West Virginia - I/DD Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The West Virginia Bureau for Medical Services (BMS) funds the Intellectual and Developmental Disabilities Waiver (IDDW), requiring prospective agencies to secure a Certificate of Need (CON) from the West Virginia Health Care Authority before applying for a behavioral health license through the Office of Health Facility Licensure and Certification (OHFLAC). The IDDW program provides a comprehensive array of home and community-based services, ranging from home-based person-centered support to licensed group home care, designed to prevent institutionalization for individuals diagnosed with intellectual or developmental disabilities prior to age 22.

Agencies must establish a physical office within West Virginia that serves a maximum of eight contiguous counties, as designated in their initial application. Case management-only agencies bypass the OHFLAC behavioral health licensure requirement but must instead obtain direct provider certification from the state's Utilization Management Contractor (UMC) before enrolling as a Medicaid provider.

1. Service Definition and Scope

The West Virginia IDDW program encompasses a broad spectrum of habilitative and supportive services delivered in natural settings, including the member's home, intensively supported settings (ISS), and licensed group homes. Services are authorized based on an annual individualized budget and interdisciplinary team (IDT) assessments.

Providers may offer direct care services, such as Home-Based Person-Centered Support (PCS) and Respite, or professional services like Service Coordination. Extended professional services, including dietary, occupational, physical, and speech therapy, must be explicitly included on the provider agency's Certificate of Need.

• Program Authority: Title XIX of the Social Security Act and Chapter 9 of West Virginia Code.
• Service Manual: BMS Provider Manual Chapter 513 (Intellectual and Developmental Disabilities Waiver).
• Direct Care Services: Includes Home-Based PCS, Crisis Site PCS, and Unlicensed Residential PCS.
• Facility-Based Services: Includes Licensed Group Home PCS (ratios from 1:1 to 1:4).
• Service Coordination: Case management services requiring distinct UMC certification if provided exclusively.
• Extended Professional Staff: Licensed Dietitians, Occupational Therapists, Physical Therapists, and Speech Therapists subcontracted by the IDDW provider.

2. Regulatory and Oversight Agencies

The Bureau for Medical Services (BMS) serves as the single state Medicaid agency overseeing the IDDW program. BMS delegates specific administrative, licensure, and utilization management functions to specialized state offices and contracted entities.

Licensure is handled by the Office of Health Facility Licensure and Certification (OHFLAC), while market entry is controlled by the West Virginia Health Care Authority. The Utilization Management Contractor (UMC), currently KEPRO/Acentra, manages service authorizations and case management certifications.

• Bureau for Medical Services (BMS): Administers the Medicaid program and sets IDDW policy (https://bms.wv.gov/).
• Office of Health Facility Licensure and Certification (OHFLAC): Inspects and issues behavioral health licenses to IDDW providers (https://ohflac.wv.gov/).
• West Virginia Health Care Authority (WVHCA): Reviews and issues the required Certificate of Need (https://hca.wv.gov/).
• Utilization Management Contractor (UMC): KEPRO/Acentra performs administrative functions, authorizations, and case management certification (https://wvaso.acentra.com/).
• Medicaid Fiscal Agent: Molina Medicaid Solutions / DXC operates the Health PAS-Online portal for claims and enrollment (https://www.wvmmis.com/).

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia strictly controls the entry of new IDDW providers through a Certificate of Need (CON) process. An applicant cannot submit a behavioral health license application to OHFLAC or a Medicaid enrollment application to BMS without first securing this approval or a formal exemption.

Additionally, the state imposes strict geographic and physical presence requirements. Providers must operate a physical office within the state and are geographically restricted in their service delivery footprint.

