Virginia - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Virginia Medicaid reimburses in-home skilled nursing services primarily through the Commonwealth Coordinated Care Plus (CCC Plus) and Developmental Disabilities (DD) waivers, requiring providers to first obtain a Home Care Organization (HCO) license from the Virginia Department of Health (VDH). The service delivers acute, chronic, or continuous nursing care by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) directly in a waiver member's home under the prescriptive orders of a physician.

Before a provider can actively bill for the vast majority of these services, they must secure network contracts with the Managed Care Organizations (MCOs) that administer the CCC Plus program. While Virginia does not restrict the number of HCO licenses issued through a Certificate of Need (CON) process for non-Medicare skilled nursing, MCO credentialing panels can be restricted based on network adequacy, serving as a structural gate to operational viability.

1. Service Definition and Scope

Skilled Nursing Services in Virginia Medicaid HCBS provide physician-ordered, complex medical care delivered in the individual's primary residence. Under the CCC Plus, Community Living (CL), and Family and Individual Support (FIS) waivers, these services are authorized when the individual requires ongoing nursing assessment, medication administration via specialized routes (e.g., intravenous or tube feeding), wound care, or ventilator/tracheostomy management that exceeds the scope of personal care or home health aide services.

The scope strictly prohibits the provision of nursing services for purely delegateable tasks that a trained personal care aide or family member could safely perform. Nursing hours are prior-authorized based on a detailed medical necessity assessment and a physician-approved Plan of Care.

• Service Setting: Member's primary residence or community settings outlined in the waiver; explicitly excludes hospitals, nursing facilities, or ICF/IIDs.
• Authorized Personnel: Must be delivered by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) practicing under the supervision of an RN.
• Order Requirement: Requires a current, signed physician's order and a Plan of Care updated at least every 60 days.
• Waiver Authorities: Primarily funded via the CCC Plus Waiver and the Developmental Disabilities (DD) waivers (CL and FIS).
• Exclusions: Cannot be billed concurrently with Hospice or standard Medicare Home Health for the same specific skilled task during the same hours.

2. Regulatory and Oversight Agencies

Licensure, enrollment, and clinical oversight are divided between the state's health department and its Medicaid agency.

• Virginia Department of Health (VDH), Office of Licensure and Certification (OLC): Issues the foundational Home Care Organization (HCO) license required to operate and conducts unannounced health and safety compliance surveys. (https://www.vdh.virginia.gov/licensure-and-certification/)
• Department of Medical Assistance Services (DMAS): The state Medicaid agency that sets HCBS waiver policy, defines skilled nursing service rules, and manages the fee-for-service payment system. (https://www.dmas.virginia.gov/)
• Virginia Medicaid Enterprise System (MES): The centralized portal for Medicaid provider enrollment, revalidation, and fee-for-service claims submission. (https://vamedicaid.dmas.virginia.gov/)
• Virginia Department of Health Professions (DHP), Board of Nursing: Licenses and disciplines the RNs and LPNs delivering the direct care. (https://www.dhp.virginia.gov/Boards/Nursing/)
• Managed Care Organizations (MCOs): Entities such as Anthem HealthKeepers Plus, Sentara Community Plan, and UnitedHealthcare Community Plan that manage the CCC Plus network, authorize hours, and process most claims. (https://www.dmas.virginia.gov/for-providers/managed-care/ccc-plus/)

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia does not require a Certificate of Need (CON) for standard state-licensed Home Care Organizations providing Medicaid waiver skilled nursing. However, strict sequential prerequisites dictate the application flow.

• Licensure Prerequisite: A completed, unencumbered VDH Home Care Organization (HCO) license or Medicare Home Health Agency (HHA) certification is a hard prerequisite; DMAS will not accept a provider enrollment application without it.
• MCO Network Adequacy Closures: Because the CCC Plus waiver covers the vast majority of medical HCBS nursing, providers must contract with the state's contracted MCOs. MCOs may close their skilled nursing networks to new providers if they determine they have adequate capacity in a specific region, blocking newly licensed providers from taking CCC Plus members.
• Physical Office Requirement: VDH regulations mandate that the HCO maintain a physical business office located within the Commonwealth of Virginia or within 50 miles of the state line, equipped to securely store records and host surveyors.
• Administrator Qualifications: The agency must designate an Administrator who meets 12VAC5-381-170 requirements, which includes specific management experience in a health care delivery system.
• Liability Insurance: Proof of a minimum of $500,000 in malpractice and liability insurance must be secured prior to licensure application.

