District of Columbia - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The District of Columbia Department of Health Care Finance (DHCF) funds Skilled Nursing Services through the Elderly and Physical Disabilities (EPD) Waiver and the Individual and Family Support (IFS) Waiver, requiring providers to hold a Home Care Agency (HCA) license from DC Health. RN and LPN services delivered in the home under physician orders encompass assessments, medication administration, and skilled treatments for waiver participants.

Prospective providers must submit a formal Letter of Intent (LOI) to the DHCF Long Term Care Administration (LTCA) and attend a mandatory Provider Enrollment Information Session before gaining access to the Maximus Provider Data Management System (PDMS) application. Agencies must also maintain a physical operating office within the District of Columbia staffed eight hours per day, Monday through Friday, to qualify for HCA licensure.

1. Service Definition and Scope

Skilled Nursing Services in DC Medicaid HCBS waivers provide complex medical care in the participant's home that exceeds the scope of personal care aides. Services are delivered by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) under the direct order of a physician.

The service includes comprehensive nursing assessments, medication administration, wound care, and other skilled treatments defined in the participant's Person-Centered Service Plan.

• Service Components: Assessment, medication administration, wound care, and intravenous therapy.
• Supervision: LPNs must be supervised by an RN.
• Plan of Care: Must be approved and signed by a physician within 30 days of the start of care.
• Coordination: Agencies providing multiple skilled services must document care coordination in the clinical record.

2. Regulatory and Oversight Agencies

Multiple District agencies oversee the licensure, enrollment, and operation of Skilled Nursing providers. DC Health handles facility licensure, while DHCF and DDS manage waiver operations and Medicaid enrollment.

Providers must maintain compliance with the rules of both the licensing body and the specific waiver operating agency.

• Licensing Authority: DC Health Health Regulation and Licensing Administration (HRLA) (https://dchealth.dc.gov)
• Medicaid Authority: Department of Health Care Finance (DHCF) (https://dhcf.dc.gov)
• IDD/IFS Waiver Operating Agency: Department on Disability Services (DDS) (https://dds.dc.gov)
• Enrollment Vendor: Maximus Provider Data Management System (PDMS) (https://www.dcpdms.com)

3. Gatekeeping Prerequisites: Who Can Even Apply

DC imposes strict sequencing and physical presence requirements before a Medicaid application is accepted. Providers cannot simply submit an enrollment application; they must pass through DHCF's readiness review process.

The physical office requirement and the LOI process act as the primary structural preconditions for entering the DC Medicaid HCBS market.

• Physical Office Mandate: Must maintain an operating office within the District of Columbia, staffed eight hours per day, Monday through Friday (22-B DCMR § 3900.5).
• Letter of Intent (LOI): Must submit an LOI to the DHCF Long Term Care Administration (LTCA) at [email protected] detailing readiness and service scope.
• Mandatory Information Session: Applicants must attend a DHCF Provider Enrollment Information Session after LOI approval.
• Application Window: The Maximus PDMS application must be submitted within 90 days of attending the information session.

4. Licensure and Certification Requirements

Providers must obtain a Home Care Agency (HCA) license from DC Health under 22-B DCMR Chapter 39. The licensure process involves policy reviews and an on-site survey.

The agency must explicitly be licensed to provide skilled nursing services, as HCAs can also be licensed solely for personal care or therapy.

• License Type: Home Care Agency (HCA) License.
• Regulatory Citation: 22-B DCMR Chapter 39.
• Service Designation: The HCA must be licensed to provide skilled nursing as one of its core services (22-B DCMR § 3900.4).
• Medicare/Medicaid Compliance: HCAs serving DC Medicaid patients must comply with all applicable conditions of participation for the program.

5. Medicaid Provider Enrollment

After obtaining the HCA license and passing the DHCF LOI stage, providers enroll via the Maximus PDMS portal. The process requires extensive corporate and financial disclosures.

Maximus acts as the initial clearinghouse, ensuring all required documents are present before DHCF conducts the final programmatic review.

