Guides Medicare home health
Service-line guide
Medicare home health
How a home health agency becomes Medicare-certified, what Medicare requires of it, how it is paid, and where state law adds its own gate. Medicare certification is a federal step for agencies that bill Medicare; it is separate from, and usually comes after, the state license.
Educational summary, last reviewed October 17, 2026. Not legal advice — confirm with the state licensing agency or counsel.
Last reviewed October 17, 2026. 40 findings: 34 verified, 6 provisional. 5 time-sensitive, flagged with a recheck date. How findings are sourced and labelled.
1What it is
“Home health” means two different legal things: any state-licensed agency giving skilled nursing or therapy at home, and a Medicare-certified home health agency meeting 42 CFR Part 484. This guide is about the second; the 50-State Regulatory Atlas covers the first.
Who Medicare home health covers
VerifiedAll five conditions must be met: the patient is confined to the home; is under the care of a physician or allowed practitioner who establishes the plan of care; needs intermittent skilled nursing, physical therapy or speech-language pathology, or continuing occupational therapy; is under a plan of care; and receives services from, or under arrangements with, a participating agency (42 CFR 409.42).
Source: 42 CFR 409.42
Allowed practitioners
VerifiedAn “allowed practitioner” is a physician assistant, nurse practitioner or clinical nurse specialist (42 CFR 484.2). With a physician, they may certify eligibility and establish the plan of care.
Source: 42 CFR 484.2
Homebound
ProvisionalCriterion one (meet one): because of illness or injury the patient needs a supportive device, special transportation or another person’s help to leave home, or leaving home is medically contraindicated. Criterion two (meet both): a normal inability to leave home, and leaving requires a considerable and taxing effort. Infrequent or short absences, or absences for health care such as adult day care or dialysis, do not end homebound status.
Not yet confirmed — check with the current Medicare Benefit Policy Manual, chapter 7 §30.1.1.
Source: CMS Transmittal R172BP (2013)
The certifying practitioner certifies that the patient needs intermittent skilled care, is confined to the home, has a plan of care that is periodically reviewed, and is under the practitioner’s care, and documents the date of a face-to-face encounter related to the primary reason for home care that occurred within 90 days before or 30 days after the start of care. The encounter may be by telehealth (42 CFR 424.22(a)).
Source: 42 CFR 424.22
From January 1, 2026, a physician, nurse practitioner, clinical nurse specialist or physician assistant may perform the face-to-face encounter whether or not they are the certifying practitioner.
Source: CMS fact sheet: CY 2026 HH PPS final rule (CMS-1828-F)42 CFR 424.22
Recertification
VerifiedRecertification is required at least every 60 days while care continues. Payment periods are 30 days, but recertification, plan-of-care review and the OASIS assessment still follow the 60-day certification period.
Source: 42 CFR 424.22CMS: Home Health Prospective Payment System
2Who regulates it
CMS sets the Conditions of Participation and pays; the Medicare Administrative Contractor (MAC) enrolls; a state survey agency or a CMS-approved accrediting organization surveys; the state licenses separately.
Conditions of Participation
VerifiedMedicare-certified agencies meet 42 CFR Part 484: patient care (OASIS reporting, patient rights, comprehensive assessment, discharge planning, care planning and coordination, QAPI, infection control, skilled professional services, aide services) and organizational requirements (compliance with law, emergency preparedness, organization and administration, clinical records, personnel qualifications).
Under SSA §1865(a), CMS approves accrediting organizations whose standards and survey processes meet or exceed its own; an agency they accredit has “deemed status”. Accreditation “is voluntary and is not required for Medicare participation” (SOM ch. 2 §2003C). CHAP, ACHC and The Joint Commission have held home health deeming authority since 2000, 2006 and earlier respectively.
In practice: Current approval terms for each accreditor: Accreditation & Surveys; how the state survey, accreditation and certification fit together: Surveys and certification.
Source: CMS State Operations Manual, Chapter 265 FR, Feb 22, 2000 (CHAP)71 FR, Feb 24, 2006 (ACHC)
How often agencies are surveyed
VerifiedEach agency is subject to a standard survey within a 36-month interval (SSA §1891(c)(2)(A)); CMS tracks it as 36.9 months. Surveys are meant to be unpredictable, not in the same month each year (SOM ch. 2 §2008F).
