CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A
CHAPTER 513 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES WAIVER (IDDW)
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Specifications for administration, provider requirements, service options, and documentation for West Virginia's Medicaid Intellectual and Developmental Disabilities Waiver affecting enrolled providers and eligible Medicaid members in West Virginia.
Policy Summary
PayerWest Virginia Bureau for Medical Services (Department of Human Services)
PolicyCHAPTER 513 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES WAIVER (IDDW)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateAug 1, 2026
Next Review DateN/A
Key ActionUpload the finalized Individual Program Plan (IPP) into the UMC portal within 10 business days of the IDT meeting to ensure timely authorization of services.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2026-08-01effective date
2service options
10bdminimum IPP upload timeline
768BSP annual max units
24hincident report entry
Coverage criteria and program rules
Coverage Overview
High-level coverage stance for IDDW services.
IDDW reimburses community-based services to instruct, train, support, supervise, and help individuals with intellectual and/or developmental disabilities to achieve independence and self-sufficiency; services are authorized based on the member's annual functional assessment and individualized budget.
Any service, procedure, item, or situation not discussed in the manual is presumed non-covered; all covered services must be provided by enrolled providers practicing within the scope of their license and meet state and federal requirements.
Service Options
Service delivery options available under the waiver.
Traditional Service Option: Most services (all except participant-directed goods and services) available through enrolled IDDW providers statewide; case management must be received through the Traditional Option.
Participant-Directed (Personal Options) Option: Available to eligible members who choose to direct certain services and budget authority/person-centered supports; includes person-centered support, respite, transportation, OT/PT/ST, dietary therapy, environmental accessibility adaptations and participant-directed goods and services (subject to eligibility and rules).
Eligibility and compliance criteria for settings and transitions
Requirements and processes to ensure settings comply with the HCBS Final Rule and actions when non-compliance is identified.
ALL of the following
- Case manager must assess each new member at enrollment and each active member annually using the member-controlled setting assessment (up to 90 days prior to anchor date) to confirm compliance.
- UMC and BMS perform verification of provider-controlled settings at least annually; agencies must notify BMS within 15 days of changes to settings they own/operate.
ALL of the following
- Member-controlled settings: case manager develops remediation plan to correct non-compliant requirements within 30 days and conducts follow-up within an additional 30 days.
- Provider-controlled settings: case manager collaborates with provider to develop remediation plan within 30 days; UMC conducts follow-up within an additional 30 days; BMS monitors remediation and provides assistance as needed.
ALL of the following
- If compliance not achieved within 90 days the setting is considered non-compliant with the federal HCBS settings rule.
- For provider-controlled settings BMS (via UMC) notifies provider by certified mail and email and the provider must begin a 90-day transition phase to relocate affected members or initiate disenrollment.
ALL of the following
- Provider must notify affected members within 10 calendar days after receiving BMS notice of non-compliance; BMS will also notify members five business days after provider notification.
- Within 30 business days of the BMS non-compliance notice the provider must submit an Agency Transition Plan (addresses of non-compliant settings; names and Medicaid numbers of affected members; services received; Critical Juncture meeting dates and outcomes; planned transition dates) and must update the plan weekly until transitions are finalized.
- During the 90-day transition phase members may remain in the non-compliant setting but HCBS services cannot be billed for that setting; BMS will start disenrollment at 45 days or when all members have transitioned.
ALL of the following
- Any restrictions (privacy, visitors, locks on bedroom doors, freedom of movement, access to food, etc.) must be documented in the IPP with less restrictive measures and HRC review when applicable.
ALL of the following
- UMC conducts compliance reviews and follow-up for provider-controlled settings; case managers conduct follow-up for member-controlled settings; BMS and UMC evaluate provider-controlled settings at least annually.
IDDW provider participation and compliance criteria
Provider enrollment, licensure, administrative, staffing, training, documentation, and member/staff responsibilities required to participate in IDDW.
ALL of the following
- Providers must obtain CON approval when required and maintain behavioral health licensure via OHFLAC (not required for case-management-only agencies).
- Providers must obtain and maintain UMC provider certification and BMS enrollment with a valid provider agreement and Medicaid enrollment agreement.
ALL of the following
- Providers must hire and retain a qualified workforce, maintain training verification records, implement utilization review/quality improvement processes, and provide an assigned agency IDDW contact responsible for oversight of home and day service visits and IPP implementation.
- Providers must maintain written policies and procedures to avoid conflicts of interest when applicable and implement the IDDW Quality Improvement System.
ALL of the following
- All direct-contact staff must meet approved criminal background checks, not be OIG-excluded, be over age 18, and be able to perform required tasks; licensed group home medication administrators must meet AMAP requirements.
- Transportation staff must have valid driver's license, insurance and registration; staff must have documented emergency/crisis training and training in reporting suspected abuse/neglect/exploitation.
ALL of the following
- Agency staff must receive mandatory IDDW training at hire and annually; training must be competency-based with measurable objectives; internet-based training requires UMC approval prior to use.
- Training documentation must include topic, dates/times, location, instructor and trainee signatures; minimum passing score on post-test is 80% for specified trainings (70% generally; 80% for case management certification).
ALL of the following
- Providers must maintain required documentation onsite and demonstrate utilization review/QI processes; training records must be made available within seven calendar days upon request; service delivery documentation (progress notes, case management logs, behavioral data, attendance) must substantiate billed services.
Conflict of Interest Safeguards
Conflict-free case management and organizational safeguards required when an agency provides both case management and other HCBS:
ALL of the following
- Agencies that provide case management cannot provide other IDDW/HCBS services to the same member if doing so would result in financial gain, potential financial gain, or job security for the case manager or agency; payee services by a case management agency are considered a conflict though exceptions may be granted case-by-case.
ALL of the following
- Maintain separate files for case management and other HCBS; maintain separate office location or physical separation if co-located; no sharing of supervisory staff between case management and HCBS services.
- Case manager may not provide other HCBS services to the member; case managers must sign Conflict-of-Interest Assurance and agencies must provide organizational charts showing administrative separation to BMS/UMC upon request.
ALL of the following
- Case managers must remain neutral during IPP development, be excused from completion of Freedom of Choice to avoid influencing member choice, and grievance/complaint procedures must be available and clear to members/legal representatives.
ALL of the following
- Failure to comply with conflict-free case management requirements may result in targeted reviews, referral/admissions exclusion, reduction in caseload size, or disenrollment as an IDDW provider.
Office Criteria
Office and operational requirements for IDDW provider-designated physical offices:
ALL of the following
- Each provider must designate and staff at least one physical office in West Virginia (no PO boxes); office must be ADA accessible, readily identifiable to the public, have primary telephone listed with name and local address, maintain a 24-hour contact method, and be open to the public at least 40 hours per week.
- Office must have access to computer, fax, secure HIPAA-compliant email, scanner, and internet; space for securely maintaining program and personnel records must be provided.
ALL of the following
- When transmitting sensitive information use HIPAA-compliant secure email; do not include PII in subject lines; personal electronic devices are prohibited when using PII; electronic authentication methods for signatures must be unique, verifiable, under sole control, and linked to data so that data changes invalidate the signature.
Quality Improvement and Monitoring
Quality Improvement System components and provider obligations:
ALL of the following
- BMS and UMC operate the Quality Improvement System (QIS); providers and Personal Options vendor must participate in QIS activities to measure performance, track remediation, and meet CMS Quality Assurances.
ALL of the following
- UMC conducts on-site and desk provider reviews, interviews, satisfaction surveys, and day service visits; targeted reviews may follow incidents or complaints.
- UMC issues draft exit report and draft Plan of Correction (POC) within 120 days of exit summation; providers have 30 days to submit comments and a completed POC; failure to submit may result in BMS placing a hold on payments; finalized disallowances may require repayment or recovery plans and providers may appeal per Chapter 800 within 30 days.
