West Virginia - Personal Assistance Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

West Virginia’s Bureau for Medical Services (BMS) administers Personal Care Services under Chapter 517 of the Medicaid Provider Manual and the Aged and Disabled Waiver (ADW), requiring prospective agencies to secure a Certificate of Need (CON) from the West Virginia Health Care Authority before initiating provider enrollment. The service delivers hands-on assistance with activities of daily living, such as bathing, dressing, and transferring, to medically eligible residents in their own homes.

Approval mandates a sequential process beginning with the CON, followed by a Certification Application submitted to the Operating Agency, and final enrollment through the WVMMIS portal managed by Gainwell Technologies. Agencies must establish a physical, ADA-compliant office within West Virginia that is open to the public at least 40 hours per week and maintain strict fingerprint-based background check protocols for all direct care staff.

1. Service Definition and Scope

West Virginia Medicaid defines Personal Care Services as direct, hands-on assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) provided in the member's residence. Services are governed by Chapter 517 of the BMS Provider Manual and cannot solely involve ancillary tasks like housekeeping.

• Covered Tasks: bathing, dressing, transferring, toileting, and personal hygiene.
• Excluded Tasks: services solely involving housekeeping or chore assistance.
• Age Restrictions: none; available to eligible members of all ages.
• Family Member Restriction: spouses and parents of minor children (under 18) cannot be reimbursed as direct care workers.
• Medical Eligibility: determined via the Pre-Admission Screening (PAS) tool.

2. Regulatory and Oversight Agencies

Multiple state entities oversee the certification, need-determination, and enrollment of Personal Care providers in West Virginia. The Department of Health and Human Resources (DHHR) umbrella includes the Bureau for Medical Services (BMS) and the Office of Health Facility Licensure and Certification (OHFLAC).

• Bureau for Medical Services (BMS): administers the Medicaid program and sets Chapter 517 policy (https://bms.wv.gov).
• West Virginia Health Care Authority (WVHCA): reviews and issues the required Certificate of Need (https://hca.wv.gov).
• Office of Health Facility Licensure and Certification (OHFLAC): conducts facility and agency surveys and investigations (https://ohflac.wvdhhr.org/).
• Gainwell Technologies: operates the WVMMIS Medicaid provider enrollment portal (https://www.wvmmis.com).

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia strictly regulates market entry for Personal Care Services through a Certificate of Need (CON) program. An applicant cannot submit a Certification Application to the Operating Agency or enroll in Medicaid without first obtaining this statutory approval.

• Certificate of Need (CON): mandatory approval from the WV Health Care Authority demonstrating financial feasibility and alignment with the WV State Health Plan.
• CON Exemptions: limited strictly to Senior Centers, WV licensed Comprehensive Behavioral Health Care Centers, and Specialized Family Care Providers.
• Physical Location: must maintain a physical business office located within the state of West Virginia.
• Accessibility: the physical office must meet Americans with Disabilities Act (ADA) requirements (28 CFR 36).
• Operating Hours: must have posted hours showing the business is open to the public at least 40 hours per week.

4. Licensure and Certification Requirements

After securing a CON, agencies must obtain provider certification from the Operating Agency before Medicaid enrollment. This certification verifies the agency's operational readiness, business standing, and communication infrastructure.

• Certification Application: submitted to the Operating Agency demonstrating compliance with Chapter 517.3 standards.
• Business License: must hold and maintain a valid business license issued by the State of West Virginia.
• Tax Identification: must provide a federal tax identification number (FEIN).
• Communication Infrastructure: must maintain a primary telephone listed under the business name (pagers, cell phones, or shared lines are prohibited).
• Secure Email: must maintain a HIPAA-compliant email address for official communication with BMS and the Operating Agency.

5. Medicaid Provider Enrollment

Certified agencies must enroll as billing providers through the West Virginia Medicaid Management Information System (WVMMIS). Enrollment requires agreeing to the stipulations in Common Chapter 300 (Provider Participation) and Chapter 800(A) (General Administration).

• Enrollment Portal: applications are processed online via the Gainwell Technologies WVMMIS provider portal.
• Provider Agreement: applicants must sign the standard BMS provider agreement binding them to state and federal Medicaid regulations.
• NPI Requirement: agencies must obtain and register a Type 2 National Provider Identifier (NPI).
• Application Fee: subject to the ACA institutional provider application fee unless waived by Medicare or another state's Medicaid program.
• Revalidation: enrolled providers must revalidate their Medicaid enrollment at least every five years.

