Virginia - Transitional Assistance Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Virginia, Transitional Assistance Services are officially known as "Transition Services" and are covered under the state's Developmental Disability (DD) Waivers (Building Independence, Family and Individual Supports, and Community Living) as well as the Commonwealth Coordinated Care (CCC) Plus Waiver. This service provides up to $5,000 in one-time setup expenses—such as security deposits, essential furniture, and utility setup fees—for Medicaid members moving from an institutional setting (like a nursing facility or ICF/IID) into a private community residence.

The single biggest structural barrier to entry for this service in Virginia is that the state does not issue a standalone "Transition Services" facility or agency license. Instead, access is gatekept by provider type and fiscal capacity. To enroll, an applicant must typically already be an established Center for Independent Living (CIL), a Community Services Board (CSB), or an existing Medicaid-enrolled provider (such as a Case Management agency) that agrees to act as the fiscal agent. Providers must have the capital to purchase these transition items upfront and await Medicaid reimbursement, and they must secure a Home and Community-Based Services (HCBS) compliance letter from the Department of Medical Assistance Services (DMAS) before their enrollment application is even accepted.

1. Service Definition and Scope

Transition Services in Virginia are designed to eliminate the financial barriers that prevent Medicaid members from leaving institutional care. The service operates on a reimbursement model where the enrolled provider acts as a fiscal agent, purchasing necessary goods and services on behalf of the transitioning individual and then billing Medicaid for the exact costs.

The scope of allowable expenses is strictly defined by DMAS. It covers essential physical items and deposits required to establish a basic household, but explicitly excludes ongoing living expenses, luxury items, or services that are covered under other waiver categories.

• Service Name: Transition Services, available under the DD Waivers and the CCC Plus Waiver.
• Funding Limit: Capped at a maximum of $5,000 per person per lifetime transition.
• Eligible Settings: The member must be transitioning from an ICF/IID, nursing facility, or specialized care facility to a private home or apartment in the community.
• Covered Expenses: Security deposits, utility setup fees, essential furniture (beds, tables), window coverings, pest control, and moving fees.
• Excluded Expenses: Monthly rent, mortgage payments, food, recreational electronics (TVs, computers), and ongoing utility charges.
• Service Authorization: Requires prior authorization from the Support Coordinator via the Waiver Management System (WaMS) or the CCC Plus Managed Care Organization (MCO).

2. Regulatory and Oversight Agencies

The administration of Transition Services is split between the state's Medicaid authority and the behavioral health department. The Department of Medical Assistance Services (DMAS) (https://www.dmas.virginia.gov/) holds the ultimate authority over Medicaid funding, provider enrollment, and the CCC Plus Waiver.

The Department of Behavioral Health and Developmental Services (DBHDS) (https://dbhds.virginia.gov/) operates the DD Waivers on a day-to-day basis. DBHDS manages the Waiver Management System (WaMS) (https://www.wamsvirginia.org/), which is used for service authorizations and individual support planning.

• Virginia Department of Medical Assistance Services (DMAS): Administers the Medicaid program, oversees the CCC Plus Waiver, and manages provider enrollment (https://www.dmas.virginia.gov/).
• Department of Behavioral Health and Developmental Services (DBHDS): Operates the DD Waivers and oversees the Support Coordinators who draft the Transition Plans (https://dbhds.virginia.gov/).
• Medicaid Enterprise System (MES): The central DMAS portal for provider enrollment, credentialing, and fee-for-service claims processing (https://vamedicaid.dmas.virginia.gov/).
• Centers for Medicare & Medicaid Services (CMS): The federal agency that approves Virginia's 1915(c) waiver amendments and sets the overarching HCBS settings rules (https://www.medicaid.gov/).

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia does not utilize a Certificate of Need (CON) process for Transition Services, nor does it require a distinct direct-care license from the DBHDS Office of Licensing. However, there are strict structural preconditions that block general applicants from enrolling.

The primary gatekeeper is the requirement to be an established entity capable of acting as a fiscal agent, combined with mandatory HCBS settings compliance. A provider cannot simply apply to be a "Transition Services" agency without first meeting these foundational criteria.

• Provider Type Restriction: Applicants are typically restricted to established Centers for Independent Living (CILs), Community Services Boards (CSBs), or existing Medicaid-enrolled providers (like Case Management agencies) willing to act as fiscal agents.
• Fiscal Agent Capacity: The applicant must possess the financial reserves to purchase transition items (up to $5,000 per member) upfront out-of-pocket before seeking Medicaid reimbursement.
• HCBS Settings Compliance Letter: Applicants must complete the DMAS HCBS Settings Toolkit and obtain a formal compliance letter from DMAS prior to completing the DMAS enrollment application.
• No Standalone Licensure: The DBHDS Office of Licensing does not issue a distinct facility or agency license for Transition Services; access is granted purely through administrative Medicaid enrollment.
• MCO Network Contracting: For the CCC Plus Waiver, providers must successfully credential and contract with the designated Managed Care Organizations (MCOs) after DMAS enrollment to receive authorizations.