ALL of the following
- POC must be completed and electronically submitted within 30 calendar days and include corrective actions, systems to prevent recurrence, monitoring plan, responsible parties, completion date, and any provider-specific training requests.
ALL of the following
- Providers must submit annual self-review evidence and signed attestation per agency review schedule with due date communicated at least 45 days prior; UMC provides training and technical assistance to improve compliance and quality.
ALL of the following
- Providers must implement Utilization Guidelines to track authorized services, units used, and budget adherence and report units available at IDT meetings; Utilization Guidelines support QIS monitoring.
Utilization Guidelines and service authorization
Utilization Guidelines and service delivery expectations
ALL of the following
- Each agency must implement Utilization Guidelines to ensure members receive authorized services at the right time, in the right amount, and for as long as needed; guidelines must track units utilized and billed and allow reporting of units used and units available at IDT meetings.
ALL of the following
- Except for crisis services, agencies must receive prior authorization for each service provided; services must be based on assessed need within the individualized budget and IDDW service caps unless an approved exception per Section 513.25.4.1 is granted.
ALL of the following
- Agency internal Utilization Guidelines policy must address staff training, schedules, authorized units and averages of usage, individualized training needs, service request basis on identified need, monitoring utilization, and empowering members and families to make informed choices.
Case management-only agency certification
Provider certification requirements for case management-only agencies
ALL of the following
- Case management-only agencies must be certified by the UMC via a completed certification application and must maintain a state business license, FEIN, organizational chart (updated on changes), board list (if applicable), and staff list with qualifications.
ALL of the following
- Agencies must have a Quality Management Plan and written policies for complaints/grievances, electronic device use, transfers, discontinuation, conflict-of-interest, office confidentiality, emergency plans, and accessibility for limited English/accessible format needs.
ALL of the following
- Case management-only agencies must accept referrals in the UMC portal within five business days or forfeit the referral, participate in mandatory training, and ensure services and documentation meet standards before claims submission; agencies will be reviewed by UMC within six months of certification and annually thereafter.
Staff qualifications, training, and documentation
Staff training and competency
ALL of the following
- All staff must be trained in a culturally and linguistically appropriate, competency-based curriculum aligned to role responsibilities; competency demonstrated by a minimum post-test score (70% generally; 80% for Case Management Certification) and remediation/retesting required if competency not met.
- Internet-based training must be submitted to and approved by the UMC before use; UMC provides written determination.
ALL of the following
- Providers must maintain training documentation including staff name, topic/content, date, beginning and ending times, location, instructor signature, trainee signature/attestation, evidence of competency (test scores/skills validation); Personal Options staff require member signature as evidence.
ALL of the following
- Required trainings include treatment policies/confidentiality, member rights, infectious disease control, direct-care ethics, emergency care/crisis plans, member-specific needs and health/welfare needs, abuse/neglect/exploitation recognition/reporting, CPR/First Aid (cards required for direct service staff), and WV APBS or WVU CED PBS overviews where indicated.
Incident reporting via WV IMS and notifications
Incident reporting and related responsibilities
ALL of the following
- Anyone suspecting abuse/neglect must report per state rules and may use the statewide hotline; providers must also report to OHFLAC and notify Medley advocates if applicable.
ALL of the following
- All incidents must be entered into the WV Incident Management System (WV IMS) within 24 hours of learning of the incident; investigations must start within 24 hours; a completed Incident Report must be entered within 10 business days of the incident.
ALL of the following
- Providers must report to APS/CPS immediately if allegations arise and are responsible for investigating incidents even if reported to APS/CPS; results must be shared with the person/legal representative; when incidents occur in settings where another agency provides case management or services are self-directed, residential/day service agency or resource consultant must notify the case manager within two business days and provide documentation.
Documentation and retention requirements
Documentation and record retention
ALL of the following
- Providers must maintain all required documentation per Chapters 100 and 300 and keep documentation for at least five years (or until dispute resolution) available for review by BMS or contracted agents; failure to provide documentation may result in payment holds, disallowance, and recovery.
ALL of the following
- Providers must maintain records evidencing delivery of services (progress notes, case management logs, behavioral data, attendance records) to substantiate billed services; specific documentation requirements are in Section 513.9 and service definitions.
ALL of the following
- The original physical copy of the annual UMC assessment must be preserved by the primary service provider and made available to member/guardian/IDT for review; the IPP must be attached in the UMC portal prior to UMC making prior authorization decisions; when members reside in unlicensed/licensed group homes certain documents (IPP, doctor's orders, medication records, daily support documentation) must be maintained in the member's home.
IDDW enrollment and documentation criteria
IDDW enrollment and documentation criteria — applicants must meet medical and financial eligibility and secure a funded slot for enrollment.
ALL of the following
- Applicant submits WV-BMS-IDD-1 to UMC; UMC time/date stamps and contacts applicant within 3 business days and provides list of IPN psychologists.
- Applicant selects an IP from the IPN and schedules the IPE within 14 calendar days; IP completes and uploads the IPE within 60 calendar days of the IPN Response form; MECA makes medical eligibility determination within 30 calendar days of receipt of the completed IPE.
ALL of the following
- Diagnosis of intellectual or developmental disability or a related condition with onset prior to age 22; functionality defined as substantial deficits in at least three of six major life areas supported by standardized measures and narrative documentation; need for active treatment/ICF-IID level of care.
ALL of the following
- Enrollment depends on availability of a funded IDDW slot; when a slot is available the applicant completes financial eligibility at local DoHS office (income <= 300% of current maximum monthly SSI; assets excluding residence/furnishings/vehicle <= $2,000) and enrollment occurs after financial approval.
ALL of the following
- Providers must retain detailed service documentation (progress notes, case management logs, behavioral data, attendance) and maintain the original annual assessment; IPP must be attached in the UMC portal prior to prior authorization decisions.
Eligibility, slot allocation, redetermination, and IPP criteria
Eligibility, slot allocation, redetermination, and IPP criteria required for IDDW enrollment and continued services.
ALL of the following
- Applicant's monthly income may not exceed 300% of the current maximum monthly SSI payment for a single individual; only the applicant's personal income and assets are considered; asset limit (excluding residence, furnishings, and personal vehicle) may not exceed $2,000; parent/spouse income/assets are not considered.
ALL of the following
- Medical eligibility redetermination must occur at least annually with the anchor date set to the anniversary of the first month after initial medical eligibility; UMC service support facilitators conduct re-evaluations using structured interviews and standardized adaptive behavior measures.
ALL of the following
- Slots are allocated chronologically by date UMC receives a fully completed application or fair hearing decision; enrollee must return Freedom of Choice within 30 days and must access case management and at least one direct-care service within 180 days of slot availability or be discharged.
ALL of the following
- Initial IPP must be developed within 7 calendar days of intake/admission; IPP must be developed annually and reviewed at least every three months (no more than six months between reviews); IPP must be signed in real time by attending IDT members and uploaded to the UMC portal within 10 business days.
Coverage and authorization criteria tied to IPP validity
Conditions that affect reimbursement and valid authorizations tied to IPP validity.
ALL of the following
- All attending IDT members must sign the IPP in real time prior to conclusion of the meeting; if required signatures are missing or the IPP has expired, Medicaid cannot reimburse services delivered during that period.
ALL of the following
- Case manager must distribute a copy of the finalized IPP to all team members and upload it into the UMC portal within 10 business days to ensure timely authorization of services.
ALL of the following
- Initial in-person IDT meeting must occur within seven calendar days of admission/intake; IPP must be reviewed at least quarterly and no less frequently than every six months; Critical Juncture meetings require IPP updates as needed.
