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

Last reviewed: 2026-08-16

In Wisconsin, Skilled Respite Service provides temporary, intermittent relief to primary caregivers of individuals with complex medical needs. Because the care requirements exceed what an unlicensed personal care worker can safely manage, these services must be delivered by licensed nursing personnel (Registered Nurses or Licensed Practical Nurses). This service is primarily funded through Wisconsin's Home and Community-Based Services (HCBS) waivers, including Family Care, the Include, Respect, I Self-Direct (IRIS) program, and the Children's Long-Term Support (CLTS) waiver.

The single biggest structural barrier to entry for a prospective Skilled Respite provider in Wisconsin is the state's reliance on a managed care model for adult HCBS. Simply obtaining a state license and enrolling in Wisconsin Medicaid via ForwardHealth is not enough to receive clients or bill for services. Providers must successfully negotiate and secure active network contracts with regional Managed Care Organizations (MCOs) for the Family Care program, or be explicitly selected by participants and authorized by an IRIS Consultant Agency (ICA) in the self-directed IRIS program.

1. Service Definition and Scope

Skilled Respite provides short-term nursing care to participants whose medical acuity requires continuous monitoring, medication administration, or clinical interventions that cannot be legally delegated to unlicensed staff. It is designed to sustain the primary caregiver's ability to keep the participant in a community setting.

In Wisconsin, this service is not a standalone program but a specific service line authorized under the participant's overarching HCBS waiver care plan. It is strictly limited to the hours and scope approved by the participant's interdisciplinary care team.

• Target Population: Medicaid waiver participants with complex medical needs requiring RN or LPN-level care.
• Allowed Settings: The participant's private residence or a licensed community facility approved for respite care.
• Provider Types: Licensed Home Health Agencies (HHAs) or independent licensed nurses (specifically for IRIS and CLTS).
• Excluded Activities: Standard personal care or supportive home care tasks that do not require nursing licensure, unless performed incidentally to the skilled care.
• Duration Limits: Authorized on a short-term, intermittent basis (e.g., hourly or daily) as explicitly specified in the Individualized Service Plan (ISP).
• Clinical Scope: Includes ventilator management, complex wound care, tube feedings, and intensive seizure monitoring.

2. Regulatory and Oversight Agencies

Oversight of Skilled Respite in Wisconsin is bifurcated between facility/agency licensure and Medicaid program administration. The Wisconsin Department of Health Services (DHS) manages both functions through separate divisions.

Providers must maintain compliance with state licensing surveyors while simultaneously adhering to the billing and credentialing standards of the Medicaid program and regional managed care entities.

• Licensing Authority: DHS Division of Quality Assurance (DQA) (https://www.dhs.wisconsin.gov/dqa/index.htm).
• Medicaid Agency: DHS Division of Medicaid Services (DMS) (https://www.dhs.wisconsin.gov/dms/index.htm).
• Enrollment Portal: ForwardHealth (https://www.forwardhealth.wi.gov).
• Adult Managed Care: Family Care MCOs, such as My Choice Wisconsin (https://mychoicewi.org).
• Self-Directed Program: IRIS (Include, Respect, I Self-Direct) (https://www.dhs.wisconsin.gov/iris/index.htm).
• Nursing Board: Wisconsin Department of Safety and Professional Services (DSPS) (https://dsps.wi.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Wisconsin does not utilize a Certificate of Need (CON) program for home health or respite services. However, the state heavily restricts HCBS market access through its managed care and county-administered waiver structures.

You cannot simply bill Medicaid for HCBS skilled respite without a prior network affiliation or direct participant selection. The following structural preconditions must be met before a provider can actively serve Medicaid waiver participants.

• MCO Contracting: To serve adult managed care participants, providers must secure a network contract with a regional Family Care MCO (e.g., Lakeland Care, Community Care, Inclusa). MCOs may close their networks if they determine they have adequate capacity.
• IRIS Participant Selection: For the IRIS waiver, providers cannot receive general referrals; they must be actively selected by a participant and authorized by their IRIS Consultant Agency (ICA) before providing services.
• CLTS County Authorization: For children, providers must be registered with the state but authorized directly by the local County Waiver Agency (CWA).
• Underlying Licensure: Agencies must hold an active Wisconsin Home Health Agency license under Wis. Admin. Code ch. DHS 133 before Medicaid enrollment is approved.
• HCBS Settings Rule Compliance: Providers must pass DHS validation ensuring they do not operate in an institutional setting, per federal HCBS requirements.

