West Virginia - Residential Care Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

West Virginia funds 24-hour residential habilitation, supervision, and personal care primarily through the Intellectual and Developmental Disabilities Waiver (IDDW), requiring agencies to become licensed Behavioral Health Centers. The Bureau for Medical Services (BMS) administers the waiver, while the Office of Health Facility Licensure and Certification (OHFLAC) oversees the physical settings and programmatic compliance for these residential environments.

Before submitting a licensure application to OHFLAC, prospective providers must secure a Certificate of Need (CON) from the West Virginia Health Care Authority (WVHCA) or obtain a formal exemption from the CON Summary Review Committee. Without this statutory approval of need, no architectural plans can be reviewed, no behavioral health license can be issued, and no Medicaid enrollment application will be accepted by the state's fiscal agent.

1. Service Definition and Scope

Under the West Virginia IDDW program, 24-hour residential care is delivered as an Intensively Supported Setting (ISS) or through licensed group home environments. These services provide habilitation, supervision, and personal care to individuals with intellectual and developmental disabilities in a community-based residential setting.

The service is designed to maximize independence while ensuring health and safety. Providers are responsible for integrating the individual into the community, managing medication, and executing the goals outlined in the Person-Centered Support Plan (PCSP).

• Service Name: Intensively Supported Setting (ISS) or Group Home under the IDDW program.
• Target Population: Individuals with an intellectual disability or related condition originating before age 18, requiring ICF/IID level of care.
• Included Supports: Direct care, personal assistance, habilitation, and supervision provided 24 hours a day.
• Excluded Services: Room and board costs are not covered by Medicaid and must be paid from the individual's own resources.
• Setting Requirements: Must comply with the CMS HCBS Settings Rule, ensuring privacy, access to food at any time, and integration into the broader community.
• Capacity Limits: Group settings are typically limited in size (often 4 or fewer beds) to maintain a home-like environment, subject to OHFLAC physical plant rules.

2. Regulatory and Oversight Agencies

Multiple state agencies govern the approval and operation of residential care providers in West Virginia. The West Virginia Health Care Authority controls market entry through the Certificate of Need process, ensuring new facilities do not duplicate existing services.

Once need is established, the Office of Health Facility Licensure and Certification (OHFLAC) handles life safety inspections and issues the Behavioral Health License. Finally, the Bureau for Medical Services (BMS) and its fiscal agent manage Medicaid enrollment and claims processing.

• West Virginia Health Care Authority (WVHCA): Administers the Certificate of Need program (https://hca.wv.gov).
• Office of Health Facility Licensure and Certification (OHFLAC): Conducts life safety reviews and issues Behavioral Health Licenses (https://ohflac.wv.gov).
• Bureau for Medical Services (BMS): The single state Medicaid agency responsible for IDDW policy (https://bms.wv.gov).
• Gainwell Technologies: The Medicaid fiscal agent managing the provider enrollment portal and MMIS (https://www.wvmmis.com).
• Bureau for Behavioral Health (BBH): Provides programmatic oversight and policy direction for behavioral health services (https://dhhr.wv.gov/bbh).

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia strictly controls the expansion of residential health care facilities through a statutory Certificate of Need (CON) process. A prospective provider cannot simply lease a building and apply for a license; they must first prove to the state that a need exists for the specific service in the proposed geographic area.

If a provider believes their specific model or population size exempts them from a full CON review, they must still file an exemption application with the WVHCA. Only after receiving a formal CON or a written exemption can the provider proceed to OHFLAC for architectural and life safety reviews.

• Certificate of Need (CON): Required from the WVHCA before any new health care facility can be constructed, developed, or established.
• CON Exemption: Providers may file an exemption application detailing which statutory exemption applies and the circumstances justifying it.
• Architectural Plan Review: OHFLAC Life Safety Program must approve all building sites and architectural plans prior to any construction or renovation.
• Site Inspection Request: A mandatory form submitted to OHFLAC to ensure the proposed location has proper utilities and meets safety requirements.
• Local Zoning Approval: Applicants must secure and document local municipal or county zoning approval for a residential care facility before state licensure.

