District of Columbia - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-15

In the District of Columbia, Assisted Living Residences (ALRs) are licensed congregate care settings that combine housing, 24-hour supervision, and personal care assistance. For Medicaid reimbursement, these services are covered under the Elderly and Persons with Physical Disabilities (EPD) Waiver, which funds the service and care components of the facility while room and board are covered privately or through state supplements.

The single biggest structural barrier to entry in the District of Columbia is the dual-gatekeeping requirement: a provider cannot initiate a Medicaid enrollment application until they have first secured a finalized ALR license from DC Health and subsequently submitted a Letter of Intent (LOI) to the Department of Health Care Finance (DHCF) Long Term Care Administration to obtain a formal Pre-Approval Notice. Without this specific DHCF pre-approval, the enrollment portal will automatically reject the application.

1. Service Definition and Scope

Assisted Living Residences in the District of Columbia provide a home-like, non-institutional setting for individuals who require assistance with activities of daily living but do not need 24-hour skilled nursing care. The philosophy of the DC ALR model is to enhance a resident's ability to age in place while ensuring all scheduled and unscheduled needs are met.

Under the EPD Waiver, Medicaid covers the costs of personal care, homemaker services, chore services, medication administration, and 24-hour on-site response. Medicaid HCBS funds strictly prohibit payment for room and board, meaning facilities must separate service costs from housing costs in their financial agreements.

• Statutory Authority: Regulated under the Assisted Living Residence Regulatory (ALR) Act of 2000 (D.C. Official Code 44-101.01 et seq.).
• Medicaid Authority: Covered under the District's 1915(c) Elderly and Persons with Physical Disabilities (EPD) Waiver.
• Covered Services: Personal care, medication management, chore services, and 24-hour supervision.
• Excluded Costs: Room and board, which must be paid via private funds, SSI, or the Optional State Supplement Payment Program (OSSP).
• Setting Requirements: Must fully comply with the CMS HCBS Final Rule, ensuring community integration, lockable doors, and choice of roommates.

2. Regulatory and Oversight Agencies

Oversight of Assisted Living Residences in the District is bifurcated between health regulation and Medicaid finance. The physical facility, life safety, and baseline care standards are regulated by the local health department, while waiver compliance and reimbursement are managed by the Medicaid agency.

Providers must maintain active standing with both agencies, as well as the District's business and tax regulatory bodies, to operate and bill successfully.

• Licensing Agency: DC Health (DOH), Health Regulation and Licensing Administration (HRLA).
• Licensing Division: Community Residence Facilities Branch (CRF) within the Child and Residential Care Facilities Division.
• Medicaid Authority: Department of Health Care Finance (DHCF), Long Term Care Administration (LTCA).
• Enrollment Vendor: Maximus, which manages the District of Columbia Provider Data Management System (DCPDMS).
• Business Regulator: Department of Licensing and Consumer Protection (DLCP), responsible for issuing the Certificate of Occupancy.

3. Gatekeeping Prerequisites: Who Can Even Apply

The District of Columbia imposes strict, sequential prerequisites that block an applicant from entering the Medicaid enrollment queue. A provider cannot simply apply to be a Medicaid ALR; they must first secure physical location approvals, obtain an ALR license, and pass DHCF's pre-approval phase.

Failure to obtain the exact pre-approval documentation from DHCF LTCA will result in an immediate rejection of any application submitted to the Medicaid enrollment portal.

• DHCF Pre-Approval: Applicants must submit a Letter of Intent (LOI) to dhcf.epdproviderenrollment@dc.gov and receive a formal Pre-approval notice from DHCF LTCA before accessing DCPDMS.
• Certificate of Occupancy: Required from DLCP specifically for the ALR use-case before DC Health will conduct a pre-licensure inspection.
• Clean Hands Certification: Mandatory clearance from the DC Office of Tax and Revenue (OTR) proving the entity owes no debts over $100 to the District.
• Fire Inspection Letter: Must pass a DC Fire and EMS Department inspection prior to submitting the ALR application package to DC Health.
• Proof of Solvency: Required by DC Health during the pre-licensure inspection pursuant to D.C. Code 44-101.01.
• In-District Location: The primary service address must be physically located within the District of Columbia; out-of-state facilities cannot enroll for this specific EPD Waiver service.

