Idaho - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The Idaho Department of Health and Welfare (IDHW) Bureau of Facility Standards requires Home Health Agencies to obtain federal Medicare certification to participate in the state's Medicaid program under IDAPA 16.03.09.725. Effective July 1, 2025, under the Streamlined Facilities Licensing and Inspection Act, Medicare-certified Home Health Agencies are no longer required to hold a separate state license in Idaho, shifting the primary structural gate entirely to the federal Centers for Medicare and Medicaid Services (CMS) initial certification survey process.

Agencies must first secure Medicare certification through a CMS-approved accrediting organization or state survey before Gainwell Technologies will process their Idaho Medicaid provider enrollment application. The service delivers intermittent skilled nursing and at least one therapeutic service, such as physical therapy or home health aide services, directly to Medicaid members in their places of residence.

1. Service Definition and Scope

In Idaho, a Home Health Agency (HHA) provides skilled nursing services by licensed nurses and at least one other therapeutic service in the patient's residence. These services are authorized under IDAPA 16.03.07 and IDAPA 16.03.09.725 for Medicaid basic plan benefits.

The scope of services must be ordered by a physician and delivered on an intermittent basis. Entities whose sole payor source is the Department of Labor are exempt from federal Conditions of Participation but must meet specific accreditation requirements.

• Skilled Nursing: services provided directly by a licensed nurse to promote, maintain, or restore health.
• Therapeutic Services: includes physical therapy, speech-language pathology, occupational therapy, medical social services, or home health aide services.
• Setting: services must be delivered in the place of residence used as the patient's home.
• Physician Orders: all care must be delivered under a physician-ordered plan of care.
• Exemptions: entities serving only the Energy Workers Program under the Department of Labor have distinct accreditation paths.

2. Regulatory and Oversight Agencies

The Idaho Department of Health and Welfare (IDHW) oversees both the facility standards and the Medicaid program. The Bureau of Facility Standards (BFS) manages the Medicare certification survey process and state licensure (until the July 2025 sunset).

Medicaid enrollment and claims processing are administered by Gainwell Technologies, which operates the state's Medicaid Management Information System (MMIS).

• Idaho Department of Health and Welfare (IDHW): administers the Medicaid program and sets policy rules at [healthandwelfare.idaho.gov](https://healthandwelfare.idaho.gov/).
• Bureau of Facility Standards (BFS): conducts initial surveys and processes CMS certification applications at [facilitystandards.idaho.gov](https://facilitystandards.idaho.gov/).
• Gainwell Technologies: operates the Idaho Medicaid Health PAS OnLine portal for provider enrollment and claims at [idmedicaid.com](https://www.idmedicaid.com/).
• Centers for Medicare and Medicaid Services (CMS): issues the federal certification required for Idaho Medicaid participation at [cms.gov](https://www.cms.gov/).

3. Gatekeeping Prerequisites: Who Can Even Apply

Idaho Medicaid strictly requires Medicare certification as a precondition for Home Health Agency enrollment under IDAPA 16.03.09.725. An applicant cannot enroll in Idaho Medicaid as a Home Health Agency without first securing this federal certification.

Additionally, agencies must establish a Trading Partner Account with Gainwell Technologies before accessing the electronic Provider Enrollment application. There are currently no Certificate of Need (CON) laws or county sponsorship requirements blocking home health market entry in Idaho.

• Medicare Certification: mandatory prerequisite under IDAPA 16.03.09.725; loss of Medicare certification automatically terminates Medicaid provider status.
• Trading Partner Account: required registration step on the Gainwell portal before an enrollment application can be initiated.
• National Provider Identifier (NPI): agencies must obtain an organizational NPI from NPPES prior to applying.
• Licensure Sunset: effective July 1, 2025, state licensure is no longer a prerequisite for Medicare-certified agencies due to the Streamlined Facilities Licensing and Inspection Act.

4. Licensure and Certification Requirements

Prior to July 1, 2025, agencies must apply for a state license through the IDHW Bureau of Facility Standards. After this date, the state will no longer issue new home health licenses to Medicare-certified agencies.

To achieve Medicare certification, agencies must submit the CMS 1561 Form (Health Insurance Benefits Agreement) and undergo an initial survey by the state agency or an approved accrediting organization to verify compliance with federal Conditions of Participation (42 CFR Part 484).

• CMS 1561 Form: Health Insurance Benefits Agreement required for Medicare certification.
• Initial Survey: must be completed by BFS or an accrediting organization to verify compliance with 42 CFR Part 484.
• State License Application: required only until July 1, 2025, submitted to the Bureau of Facility Standards.
• Name Change Notice: agencies must notify the Department in writing at least 30 days prior to any proposed name change.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed through the Idaho Medicaid Health PAS OnLine portal managed by Gainwell Technologies. Enrollment is not retroactive and becomes effective only after the application is approved and the initial survey is completed.

Providers receive a unique seven-digit Idaho Medicaid provider number upon approval. This state-specific identifier is required for billing and is distinct from the federal NPI.

