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

Last reviewed: 2026-09-10

West Virginia Medicaid reimburses Home Health services under Chapter 508 of the Bureau for Medical Services (BMS) Provider Manual, requiring providers to first obtain a Certificate of Need (CON) and Medicare certification through the Office of Health Facility Licensure and Certification (OHFLAC). The service delivers intermittent skilled nursing (SN), physical therapy (PT), speech-language pathology (ST), and occupational therapy (OT) to members needing nursing facility level of care in the community.

Approval to bill the West Virginia Medicaid Management Information System (WVMMIS) mandates that agencies maintain their Medicare Title XVIII status and submit their Medicare rate letters to BMS. Providers must also integrate with the state's electronic visit verification (EVV) vendor, HHAeXchange, and process staff background checks through the WV CARES registry.

1. Service Definition and Scope

Under BMS Chapter 508, Home Health provides medically necessary skilled nursing and therapeutic services on a part-time or intermittent basis. West Virginia Medicaid does not require the member to be homebound, diverging from Medicare criteria, but does require a physician's written plan of care (POC).

Services are limited to 60 visits per calendar year before prior authorization is required. Medical social services are explicitly excluded from coverage under the West Virginia Medicaid Home Health Program.

• Covered Services: Skilled nursing (RN/LPN), physical therapy, speech-language pathology, occupational therapy, and home health aide services.
• Excluded Services: Medical social services and comfort/convenience items are non-covered.
• Homebound Status: West Virginia Medicaid does not follow the Medicare guideline definition for homebound status.
• Visit Limits: All Home Health services that exceed 60 visits in a calendar year require prior authorization.
• EVV Requirement: Claims for Home Health services must include the enrolled rendering provider's individual NPI and be submitted through HHAeXchange.

2. Regulatory and Oversight Agencies

The West Virginia Department of Health Facilities oversees licensure and certification, while the Department of Human Services (DoHS) Bureau for Medical Services (BMS) administers Medicaid.

Gainwell Technologies operates the Medicaid enrollment portal and claims system, and the Utilization Management Contractor (UMC) handles prior authorizations.

• Office of Health Facility Licensure and Certification (OHFLAC): Certifies and licenses agencies (https://ohflac.wvdhhr.org/).
• Bureau for Medical Services (BMS): Administers Medicaid policy and coverage (https://bms.wv.gov).
• Gainwell Technologies: Manages the WVMMIS Health PAS-OnLine portal (https://www.wvmmis.com).
• WV CARES: Manages the centralized background check registry for healthcare workers (https://wvcares.wvdhhr.org/).

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia imposes strict market entry controls on Home Health agencies. An applicant cannot simply apply for a license or Medicaid enrollment without first clearing state need-review and federal certification hurdles.

Agencies must secure a Certificate of Need and achieve Medicare certification before BMS will accept a Medicaid provider enrollment application.

• Certificate of Need (CON): Required by the West Virginia Health Care Authority before establishing a new skilled home health agency.
• Medicare Certification (Title XVIII): Must have certification for participation in Medicare by OHFLAC prior to enrolling with West Virginia Medicaid.
• OHFLAC Licensure: Must hold an active state license as a Home Health Agency from the Office of Health Facility Licensure and Certification.
• Medicare Rate Letter: Must possess a formal rate of reimbursement set by Medicare to submit with the Medicaid application.

4. Licensure and Certification Requirements

OHFLAC acts as the state survey agency for both state licensure and Medicare certification. Agencies must comply with the Code of Federal Regulations 42 CFR 484 for Home Health Services.

The initial survey process verifies compliance with federal conditions of participation and state operational rules before certification is granted.

• Application: Submitted to OHFLAC with applicable fees and CON approval documentation.
• Initial Survey: OHFLAC conducts an on-site survey to verify compliance with 42 CFR 484.
• Administrator Qualifications: Must designate a qualified administrator to oversee day-to-day operations.
• Medicare Tie-In: OHFLAC recommends Medicare certification to CMS, which issues the CMS Certification Number (CCN).

5. Medicaid Provider Enrollment

Enrollment is processed through the WVMMIS Health PAS-OnLine portal managed by Gainwell Technologies. Providers must meet the conditions in Chapter 300, Provider Participation Requirements, and Chapter 508.

Agencies must upload their Medicare certification and rate letters during the enrollment process.

