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

Last reviewed: 2026-08-16

In West Virginia, Personal Assistance Services are primarily delivered through the Medicaid Personal Care Services (PCS) Program under the State Plan, and the Aged and Disabled Waiver (ADW). These programs provide hands-on assistance with Activities of Daily Living (ADLs) such as bathing, dressing, transferring, and toileting, as well as Instrumental Activities of Daily Living (IADLs) like light housekeeping and meal preparation, allowing individuals to remain safely in their own homes.

The single biggest structural barrier to entry in West Virginia is that the state does not issue a specific "non-medical home care" license, meaning approval hinges entirely on Medicaid provider enrollment, Bureau of Senior Services (BoSS) certification, and Managed Care Organization (MCO) network contracting. If a provider chooses to offer these services as a licensed Home Health Agency to include skilled nursing, they face a strict Certificate of Need (CON) requirement from the West Virginia Health Care Authority, which severely limits new market entrants based on geographic need.

1. Service Definition and Scope

West Virginia defines these services under two main authorities: the State Plan Personal Care Services (PCS) Program and the Aged and Disabled Waiver (ADW). Both programs are designed to prevent institutionalization by providing in-home support to individuals who require assistance with daily functioning.

Services must be delivered in the member's home or community and cannot duplicate care already provided by residential facilities like assisted living or adult family care homes. Care is strictly non-medical and must be guided by an individualized plan of care developed by a Registered Nurse.

• Program Names: West Virginia Medicaid Personal Care Services (PCS) and the Aged and Disabled Waiver (ADW).
• ADL Support: Hands-on assistance with bathing, dressing, grooming, eating, mobility, and toileting.
• IADL Support: Light housekeeping, meal preparation, and essential shopping, provided these are incidental to the ADL care.
• Setting Restrictions: Services are delivered in the member's personal residence; they are generally not payable if the member resides in an adult family care home or assisted living facility.
• Self-Direction: West Virginia allows a self-directed model (Personal Options) where members hire their own workers, but agency-directed providers must supply their own W-2 employees.
• Service Limits: State Plan PCS participants can receive up to 210 hours per month based on their medical necessity evaluation.

2. Regulatory and Oversight Agencies

Because West Virginia does not separately license non-medical personal care agencies, oversight is driven by the agencies that control Medicaid funding and waiver operations. The Bureau for Medical Services (BMS) is the primary Medicaid authority.

For waiver-specific operations, the Bureau of Senior Services (BoSS) manages provider certification. If a provider operates as a Home Health Agency, they are regulated by the Office of Health Facility Licensure and Certification (OHFLAC).

• Medicaid Authority: West Virginia Bureau for Medical Services (BMS) (https://bms.wv.gov)
• Waiver Operating Agency: West Virginia Bureau of Senior Services (BoSS) (https://adwprogram.wv.gov)
• Licensing Agency (Home Health): Office of Health Facility Licensure and Certification (OHFLAC) (https://oig.wv.gov/OHFLAC)
• Utilization Management: Acentra Health (formerly KEPRO) (https://wva.acentra.com)
• Medicaid Portal: WVMMIS via Gainwell Technologies (https://www.wvmmis.com)
• State Plan PCS Information: West Virginia Personal Care Services Program (https://pcs.wv.gov)

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia presents a unique gatekeeping environment. There is no state licensure requirement or Certificate of Need (CON) for standalone, non-medical personal care agencies. However, to receive Medicaid reimbursement, providers must pass strict enrollment and certification gates.

For State Plan PCS, the primary barrier is securing network contracts with the state's Managed Care Organizations (MCOs). For the ADW program, providers must pass a readiness review and obtain certification from the Bureau of Senior Services (BoSS) before Gainwell Technologies will accept their Medicaid enrollment application.

• Certificate of Need (CON): Required ONLY if applying as a licensed Home Health Agency (issued by WV Health Care Authority); strictly limits new market entrants based on county need.
• Non-Medical Exemption: Standalone non-medical personal care agencies do not require a CON or OHFLAC license to operate, bypassing the state's strictest barrier.
• MCO Contracting: Required for State Plan PCS; providers must secure network contracts with MCOs (e.g., Aetna Better Health, The Health Plan, UniCare) to be reimbursed.
• Waiver Certification: ADW providers must apply to and be certified by the Bureau of Senior Services (BoSS) prior to submitting a Medicaid enrollment application.
• Business Registration: Applicants must hold a valid West Virginia Business Registration Certificate from the State Tax Department before applying to any state agency.