• Certificate of Need (CON): Required approval from the West Virginia Health Care Authority through the full-length CON process or Summary Review process.
• Physical Office Mandate: Providers must designate and staff at least one physical office physically located in West Virginia; P.O. boxes or commercial mailboxes are prohibited.
• Geographic Restriction: An agency office site can serve no more than eight contiguous counties in West Virginia.
• Service Area Expansion: Changes to the approved eight-county service area can only be requested annually and require written approval from the UMC.
• Extended Therapy CON: To contract with extended professionals (PT, OT, Speech, Dietary), those specific services must be explicitly listed on the agency's CON.

4. Licensure and Certification Requirements

Most IDDW providers must obtain a behavioral health license from OHFLAC to operate legally in West Virginia. This licensure process involves submitting the approved CON, passing life safety and programmatic inspections, and demonstrating compliance with state behavioral health standards.

Agencies that exclusively provide Service Coordination (case management) are exempt from OHFLAC licensure. Instead, they must apply for and maintain Provider Agency Certification directly through the UMC.

• Standard Licensure: Behavioral health license issued by OHFLAC, required for all direct-care and residential IDDW providers.
• Case Management Exemption: Case management-only agencies do not require OHFLAC licensure.
• UMC Certification: Required for case management-only agencies; involves submitting an application directly to KEPRO/Acentra.
• Business Licensure: All applicants must hold a valid business license issued by the state of West Virginia.
• Organizational Documentation: UMC certification requires submission of an organizational chart, Board of Directors list (if applicable), and a Quality Management Plan.

5. Medicaid Provider Enrollment

After securing the necessary CON and OHFLAC license (or UMC certification), agencies must enroll as West Virginia Medicaid providers. Enrollment is processed through the DXC Health PAS-Online web portal.

Providers must sign a valid provider agreement with BMS specifically for the IDDW program, in addition to the standard Medicaid enrollment agreement, acknowledging compliance with Chapter 300 and Chapter 513 manual requirements.

• Enrollment Portal: Applications are submitted via the DXC Health PAS-Online portal (https://www.wvmmis.com/).
• Provider Agreement: Must maintain a valid provider agreement signed by the IDDW provider and BMS.
• General Requirements: Must meet all stipulations in Chapter 300, Provider Participation Requirements.
• Program-Specific Requirements: Must meet all stipulations in Chapter 513, Intellectual and Developmental Disabilities Waiver.
• Tax Identification: Must supply a Federal Tax Identification Number (FEIN) during enrollment.

6. Staffing, Training and Background Checks

IDDW agencies must ensure all staff meet the qualifications outlined in the Chapter 513 manual. Recent Electronic Visit Verification (EVV) mandates require specific direct-care workers to obtain unique identifiers to link their services to the employing agency.

Agencies must maintain a roster of all staff and their qualifications, and ensure that extended professional staff (therapists) are themselves enrolled Medicaid providers who subcontract with the agency.

• NPI Requirement: Direct-care workers billing for Home-Based PCS, Respite, and Non-Medical Transportation must obtain a National Provider Identifier (NPI).
• Direct-Care Taxonomy: Workers registering for an NPI on the NPPES website must use taxonomy code 3747P1801X.
• Service Coordinator Taxonomy: Service Coordinators must use taxonomy code 171M00000X when applying for an NPI.
• EVV Linkage: Agencies must link their workers' NPIs to the agency profile on the DXC Health PAS-Online web portal.
• Subcontractor Enrollment: Extended Professional Staff (Dietitians, OTs, PTs, SLPs) must be individually enrolled WV Medicaid providers.

7. Documentation, Policies and Records

Providers must maintain comprehensive documentation to support all billed services and demonstrate compliance with waiver rules. All required documentation forms are standardized and published on the BMS website.

Agencies must implement specific internal policies, particularly regarding grievance procedures and quality management, to protect member rights and ensure continuous service improvement.

• Quality Management Plan: A formal, written plan required for agency certification and ongoing compliance.
• Grievance Policy: Written policies and procedures for processing complaints and grievances from staff or members.
• Non-Retaliation Policy: Must ensure members or staff are not discharged or retaliated against for filing complaints or participating in investigations.
• Staff Qualifications List: Agencies must maintain an updated list of all agency staff including their verified qualifications.
• Standardized Forms: Providers must use the official documentation forms provided on the BMS IDDW webpage.