Coverage criteria and requirements
Summary of coverage and conditions across service options and BSP services.
ALL of the following
- Members may choose Traditional or Participant-Directed Service options; Participant-Directed Option is not available to members in OHFLAC licensed residential settings.
ALL of the following
- All services (including BSP) require prior authorization based on assessed need from the annual functional assessment and must be within the member's individualized budget unless an exception is approved per Section 513.25.4.1.
ALL of the following
- BSP services include FBA, PBS plans, staff training, monitoring, development of habilitation plans and attendance at IDT meetings; BSP must document specified elements (member, code, date, times, total time, data analysis, clinical outcome, plan, signature/credentials); unit = 15 minutes and all units must be prior authorized.
Coverage criteria and requirements (BSP, IPP, Crisis, Dietary)
Services are covered when prior authorized based on assessed need from the annual functional assessment, within the member's individualized budget unless an approved exception exists. Documentation and staff qualifications must meet specified requirements.
ALL of the following
- All units of BSP, IPP planning events, crisis services, and dietary therapy must be prior authorized based on assessed need from the annual functional assessment and must be within the member's individualized budget unless an exception is approved per Section 513.25.4.1.
ALL of the following
- BSP direct services: unit = 15 minutes; max 768 units (192 hours) per IPP year.
- BSP IPP planning: unit = event; maximum 4 events per IPP year.
- Crisis services: unit = 15 minutes; 2:1 ratio; max 17,280 units (4,320 hours) per IPP year; emergent implementation up to 72 hours without prior authorization; utilization reviewed by IDT at least every 3 months.
- Dietary therapy: unit = 15 minutes; 1:1 ratio; max 416 units (104 hours) per IPP year combined with PT/OT; providers must be licensed WV registered dietary therapists and enrolled in Medicaid.
ALL of the following
- Detailed progress note/evaluation required for each service including member name, service code, date, start/stop time, total time, description of service, assessment of progress, plan, and staff signature/credentials; BSP and crisis billing limited to direct service activities and not administrative/travel time.
Coverage Criteria for Waiver Therapy Services
Coverage is conditional and subject to prior authorization, member budget, age restrictions, and provider qualifications.
ALL of the following
- Therapy and dietary waiver services are generally limited to members 21 years and older under the waiver; members under 21 may access comparable services through EPSDT as noted.
ALL of the following
- Therapists (OT, PT, ST) and dietary therapists must be licensed to practice in West Virginia and individually enrolled as West Virginia Medicaid providers (contracted therapists must also be individually enrolled).
ALL of the following
- OT/PT/dietary combined: maximum 416 units (104 hours) per IPP year; speech therapy limits vary by age (96 events/year for <22; 48 events/year for 22+); 1:1 staff-to-member ratio required for listed therapies; detailed progress note/evaluation required for each service.
Coverage criteria and operational rules
Conditions, limits, and requirements for waiver-provided dietary, occupational, physical, speech therapy, and electronic monitoring services.
ALL of the following
- All units of OT, PT, ST, and dietary therapy must be prior authorized before provision based on assessed need from the annual functional assessment and must fit within the member's individualized budget unless an approved exception exists per Section 513.25.4.1.
ALL of the following
- Therapists and dietary therapists must be licensed in West Virginia and individually enrolled as Medicaid providers; contracted therapists must also be individually enrolled and licensed to bill waiver services.
ALL of the following
- Maximum combined OT/PT/dietary = 416 units (104 hours) per IPP year; PT and OT each limited to 416 units/year; speech therapy: 96 events/year for members under 22 and 48 events/year for members 22+; 1:1 staff-to-member ratio generally required; staff providing PT may not live in the member's home and may not bill for administrative activities.
ALL of the following
- Electronic monitoring is only used when there is no paid staff in the member's home; monitoring systems/companies must meet BMS standards, be pre-approved and annually approved; case manager and IDT must submit Risk Assessment IDD-17, Remote Monitoring Application IDD-15, and Remote Monitoring Equipment IDD-16 to UMC prior to implementation; HRC approval and informed consent required; monitoring base staff must have two-way audio/video, smoke/heat notifications, focus solely on monitoring, call 911 when necessary and maintain engagement until stand-by staff or emergency responders arrive; stand-by staff must respond within 20 minutes or shorter if set by IDT; service is limited to members over age 18 and annual caps apply depending on residential setting.
Coverage Criteria
Coverage rules and conditions for service provision, eligibility, and limitations (electronic monitoring, EAA, and related operational constraints).
ALL of the following
- Electronic monitoring may be used only when there is no paid staff in the member's home and only after member/legal representative/IDT request and HRC approval documented on the IPP; all systems/companies must meet BMS standards and be pre-approved and annually approved.
ALL of the following
- Monitoring systems must include smoke/heat alert notification, two-way full-duplex audio, visual oversight of necessary areas, and monitoring base staff may have no other duties while monitoring; monitoring staff must call 911 first if necessary and remain engaged until stand-by staff or emergency personnel arrive; programmatic reviews and drills required at 7 and 14 days after implementation and at least quarterly thereafter.
ALL of the following
- Providers must maintain stand-by intervention staff who respond within 20 minutes (or shorter if set by IDT); emergency responses must be reported to WV IMS; electronic monitoring units are limited by individualized budget and maximum annual caps by residential setting (e.g., 23,360 units/5,840 hours for licensed group home/unlicensed residential).
ALL of the following
- Environmental Accessibility Adaptations (EAA) have a combined $1,000 annual cap per member (Traditional/Personal Options/PDGS combined); EAAs require Request for EAA form (WV-BMS-IDD-08), proof of purchase, and vendor payment rules (case management agency or Personal Options vendor must not pay EAA funds to member, staff, or family/legal representative).
Coverage criteria and limits for listed services
Coverage requires prior authorization based on the annual functional assessment, services to be within the individualized budget unless an exception is approved, and adherence to service-specific limits and documentation.
ALL of the following
- All units of service across listed services (facility-based day habilitation, pre-vocational, job development, supported employment, EAA, PDGS, etc.) must be prior authorized before delivery; authorizations are based on assessed need identified on the annual functional assessment and must fit within the member's individualized budget unless an exception is approved per Section 513.25.4.1.
ALL of the following
- Standard service unit = 15 minutes for facility-based day habilitation, pre-vocational, job development, and supported employment; many of these services are limited to members age 18 and over.
ALL of the following
- Combined maximum annual direct-care units may not exceed specified caps (e.g., 6,240 units/1,560 hours for certain day services combined with other direct-care); these services may not be billed concurrently with other direct-care/direct-support services per service definitions.
ALL of the following
- Providers must maintain Direct-Support Service Log (WV-BMS-IDD-7), task analyses, transportation logs when applicable, proof of purchase for EAA, and other IPP documentation; staff must meet IDDW staff requirements and service-specific supervision/training standards (e.g., BSP supervision for pre-vocational and supported employment).
Coverage criteria for services in excerpt
Services are available when assessment-identified needs are documented on the IPP and are within the member's individualized budget; exceptions require approval per Section 513.25.4.1.
ALL of the following
- All units must be prior authorized based on assessed need identified on the annual functional assessment and must be within the member's individualized budget; exceptions require formal approval per Section 513.25.4.1.
ALL of the following
- Supported employment must be provided in an integrated community work setting (not in settings owned/leased by an IDDW provider) unless the member is self-employed; documentation that a referral was made to Division of Rehabilitation Services (DRS) or equivalent programs must be kept in the member file prior to billing supported employment.
ALL of the following
- PDGS items must be pre-approved by the UMC, supported by assessed need documented on the IPP, be age-appropriate, purchased from established vendors, evidenced by dated itemized receipts, and limited to the participant-directed budget (PDGS capped at 1000 units = $1,000 per IPP year combined with EAA). PDGS cannot reimburse past purchases and may not be transferred into certain other budget categories.
