What becoming a Medicaid provider involves

The steps, in plain terms

1. Identify the Medicaid program and provider type in your state that pays for the services you plan to offer.
2. Meet the state’s licensing or certification requirements and the provider qualifications for that program.
3. Apply to your state Medicaid agency with the ownership and control disclosures it asks for.
4. Complete screening: license verification and federal database checks, plus a site visit or fingerprinting if your provider type is screened at a higher risk level.
5. Sign the provider agreement, and credential with each Medicaid managed care plan if your state uses them for your service.
6. Operate to the program’s rules, including electronic visit verification where it applies, report ownership changes, and revalidate when the state asks.

The order and exact steps differ by state. This list follows the federal rules cited below; it is not your state’s process.

1. Find the program and provider type

Medicaid pays for home care through specific programs. States can cover personal care as a state plan benefit and can run home and community-based services through options such as 1915(c) waivers, 1915(i) state plan services, 1915(j) self-directed personal assistance services and 1915(k) Community First Choice. Each program defines its services and provider qualifications.

Under 1915(c), states must set adequate and reasonable provider standards for the people a waiver serves, and services must follow an individualized, person-centered plan of care.

2. Licensing and license verification

The state Medicaid agency must have a way to verify that a provider claiming a state license is licensed, that the license has not expired, and that there are no current limitations on it. Medicaid enrollment does not replace licensing; it checks it.

For your state’s licensing items, homecarelicenseguide.com (also published by Home Care Agency Blueprint) collects them with sources.

3. Disclosures

The state must obtain disclosures from the providers it enrolls, including the name and address of each person or corporation with an ownership or control interest, the date of birth and Social Security number of individuals, the tax ID of corporate owners, family relationships among owners, and the name, address, date of birth and Social Security number of managing employees. Disclosures are due with the application, when you sign the provider agreement, on request during revalidation, and within 35 days after any change in ownership.

4. Screening

States screen every new application at a categorical risk level of limited, moderate or high.

The federal databases include the Social Security Administration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the OIG List of Excluded Individuals and Entities (LEIE), and the Excluded Parties List System; states must check the exclusion lists at least monthly. Your state decides which risk level applies to your provider type.

Before executing a provider agreement, states must collect the applicable application fee, with exceptions that include individual physicians and nonphysician practitioners, providers enrolled in Medicare or in another state’s Medicaid or CHIP program, and providers that already paid the fee to Medicare or another state. Ask your state whether a fee applies to you and how much it is.

5. Managed care credentialing

If your state delivers your service through Medicaid managed care plans, enrolling with the state is not the last step. Each state must set a uniform credentialing and recredentialing policy that covers long-term services and supports providers, and each plan must follow a documented credentialing process. Plans may not employ or contract with providers excluded from federal health care programs.

6. Operating under Medicaid rules

Section 12006 of the 21st Century Cures Act requires states to use electronic visit verification (EVV) for Medicaid personal care services and home health care services that require an in-home visit. States had to require EVV for personal care by January 1, 2020 and for home health care by January 1, 2023. EVV records the type of service, the person receiving it, the date, the location, the person providing it, and the start and end times.

States must also revalidate every provider’s enrollment at least every five years, and you must report ownership changes within 35 days.