8. Billing, Rates and Claims

Claims for IDDW services are processed by Molina Medicaid Solutions (the BMS Fiscal Agent) through the WVMMIS system. Services must be prior-authorized by the UMC and provided within the member's annual individualized budget.

Rates are established by BMS and vary based on the service type, setting, and staffing ratio. Providers must bill using specific HCPCS codes and modifiers that correspond to the authorized service level.

• Claims Processor: Molina Medicaid Solutions handles all claims via WVMMIS (https://www.wvmmis.com/).
• Home-Based PCS 1:1: Billed using code S5125 with modifier U7.
• Home-Based PCS 1:2: Billed using code S5125 with modifier U8.
• In-Home Respite 1:1: Billed using code T1005 with modifier UA.
• Service Coordination: Billed using code T1016 with modifier HI.
• Prior Authorization: All services must be authorized by the UMC (KEPRO/Acentra) prior to claim submission.

9. Approval Sequence and Timeline

Becoming an IDDW provider is a sequential, multi-agency process that cannot be expedited by skipping steps. The process begins with the Health Care Authority and ends with Medicaid enrollment activation.

Because the Certificate of Need process involves public notice and review periods, and OHFLAC licensure requires physical site inspections, prospective providers should anticipate a lengthy startup timeline.

• Step 1: Obtain Certificate of Need (CON) approval from the WV Health Care Authority.
• Step 2: Secure a physical office location within West Virginia.
• Step 3: Apply for and pass inspections to obtain an OHFLAC behavioral health license (or UMC certification for case management).
• Step 4: Submit Medicaid enrollment application via DXC Health PAS-Online.
• Step 5: Ensure all direct-care staff obtain NPIs and link them to the agency in the EVV system.

10. Common Denials and Survey Findings

Applications are frequently rejected at the initial stages if the prospective provider attempts to bypass the Certificate of Need requirement or fails to establish a compliant physical presence in the state.

During OHFLAC surveys or UMC audits, established providers often face citations for failing to maintain updated staff qualifications, exceeding their approved eight-county service area, or lacking required EVV NPI linkages.

• Missing CON: Immediate rejection of licensure or enrollment applications if the WVHCA Certificate of Need is absent.
• Out-of-State Office: Denial of enrollment if the agency attempts to use a P.O. Box or an office located outside West Virginia borders.
• Service Area Violations: Providing services in a county outside the agency's approved contiguous eight-county footprint without prior UMC approval.
• EVV Non-Compliance: Claims denials resulting from direct-care workers lacking an NPI or failing to link it in the DXC portal.
• Unapproved Therapies: Contracting for extended professional services (like PT or OT) when those services are not explicitly listed on the agency's CON.

11. Key Contacts and Resources

Prospective providers must interact with multiple state systems and contractors to complete the enrollment process. The BMS Provider Manual Chapter 513 is the primary regulatory document governing the IDDW program.

Providers should bookmark the portals for the UMC, the Medicaid fiscal agent, and the state licensure office to ensure they access the most current forms and bulletins.

• Bureau for Medical Services (BMS): 350 Capitol Street, Room 251, Charleston, WV 25301 (https://bms.wv.gov/).
• OHFLAC: 408 Leon Sullivan Way, Charleston, WV 25301 (https://ohflac.wv.gov/).
• Utilization Management Contractor (KEPRO/Acentra): 100 Capitol Street, Suite 600, Charleston, WV 25301 (https://wvaso.acentra.com/).
• Medicaid Claims/Enrollment (Molina/DXC): Health PAS-Online portal (https://www.wvmmis.com/).
• WV Health Care Authority (CON): Oversees the Certificate of Need process (https://hca.wv.gov/).

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