Washington - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Washington State Department of Social and Health Services (DSHS), Aging and Long-Term Support Administration (ALTSA) licenses Assisted Living Facilities under WAC 388-78A and contracts for Medicaid services through the Community First Choice (CFC) state plan and 1915(c) waivers like COPES. Facilities provide housing, meals, and personal care to seven or more residents, with Medicaid reimbursement requiring a specific Adult Residential Care (ARC), Enhanced Adult Residential Care (EARC), or Assisted Living (AL) contract.

Approval requires securing a state facility license from the Residential Care Services (RCS) division before a Medicaid contract application is accepted. Applicants must pass a physical plant inspection, complete required administrator training, and enroll as a billing provider through the Washington Health Care Authority's ProviderOne system.

1. Service Definition and Scope

In Washington, an Assisted Living Facility (ALF) provides room, board, and assistance with activities of daily living (ADLs) for seven or more residents. Under Medicaid, ALFs operate under three distinct contract types: Adult Residential Care (ARC), Enhanced Adult Residential Care (EARC), and Assisted Living (AL) services, each offering varying levels of personal care and medication administration.

These services are funded through the Community First Choice (CFC) state plan option and 1915(c) waivers. Facilities may also obtain specialty designations to serve individuals with developmental disabilities, mental illness, or dementia.

• Licensure Authority: WAC 388-78A governs the base licensing of all ALFs in Washington.
• Medicaid Contract Standards: WAC 388-110 dictates the specific requirements for ARC, EARC, and AL Medicaid contracts.
• Capacity Minimum: Facilities must serve seven or more residents to be licensed as an ALF, distinguishing them from Adult Family Homes.
• Service Tiers: ARC provides basic personal care, EARC adds intermittent nursing, and AL requires private apartments and higher care levels.
• Specialty Designations: Facilities can earn specific endorsements for Developmental Disabilities, Mental Health, or Dementia care.

2. Regulatory and Oversight Agencies

DSHS ALTSA is the primary regulatory body for ALFs in Washington, handling both licensure and Medicaid contracting. The Residential Care Services (RCS) division within ALTSA conducts inspections and issues licenses.

The Washington State Health Care Authority (HCA) manages the Medicaid program and oversees the ProviderOne billing system.

• Licensing Agency: DSHS Aging and Long-Term Support Administration (ALTSA) Residential Care Services (https://www.dshs.wa.gov/altsa/residential-care-services).
• Medicaid Agency: Washington State Health Care Authority (HCA) (https://www.hca.wa.gov).
• Enrollment Portal: ProviderOne (https://www.hca.wa.gov/billers-providers-partners/providerone).
• Waiver Authority: DSHS Home and Community Living Administration (HCLA) (https://www.dshs.wa.gov/altsa/home-and-community-services).
• Training Oversight: CareLearn Washington (https://carelearnwa.com).

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington does not require a Certificate of Need (CON) or a Request for Proposals (RFP) procurement to open an Assisted Living Facility. The market is open to any qualified applicant who can meet the physical plant and operational standards.

However, a facility must obtain an active ALF license from DSHS Residential Care Services before applying for a Medicaid contract. Medicaid enrollment is strictly contingent on holding this license and passing the initial physical plant inspection.

• Certificate of Need: Explicitly not required for Assisted Living Facilities in Washington.
• Procurement Windows: None; applications for licensure and Medicaid contracts are accepted on a rolling basis.
• Licensure Prerequisite: An active DSHS ALF license is a mandatory precondition for submitting a Medicaid contract application.
• Physical Plant Approval: Facilities must pass a DSHS construction review and physical plant inspection before a license is issued.
• Medicaid Contract Requirement: Providers must secure an ARC, EARC, or AL contract from DSHS before enrolling in ProviderOne.

4. Licensure and Certification Requirements

ALF licensure requires submitting a detailed application to the DSHS Business Analysis and Applications Unit (BAAU). The process includes a review of policies, procedures, and the facility's physical environment.

Facilities must comply with WAC 388-78A for general operations and WAC 388-110 for Medicaid-specific physical requirements, such as private rooms and accessible bathrooms for the AL contract tier.

• Application Unit: DSHS Business Analysis and Applications Unit (BAAU) processes all initial ALF license applications.
• Physical Plant Standards: WAC 388-110-140 outlines specific physical requirements for facilities holding an AL Medicaid contract.
• Room Sharing: DSHS Form 15-447 (Resident Choice Regarding ALF Room Requirements) is required if Medicaid residents choose to share a room.
• Administrator Qualifications: Administrators must meet specific education and experience requirements outlined in WAC 388-78A.
• Change of Information: Providers must use DSHS Form 10-601 to report any changes in facility information.

5. Medicaid Provider Enrollment

After obtaining a license and a DSHS Medicaid contract, ALFs must enroll as a billing provider with the Washington Health Care Authority (HCA). This is done through the ProviderOne system.

Facilities enroll as a Fac/Agncy/Orgn/Inst provider type and must sign a Core Provider Agreement with HCA to bill for services.

