Home Health Agencies: Application for State Licensure and Federal Certification

Medicare-certified and state-licensed HHAs need to meet all the regulations listed below. Review these regulations before applying:

• Wisconsin Admin. Code ch. DHS 133
• Wisconsin Stats. § 50.49
• 42 CFR 484

The following accrediting organizations are approved to provide this combined survey process:

• Accreditation Commission for Health Care (ACHC)
• Community Health Accreditation Partners (CHAP)
• The Joint Commission (TJC)

Follow this process for the combined application:

1. Choose and contact an accrediting organization. This organization should provide a letter indicating the prospective HHA has been accepted into the survey program.
2. Send the following to DQA:
   • Letter of acceptance from your chosen accrediting agency.
   • Letter of intent with a detailed description of the proposed HHA. Include credentials to show the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 133.06 for details.
   • Completed Wisconsin Home Health Agency License Application, F-62674 (Word).
   • HHA application fee ($300), payable to The Division of Quality Assurance.
   • Entity Caregiver Background Checks completed online. Include fees ($10 per individual).
   • Organizational chart, including any other entities owned by the proposed HHA.
   • Financial references, which could include:
     • Letter of reference from HHA's financial institution.
     • Bank statement.
     • Evidence of stock ownership.
     • Verification of outside employment or other income.
   • A proposed operating budget for the first 90 days of operation. Use the Model Balance Sheet, F-62674A.
   • Copy of the Internal Revenue Service's letter showing your Employer Identification Number.
   • Organizational documents depending on your HHA structure:
     • Corporations: Provide a copy of articles of incorporation.
     • Limited liability companies (LLCs): Provide a copy of articles of organization and operation agreement.
     • Limited liability partnerships (LLPs): Provide a copy of the partnership agreement.

3. Submit a copy of your state HHA Wisconsin Home Health Agency License Application, F-62674 (Word) to your accrediting organization. Also include all agency policies and procedures.

   Policies and Procedures: Demonstrate, via submission of agency policies and procedures and patient care documentation, your compliance with Wis. Admin. Code ch. DHS 133 for Home Health Agencies. Also, demonstrate via submission of agency policies and procedures, your compliance with Wis. Admin. Code ch. DHS 13 Reporting and Investigation of Caregiver Misconduct. Refer to Chapter 6 of the Wisconsin Caregiver Program Manual, P-00038 (PDF).

4. DQA will send a letter to the prospective HHA and the accrediting organization once the application is approved. This triggers the accrediting organization to conduct a provisional licensure survey.
5. The accrediting organization approves the prospective HHA for one year of provisional accreditation. DQA then grants provisional state licensure with the same effective date.

Note: Wisconsin provisional licensure is good for three months. It is extendable up to three times (one year total). Send a letter to DQA requesting extensions if necessary.

The now-provisional HHA can begin serving clients.

Once you've served 10 clients with skilled nursing care (including seven active clients), send a letter and 10 patient care plans to DQA and the accrediting organization. The accrediting organization will start a combined unannounced Wisconsin licensure and Medicare certification survey. The accrediting organization will notify HHA and DQA once the survey is complete and the HHA is approved.

During the provisional licensure period, begin submitting required Medicare certification documents, including:

• CMS-855 Medicare Enrollment Application (PDF) submitted to Wisconsin's Medicare Administrative Contractor, currently National Government Services (NGS). Once the administrative contractor has approved this form, they'll send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your accrediting agency. They'll need this document before performing your final certification and licensure survey.
• A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.

Once DQA has these documents and the accreditation organization survey, it can issue permanent state licensure and recommend Medicare certification to CMS.

Note that state licensure should be completed at the same time or before Medicare or Medicaid certification. State licensure does not guarantee Medicare certification.

As a prospective HHA, you must complete an application, pay fees, and submit supporting documentation that shows your compliance with Wis. Admin. Code ch. DHS 133 before receiving a license.

Send the following to DQA:

• Letter of intent with a detailed description of the proposed HHA. Include credentials to show the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 133.06 for details.
• Completed Wisconsin Home Health Agency License Application, F-62674 (Word).
• HHA application fee ($300), payable to The Division of Quality Assurance.
• Entity Caregiver Background Checks completed online. Include fees ($10 per individual).
• Organizational chart, including any other entities owned by the proposed HHA.
• Financial references, which could include:
  • Letter of reference from the HHA's financial institution.
  • Bank statement.
  • Evidence of stock ownership.
  • Verification of outside employment or other income.
• A proposed operating budget for the first 90 days of operation. Use the Model Balance Sheet, F-62674A.
• Copy of the Internal Revenue Service's letter showing your Employer Identification Number.
• Organizational documents depending on your HHA structure:
  • Corporations: Provide a copy of articles of incorporation.
  • Limited liability companies (LLCs): Provide a copy of articles of organization and operation agreement.
  • Limited liability partnerships (LLPs): Provide a copy of the partnership agreement.
• Show compliance with these policies and procedures:
  • Wisconsin Admin. Code ch. DHS 133
  • Wisconsin Admin. Code ch. DHS 13, refer to Chapter 6 of the Wisconsin Caregiver Program Manual, P-00038 (PDF)