4. Licensure and Certification Requirements

Because Transition Services involve the procurement of goods and coordination of logistics rather than the provision of direct physical or medical care, standard DBHDS direct-care licensure is not required. Providers bypass the DBHDS Office of Licensing for this specific service.

Instead of a license, certification is achieved through business registration, obtaining standard healthcare identifiers, and proving compliance with federal Home and Community-Based Services (HCBS) settings regulations.

• DBHDS Licensure Exemption: Direct care licensure is not required for agencies acting solely as fiscal agents and coordinators for Transition Services.
• Business Registration: The entity must be registered and in good standing with the Virginia State Corporation Commission (SCC) to conduct business in the Commonwealth.
• National Provider Identifier (NPI): The agency must obtain a Type 2 (Organization) NPI from the National Plan and Provider Enumeration System (NPPES).
• HCBS Settings Toolkit: Providers must submit documentation proving they do not isolate individuals from the broader community, resulting in a DMAS HCBS compliance certification.
• Tax Identification: Must possess a valid Employer Identification Number (EIN) matching the SCC registration and NPI profile.

5. Medicaid Provider Enrollment

All prospective Transition Services providers must enroll directly with DMAS through the Medicaid Enterprise System (MES) Provider Resources System Solution (PRSS) portal. This system replaced the legacy VAMMIS system in 2022.

During enrollment, providers must sign the DMAS Provider Participation Agreement, legally binding them to state and federal Medicaid regulations. For DD Waiver services, enrollment in MES PRSS is sufficient for fee-for-service billing, but CCC Plus providers must take the additional step of MCO credentialing.

• Enrollment Portal: Applications must be submitted electronically through the MES PRSS Provider Portal (https://vamedicaid.dmas.virginia.gov/).
• Application Fee: Subject to the federal ACA institutional provider application fee (approximately $731 for 2024) unless the provider qualifies for a waiver or has already paid it to Medicare.
• Required Form: Applicants must electronically sign and submit the DMAS Provider Participation Agreement within the PRSS portal.
• WaMS Registration: DD Waiver providers must register in the DBHDS Waiver Management System (WaMS) to receive and view service authorizations from Support Coordinators.
• MCO Credentialing: To serve CCC Plus Waiver members, providers must separately apply to join the networks of MCOs like Aetna Better Health of Virginia and Anthem HealthKeepers Plus.

6. Staffing, Training and Background Checks

While Transition Services do not require licensed medical staff, the personnel coordinating the purchases and logistics must meet basic competency and background check requirements. Virginia mandates strict background screenings for any staff interacting with waiver individuals.

Agencies must maintain personnel files proving that staff have the necessary experience in community resources and have passed all required state and federal registry checks before providing services.

• Criminal Background Checks: Mandatory fingerprint-based background checks via the Virginia State Police for all personnel interacting with Medicaid members.
• Child Protective Services (CPS): Registry checks through the Virginia Department of Social Services (VDSS) are required if the agency serves individuals under the age of 18.
• OIG LEIE Screening: Agencies must conduct monthly screenings of all staff against the HHS Office of Inspector General List of Excluded Individuals/Entities.
• Staff Qualifications: Transition coordinators must demonstrate knowledge of local community resources, housing logistics, and experience supporting individuals with developmental disabilities.
• DBHDS Orientation: It is highly recommended that coordinating staff complete the DBHDS Provider Orientation training modules to understand waiver values and person-centered practices.

7. Documentation, Policies and Records

Because Transition Services operate on a cost-reimbursement model, documentation requirements are heavily focused on financial records and proof of purchase. DMAS Program Integrity auditors require a clear paper trail from the initial authorization to the final delivery of goods.

Providers must maintain robust internal financial policies detailing how funds are disbursed, tracked, and reconciled against the individual's approved Transition Plan.

• Transition Plan: The specific items, deposits, and estimated costs must be explicitly documented and approved in the individual's Individual Support Plan (ISP) prior to purchase.
• Original Receipts: Providers must retain original vendor receipts, store invoices, and cleared checks for every single item or deposit purchased.
• Delivery Verification: The provider must secure signed and dated documentation from the member or their family confirming physical receipt of the purchased goods or services.
• Record Retention: DMAS regulations require all Medicaid financial and service records to be retained for a minimum of five years from the date of service.
• Financial Policies: Agencies must maintain written internal controls detailing the procurement process, fraud prevention, and reconciliation of transition expenses.