4. Licensure and Certification Requirements

To legally provide skilled nursing in the home, the entity must be licensed by VDH OLC as a Home Care Organization under the statutory authority of Code of Virginia 32.1-162.9.

The licensure process requires the submission of a comprehensive application packet, policies and procedures for review, and passing an initial on-site survey.

• Governing Regulation: 12VAC5-381 (Regulations for the Licensure of Home Care Organizations).
• Application Form: VDH OLC Application for Licensure as a Home Care Organization detailing ownership, organizational structure, and service areas.
• Application Fee: $500 initial application fee submitted to VDH.
• Policy Review: Applicants must submit their entire operating policy manual, including infection control, emergency preparedness, and patient rights, for VDH desk review prior to the initial survey.
• Initial Survey: OLC conducts an initial on-site inspection of the administrative office and a review of employee files (and simulated or actual patient files) before issuing the permanent license.
• License Renewal: HCO licenses are valid for one year and must be renewed annually with a $500 fee.

5. Medicaid Provider Enrollment

Once licensed by VDH, the agency must enroll as a Medicaid provider through the DMAS Medicaid Enterprise System (MES) Provider Resources System (PRSS). Skilled nursing is typically enrolled under specific provider types tied to home health or waiver services.

Providers must enroll as typical billing providers, meaning they must possess an organizational National Provider Identifier (NPI) from the federal NPPES registry before initiating the PRSS application.

• Enrollment Portal: MES PRSS via the Virginia Medicaid web portal.
• Provider Type: Usually enrolls under Provider Type 087 (Home Care Organization) or a specific HCBS waiver nursing taxonomy, depending on the exact waiver targeted.
• Required Documentation: W-9, organizational NPI, VDH HCO license, and proof of general liability insurance.
• Application Fee: Subject to the federal Medicaid/Medicare application fee (approx. $709 for 2024), unless already paid to Medicare or another state's Medicaid program.
• Screening Risk Level: Classified as a High or Moderate risk provider type, requiring owners with 5% or more interest to undergo fingerprint-based criminal background checks during enrollment.
• MCO Credentialing: After DMAS approves the PRSS enrollment and issues a Virginia Medicaid ID, the provider must separately apply for credentialing and contracting with each CCC Plus MCO.

6. Staffing, Training and Background Checks

Agencies must ensure all clinical staff maintain active, unencumbered licenses with the Virginia Board of Nursing and comply with stringent background screening laws. Under Code of Virginia 32.1-162.9:1, stringent barrier crime laws apply to any compensated employee of an HCO.

Virginia requires clinical supervision protocols, meaning LPNs cannot practice independently and must be supervised by an RN.

• Nurse Licensure: RNs and LPNs must hold current Virginia licenses or multistate compact licenses recognized by the DHP.
• RN Supervision: An RN must conduct the initial nursing assessment, develop the nursing plan of care, and conduct supervisory visits for LPNs at least every 30 days.
• Criminal Background Checks: All direct care employees must clear a Virginia State Police criminal record check prior to employment.
• Barrier Crimes: Individuals convicted of barrier crimes listed in Code of Virginia 19.2-392.02 (including abuse, neglect, and severe felonies) are strictly prohibited from employment.
• Central Registry Search: A search of the Virginia Department of Social Services (VDSS) Child Protective Services (CPS) Central Registry is required if serving minors.
• Health Screening: TB screening must be completed for all direct care staff within 30 days of employment in accordance with VDH guidelines.

7. Documentation, Policies and Records

DMAS and VDH maintain strict documentation standards to justify the medical necessity of private duty or skilled nursing. The provider must maintain a comprehensive clinical record for each member.

Failure to maintain signed physician orders or to document exact clock hours of service delivery is a primary cause for Medicaid clawbacks in Virginia.

• Plan of Care (CMS-485 or DMAS-7): A comprehensive physician-signed plan of care detailing diagnoses, medications, treatments, frequency, and duration of nursing visits.
• Physician Orders: All medications and treatments administered must trace back to a current, signed physician order updated at least every 60 days.
• Nursing Assessments: An initial comprehensive RN assessment and ongoing nursing assessments (typically every 30-60 days) documenting the member's clinical status.
• Visit Notes: Daily clinical notes detailing vital signs, treatments performed, patient response, and exact in/out times signed by the nurse.
• Record Retention: Clinical records must be retained for a minimum of six years from the date of discharge (or longer for minors, generally until age 21).
• EVV Exemption: While Personal Care requires Electronic Visit Verification (EVV), pure skilled nursing visits generally do not fall under the 21st Century Cures Act EVV mandate in Virginia, though exact clock time must still be recorded.

