West Virginia - Adult Companion Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

West Virginia Medicaid does not cover "Adult Companion Services" as a standalone, distinct waiver service. Instead, non-medical supervision, socialization, and community support are absorbed into and billed as "Personal Attendant Services" under the Aged and Disabled Waiver (ADW) or "Person-Centered Support" under the Intellectual/Developmental Disabilities (I/DD) Waiver. Providers must be approved for these broader service categories to offer companion-like care, as detailed in the [West Virginia Waiver Factsheet](https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/Waiver-Descript-Factsheet/WV).

The single biggest structural barrier to entry for this service in West Virginia is the Certificate of Need (CON) requirement. Before an applicant can even submit a licensure application to the state, they must obtain a formal Certificate of Need or a statutory Exemption from Review from the West Virginia Health Care Authority (HCA). Without this prior approval, the licensing body will automatically reject the application.

1. Service Definition and Scope

Because West Virginia does not utilize a distinct "Companion Care" billing code, providers deliver these supports through Personal Attendant Services (ADW) or Person-Centered Support (I/DD). These services ensure the health and safety of the waiver participant while facilitating community integration and socialization.

The services are strictly non-medical and focus on cueing, supervision, and preventing institutionalization, allowing the adult to remain safely in their home environment.

• Service Authority: Covered under the WV Aged and Disabled Waiver (ADW) and the I/DD Waiver.
• Scope of Care: Non-medical supervision, socialization, cueing, and light assistance to maintain community living.
• Target Population: Adults 18 and older who meet nursing facility or ICF/IID level of care criteria.
• Exclusions: Cannot be billed concurrently with residential services, adult day care, or by immediate family members living in the same household.

2. Regulatory and Oversight Agencies

Oversight in West Virginia is bifurcated. The Bureau for Medical Services (BMS) manages Medicaid policy and waiver administration, while the Office of Health Facility Licensure and Certification (OHFLAC) handles physical facility and agency licensing.

Providers must interact with multiple state portals, including the WVMMIS system for enrollment and WV CARES for background screening.

• Medicaid Authority: West Virginia Bureau for Medical Services (BMS) [https://bms.wv.gov/]
• Licensing Agency: Office of Health Facility Licensure and Certification (OHFLAC) [https://oig.wv.gov/OHFLAC]
• Need Review Authority: West Virginia Health Care Authority (HCA) [https://hca.wv.gov/]
• Background Screening: WV CARES (Clearance for Access: Registry and Employment Screening) [https://wvcares.wv.gov/]
• Medicaid Portal: WVMMIS / Gainwell Technologies [https://www.wvmmis.com/]

3. Gatekeeping Prerequisites: Who Can Even Apply

The West Virginia Health Care Authority (HCA) acts as the absolute gatekeeper for new personal care and home health agencies. You cannot apply for an OHFLAC license without first clearing the HCA's Certificate of Need process.

This structural precondition prevents market saturation and requires applicants to prove a regional need for their services before any operational steps are taken.

• Certificate of Need (CON): Mandatory prior approval from the WV HCA demonstrating a regional need for new personal care/attendant services.
• CON Exemption: A formal Letter of Exemption from the HCA if the agency meets specific statutory non-reviewability criteria.
• Business Registration: Active registration and good standing with the West Virginia Secretary of State.
• National Provider Identifier: Must possess an organizational Type 2 NPI before initiating the Medicaid enrollment process.

4. Licensure and Certification Requirements

Once the CON is secured, providers must apply for licensure through OHFLAC. Depending on the specific waiver services offered, this will be under the Behavioral Health Center rules or Home Health/Personal Care rules.

OHFLAC requires a comprehensive review of the agency's operational policies and a physical site inspection before granting the initial license, as noted in [OHFLAC: West Virginia Behavioral Health](https://behavehealth.com/organizations/west-virginia-ohflac).

• Licensure Rule: W. Va. Code R. 64-11 (Behavioral Health Centers) or W. Va. Code R. 64-14 (Home Health Agencies).
• Application Portal: OHFLAC online application system for initial licensure.
• Initial Survey: OHFLAC conducts a mandatory on-site inspection to verify policy and physical compliance before issuing a license.
• Insurance Requirements: Proof of comprehensive general liability and professional liability insurance.
• Licensure Fee: Initial application fee, typically ranging from $50 to $100 depending on the exact facility classification.

5. Medicaid Provider Enrollment

After obtaining OHFLAC licensure, agencies must enroll as Medicaid providers through the WVMMIS portal managed by Gainwell Technologies.

Providers must also contract with Managed Care Organizations (MCOs) if serving populations under managed care, which requires a separate credentialing process after state enrollment.

