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Certificate of need for care businesses: which states require one, by license type

A certificate of need (CON) is a state finding that your area needs another provider, and where it applies you cannot get the license without it. For care businesses it mostly reaches home health agencies, in 14 states and DC, and fewer states apply it to assisted living, residential care or adult day. A handful more cap supply through licensing moratoriums, and Medicare enrollment of new home health agencies has been frozen nationwide since May 13, 2026.

Written by Editorial team Checked against 107 official sources Last reviewed How we review
Contents9 sections

Key takeaways

  • North Carolina accepts CON applications only where its annual plan shows need, and the 2026 Plan shows no need for a new Medicare-certified home health agency anywhere in the state.⁠66
  • Maryland is not accepting home health CON applications while its 2025-2026 statewide review runs, and New Jersey postponed its July 1, 2025 home health call with no new date.⁠45⁠61
  • South Carolina's 2023 rollback left home health under CON: S.C. Code 44-69-75 still requires one before licensure.⁠7
  • California has barred new home health agency licenses since June 29, 2026 under SB 164, except on a written finding of unmet need, and Louisiana's statute bars new home health licenses until LDH certifies survey funding.⁠21⁠39
  • CMS's home health enrollment moratorium took effect May 13, 2026 for six months. As of November 11, 2026, no extension had been published in the Federal Register.⁠90⁠91

Quick facts

Home health CONRequired in 14 states and DC; closed for now in MD, MS, NJ, NC and VT
Assisted living CONAR, MO, NJ and NC (7+ beds); only some types in AL, CT, GA, KY
Licensing freezesCalifornia home health (June 29, 2026); Louisiana home health (statutory bar)
Bed moratoriumsArkansas residential care (since 2005); North Dakota basic care (to July 31, 2029)
FederalCMS home health enrollment moratorium since May 13, 2026; 6 months, no extension published

Status as checked on 2026-11-11. CON programs change by statute and by agency schedule; confirm with the state agency before you sign a lease or buy a site.

Certificate of need and the license are two different approvals

A certificate of need (CON) is a state approval to create or expand a health service, granted only when the state finds the service is needed ⁠1. The license comes later and tests something else: whether your building, staff and policies meet the rules. A state with a CON law will usually not license a covered business without one. Missouri’s statute says no licensing agency may license a facility developed without a required certificate ⁠1, and Georgia makes a home health agency submit evidence of its CON when it applies for the license ⁠2.

Three things decide whether CON reaches your business:

  • The state’s list of covered facilities. Home health agencies appear on some states’ lists (Alabama, Georgia, Maryland, North Carolina, South Carolina) and not on others (Florida, Maine, Delaware) ⁠3⁠4⁠5⁠6⁠7⁠8⁠9⁠10.
  • A trigger inside the list. Some states cover a type only above a threshold: DC covers a home health agency with an annual operating budget of $500,000 or more ⁠11, Georgia covers a personal care home only if it is Medicaid-certified with at least 25 beds ⁠4, and Missouri reviews an assisted living or residential care facility when the project costs more than $600,000 or adds more than 10 beds or 10% of capacity, whichever is less, over two years ⁠12.
  • Payer status. Washington and Hawaii tie home health CON to Medicare or Medicaid certification ⁠13⁠14. In North Carolina, a “home health agency” is by definition a Medicare- and Medicaid-certified one ⁠15.

State-by-state table

“Yes” means a new business of that type needs a CON or an equivalent approval before it can be licensed. “No” means the state’s CON statute or agency excludes the type, or an official source says the state has no CON program. “None found” means the state has no CON program covering these types in the statutes and agency pages checked; confirm with the licensing agency before you rely on it. The table covers the three facility-based types most CON laws reach. Non-medical home care and child care appear only where a state reviews them, in the “Other” column.