ALL of the following
- Family person-centered support must be assessment-based, on the IPP, provided by eligible family members or specialized family care providers, documented on the Direct-Support Service Log, subject to annual unit caps, and spouses are excluded from providing this service as payable providers.
Procedure codes, units, and limits
Documentation requirementsmixed
| No codes listed |
Crisis services codeHCPCSCovered
| T2017 | Crisis Services (2:1 ratio) |
Dietary therapy codeCPTCovered
| 97802AE | Dietary Therapy (15-minute unit; 1:1 ratio) |
Occupational Therapy ProcedureCPTCovered
| 97530GO | Occupational therapy, unit = 15 minutes (1:1 ratio) |
| 97530GOUG | Occupational therapy direct-care code; 1:1 ratio; unit = 15 minutes |
Physical Therapy ProcedureCPTCovered
| 97530GP | Physical therapy, unit = 15 minutes (1:1 ratio) |
| 97530GPUG | Physical therapy direct-care code; 1:1 ratio; unit = 15 minutes |
Speech Therapy ProcedureCPTCovered
| 92507GN | Speech therapy, unit = 1 event (1:1 ratio) |
| 92507GNUG | Speech therapy direct-care code; unit = 1 event |
Dietary Therapy ProcedureCPTCovered
| 97802AEUG | Dietary therapy, unit = 15 minutes (1:1 ratio) |
| 97802AE | Dietary Therapy (15-minute unit; 1:1 ratio) |
Waiver direct-care procedure codesCPTCovered
| 97530GOUG | Occupational therapy direct-care code; 1:1 ratio; unit = 15 minutes |
| 97530GPUG | Physical therapy direct-care code; 1:1 ratio; unit = 15 minutes |
| 92507GNUG | Speech therapy direct-care code; unit = 1 event |
IDDW service procedure codes in this sectionmixedCovered
| S5161U1 | Electronic monitoring with 1:1 stand-by ratio |
| S5161U2 | Electronic monitoring with 1:2 stand-by ratio |
| S5161U3 | Electronic monitoring with 1:3 stand-by ratio |
| S5161U4 | Electronic monitoring with 1:4 stand-by ratio |
| S5165 | Environmental Accessibility Adaptations-Home (Traditional) |
| T2039 | Environmental Accessibility Adaptations-Vehicle (Traditional) |
| S5165UG | Environmental Accessibility Adaptations-Home (Participant-Directed/Personal Options) |
| T2039UG | Environmental Accessibility Adaptations-Vehicle (Participant-Directed/Personal Options) |
Facility-Based Day Habilitation codesHCPCSCovered
| T2021U5 | Facility-Based Day Habilitation, 1:1-2 ratio |
| T2021U6 | Facility-Based Day Habilitation, 1:3-4 ratio |
| T2021U7 | Facility-Based Day Habilitation, 1:5-6 ratio |
Pre-vocational codesHCPCSCovered
| T2021U1 | Pre-vocational, 1:1-2 ratio |
| T2021U2 | Pre-vocational, 1:3-4 ratio |
| T2021U3 | Pre-vocational, 1:5-6 ratio |
Job Development codesHCPCSCovered
| T1019HB | Job Development, 1:1 ratio |
Supported Employment codesHCPCSCovered
| T2019 | Supported Employment, 1:1 ratio |
| T2019HQ | Supported Employment, 1:2-4 ratio |
Procedure codes in this excerptmixedCovered
| T2019 | Supported employment (1:1 ratio) |
| T2019HQ | Supported employment (1:2-4 ratio) |
| T2028SC | Participant-directed goods and services (unit = $1.00) |
| S5125U5 | Family person-centered support (1:1 ratio) |
| S5125U6 | Family person-centered support (1:2 ratio) |
IPE upload deadline and related timings
IPE upload deadlineIPN psychologist must complete and upload the Independent Psychological Evaluation (IPE) within 60 calendar days of receipt of the IPN Response form.
Applicant scheduling windowApplicant must schedule appointment with chosen IPN psychologist within 14 calendar days of receiving the IP list.
UMC contact after applicationUMC contacts the applicant within 3 business days of receipt of the WV-BMS-IDD-1 application.
MECA decision timeframe and appeals
MECA decision timeframeMECA makes a medical eligibility determination within 30 calendar days of receipt of the completed IPE.
Right to second evaluationApplicant may request a second medical evaluation to be completed within 60 calendar days by a different IPN member at BMS expense if requested after denial.
Notice and appeal windowIf denied, a Notice of Decision is mailed and the applicant may appeal via Medicaid Fair Hearing within 90 calendar days.
Service unit and related billing rules
Service unit definitionService unit for BSP and many direct-care services is 15 minutes.
Billing requirementAll units of service must be prior authorized before being provided based on assessed need from the annual functional assessment.
Documentation requirementDetailed progress notes and documentation elements required for each billed service (member, code, date, times, total time, clinical analysis, plan, signature).
Behavior Support Professional (BSP) annual maximums
BSP annual maximum unitsMaximum annual BSP services cannot exceed 768 units (192 hours) per IPP year.
Prior authorization requirementAll BSP units must be prior authorized based on the annual functional assessment and within the individualized budget unless exception approved.
Staffing restrictionBSP staff providing services may not live in the member's home.
BSP IPP planning event limits
BSP IPP planning events capMaximum of 4 BSP IPP planning events (combined BSP I & II) per member's IPP year.
Billing for planning eventsTo bill BSP IPP Planning, the BSP professional must be present for the duration of the IPP meeting; partial attendance billed as direct BSP time.
IPP planning billing exclusionIPP planning cannot be billed for preparation or follow-up time outside the meeting.
Crisis services maximums and rules
Crisis services annual maximumMaximum annual units for Crisis Services = 17,280 units (4,320 hours) per IPP year.
Staff-to-member ratioCrisis services require a 2:1 agency staff-to-member ratio.
Emergent implementation allowanceUnder emergent circumstances, crisis services may be implemented up to 72 hours without prior authorization.
Dietary therapy annual limits
Dietary therapy annual maximum (combined with PT/OT)Maximum annual units for Dietary Therapy = 416 units (104 hours) per IPP year (combined with physical and occupational therapy).
Age and staffingDietary therapy under waiver is limited to members 21+; staff-to-member ratio is 1:1 and agency staff may live in the member's home.
Provider enrollmentDietary therapists must be licensed in West Virginia and individually enrolled as Medicaid providers to bill.
Speech therapy annual and event limits
Speech therapy annual limits (age-based)Speech therapy limits: 96 events per IPP year for members below age 22; 48 events per IPP year for members age 22 and over.
Staffing and siteSpeech therapy requires a 1:1 staff-to-member ratio; agency staff may not live in the member's home.
Prior authorization and documentationAll speech therapy units require prior authorization and detailed progress notes to support medical necessity within the individualized budget.
Combined annual limit for PT/OT/Dietary and per-discipline maxima
Combined annual limit (PT/OT/Dietary)Maximum combined annual units for Physical Therapy, Occupational Therapy and Dietary Therapy = 416 units (104 hours) per IPP year.
Per-discipline maximaEach of Physical Therapy and Occupational Therapy individually may not exceed 416 units (104 hours) per IPP year; speech therapy limits differ by age.
1:1 staffing requirementTherapy services require a 1:1 staff-to-member ratio and therapists must be licensed and individually enrolled in WV Medicaid.
Maximum annual units (OT/PT/Dietary combined and per-discipline caps)
OT/PT/Dietary combined maximumOT/PT/Dietary combined: 416 units (104 hours) per IPP year; Physical Therapy max 416 units/104 hours; Occupational Therapy max 416 units/104 hours.
