Introduction 

Becoming a licensed Medicaid Waiver provider in West Virginia enables agencies and individuals to offer home and community-based services (HCBS) to Medicaid recipients, including the elderly, individuals with disabilities, and those in need of long-term care. West Virginia administers various Medicaid Waiver programs, including the Aged and Disabled Waiver (ADW), Intellectual/Developmental Disabilities Waiver (IDDW), and Traumatic Brain Injury Waiver (TBIW). This guide provides a step-by-step overview of the specific licensing and application process for Medicaid Waiver providers in West Virginia. 

1. Familiarize Yourself with West Virginia's Medicaid Waiver Programs 

Description: 

West Virginia offers several Medicaid Waiver programs designed to provide care and services in home and community settings. Each program has specific eligibility criteria and service offerings. Understanding these programs is the first step in becoming a licensed provider. 

Key Programs: 

Aged and Disabled Waiver (ADW): Provides personal care, homemaker services, and case management for individuals aged 18 or older who require nursing home-level care. 

Intellectual/Developmental Disabilities Waiver (IDDW): Offers case management, habilitation, and other services for individuals with intellectual and developmental disabilities. 

Traumatic Brain Injury Waiver (TBIW): Provides services for individuals aged 22-64 who have experienced a traumatic brain injury and require long-term support. 

Key Steps: 

Research Waiver Programs: Review each program’s service offerings and determine which one aligns with your agency’s service capabilities. 

Determine Target Population: Identify whether you want to provide services for the elderly, individuals with intellectual disabilities, or those with brain injuries, as this will guide your licensing path. 

Review Provider Requirements: Each waiver has specific provider qualifications and service definitions, which are outlined by the West Virginia Bureau for Medical Services (BMS). Visit the West Virginia Medicaid Waiver website for comprehensive program details. 

Tips: 

Contact the West Virginia Bureau for Medical Services or a waiver program coordinator to gain further insight into each program's requirements. 

2. Ensure Your Agency Meets Basic Eligibility Criteria 

Description: 

To apply for Medicaid Waiver provider licensing, your agency must meet specific state and federal eligibility criteria. These criteria help ensure that providers are qualified to deliver care to vulnerable populations. 

Key Steps: 

Establish a Legal Business Entity: Register your agency as a legal entity (e.g., LLC or corporation) with the West Virginia Secretary of State’s office. Obtain a Tax Identification Number (TIN) or Employer Identification Number (EIN) from the IRS. 

Secure Liability Insurance: Obtain general and professional liability insurance that meets the minimum requirements set by the state. Ensure your insurance policy covers the scope of services you plan to offer. 

Verify Staffing Requirements: Ensure that your agency hires appropriately credentialed staff, which may include: 

Direct Care Workers: Certified Nursing Assistants (CNAs), personal care aides, or home health aides with CPR and First Aid certifications. 

Clinical Staff: Registered nurses, case managers, and other licensed professionals, depending on the services provided. 

Meet Facility Requirements (if applicable): If you plan to operate a residential or day facility, ensure that the location complies with state health and safety regulations. 

Tips: 

Maintain records of staff qualifications, certifications, and background checks, as they will be needed during the licensing process. 

3. Complete the West Virginia Medicaid Provider Enrollment Application 

Description: 

To provide Medicaid Waiver services, you must first become an approved Medicaid provider through the West Virginia Bureau for Medical Services. The application process involves submitting detailed information about your agency, services, staff, and compliance with state regulations. 

Key Steps: 

Access the Application: Visit the West Virginia Medicaid Provider Enrollment Portal to access the online application form. You can also request a paper application by contacting the Provider Enrollment Unit at (888) 483-0793. 

Prepare Required Documentation: Gather the following documentation to submit with your provider application: 

Proof of business registration from the West Virginia Secretary of State. 

A completed IRS W-9 form for tax purposes. 

Proof of general and professional liability insurance. 

Staff licenses, certifications, and background checks. 

Policies and procedures for client intake, assessment, care delivery, and incident reporting. 

Develop Service-Specific Documentation: Based on the waiver program you are applying for, you will need to submit service-specific documentation, such as: 

Care plans, service delivery protocols, and staff training plans. 

Facility health and safety documentation (if applicable). 

Submit the Application: After completing the application and gathering the required documentation, submit your materials through the online portal or by mail to the Provider Enrollment Unit. 

Tips: 

Keep copies of all submitted documents and track the status of your application through the West Virginia Medicaid Provider Enrollment Portal. 

4. Undergo Background Checks and Staff Credential Verification 

Description: 

West Virginia requires all Medicaid Waiver providers, as well as their staff, to undergo criminal background checks to ensure the safety of Medicaid recipients. Additionally, licensed staff must have their credentials verified. 

