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

Last reviewed: 2026-08-16

In Washington, Home Health Services provide intermittent skilled nursing, physical therapy, occupational therapy, and speech therapy to individuals in their places of residence. These services are regulated by the Washington State Department of Health (DOH) under the In-Home Services Agencies licensure category and are reimbursed by the Washington State Health Care Authority (HCA) through the Apple Health (Medicaid) program.

The single biggest structural barrier to entry for this service in Washington is the Certificate of Need (CON) requirement. Before a provider can even apply for a license to operate a new Medicare-certified Home Health Agency, they must undergo a rigorous, highly competitive CON review process by the DOH to prove quantitative need in a specific county, which effectively blocks new entrants in saturated markets.

1. Service Definition and Scope

Washington defines home health services under WAC 246-335-510 as services delivered to individuals in places of temporary or permanent residence. A licensed agency provides these services under a physician-ordered plan of care.

The scope encompasses skilled nursing and specialized therapies, often supplemented by home health aide services. Agencies must ensure all care is intermittent and medically necessary.

• Skilled Nursing: Intermittent care provided by a registered nurse (RN) or a licensed practical nurse (LPN) under RN supervision.
• Therapy Services: Physical therapy, occupational therapy, and speech therapy provided by licensed practitioners.
• Home Health Aide Services: Non-medical personal care and assistance provided by a certified or registered nursing assistant under the direct supervision of an RN or therapist.
• Plan of Care: A written document established and periodically reviewed by a physician or advanced practice clinician dictating the frequency and duration of services.
• Setting Limitations: Services must be delivered in the patient's temporary or permanent residence, not in a hospital or skilled nursing facility.

2. Regulatory and Oversight Agencies

Home health agencies in Washington are jointly overseen by health and social service departments. The Department of Health handles facility licensing and market entry, while the Health Care Authority manages Medicaid funding.

Providers must interact with multiple state portals for compliance, background checks, and claims processing.

• Washington State Department of Health (DOH): Licenses In-Home Services Agencies and conducts surveys (https://doh.wa.gov).
• DOH Certificate of Need (CON) Program: Evaluates and approves the establishment of new healthcare facilities based on regional need (https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/certificate-need).
• Washington State Health Care Authority (HCA): Administers the Apple Health Medicaid program and oversees provider enrollment (https://www.hca.wa.gov).
• ProviderOne: The official Medicaid Management Information System (MMIS) and provider enrollment portal for Washington (https://www.hca.wa.gov/billers-providers-partners/providerone).

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington imposes strict market-entry barriers for home health providers. The state utilizes a Certificate of Need (CON) program to control the proliferation of Medicare-certified home health agencies.

You cannot submit a licensure application for a Medicare-certified home health agency without first obtaining a CON. If a county's need methodology shows no unmet need, new applications are not accepted.

• Certificate of Need (CON): Required under WAC 246-310-020 prior to establishing a new Medicare-certified home health agency or expanding into a new county.
• Letter of Intent: A formal notice that must be submitted to the DOH CON program before a full CON application can be filed.
• Need Methodology Review: CON approval requires demonstrating a quantitative unmet need for home health services in the target county planning area based on state formulas.
• Medicare Certification Prerequisite: HCA requires home health agencies billing Apple Health to be Medicare-certified, which triggers the CON requirement.
• Existing Licensure Prerequisite: Agencies must secure the CON and DOH In-Home Services Agency license before HCA will process a ProviderOne Medicaid enrollment application.

4. Licensure and Certification Requirements

Agencies must be licensed as an In-Home Services Agency with a Home Health category under RCW 70.127 and WAC 246-335. The DOH Office of Investigation and Inspection manages this process.

The application requires detailed operational disclosures and a successful initial on-site survey before a license is granted.

• Application Form: Providers must submit the DOH In-Home Services Agency License Application (Form DOH 505-052).
• FTE Worksheet: Applicants must complete the Full-Time Equivalent worksheet (Form DOH 505-137) to calculate initial and ongoing licensing fees.
• Administrator Qualifications: The on-site administrator must meet specific experience requirements outlined in WAC 246-335-320.
• Director of Clinical Services: The agency must appoint an RN with specific home health experience to oversee clinical operations.
• Initial Survey: DOH schedules and conducts an initial on-site survey to verify compliance with WAC 246-335 after application acceptance.
• Application Expiration: Under WAC 246-335-320(4), DOH may close an application without a refund if the applicant does not complete all licensure steps within nine months.

5. Medicaid Provider Enrollment

Once licensed and Medicare-certified, agencies must enroll in Washington Apple Health via the ProviderOne portal. Enrollment is mandatory even if the provider only intends to bill managed care organizations.

Agencies enroll as institutional providers and must complete the state's specific provider agreements.