Speech therapy specificationSpeech therapy: 96 events per year for members under age thresholds; 48 events for older members (see speech service definitions).
Prior authorization necessityAll therapy units must be prior authorized based on assessed need from the annual functional assessment and within the individualized budget unless exception approved.
Electronic monitoring annual maximums by residential type
Electronic monitoring annual max (group/unlicensed residential)Maximum electronic monitoring units for members in licensed group homes or unlicensed residential homes = 23,360 units (5,840 hours) per IPP year.
Electronic monitoring annual max (natural family/specialized family care)Maximum for members in natural family or specialized family care homes = 11,680 units (2,920 hours) per IPP year.
Service combination ruleElectronic monitoring is treated as a replacement for direct-care staff; no other direct-care service may be billed concurrently for residents of the monitored home.
EAA annual combined dollar limit and rules
EAA annual combined dollar limit per memberEnvironmental Accessibility Adaptations (EAA) combined annual cap per member = $1,000 per IPP year (combined across Traditional, Personal Options EAA-Home/Vehicle and PDGS).
Payment ruleCase management agencies and Personal Options vendor must not pay EAA funds to the member, staff, or family; payments must be issued to the EAA vendor or Personal Options FMS as applicable.
EAA restrictionsEAA may not be used to buy/lease vehicles, for routine vehicle upkeep (except upkeep of modifications), or to adapt provider-owned vehicles; adaptations to rental residences must be portable.
Maximum annual units for combined direct-care day services
Maximum annual units (combined direct-care services)Maximum annual combined direct-care units (facility-based day habilitation, pre-vocational, supported employment, etc.) = 6,240 units (1,560 hours) per IPP year.
Counting toward daily capUnits for these day services count toward the daily cap when the member accesses other direct-care services; services may not be billed concurrently with other direct-care services.
Age restriction for day/work servicesFacility-based day habilitation, pre-vocational, job development and supported employment generally limited to members 18 years and older.
Service maximums, PDGS and supported employment caps
Maximum annual units (combined OT/PT/Dietary & direct-care limits)Service maximums and budget limits include supported employment max 8,320 units (2,080 hours) annually (combined with other direct-care); family person-centered support max 7,320 units (<18) or 11,680 units (18+) annually; PDGS capped at 1,000 units ($1,000) per IPP year.
PDGS dollar-unit relationshipParticipant-Directed Goods and Services (PDGS) cap: 1,000 units = $1,000 per IPP year and funds must be paid to vendor with receipts; PDGS cannot reimburse past purchases.
Supported Employment referral requirementSupported Employment may not be billed without documentation of a referral to the Division of Rehabilitation Services (DRS).
Electronic monitoring / EAA procedure codes and pre-implementation rules
Procedure codes included (electronic monitoring & EAA)Key procedure codes in the electronic monitoring and EAA section include: S5161U1/2/3/4 (electronic monitoring ratios), S5165/T2039 (EAA-Home/Vehicle Traditional), S5165UG/T2039UG (EAA Participant-Directed).
Prior authorization requirementAll units of these services must be prior authorized and be within the member's individualized budget unless an exception is approved.
Pre-implementation documentation (electronic monitoring)Before implementation, case manager, member and IDT must submit Risk Assessment (IDD-17), Remote Monitoring Application (IDD-15), and Remote Monitoring Equipment (IDD-16) to UMC; HRC approval and informed consent required and documented on IPP.
Provider obligations, authorizations, and operational steps
Documentation Required
Maintain licensure, enrollment, and medical-necessity documentation
Enrolled providers must practice within the scope of their license and keep current, accurate, legible, and completed documentation that justifies medical necessity; this documentation must be made available to BMS or its designee upon request.
Documentation Required
Notify BMS and members; submit Agency Transition Plan on setting changes/non‑compliance
Providers who own or operate waiver settings must notify BMS within 15 days of any change in status for those settings; if BMS issues a non‑compliance notice providers must notify affected members within 10 calendar days and submit an Agency Transition Plan to BMS within 30 business days.
- Notify BMS within 15 days of added/removed sites (provider-owned settings).
- Notify affected members within 10 calendar days after BMS non‑compliance notice.
- Submit Agency Transition Plan to BMS within 30 business days; update weekly until transitions finalized.
Prior Authorization
Obtain service authorization from the UMC
The UMC, acting as BMS's agent, provides authorization for services based on the member's assessed needs and communicates authorization information to the claim payer.
Note
UMC authorizes services and notifies payers
The UMC is responsible for authorizing services per assessed needs and for providing authorization details to the claim payer as part of its role as BMS's agent.
Denial Risk
Respond to UMC reviews and submit Plan of Correction within 30 days
Respond to UMC provider reviews: after an exit summation the UMC issues a draft exit report and Plan of Correction; providers have 30 days to submit comments and a completed POC and failure to submit may result in BMS placing a hold on payments.
- UMC will provide a draft exit report and POC within 120 days of exit summation.
- Provider must submit comments and completed POC within 30 days of draft receipt or risk payment hold.
Prior Authorization
Prior authorization required for non‑crisis services
Except for crisis services, agencies must obtain prior authorization for each service provided as specified under Section 513.22 and in each service's 'Prior Authorization' statement.
Prior Authorization
Attach IPP in UMC portal before prior‑authorization decisions
Attach the member's finalized IPP in the UMC portal prior to the UMC making decisions on prior authorization requests for IDDW services; the IPP must be available to support authorization decisions.
Documentation Required
Accept UMC referrals, meet eligibility checks, and upload IPP for authorization
UMC refers newly allocated enrollees to the chosen case management provider upon receipt of a signed Freedom of Choice; case managers must upload the IPP into the UMC portal (per IPP timelines) to support authorization, and may reject referrals only for error or inability to meet needs.
- Case manager may reject referral only if received in error or unable to meet medical/behavioral needs.
- Proof of medical and financial eligibility is required before accessing a slot.
- Upload IPP within required timelines to ensure timely authorization.
Prior Authorization
Upload finalized IPP to UMC within 10 business days
Upload the IPP into the UMC portal within 10 business days of the IDT meeting to ensure timely authorization of services.
- Case manager distributes IPP to team and uploads to UMC portal within 10 business days.
Prior Authorization
Submit transfer/discharge and WVBMS-IDD-10 within five business days
For transfers/discharges, submit the transfer via the UMC portal and attach the Transfer/Discharge form (WVBMS-IDD-10) within five business days of the transfer/discharge IDT meeting.
Documentation Required
Request purchases/modifications in UMC portal and deliver IPP to transferee
Make purchases and modifications in the UMC portal prior to the effective transfer date and send the completed IPP to the transfer‑to agency within 10 business days.
- Case manager must send completed IPP to transfer‑to agency within 10 business days.
- Request purchases/modifications in the UMC portal before the transfer effective date.
Prior Authorization
Prior authorize all BSP units and ensure they fit within the individualized budget
All units of Behavior Support Professional (BSP) services must be prior authorized based on assessed need identified on the annual functional assessment and must fit within the member's individualized budget unless an exception is approved.
Prior Authorization
Obtain prior authorization for direct BSP services (Level I/II)
Direct BSP Level I and II services require prior authorization before provision; authorizations are based on assessed need from the annual functional assessment and must be within the individualized budget unless an approved exception exists.
- Bill BSP direct‑care codes only after prior authorization is obtained.
Prior Authorization
Prior authorize BSP IPP planning events
BSP Individual Program Planning (event) services must be prior authorized; all planning events are authorized based on assessed need from the annual functional assessment.
Prior Authorization
Prior authorization and utilization review for crisis services (2:1 ratio)
Crisis services require prior authorization; they may be authorized for the IPP year and used intermittently, must be reviewed by the IDT at least every three months, and emergent crisis implementation may occur up to 72 hours without prior authorization.