8. Billing, Rates and Claims

Reimbursement for waiver skilled nursing is based on 15-minute increments or per-visit codes, depending on the specific waiver and MCO authorization. Rates are published on the DMAS fee schedule and vary depending on whether the care is delivered by an RN or an LPN.

Because most skilled nursing is carved into managed care via CCC Plus, claims are predominantly submitted to the MCOs through their respective clearinghouses (e.g., Availity) rather than directly to DMAS fee-for-service.

• Procedure Codes: Common codes include T1002 (RN services, up to 15 minutes) and T1003 (LPN services, up to 15 minutes). Congregate or continuous care may use modified codes.
• Prior Authorization: 100% of waiver skilled nursing hours must be prior-authorized by the MCO or the state's FFS authorization contractor (Acentra Health).
• Rate Lookup: Providers check exact FFS rates via the DMAS MES portal under the Provider Fee Search tool; MCO rates are negotiated but typically align with or slightly exceed the DMAS floor.
• Claim Format: Billed on a CMS-1500 professional claim form or via the 837P electronic transaction.
• Timely Filing: FFS claims must be submitted within 365 days of the date of service; MCO timely filing limits are often much shorter (e.g., 90 or 120 days depending on the contract).
• Third-Party Liability (TPL): If the member has primary commercial insurance or Medicare that covers the specific skilled need (e.g., post-acute home health), the primary payer must be billed and a denial or payment received before Medicaid will pay as the payer of last resort.

9. Approval Sequence and Timeline

Becoming an operational, billing provider requires sequentially clearing VDH, DMAS, and MCO hurdles. The entire process from company formation to seeing the first CCC Plus member typically takes 6 to 9 months.

• Step 1: HCO Application (1-2 months): Submit the VDH OLC application, policies, and fee. OLC conducts a desk review of the policy manual.
• Step 2: VDH Initial Survey (1-2 months): OLC schedules and conducts the initial on-site administrative survey. If deficiencies are found, a Corrective Action Plan (CAP) must be submitted and approved.
• Step 3: License Issuance (2-4 weeks): VDH issues the HCO license after successful survey and CAP clearance.
• Step 4: DMAS PRSS Enrollment (30-60 days): Submit the Medicaid enrollment application via MES. Includes fingerprinting and federal fee processing.
• Step 5: MCO Credentialing (90-120 days): Submit credentialing and contracting packets to CCC Plus MCOs. Network capacity constraints can extend this timeline indefinitely if panels are closed.

10. Common Denials and Survey Findings

Applicants and existing providers frequently face delays or citations due to administrative oversights during the licensing phase and clinical documentation errors during post-payment audits.

• Incomplete Policy Manuals: VDH frequently delays initial licensure applications because the submitted policies do not address every specific code subsection of 12VAC5-381.
• Premature Medicaid Apps: DMAS immediately denies PRSS applications submitted before the final VDH HCO license certificate is physically issued and attached.
• Background Check Lapses: VDH surveyors frequently cite agencies for allowing staff to provide direct care before the Virginia State Police background check results are received in hand.
• Missing Signatures: DMAS and MCO auditors commonly recoup funds when the CMS-485 Plan of Care is missing the physician's dated signature prior to the start of the certification period.
• Supervisory Deficiencies: OLC citations for RNs failing to conduct and document the required 30-day supervisory visits for LPNs.

11. Key Contacts and Resources

The following resources provide official guidance, applications, and portals for skilled nursing providers in Virginia.

• Virginia Department of Health (VDH) Office of Licensure and Certification: Regulates and issues the HCO license. (https://www.vdh.virginia.gov/licensure-and-certification/)
• Virginia Medicaid Enterprise System (MES) Portal: Hub for DMAS provider enrollment (PRSS) and FFS claims. (https://vamedicaid.dmas.virginia.gov/)
• Department of Medical Assistance Services (DMAS) Provider Manuals: Official source for waiver manuals, including CCC Plus and DD waivers. (https://vamedicaid.dmas.virginia.gov/provider/manuals)
• Virginia Department of Health Professions (DHP) License Lookup: Used to verify RN and LPN credentials. (https://www.dhp.virginia.gov/Boards/Nursing/)
• Acentra Health (formerly Kepro): The FFS prior authorization and pre-admission screening contractor for Virginia Medicaid. (https://dmas.kepro.com/)
• CCC Plus Managed Care Program Information: DMAS directory of currently contracted MCOs for network credentialing. (https://www.dmas.virginia.gov/for-providers/managed-care/ccc-plus/)

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