Source: CMS State Operations Manual, Chapter 2CMS FY 2027 Mission and Priority Document
The state license is separate
VerifiedStates license home health on their own terms. Texas, for example, issues separate categories: licensed and certified home health (Medicare), licensed home health (no Medicare), hospice and personal assistance services (26 TAC §558.13).
In practice: Each state’s license, branch and certificate-of-need rules are on its state page.
Source: 26 TAC §558.13
3Federal rules agencies run on
The administrator is a licensed physician, a registered nurse, or holds an undergraduate degree, with health-service administration experience including at least one year supervisory or administrative in home health or a related program. The clinical manager is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker or registered nurse (42 CFR 484.115).
Source: 42 CFR 484.115
Home health aides
VerifiedAides complete at least 75 hours of classroom and supervised practical training, with at least 16 classroom hours before 16 practical hours, and an RN-run competency evaluation. For patients receiving skilled services, aide supervision is at least every 14 days with an annual onsite observation; for non-skilled patients, an onsite RN visit every 60 days (42 CFR 484.80).
Source: 42 CFR 484.80
Branch offices
VerifiedA branch is an approved location serving part of the parent agency’s area, under the parent’s supervision and administrative control; it need not meet the Conditions of Participation on its own (42 CFR 484.2). Subunits are no longer permitted after January 13, 2018.
Branches across a state line
VerifiedCMS considers the parent’s ability to supervise and its compliance history; a written reciprocal agreement between the two state survey agencies is required, and the agency must meet the other state’s licensure and personnel rules (SOM §2184; S&C-02-30).
Source: CMS S&C-02-30SOM Exhibit 289
4Certification and enrollment
Effective May 13, 2026, CMS imposed six-month moratoria on new Medicare enrollment of home health agencies and hospices nationwide, extendable in six-month increments (42 CFR 424.570). No new initial enrollment applications or new home health branches are accepted or approved while it lasts, and it reaches specified changes of ownership that need new enrollment. Applications received before May 13, 2026 are processed and exempt. Enrolled agencies are not affected.
Time-sensitive. The first six-month term runs to about November 13, 2026, when CMS reassesses it. Whether it has been extended is not yet confirmed: check the Federal Register after that date.
Source: CMS FY 2027 Mission and Priority DocumentFederal Register 2026-09718: HHA and hospice enrollment moratoria
The moratorium restricts Medicare enrollment. It does not stop forming a company, obtaining a state license, hiring, writing policies or serving patients under other payers; it pauses the step of becoming a Medicare provider.
In practice: Medicaid and CHIP were left to each state’s discretion.
Source: CMS FY 2027 Mission and Priority DocumentFederal Register 2026-09718: HHA and hospice enrollment moratoria
Initial certification surveys of agencies not exempt from the moratorium “shall not continue for the duration of the nationwide moratorium”; exempt applicants may continue with an approved CMS-855A.
Time-sensitive. Tied to the moratorium; recheck after about November 13, 2026.
High-risk screening
VerifiedNewly enrolling agencies are screened at the high-risk level, which adds fingerprints and an FBI criminal history check for every person with a 5% or greater ownership interest to the site visit and other checks (42 CFR 424.518).
Source: 42 CFR 424.518
Initial reserve operating funds
VerifiedThe agency must show funds for its first three months of operation after billing privileges, excluding Medicare receivables, available at application and throughout those months. The MAC computes the amount from comparable agencies’ costs; at least 50% must be non-borrowed (42 CFR 489.28).
Source: 42 CFR 489.28
Each applicant must have provided skilled home health services to at least 10 patients before a survey; at least 7 of them should be receiving care at the time of the initial survey (SOM ch. 2 §2008B).
Accrediting organizations may not survey initial applicants until the applicant shows the MAC has reviewed its CMS-855A and recommended approval (SOM ch. 2 §2003C).
In the FY 2027 Mission and Priority Document, ordinary initial certification surveys by state survey agencies are Tier 3, below 36.9-month recertifications; they rise to Tier 2 only where CMS finds an access-to-care issue.