4. Licensure and Certification Requirements

West Virginia explicitly does not license non-medical home care or personal care agencies as a distinct category. Providers operate legally as standard businesses that hold Medicaid provider agreements.

If a provider wishes to offer skilled nursing or therapy alongside personal care, they must obtain a Home Health Agency license from OHFLAC under Legislative Rule 64-39, which triggers the CON requirement mentioned above.

• Licensure Status: West Virginia does not separately license non-medical personal care agencies; no OHFLAC application is required for non-medical providers.
• Home Health Alternative: Providers seeking to offer skilled care must obtain a Home Health Agency license via OHFLAC (Legislative Rule 64-39).
• BoSS Readiness Review: ADW applicants must pass a comprehensive policy and procedure review by BoSS to ensure compliance with waiver standards.
• NPI Requirement: Agencies must obtain a Type 2 (Organizational) National Provider Identifier (NPI) from the NPPES registry.
• Liability Insurance: Providers must maintain general and professional liability insurance as dictated by BMS provider manuals.
• Physical Office: Providers must maintain a physical business office in West Virginia or a border county, with secure storage for HIPAA-compliant records.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed through the West Virginia Medicaid Management Information System (WVMMIS), operated by Gainwell Technologies. Providers must enroll under specific provider types depending on the program they intend to serve.

Enrollment requires paying the federal application fee and submitting proof of BoSS certification (for ADW) or MCO credentialing intent (for PCS).

• Enrollment Portal: WVMMIS Provider Enrollment Portal operated by Gainwell Technologies (https://www.wvmmis.com).
• Provider Types: Enroll as Provider Type 74 for State Plan Personal Care Services, or Provider Type 59 for the Aged and Disabled Waiver.
• Application Fee: Subject to the federal Medicaid/Medicare institutional application fee (approximately $732) unless waived by prior Medicare enrollment.
• EFT Setup: Must complete Electronic Funds Transfer (EFT) authorization during the Gainwell enrollment process to receive payments.
• Revalidation: Providers must revalidate their Medicaid enrollment every five years through the WVMMIS portal.
• Ownership Disclosure: Must complete strict disclosures of ownership and control interest to comply with federal Medicaid integrity rules.

6. Staffing, Training and Background Checks

Direct care workers, known as Personal Attendants, must meet specific age, education, and training requirements set by BMS. Agencies must also employ or contract with a Registered Nurse (RN) to oversee clinical operations.

Background checks are centralized and strictly enforced through the WV CARES system, which conducts fingerprint-based state and federal criminal history checks.

• Background Checks: Mandatory fingerprint-based state and federal background checks via WV CARES (West Virginia Clearance for Access: Registry and Employment Screening) (https://wvcares.wvdhhr.org).
• Basic Qualifications: Personal Attendants must be at least 18 years old and possess a high school diploma, GED, or demonstrate the ability to read and write.
• Initial Training: Attendants must complete a state-approved training curriculum covering CPR, First Aid, and ADL assistance techniques before providing independent care.
• RN Supervision: Agencies must employ or contract with an RN to conduct initial member assessments, develop care plans, and perform periodic supervisory visits.
• Family Caregivers: Under the agency-directed model, legally responsible individuals (such as spouses) cannot be hired as paid caregivers.
• OIG Exclusion: Agencies must check all staff monthly against the federal OIG List of Excluded Individuals/Entities (LEIE).

7. Documentation, Policies and Records

Providers must maintain rigorous clinical and financial records to justify Medicaid billing. The Utilization Management Contractor (Acentra Health) dictates the functional assessments that form the basis of the care plan.

West Virginia mandates the use of Electronic Visit Verification (EVV) for all personal care services to comply with the federal 21st Century Cures Act.

