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

Follow these steps if your HHA chooses to seek state licensure and Medicare certification simultaneously using a state- and federally-approved accrediting organization:

1. Choose and contact an accrediting organization.
   • The following accrediting organizations are approved to provide this combined survey process. Please get in touch with one and say you would like to seek simultaneous Wisconsin state licensure and Medicare certification. Additional fees may apply when using one of these organizations.
     • Accreditation Commission for Health Care (ACHC)
     • Community Health Accreditation Partners (CHAP)
     • The Joint Commission (TJC)
   • Once you have successfully enrolled in their survey program, they will provide you with a letter accepting you into their program.
2. Apply for a provisional license by sending the following to DQA:
   • Letter of acceptance from your chosen accrediting agency in step 1.
   • Letter of intent with a detailed description of the proposed HHA.
   • Completed Wisconsin Home Health Agency License Application, F-62674 (Word).
   • Credentials showing that the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 133.06 for details.
   • HHA application fee ($300), payable to The Division of Quality Assurance.
   • Background Check Program completed online. Include fees ($15 per individual).
   • Organizational chart, including any other entities owned by the proposed HHA.
   • A proposed operating budget for the first 90 days of operation. Use the Model Balance Sheet, F-62674A.
   • Financial references showing your HHA has the funding or revenue necessary to continue operating the business during provisional licensure, such as:
     • Letter of reference from HHA's financial institution.
     • Bank statement.
     • Evidence of stock ownership.
     • Verification of outside employment or other income.
   • 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.
   • You should also submit the following to your chosen accrediting organization at this time:
     • 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).
     • A copy of the same Wisconsin Home Health Agency License Application, F-62674 (Word) submitted to DQA.
3. Wait for an accreditation agency to review your application.
   • Once all required materials mentioned above are received, DQA will perform a fit and qualified review of the applicant under Wis. Admin. Code § DHS 133.03(i). If no issues are found during this review, DQA will send a letter to the prospective HHA and their chosen accrediting organization. This triggers the accrediting organization to conduct a provisional licensure survey.
   • The accrediting organization will then perform a provisional licensure survey. Once that survey process is complete, the accrediting organization will inform the state and a provisional HHA license will be issued
4. Operate under a provisional license.
   • The now-provisional HHA can begin serving clients. Please note that the HHA is still not Medicare or Medicaid certified, so those funding sources will not be available during this period.
   • This provisional licensure is good for three months. It is extendable up to three times (providing one year in total). The goal of this provisional licensing period is to serve 10 clients that require skilled nursing services. Send a letter to DQA requesting extensions as necessary.
5. Submit Medicare certification documents.
   • Also during this provisional licensure period, begin submitting required Medicare certification documents to DQA, 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 will send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your accrediting agency. They will need this document before performing your final certification and licensure survey.
     • A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.
     • A screenshot/copy of the confirmation page from CMS’s Office of Civil Rights Assurance of Compliance process.
6. Accrediting organization permanent licensure and Medicare certification survey.
   • Once the HHA has served 10 clients requiring skilled nursing care, the HHA should send a letter, along with 10 patient care plans, to their chosen accrediting organization. This will trigger the accrediting organization to perform an on-site unannounced survey toward state HHA licensing requirements and the Medicare Conditions of Participation.
7. Obtaining permanent HHA licensure and Medicare certification.
   • Once the accrediting organization’s onsite survey process is complete, including any required corrections, a permanent HHA license can be issued.
   • If DQA has received all federal certification documents mentioned in step 3 above, DQA can also recommend Medicare certification to the Centers for Medicare and Medicaid Services (CMS) at this time. CMS will ultimately be responsible for approving or denying the recommendation and issuing a Medicare number.