• Enrollment Portal: WVMMIS Provider Enrollment Application (PEA) [https://www.wvmmis.com/Provider-Enrollment.aspx].
• Provider Type: Enrolled as a Waiver Provider (e.g., ADW or I/DD specific provider codes).
• Application Fee: Subject to the federal ACA provider screening fee (approximately $732) unless already paid to Medicare or another state.
• MCO Credentialing: Must establish contracts with WV MCOs such as Aetna Better Health of West Virginia [https://www.aetnabetterhealth.com/westvirginia/index.html].

6. Staffing, Training and Background Checks

West Virginia strictly enforces background screening through its centralized WV CARES system. Direct care staff must clear this system before having any unsupervised contact with waiver participants.

Agencies are responsible for ensuring all staff meet basic health and safety training requirements prior to billing for any services.

• Background Screening: Mandatory fingerprint-based state and federal background check via WV CARES.
• Basic Certifications: Current CPR and First Aid certification required for all direct care workers.
• Waiver Training: Completion of BMS-approved ADW or I/DD waiver-specific training modules prior to service delivery.
• Supervision: Agencies must employ a qualified supervisor (often a Registered Nurse or qualified human services professional) to oversee direct care staff.

7. Documentation, Policies and Records

Providers must maintain rigorous documentation to survive OHFLAC surveys and BMS audits. This includes detailed personnel files and participant service records.

Electronic Visit Verification (EVV) is a critical component of documentation, and failure to maintain accurate EVV logs will result in immediate claim denials.

• Service Plan: An Individualized Service Plan (ISP) that explicitly details the frequency, duration, and scope of socialization and supervision.
• EVV Compliance: Mandatory use of Electronic Visit Verification (EVV) to log the exact start and end times of in-home shifts.
• Personnel Files: Must contain WV CARES clearance letters, I-9s, training certificates, and performance evaluations.
• Incident Reporting: Written policies for reporting critical incidents to OHFLAC and West Virginia Adult Protective Services (APS).

8. Billing, Rates and Claims

Claims are processed through the WVMMIS system for fee-for-service members or through the respective MCO portals. EVV data must perfectly match billed units.

All services must be prior-authorized by the state's designated utilization management contractor before any care is delivered or billed.

• Billing System: WVMMIS portal for FFS claims or clearinghouses for MCO claims.
• EVV Vendor: Must utilize the state-sponsored EVV system, CareBridge [https://www.carebridgehealth.com/wv], or an approved alternate.
• Unit of Service: Services are typically billed in 15-minute increments using specific HCPCS codes (e.g., S5125 or T1019 depending on the exact waiver crosswalk).
• Prior Authorization: All waiver services require prior authorization from the state's Utilization Management Contractor, Kepro/Acentra Health [https://wva.kepro.com/].

9. Approval Sequence and Timeline

The approval process is strictly sequential. Attempting to skip steps, such as applying to OHFLAC without a CON, will result in immediate rejection.

Providers should expect the entire process from CON application to active Medicaid billing status to take several months.

• Step 1: Obtain Certificate of Need or Exemption from WV HCA (30 to 90 days).
• Step 2: Submit OHFLAC Licensure Application and pass the initial on-site survey (60 to 120 days).
• Step 3: Submit the WVMMIS Provider Enrollment Application via the PEA portal (30 to 60 days).
• Step 4: Complete credentialing and contracting with West Virginia Medicaid MCOs (60 to 90 days).

10. Common Denials and Survey Findings

Regulators frequently penalize providers for administrative oversights rather than direct care failures. Strict adherence to the sequential application process and background check rules is critical.

Routine audits by BMS and OHFLAC often target personnel files and EVV compliance.

• Premature Application: OHFLAC applications denied outright because the provider lacks a CON or HCA exemption.
• WV CARES Violations: Citations for allowing staff to provide care before the final WV CARES clearance letter is issued.
• EVV Discrepancies: Claims denied because the EVV clock-in/out data does not match the billed 15-minute units.
• Training Lapses: Survey deficiencies for missing or expired CPR/First Aid certificates in employee personnel files.

11. Key Contacts and Resources

Prospective providers should bookmark these official state resources to navigate the licensure and enrollment process.

Relying on the official state portals ensures access to the most current forms, fee schedules, and regulatory updates.

• WV Bureau for Medical Services (BMS): [https://bms.wv.gov/]
• WV Office of Health Facility Licensure and Certification (OHFLAC): [https://oig.wv.gov/OHFLAC]
• WV Medicaid Provider Portal (WVMMIS): [https://www.wvmmis.com/]
• WV CARES Background Screening: [https://wvcares.wv.gov/]
• WV Health Care Authority (HCA): [https://hca.wv.gov/]

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