prerequisite: Institutional or residential respite providers must hold an active DQA license (e.g., DHS 83, DHS 88) before applying for Medicaid enrollment.
• Moratoriums: As of May 2026, federal moratoriums block new home health and hospice agencies, which may impact agencies trying to add respite under those specific licenses.

4. Licensure and Certification Requirements

Wisconsin does not issue a specific "Respite Care Agency" license. Instead, providers operate either as unlicensed individual participant-hired workers, Supportive Home Care agencies, or licensed residential facilities.

Facilities providing out-of-home respite must hold the appropriate DQA license for their setting type and comply with the specific administrative code chapters governing that facility.

• In-Home Agency Standards: Must comply with the Training and Documentation Standards for Supportive Home Care (DHS publication P-01602).
• Adult Family Homes (3-4 bed): Must be licensed under Wis. Admin. Code Chapter DHS 88.
• Community-Based Residential Facilities (CBRF): Must be licensed under Wis. Admin. Code Chapter DHS 83.
• Camp Settings: Must be licensed by the state under Wis. Admin. Code Chapter ATCP 78.

5. Medicaid Provider Enrollment

All providers must enroll through the ForwardHealth Portal to receive a Medicaid ID. Residential providers or those at fixed-site facilities must enroll and receive a unique Medicaid ID for each physical location.

Providers must sign a provider agreement electronically, attesting that they hold all necessary licenses and meet the requirements specified in Wis. Admin. Code chs. DHS 101-109.

• Enrollment System: Applications are submitted online through the ForwardHealth Portal.
• Processing Timeframe: ForwardHealth provider enrollment applications may take up to 60 days to process.
• Tax Information: The Taxpayer Name submitted on the application must exactly match the tax name on file with the Internal Revenue Service (IRS).
• Revalidation: All enrolled providers are required to revalidate their enrollment information every three years.

6. Staffing, Training and Background Checks

Respite workers must meet baseline age and background check requirements under Wisconsin law. Training requirements vary depending on whether the provider is an agency or a participant-hired worker.

While IRIS participants train their own workers, agency staff must complete standardized training, often utilizing resources like the Respite Care Association of Wisconsin.

• Age Requirement: All staff members providing respite services must be at least 18 years of age.
• Background Checks: Mandatory screening is required in compliance with the Wisconsin Caregiver Law.
• Participant-Led Training: Under the IRIS waiver, it is the participant's responsibility to hire and train their respite staff.
• Certification Program: Workers may complete the Respite Care Certificate Program offered by the Respite Care Association of Wisconsin.

7. Documentation, Policies and Records

Providers must maintain strict documentation to prove that respite services were delivered at distinct times from other waiver services. Agencies enrolling in Wisconsin Medicaid must also report specific personnel information.

Institutional respite providers must document the planned length of stay and any barriers to using alternative community-based services.

• Service Separation: Clear documentation must exist showing service delivery occurred at distinct times if billed on the same day as Supportive Home Care.
• Personnel Reporting: Home health and personal care agencies must report specific personnel information to ForwardHealth upon enrollment.
• Length of Stay Records: Institutional respite providers must document the planned length of stay in the enrollee's record.
• Training Documentation: Providers will only be reimbursed if staff training is documented in the provider's personnel file.

8. Billing, Rates and Claims

Respite services are authorized and billed based on the setting and duration of care. Room and board costs must be explicitly excluded from provider budgets and claims for in-home or unlicensed settings.

Providers must use the existing IRIS Service Plan (ISP) and Additional Funding Request policies to develop authorizations reflecting identified needs.

• WISITS Mapping: Services are mapped in the Wisconsin Individual Record and Information System (WISITS) using specific codes like "Respite in Other Setting Live-in (71 Minutes)".
• Room and Board Exclusion: Providers must reduce their budgets to exclude room and board prior to authorization, unless in a state-approved facility.
• Substitute Staff Prohibition: Respite cannot be billed to compensate relief staff for residential agencies providing >8 consecutive hours of care.
• Funding Requests: Providers must use the existing IRIS Service Plan (ISP) and Additional Funding Request policies for authorizations.

9. Approval Sequence and Timeline

The approval sequence begins with securing the necessary facility license or participant/MCO relationship, followed by ForwardHealth enrollment.

Once enrolled, providers must ensure all authorizations comply with the most current Service Definition Manual.

• Step 1: Obtain DQA facility licensure or establish an agency structure meeting Supportive Home Care standards.
• Step 2: Secure a participant-hired worker agreement (IRIS) or an MCO subcontract (Family Care).
• Step 3: Submit the Medicaid enrollment application via the ForwardHealth Portal (takes up to 60 days).
• Step 4: Update authorizations within 90 days of any Service Definition Manual publication changes.

10. Common Denials and Survey Findings

ForwardHealth and MCOs actively monitor respite claims for compliance with service definitions. Denials frequently occur when respite is improperly used to fill standard staffing shortages.

Claims are also rejected if room and board is inappropriately billed in an unlicensed setting or if the provider shares a residence with the participant.

• Inappropriate Use: Denials occur if respite is used in lieu of more applicable support services like Supportive Home Care.
• Staffing Shortages: Services will be rejected if used to fill gaps in an enrollee's service plan due to worker shortages.
• Live-in Provider Rule: Respite claims are denied if the provider is the primary caregiver sharing a residence with the participant.
• Unapproved Extensions: Stays exceeding 28 days without prior MCO/ICA approval will not be reimbursed.

11. Key Contacts and Resources

Providers should utilize state portals and association resources for training and enrollment guidance. The ForwardHealth Portal is the primary hub for Medicaid interactions.

For facility-based providers, the Division of Quality Assurance provides all necessary licensing applications and regulatory codes.

• ForwardHealth Portal: Medicaid enrollment and MMIS system (https://www.forwardhealth.wi.gov).
• Wisconsin DHS IRIS Program: Waiver information and service definitions (https://www.dhs.wisconsin.gov/iris/index.htm).
• DHS Division of Quality Assurance: Facility licensing and certification (https://www.dhs.wisconsin.gov/dqa/index.htm).
• Respite Care Association of Wisconsin: Training and certification programs (https://respitecarewi.org).

See all Wisconsin services · Wisconsin Medicaid consulting · book a consultation.