4. Licensure and Certification Requirements

After clearing the CON hurdle and completing construction or renovation, the facility must pass an OHFLAC Life Safety inspection. This inspection verifies compliance with the 2012 Edition NFPA 101 Life Safety Code and applicable Facility Guidelines Institute (FGI) standards.

Following physical plant approval, the agency must demonstrate compliance with programmatic rules to receive a Behavioral Health License. Initial licenses are typically issued for a short duration to allow the state to monitor early operations before granting a standard license.

• Life Safety Inspection: Conducted by OHFLAC to approve the physical plant prior to occupancy.
• Behavioral Health License Application: Submitted to OHFLAC with proof of CON or exemption, policies, and procedures.
• Initial License Duration: Newly approved facilities are typically issued an initial license for 6 months.
• Regular License: Issued for up to two years after a successful review prior to the expiration of the initial license.
• Deemed Status: For children's facilities, a license from the Bureau for Social Services (BSS) is deemed by OHFLAC to issue the Behavioral Health License.

5. Medicaid Provider Enrollment

Medicaid enrollment cannot begin until the provider holds both a valid CON (or exemption) and an active OHFLAC Behavioral Health License. Enrollment is processed through the West Virginia Medicaid Provider Enrollment Portal managed by Gainwell Technologies.

Providers must enroll specifically as an Intellectual Disabilities and Developmental Disabilities Waiver (IDDW) Provider. The enrollment packet must include all facility licenses, ownership disclosures, and the required application fee.

• Enrollment Portal: Applications are submitted electronically via the Gainwell Technologies WVMMIS portal.
• Provider Type: Must enroll as an Intellectual Disabilities and Developmental Disabilities Waiver (IDDW) Provider.
• Required Attachments: A copy of the valid CON (or exemption) and the OHFLAC Behavioral Health License must be uploaded.
• Application Fee: Providers must pay the federal Medicaid application fee unless proof of payment to Medicare or another state's Medicaid program is provided.
• NPI Requirement: The agency must obtain a Type 2 National Provider Identifier (NPI) matching the exact legal name on the licensure documents.
• Effective Date: Medicaid payment will not be issued for any dates of service prior to the official enrollment effective date.

6. Staffing, Training and Background Checks

West Virginia Chapter 513 IDDW policy dictates strict qualifications for all agency staff providing direct care. Agencies must ensure that all personnel meet age, background, and training requirements before they provide any billable service to a waiver participant.

Background checks are centralized through the WV CARES system, which requires fingerprint-based state and federal criminal history checks. Staff must also complete specific training modules, including CPR, First Aid, and positive behavior support.

• Age Requirement: All direct support staff must be at least 18 years of age.
• Background Checks: Mandatory fingerprint-based checks through the West Virginia Clearance for Access: Registry and Employment Screening (WV CARES) system.
• CPR and First Aid: Staff must hold current certification; online-only courses without an in-person skills demonstration are generally not accepted.
• Positive Behavior Support: Staff must complete a facilitated Overview of Positive Behavior Support training.
• Medication Administration: Staff administering medication must complete the state-approved AMAP (Approved Medication Assistive Personnel) training.
• Annual Training: Agencies must document ongoing annual training within the month the previous training expires.

7. Documentation, Policies and Records

IDDW providers must maintain comprehensive records on behalf of the State of West Virginia. Documentation must prove that services were delivered exactly as authorized in the Person-Centered Support Plan (PCSP) and must support every claim billed to Medicaid.

Agencies may store documents electronically, but they must be immediately available upon request by state or federal monitors. Failure to maintain contemporaneous, accurate records is a primary driver of Medicaid clawbacks during audits.

• Service Notes: Must include the date, start and end times, specific interventions provided, and the signature of the staff member.
• Person-Centered Support Plan (PCSP): The foundational document that dictates the frequency, scope, and duration of all residential services.
• Incident Reporting: Providers must utilize the state's Incident Management System to report critical incidents within mandated timeframes.
• Medication Administration Records (MAR): Must be maintained for all individuals receiving medication assistance, documenting every dose administered or missed.
• Electronic Storage: Permitted, provided the system is secure, HIPAA-compliant, and capable of producing legible hard copies for surveyors.
• Record Retention: Records must typically be retained for a minimum of five years from the date of service or longer if an audit is pending.

