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

Last reviewed: 2026-08-16

In West Virginia, Assisted Living Residences (ALRs) are licensed congregate care settings that provide housing, personal assistance, and supervision to four or more adults. While the state licenses the facility itself, West Virginia Medicaid does not pay for room and board in an ALR; instead, providers must separately enroll in the Medicaid Aged and Disabled Waiver (ADW) program to receive reimbursement for the medically necessary personal care services delivered to eligible residents.

The single biggest structural barrier to entry for a new ALR in West Virginia is the mandatory pre-licensure Architectural Plan Review and State Fire Marshal Life Safety Code approval. Before the Office of Health Facility Licensure and Certification (OHFLAC) will even accept a licensure application or schedule an initial survey, applicants must have their facility blueprints approved and secure a permanent certificate of occupancy, a process that requires significant upfront capital investment without guaranteed Medicaid enrollment timelines.

1. Service Definition and Scope

West Virginia defines an Assisted Living Residence (ALR) as any living facility providing sleeping accommodations, personal assistance, and supervision to four or more residents who are dependent on the services of others by reason of physical or mental impairment. The service is designed to promote resident independence while ensuring health and safety.

Because Medicaid does not cover the cost of rent or meals in these facilities, the scope of Medicaid-reimbursable services is limited strictly to personal care and waiver services. These are billed through the state's Aged and Disabled Waiver (ADW) program for residents who meet nursing facility level of care criteria.

• Licensure Category: Assisted Living Residence (ALR).
• Regulatory Citation: West Virginia Code of State Rules (CSR) Section 64-14.
• Medicaid Vehicle: Aged and Disabled Waiver (ADW) program.
• Covered Medicaid Services: Medically necessary personal care, medication administration, and supervision.
• Excluded Services: Room, board, meals, and rent are strictly private pay or funded by third-party non-Medicaid sources.
• Capacity Minimum: Must serve four or more unrelated adults to fall under ALR licensure.

2. Regulatory and Oversight Agencies

The primary regulatory body for facility licensure is the Office of Health Facility Licensure and Certification (OHFLAC), which operates under the West Virginia Office of Inspector General. OHFLAC conducts all initial, renewal, and complaint surveys for ALRs.

For Medicaid reimbursement, providers interact with the Bureau for Medical Services (BMS), which administers the Medicaid program. Enrollment and claims processing are managed through Gainwell Technologies via the West Virginia Medicaid Management Information System (WVMMIS).

• Licensing Agency: Office of Health Facility Licensure and Certification (OHFLAC) (https://oig.wv.gov/OHFLAC).
• Medicaid Authority: West Virginia Bureau for Medical Services (BMS) (https://dhhr.wv.gov/bms).
• Medicaid Enrollment Portal: Gainwell Technologies WVMMIS Provider Enrollment Application (PEA) (https://www.wvmmis.com).
• Background Check Agency: WV CARES (https://wvoig.wv.gov/wvcares).
• Fire Safety Oversight: West Virginia State Fire Marshal (https://firemarshal.wv.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Unlike skilled nursing facilities or home health agencies in West Virginia, standard Assisted Living Residences are exempt from the state's Certificate of Need (CON) process, provided they do not add skilled nursing beds. Therefore, there are no CON moratoriums or RFP procurement windows blocking market entry.

However, strict structural preconditions exist before an application is accepted. Applicants must pass a mandatory Architectural Plan Review and obtain local zoning and State Fire Marshal approvals. Without these physical plant clearances, OHFLAC will reject any initial licensure application.

• Certificate of Need (CON): Not required for standard ALRs under West Virginia Health Care Authority rules, meaning open market entry is permitted.
• Architectural Plan Review: Mandatory submission of construction or renovation blueprints to OHFLAC and the State Fire Marshal before any building modifications begin.
• State Fire Marshal Approval: Required Life Safety Code inspection and issuance of a certificate of occupancy before OHFLAC will schedule an initial licensure survey.
• Local Zoning Approval: Must obtain and submit written verification of compliance with municipal or county zoning ordinances prior to application submission.
• Financial Disclosures: Submission of a projected operating budget and proof of financial viability for the first year of operation is required with the initial application.