4. Licensure and Certification Requirements

ALR licensure requires a comprehensive application package submitted to the CRF Branch of DC Health. The process is heavily focused on physical plant safety, operational policies, and resident rights.

Once the paper application is accepted, the Mayor (via DC Health inspectors) conducts an initial pre-licensure inspection of the premises and records. Passing this inspection results in an initial license.

• Application Package: Must include the License Application, Clean Hands Certification, Insurance Verification Request, and Fire Inspection Letter.
• Pre-Licensure Inspection: DC Health reviews the physical plant, disaster plan, staffing plan, and resident agreements on-site.
• Initial License Duration: Approved unconditionally for 12 months upon passing the pre-licensure inspection.
• Insurance Minimums: Must provide proof of general and professional liability insurance meeting DC Medicaid and HRLA standards.
• HCBS Settings Compliance: Must document compliance with the CMS HCBS Final Rule, including person-centered Individualized Support Plans (ISPs) and Human Rights Committee (HRC) reviews for any restrictions.
• Program Statement: Must submit a detailed program statement outlining the maximum number of residents to be served and the scope of care.

5. Medicaid Provider Enrollment

After obtaining the ALR license and DHCF LTCA pre-approval, providers enroll via the District of Columbia Provider Data Management System (DCPDMS). Maximus processes these applications on behalf of DHCF.

The enrollment process requires uploading all prerequisite approvals and linking the facility's National Provider Identifier (NPI) to the specific EPD Waiver taxonomy.

• Enrollment Portal: District of Columbia Provider Data Management System (DCPDMS), managed by Maximus.
• Application Type: Must select the EPD-Waiver provider application track.
• Required Uploads: DC Health ALR License, DHCF Pre-approval notice, W-9, and NPI verification.
• NPI Requirement: Must obtain a Type 2 (Organizational) National Provider Identifier (NPI) with taxonomy code 310400000X (Assisted Living Facility).
• Application Fee: Subject to the ACA institutional provider application fee unless proof of payment to Medicare or another state Medicaid program is provided.
• Revalidation: Providers must revalidate their Medicaid enrollment through DCPDMS every three to five years as directed by DHCF.

6. Staffing, Training and Background Checks

ALRs must maintain sufficient staff to meet the 24-hour scheduled and unscheduled needs of residents. The District requires specific local certifications for direct care and medication administration staff.

All staff must pass strict DC-specific background checks before having direct contact with residents.

• Administrator: Must oversee day-to-day operations and meet DC Health qualifications for ALR Directors, including specific training in geriatric care and facility management.
• Direct Care Staff: Must be DC-certified Home Health Aides (HHAs) or Certified Nursing Assistants (CNAs).
• Medication Administration: Handled by Licensed Nurses (RN/LPN) or Trained Medication Employees (TMEs) who hold active certification in the District.
• Background Checks: Mandatory criminal background checks via the DC Metropolitan Police Department (MPD) and federal databases for all direct care staff.
• Staffing Plan: Must be submitted during the pre-licensure inspection detailing ratios, 24-hour coverage, and emergency backup protocols.
• First Aid/CPR: All direct care staff must maintain current CPR and First Aid certifications.

7. Documentation, Policies and Records

DC Code 44-101.01 mandates that specific operational policies be available during the pre-licensure inspection and maintained continuously. Recordkeeping must align with both HRLA health standards and DHCF Medicaid waiver rules.

Facilities are heavily scrutinized on their financial agreements and how they manage resident funds, ensuring transparency between Medicaid-covered services and private room and board costs.

• Individual Service Plan (ISP): Policy and procedures for developing person-centered ISPs for every resident, updated annually or upon a change in condition.
• Resident Agreements: Must maintain both financial and nonfinancial resident agreements on file, clearly delineating costs.
• Funds Management: Documented resident funds management system to protect consumer personal resources and prevent commingling of funds.
• Medication Management System: Written protocols for prescribing, storing, and administering medications, including TME oversight.
• Discharge/Transfer Policies: Strict adherence to DC regulations regarding involuntary discharge, requiring a 30-day written notice and safe discharge planning.
• Disaster Plan: Comprehensive emergency preparedness plan tailored to the physical location of the ALR.

