NOTE TO APPLICANTS: Initial Surveys for Medicare Participation: S&C Memo 08-03: Initial Surveys for New Medicare Providers.
This application process is for entities providing skilled nursing and other therapeutic services. Please review DHS 133 via Rules & Regulations for requirements before seeking this application.
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.
OPTIONAL FIRST STEP
DQA has developed a webcast that we encourage you to review prior to beginning the licensing process.
This webcast is designed for all potential new home health care agency providers. It complements the more in depth information available online. Presenters familiar with all aspects necessary to establish a successful home health care business will lead viewers through the application process, outline regulatory requirements and provide an overview of certification.
This webcast is an excellent tool for self-assessment. It will assist viewers in gauging their own readiness and resources for submitting an application and ultimately succeed in its operation. When you have completed viewing the webcast contact the Division of Quality Assurance (DQA) for an application.
The link will take you to the DQA webcasts. Scroll down to the Home Health Application Process Webcast, dated December 13, 2007. Be sure to select the handouts and print and/or retain a copy of the Home Health State Rules and Federal Conditions of Participation.
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 that 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.
APPLICATION FOR LICENSE
PROBATIONARY LICENSE: As a home health 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 Wisconsin Administrative Rule DHS 133 for Home Health Agencies before a license will be issued.
The following must be completed:
You must complete an application which may be obtained from the Home Health Licensing Specialist who can be reached at 608-266-7297.
Demonstrate compliance with Caregiver Background Check process.
Submit required application fees.
Demonstrate, via submission of agency policies and procedures and patient care documentation, your compliance with Wisconsin Administrative Rule DHS 133 for Home Health Agencies.
Demonstrate, via submission of agency policies and procedures, your compliance with Wisconsin Administrative Rule DHS 13: Reporting & Investigation of Caregiver Misconduct. Refer to Chapter 6 of the Wisconsin Caregiver Program Manual. (PDF, 24 KB)
A nonrefundable fee of $300.00 must be included with your application as required under DHS 133.03(3). Your check should be made payable to the: Division of Quality Assurance.
- Caregiver Background Check Process - A caregiver background check (CBC) is required to be completed for all applicants/legal representatives prior to the approval of any new license, certification or registration of a DQA regulated entity.
Review information for Licensee Applicants/License Holder Background Checks found on the Caregiver Background Check Process web page for the completion of the Background Information Disclosure (BID) form and Appendix. Complete either the Online Caregiver Background Check (CBC) process or the manual application process.
Also review information on the requirement for Employee Background Checks found on the Caregiver Background Check Process web page.
Wisconsin has a two-tier probationary license application review process. The first tier 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 home health 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 tier review is completed by a Registered Nurse (RN) who will review the applicants policies and procedures to determine whether they meet administrative rule requirements of DHS 133 and DHS 13. The RN will consult with the applicant during this review process if needed. When tier one and tier two reviews are complete and a determination is made that the applicant satisfies all policy code requirements, a 90-day probationary license will be recommended.
Regular, Non-Expiring License:
Following issuance of the probationary license, the licensee has up to 90 days in which to receive an on-site survey that is used to evaluate the level of care provided to patients. This on-site survey will consist of a review of patient care, review of records and documentation, interviews with staff, and observation of cares being given in the home setting. No on-site survey will be conducted unless the licensee can demonstrate they meet the following criteria:
Admitted and cared for at least ten (10) skilled nursing level patients; and retain on active service seven (7) skilled nursing patients at the time the written request for on-site survey is requested.
If licensee is seeking Medicare certification, have the CMS 855 enrollment application completed.
Capitalization requirements completed.
Fiscal intermediary approval received.
NOTE: If you are seeking Medicare certification, you are advised to submit application materials and supporting documentation at the same time you seek Wisconsin licensure.
Failure to meet these minimum on-site state licensure survey standards, by the expiration date of the 90-day probationary license, may result in license cancellation.
When the applicant can demonstrate readiness for the on-site survey, send a written request for the survey that includes the following:
Full Operation Letter - Prepare and submit a written notification once you are in "full operation," i.e., the agency has provided services to patients and has records to review. Do this:
- once the agency is operational
- has served at least ten (10) patients requiring skilled nursing
- at least seven (7) skilled nursing patients remain active
- the CMS 855 enrollment application has been completed
- capitalization requirements have been completed
- agency has been approved by the fiscal intermediary
This notification does not have to be provided with the federal application materials, but may be submitted via a separate letter at a time feasible to the provider.
This notification is required in order to signal that your agency is ready for a state and federal onsite survey to determine if all conditions of participation and compliance with DHS 133 are met.
- It is important to remember that a survey will not be scheduled until the notification is received.
Send the written request for the on-site survey to:
Home Health Licensing Specialist, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969.
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 performance reviews.
F-62536 Prelicensure Desk Review Checklist (PDF, 28 KB)
F-62653 Licensure Survey Entrance Conference Guide (PDF, 14 KB)
F-62654 Licensure Survey Exit Conference Guide (PDF, 14 KB)
F-62601 Rights of Home Health Agency Patients (PDF, 29 KB)
F-62646 Patient Rights Statement Review (PDF, 22 KB)
F-62651 Calendar Worksheet - Prescribed Visits (PDF, 13 KB)
F-62657 Contract Review Worksheet (PDF, 12 KB)
F-62658 Program Evaluation Review Worksheet (PDF, 38 KB)
F-62680 Clinical Record Review (PDF, 13 KB)
F-62231 Personnel Record Review (PDF, 10 KB)
F-62520 Caregiver Program Compliance Check (PDF, 22 KB)
F-62652 Licensure Survey Home Visit Guide (PDF, 20 KB)
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 probationary license. The medicare home health agency requirements are:
Federal Conditions of Participation for Home Health Agencies, 42 CFR 484, via Code of Federal Regulations
Contact your Fiscal Intermediary to have a Medicare General Enrollment Health Care Provider/Supplier Application (CMS- 855A) completed and submitted.
This separate enrollment requirement must precede survey and certification.
- In Wisconsin, the fiscal intermediary is United Government Services in Milwaukee unless your facility is affiliated with a CMS-designated chain, in which case, it may have a designated single U.S. fiscal intermediary.
Submit the following federal forms (see "Forms" section in Medicare Certification Materials)
- CMS 1572
Two copies of CMS 1561
-The person signing the Health Insurance Benefits Agreement (CMS 1561) must be someone who has the authorization of the owners of the agency to enter into this agreement.
Office for Civil Rights forms; Hard copies or complete/submit On line:
- Data Request Checklist-Civil Rights Information Request
- HHS 690- Assurance of Compliance form (two signed copies if completing hard copies)
All forms to be submitted to Division of Quality Assurance (address in "Forms" section in Medicare Certification Materials) - Ignore any other send-to addresses on forms.
See Medicare Certification Materials for links to the necessary items.
Medicaid Certification with the Wisconsin Medical Assistance (Medicaid) Program (WMAP) (Optional):
If you are interested in becoming a certified provider with the WMAP, you are encouraged to apply at the same time that you apply to Medicare. See Wisconsin Medicaid provider certification packets on the Wisconsin ForwardHealth website.
Application materials can be obtained by writing to EDS, Attention: Provider Maintenance, 6406 Bridge Road, Madison, WI 53713, or by calling 1-800-947-9627 (in-state toll free) or 608-221-9883.
Change of Ownership - 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 Division of Quality Assurance at the time you are planning a change-of-ownership transfer as your license is non-transferable.
Complete all applicable sections of application, including Section B.