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Long-Term Care Agency Provider

Image shows a care aid with a clip board and stethoscope interviewing an older woman in a home.


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.

Applicants applying to the Ohio Department of Aging to be certified as an agency provider for the PASSPORT Medicaid Waiver Program may request certification for the following services:

  • Adult Day Services: Enhanced
  • Independent Living Assistance: Telephone Support
  • Adult Day Services: Intensive   
  • Independent Living Assistance: Travel Attendant
  • Alternative Meals
  • Minor Home Modification
  • Choices Home Care Attendant
  • Non-Emergency Medical Transportation
  • Chore Services
  • Non-Medical Transportation
  • Community Transition
  • Nutrition Consultation
  • Emergency Response System
  • Out-of-Home Respite
  • Enhanced Community Living
  • Personal Care Service
  • Home Delivered Meals
  • Pest Control
  • Home Medical Equipment/Supplies
  • Social Work/Counseling
  • Homemaker
  • Waiver Nursing
  • Independent Living Assistance: In-Person Activities

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 $688 per application and is non-refundable. The fee applies to agency applicants. The fee will not be required if the agency 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 agency 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:

  • Evidence of Services Provided: Documentation you have provided services to two adults for a minimum of three months for all services you are requesting certification.  (Example: requesting certification as a personal care provider, please provide time sheets or task sheets that clearly show the duties completed in the consumer's home.)
  • Evidence of Payment for Services: Documentation you have received payment for services provided to two adults for a minimum of three months (Example: copy of invoice used to bill consumer for services and evidence you received payment for those services.)  Payment for services can be from private pay, insurance, other Medicaid/Medicare programs, etc.
  • 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 policy for employee dishonesty 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.
  • Completed and Signed W-9: This for will be automatically completed and available to download for signature during the online application process.
  • Proof of Residency:  Evidence that applicant/CEO has been 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 or 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.
  • BCI Background Check: You are required to obtain a criminal record check (BCI) for each owner at the time of application. All results must be sent directly to the Ohio Department of Aging. You must use one of the approved reason codes. Please see the attachment above (Long-Term Care Agency Checklist) for complete details.
  • FBI record check (if lived outside of Ohio in past five years): 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. You must use only the approved reason code for FBI record checks. Please see the attachment above (Long-Term Care Agency Checklist) for complete details.
  • Non-Disclosure Statement: This form will be available to download for signature during the online application process.

How to submit documentation:

All supporting documents must be uploaded in the application.  The system will not allow you to submit your application until you have uploaded your required documentation.  

By continuing, you signify that you have read and understand the above information.

To submit an application through the Provider Network Module (PNM), please visit https://ohpnm.omes.maximus.com/OH_PNM_PROD/Process/GroupReview.aspx.  

If you need assistance signing into PNM or acquiring you OH|ID, please contact the Ohio Department of Medicaid’s Integrated Help Desk at 800-686-1516 or email ihd@medicaid.ohio.gov.