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

Last reviewed: 2026-08-16

In West Virginia, "Skilled Respite" is not issued as a standalone provider license. Instead, it is a specialized service definition under Medicaid Home and Community-Based Services (HCBS) waivers—such as the Intellectual/Developmental Disabilities Waiver (IDDW) and Traumatic Brain Injury Waiver (TBIW)—delivered by licensed nurses (RNs or LPNs) to participants with complex medical needs. Providers must first be licensed as a broader healthcare facility, typically a Behavioral Health Center (BHC) or a Home Health Agency, before they can enroll to bill for this specific service.

The single biggest structural barrier to entry is the state's facility licensure and Certificate of Need (CON) framework. If a provider chooses to operate under a Home Health Agency model to deliver these services, they face a strict CON requirement enforced by the West Virginia Health Care Authority, which effectively blocks new entrants unless they can legally prove an unmet regional need. Alternatively, obtaining a Behavioral Health Center license through the Office of Health Facility Licensure and Certification (OHFLAC) avoids the CON but requires a rigorous, months-long initial survey and policy review process before Medicaid enrollment can even begin.

1. Service Definition and Scope

The West Virginia Bureau for Medical Services (BMS) defines skilled respite as short-term relief provided to the primary unpaid caregiver of a waiver participant who requires continuous nursing-level care. This service is utilized when the participant's medical acuity (e.g., ventilator dependency, complex tracheostomy care, or unstable seizure disorders) exceeds the scope of practice for an unlicensed Direct Support Professional (DSP).

Skilled respite is not intended to replace continuous daily nursing care or regular home health services. It is strictly a caregiver-relief service authorized in limited durations, subject to the participant's annual waiver budget and prior authorization.

• Service Modality: Short-term, temporary nursing care delivered in the participant's home or an approved licensed facility.
• Applicable Waivers: Primarily utilized under the Intellectual/Developmental Disabilities Waiver (IDDW) and Traumatic Brain Injury Waiver (TBIW).
• Excluded Tasks: Cannot be billed concurrently with other skilled nursing services or used as a substitute for daily continuous nursing.
• Provider Types: Must be delivered by an agency holding an active OHFLAC license as a Behavioral Health Center or Home Health Agency.
• Duration Limits: Subject to strict annual budget caps and hourly limits as defined in the participant's Individualized Support Plan (ISP).

2. Regulatory and Oversight Agencies

Oversight of skilled respite in West Virginia is bifurcated. Facility licensure and safety are governed by the Office of Inspector General (OIG), while Medicaid policy, funding, and enrollment are managed by the Department of Human Services (DoHS).

Providers must interact with multiple state contractors for enrollment, background checks, and service authorizations.

• Medicaid Authority: WV Bureau for Medical Services (BMS) (https://dhhr.wv.gov/bms) administers the HCBS waiver programs and sets service policies.
• Licensing Body: WV Office of Inspector General, Office of Health Facility Licensure and Certification (OHFLAC) (https://oig.wv.gov/OHFLAC) licenses the parent agencies.
• Utilization Management: Acentra Health (https://wv.acentra.com) handles prior authorizations, level-of-care determinations, and ISP approvals.
• Enrollment Broker: Gainwell Technologies (https://www.wvmmis.com) manages the WVMMIS provider enrollment portal and claims processing.
• Background Screening: WV CARES (https://www.wvdhhr.org/wvcares) processes mandatory fingerprint-based background checks for all staff.

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia does not allow individuals or businesses to simply apply to be a "Skilled Respite Provider." You must first clear major structural hurdles to establish a qualifying healthcare agency.

The most significant barrier is the Certificate of Need (CON) for home health models. If you cannot secure a CON or do not wish to operate a full Behavioral Health Center, you cannot enroll to provide this service.

• Certificate of Need (CON): Required by the WV Health Care Authority if enrolling as a Home Health Agency; this blocks entry unless a regional unmet need is legally proven.
• Facility Licensure: Must hold an active, unencumbered OHFLAC license as a Behavioral Health Center (BHC) or Home Health Agency before Medicaid enrollment is permitted.
• Business Registration: Must be registered and in good standing with the WV Secretary of State (https://sos.wv.gov).
• NPI Requirement: Must obtain a Type 2 National Provider Identifier (NPI) specific to the agency's organizational structure.
• Waiver Allocation: Services can only be billed for participants who have already secured a funded slot in a capacity-capped waiver program.

4. Licensure and Certification Requirements

Because skilled respite is a service rather than a license type, prospective providers must apply for a Behavioral Health Center (BHC) or Home Health license through OHFLAC. This process involves extensive policy reviews and physical inspections.

Agencies must demonstrate clinical competency, emergency preparedness, and strict adherence to West Virginia legislative rules governing health facilities.

• Application Form: Submission of the OHFLAC Initial License Application for Behavioral Health Centers or Home Health Agencies.
• Licensing Fee: Varies by facility type and services offered, submitted directly to OHFLAC with the initial application.
• Life Safety Code: If providing facility-based respite, the physical location requires a State Fire Marshal inspection and OHFLAC Life Safety Code approval.
• Initial Survey: OHFLAC conducts a comprehensive on-site initial licensing survey prior to issuing the operating certificate.
• Policy Review: Requires submission of comprehensive operational, clinical, and emergency policies to OHFLAC for approval.

5. Medicaid Provider Enrollment

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

Providers must enroll under specific waiver specialty codes to bill for skilled respite and must link their Type 2 NPI to their OHFLAC license.

