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

Last reviewed: 2026-08-16

In West Virginia, Respite Care Services provide short-term, temporary relief to unpaid primary caregivers of individuals enrolled in Medicaid Home and Community-Based Services (HCBS) waivers. These services ensure the participant continues to receive necessary supervision, assistance with activities of daily living, and behavioral support while the primary caregiver steps away. Respite is funded primarily through the Aged and Disabled Waiver (ADW), the Intellectual/Developmental Disabilities (I/DD) Waiver, the Children with Serious Emotional Disorder Waiver (CSEDW), and the Traumatic Brain Injury Waiver (TBIW).

The single biggest structural barrier to entry in West Virginia is that the state does not issue a standalone "Respite Care Provider" license. Instead, an agency must first obtain a foundational facility or agency license from the Office of Health Facility Licensure and Certification (OHFLAC)—such as a Behavioral Health Center license for I/DD waiver services or a Home Health/Personal Care Agency license for ADW—before they are permitted to enroll with the Bureau for Medical Services (BMS) to bill for respite care. You cannot simply apply to be a Medicaid respite provider without first securing this underlying state licensure.

1. Service Definition and Scope

Respite care in West Virginia is defined as intermittent or scheduled relief provided to a primary unpaid caregiver. The service is designed to prevent institutionalization by sustaining the family caregiving arrangement.

Depending on the specific waiver program, respite can be delivered in the participant's home, the provider's residence, or a licensed community setting. It covers non-medical supervision and support, though skilled nursing respite is available if medically necessary and authorized.

• Covered Tasks: Assistance with activities of daily living (ADLs), meal preparation, light housekeeping, and behavioral redirection.
• Medication Limitations: Staff may provide medication reminders, but actual medication administration requires nursing delegation or specific RN oversight.
• Duration Flexibility: Services can be authorized for a few hours, overnight, or for multiple consecutive days depending on the caregiver's needs.
• Waiver Availability: Covered under the ADW, I/DD, CSEDW, and TBIW Medicaid programs.
• Setting Restrictions: Out-of-home respite for children on the CSEDW is typically provided in specialized therapeutic foster care homes.

2. Regulatory and Oversight Agencies

Oversight of respite care in West Virginia is divided between the agency that manages Medicaid policy and funding, and the agency responsible for facility and agency licensure.

Providers must maintain compliance with both entities, as well as the state's utilization management contractor, to remain in good standing.

• Policy and Funding: The Bureau for Medical Services (BMS) (https://bms.wv.gov) manages Medicaid waivers and enforces provider policy.
• Licensure: The Office of Health Facility Licensure and Certification (OHFLAC) (https://oig.wv.gov/OHFLAC) issues the foundational agency licenses required to operate.
• Utilization Management: Acentra Health (https://wv.acentra.com) conducts functional assessments, service authorizations, and reviews the Individualized Service Plan (ISP).
• Medicaid Enrollment: Gainwell Technologies (https://www.wvmmis.com) operates the West Virginia Medicaid Management Information System (WVMMIS) provider portal.
• Background Checks: WV CARES (https://wvcares.wv.gov) manages the mandatory state registry and employment screening for all direct care workers.

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia does not require a Certificate of Need (CON) for basic respite care services, nor does the Bureau for Medical Services utilize closed networks, moratoria, or Request for Proposal (RFP) procurement windows for HCBS waiver enrollment. The state operates an open enrollment model for qualified providers.

However, the absolute structural precondition that blocks an applicant from enrolling in Medicaid is the requirement to hold an active, foundational state license. You cannot submit a Medicaid enrollment application for respite without this prerequisite license already in hand.

• Foundational Licensure: Applicants must hold an active OHFLAC license (e.g., Behavioral Health Center or Home Health Agency) before applying for Medicaid waiver enrollment.
• Business Registration: The entity must be registered and in good standing with the West Virginia Secretary of State (https://sos.wv.gov).
• NPI Requirement: The agency must obtain a Type 2 National Provider Identifier (NPI) from the federal NPPES registry.
• No Certificate of Need: Respite and basic HCBS waiver services are exempt from CON review by the West Virginia Health Care Authority.
• No Closed Networks: BMS accepts Medicaid provider applications year-round via Gainwell Technologies; there are no procurement-only access restrictions.

4. Licensure and Certification Requirements

Because West Virginia does not have a distinct "Respite Care" license, providers must meet the regulatory requirements of their underlying OHFLAC license. For example, agencies serving the I/DD waiver typically seek licensure as a Behavioral Health Center under W. Va. Code R. § 64-11.

The licensure process involves a comprehensive review of the agency's operational policies, physical location (if providing out-of-home services), and administrative structure.

• Application Portal: Initial licensure applications must be submitted directly to OHFLAC via their state portal.
• Policy Manual: Applicants must submit a comprehensive Policy & Procedure Manual detailing participant safety, emergency protocols, and grievance processes.
• Life Safety Code: If providing out-of-home respite in a facility, the physical site must pass an OHFLAC Life Safety and environmental inspection.
• Initial Survey: An on-site or desk survey by OHFLAC surveyors is required before the foundational license is granted.
• Licensure Fees: Subject to OHFLAC statutory fee schedules, which vary based on the primary license type (e.g., Behavioral Health Center vs. Home Health).

5. Medicaid Provider Enrollment

Once the foundational OHFLAC license is secured, the agency must enroll as a Medicaid provider through the WVMMIS portal managed by Gainwell Technologies.

Providers must select the specific waiver program they intend to serve (e.g., ADW or I/DD) and agree to the specific reimbursement and compliance terms of that waiver.