• Portal: Applications are submitted via the WVMMIS Health PAS-OnLine portal.
• Medicare Documentation: Must provide a copy of Medicare certification along with the rate of reimbursement set by Medicare for each service.
• Rate Changes: A change in the Medicare rate and/or services provided must be submitted on Medicare letterhead to the Medicaid agency.
• EVV Registration: Must register with HHAeXchange to submit EVV-compliant claims.

6. Staffing, Training and Background Checks

Agencies must utilize licensed professionals and clear all staff through the West Virginia Clearance for Access Registry and Employment Screening (WV CARES) system.

West Virginia participates in the Enhanced Nursing Licensure Compact (eNLC), allowing nurses licensed in other compact states to practice in WV.

• Background Checks: All staff must clear criminal background checks through WV CARES as outlined in Chapter 700.
• Skilled Nurse (SN): Must be professionally licensed by the State of West Virginia as a Registered Nurse (RN) or a Licensed Practical Nurse (LPN).
• Nursing Compact: West Virginia is an eNLC state; out-of-state nurses must adhere to compact rules.
• Aide Supervision: Home health aide services are only covered if the member also requires skilled nursing or therapy services.

7. Documentation, Policies and Records

Providers must maintain comprehensive medical records, including the physician-ordered Plan of Care (POC) and OASIS assessments.

Documentation must clearly indicate the medical necessity for nursing facility level services in the community.

• Plan of Care: Must maintain the POC form (CMS-485 and CMS-486) or the agency's equivalent POC form on file.
• OASIS: Must maintain Outcome and Assessment Information Set (OASIS) assessments on file.
• Physician Orders: Services and supplies must be provided pursuant to a physician's written order detailing the member-specific POC.
• Record Retention: Documentation must be maintained at the agency on behalf of the State of West Virginia and accessible for state and federal audits.

8. Billing, Rates and Claims

Claims are submitted to WVMMIS or the applicable Managed Care Organization (MCO) under the Mountain Health Trust program.

Reimbursement is tied to the agency's Medicare rates, and EVV data must match the billed claims.

• EVV Claims: Effective December 1, 2022, claims must include the enrolled rendering provider's individual NPI and be submitted through HHAeXchange.
• Prior Authorization: The Utilization Management Contractor (UMC) must authorize visits exceeding 60 per calendar year.
• MCO Billing: Providers enrolled with WV Medicaid do not need a separate enrollment application for MCOs but must contract with them for Mountain Health Trust members.
• Supplies: Must use reasonable quantities of the least costly product; comfort items and over-the-counter medications are non-covered.

9. Approval Sequence and Timeline

The approval sequence is strictly linear, beginning with the Certificate of Need and ending with Medicaid portal activation.

Providers cannot bill Medicaid until the Medicare tie-in is complete and the WVMMIS enrollment is approved.

• Step 1: Obtain Certificate of Need (CON) approval from the Health Care Authority.
• Step 2: Submit state licensure application to OHFLAC.
• Step 3: Pass OHFLAC initial survey and receive Medicare Certification (Title XVIII).
• Step 4: Submit Medicaid enrollment via WVMMIS with Medicare rate letter.
• Step 5: Complete HHAeXchange EVV integration.

10. Common Denials and Survey Findings

OHFLAC and the PERM Review Contractor (Empower AI) frequently cite agencies for documentation failures and EVV mismatches.

Failure to return documentation during PERM audits results in pay-holds and recoupments.

• PERM Audits: Failure to submit medical records to Empower AI results in payment recovery and pay-holds.
• EVV Mismatches: Claims lacking the rendering provider's NPI or failing HHAeXchange validation are denied.
• PA Exhaustion: Billing for visits beyond the 60-visit annual limit without UMC prior authorization.
• POC Lapses: Missing physician signatures on the CMS-485 or failing to update the POC.

11. Key Contacts and Resources

Essential contacts for West Virginia Home Health providers navigating licensure, Medicare certification, and Medicaid enrollment.

Providers should monitor the WVMMIS portal for policy updates and PERM audit announcements.

• OHFLAC: https://ohflac.wvdhhr.org/
• Bureau for Medical Services (BMS): https://bms.wv.gov
• WVMMIS Provider Portal: https://www.wvmmis.com
• WV CARES: https://wvcares.wvdhhr.org/

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