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West Virginia - Day Habilitation Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Facility-Based Day Habilitation in West Virginia is funded through the Intellectual/Developmental Disabilities (I/DD) Waiver administered by the Bureau for Medical Services (BMS) and requires providers to first obtain a Behavioral Health Center license. The service provides structured daytime programming outside the participant's residence to build self-help, socialization, and adaptive skills for individuals with intellectual and developmental disabilities.

An applicant cannot submit a Medicaid provider enrollment application for this service until they have successfully completed the initial licensure process through the Office of Health Facility Licensure and Certification (OHFLAC). Once licensed, the agency must enroll as an atypical provider through the West Virginia Medicaid Management Information System (WVMMIS) portal managed by Gainwell Technologies.

1. Service Definition and Scope

Under the West Virginia I/DD Waiver, Facility-Based Day Habilitation provides meaningful, structured activities in a non-residential, provider-operated setting. The service focuses on acquiring, retaining, or improving self-help, socialization, and adaptive skills necessary for successful community living.

Services must be delivered in a facility licensed by the state and cannot be billed concurrently with Supported Employment or Pre-Vocational Services. The programming must align with the participant's Individualized Support Plan (ISP) and offer distinct, measurable goals rather than serving as mere custodial care.

2. Regulatory and Oversight Agencies

The Bureau for Medical Services (BMS) serves as the single state Medicaid agency, holding ultimate authority over the I/DD Waiver and its service definitions. BMS contracts with a utilization management entity to authorize individual service plans and budgets.

The Office of Health Facility Licensure and Certification (OHFLAC) is the regulatory body responsible for inspecting and licensing the physical facilities and operational policies of Behavioral Health Centers, which encompasses Day Habilitation providers.

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia does not require a Certificate of Need (CON) for Facility-Based Day Habilitation centers, nor does it restrict enrollment to a closed network or RFP procurement process. However, the state enforces a strict sequential gate: Medicaid enrollment is entirely blocked until the applicant secures a Behavioral Health Center license from OHFLAC.

To obtain this license, the applicant must have a physical commercial location in West Virginia that meets State Fire Marshal codes and local zoning ordinances. The facility must pass an initial OHFLAC life safety and policy survey before any Medicaid application can be initiated.

4. Licensure and Certification Requirements

Providers must be licensed as a Behavioral Health Center under West Virginia Code of State Rules (W. Va. Code R.) Title 64, Series 11. The licensure process requires submitting a comprehensive application to OHFLAC, including detailed operational policies, emergency preparedness plans, and proof of commercial insurance.

OHFLAC conducts an initial on-site survey to verify compliance with physical environment standards, ADA accessibility, and life safety codes. Licenses are typically issued for a one-year period initially and must be renewed annually based on subsequent survey performance.

5. Medicaid Provider Enrollment

Once the OHFLAC license is secured, the agency must enroll as a Medicaid provider through the Gainwell Technologies WVMMIS Provider Enrollment portal. Facility-Based Day Habilitation providers enroll as atypical providers, meaning they do not require an NPI for this specific waiver service, though the agency may have an NPI for other services.

The enrollment process requires payment of the federal Medicaid application fee and submission of the OHFLAC license, W-9, and ownership disclosure forms. Providers must revalidate their enrollment every five years to maintain active billing status.

6. Staffing, Training and Background Checks

Direct care staff providing Facility-Based Day Habilitation must meet the qualifications of a Direct Support Professional (DSP). West Virginia mandates that all DSPs be at least 18 years old, hold a high school diploma or GED, and possess a valid driver's license if transporting participants.

Before any client contact, all staff must clear a fingerprint-based state and federal background check through the WV CARES system. Staff must also complete required training in CPR, First Aid, and the specific I/DD Waiver curriculum, including abuse and neglect reporting.

7. Documentation, Policies and Records

Providers must maintain comprehensive records for each participant, including the approved Individualized Support Plan (ISP), daily attendance logs, and progress notes detailing the specific activities and goals addressed during the habilitation session.

Agency policies must strictly adhere to West Virginia's incident management regulations, requiring immediate reporting of critical incidents, abuse, or neglect to the WV Incident Management System (WVIMS) and Adult Protective Services.

8. Billing, Rates and Claims

Facility-Based Day Habilitation is billed in 15-minute increments using specific HCPCS codes and modifiers designated in the WV I/DD Waiver Provider Manual. Claims are submitted electronically to Gainwell Technologies via the WVMMIS portal or an approved clearinghouse.

Rates are established by the Bureau for Medical Services and are uniform statewide. Providers cannot bill for days the participant is absent, nor can they bill for time spent transporting the individual to and from the facility, as transportation is a separately billed service.

9. Approval Sequence and Timeline

The approval process begins with securing a commercial location and passing the State Fire Marshal inspection, which can take 1 to 3 months. Following this, the OHFLAC Behavioral Health Center initial license application and survey process typically requires 3 to 6 months, depending on surveyor availability and the need for physical plant corrections.

Once the OHFLAC license is in hand, the Medicaid enrollment application through Gainwell Technologies takes approximately 30 to 60 days to process. The entire sequence from securing a building to billing the first claim generally spans 6 to 10 months.

10. Common Denials and Survey Findings

OHFLAC licensure applications are frequently delayed or denied due to inadequate physical plant conditions, such as failing to meet ADA bathroom requirements or lacking a finalized State Fire Marshal approval. Deficient emergency preparedness plans are also a top citation during initial surveys.

On the Medicaid enrollment side, Gainwell Technologies commonly returns applications for missing ownership disclosures, mismatched legal names between the IRS W-9 and the OHFLAC license, or failure to pay the required application fee.

11. Key Contacts and Resources

Prospective providers should begin by reviewing the current WV I/DD Waiver Provider Manual on the BMS website and the Behavioral Health Center licensure rules on the OHFLAC website. These documents contain the definitive standards for facility operations and service delivery.

For enrollment portal technical assistance, providers must contact the Gainwell Technologies Provider Enrollment team. Background check inquiries should be directed to the WV CARES program.

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