4. Licensure and Certification Requirements

Wisconsin does not issue a specific "Skilled Respite" license. Instead, agencies providing this service using employed nurses must be licensed as a Home Health Agency (HHA) under Wis. Admin. Code ch. DHS 133.

The licensure process requires a formal application, fee submission, and an on-site survey by the Division of Quality Assurance (DQA) to verify operational readiness and clinical compliance.

• Application Form: Wisconsin Home Health Agency License Application (Form F-62674).
• Licensure Fee: Ranges from $500 to $2,500 depending on agency size and services provided, submitted to DHS DQA.
• Letter of Intent: Applicants must submit a detailed description of the proposed HHA operations prior to or alongside the application.
• Initial Survey: DQA conducts an on-site initial licensing survey to verify compliance with DHS 133 before issuing the license.
• Administrator Qualifications: The agency must designate an administrator who is a licensed physician, RN, or has documented training and experience in health service administration.
• Policy Manual: Must submit comprehensive clinical and administrative policies for DQA review during the initial survey.

5. Medicaid Provider Enrollment

After obtaining DQA licensure, agencies must enroll in Wisconsin Medicaid via the ForwardHealth Portal. This step is required to obtain a Medicaid Provider ID, which is a prerequisite for MCO contracting.

Providers must enroll under the specific provider type applicable to their licensure (e.g., Home Health Agency) and ensure they are approved for HCBS waiver services.

• System: ForwardHealth Provider Portal.
• Application Type: Medicaid Provider Enrollment Application for Home Health Agencies.
• NPI Requirement: The agency must obtain and register a Type 2 National Provider Identifier (NPI).
• Application Fee: Subject to the federal Medicaid/Medicare application fee (approximately $709) unless already paid to Medicare or waived.
• Risk Level: Home Health Agencies are typically subject to a moderate or high categorical risk screening, which may require fingerprint-based background checks for owners.
• Revalidation: Required every three years to maintain active ForwardHealth enrollment.

6. Staffing, Training and Background Checks

Because Skilled Respite requires clinical interventions, agencies must ensure all direct care workers hold active professional credentials. Wisconsin also enforces strict caregiver background check laws.

Agencies are responsible for verifying credentials upon hire and tracking them continuously to prevent lapsed licenses from triggering Medicaid claim recoupments.

• Clinical Licensure: Direct care staff must hold an active, unencumbered Registered Nurse (RN) or Licensed Practical Nurse (LPN) license from the Wisconsin DSPS.
• Background Check System: Must process all staff through the Wisconsin Department of Justice (DOJ) Wisconsin Online Record Check System (WORCS).
• Caregiver Registry: Mandatory search of the DHS Caregiver Misconduct Registry prior to hire and annually thereafter.
• Supervision: LPNs providing skilled respite must be supervised by an RN in accordance with Wisconsin Board of Nursing regulations.
• Training: Staff must complete agency-specific orientation, including HCBS waiver participant rights, abuse/neglect reporting, and emergency procedures.
• CPR Certification: All nursing staff must maintain current, hands-on CPR/Basic Life Support certification.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records compliant with DHS 133 and ForwardHealth requirements. MCOs and the state will audit these records regularly.

Failure to maintain contemporaneous, accurate documentation of skilled interventions is a primary driver of audit failures and fund recoupments.

• Plan of Care: Must maintain a written plan of care authorized by the participant's physician and the MCO/ICA interdisciplinary team.
• Medication Profile: A complete medication list including start/stop dates, dosage, route, and frequency, updated with each nursing visit.
• Visit Notes: Contemporaneous clinical notes detailing the skilled interventions provided, participant response, and exact time in/out.
• Electronic Visit Verification (EVV): Must use the DHS-sponsored EVV system (Sandata) or an alternate approved EVV system for all in-home visits.
• Record Retention: Medical records must be retained for a minimum of 7 years following the last date of service.
• Incident Reporting: Must have policies for reporting critical incidents (e.g., falls, medication errors) to the authorizing MCO or ICA within 24 hours.