4. Licensure and Certification Requirements

To obtain an ALR license, facilities must adhere to the physical plant and operational rules set forth in CSR Section 64-14. OHFLAC requires a comprehensive application package followed by an on-site initial survey to verify compliance.

Physical space requirements are strictly enforced. Facilities must ensure adequate square footage per resident and maintain environments that do not utilize physical or chemical restraints, as such residents are prohibited from admission.

• Application Form: OHFLAC Initial Application for Assisted Living Residence Licensure.
• Private Room Standards: Minimum 100 square feet of open space per resident in a private occupancy room for facilities constructed or renovated after May 2006.
• Shared Room Standards: Minimum 90 square feet per resident in shared rooms, with an absolute maximum of two occupants per room.
• Resident Assessments: Required signed medical assessment by a licensed professional dated no more than 60 days prior to admission or completed within 5 days of admission.
• Initial Survey: Comprehensive on-site inspection by OHFLAC surveyors to verify physical plant, policy, and life safety compliance.
• Licensure Fee: Tiered annual fee based on licensed bed capacity, submitted with the initial and renewal applications.

5. Medicaid Provider Enrollment

Because there is no blanket Medicaid facility rate for ALRs in West Virginia, the facility or its operating entity must enroll as an Aged and Disabled Waiver (ADW) provider to bill for personal care services. This is done through the WVMMIS portal.

The enrollment process requires the provider to submit their OHFLAC license, NPI, and ownership disclosures. Gainwell Technologies processes these applications on behalf of the Bureau for Medical Services.

• Enrollment Portal: Gainwell Technologies Provider Enrollment Application (PEA) via WVMMIS (https://www.wvmmis.com).
• Provider Type: Must enroll under the specific taxonomy for ADW Personal Care or Waiver Services.
• Application Timeline: Providers have exactly 120 days from the date of initiating the application in the PEA portal to complete and submit it.
• Required Identifiers: National Provider Identifier (NPI) and Employer Identification Number (EIN) matching the licensed entity.
• Application Fee: Subject to the federal ACA institutional provider application fee unless waived by prior Medicare enrollment.
• Processing Time: Typically takes 60 to 90 days for BMS and Gainwell to process and approve the enrollment once submitted.

6. Staffing, Training and Background Checks

West Virginia requires ALRs to maintain sufficient awake staff 24 hours a day to meet the scheduled and unscheduled needs of all residents. Staffing ratios are dictated by resident acuity and fire safety evacuation capabilities rather than a strict numerical formula.

All direct access personnel must undergo rigorous background screening through the state's centralized system, and specific training is required for staff administering medications.

• Background Checks: Mandatory fingerprint-based state and federal criminal history checks via WV CARES (https://wvoig.wv.gov/wvcares) prior to employment.
• Administrator Qualifications: Must be at least 21 years old, possess a high school diploma or GED, and complete an OHFLAC-approved administrator training program.
• Medication Administration: Unlicensed staff must complete the Approved Medication Assistive Personnel (AMAP) training program to legally administer medications.
• Direct Care Staffing: Must maintain awake staff 24 hours a day, capable of executing the facility's emergency evacuation plan.
• First Aid and CPR: At least one staff member with current CPR and First Aid certification must be on duty and on-site at all times.
• Initial Training: All staff must receive orientation on resident rights, infection control, and emergency procedures before providing any direct care.

7. Documentation, Policies and Records

OHFLAC mandates that ALRs maintain comprehensive administrative, personnel, and resident records. These records are heavily scrutinized during annual and complaint surveys.

Facilities must have clear, written policies regarding admission and discharge criteria, specifically documenting that they cannot safely serve individuals who require restraints or pose a danger to themselves or others.

• Admission Agreement: Must disclose the costs of all services, basic or specialized, in writing at or before the time of admission.
• Resident Assessments: Must comprehensively document health status, psycho-social analysis, activity levels, and dietary needs.
• Service Plans: Individualized care plans must be developed within 14 days of admission and updated annually or upon a significant change in condition.
• Exclusion Policy: Documented policy explicitly prohibiting the admission or retention of individuals needing chemical or physical restraints.
• Medication Records: Maintenance of a Medication Administration Record (MAR) for all residents receiving AMAP assistance.
• Disaster Preparedness: Written emergency plan with documented quarterly fire drills conducted on each shift.

