Home Health Agency: Application for State Licensure and Federal Certification

As a result of 2017 Wisconsin Act 59 (page 222) home health agencies (HHAs) in Wisconsin can now utilize outside accrediting organizations approved by both the Division of Quality Assurance (DQA) and CMS for combined initial licensure and Medicare certification surveys. These changes mean that, whereas HHAs previously had to go through a state licensure survey and then seek a Medicare certification survey from an outside accrediting organization, that process can now be completed as a part of a single streamlined process.

HHAs that will be seeking both state licensure and Medicare certification should follow the process under the “Combined Application” tab below. HHAs that do not plan to seek Medicare certification should follow the process under the “State Licensure Application” tab.

The Division of Quality Assurance is currently working with the three CMS-approved accrediting organizations to include standards that will meet Wisconsin home health agency (HHA) licensure rules:

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

As of July 2020, ACHC has completed the process of incorporating Wisconsin’s state licensing standards into their initial and continuing HHA survey process. The other accrediting organizations may complete this integration process in the future.

Please check back to this webpage for regular updates.

General information and definitions

The definition of a home health agency in Wis. Stats. § 50.49(1)(a) is an organization that “Primarily provides skilled nursing and other therapeutic services." Refer to Defining "Skilled Care" for Wisconsin Home Health Agency (HHA) Licensure, P-01212 (PDF) for more information on what constitutes skilled nursing care.

Do not complete a home health agency application if the intent is to provide only personal care services that include assistance with activities of daily living, housekeeping activities, and/or accompanying client to medical appointments. If you are interested in personal care agency information please visit Personal Care Agencies (PCAs).

Medicare certified and state licensed HHAs will need to meet all regulations listed below. Please review these regulations before preparing your application:

Combined
Application

Combined State Licensure and Medicare Certification

Currently the only accrediting organization approved to provide this combined survey is Accreditation Commission for Health Care (ACHC):

Accreditation Commission for Health Care
139 Weston Oaks Ct.
Cary, NC 27513
achc.org
855-937-2242

The combined state licensure and Medicare certification process is as follows:

  • Choose and contact an accrediting organization to begin their application process. The outside accrediting organization should provide the prospective HHA with a letter indicating they have been accepted into their survey program.
  • Provide the following to DQA:
    • The letter from your chosen accrediting agency indicating the prospective HHA has been accepted into their survey program.
    • Letter of intent with a detailed description of the proposed home health agency, including credentials showing the administrator and substitute administrator meet the requirements for these positions detailed in Wis. Admin. Code § DHS 133.06.
    • Wisconsin Home Health Agency License Application, F-62674 (Word) completed in its entirety.
    • HHA application fee ($300).
    • Entity Caregiver Background Checks completed online including $10 per individual.
    • Organizational chart identifying any other entities owned by the organization.
    • Financial reference, 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 using Model Balance Sheet, F-62674A
    • Copy of the Internal Revenue Service (IRS) Employer Identification Number (EIN) letter.
    • Organizational documents:
      • Corporation: provide copy of articles of incorporation
      • Limited liability company (LLC): provide copy of articles of organization and operation agreement
      • Limited liability partnership (LLP): provide copies of partnership agreement
  • Submit a copy of your state HHA license application (F-62674) to your chosen accrediting organization, along with all agency policies and procedures.
  • Once DQA approves the application materials listed above, they will send an approval letter to the prospective HHA, copying the accrediting organization. This will trigger a provisional licensure survey by the accrediting organization.
  • Once the accrediting organization has approved the prospective HHA for one year of provisional accreditation, DQA will be notified and grant provisional state licensure with the same effective date.
    • While Wisconsin provisional licensure is good for three months, it is extendable up to three times, for a total of one year. Please send a letter to DQA requesting these extensions as necessary.

The now-provisional HHA should begin serving clients. Once the HHA has served ten clients requiring skilled nursing care (seven of whom are still active) they should send a letter, along with ten patient care plans, to both DQA and the chosen accrediting organization. This will trigger a combined unannounced Wisconsin licensure and Medicare certification survey by the accrediting organization. The accrediting organization will then notify the HHA and DQA once the survey process is complete and the HHA is approved for state licensure and Medicare certification.

During the provisional licensure period, the provisional HHA should also begin submitting the required Medicare certification document, including:

  • CMS-855 submitted to Wisconsin’s assigned Medicare Administrative Contractor (MAC), which is currently National Government Services (NGS). Once the MAC has approved this form, they will send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your chosen accrediting agency. They will need this document before your final certification and licensure survey can be performed.
  • A signed CMS-1561 Health Insurance Benefits Agreement should be submitted to DQA.

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

State Licensure
Application

You must complete the state licensure process at the same time or before you complete the Medicare and Medicaid certification processes. Similarly, you must complete the Medicare certification at the same time or before you complete the certification process for Medicaid.

The issuance of a license to operate a home health agency in the state of Wisconsin is not part of the Medicare provider enrollment process and therefore will not automatically assure either certification in the Medicare program or Medicare payment.

Provisional License

As a home health agency applicant, you are required to complete an application, pay fees and submit supporting documentation in the form of policies and procedures that will demonstrate your compliance with Wis. Admin. Code ch. DHS 133 for home health agencies before a license will be issued.