8. Billing, Rates and Claims

Billing pathways for Skilled Respite depend entirely on the participant's specific waiver program. While ForwardHealth MMIS is used for fee-for-service, most skilled respite is billed to MCOs or IRIS Fiscal Employer Agents (FEAs).

Rates are generally negotiated with the MCOs or set by the state for self-directed programs, and all services must be strictly prior-authorized.

• Family Care Claims: Billed directly to the authorizing MCO (e.g., Lakeland Care, My Choice Wisconsin) using their specific clearinghouse or provider portal.
• IRIS Claims: Billed to the participant's chosen Fiscal Employer Agent (e.g., iLIFE, GT Independence, Premier).
• CLTS Claims: Billed through the ForwardHealth Portal using the WPS (Wisconsin Physicians Service) claims system or county-specific processes.
• Service Codes: Typically billed using HCPCS codes such as S9123 (Nursing care, in the home; by registered nurse, per hour) or S9124 (LPN), modified for respite.
• Prior Authorization: 100% of skilled respite hours must be prior-authorized in the participant's Individualized Service Plan (ISP); unapproved hours will be denied.
• EVV Matching: Claims submitted without matching EVV data for in-home services will be automatically denied by the clearinghouse.

9. Approval Sequence and Timeline

The end-to-end process from business formation to billing the first claim is lengthy. This is primarily due to the sequential nature of DQA licensure, ForwardHealth enrollment, and MCO contracting.

Providers should anticipate a minimum of 6 to 9 months before they are fully credentialed and able to accept Family Care referrals.

• Step 1: Submit Letter of Intent and Form F-62674 to DHS DQA (30-60 days for initial review).
• Step 2: Pass DQA initial on-site survey and receive HHA license (60-90 days).
• Step 3: Submit ForwardHealth Medicaid enrollment application (30-45 days for processing).
• Step 4: Apply for network contracts with regional Family Care MCOs (90-120 days, subject to MCO network need and credentialing committees).
• Step 5: Complete EVV system training and integration (14-30 days).
• Step 6: Receive first authorized ISP and begin delivering services.

10. Common Denials and Survey Findings

DQA surveyors and MCO auditors frequently cite agencies for administrative oversights and failure to follow the authorized care plan. These findings can result in corrective action plans or contract termination.

Medicaid claim denials are most often tied to authorization mismatches or EVV failures rather than clinical errors.

• Care Plan Deviations: Providing services or hours beyond what is explicitly authorized in the MCO/ICA care plan.
• Background Check Lapses: Failure to run the DHS Caregiver Misconduct Registry or WORCS checks before the first day of direct client contact.
• EVV Non-Compliance: Missing or mismatched Electronic Visit Verification data leading to automatic claim denials.
• Inadequate Supervision: Lack of documented RN supervision for LPNs providing skilled respite in the home.
• Credential Expirations: Allowing nursing staff to provide care with lapsed DSPS licenses or expired CPR certifications.
• Missing Physician Orders: Failure to obtain or renew physician orders for the specific skilled nursing tasks being performed during respite.

11. Key Contacts and Resources

Prospective providers should utilize state resources and MCO provider relations departments to navigate the certification and contracting processes.

Maintaining direct contact with the DQA and ForwardHealth help desks is essential for resolving application bottlenecks.

• DHS Division of Quality Assurance (DQA): Licensing requirements and survey information (https://www.dhs.wisconsin.gov/dqa/index.htm).
• ForwardHealth Provider Portal: Medicaid enrollment and fee-for-service billing (https://www.forwardhealth.wi.gov).
• Wisconsin Department of Safety and Professional Services (DSPS): Nursing license verification (https://dsps.wi.gov).
• IRIS Program Information: Self-directed waiver guidelines (https://www.dhs.wisconsin.gov/iris/index.htm).
• Wisconsin Online Record Check System (WORCS): Background checks (https://recordcheck.doj.wi.gov).
• My Choice Wisconsin: Example of a regional Family Care MCO for contracting (https://mychoicewi.org).

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