West Virginia - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The West Virginia Bureau for Medical Services (BMS) funds skilled respite—respite care delivered by a Registered Nurse (RN) or Licensed Practical Nurse (LPN)—through the Intellectual/Developmental Disabilities Waiver (IDDW) and the Children with Serious Emotional Disorders Waiver (CSEDW). Agencies cannot apply directly for a standalone skilled respite license; they must first secure a Certificate of Need (CON) from the West Virginia Health Care Authority to operate as a Home Health Agency, or obtain a Behavioral Health Center license from the Office of Health Facility Licensure and Certification (OHFLAC).

Once licensed, providers enroll through the West Virginia Medicaid Management Information System (WVMMIS) portal. Approval requires passing OHFLAC surveys, securing Medicare certification if operating as a Home Health Agency, and contracting with Aetna Better Health of West Virginia for CSEDW members or KEPRO for IDDW utilization management.

1. Service Definition and Scope

West Virginia does not issue a distinct "Skilled Respite" license. Instead, skilled respite is a specific service line delivered by licensed Home Health Agencies or Behavioral Health Centers to provide temporary relief for primary caregivers of members with complex medical needs.

The service requires nursing assessment or intervention that exceeds the scope of an unlicensed direct care worker. It is governed by the clinical standards of the West Virginia RN and LPN Boards and the specific waiver manual under which the member is enrolled.

• Service Nomenclature: Billed as LPN Respite or RN Respite under the IDDW, or In-Home Respite under the CSEDW.
• Delivery Setting: Provided in the member's home or an OHFLAC-licensed out-of-home facility.
• Scope of Practice: Interventions must fall within the legal scope of practice defined by the West Virginia Nurse Practice Act.
• Service Exclusions: Cannot be billed simultaneously with other skilled nursing waiver services or when the member does not have a documented medical need for nursing-level care.

2. Regulatory and Oversight Agencies

The Bureau for Medical Services (BMS) is the single state Medicaid agency responsible for waiver policy and funding. Facility licensure and compliance surveys are conducted by the Office of Health Facility Licensure and Certification (OHFLAC).

Day-to-day utilization management and provider network operations are delegated to contracted entities, including KEPRO for the IDDW and Aetna Better Health of West Virginia for the CSEDW.

• Medicaid Authority: West Virginia Bureau for Medical Services (BMS) (https://dhhr.wv.gov/bms)
• Licensing Agency: Office of Health Facility Licensure and Certification (OHFLAC) (https://ohflac.wvdhhr.org/)
• IDDW Utilization Management: KEPRO (https://wvaso.kepro.com)
• CSEDW Managed Care Organization: Aetna Better Health of West Virginia (https://www.aetnabetterhealth.com/westvirginia)
• Medicaid Enrollment Portal: WVMMIS (https://www.wvmmis.com)

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia imposes strict structural preconditions on agencies seeking to provide skilled nursing services. A provider cannot simply submit a Medicaid enrollment application for skilled respite without first clearing these state-mandated hurdles.

The most rigid requirement applies to agencies operating under the home health model, which must navigate the state's Certificate of Need process before OHFLAC will even accept a licensure application.

• Certificate of Need (CON): Required from the West Virginia Health Care Authority for any new entity seeking to operate as a Home Health Agency.
• Medicare Certification: BMS Chapter 508 requires Home Health Agencies to obtain Medicare certification prior to enrolling with West Virginia Medicaid.
• Facility Licensure: IDDW providers must hold an active OHFLAC Behavioral Health Center license before applying to bill waiver services.
• MCO Contracting: To serve CSEDW members, the agency must successfully credential and secure a network contract with Aetna Better Health of West Virginia.

4. Licensure and Certification Requirements

Agencies must apply for the appropriate facility license through OHFLAC's online portal. The type of license depends on the agency's operational model and the specific waivers they intend to serve.

OHFLAC conducts initial and routine unannounced surveys to ensure compliance with state codes of rules regarding patient rights, clinical records, and nursing supervision.

• Home Health Rule: Governed by West Virginia Code of State Rules §64-74.
• Behavioral Health Rule: Governed by West Virginia Code of State Rules §64-11 for IDDW providers.
• Application Method: Submitted electronically via the OHFLAC licensure portal.
• Administrator Qualifications: Agencies must designate a qualified administrator and a clinical director (typically an RN) meeting state experience requirements.

5. Medicaid Provider Enrollment

Once licensed and certified, agencies must enroll as institutional providers through the West Virginia Medicaid Management Information System (WVMMIS).