The following must be submitted to DQA as part of the state licensure process:

  • Letter of intent with a detailed description of the proposed home health agency, including credentials showing the administrator and substitute administrator meet the requirements for these positions detailed in Wis. Admin. Code § DHS 133.06.
  • Wisconsin Home Health Agency License Application, F-62674 (Word) completed in its entirety.
  • HHA application fee ($300).
  • Entity Caregiver Background Checks completed online including $10 per individual.
  • Organizational chart identifying any other entities owned by the organization.
  • Financial reference, 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 using Model Balance Sheet, F-62674A
  • Copy of the Internal Revenue Service (IRS) Employer Identification Number (EIN) letter.
  • Organizational documents:
    • Corporation: provide copy of articles of incorporation
    • Limited liability company (LLC): provide copy of articles of organization and operation agreement
    • Limited liability partnership (LLP): provide copies of partnership agreement
  • 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).

Once all of the requested application materials are received an application is considered complete. Wisconsin has a two-step application review process. The first review determines whether an applicant is fit and qualified and includes an analysis of a variety of factors including financial solvency, personnel qualifications, criminal background clearance, payment of required fees, history of operating health care agencies in other states, and documentation that demonstrates the provision of the following required services to patients in their homes:

  • Skilled nursing, and
  • Therapeutic Services (physical therapy, speech therapy, occupational therapy, medical social services or home health aide).

Following a determination the applicant meets the fit and qualified criteria, the second review is completed by a Registered Nurse (RN) who will review the applicants policies and procedures to determine whether they meet Wis. Admin. Code chs. DHS 133 and DHS 13. The RN will consult with the applicant during this review process if needed.

Once DQA has approved the prospective HHA, provisional state licensure will be granted. While Wisconsin provisional licensure is good for three months, it is extendable up to three times, for a total of one year. Please send a letter to DQA requesting these extensions as necessary The now-provisional HHA should begin serving clients.

Once the HHA has served ten clients requiring skilled nursing care (seven of whom are still active) they should send a letter, along with ten patient care plans, to DQA. This will trigger an unannounced Wisconsin licensure survey by state surveyors. Once this survey process is complete, including any necessary corrections, permanent HHA licensure can be granted by DQA.

Medicare
Certification

If you are seeking Medicare certification, you are advised to submit application materials and supporting documentation at the same time you seek Wisconsin state licensure.

You must complete the state licensure process at the same time or before you complete the Medicare and Medicaid certification processes. Similarly, you must complete the Medicare certification at the same time or before you complete the certification process for Medicaid.

The issuance of a license to operate a home health agency in the state of Wisconsin is not part of the Center for Medicare and Medicaid (CMS) Medicare provider enrollment process and therefore will not automatically assure either certification in the Medicare program or Medicare payment.

Medicare Certification (Optional)

In order to become certified in the Medicare Program, a home health agency must first meet State of Wisconsin licensing requirements and obtain a provisional license.

Steps to obtain Medicare certification:

  1. Review the following CMS Medicare information for home health agencies:
  1. Complete a CMS-855 submitted to Wisconsin’s assigned Medicare Administrative Contractor (MAC), which is currently National Government Services (NGS). Once the MAC has approved this form, they will send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your chosen accrediting agency. They will need this document before your final certification and licensure survey can be performed.
  2. Contact a CMS Approved Accrediting Organization to perform the Medicare Certification survey (this is separate from the Wisconsin state licensure survey).
  3. Submit a signed CMS-1561 Health Insurance Benefits Agreement to DQA.

Once DQA has issued your HHA license and has copies of your CMS-855 form, full accrediting agency survey report, and signed CMS-1561, DQA will provide these documents to CMS and recommend Medicare certification approval.

Medicaid
Certification

Medicaid Certification (Optional)

In order to become Medicaid certified, a home health agency must first meet State of Wisconsin licensing requirements and obtain a provisional license.

If you are interested in becoming a certified provider with Wisconsin Medical Assistance (Medicaid) Program, you are encouraged to apply at the same time that you apply to Medicare. See Wisconsin Medicaid provider certification on the Wisconsin ForwardHealth website.

Refer to Medicaid Contacts for additional contact information.

Reporting agency changes

  • If your existing home health agency is undergoing name, address, administrator, accreditation status, change of ownership (CHOW), or change of ownership information you must contact DQA. You may contact a licensing specialist directly at 608-266-7297 or email the Division of Quality Assurance, Licensing, Certification and CLIA Section.
  • CHOW – If operation of the home health agency is later transferred to another owner, ownership group, or to a lessee, the Health Insurance Benefits Agreement will be transferred.
  • You are required to notify the DQA at the time you are planning a change of CHOW as your license is non-transferable. DQA will provide instructions regarding the CHOW process.

Additional resources

Compliance Review Tools: You may find the following forms useful in conducting an agency self-evaluation of compliance with Wisconsin administrative rule requirements. These forms are used by surveyors during on-site state licensure surveys.

Contact us

Any questions can be directed to Thomas Rylander at 608-266-7297.

Mailing address:

Department of Health Services
Division of Quality Assurance/BHS/LCCS
PO Box 2969
Madison, WI 53701-2969

Last Revised: July 23, 2020