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

Last reviewed: 2026-08-16

West Virginia's Intellectual and Developmental Disabilities Waiver (IDDW) is a 1915(c) Medicaid waiver providing home and community-based services (HCBS) to individuals with I/DD. Administered by the Bureau for Medical Services (BMS), the program covers a comprehensive array of supports, from case management and behavior support to supported living and crisis intervention, allowing members to live in their communities rather than in Intermediate Care Facilities (ICF/IIDs).

The single biggest structural barrier to entry for prospective IDDW providers in West Virginia is obtaining a Behavioral Health Center (BHC) license from the Office of Health Facility Licensure and Certification (OHFLAC) prior to Medicaid enrollment. While there is no Certificate of Need (CON) or closed-network RFP required for standard IDDW waiver services, the OHFLAC licensure process is rigorous, requiring comprehensive policy reviews and on-site life safety inspections before the state's Medicaid fiscal agent will even accept a provider enrollment application.

1. Service Definition and Scope

The IDDW program is administered by the Bureau for Medical Services (BMS) under Chapter 513 of the West Virginia Medicaid Provider Manual. It is designed to maximize independence and community integration for individuals with intellectual and developmental disabilities.

Providers can be approved to deliver various services within the waiver array, provided they meet the specific credentialing and licensure requirements for each distinct service type.

• Service Array: Includes case management, behavior support, crisis services, electronic monitoring, supported living, and extended professional services (PT, OT, Speech, Dietary).
• Target Population: West Virginia residents aged three or older with an I/DD diagnosis manifesting before age 22.
• Setting Requirements: Services must be delivered in HCBS-compliant settings (homes, communities, workplaces) rather than institutional ICF/IID settings.
• Governing Manual: Operations and service definitions are strictly governed by the WV BMS Provider Manual Chapter 513 (Intellectual and Developmental Disabilities Waiver).

2. Regulatory and Oversight Agencies

Oversight of the IDDW program is divided among the state Medicaid agency, the state licensing body, and a contracted utilization management entity. Providers must interact with all of these entities to maintain compliance, licensure, and authorization to bill.

Failure to maintain good standing with any single oversight agency will result in the suspension of Medicaid billing privileges and potential revocation of the provider's operating license.

• Bureau for Medical Services (BMS): The state Medicaid agency responsible for overall IDDW policy, funding, and provider enrollment (https://bms.wv.gov/).
• Office of Health Facility Licensure and Certification (OHFLAC): The regulatory body that licenses Behavioral Health Centers and conducts life safety and compliance surveys (https://oig.wv.gov/OHFLAC).
• Acentra Health: The contracted Utilization Management Contractor (UMC) that handles functional assessments, service authorizations, and annual provider reviews (https://wvaso.acentra.com/wv-aso-intellectual-developmental-disabilities/).
• Gainwell Technologies: The fiscal agent managing the WVMMIS provider enrollment portal and claims processing system (https://www.wvmmis.com).

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia genuinely does not utilize a closed network, Request for Proposals (RFP) procurement, moratoria, or Certificate of Need (CON) process for standard IDDW home and community-based services. The market is open enrollment for any agency that can meet the structural and licensing prerequisites.

However, the absolute gatekeeper is the OHFLAC Behavioral Health Center (BHC) licensure. An agency cannot simply apply to West Virginia Medicaid as an IDDW provider; it must first secure this state license, which requires a physical commercial office in West Virginia and a fully developed operational infrastructure ready for state inspection.

• Certificate of Need (CON): Genuinely not required for IDDW HCBS services, though it remains required for institutional ICF/IID facilities.
• Network Status: Open enrollment; there are no moratoria, RFPs, or closed managed care networks blocking new IDDW providers.
• Licensure Prerequisite: Applicants must obtain an OHFLAC Behavioral Health Center (BHC) license before the WVMMIS Medicaid enrollment application will be accepted.
• Business Registration: Must be registered and in good standing with the West Virginia Secretary of State.
• Physical Location: Must maintain a physical administrative office within West Virginia that is subject to OHFLAC inspection.