If the initial survey finds all requirements met, the agreement is effective on the last day of the survey; with standard-level deficiencies only, on the date an acceptable plan of correction is received (SOM ch. 2 §2008D; 42 CFR 489.13).
A change in majority ownership within 36 months of initial enrollment or the last majority change means the billing privileges do not convey: the new owner enrolls as a new agency and is surveyed or accredited again, unless an exception applies (42 CFR 424.550(b)). A billing number may never be sold or lent (424.550(a)).
Source: 42 CFR 424.550
5Payment
PDGM
VerifiedSince January 1, 2020, Medicare pays a national 30-day period rate adjusted for case mix (432 groups built from admission source, timing, clinical group, functional impairment and comorbidity) and area wages. Periods below a visit threshold are paid per visit (LUPA). Outlier payments are capped at 2.5% of total home health payments.
Calendar year 2026 payment
VerifiedThe CY 2026 final rule reduced aggregate payments 1.3% (about $220 million) from CY 2025, combining a 2.4% update with a permanent −1.023% behavioral adjustment and a one-year −3.0% temporary adjustment.
Source: CMS fact sheet: CY 2026 HH PPS final rule (CMS-1828-F)Federal Register 2025-21767: CY 2026 HH PPS final rule
CY 2026 national 30-day base rate
ProvisionalThe CY 2026 national standardized 30-day rate is reported as $2,038.22, down from $2,057.35 in CY 2025.
Not yet confirmed — check with the CMS CY 2026 rate tables.
Source: Federal Register 2025-21767: CY 2026 HH PPS final rule
Calendar year 2027 proposal
VerifiedThe CY 2027 proposed rule (July 1, 2026) would raise aggregate payments 2.4% (about $420 million), continue the 3.0% temporary reduction and add enrollment denial and revocation grounds.
Time-sensitive. Proposed only. The final rule is expected around November 2026; recheck then.
Source: CMS fact sheet: CY 2027 HH PPS proposed rule (CMS-1844-P)
Value-based purchasing
VerifiedThe expanded Home Health Value-Based Purchasing Model applies to every Medicare-certified agency and adjusts payment from −5% to +5% based on OASIS, claims and HHCAHPS measures; CY 2025 was the first payment year.
Source: CMS: Expanded HHVBP Model
Review Choice Demonstration
VerifiedAgencies in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma choose pre-claim or postpayment review; the demonstration was extended five years from June 1, 2024.
Federal deadlines: states had to require EVV for Medicaid personal care services by January 1, 2020 and for Medicaid home health care services by January 1, 2023 (SSA §1903(l)). State implementation dates differ; some states, Texas among them, had extensions to January 1, 2024. EVV is a Medicaid requirement, not a Medicare one.
Source: CMS Informational Bulletin, May 16, 2018Medicaid.gov: EVV compliance status, home health
6How states differ
Federal rules set the floor for Medicare agencies. States decide whether a license is needed at all, whether entry is need-gated, and their own staffing minimums.
Certificate of need
ProvisionalA trade association’s 2026 survey lists certificate-of-need programs for home health in Alabama, Arkansas, Connecticut, DC, Georgia, Hawaii, Kentucky, Mississippi, New Jersey, New York, North Carolina, Rhode Island, South Carolina, Tennessee, Washington and West Virginia. Counts differ between sources.
Not yet confirmed — check with each state’s planning agency.
In practice: Each state page gives its own certificate-of-need finding with the state source.
New York public need
ProvisionalNew York applies a public-need test even to licensed home care services agencies: under a 2022 methodology there is a rebuttable presumption of no need in a county already served by five or more.
Not yet confirmed — check with the New York State Department of Health.
Texas sequencing
VerifiedAn applicant for licensed and certified home health in Texas applies to CMS; while CMS review is pending, the state issues a licensed home health services license and the agency must comply with 42 CFR 484 as if certified (26 TAC §558.13).
Source: 26 TAC §558.13
7How to start
Order of steps
ProvisionalThe cited requirements put the work in this order: the state license, and a certificate of need where the state has one; operation under the Conditions of Participation with at least 10 skilled patients served; the CMS-855A with proof of reserve funds; the initial survey by the state agency or an accreditor once the MAC recommends approval; then the provider agreement. No single official checklist sets this order.