• Care Plans: The supervising RN must develop an individualized Plan of Care based on the Medical Necessity Evaluation Request (MNER) and Acentra Health's assessment.
• EVV Compliance: Must use a compliant Electronic Visit Verification (EVV) system to capture the date, time, location, and type of service for every shift.
• Service Logs: Must maintain daily documentation detailing the specific ADLs and IADLs performed, matching the authorized care plan.
• Incident Reporting: Must have policies for reporting critical incidents (abuse, neglect, exploitation) to Adult Protective Services and BMS within 24 hours.
• Supervisory Notes: The RN must document all in-home supervisory visits, noting the attendant's competency and any changes in the member's condition.
• Record Retention: All Medicaid billing, EVV data, and clinical records must be retained for a minimum of five years.

8. Billing, Rates and Claims

Billing procedures depend on the program. ADW services are billed directly to WVMMIS (fee-for-service), while State Plan PCS claims are submitted to the member's respective Managed Care Organization (MCO).

All services require prior authorization from Acentra Health, and claims will be denied if they are not supported by matching EVV data.

• Billing System: Claims are submitted via WVMMIS (Gainwell) for ADW, or through MCO clearinghouses for State Plan PCS, using standard CMS-1500 formats.
• Procedure Codes: T1019 is the standard code for Personal Care Services, typically billed in 15-minute increments.
• Prior Authorization: All services must be prior-authorized by Acentra Health (UMC) before any care is delivered or billed.
• EVV Tie-in: Claims submitted without corresponding, validated EVV data will be automatically denied by the MMIS or MCO.
• Rate Setting: Reimbursement rates are established by BMS and published in the annual fee schedules on the BMS website.
• Third-Party Liability: Medicaid is the payer of last resort; providers must bill any applicable long-term care insurance before billing Medicaid.

9. Approval Sequence and Timeline

Becoming a fully approved provider takes several months due to the sequential nature of the process. Providers cannot enroll in Medicaid until they have their business structure and program-specific certifications in place.

MCO credentialing for State Plan PCS is often the longest phase, as each health plan conducts its own network adequacy and credentialing review.

• Step 1: Business Registration: Register the entity with the WV Secretary of State and obtain a State Tax Department certificate (1-2 weeks).
• Step 2: BoSS Certification (ADW Only): Submit policies and procedures to the Bureau of Senior Services for readiness review and certification (2-3 months).
• Step 3: WVMMIS Enrollment: Submit the Medicaid provider application via Gainwell Technologies, paying the application fee (30-60 days).
• Step 4: WV CARES Setup: Register the agency in the WV CARES system to begin processing staff background checks (2-4 weeks).
• Step 5: MCO Credentialing (PCS Only): Apply for network contracts with WV Medicaid MCOs (90-120 days).

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete ownership disclosures or failure to pay the federal application fee. Once operational, providers face strict audits from BMS and MCOs.

Audit failures most commonly stem from EVV discrepancies and lapses in required RN supervision.

• Application Denial: Failure to provide a valid Type 2 NPI or incomplete ownership disclosure forms in the Gainwell portal.
• Audit Failure: Missing or incomplete Electronic Visit Verification (EVV) data that fails to match the billed claims.
• Supervision Lapses: The RN failing to conduct and document the required periodic supervisory visits in the member's home.
• Background Check Violations: Allowing a Personal Attendant to begin providing care before their WV CARES background check has fully cleared.
• Care Plan Deviations: Billing for tasks or hours not explicitly authorized in the Acentra Health-approved plan of care.
• Unapproved Settings: Billing for services provided while the member was admitted to a hospital or nursing facility.

11. Key Contacts and Resources

Prospective providers should rely on the official state portals for the most current provider manuals, fee schedules, and enrollment forms.

The Bureau for Medical Services and Gainwell Technologies are the primary contacts for billing and enrollment technical assistance.

• WV Bureau for Medical Services (BMS): https://bms.wv.gov
• WV Bureau of Senior Services (BoSS): https://adwprogram.wv.gov
• WVMMIS Provider Portal (Gainwell): https://www.wvmmis.com
• Acentra Health (UMC): https://wva.acentra.com
• WV CARES (Background Checks): https://wvcares.wvdhhr.org
• OHFLAC (For Home Health CON/Licensure): https://oig.wv.gov/OHFLAC
• WV Personal Care Services Program: https://pcs.wv.gov

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