4. Licensure and Certification Requirements

To provide direct care, supported living, or day services under the IDDW, agencies must be licensed as a Behavioral Health Center (BHC) by OHFLAC. This process is governed by West Virginia Code of State Rules (CSR) Title 64, Series 11.

The licensure process involves submitting a detailed application, paying applicable fees, and passing an initial on-site survey that reviews physical plant safety, administrative policies, and clinical protocols.

• Governing Rule: West Virginia CSR 64-11 (Behavioral Health Centers Licensure).
• Application Portal: Submitted directly to OHFLAC's Behavioral Health program unit via paper application or their designated state portal.
• Initial Survey: Requires an on-site inspection by OHFLAC surveyors to verify compliance with life safety codes and administrative rules.
• HCBS Settings Rule: New settings must pass an HCBS compliance validation to ensure they do not have institutional characteristics.
• License Renewal: BHC licenses are typically issued for one year and require annual renewal and periodic re-survey by OHFLAC.

5. Medicaid Provider Enrollment

Once OHFLAC licensure is secured, providers must enroll with the Bureau for Medical Services (BMS) through the West Virginia Medicaid Management Information System (WVMMIS). Gainwell Technologies operates this portal as the state's fiscal agent.

Providers must enroll under specific provider types and specialties corresponding to IDDW services, submitting their OHFLAC license, NPI, and ownership disclosures for federal screening.

• Enrollment Portal: WVMMIS Provider Enrollment Portal managed by Gainwell Technologies (https://www.wvmmis.com).
• Application Fee: Subject to the federally mandated Medicaid provider application fee (approximately $732) unless waived by concurrent Medicare enrollment.
• Required Documents: IRS W-9, OHFLAC BHC license, proof of general and professional liability insurance, and Secretary of State business registration.
• Provider Agreement: Must sign the WV Medicaid Provider Agreement binding the agency to Chapter 513 manual rules.
• Revalidation: Providers must revalidate their Medicaid enrollment every five years through the WVMMIS portal.

6. Staffing, Training and Background Checks

West Virginia mandates strict background screening and training protocols for all IDDW staff. The state utilizes the WV CARES (Clearance for Access: Registry & Employment Screening) system for mandatory fingerprint-based background checks.

Direct Support Professionals (DSPs) and clinical staff must meet the specific educational and training requirements outlined in Chapter 513 before providing billable services to waiver members.

• Background Checks: Mandatory fingerprint-based state and federal criminal history checks processed exclusively through WV CARES.
• Registry Checks: Must clear the West Virginia State Police abuse registry, Medicaid exclusion list (OIG LEIE), and state nurse aide registry.
• Basic Training: DSPs must hold current CPR and First Aid certifications prior to independent client contact.
• Program-Specific Training: Staff must complete training on the member's specific Individualized Support Plan (ISP) and positive behavior support plans.
• Clinical Qualifications: Psychologists, RNs, and therapists must hold active, unencumbered West Virginia state licenses in their respective disciplines.

7. Documentation, Policies and Records

IDDW providers must maintain comprehensive clinical and administrative records subject to audit by BMS, OHFLAC, and Acentra Health. Documentation must strictly align with the member's authorized Individualized Support Plan (ISP).

Agencies are required to have robust internal policies covering incident reporting, medication administration, and grievance procedures as dictated by BHC licensure rules.

• Service Notes: Must include date, start/stop times, specific interventions linked to the ISP, and the signature of the staff providing the service.
• Incident Reporting: Critical incidents (abuse, neglect, exploitation, death) must be reported to OHFLAC and Acentra Health within 24 hours.
• Medication Administration: Must follow OHFLAC Approved Medication Assistive Personnel (AMAP) rules if unlicensed staff administer medications.
• Record Retention: Medicaid records must be retained for a minimum of five years from the date of service or longer if under active audit.
• Quality Assurance: Providers must maintain an internal Quality Improvement (QI) committee and policy as mandated by CSR 64-11.