Not yet confirmed — check with your MAC and state survey agency.
Time-sensitive. While the moratorium lasts, the Medicare enrollment step is closed to new applicants; recheck after about November 13, 2026.
Source: CMS State Operations Manual, Chapter 242 CFR 489.2826 TAC §558.13
Timelines
ProvisionalNo official source gives typical months from license to certification; this guide does not publish one.
Not yet confirmed — check with your MAC and accrediting organization.
8Common pitfalls
A conflicted certifier
VerifiedA practitioner with a financial relationship with the agency may not certify, recertify, establish or review the plan of care, or perform the face-to-face encounter, unless a Stark exception applies (42 CFR 424.22(d)).
Source: 42 CFR 424.22
Agency notes standing alone
VerifiedAgency documentation supports certification only when the certifier’s or facility’s records corroborate it and the certifier signs it (42 CFR 424.22(c)).
Source: 42 CFR 424.22
Reserve funds that do not stay
VerifiedThe reserve must be available from application through three months after billing privileges begin; failing to maintain it leads to denial or revocation (42 CFR 489.28).
Source: 42 CFR 489.28
New home health branches are not accepted or approved while the moratorium lasts, so geographic growth through a Medicare branch waits.
Time-sensitive. Recheck after about November 13, 2026.
Official sources
- 42 CFR 409.42
- 42 CFR 484.2
- CMS Transmittal R172BP (2013)
- 42 CFR 424.22
- CMS fact sheet: CY 2026 HH PPS final rule (CMS-1828-F)
- CMS: Home Health Prospective Payment System
- 42 CFR 484 Subpart B
- 42 CFR Part 484
- CMS State Operations Manual, Chapter 2
- 65 FR, Feb 22, 2000 (CHAP)
- 71 FR, Feb 24, 2006 (ACHC)
- CMS FY 2027 Mission and Priority Document
- 26 TAC §558.13
- 42 CFR 484.115
- 42 CFR 484.80
- Minnesota DOH: adding a branch
- CMS S&C-02-30
- SOM Exhibit 289
- Federal Register 2026-09718: HHA and hospice enrollment moratoria
- 42 CFR 424.518
- 42 CFR 489.28
- 42 CFR 424.550
- Federal Register 2025-21767: CY 2026 HH PPS final rule
- CMS fact sheet: CY 2027 HH PPS proposed rule (CMS-1844-P)
- CMS: Expanded HHVBP Model
- CMS: Review Choice Demonstration for Home Health
- CMS Informational Bulletin, May 16, 2018
- Medicaid.gov: EVV compliance status, home health
- Alliance for Care at Home: CON programs (2026)
- Manatt: NY DOH LHCSA application requirements
Revision history
| Date | Change |
|---|---|
| 2026-10-17 | First published |
About this guide. Published and maintained by Paloma Health Technologies; Findings are cited to official sources, dated and status-labelled; see the editorial policy. Educational summary, last reviewed October 17, 2026. Not legal advice — confirm with the state licensing agency or counsel.
Questions
Medicare home health: common questions
Is Medicare certification required to run a home health agency?
No. Medicare certification under 42 CFR Part 484 is a federal step for agencies that bill Medicare home health. The state license is separate; a few states tie entry to certification, and their state pages say so.
Can a new agency enroll in Medicare home health now?
Not while the nationwide moratorium that began May 13, 2026 lasts, unless its application was received before that date. Its first six-month term runs to about November 13, 2026, when CMS reassesses it.
Does the moratorium stop a company from getting a state license?
No. It restricts Medicare enrollment only. Forming the company, obtaining the state license and serving patients under other payers are not affected.
How many patients must an agency serve before its Medicare survey?
At least 10 patients receiving skilled home health services, with at least 7 under care at the time of the initial survey (SOM chapter 2 §2008B).
When did EVV become required for Medicaid home health?
The federal deadline was January 1, 2023 (January 1, 2020 for personal care). State implementation dates vary, and some states had extensions to January 1, 2024.