Follow this process if your HHA chooses to seek state licensure and Medicare certification simultaneously through a state agency survey process:

1. Apply for a provisional license by sending the following to DQA:
   • Letter of intent with a detailed description of the proposed HHA.
   • Completed Wisconsin Home Health Agency License Application, F-62674 (Word).
   • Credentials showing that the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 133.06 for details.
   • HHA application fee ($300), payable to The Division of Quality Assurance.
   • Background Check Program completed online. Include fees ($15 per individual).
   • Organizational chart, including any other entities owned by the proposed HHA.
   • A proposed operating budget for the first 90 days of operation. Use the Model Balance Sheet, F-62674A.
   • Financial references showing your HHA has the funding or revenue necessary to continue operating the business during provisional licensure, such as:
     • Letter of reference from HHA's financial institution.
     • Bank statement.
     • Evidence of stock ownership.
     • Verification of outside employment or other income.
   • 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.
   • 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 required materials mentioned above are received, DQA will have up to 90 days to review your application materials, including a detailed review of your policies and procedures. Upon completion of that review, DQA will issue a provisional HHA license.
2. Operate under a provisional license.
   • The now-provisional HHA can begin serving clients. Please note that the HHA is still not Medicare or Medicaid certified, so those funding sources will not be available during this period.
   • This provisional licensure is good for three months. It is extendable up to three times (providing one year in total). The goal of this provisional licensing period is to serve 10 clients that require skilled nursing services. Send a letter to DQA requesting extensions as necessary.
   • Once the HHA has served 10 clients requiring skilled nursing care, send a letter, along with 10 patient care plans, to DQA. This will trigger DQA to perform an on-site unannounced survey toward state HHA licensing requirements and the Medicare Conditions of Participation.
3. Submit Medicare certification documents.
   • Also during this provisional licensure period, begin submitting required Medicare certification documents to DQA, 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 will send a copy to DQA.
     • A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.
     • A screenshot/copy of the confirmation page from CMS’s Office of Civil Rights Assurance of Compliance process.
4. DQA completes survey.
   • Once DQA has received the HHA’s 10 patient care plans, as mentioned in step 2 above, surveyors will perform an unannounced on-site survey toward state HHA regulations and the Medicare Conditions of Participation. If any issues are identified during that survey, a plan of correction will need to be submitted.
5. Obtaining permanent HHA licensure and Medicare certification.
   • Once DQA's onsite survey process is complete, including any required corrections, a permanent HHA license can be issued.
   • If DQA has received all federal certification documents mentioned in step 3 above, DQA can also recommend Medicare certification to the Centers for Medicare and Medicaid Services (CMS) at this time. CMS will ultimately be responsible for approving or denying the recommendation and issuing a Medicare number.

Follow this process if you plan to seek HHA licensure and not Medicare or Medicaid certification at this time. Please note that Medicare certification and licensure are requirements for Medicaid certification. It is not possible to only maintain Medicaid certification as an HHA without Medicare certification. Additionally, this is the procedure you would follow if applying for a HHA license to serve Wisconsin residents in their home from a HHA in another state, as your Medicare certification would be handled by your home state.

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.
• Background Checks Program completed online. Include fees ($15 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 an applicant intends to seek both Wisconsin HHA licensure and Medicare/Medicaid certification, DQA advises following one of the streamlined processes in the “Simultaneous state licensure and Medicare certification via accrediting organization” or “Simultaneous state licensure and Medicare certification via state agency survey” tabs above rather than completing licensure and Medicare certification separately.

State licensure does not guarantee Medicare or Medicaid certification.

If an already-licensed HHA would like to seek Medicare certification, please provide the state with the following:

• 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 will send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your accrediting agency. They will need this document before performing your final certification and licensure survey.
• A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.
• A screenshot/copy of the confirmation page from CMS’s Office of Civil Rights Assurance of Compliance process.
• A copy of your full survey report from your Medicare certification survey. This survey can either be performed by state agency surveyors or by one of these federally-approved accreditation organizations:
  • Accreditation Commission for Health Care (ACHC)
  • Community Health Accreditation Partners (CHAP)
  • The Joint Commission (TJC)

Once DQA has received these federal certification documents they can recommend Medicare certification to CMS. CMS will ultimately be responsible for approving or denying the recommendation and issuing a Medicare number.

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)
• Rights of HHA Patients, F-62601 (PDF)
• Contract Review Worksheet, F-62657 (PDF)
• Program Evaluation Review Worksheet, F-62658 (PDF)