Key Steps: 

Complete Criminal Background Checks: All direct care staff, administrators, and clinical personnel must pass state and federal background checks. Submit fingerprints and criminal background check forms through the West Virginia State Police or a designated fingerprinting service. 

Verify Staff Licenses and Certifications: Ensure that all licensed professionals, such as nurses, case managers, and therapists, have active licenses that are free of sanctions. These licenses will need to be verified as part of the application. 

Maintain Ongoing Compliance: Regularly verify that all staff certifications, including CPR and First Aid, are current and meet state Medicaid Waiver requirements. 

Tips: 

Start the background check and credentialing process early to avoid delays in the application process. 

5. Prepare for Facility Inspections and Licensing (If Applicable) 

Description: 

If your agency will provide Medicaid Waiver services in a residential or day program setting, you will need to pass a facility inspection conducted by the state to ensure compliance with health, safety, and accessibility regulations. 

Key Steps: 

Prepare Your Facility: Ensure that your facility meets all local building codes, fire safety regulations, and health department standards. This includes having functional fire alarms, emergency exits, clean and sanitary conditions, and adequate space for services. 

Comply with ADA Requirements: Your facility must be accessible to individuals with disabilities, including providing wheelchair access, ramps, and accessible bathrooms. 

Request a Pre-Licensing Inspection: Schedule a pre-licensing inspection with the West Virginia Office of Health Facility Licensure & Certification (OHFLAC) if you operate a residential or day service program. The inspection will cover health, safety, and environmental standards. 

Address Deficiencies: If the inspection reveals deficiencies, address them promptly and schedule a follow-up inspection. 

Tips: 

Perform a self-audit of your facility using a checklist from OHFLAC to ensure it is ready for inspection. 

6. Submit Additional Waiver-Specific Documents and Complete Training 

Description: 

Each waiver program in West Virginia has specific documentation and training requirements that must be completed as part of the licensing process. Completing these steps ensures that your agency is equipped to meet the unique needs of waiver recipients. 

Key Steps: 

Aged and Disabled Waiver (ADW): Submit policies for service coordination, personal care assistance, and case management. Providers must complete ADW-specific training modules on care planning and assessment. 

Intellectual/Developmental Disabilities Waiver (IDDW): Submit habilitation service plans, training protocols, and documentation demonstrating that staff have completed person-centered planning training. 

Traumatic Brain Injury Waiver (TBIW): Provide proof of specialized staff training for working with individuals with traumatic brain injuries, as well as documentation of client intake and service delivery plans. 

Attend Required Training: Some programs may require providers to complete waiver-specific training courses or orientations. These sessions cover key compliance topics, billing practices, and service coordination. 

Tips: 

Contact your program coordinator for guidance on completing the training and submitting the necessary waiver-specific documentation. 

7. Receive Provider Approval and Start Delivering Services 

Description: 

After your application has been approved, background checks completed, and any necessary inspections passed, you will receive official certification as a Medicaid Waiver provider. This allows you to begin offering services and billing Medicaid for eligible care. 

Key Steps: 

Obtain Your Provider Number: Upon approval, you will receive a Medicaid Provider Identification Number (PID) or National Provider Identifier (NPI), which is necessary for billing and reimbursement. 

Register for Medicaid Billing: Enroll in West Virginia’s Medicaid billing system to submit claims for services provided to waiver recipients. The system is accessed through the West Virginia Medicaid Management Information System (WVMMIS). 

Start Delivering Services: Once approved, begin delivering services to eligible Medicaid Waiver clients. Ensure that all services are documented accurately and follow the policies and procedures outlined in your application. 

Maintain Ongoing Compliance: Continue to monitor staff certifications, update care plans, and audit billing and documentation practices to ensure compliance with state and federal Medicaid regulations. 

Tips: 

Review Medicaid billing guidelines regularly and ensure that all claims are supported by proper documentation to avoid claim denials or audits. 

8. Maintain Licensing Compliance and Prepare for Audits 

Description: 

Once you become a licensed Medicaid Waiver provider, you will be subject to periodic audits, inspections, and reviews to ensure compliance with West Virginia’s Medicaid Waiver regulations. Staying compliant is critical for maintaining your provider status. 

Key Steps: 

Conduct Internal Audits: Regularly review client documentation, staff training records, and billing practices to ensure compliance with Medicaid Waiver regulations. Address any discrepancies or non-compliance issues promptly. 

Renew Your License and Certifications: Ensure that your agency’s Medicaid Waiver provider license and any staff certifications (e.g., CPR, CNA licenses) are renewed on time. Failing to renew could lead to lapses in service eligibility. 

Prepare for State Audits and Reviews: Be prepared for audits conducted by the West Virginia Bureau for Medical Services or OHFLAC. These audits typically focus on service documentation, client care plans, billing records, and facility conditions. 

Tips: 

Keep detailed records of all compliance activities, including internal audits, staff training, and incident reports, to make audits and inspections smoother.