8. Billing, Rates and Claims

Residential services under the IDDW program are billed to the Bureau for Medical Services through the Gainwell Technologies MMIS. Providers submit claims using standard HIPAA-compliant formats, such as the 837P electronic transaction or the CMS-1500 paper form.

All services require prior authorization based on the individual's approved budget and PCSP. The state utilizes a contracted utilization management agency (currently Kepro/Acentra) to review and authorize service units before they can be billed.

• Fiscal Agent: Gainwell Technologies processes all fee-for-service Medicaid claims for the IDDW program.
• Prior Authorization: Mandatory for all residential habilitation services; authorized units are transmitted to the MMIS by the utilization management contractor.
• Claim Format: Billed using the 837P electronic format or the CMS-1500 form via the provider portal.
• Procedure Codes: Providers must use the specific HCPCS codes and modifiers outlined in the current IDDW Chapter 513 rate schedule.
• Timely Filing: Claims must generally be submitted within 365 days of the date of service to be considered for payment.
• Rate Setting: Rates are established by BMS and published in the IDDW fee schedule; providers cannot bill Medicaid more than their usual and customary charge.

9. Approval Sequence and Timeline

Opening a residential care facility in West Virginia is a strictly sequential process. Attempting to skip a step, such as signing a lease before securing a CON, can result in significant financial loss and application denial.

The entire process from initial CON application to an active Medicaid provider number typically takes 9 to 18 months, depending on construction timelines and state review queues.

• Step 1: Obtain a Certificate of Need (CON) or formal exemption from the WVHCA.
• Step 2: Submit architectural plans to the OHFLAC Life Safety Program for review and approval.
• Step 3: Complete construction/renovation and pass the OHFLAC Life Safety site inspection.
• Step 4: Submit the Behavioral Health License application and pass the programmatic review to receive an initial 6-month license.
• Step 5: Submit the Medicaid enrollment application through the Gainwell portal with the CON and license attached.
• Step 6: Complete WV CARES background checks and required training for all hired staff before admitting the first resident.

10. Common Denials and Survey Findings

Applications are most frequently delayed or denied at the gatekeeping phase due to incomplete Certificate of Need applications or failure to justify the statutory need for a new facility. OHFLAC will not process a licensure application without this approval.

During post-enrollment surveys, OHFLAC and BMS frequently cite providers for documentation failures. Missing signatures, lapsed CPR certifications, and failure to report incidents within required timeframes are the most common triggers for corrective action plans.

• CON Denial: Failing to prove community need or duplicate service avoidance in the WVHCA application.
• Life Safety Violations: Failing the physical plant inspection due to improper fire doors, inadequate egress, or unapproved architectural changes.
• WV CARES Non-Compliance: Allowing staff to provide direct care before the fingerprint-based background check is fully cleared.
• Lapsed Training: Surveyors frequently cite agencies for staff whose CPR, First Aid, or AMAP certifications expired prior to a shift.
• Documentation Gaps: Billing for residential services without corresponding daily service notes that match the times on the timesheet.
• Unapproved Settings: Operating a residential site that has not been specifically inspected and added to the agency's Behavioral Health License.

11. Key Contacts and Resources

Providers must interact with multiple state portals and help desks throughout the lifecycle of their agency. Maintaining current contact information for the WVHCA, OHFLAC, and Gainwell is essential for resolving application bottlenecks.

The Bureau for Medical Services publishes all policy manuals, including Chapter 513 for the IDDW program, on its official website. Providers should subscribe to BMS email alerts for updates on rate changes and policy revisions.

• WV Health Care Authority (WVHCA): For Certificate of Need applications and exemptions (https://hca.wv.gov).
• OHFLAC Life Safety Program: For architectural plan reviews and physical plant inspections (https://ohflac.wv.gov).
• Gainwell Technologies Provider Services: For Medicaid enrollment and MMIS portal support (https://www.wvmmis.com).
• WV CARES: For mandatory staff background checks and fingerprinting (https://wvcares.wv.gov).
• Bureau for Medical Services (BMS): For Chapter 513 IDDW policy manuals and waiver appendices (https://bms.wv.gov).
• Kepro/Acentra Health: The utilization management contractor for IDDW prior authorizations (https://wvaso.kepro.com).

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