The enrollment process requires submission of all OHFLAC licenses, Medicare certification letters (if applicable), and payment of federal application fees.

• Enrollment Portal: WVMMIS Provider Enrollment (https://www.wvmmis.com/Provider-Enrollment.aspx)
• Application Fee: Providers enrolling as institutional entities must pay the federal Medicaid application fee unless waived by Medicare enrollment.
• EFT Requirement: Mandatory Electronic Funds Transfer setup is required for all WV Medicaid providers.
• Out-of-Network Providers: Agencies located beyond a 30-aeronautical mile radius of the WV border must obtain prior authorization for all non-emergent services.

6. Staffing, Training and Background Checks

Skilled respite must be delivered by nurses holding valid, unencumbered licenses. West Virginia is a member of the Enhanced Nurse Licensure Compact (eNLC).

All staff must clear rigorous state and federal background checks before having direct contact with waiver members.

• Nursing Licensure: Must hold an active license from the West Virginia RN Board, LPN Board, or an eNLC compact state.
• Background Screening: Mandatory processing through WV CARES (West Virginia Clearance for Access: Registry & Employment Screening).
• OIG Exclusion: Agencies must check staff monthly against the federal OIG List of Excluded Individuals/Entities (LEIE).
• Basic Certifications: All direct care staff must maintain current CPR and First Aid certifications.

7. Documentation, Policies and Records

Clinical documentation must explicitly justify the need for skilled nursing during the respite period. Basic caregiving notes are insufficient for RN/LPN billing.

Agencies must maintain comprehensive medical records that align with BMS provider manual requirements and OHFLAC regulations.

• Plan of Care (POC): Must use CMS-485 or an equivalent agency POC form detailing the specific skilled interventions required.
• Nursing Notes: Shift notes must document the skilled assessments, medication administrations, or treatments performed.
• Electronic Visit Verification (EVV): Required for in-home respite services to capture the exact start and end times of the shift.
• Record Retention: Medical and billing records must be retained for a minimum of five years per BMS policy.

8. Billing, Rates and Claims

Reimbursement for skilled respite depends on the member's waiver program. IDDW claims are billed fee-for-service through WVMMIS, while CSEDW claims go through the MCO.

Rates are established by BMS and published in the respective waiver fee schedules.

• FFS Billing: Submitted via the WVMMIS portal for IDDW members.
• MCO Billing: Submitted via the Aetna Better Health WV clearinghouse for CSEDW members.
• Prior Authorization: Mandatory approval required from KEPRO (IDDW) or Aetna (CSEDW) before any respite shifts are worked.
• Procedure Codes: Billed using specific HCPCS codes (e.g., T1005) with modifiers indicating RN or LPN level of care.

9. Approval Sequence and Timeline

Becoming a skilled respite provider is a lengthy process, primarily due to the facility licensure and certification prerequisites.

Agencies should expect the entire sequence to take between 9 and 18 months from initial planning to billing the first claim.

• Step 1: Obtain Certificate of Need (Home Health) or OHFLAC Behavioral Health license approval (6-12 months).
• Step 2: Secure Medicare Certification (Home Health only, 3-6 months).
• Step 3: Complete WVMMIS Medicaid Enrollment (30-60 days).
• Step 4: Complete MCO Credentialing with Aetna for CSEDW participation (60-90 days).

10. Common Denials and Survey Findings

OHFLAC surveyors and BMS auditors frequently penalize agencies for documentation gaps and failure to justify the skilled level of care.

Medicaid enrollment applications are most commonly rejected for missing required facility licenses or incomplete ownership disclosures.

• Unjustified Skill Level: Billing for RN/LPN respite when the shift notes only reflect basic supervision and ADL assistance.
• Missing Signatures: Physician orders or Plans of Care not signed within the regulatory timeframes.
• Background Check Gaps: Allowing a nurse to work a respite shift before the WV CARES clearance is fully approved.
• EVV Non-Compliance: Missing or manually entered electronic visit verification data without proper justification.

11. Key Contacts and Resources

Providers must regularly consult official state portals for manual updates, fee schedules, and policy bulletins.

The following links are the authoritative sources for West Virginia Medicaid enrollment and facility licensure.

• WV Bureau for Medical Services: https://dhhr.wv.gov/bms
• WV OHFLAC: https://ohflac.wvdhhr.org/
• WVMMIS Provider Portal: https://www.wvmmis.com
• WV CARES: https://www.wvdhhr.org/wvcares/
• KEPRO WV (IDDW UM): https://wvaso.kepro.com
• Aetna Better Health WV: https://www.aetnabetterhealth.com/westvirginia

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