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

Last reviewed: 2026-09-10

Washington State Department of Health (DOH) licenses the delivery of in-home RN and LPN care under the In-Home Services Agency umbrella, specifically designating these providers as Home Health Agencies under WAC 246-335. The Washington State Health Care Authority (HCA) reimburses these skilled nursing services through the Apple Health (Medicaid) program using the ProviderOne billing system.

Approval to bill Apple Health for home health skilled nursing requires the agency to first obtain a Certificate of Need (CN) from DOH, followed by Medicare certification, before Medicaid enrollment is permitted. Independent registered nurses may only enroll to provide these services in geographic areas where no home health agency exists.

1. Service Definition and Scope

Skilled nursing services in Washington include intermittent or part-time nursing care provided by a registered nurse (RN) or licensed practical nurse (LPN) in the client's residence. These services must be ordered by a physician, physician assistant (PA), or advanced registered nurse practitioner (ARNP) as part of a written plan of care.

The scope of practice includes comprehensive assessments, medication administration, wound care, and other skilled treatments that require the clinical judgment of a licensed nurse. Washington Medicaid covers these services primarily through licensed and certified Home Health Agencies.

2. Regulatory and Oversight Agencies

The Washington State Department of Health (DOH) is the primary regulatory body responsible for licensing In-Home Services Agencies, conducting initial and ongoing surveys, and managing the Certificate of Need program. DOH's Office of Investigation and Inspection handles the physical site surveys and Medicare certification recommendations.

The Washington State Health Care Authority (HCA) administers the Apple Health (Medicaid) program, manages provider enrollment, and sets reimbursement policies. HCA utilizes the ProviderOne system for all Medicaid provider enrollment and claims processing.

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington imposes strict market-entry controls on new Home Health Agencies seeking to serve Medicare and Medicaid populations. An applicant cannot simply apply for a license and enroll in Medicaid; they must first pass a formal need-review process.

The state requires a Certificate of Need (CN) for any home health agency seeking Medicare certification, and HCA requires Medicare certification for an agency to enroll as a Medicaid home health provider. This means a new agency must prove a quantitative need for additional home health services in their proposed county before DOH will accept a Medicare certification application.

4. Licensure and Certification Requirements

Agencies must apply for an In-Home Services Agency license with a Home Health service category through DOH. The application requires a detailed organizational structure, a description of how management and supervision will be provided across all service areas, and a completed full-time equivalent (FTE) worksheet.

State licensure is a mandatory prerequisite for federal certification. Once licensed, the agency must submit a Medicare application (Form 855A) to the CMS Fiscal Intermediary and undergo an on-site survey by the DOH Office of Investigation and Inspection.

5. Medicaid Provider Enrollment

Once licensed and Medicare-certified, the agency must enroll as a billing provider with the Washington State Health Care Authority using the ProviderOne portal. The agency must sign a Core Provider Agreement (CPA) without modification.

Under WAC 182-502-0010, HCA assesses the risk of fraud, waste, and abuse using screening level risk categories. Home health agencies are typically subject to high-risk screening requirements, which include application fees and fingerprint-based background checks.

6. Staffing, Training and Background Checks

Washington requires strict background checks and specific leadership qualifications for home health agencies. The agency must designate an on-site administrator and a director of clinical services who meet the qualifications outlined in WAC 246-335.

Criminal history background checks must be processed through the Washington State Patrol (WSP) for key personnel. These checks must be recent and documented in the agency's application materials.

7. Documentation, Policies and Records

Agencies must develop and operationalize comprehensive delivery of services policies and procedures as required by WAC 246-335-420. This includes detailed admission, transfer, discharge, and referral processes.

To prevent client abandonment, agencies must provide at least a 48-hour written or verbal notice prior to discharge, documented in the client record, unless worker safety is at risk or a medical emergency occurs.

8. Billing, Rates and Claims

Home health skilled nursing services are billed to HCA through the ProviderOne system using standard HIPAA-compliant HCPCS codes and modifiers. Claims must reflect the specific level of nursing provided (RN vs. LPN) and align with the authorized plan of care.

Reimbursement rates are established by HCA and published in the Apple Health Home Health Services fee schedule. Agencies must verify client eligibility in ProviderOne prior to service delivery, as federal changes to Apple Health eligibility may impact coverage.

9. Approval Sequence and Timeline

The approval sequence in Washington is linear and strictly enforced. An applicant must first secure a Certificate of Need from DOH, which can take several months of review and public comment.

Following CN approval, the agency submits the state license application and Medicare 855A form. DOH conducts the initial survey, and upon passing, issues the state license and recommends Medicare certification, allowing the agency to finally submit the ProviderOne Medicaid enrollment application.

10. Common Denials and Survey Findings

DOH frequently closes applications without refunding licensing fees if the applicant fails to complete all required steps within the mandated timeframe. WAC 246-335-320(4) strictly enforces a nine-month window for licensure completion.

During initial surveys, agencies often face citations for inadequate policy documentation, particularly regarding the 48-hour discharge notice requirements, or for submitting Washington State Patrol background checks that are older than the allowed three-month window.

11. Key Contacts and Resources

Providers should utilize the official Washington State Department of Health and Health Care Authority websites for the most current applications, fee schedules, and regulatory updates. The DOH Certificate of Need program is the mandatory first point of contact for new agencies.

For Medicaid billing and enrollment support, HCA provides detailed provider guides and maintains the ProviderOne portal for all electronic transactions.

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