• Enrollment System: ProviderOne is the mandatory portal for all Washington Medicaid provider enrollments.
• Provider Type: ALFs must select the Fac/Agncy/Orgn/Inst enrollment type in ProviderOne.
• Core Agreement: All billing providers must sign the HCA Core Provider Agreement.
• Contract Verification: HCA verifies the active DSHS ARC, EARC, or AL contract before approving ProviderOne enrollment.
• Support Contact: HCA Provider Enrollment can be reached at 1-800-562-3022, ext. 16137 for application assistance.

6. Staffing, Training and Background Checks

Washington requires extensive training for ALF staff, overseen by DSHS. Direct care workers must complete a 75-hour training program and obtain Home Care Aide certification from the Department of Health.

Administrators and designees must complete specific specialty training if the facility serves populations with developmental disabilities, mental illness, or dementia.

• Basic Training: Direct care staff must complete 75 hours of basic training and obtain Home Care Aide certification.
• Specialty Training: Manager Specialty Training is required for facilities with Developmental Disability, Mental Health, or Dementia designations.
• Training Verification: Case managers verify instructor credentials through the DSHS approved instructor list.
• Background Checks: All staff with unsupervised access to residents must pass a Washington State Patrol and DSHS background check.
• Continuing Education: Staff must complete annual continuing education approved by DSHS.

7. Documentation, Policies and Records

ALFs must maintain comprehensive records in accordance with WAC 388-78A. This includes negotiated service agreements for each resident, detailing their assessed needs and the services provided.

Facilities must also maintain policies on resident rights, emergency preparedness, and medication management, ensuring compliance with the federal Home and Community-Based Services (HCBS) settings rule.

• Service Agreements: Facilities must develop and maintain a negotiated service agreement for every resident.
• HCBS Compliance: Policies must align with WAC 388-823-1096 regarding HCBS setting requirements, ensuring resident autonomy and integration.
• Medication Records: Strict documentation of medication administration is required, especially for EARC and AL contract holders.
• Incident Reporting: Facilities must have policies for reporting abuse, neglect, and significant incidents to DSHS.
• Record Retention: Resident and facility records must be retained for a minimum period as specified in state regulations.

8. Billing, Rates and Claims

ALFs bill for Medicaid services through the HCA ProviderOne system. Reimbursement rates are established by DSHS and vary based on the client's assessed classification group in the CARE assessment tool.

Washington strictly prohibits supplementation; facilities cannot charge Medicaid clients additional fees for services covered under the daily Medicaid rate.

• Billing System: All claims must be submitted electronically through ProviderOne.
• Rate Determination: Daily rates are based on the client's CARE assessment classification (WAC 388-106-0115).
• Supplementation Ban: Per 42 CFR 447.15 and DSHS policy, providers may not request supplemental payment for covered services.
• Client Participation: Facilities are responsible for collecting any assessed client participation (room and board) directly from the resident.
• Contract Tiers: Reimbursement varies depending on whether the facility holds an ARC, EARC, or AL contract.

9. Approval Sequence and Timeline

The approval process begins with the physical plant review and ALF licensure application to DSHS BAAU. Once licensed, the facility applies for a Medicaid contract (ARC, EARC, or AL) through ALTSA.

After the contract is awarded, the final step is enrolling in ProviderOne with HCA. The entire process can take several months, heavily dependent on construction reviews and inspection scheduling.

• Step 1: Submit construction documents and physical plant plans to DSHS for review.
• Step 2: Submit the ALF licensure application to the DSHS Business Analysis and Applications Unit (BAAU).
• Step 3: Pass the initial DSHS Residential Care Services on-site licensing inspection.
• Step 4: Apply for the specific Medicaid contract (ARC, EARC, or AL) through DSHS ALTSA.
• Step 5: Complete the HCA ProviderOne enrollment as a Fac/Agncy/Orgn/Inst billing provider.

10. Common Denials and Survey Findings

DSHS Residential Care Services conducts regular surveys to ensure compliance. Common citations involve medication administration errors and failure to update negotiated service agreements.

Licensure or contract applications may be delayed or denied if the physical plant does not meet the specific WAC 388-110 requirements for the requested contract tier, such as lacking private bathrooms for AL contracts.

• Physical Plant Failures: Denials often occur if the facility fails to meet WAC 388-110-140 physical requirements for AL contracts.
• Incomplete Training: Citations frequently result from staff lacking required 75-hour training or specialty certifications.
• Service Agreement Lapses: Failure to update negotiated service agreements when a resident's condition changes is a common survey finding.
• Medication Errors: Improper documentation or administration of medications, especially under EARC contracts, leads to citations.
• HCBS Settings Violations: Facilities may face contract issues if they fail to comply with federal HCBS settings rules regarding resident privacy and access.

11. Key Contacts and Resources

Providers should utilize DSHS and HCA resources for guidance throughout the licensure and enrollment process. The ALTSA website provides comprehensive manuals and forms.

The HCA Provider Enrollment team offers support for the ProviderOne system, and CareLearn Washington manages training requirements.

• DSHS ALTSA Residential Care Services: https://www.dshs.wa.gov/altsa/residential-care-services
• HCA Provider Enrollment: https://www.hca.wa.gov/billers-providers-partners/become-apple-health-provider/enroll-provider
• ProviderOne Portal: https://www.hca.wa.gov/billers-providers-partners/providerone
• CareLearn Washington: https://carelearnwa.com
• DSHS BAAU Application Processing: https://www.dshs.wa.gov/altsa/baau-application-processing-timeline

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