• Enrollment Portal: Maximus Provider Data Management System (PDMS).
• Initial Review: Maximus conducts an initial document review before forwarding the application to DHCF.
• NPI Requirement: Must obtain a Type 2 National Provider Identifier (NPI) specific to the agency.
• Corporate Proof: Must submit proof of incorporation in the District of Columbia.

6. Staffing, Training and Background Checks

DC Health regulations mandate strict personnel files and credentialing for all skilled nursing staff. Nurses must hold active DC licenses.

Agencies must verify credentials prior to patient contact and maintain ongoing documentation of health status and training.

• RN/LPN Licensure: Must hold an active, unencumbered license from the DC Board of Nursing.
• CPR Certification: Documentation of current CPR certification is required in the personnel file.
• Health Certification: Staff must have health clearance, including communicable disease screening.
• Identification: Employees must present valid agency identification prior to entering a patient's home.

7. Documentation, Policies and Records

Clinical records must be maintained for every patient, detailing admissions, physician orders, and ongoing assessments. 22-B DCMR § 3909 outlines specific record contents.

Agencies must also provide written disclosures to patients regarding their rights, billing procedures, and complaint mechanisms.

• Physician Orders: Must be signed within 30 days; telephone orders must be immediately reduced to writing.
• Clinical Notes: Progress and summary notes must be signed and dated by the professional staff.
• Medication Sheet: Required component of the patient's clinical record.
• Patient Rights: Must provide written notice of services, billing procedures, and the DC Health Home Health Hotline number.

8. Billing, Rates and Claims

Skilled Nursing Services are billed to the DC Medicaid Management Information System (MMIS) using specific HCPCS codes. Rates are established by DHCF and published in the Medicaid fee schedule.

Providers must ensure services are prior-authorized in the participant's Person-Centered Service Plan before rendering care.

• Billing System: DC MMIS.
• Third Party Liability (TPL): Providers must verify and bill other health insurance before billing Medicaid.
• Prior Authorization: Services must be authorized in the participant's approved Person-Centered Service Plan.
• Unit of Service: Typically billed in 15-minute increments or per-visit rates as defined by the specific waiver appendix.

9. Approval Sequence and Timeline

The end-to-end process involves DC Health licensure followed by DHCF Medicaid enrollment. The timeline is heavily dependent on survey readiness and DHCF review cycles.

Providers must carefully sequence their physical office setup, licensure application, and DHCF LOI submission to avoid delays.

• Step 1: Establish a staffed physical office in the District of Columbia.
• Step 2: Apply for and obtain the Home Care Agency (HCA) license from DC Health.
• Step 3: Submit Letter of Intent (LOI) to DHCF LTCA.
• Step 4: Attend the mandatory DHCF Provider Enrollment Information Session.
• Step 5: Submit the Maximus PDMS application within 90 days of the information session.

10. Common Denials and Survey Findings

Applications and surveys frequently fail due to administrative omissions or failure to meet the physical office requirements. DC Health and DHCF strictly enforce these structural rules.

Missing the strict submission windows during the DHCF enrollment process will result in the application being rejected.

• Office Staffing: Failure to maintain the DC office staffed eight hours per day, M-F.
• Timeline Expiration: Missing the 90-day window to submit the Maximus application after the information session.
• Incomplete LOI: Failing to demonstrate knowledge of the relationship between State Plan and Waiver services in the LOI.
• Unsigned Orders: Physician orders or plans of care not signed within the 30-day regulatory window.

11. Key Contacts and Resources

Providers must interact with multiple portals and divisions to maintain compliance. Bookmarking these official resources is essential.

Always refer to the official DC government websites for the most current forms, fee schedules, and regulatory updates.

• DC Health HRLA: https://dchealth.dc.gov
• DHCF Medicaid Provider Enrollment: https://dhcf.dc.gov/page/long-term-care-services-and-supports-provider-enrollment-process
• Maximus PDMS Portal: https://www.dcpdms.com
• DDS Waiver Information: https://dds.dc.gov/page/hcbs-waiver-service-description

See all District of Columbia services · District of Columbia Medicaid consulting · book a consultation.