8. Billing, Rates and Claims

Medicaid billing for ALR residents is restricted to ADW personal care services, which are billed fee-for-service through the WVMMIS portal. Providers must maintain strict separation between Medicaid claims and private-pay room and board charges.

Rates for ADW services are established by the Bureau for Medical Services and require prior authorization from the state's Utilization Management Contractor before services can be rendered and billed.

• Billing System: Claims are submitted electronically via the Gainwell Technologies WVMMIS portal (https://www.wvmmis.com).
• Reimbursement Model: Fee-for-service hourly or per-diem rates for ADW personal care services, established by BMS.
• Room and Board: Strictly private pay; facilities must maintain separate ledgers for Medicaid service billing and private rent collection.
• Prior Authorization: ADW services require prior authorization from the state's Utilization Management Contractor (UMC) before billing.
• Claim Timely Filing: Medicaid claims must generally be submitted within 365 days of the date of service to avoid denial.
• Cost Reporting: Providers may be required to submit annual cost reports to BMS for state rate-setting and audit purposes.

9. Approval Sequence and Timeline

The path to becoming a Medicaid-reimbursed ALR in West Virginia is sequential and cannot be expedited. Physical plant approvals must precede licensure, and licensure must precede Medicaid enrollment.

The entire process typically takes 6 to 12 months from the submission of architectural plans to the receipt of an active Medicaid provider number.

• Step 1: Architectural Plan Review: Submit blueprints to OHFLAC and the State Fire Marshal for approval (30-60 days).
• Step 2: Construction and Renovation: Complete facility build-out according to the approved plans.
• Step 3: Life Safety Inspection: Obtain a certificate of occupancy from the State Fire Marshal (14-30 days).
• Step 4: OHFLAC Licensure Application: Submit the initial application, fee, and operational policies to OHFLAC.
• Step 5: Initial Licensure Survey: OHFLAC conducts an on-site inspection and issues the ALR license (30-60 days).
• Step 6: Medicaid Enrollment: Submit the PEA through WVMMIS to BMS for ADW provider status (60-90 days).

10. Common Denials and Survey Findings

OHFLAC frequently cites new and existing facilities for physical plant deficiencies and medication administration errors. Understanding these common pitfalls is critical for maintaining licensure and Medicaid billing privileges.

On the enrollment side, the most common reason for denial is application abandonment within the WVMMIS portal due to missing documentation or missed deadlines.

• Physical Plant Deficiencies: Failure to meet the 100 square feet per resident requirement for private rooms built after May 2006.
• Medication Errors: Allowing unlicensed staff to administer medications without current AMAP certification.
• Assessment Delays: Admitting residents without a signed medical assessment completed within the required 60-day pre-admission or 5-day post-admission window.
• Background Check Violations: Allowing staff to provide direct care before receiving official WV CARES clearance.
• Enrollment Timeout: Failure to complete the Gainwell PEA portal application within the 120-day window, resulting in automatic application abandonment.
• Improper Admissions: Admitting or retaining residents whose acuity exceeds ALR regulatory limits, such as those requiring physical restraints.

11. Key Contacts and Resources

Prospective ALR providers must coordinate with multiple state agencies to achieve licensure and Medicaid enrollment. The primary contacts are OHFLAC for facility rules and BMS for Medicaid reimbursement.

Utilizing the official state portals for background checks and provider enrollment is mandatory for compliance.

• WV Office of Health Facility Licensure and Certification (OHFLAC): https://oig.wv.gov/OHFLAC
• WV Bureau for Medical Services (BMS): https://dhhr.wv.gov/bms
• WVMMIS Provider Enrollment Portal (Gainwell): https://www.wvmmis.com
• WV CARES (Background Checks): https://wvoig.wv.gov/wvcares
• WV State Fire Marshal: https://firemarshal.wv.gov
• WV Secretary of State (Code of State Rules): https://apps.sos.wv.gov/adlaw/csr/

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