• Enrollment Portal: Applications are submitted electronically via the WVMMIS Provider Portal (https://www.wvmmis.com).
• Provider Type/Specialty: Must enroll under the specific waiver specialty codes (e.g., IDDW Provider or TBIW Provider).
• Application Fee: Subject to the federal Medicaid institutional provider application fee (approximately $731) unless waived by Medicare enrollment.
• Required Attachments: Must upload the active OHFLAC license, IRS CP575 (EIN verification), W-9, and a voided check for EFT setup.
• Revalidation: Providers must revalidate their Medicaid enrollment every 5 years through the WVMMIS portal to maintain active billing status.

6. Staffing, Training and Background Checks

Skilled respite must be delivered by licensed nursing professionals. Unlicensed Direct Support Professionals (DSPs) cannot perform skilled respite under any circumstances.

All staff must clear strict state background checks and complete waiver-specific training before having any contact with participants.

• Professional Licensure: Staff must hold an active, unencumbered Registered Nurse (RN) or Licensed Practical Nurse (LPN) license verified through the WV RN Board or WV LPN Board.
• Background Screening: Mandatory fingerprint-based check through WV CARES prior to the first day of employment or patient contact.
• CPR/First Aid: All direct care nursing staff must maintain active, hands-on CPR and First Aid certification.
• Abuse/Neglect Training: Mandatory training on mandatory reporting requirements to WV Adult Protective Services (APS) or Child Protective Services (CPS).
• Waiver-Specific Training: Must complete BMS-mandated modules on incident reporting, HIPAA, participant rights, and person-centered planning.

7. Documentation, Policies and Records

BMS and OHFLAC require rigorous clinical documentation to justify the medical necessity of skilled respite. Missing or incomplete documentation is the leading cause of Medicaid clawbacks.

Agencies must maintain detailed nursing care plans that align perfectly with the participant's authorized Individualized Support Plan (ISP).

• Individualized Support Plan (ISP): Skilled respite must be explicitly authorized in the participant's Acentra Health-approved ISP.
• Nursing Care Plan: A detailed clinical plan outlining the specific medical tasks (e.g., tube feeding, tracheostomy care) required during the respite period.
• Time Logs: Electronic Visit Verification (EVV) or detailed timesheets showing exact in/out times, dates, and specific tasks performed.
• Incident Reporting: Policies must align with the WV Incident Management System (WVIMS) for reporting critical incidents within 24 hours.
• Record Retention: Medicaid requires all clinical, training, and billing records to be retained for a minimum of 5 years.

8. Billing, Rates and Claims

Claims for skilled respite are processed by Gainwell Technologies. Reimbursement rates are fixed by the BMS fee schedules for the specific waiver program.

Providers cannot bill for services that exceed the authorized units in the ISP, and claims will automatically deny without a matching prior authorization on file.

• Billing System: Claims are submitted via the WVMMIS portal or an approved clearinghouse using standard 837P/837I formats.
• Prior Authorization: Claims will deny without an active authorization on file from Acentra Health.
• Procedure Codes: Billed using specific HCPCS codes (e.g., T1005) with waiver-specific modifiers indicating skilled nursing level (RN vs. LPN).
• Rate Structure: Reimbursed in 15-minute increments or per diem, strictly adhering to the published BMS IDDW or TBIW fee schedules.
• EVV Mandate: In-home skilled respite is subject to federal Electronic Visit Verification (EVV) requirements to validate the location and time of service delivery.

9. Approval Sequence and Timeline

Becoming a skilled respite provider is a lengthy, sequential process. You cannot enroll in Medicaid until the facility license is fully approved.

The timeline is heavily dependent on OHFLAC's survey schedule and the provider's readiness to pass the initial inspection.

• Phase 1: Business formation and CON approval (if pursuing a Home Health model) (3-12 months).
• Phase 2: OHFLAC Licensure application submission and policy review (1-2 months).
• Phase 3: OHFLAC Initial On-Site Survey and correction of any deficiencies (1-3 months depending on state backlog).
• Phase 4: WV CARES enrollment and initial staff background checks (2-4 weeks).
• Phase 5: Gainwell Technologies Medicaid Enrollment and WVMMIS portal setup (30-60 days).

10. Common Denials and Survey Findings

During OHFLAC surveys and BMS audits, providers are frequently cited for administrative oversights and documentation gaps.

Failure to maintain continuous compliance with staff credentialing is a major trigger for Medicaid payment retractions.

• Licensure Lapses: Allowing RN/LPN licenses or CPR certifications to expire while the nurse continues to provide care.
• WV CARES Violations: Failing to complete the fingerprint background check before the nurse's first shift with a participant.
• Unauthorized Services: Billing for skilled respite when the ISP only authorized basic, unskilled respite.
• Documentation Gaps: Missing nursing notes that fail to justify the medical necessity of the skilled care provided during the shift.
• EVV Non-Compliance: Failing to capture required location and time data for in-home visits, leading to claim denials.

11. Key Contacts and Resources

Prospective providers must utilize these official state portals and agency contacts to navigate the licensure and enrollment process.

Always refer to the official .gov or state-contractor websites for the most current manuals, fee schedules, and application forms.

• WV Bureau for Medical Services (BMS): Medicaid policy and waiver manuals (https://dhhr.wv.gov/bms).
• WV Office of Inspector General (OHFLAC): Facility licensure and regulations (https://oig.wv.gov/OHFLAC).
• Gainwell Technologies (WVMMIS): Medicaid provider enrollment and claims (https://www.wvmmis.com).
• Acentra Health: Utilization management and ISP authorizations (https://wv.acentra.com).
• WV CARES: Mandatory background screening registry (https://www.wvdhhr.org/wvcares).
• WV Secretary of State: Business registration and entity search (https://sos.wv.gov).

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