• Enrollment Portal: applications are submitted electronically via [idmedicaid.com](https://www.idmedicaid.com/).
• Effective Date: reimbursement is not retroactive; the requested effective date must be covered by the submitted Medicare certification.
• Provider Agreement: successful enrollment results in a signed provider agreement with IDHW.
• Seven-Digit Provider ID: state-assigned number issued by Gainwell upon enrollment approval.

6. Staffing, Training and Background Checks

Home Health Agencies must employ qualified personnel sufficient in number and training to meet the needs of their patient census. Skilled nursing must be provided by nurses licensed to practice in Idaho.

All staff providing direct care must pass comprehensive background checks as mandated by IDHW. Credentialing for individual practitioners is handled separately by managed care plans if the agency participates in specific networks.

• Skilled Nurses: must hold current, valid nursing licenses recognized by the Idaho Board of Nursing.
• Therapists: physical, occupational, and speech therapists must be licensed in Idaho.
• Background Checks: mandatory criminal history and exclusion screening (OIG/SAM.gov) for all direct-care staff.
• Administrator: must meet federal Conditions of Participation qualifications for managing agency operations.

7. Documentation, Policies and Records

Agencies must maintain comprehensive clinical records for every patient, including the physician-ordered plan of care, nursing notes, and therapy evaluations. Idaho mandates the use of Electronic Visit Verification (EVV) for home health services delivered in the member's home.

Failure to submit an annual report or providing no home health services in a calendar year is considered a voluntary withdrawal of the agency's status under IDAPA 16.03.07.

• Plan of Care: must be ordered by a physician and updated according to federal certification standards.
• Electronic Visit Verification (EVV): mandatory data capture for in-home visits, matching the member, service, times, and caregiver.
• Annual Report: required submission to maintain active status; failure results in voluntary withdrawal.
• Clinical Records: must be retained and safeguarded in compliance with HIPAA and state regulations.

8. Billing, Rates and Claims

Idaho Medicaid reimburses home health services at the lesser of the provider's billed amount (usual and customary charge) or the maximum allowable fee established by the IDHW Division of Medicaid. Claims must be submitted within 365 days of the date of service.

Providers must bill their usual and customary charge applied to non-Medicaid patients. Zero-priced codes on the fee schedule indicate manual pricing or invoice-based reimbursement, not a lack of coverage.

• Timely Filing: claims must be submitted to Gainwell within 12 months (365 days) of the service date.
• Reimbursement Rate: lesser of the billed amount or the IDHW maximum allowable fee.
• Usual and Customary Charge: providers must bill the rate they charge non-Medicaid patients.
• Medicare Crossovers: exceptions to the 365-day rule exist for Medicare crossover claims, allowing 6 months from the Medicare EOB date.

9. Approval Sequence and Timeline

The approval sequence begins with obtaining an NPI and submitting the CMS 1561 Form to the Bureau of Facility Standards. The agency must then pass the initial Medicare certification survey.

Once certified, the agency registers for a Trading Partner Account on the Gainwell portal and submits the Medicaid enrollment application. The entire process from survey readiness to Medicaid approval typically spans several months.

• Step 1: obtain an organizational NPI and prepare for Medicare Conditions of Participation.
• Step 2: submit CMS 1561 Form and request an initial survey from BFS or an accrediting body.
• Step 3: complete the initial survey and receive federal Medicare certification.
• Step 4: register for a Trading Partner Account at [idmedicaid.com](https://www.idmedicaid.com/).
• Step 5: submit the Medicaid provider enrollment application via Gainwell.

10. Common Denials and Survey Findings

Medicaid enrollment applications are frequently delayed or denied if the agency applies before securing Medicare certification or if the requested effective date precedes the certification date. Claims are commonly denied due to EVV data mismatches.

During initial surveys, agencies often face deficiencies related to incomplete physician orders, inadequate clinical documentation, or failure to demonstrate sufficient qualified personnel.

• Premature Application: applying for Medicaid enrollment before Medicare certification is finalized.
• EVV Mismatches: claims denied because EVV data does not match the billed member, service, or times.
• Unenrolled Referring Physicians: claims denied if the referring physician is not enrolled in Idaho Medicaid.
• Personnel Deficiencies: survey findings citing a lack of staff sufficient in number or qualifications.

11. Key Contacts and Resources

Providers should utilize the official IDHW and Gainwell portals for the most current manuals, fee schedules, and enrollment guides. The Bureau of Facility Standards handles all inquiries related to the Medicare certification survey process.

The CMS State Operations Manual (SOM) Chapter 2 provides the federal guidance for home health certification.

• Bureau of Facility Standards: (208) 334-6626 or [email protected] for certification inquiries.
• Idaho Medicaid Provider Portal: [idmedicaid.com](https://www.idmedicaid.com/) for enrollment and claims.
• IDHW Provider Enrollment Info: [healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/provider-enrollment](https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/provider-enrollment).
• CMS State Operations Manual: [cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984) for survey regulations.

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