Certificate of need for care businesses by state, as checked on November 11, 2026
State Home health Assisted living / residential care Adult day Other need review or moratorium Sources
Alabama Yes; county must show need for 100+ more patients, 1 approval per county per cycle Specialty care (SCALF) beds only, 6 per 1,000 age 65+; regular ALFs not listed No (not listed) — ⁠3⁠16
Alaska No No Not confirmed; ask the Department of Health CON list covers hospitals, nursing and other listed facilities ⁠17
Arizona None found None found None found No program found; confirm with ADHS —
Arkansas Yes, Permit of Approval (POA) ALF: Yes, POA. Residential care facility: no new beds since July 1, 2005 No (not on POA list) POAs filed Feb 1, May 1, Aug 1, Nov 1 ⁠18⁠19⁠20
California No CON, but no new licenses since June 29, 2026 (SB 164), except on an unmet-need finding None found None found SB 164 adds an unmet-need showing ⁠21
Colorado No No No HCPF: no CON program (2026 federal grant narrative) ⁠97
Connecticut No Residential care home: Yes (DSS). Assisted living services agency: No No (not listed) — ⁠22⁠23
Delaware No No No Review covers hospitals, nursing homes and listed centers ⁠10
District of Columbia Yes if annual operating budget is $500,000+ ALR: No Adult day health: CON required of EPD waiver providers (2015 waiver appendix) No new ID community residence facility licenses ⁠11⁠24⁠25
Florida No No No CON covers nursing homes, hospices, ICF/DD ⁠8
Georgia Yes; batching cycles after DCH finds need ALC: letter of determination. Personal care home: CON if Medicaid-certified with 25+ beds No (not listed) — ⁠4⁠26⁠27⁠28
Hawaii Yes if Medicare/Medicaid; otherwise SHPDA no-CON letter No (ALFs and extended care ARCHs exempt) Adult day health center: CON or SHPDA letter first — ⁠14⁠29⁠30
Idaho No No No DHW: no CON requirements (2026 federal grant narrative) ⁠98
Illinois No No No Covers hospitals, long-term care and listed centers ⁠31
Indiana No No No CON covers nursing-level (comprehensive care) beds ⁠32
Iowa No No (residential care excluded; assisted living programs exempt) No — ⁠33⁠34⁠35
Kansas No No No CON article (K.S.A. 65-4801 et seq.) repealed, L. 1997, ch. 16 ⁠99
Kentucky Yes; quarterly filing cycles Assisted living community: No. Personal care home: Yes Adult day health: Yes — ⁠36⁠37⁠38
Louisiana No CON, but statute bars new licenses until LDH certifies survey funding Adult residential care: no FNR if licensed Aug 1, 2022 or later No (not on FNR list) Facility Need Review for personal care attendant, respite, SIL and MIHC providers ⁠39⁠40⁠41⁠42
Maine No No (nursing-bed conversion to residential care is CON-exempt; MaineCare needs department approval to pay) No — ⁠9⁠43
Maryland Yes; MHCC not accepting applications (May 2026 schedule) Not confirmed; ask MHCC Not confirmed; ask MHCC — ⁠5⁠44⁠45
Massachusetts Not confirmed; ask DPH Not confirmed; ask DPH Adult day health: No MassHealth adult day health enrollment moratorium from May 19, 2026 ⁠46⁠47
Michigan No No No CON covers hospitals, psychiatric beds, nursing homes, surgical facilities and listed clinical services ⁠48⁠94⁠95
Minnesota No No New licenses paused Feb 1, 2026 to Jan 31, 2028 (expected) Adult foster care and community residential setting moratoria ⁠49⁠50
Mississippi Yes (CON); Legislature reaffirmed the moratorium on CONs for new agencies, effective April 17, 2026 No (personal care homes not reviewable) Not confirmed; ask MSDH — ⁠51
Missouri No (home health excluded) Yes (RCF and ALF): $600,000 or 10-bed trigger Not confirmed; ask the CON Program — ⁠52⁠12⁠1
Montana No No No CON covers nursing-level long-term care ⁠53⁠54
Nebraska No No No CON only for rehabilitation and nursing home beds ⁠55
Nevada No No No Approval for health facility construction over $2 million in smaller counties ⁠56
New Hampshire No No No Moratorium on new nursing homes, SNFs, ICFs, rehab facilities ⁠57
New Jersey Yes, only in a DOH call; 2025 call postponed with no new date ALR: Yes (expedited review) No (exempt, N.J.S.A. 26:2H-7a) — ⁠58⁠59⁠60⁠61⁠96
New Mexico No No No CON process discontinued in 1987; DOH issues none (2003 fiscal report) [100]
New York LHCSA: public need review (PHL 3605); CHHA not confirmed; ask DOH Adult home or enriched housing: public need test Not confirmed; ask DOH LHCSA moratorium ended March 31, 2020 ⁠62⁠63⁠64
North Carolina Medicare-certified agencies: Yes; 2026 Plan shows no need Adult care homes, 7+ beds: Yes, only where the Plan shows need No — ⁠6⁠15⁠65⁠66
North Dakota No (repealed 1995) ALF: No. Basic care: no new beds Aug 1, 2025 to Jul 31, 2029 No Medicaid moratorium on new QSP agencies in Burleigh and Cass since June 11, 2026 ⁠67⁠68⁠69
Ohio No No No CON covers nursing home beds ⁠70
Oklahoma No No (only for a nursing component) No CON covers nursing and specialized facilities ⁠71
Oregon No No No CON covers hospitals and nursing facilities ⁠72
Pennsylvania No No No CON provisions of the Health Care Facilities Act terminated Dec 18, 1996 [101]
Rhode Island Yes until June 12, 2026; No since (P.L. 2026, ch. 84); RIDOH rule not yet updated No No — ⁠73⁠74[107]
South Carolina Yes (S.C. Code 44-69-75) No No Otherwise nursing homes; hospitals until Jan 1, 2027 ⁠7⁠75
South Dakota No No No CON repealed 1988; nursing facility bed moratorium only [102]
Tennessee Yes, except agencies serving only under-18 or EEOICPA patients No Not confirmed; ask HFC — ⁠76⁠77
Texas No No No HHSC: no CON or CON-equivalent statutes (2026) [103]
Utah No No No DHHS: no CON in any facility category (2026) [104]
Vermont Yes; none granted for new home health before Jan 1, 2030 Not confirmed; ask the Green Mountain Care Board Not confirmed; ask the Green Mountain Care Board — ⁠78⁠79
Virginia No No No COPN covers hospitals, nursing homes, ICFs, listed centers ⁠80
Washington Medicare/Medicaid-certified agencies: Yes No No — ⁠13⁠81⁠82
West Virginia Yes Exempt, with an exemption filing Not confirmed; ask the Health Care Authority Personal care services also need CON ⁠83⁠84
Wisconsin No No No Prior approval covers nursing homes and nursing home/developmental-disability facility conversions only (Wis. Stat. 150.21) [105]
Wyoming No No No New institutional health services article (W.S. 35-2-201 et seq.) repealed 1985-1987 [106]