8. Billing, Rates and Claims

ALR services under the EPD Waiver are billed to the DC Medicaid MMIS. Providers must strictly separate Medicaid-billable service costs from non-billable room and board costs.

Because housing costs in DC are high, many facilities utilize state supplement programs to help residents afford the room and board portion of their stay.

• Billing System: Claims are submitted through the DC Medicaid MMIS web portal.
• Procedure Code: Typically billed using T2031 (Assisted living waiver, per diem).
• Room and Board: Billed privately to the resident or subsidized via the Optional State Supplement Payment Program (OSSP).
• Prior Authorization: Services must be authorized in the resident's ISP and approved by DHCF or its designated utilization management vendor before billing.
• Timely Filing: Claims must generally be submitted within 365 days from the date of service.
• Electronic Visit Verification (EVV): While primarily for home health, ALRs must verify DHCF requirements for shift documentation and attendance tracking.

9. Approval Sequence and Timeline

The end-to-end process for becoming a Medicaid ALR in DC is lengthy due to sequential dependencies. Facility build-out and local zoning approvals must precede DC Health licensure, which in turn precedes DHCF Medicaid enrollment.

Providers should expect the entire process, from securing a building to billing Medicaid, to take 9 to 18 months.

• Step 1: Local Approvals: Obtain Certificate of Occupancy from DLCP and Fire Inspection Letter from DC Fire and EMS.
• Step 2: DC Health Licensure: Submit ALR application to CRF Branch and undergo the pre-licensure inspection (3-6 months).
• Step 3: DHCF Pre-Approval: Submit Letter of Intent to LTCA and receive formal pre-approval notice (30-60 days).
• Step 4: Medicaid Enrollment: Submit application via DCPDMS; Maximus processes the credentialing (90-120 days).
• Step 5: HCBS Settings Review: DHCF verifies compliance with community integration standards before final activation.
• Step 6: Contracting: If serving managed care populations, execute contracts with DC Medicaid Managed Care Organizations (MCOs).

10. Common Denials and Survey Findings

Applications and surveys frequently fail due to incomplete physical plant requirements or failure to adhere to the CMS HCBS Final Rule. DC Health and DHCF conduct rigorous reviews of both the facility and the administrative policies.

Attempting to bypass the sequential gatekeeping steps is the most common reason for administrative denial during the enrollment phase.

• Premature Medicaid Application: Applying in DCPDMS without the DHCF LTCA Pre-approval notice results in immediate rejection.
• HCBS Settings Violations: Failing to provide lockable doors, choice of roommates, or unrestricted access to food and visitors.
• Incomplete Clean Hands: Outstanding tax liabilities with the DC OTR blocking the licensure application.
• Staff Credential Lapses: Utilizing HHAs or TMEs whose DC certifications have expired or who lack proper MPD background clearances.
• Medication Errors: Survey citations for improper storage, labeling, or administration of medications by uncertified staff.
• Commingling Funds: Failing to maintain a compliant resident funds management system separate from facility operating accounts.

11. Key Contacts and Resources

Providers must interact with multiple District agencies to maintain compliance. Keeping direct contact with the specific branches handling ALRs and EPD Waivers is essential for navigating the bureaucracy.

Utilize the official DC government portals for the most up-to-date forms, fee schedules, and regulatory guidance.

• DC Health HRLA (CRF Branch): Regulates ALR licensure and conducts pre-licensure inspections.
• DHCF Long Term Care Administration (LTCA): Issues EPD Waiver pre-approvals via dhcf.epdproviderenrollment@dc.gov.
• Maximus / DCPDMS: Manages the Medicaid provider enrollment portal and credentialing process.
• DC Department of Licensing and Consumer Protection (DLCP): Issues Certificates of Occupancy and basic business licenses.
• DC Office of Tax and Revenue (OTR): Issues the mandatory Clean Hands Certification.
• DC Fire and EMS Department: Conducts mandatory life safety and fire inspections for the application package.

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