- Procedure code: T2017 (2:1 ratio); unit = 15 minutes.
- Prior authorization based on assessed need; utilization reviewed quarterly by IDT.
Prior Authorization
Prior authorize dietary therapy units
Dietary therapy units must be prior authorized based on assessed need identified on the annual functional assessment and must be within the member's individualized budget unless an approved exception applies.
- Procedure code: 97802AE (15‑minute unit); site and documentation requirements apply.
Prior Authorization
Prior authorization required for occupational therapy units
All occupational therapy units under the waiver must be prior authorized before provision based on assessed need from the annual functional assessment and fit within the member's individualized budget unless an exception is approved.
- Procedure code: 97530GOUG; unit = 15 minutes.
- Direct‑care OT must be billed with the appropriate direct‑care code after prior authorization.
Prior Authorization
Obtain prior authorization for physical therapy units
All physical therapy units must be prior authorized before provision, based on assessed need identified on the annual functional assessment and within the member's individualized budget unless an exception is approved.
- Procedure code: 97530GP; unit = 15 minutes.
- Documentation must include detailed progress notes for each service.
Prior Authorization
Prior authorization required for speech therapy units
Speech therapy units must be prior authorized based on assessed need identified on the annual functional assessment and must be within the member's individualized budget unless an exception is approved.
- Procedure codes: 92507GN (Traditional) / 92507GNUG (Participant‑Directed); unit = Event.
- Claims must contain ordering/referring NPI and therapist must be licensed and enrolled.
Prior Authorization
Prior authorize all dietary therapy units before delivery
All dietary therapy units must be prior authorized prior to provision; authorizations are based on assessed need identified on the annual functional assessment and must fit within the individualized budget unless an exception is approved.
- Procedure code: 97802AEUG; unit = 15 minutes.
- Detailed progress notes required for each service.
Prior Authorization
Universal prior authorization requirement for waiver services
Reiterate that all units of service across listed waiver services must be prior authorized before provision; authorizations are based on assessed need from the annual functional assessment and must align with the member's individualized budget unless an approved exception exists per Section 513.25.4.1.
Billing Rule
Ensure prior authorization aligns with procedure codes and billing
Prior authorization decisions must be matched to the correct billing/procedure codes; providers must ensure requested authorizations correspond to the procedure codes used to bill and validate that billed codes were authorized.
Documentation Required
Submit IDD‑17, IDD‑15, and IDD‑16 and document HRC approval before Electronic Monitoring
Before implementing Electronic Monitoring, the case manager, member, and IDT must prepare and submit the Risk Assessment (IDD-17), Remote Monitoring Application (IDD-15), and Remote Monitoring Equipment (IDD-16) to the UMC; HRC approval and informed consent must be documented and attached to the IPP.
- HRC approval must be documented and attached to IPP.
- Informed consent from member and legal representative required prior to implementation.
Prior Authorization
Prior authorization required for all units before services are provided
All units of service across waiver services must be prior authorized prior to provision; this requirement is restated to emphasize that prior authorization is required for service delivery.
Prior Authorization
Service‑specific prior authorization and referral requirements for day/work services
Facility‑Based Day Habilitation, Pre‑vocational, Job Development, and Supported Employment each require prior authorization; Supported Employment additionally requires documentation of referral to the Division of Rehabilitation Services (DRS) before billing and participant‑directed PDGS must be pre‑approved by the UMC.
- Supported Employment: must document referral to DRS; maximum annual combined supported employment units noted in limitations.
- PDGS: items must be pre‑approved by UMC and documented with receipts; prior authorization required.
Prior Authorization
Confirmation: prior authorization required per assessed need and budget
Restate that all units of service in the cited sections require prior authorization based on assessed need from the annual functional assessment and must be within the member's individualized budget unless an approved exception applies (Section 513.25.4.1).
Billing Rule
Document DRS referral for Supported Employment and pre‑approve PDGS purchases
Supported Employment may not be billed without documentation of a referral to the Division of Rehabilitation Services (DRS); participant‑directed goods and services must be pre‑approved by the UMC and purchases documented with receipts, and PDGS funds must not be paid to the member, staff, or family.
- PDGS purchases must be pre‑approved and supported by assessed need documented on the IPP.
- PDGS payments must be issued to vendors, not to members/staff/family/legal representatives.
Definitions and key terms
IDDW / IDDW Program — program definition and scope
Program definitionIDDW is West Virginia's home- and community-based services program for individuals with intellectual and/or developmental disabilities administered by BMS under a CMS-approved waiver
Service basisServices are authorized based on the member's annual functional assessment and individualized budget
Service settingsDelivery occurs in community-based settings including member's home and public community locations
HCBS Final Rule (CMS-2249-F and CMS-2296-F) — federal rule reference
Federal rule referenceHCBS Final Rule — CMS-2249-F and CMS-2296-F establishes integrated settings requirements for Medicaid HCBS programs
ImplicationsRequires training for case managers and direct-support staff on integrated settings requirements; ensures community access, integrated employment, and control over finances
Provider obligationProviders must adhere to HCBS settings requirements and BMS monitoring for compliance
Integrated settings definition — homes/apartments owned or leased by member or family
Integrated settings definitionHomes or apartments owned or leased by the HCBS member, their unpaid housemate, or the member's family by birth, marriage, or adoption
SignificanceSettings meeting this definition support HCBS Final Rule compliance and person-centered choice
ContrastDistinct from provider-controlled settings which are owned/operated by agencies or where paid unrelated caregivers live
Provider-controlled settings — examples of agency-owned or operated settings
Provider-controlled settings examplesIncludes IDDW facility-based day habilitation, specialized family care homes, 24/7 supported unlicensed residential homes, licensed group homes, and CSEDW therapeutic foster homes
Notification requirementAgencies must notify BMS within 15 days of any change in status for settings they own/operate; new settings require UMC compliance review before billing
AssessmentNew settings must be assessed by the case manager and documented prior to UMC billing approval
UMC — Utilization Management Contractor definition and role
UMC roleUtilization Management Contractor (UMC) acts as BMS agent to process eligibility packets, conduct annual functional assessments, calculate individualized budgets, provide provider education, and authorize services
Operational functionsUMC issues policy clarifications, conducts provider reviews, and provides authorization information to the claim payer
Coordination with MECAUMC and MECA collaborate to process initial applications and redetermination packets
MECA — Medical eligibility contracted agent definition
MECA definitionMedical Eligibility Contracted Agent (MECA) determines initial and redetermination medical eligibility and recruits/trains IPN psychologists
Decision timeframeMECA makes medical eligibility determinations within 30 calendar days of receiving the completed IPE
CollaborationMECA works with UMC to process eligibility and assessment materials
F/EA — Fiscal/Employer Agent definition and role
F/EA definitionFiscal/Employer Agent (F/EA) administers the Personal Options Financial Management Services (FMS) as a BMS subagent to perform employer and payroll functions for self-directed services
Support roleF/EA (Personal Options vendor) assigns resource consultants to assist self-directing members with spending plans and payroll functions
Payment dutiesF/EA acts as neutral bank receiving/disbursing public funds and monitoring budget spending
EVV — Electronic Visit Verification definition and purpose
EVV purposeElectronic Visit Verification (EVV) verifies in-home visits documenting service type, recipient, date, location, provider, and start/end times per the 21st Century Cures Act
Implementation datesEVV implemented for Personal Care Services on March 1, 2021, and for Home Health Care Services by Jan 1, 2023
Provider responsibilityProviders may use BMS-contracted EVV vendor or ensure their chosen vendor complies with Cures Act requirements