Wisconsin has a two-step application review process once DQA receives all materials. The first review determines whether an applicant is fit and qualified and includes a review of factors like:

• Financial solvency.
• Personnel qualifications.
• Criminal background clearance.
• Payment of required fees.
• History of operating HHAs in other states.
• Documentation that shows the provision of skilled nursing and therapeutic services to patients in their homes.

Once DQA deems a prospective HHA fit and qualified, a registered nurse will review policies and procedures to determine whether they meet Wisconsin codes.

Once approved, DQA will grant provisional state licensure.

Note: Wisconsin provisional licensure is good for three months. It is extendable up to three times (one year total). Send a letter to DQA requesting extensions if necessary.

The now-provisional HHA can begin serving clients.

Once you have served 10 clients with skilled nursing care (including seven active clients), send a letter and 10 patient care plans to DQA. State surveyors will then conduct an unannounced Wisconsin licensure survey. Once the survey is complete, including any necessary corrections, DQA may grant permanent HHA licensure.

If you're applying for an optional Medicare certification, DQA advises submitting application materials and supporting documentation at the same time as your Wisconsin state licensure.

Note that state licensure should be completed at the same time or before Medicare or Medicaid certification. Your Medicare certification also should be completed before your Medicaid certification. State licensure does not guarantee Medicare certification.

To become Medicare Program certified, an HHA must first meet state licensing requirements and obtain a provisional license.

To get Medicare certification:

1. Review the following CMS Medicare information for HHAs:
   • Federal Conditions of Participation for HHAs, 42 CFR 484.
   • CMS State Operations Manual (SOM) Chapter 2 – The Certification Process (PDF). Refer to Section 2202 for OASIS requirements and review 2202.10 A through F for initial certification.
   • OASIS Information.
   • SOM Appendix B – Guidance to Surveyors: HHAs (PDF).
   • CMS Home Health Prospective Payment System.
   • CMS Home Health Agency Center.
2. Complete CMS-855 Medicare Enrollment Application and submit to Wisconsin's Medicare Administrative Contractor, currently National Government Services (NGS). Once the administrative contractor has approved this form, they'll send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your accrediting agency. They'll need this document before performing your final certification and licensure survey.
3. Contact a CMS Approved Accrediting Organization (PDF) to perform the Medicare Certification survey (this is separate from the Wisconsin state licensure survey).
4. Submit a signed CMS-1561 Health Insurance Benefits Agreement (PDF) to DQA.

Once DQA has issued your HHA license, DQA will provide these documents to CMS and recommend Medicare certification approval.

To become Medicaid certified, an HHA first must meet state licensing requirements and obtain a provisional license.

If you're interested in becoming a Wisconsin Medical Assistance (Medicaid) Program certified provider, DQA recommends applying while you apply to Medicare. See Wisconsin Medicaid provider certification on ForwardHealth.

Learn more from Medicaid contacts.

You must contact DQA if your existing HHA is undergoing a:

• Name change.
• Address change.
• Administrator change.
• Accreditation status change.
• Change of ownership (CHOW).
• Change of ownership information (CHOI).

You may contact a licensing specialist directly by phone at 608-266-7297 or email at dhsdqalccs@dhs.wisconsin.gov.

Note: If HHA operation is transferred to another owner, ownership group, or lessee, the Health Insurance Benefits Agreement will be transferred. You're required to notify DQA when planning a CHOW, since your license is non-transferable. DQA will provide instructions regarding the CHOW process.

You may find the following forms useful when conducting an agency self-evaluation of compliance with Wisconsin administrative rules. Surveyors use these forms during on-site state licensure surveys.

• Pre-licensure Desk Review Checklist, F-62536 (PDF)
• Licensure Survey Entrance Conference Guide, F-62653 (PDF)
• Licensure Survey Exit Conference Guide, F-62654 (PDF)
• Rights of HHA Patients, F-62601 (PDF)
• Patient Rights Statement Review, F-62646 (PDF)
• Contract Review Worksheet, F-62657 (PDF)
• Program Evaluation Review Worksheet, F-62658 (PDF)
• Clinical Record Review, F-62680 (PDF)
• Personnel Record Review, F-62231 (PDF)
• Licensure Survey Home Visit Guide, F-62652 (Word)