• Enrollment Portal: Submit the Provider Enrollment Application (PEA) electronically via WVMMIS (https://www.wvmmis.com).
• Application Fee: Providers must pay the federal Medicaid application fee (approximately $732) unless they provide proof of prior payment to Medicare or another state's Medicaid program.
• Required Uploads: Must upload the active OHFLAC license, IRS CP575 (proof of EIN), and a current certificate of commercial liability insurance.
• Provider Agreement: Must sign the BMS provider agreement stipulating adherence to the specific HCBS waiver manual.
• Revalidation: Medicaid enrollment must be revalidated every five years through the WVMMIS portal to prevent billing suspension.

6. Staffing, Training and Background Checks

Direct Support Professionals (DSPs) and Respite Care Workers must meet strict qualifications outlined in the specific BMS waiver manuals.

West Virginia utilizes a centralized background check system, and no staff member may provide services until they have been officially cleared.

• Age Requirement: All respite care staff must be at least 18 years of age.
• Background Clearance: Mandatory fingerprint-based background checks must be processed and cleared through WV CARES (https://wvcares.wv.gov) prior to any patient contact.
• CPR and First Aid: Staff must hold current, hands-on (not strictly online) CPR and First Aid certification.
• Initial Training: Workers must complete waiver-specific training covering abuse and neglect prevention, incident reporting, and HIPAA compliance.
• Supervision: RN supervision is not required for basic non-medical respite, but is mandatory if the participant's ISP dictates skilled medical oversight.

7. Documentation, Policies and Records

Providers are required to maintain meticulous records that align with both OHFLAC licensure regulations and BMS Medicaid waiver manuals.

Documentation must clearly demonstrate that the respite services provided match the hours and goals authorized in the participant's care plan.

• Service Logs: Records must document exact start and stop times, specific activities provided, and include the signatures of the staff and the participant/caregiver.
• ISP Alignment: Services must strictly follow the authorized hours and interventions detailed in the Acentra Health-approved ISP.
• Incident Reporting: Critical incidents (e.g., injuries, suspected abuse) must be reported to BMS and OHFLAC within 24 hours of discovery.
• Personnel Files: Must contain proof of WV CARES clearance, ongoing training certificates, and annual performance evaluations.
• Record Retention: All Medicaid billing and clinical records must be securely retained for a minimum of five years.

8. Billing, Rates and Claims

Respite care is billed to Medicaid based on the specific waiver's fee schedule, utilizing either 15-minute increments or per diem rates.

Claims are processed through Gainwell Technologies, and strict adherence to prior authorizations and Electronic Visit Verification (EVV) is required for payment.

• Claims System: Claims are submitted electronically via the WVMMIS portal (https://www.wvmmis.com) or through an approved EDI clearinghouse.
• Prior Authorization: All respite hours must be pre-authorized by Acentra Health; claims submitted without a matching authorization will be denied.
• Billing Units: Typically billed in 15-minute units (e.g., HCPCS code S5150) or per diem (e.g., S5151), depending on the duration and waiver rules.
• EVV Requirement: In-home respite services require compliance with the state's Electronic Visit Verification (EVV) system to digitally capture shift start and end times.
• Service Limits: Billing is subject to annual or daily caps as dictated by the participant's specific waiver budget and ISP.

9. Approval Sequence and Timeline

Becoming a fully approved respite provider in West Virginia is a multi-step process that requires sequential approvals from the Secretary of State, OHFLAC, and BMS.

Because foundational licensure must be obtained before Medicaid enrollment, the entire process typically takes several months from start to finish.

• Phase 1: Business registration with the WV Secretary of State and obtaining an NPI (1 to 2 weeks).
• Phase 2: Submission of policies and completion of the foundational OHFLAC licensure process (60 to 90 days).
• Phase 3: Setup of the WV CARES account and processing of initial staff background checks (2 to 4 weeks).
• Phase 4: Submission and approval of the Medicaid Provider Enrollment Application via Gainwell Technologies (30 to 60 days).
• Phase 5: Receipt of participant referrals and Acentra Health authorizations to begin billing (1 to 2 weeks post-enrollment).

10. Common Denials and Survey Findings

During OHFLAC surveys and BMS audits, providers are frequently cited for administrative and documentation lapses rather than direct care issues.

Failure to strictly adhere to background check rules and EVV mandates are the most common reasons for claim denials and corrective action plans.

• WV CARES Violations: Allowing staff to begin working shifts before receiving official, final clearance from the WV CARES registry.
• EVV Non-Compliance: Failing to utilize the EVV system for in-home shifts, resulting in automatic claim denials from Gainwell.
• Unapproved Hours: Billing for respite hours that exceed the limits set by the Acentra Health prior authorization.
• Missing Signatures: Maintaining service logs that lack the required participant or primary caregiver signature verifying the time worked.
• Training Lapses: Surveyors finding expired CPR/First Aid certifications or missing annual abuse prevention training in staff personnel files.

11. Key Contacts and Resources

Prospective respite providers should utilize the official state portals for licensure, enrollment, and policy guidance.

Maintaining direct contact with these agencies is essential for navigating the sequential approval process in West Virginia.

• Bureau for Medical Services (BMS): https://bms.wv.gov
• Office of Health Facility Licensure and Certification (OHFLAC): https://oig.wv.gov/OHFLAC
• WV Medicaid Provider Portal (Gainwell Technologies): https://www.wvmmis.com
• Acentra Health (Utilization Management): https://wv.acentra.com
• WV CARES (Background Checks): https://wvcares.wv.gov
• West Virginia Secretary of State: https://sos.wv.gov

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