Conflict of interest (CFCM) — conflict definition and examples
Conflict definitionConflict of interest occurs when a case manager affiliated with a provider agency has financial gain, potential financial gain, or job security tied to the provider receiving business for the member
ProhibitionCase management agencies cannot provide other IDDW/HCBS services to the same member if it would create a conflict; payee services by case manager agency generally prohibited (exceptions case-by-case)
SanctionsFailure to comply may result in loss of IDDW certification for one year and transfer of members to other case management agencies
Office criteria — summary of office requirements
Office location requirementProvider must designate and staff at least one physical office located in West Virginia (PO boxes not acceptable)
Accessibility & hoursOffice must meet ADA requirements and be readily identifiable; must maintain primary telephone and have computer, fax, email, scanner, and internet access
SecurityUse HIPAA-compliant secure email for sensitive communications and protect PII; personal devices prohibited when using PII
Quality Improvement System (QIS) — definition and purpose
QIS purposeQuality Improvement System (QIS) is a continuous system led by BMS and UMC to measure system performance, track remediation, ensure CMS Quality Assurances, and involve stakeholders
Provider participationIDDW providers and Personal Options vendor must participate in QIS activities including reviews, remediation, and reporting
UMC roleUMC conducts on-site/desk provider reviews, issues draft exit reports and POCs, and provides training/technical assistance
Abuse — definition used in policy
Abuse definitionAbuse includes physical acts causing bodily harm, corporal punishment, restrictive intrusive procedures for punishment, psychological abuse (humiliation, threats), and verbal abuse (demeaning or threatening language)
Reporting obligationAny incident must be entered into WV IMS within 24 hours of learning of the incident; investigations start within 24 hours; completed reports within 10 business days
ConsequencesProviders must notify APS/CPS when applicable and investigate incidents even if external agencies are involved
Neglect — definition used in policy
Neglect definitionNeglect means negligent acts or patterns that caused or may have caused injury or death or placed a person at risk, including failure to carry out IPP or provide adequate nutrition, health care, or safe environment
Reporting timelineProviders must enter incidents into WV IMS within 24 hours and complete Incident Report in 10 business days
Investigation responsibilityProviders are responsible for investigating incidents and informing the person/legal representative of findings
Exploitation — definition used in policy
Exploitation definitionExploitation is the unlawful expenditure or willful dissipation of funds or assets owned by or paid for the benefit of an incapacitated individual
Incident reportingAllegations of exploitation must be reported per state rules and entered into WV IMS; providers must investigate and share results with person/legal representative
Protective actionsProviders must coordinate with APS/CPS and other agencies as required when exploitation is suspected
Independent Psychological Evaluation (IPE) — definition and content
IPE definitionIndependent Psychological Evaluation (IPE) is a comprehensive psychological evaluation completed by an IPN psychologist including background, mental status, intelligence and adaptive behavior measures used by MECA for eligibility
Uploader responsibilityIPN psychologist is responsible for completing and uploading the IPE within 60 calendar days of the IPN Response form
UseIPE is used by MECA to determine medical eligibility for IDDW
Independent Psychologist Network (IPN) — IPN definition and role
IPN definitionIndependent Psychologist Network (IPN) is a roster of WV-licensed psychologists trained by MECA and approved by BMS to perform IPEs for eligibility determinations
QualificationsIPN members must be WV-licensed psychologists and WV Medicaid providers performing evaluations independent of IDDW providers
Selection timelineUMC provides IPN list; applicant must schedule IP within 14 calendar days
Functionality — substantial limitations in major life areas definition
Functionality definitionFunctionality: substantially limited functioning in three or more of six major life areas as evidenced by standardized adaptive behavior measures and narrative documentation
Major life areasSelf-care; Receptive/expressive language; Learning (functional academics); Mobility; Self-direction; (etc.)
Eligibility useFunctionality is required to meet medical eligibility for IDDW and is assessed via standardized measures and narratives
Active treatment / ICF/IID level of care — definition and implication
Active treatment / ICF/IID levelActive treatment/ICF-IID level of care: need for intensive instruction, services, assistance, and supervision consistent with care provided in an ICF/IID
Eligibility implicationApplicants must demonstrate need for ICF/IID level of care via evaluations and narrative descriptions to qualify for IDDW medical eligibility
Choice noticeApplicants informed of right to choose between ICF/IID services and IDDW HCBS and right to fair hearing for adverse decisions
Service support facilitator — UMC-employed role and qualifications
Service support facilitator roleUMC-employed Service Support Facilitator conducts annual functional re-evaluations and assessments and must have a bachelor's in a human service field and at least one year experience with the disability population
ResponsibilitiesConducts structured interviews and standardized adaptive behavior measures and provides results to MECA for eligibility determinations
TrainingService support facilitators undergo rigorous training including trainer-led instruction and shadowing
Financial eligibility criteria — income and asset thresholds
Income thresholdFinancial eligibility: applicant's monthly income may not exceed 300% of the current maximum monthly SSI payment for a single individual
Asset limitPersonal assets (excluding residence, furnishings, personal vehicle) may not exceed $2,000
Counted resourcesOnly the applicant's personal income and assets are considered; parent/spouse income or assets are not considered
Individual Program Plan (IPP) — person-centered plan definition and required attachments
IPP definitionIndividual Program Plan (IPP) is the person-centered plan developed by the IDT documenting assessed needs, goals, selected services constrained by individualized budget, crisis plan, behavior supports, schedules, and required attachments
Timing & signaturesIPP must be developed annually, initial IPP within 7 calendar days of admission, signed in real time by attending IDT members, and uploaded to the UMC portal within 10 business days
Required attachmentsIPP includes WV-BMS-IDD-05 components: meeting minutes, goals, assessments, Behavior Support Plan (if applicable), Crisis Plan, HCBS questionnaire, Individual Spending Plan (if participant-directed), and signature sheet
Interdisciplinary Team (IDT) — IDT role and responsibilities
IDT roleInterdisciplinary Team (IDT) reviews assessments, discusses individualized needs/supports, identifies resources and service options, and prepares interventions to implement the IPP within the individualized budget
MembershipIncludes member, legal representative, case manager, providers, and others as needed; must attend IDT meetings and sign IPP when present
Decision-makingIDT must consider all paid/unpaid supports and ensure services purchased fit within individualized budget; Critical Juncture meetings convened as needed
Individualized Program Plan (IPP) — referenced forms and required contents
IPP required contentsIndividualized Program Plan (WV-BMS-IDD-5) must include cover/demographics, meeting minutes, goals, assessment summaries, medications, service plan, behavior/crisis plans, budgets, and signature sheet
Upload timingIPP must be distributed to team and uploaded into UMC portal within 10 business days of IDT meeting to ensure timely authorization
Review frequencyIPP developed annually and reviewed at least every 3 months (no more than 6 months between reviews); Critical Juncture updates as needed
Traditional Service Delivery Model — definition and constraints
Traditional Service Delivery ModelTraditional model: all services accessed through an IDDW provider who has employer authority and fiscal responsibility; case management must be accessed through this model
Participant-Directed ModelParticipant-Directed model (Personal Options) allows members to exercise employer and/or budget authority for eligible services; not available in OHFLAC licensed residential settings
Mixing optionsMembers may mix Traditional and Participant-Directed options as appropriate; changes entered into UMC portal within 2 business days
Participant-Directed Service Delivery Model — definition and availability constraints
Participant-Directed model definitionParticipant-Directed Service Delivery Model lets eligible members exercise employer authority and/or budget authority over participant-directed services with support from Personal Options FMS
Availability limitNot available to members in OHFLAC licensed residential settings