8. Billing, Rates and Claims

IDDW services are billed on a fee-for-service basis directly to West Virginia Medicaid through the WVMMIS portal. There are no managed care organizations (MCOs) intermediating IDDW waiver claims in West Virginia.

Rates are standardized and published by BMS. Providers must ensure that all billed services have a matching prior authorization from Acentra Health, or the claim will automatically deny.

• Claims System: Billed via the WVMMIS portal operated by Gainwell Technologies using standard 837P or CMS-1500 formats.
• Prior Authorization: All IDDW services require prior authorization from Acentra Health; claims without matching PA will deny.
• Rate Schedule: Standardized fee schedule published annually by BMS; providers cannot negotiate rates.
• Billing Units: Most direct care services (e.g., supported living, behavior support) are billed in 15-minute increments.
• EVV Requirement: Personal care and in-home direct care services are subject to federal Electronic Visit Verification (EVV) mandates.

9. Approval Sequence and Timeline

Becoming a fully approved IDDW provider in West Virginia is a sequential process that typically takes 6 to 9 months from initial business formation to billing the first claim.

The timeline is heavily dependent on the provider's readiness for the OHFLAC initial survey and the processing times at Gainwell Technologies for Medicaid enrollment.

• Step 1: Business Formation: Register with the WV Secretary of State and obtain an EIN and NPI (1-2 weeks).
• Step 2: OHFLAC Licensure: Submit BHC application, prepare policies, and pass the initial on-site life safety/administrative survey (3-5 months).
• Step 3: Medicaid Enrollment: Submit application via WVMMIS with the approved OHFLAC license (45-90 days).
• Step 4: UMC Registration: Register with Acentra Health's CareConnection portal to receive authorizations (1-2 weeks).
• Step 5: WV CARES Setup: Establish an account for employee background screening prior to hiring direct care staff (concurrent with Step 3).

10. Common Denials and Survey Findings

Provider applications and ongoing operations frequently face delays or sanctions due to incomplete documentation or failure to adhere to life safety codes. OHFLAC and Acentra Health conduct rigorous oversight.

New applicants often fail the initial OHFLAC survey because their physical locations lack required safety features or their policy manuals are generic and not tailored to West Virginia CSR 64-11.

• Application Denials: WVMMIS applications rejected due to missing IRS W-9s, mismatched NPI data, or lack of the required OHFLAC license.
• Life Safety Deficiencies: OHFLAC survey failures due to inadequate fire alarm systems, missing evacuation plans, or improper water temperatures in residential settings.
• Background Check Violations: Citations for allowing staff to provide direct care before receiving full WV CARES clearance.
• Documentation Audits: Recoupment of funds by BMS due to missing start/stop times or lack of staff signatures on service notes.
• AMAP Failures: Deficiencies cited for improper medication storage or administration by staff lacking current AMAP certification.

11. Key Contacts and Resources

Prospective IDDW providers should bookmark the primary regulatory portals and manuals. Technical assistance is available through Acentra Health and the BMS provider relations team.

Maintaining open communication with OHFLAC regarding licensure status is critical during the startup phase.

• Bureau for Medical Services (BMS): IDDW Program policy and Chapter 513 manuals (https://bms.wv.gov/).
• OHFLAC: Behavioral Health Center licensure and survey information (https://oig.wv.gov/OHFLAC).
• Acentra Health (UMC): CareConnection portal, provider training, and authorizations (https://wvaso.acentra.com/wv-aso-intellectual-developmental-disabilities/).
• WVMMIS / Gainwell Technologies: Medicaid provider enrollment and claims portal (https://www.wvmmis.com).
• WV CARES: State background check registry system (https://www.wvdhhr.org/wvcares/).

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