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West Virginia - Respite Care Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The West Virginia Bureau for Medical Services (BMS) funds Respite Care Services through multiple Home and Community-Based Services (HCBS) programs, including the Intellectual and/or Developmental Disabilities Waiver (IDDW) and the Children with Serious Emotional Disorder Waiver (CSEDW). This service provides short-term relief care that allows an unpaid primary caregiver to step away while ensuring the waiver participant continues to receive necessary supervision and support.

Prospective IDDW provider agencies must obtain licensure through the West Virginia Office of Health Facility Licensure and Certification (OHFLAC) before applying for Medicaid enrollment, while CSEDW providers must secure a network contract with Aetna Better Health of West Virginia, the state's designated managed care organization for that specific waiver.

1. Service Definition and Scope

In West Virginia, Respite Care Services are defined as short-term care intended to provide both the family or other primary caregiver and the participant with a break from their daily routines. It serves as relief from daily caregiving responsibilities and can be utilized as an emergency backup plan for unpaid caregivers.

The service can be delivered in the participant's home or in licensed out-of-home settings, depending on the specific waiver program. It is strictly prohibited from being used to replace day care while the participant's parent or guardian is at work.

2. Regulatory and Oversight Agencies

The West Virginia Bureau for Medical Services (BMS) serves as the single state Medicaid agency, overseeing all waiver programs and establishing provider participation requirements. BMS contracts with various operating agencies and managed care organizations to administer specific waivers.

Facility and agency licensure is managed by the Office of Health Facility Licensure and Certification (OHFLAC), while provider enrollment and claims processing are handled by Gainwell Technologies through the state's Medicaid Management Information System.

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia imposes strict structural preconditions on agencies attempting to enroll as Respite Care providers. An applicant cannot simply submit a Medicaid enrollment application without first clearing the specific gatekeeping authority designated for the target waiver.

For the IDDW program, agencies must hold an active state license. For managed care waivers, providers are locked out of enrollment unless they have an active network contract.

4. Licensure and Certification Requirements

Agencies providing Respite Care under the IDDW program must be licensed by OHFLAC, typically under Behavioral Health Center regulations, depending on the exact scope of facility-based or in-home services offered.

Providers must maintain this licensure continuously. If a provider's license expires or is revoked, their participation in the West Virginia Medicaid Program may be terminated.

5. Medicaid Provider Enrollment

Provider enrollment is managed by Gainwell Technologies through the Health PAS-Online portal. The state utilizes a phased-in approach for enrollment and revalidation, requiring providers to use the Provider Enrollment Application (PEA).

Waiver agencies have the ability to enroll healthcare providers directly through a bulk upload process, streamlining the onboarding of direct care staff.

6. Staffing, Training and Background Checks

Direct care workers providing respite services must meet baseline health, safety, and training standards before delivering care. Agencies are responsible for ensuring all staff maintain current certifications.

West Virginia strictly regulates who can be paid to provide respite, explicitly excluding primary caregivers and requiring overtime compliance under the Fair Labor Standards Act.

7. Documentation, Policies and Records

Providers must maintain comprehensive records of all respite services delivered to withstand state and federal audits. Documentation must clearly delineate respite hours from other authorized services.

West Virginia participates in the CMS Payment Error Rate Measurement (PERM) Program, which requires providers to submit medical records to review contractors upon request to verify compliance.

8. Billing, Rates and Claims

Claims for Respite Care Services are submitted electronically through the WVMMIS Health PAS-Online portal. Rates are established by the Bureau for Medical Services and vary by waiver, setting, and staffing ratio.

During the Public Health Emergency and subsequent Appendix K amendments, West Virginia implemented temporary rate increases for HCBS services, including respite.

9. Approval Sequence and Timeline

Becoming a fully approved Respite Care provider requires navigating multiple state entities in a specific sequence. Agencies cannot bill Medicaid until all licensure and enrollment steps are complete.

The timeline depends heavily on the speed of OHFLAC licensure (for IDDW) or MCO credentialing (for CSEDW), followed by the Gainwell Technologies enrollment screening.

10. Common Denials and Survey Findings

Provider applications and claims are frequently denied due to administrative omissions or failure to maintain current credentials on file with the fiscal agent.

During audits, reviewers heavily scrutinize overlapping service times and the qualifications of the individuals providing the respite care.

11. Key Contacts and Resources

Providers must interact with several state portals and contractors to maintain their enrollment and billing status. The WVMMIS portal is the primary hub for enrollment and claims.

For waiver-specific policy questions, providers should contact the Bureau for Medical Services or the designated utilization management contractor.

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