6. Staffing, Training and Background Checks

Agencies must employ qualified Direct Care Staff and at least one Registered Nurse (RN) to oversee care. West Virginia mandates strict background checks and competency-based training prior to independent client contact.

• RN Qualifications: must hold a current West Virginia RN license with documentation maintained in the employee file.
• State Background Check: fingerprint-based Criminal Investigation Bureau (CIB) check via the WV State Police contracted entity, required initially and every three years.
• Federal Background Check: FBI background check required if the prospective employee has lived out of state within the last five years.
• Registry Checks: mandatory screening against the OIG Exclusion List, CNA Registry, Board of Nursing, and WV DHHR Protective Services Record.
• CPR/First Aid: direct care staff must hold valid certification from the American Heart Association, American Red Cross, or an approved entity.
• Training Curriculum: staff must complete an Operating Agency-approved Competency Based Curriculum demonstrating skills in required care areas.

7. Documentation, Policies and Records

Providers must maintain comprehensive, legible records to justify the medical necessity of all billed services. Records are subject to audit and desk review by BMS, OHFLAC, or designated contractors.

• Medical Eligibility: files must contain the approved Pre-Admission Screening (PAS) certifying the individual's need for care.
• Personnel Files: must include continuous RN licensure documentation, background check results, and documented evidence of CPR/First Aid training.
• Service Documentation: daily logs must accurately reflect the specific ADL/IADL tasks performed, matching the authorized care plan.
• Record Retention: records must be retained in accordance with Common Chapter 100 (General Information) guidelines.
• Audit Access: agencies must make all board members, staff, and records available for BMS or Operating Agency compliance reviews.

8. Billing, Rates and Claims

Reimbursement for Personal Care Services is processed through the BMS Fiscal Agent. Providers must only bill for services that are prior authorized and delivered in accordance with the member's approved care plan.

• Fiscal Agent: claims are submitted to and processed by Gainwell Technologies.
• Billing Manual: procedures are governed by Chapter 517 of the BMS Provider Manual and supplemented by Common Chapter 200.
• Prior Authorization: services must be authorized based on the PAS and care plan before claims will be paid.
• Non-Covered Services: any service, procedure, or item not explicitly discussed in the manual is presumed non-covered and non-billable.
• Rate Publication: fee schedules are published and updated on the BMS website under the Provider Fee Schedules section.

9. Approval Sequence and Timeline

The pathway to becoming a billing provider is strictly sequential, heavily front-loaded by the CON process. Agencies cannot bypass steps or operate conditionally while awaiting final Medicaid approval.

• Step 1: Submit a Letter of Intent and subsequent Certificate of Need application to the WV Health Care Authority.
• Step 2: Obtain a West Virginia state business license and establish a compliant physical office.
• Step 3: Submit the Certification Application to the Operating Agency with the approved CON and business credentials.
• Step 4: Complete fingerprint-based background checks and training for initial RN and direct care staff.
• Step 5: Submit the Medicaid provider enrollment application via WVMMIS.

10. Common Denials and Survey Findings

Applications and ongoing certifications are frequently delayed or revoked due to administrative omissions or failure to maintain physical office standards. Surveyors strictly enforce background check timelines and training documentation.

• CON Absence: immediate rejection of the Certification Application if the agency lacks an approved Certificate of Need or valid exemption.
• Office Non-Compliance: failure to maintain a physical WV office open to the public for the required 40 hours per week.
• Communication Failures: using a cell phone, pager, or shared line as the primary business telephone.
• Background Check Lapses: missing the three-year renewal window for state CIB fingerprint checks for direct care staff.
• Training Deficiencies: expired CPR/First Aid cards or missing competency evaluations in personnel files.

11. Key Contacts and Resources

Prospective providers must coordinate with multiple state divisions to navigate the CON, certification, and enrollment phases. The primary regulatory frameworks are hosted on the BMS and OHFLAC portals.

• Bureau for Medical Services (BMS): https://bms.wv.gov
• WV Health Care Authority (CON Program): https://hca.wv.gov
• Office of Health Facility Licensure and Certification (OHFLAC): https://ohflac.wvdhhr.org/
• WVMMIS Provider Portal (Gainwell Technologies): https://www.wvmmis.com
• BMS Provider Manuals (Chapter 517): https://dhhr.wv.gov/bms/Pages/ProviderManuals.aspx

See all West Virginia services · West Virginia Medicaid consulting · book a consultation.