• Enrollment Portal: Applications must be submitted electronically through the HCA ProviderOne system.
• Provider Category: Home health agencies must enroll as a Facility or Agency using a Type 2 (Organizational) National Provider Identifier (NPI).
• Core Provider Agreement (CPA): All billing providers must sign the HCA Core Provider Agreement to participate in Apple Health.
• Application Fee: Agencies are subject to the federal institutional provider application fee unless they provide proof of payment to Medicare or another state's Medicaid program.
• Managed Care Contracting: After HCA enrollment, agencies must separately credential and contract with Apple Health MCOs like Molina Healthcare or Coordinated Care.

6. Staffing, Training and Background Checks

Washington requires rigorous background screening and credentialing for all home health personnel. The state mandates specific supervisory structures for direct care staff.

Background checks must be recent, and clinical staff must maintain active Washington state licenses.

• Background Checks: Criminal history checks processed through the Washington State Patrol (WSP) are required for the administrator and clinical director, dated within three months of the application.
• Home Health Aides: Must hold an active credential as a Nursing Assistant Certified (NAC) or Nursing Assistant Registered (NAR) under RCW 18.88A.
• Clinical Supervision: Aides must be supervised by an RN, physical therapist, occupational therapist, or speech therapist employed or contracted by the agency.
• Continuing Education: Licensed professionals must meet DOH continuing education requirements to maintain active credentials in Washington.

7. Documentation, Policies and Records

WAC 246-335 dictates strict record-keeping and policy documentation for In-Home Services Agencies. Applicants must submit structural descriptions during the licensing phase.

Clinical records must clearly tie services delivered to the physician's plan of care.

• Organizational Structure: Applicants must provide a written description listing the names of officers, the administrator, the director of clinical services, and other key positions.
• Supervision Plan: A documented description of how the agency will provide management and supervision of home health services throughout all requested service areas.
• Service Description: A clear delineation of which services the agency will offer directly with W-2 employees and which will be offered under contract.
• Business Licenses: Copies of all current government-issued business licenses for each office location, including state, county, or city licenses.
• Clinical Records: Agencies must maintain individual patient records that include the physician-ordered plan of care, clinical notes, and supervisory visit documentation.

8. Billing, Rates and Claims

Home health claims are processed through ProviderOne for fee-for-service clients or through MCO clearinghouses for managed care enrollees.

Washington enforces strict NPI rules, requiring both billing and rendering identifiers on claims.

• Billing System: Claims are submitted electronically via the ProviderOne portal or the applicable MCO's claims system.
• NPI Enforcement: Both the billing NPI (Type 2) and the rendering provider's NPI (Type 1) must be active with HCA; missing rendering NPIs will result in automatic claim denials.
• Prior Authorization: Many services, particularly extended nursing visits or specialized therapies, require prior authorization from HCA or the patient's MCO.
• Fee Schedule: Reimbursement rates are standardized and published in the HCA Home Health Services Billing Guide and Fee Schedule.
• Backdating Window: HCA occasionally offers backdating windows for enrollment effective dates, allowing providers to bill for services rendered prior to final approval if applied for within specific timeframes.

9. Approval Sequence and Timeline

Becoming a home health provider in Washington is a multi-year process primarily due to the Certificate of Need requirement.

Providers must sequence their applications carefully, as each step is a prerequisite for the next.

• CON Review Timeline: The Certificate of Need process can take 6 to 9 months, including the letter of intent, public comment periods, and DOH evaluation.
• DOH Licensure Timeline: After CON approval, the In-Home Services Agency license application and initial survey typically take 3 to 6 months.
• Medicare Certification Timeline: Coordinating the initial Medicare survey with DOH or an accrediting organization adds several additional months.
• HCA Enrollment Timeline: Once fully licensed and certified, ProviderOne Medicaid enrollment processing takes approximately 30 to 45 days for complete in-state applications.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to missing prerequisites or expired documentation.

DOH and HCA strictly enforce timelines and structural requirements.

• CON Absence: Submitting a licensure application for a Medicare-certified agency without an approved Certificate of Need results in immediate rejection.
• Outdated Background Checks: Providing Washington State Patrol background checks that are older than three months at the time of the DOH application submission.
• Incomplete FTE Worksheets: Failing to accurately complete Form DOH 505-137, which prevents DOH from calculating the correct licensing fee.
• NPI Mismatches: Attempting to bill ProviderOne without ensuring all rendering providers are individually enrolled and linked to the agency's Type 2 NPI.
• Nine-Month Expiration: Having a DOH application closed without a refund because the applicant failed to pass the initial survey within nine months of submission.

11. Key Contacts and Resources

Prospective providers should consult official DOH and HCA resources for the most current forms, fee schedules, and rule adoptions.

Utilizing the correct portals and contacting the appropriate program staff is critical for a smooth enrollment process.

• DOH Home Health Licensing: https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/home-health-agencies/license-requirements
• DOH Certificate of Need Program: https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/certificate-need
• 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

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