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Assisted Living Waiver Provider

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NOTICE: The Ohio Department of Medicaid (ODM) is introducing a new provider application system called Provider Network Module (PNM), the new single front door platform for Medicaid Providers.  ODM will roll-out the new PNM system for all new and existing Ohio Medicaid Providers later this year.  Learn more.


Prior to applying for certification, please read and understand the conditions of participation and service requirements for which you are seeking certification. View this information as well as all current effective rules.

Assisted living service is a service that promotes aging in place by supporting a consumer's independence, choice, and privacy through the provision of one or more components of the service which are a personal care service, a supportive service, an on-duty response service, meals, social and recreational programming, a non-medical transportation service, and a nursing service.

Application Fee

In accordance with federal requirements described in 42 CFR 445.460 and per Ohio Administrative Code 5160-1-17.8, the Ohio Department of Aging collects a Medicaid application fee. The fee is currently $599 per application and is non-refundable. The fee applies to assisted living applicants. The fee will not be required if the assisted living applicant has paid the fee to either Medicare or another state’s Medicaid provider enrollment program (such as the Ohio Department of Medicaid, the Ohio Department of Developmental Disabilities, or outside of Ohio) within the past two years. However, the Department of Aging requires the assisted living applicant submit proof of payment with their application.

Federal Requirements for Home and Community-Based Settings

On March 17, 2014, the Centers for Medicaid and Medicare Services (CMS) issued its final rule regarding settings for home and community-based services (HCBS) offered through the Assisted Living Waiver and the PASSPORT Waiver. For those settings that are presumed to be institutional, the state may submit evidence to CMS demonstrating the setting does not have the qualities of an institution.

Click here (opens in a new window) to read the overview of federal requirements. Print that page and upload it with your HCBS Settings Requirement Form.


Documentation you will be required to submit includes:

  • Registration with the Ohio Secretary of State: A copy of registration certificate with the Ohio Secretary of State.
  • Ohio Bureau of Workers’ Compensation Certificate:  A copy of current certification in good standing with the Ohio Bureau of Workers’ Compensation.
  • Certificate of Commercial Liability Insurance: A copy of current policy of minimum of one million dollars in commercial liability insurance.
  • Employee Dishonesty or Property Damage Insurance: A copy of current insurance policy for employee dishonest or property damage to others.  This requirement can be a warranty, surety, or business services bond.
  • Table of Organization: A copy of a table of organization that includes the full name of each position and indicates lines of authority.
  • Copy of Residential Care Facility (RCF) License & Initial Survey completed by ODH: Residential Care Facility (RCF) license issued by the Ohio Department of Health (ODH) and a copy of the initial survey completed by the ODH identifying the rooms covered under the RCF license. (Please Note: this is not an Adult Care Facility license issued by the Ohio Department of Mental Health.)
  • Completed and Signed W-9: This form will be automatically completed and available to download for signature during the online application process.
  • Proof of Residency:  Evidence that applicant/CEO has been a resident of Ohio for the last five consecutive years.  Acceptable documentation includes: valid driver's license; notification of registration as an elector; a copy of an officially filed federal and state tax form identifying the applicant's permanent residence; any other documentation the responsible entity considers acceptable showing evidence the applicant has been a resident of Ohio for the past five years.
  • FBI Background Check:  If you currently live or have lived outside of Ohio anytime in the past five years, you are required to submit an FBI background check.
  • Non-Disclosure Statement:  This form will be available to download for signature during the online application process.

How to submit documentation:

  • Upload directly to application prior to submission
  • Fax to 614-466-9812 or 614-466-5741
  • Mail to:
    Ohio Department of Aging
    Provider Certification
    246 N. High St./1st Fl.
    Columbus, Ohio 43215-2406

PLEASE NOTE: Documentation emailed to our office will not be accepted and can delay the processing of your application.

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