8. Billing, Rates and Claims

Transition Services are billed as a pass-through reimbursement rather than a traditional hourly or per-diem service rate. Providers purchase the authorized items and then submit claims for the exact dollar amount spent, up to the lifetime cap.

For DD Waiver members, claims are submitted as fee-for-service through the MES PRSS portal. For CCC Plus Waiver members, claims are submitted directly to the member's assigned MCO clearinghouse.

• HCPCS Code: Transition Services are typically billed using HCPCS code T2038 (Community Transition, waiver; per service).
• Maximum Limit: Reimbursement is strictly capped at $5,000 per individual for their lifetime, regardless of how many times they transition.
• Reimbursement Model: Exact cost reimbursement; providers cannot mark up the cost of goods or charge administrative overhead fees on top of the receipts.
• Claim System (FFS): Fee-for-service claims for DD Waivers are submitted via the MES PRSS portal (https://vamedicaid.dmas.virginia.gov/).
• Prior Authorization Requirement: Claims will automatically deny if the billed amount exceeds the specific dollar amount pre-authorized in WaMS or by the MCO.

9. Approval Sequence and Timeline

Becoming a fully approved Transition Services provider in Virginia is a multi-step process that requires sequential approvals from DMAS and, if applicable, the MCOs. Because DBHDS licensure is bypassed, the timeline is generally shorter than for direct-care residential providers.

Providers should expect the entire process, from business formation to the ability to bill an MCO, to take between 3 to 5 months, depending on the speed of the HCBS compliance review and MCO credentialing.

• Step 1: Establish the business entity, register with the Virginia SCC, and obtain an NPI and EIN (1-2 weeks).
• Step 2: Complete the DMAS HCBS Settings Toolkit and undergo review to receive the mandatory compliance letter (30-60 days).
• Step 3: Submit the DMAS Provider Enrollment application via the MES PRSS portal (45-90 days for processing).
• Step 4: Register the agency in the DBHDS WaMS system to receive DD Waiver service authorizations (1-2 weeks).
• Step 5: For CCC Plus, submit credentialing applications and negotiate contracts with Virginia Medicaid MCOs (90-120 days).

10. Common Denials and Survey Findings

When DMAS Program Integrity or MCO auditors review Transition Services claims, they focus almost exclusively on financial discrepancies and unauthorized purchases. Because this is a reimbursement service, missing documentation directly results in recouped funds.

Providers frequently face denials at the claims stage if they attempt to bill for items before the individual has actually transitioned into the community, or if the items purchased do not match the authorized Transition Plan.

• Missing Receipts: Claims are frequently recouped because the provider cannot produce the original store receipt or vendor invoice to prove the exact cost.
• Unapproved Items: Purchasing items not explicitly listed and approved in the individual's Transition Plan (e.g., buying a television instead of an authorized bed).
• Exceeding the Cap: Claim denials occur when a provider attempts to bill beyond the $5,000 lifetime limit per member.
• Lack of Delivery Proof: Auditors will cite providers for failing to document that the member actually received the furniture or that the deposit was successfully paid to the landlord.
• Lapsed Revalidation: Providers are often suspended from billing for failing to complete the mandatory 5-year DMAS revalidation process in the PRSS portal.

11. Key Contacts and Resources

Prospective providers must navigate multiple state portals and MCO networks to successfully enroll and bill for Transition Services. The MES portal is the primary hub for DMAS interactions.

For DD Waiver specific questions, DBHDS provides a Provider Network resource page, while CCC Plus providers must rely on the individual MCO provider relations departments.

• Virginia DMAS Provider Portal (MES): The central hub for Medicaid enrollment and FFS claims (https://vamedicaid.dmas.virginia.gov/).
• DBHDS Provider Network: Resources, toolkits, and WaMS information for DD Waiver providers (https://dbhds.virginia.gov/providers/).
• DMAS HCBS Settings Toolkit: Required compliance documentation for new providers (https://www.dmas.virginia.gov/for-providers/long-term-care/waivers/home-and-community-based-services-toolkit/).
• Aetna Better Health of Virginia (MCO): Provider credentialing and resources for CCC Plus (https://www.aetnabetterhealth.com/virginia/providers/index.html).
• Anthem HealthKeepers Plus (MCO): Provider enrollment and contracting for CCC Plus (https://providers.anthem.com/virginia-provider/home).
• DMAS Provider Helpline: In-state support for FFS provider enrollment and billing issues at 1-800-552-8627.

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