Supported servicesIncludes person-centered support, respite, therapies, EAA, participant-directed goods/services, transportation when certain conditions met
Personal Options FMS — fiscal/employer services vendor definition
Personal Options FMS rolePersonal Options FMS is the fiscal/employer services vendor acting as fiscal/employer agent to assist common law employers with payroll, background checks, reporting, training, and monitoring spending
Supports to membersPersonal Options vendor assigns a resource consultant to assist self-directing members to develop and monitor spending plans and ensure budget adherence
Payment rulesPersonal Options FMS issues payments to vendors; must not pay participant-directed or EAA funds to member, staff, or family/legal representative
Critical Juncture — meeting convened by case manager and IDT for key events
Critical Juncture definitionCritical Juncture is a meeting convened by the case manager and IDT when specified events occur (e.g., residence move, crisis placement, change in legal representative) to review and adjust IPP and authorizations
TimingCase manager must enter change of Service Delivery Model into UMC portal within two business days and schedule Critical Juncture IDT meeting when applicable
PurposeUsed to address key events and determine needed IPP updates and authorizations
Crisis Services — crisis service definition and purpose
Crisis services definitionShort-term, acute services using PBS planning, interventions, strategies, and direct care to respond to extraordinary behavioral or medical circumstances with a 2:1 staff-to-member ratio
Prior authorizationCrisis services require prior authorization; may be authorized for the IPP year and used intermittently; utilization reviewed at least every 3 months
Emergent allowanceUp to 72 hours of crisis services may be implemented emergently without prior authorization
Behavior Support Professional (BSP) — BSP definition and roles
BSP definitionBehavior Support Professional (BSP) are qualified professionals (Level I or II) who develop and implement PBS plans, provide training, participate in IDT/IPP meetings, and deliver direct-care interventions as authorized
Procedure codes & unitProcedure codes: T2021-HN (Level I), T2025-HO (Level II); Service unit = 15 minutes
LimitationsAll BSP units require prior authorization; maximum annual direct-service units = 768; IPP planning events max = 4 per year
Dietary Therapy (Waiver) — dietary therapy definition and age limitation
Dietary Therapy (Waiver) definitionDietary therapy under the waiver provides services for chronic conditions and maintenance to members 21+ by a WV-licensed, enrolled registered dietary therapist
Service unit & ratioProcedure code 97802AE; service unit = 15 minutes; 1:1 ratio
Prior authorization & capAll dietary therapy units require prior authorization; maximum annual units (combined with PT/OT) = 416 units (104 hours)
prior_authorization — key term definition
Prior authorization definitionPrior Authorization: authorization obtained before services are provided; based on assessed need from the annual functional assessment and limited by member's individualized budget unless exception approved per Section 513.25.4.1
ApplicabilityApplies to virtually all services in the waiver (except limited emergent crisis use); prior authorization must be obtained before service delivery
ConsequenceServices delivered without valid prior authorization may not be reimbursed by Medicaid
service_unit — key term definition
Service unit definitionService unit = 15 minutes for most direct-care services (BSP, OT, PT, dietary, day services, supported employment, etc.)
Speech therapy exceptionSpeech therapy is measured as events (unit = 1 event) per listed procedure codes
Dollar-unit servicesEnvironmental Accessibility Adaptations (EAA) and Vehicle adaptations are billed in $1.00 units
Waiver therapy scope — scope distinction between waiver therapy and State Plan services
Waiver therapy scopeWaiver therapy services (OT/PT/ST/Dietary) are for chronic conditions and maintenance, differing from State Plan services which are short-term and restorative
Eligibility ageThese waiver therapies are generally limited to members 21 and older (EPSDT applies for under-21 members)
Provider enrollmentTherapists must be licensed in WV and individually enrolled as WV Medicaid providers to bill under the waiver
Electronic Monitoring (Traditional Option) — definition and constraints
Electronic Monitoring (Traditional Option) definitionElectronic monitoring provides off-site surveillance with monitoring base staff and designated stand-by intervention staff to oversee residential settings when no paid staff are present
Pre-implementation requirementsCase manager, member and IDT must submit Risk Assessment (IDD-17), Remote Monitoring Application (IDD-15), and Remote Monitoring Equipment form (IDD-16) for UMC/BMS approval; informed consent required
Operational requirementsSystems must have two-way audio, visual oversight of necessary areas, smoke/heat alerts; monitoring base staff may have no other duties and must call 911 when needed
Electronic Monitoring (Traditional Option) — duplicate inventory term for EM
Electronic Monitoring definition (duplicate)Electronic Monitoring: off-site electronic surveillance with stand-by intervention staff to protect independence and privacy; BMS pre-approval and annual approval required
Usage conditionOnly used when no paid staff are in the member's home and limited to members over age 18
Billing implicationsElectronic monitoring replaces direct-care staff so concurrent billing for other direct-care services in the monitored home is prohibited
EAA-Home and EAA-Vehicle — Environmental Accessibility Adaptations definition
EAA-Home & EAA-Vehicle definitionEnvironmental Accessibility Adaptations (EAA) are physical adaptations to member's home or vehicle to maximize accessibility and independence; billed in $1.00 units
Approval & documentationAll EAA requests must be sent by case manager to UMC for approval; Request for EAA (WV-BMS-IDD-08), proof of purchase and IPP documentation required
Annual capCombined EAA and participant-directed goods/services cap = $1,000 per IPP year
exceptions process — process reference (Section 513.25.4.1)
Exceptions process referenceExceptions to individualized budget limits are handled per Section 513.25.4.1 (exceptions process)
ApplicationProviders and IDT may request exceptions when assessed need exceeds individualized budget; approvals documented per Section 513.25.4.1
ImpactServices beyond individualized budget require formal exception approval to be billable
15-minute unit — unit definition
15-minute unitUnit of service for many direct-care services (BSP, OT, PT, Dietary, facility-based day habilitation, pre-vocational, supported employment) = 15 minutes
Use across servicesFacility-based day habilitation, pre-vocational, job development, supported employment units are defined as 15-minute increments
Billing consistencyProviders must record start/stop times and total time to substantiate billed 15-minute units
staff-to-member ratio — staff-to-member ratio definitions for facility-based day and prevocational services
Staff-to-member ratio definitionsCommon staff-to-member ratios for facility-based day habilitation and pre-vocational services include 1:1-2, 1:3-4, and 1:5-6 depending on service code
Service age limitsFacility-based day habilitation, pre-vocational, job development, and job-related services are limited to members 18+
Supervision requirementsThese services require supervision by qualified staff (BSP or program supervisor) and adherence to training/qualification standards
PDGS — Participant-Directed Goods and Services definition
PDGS definitionParticipant-Directed Goods and Services (PDGS) are items/services not otherwise covered that address an identified IPP need and decrease need for Medicaid services or increase community inclusion
Access & capPDGS monies limited by participant-directed budget; capped at 1,000 units ($1,000) per IPP year and require pre-approval and dated itemized receipts
Eligibility conditionTo access PDGS, member must also access at least one other participant-directed service during the budget year
Provider qualifications — qualifications for supported employment and person-centered support staff
Provider qualifications summarySupported Employment and Family Person-Centered Support staff must meet IDDW agency staff requirements in Sections 513.2 - 513.2.1; paraprofessionals need documented training/experience
SupervisionSupported employment and job development must be supervised by a supported employment supervisor or BSP; BSPs or RNs may bill for staff training where specified
Training documentationProviders must maintain training records, competency evidence, and meet criminal background and exclusion checks per staff requirements
Policy Summary
PayerWest Virginia Bureau for Medical Services (Department of Human Services)
PolicyCHAPTER 513 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES WAIVER (IDDW)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateAug 1, 2026
Next Review DateN/A
Key ActionUpload the finalized Individual Program Plan (IPP) into the UMC portal within 10 business days of the IDT meeting to ensure timely authorization of services.
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OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.