Scroll the table sideways to see every column.

Where certificate of need actually stops a founder

In the states below, the review decides whether, where and when a new business can open.

North Carolina: need shown in the annual plan, or no application

No one may develop a new institutional health service without a CON, and both adult care homes (seven or more beds) and home health agency offices count as health service facilities ⁠6. The annual State Medical Facilities Plan sets where new adult care home beds are needed. DHSR schedules reviews only for counties with a need, and accepts applications only there ⁠65. Once a review starts, written comments are due within 30 days, a public hearing is held 30 to 50 days in, and the decision is due within 150 days. The certificate issues 35 days after approval unless someone files a contested case ⁠65. For home health, every site needs its own CON and license ⁠15. The 2026 Plan shows no need for a new Medicare-certified home health agency anywhere in the state ⁠66. NCDHHS describes the CON and license steps only for an agency seeking Medicare and Medicaid certification ⁠15; ask DHSR whether a home care agency that does not seek certification needs a CON. See the North Carolina certified home health guide and the adult care home guide.

Georgia: a county formula and 25-day intent deadlines

Georgia’s CON rules count home health agencies and personal care homes as health care facilities ⁠4. DCH’s fact sheet lists new or expanding home health agencies among the projects that need a CON ⁠93. Need is calculated county by county; the use rates and the unmet-patient thresholds for expansion and for new agencies are in Rule 111-2-2-.32 ⁠26. Applications are accepted only in batching cycles after DCH publishes a need finding. You must file a letter of intent by the 25th calendar day after publication or sit out that cycle ⁠4. For residential care, the full CON applies only to a personal care home of 25 or more beds that is Medicaid-certified ⁠4. An assisted living community still needs a letter of determination from DCH’s Office of Health Planning before HFRD will license it ⁠28. See the Georgia home health guide and the assisted living community guide.

Kentucky: quarterly windows and a fee schedule

Assisted living communities and family care homes are exempt from Kentucky CON ⁠36, but home health agencies, personal care homes and adult day health care programs are not. KRS 216B.020’s outpatient exemptions do not cover adult day health ⁠36, and a personal care home license follows CON approval and then plan approval ⁠38. Home health applications are published in the CON newsletter only on the third Thursday of February, May, August and November. Formal review is completed within 90 days of its start ⁠37. The State Health Plan finds need for a new home health agency when a county’s projected need reaches 250 patients, and for an expansion at 125 ⁠85. The fee is $1,000 for a project with no capital expenditure or one up to $200,000. Above that it is 0.5% of the capital expenditure up to $5,000,000, and $25,000 above $5,000,000 ⁠86. See the Kentucky home health guide and the adult day health guide.

Maryland and New Jersey: the window is closed

Maryland requires a CON from the Maryland Health Care Commission before an additional home health agency, branch or service is established, or before an agency serves an area outside its CON or license ⁠5. OHCQ will not start a license application without one ⁠44. MHCC’s review schedule posted in May 2026 says the 2025-2026 statewide home health review is still under way and no more home health CON applications are being accepted ⁠45. See the Maryland home health guide.

New Jersey reviews new home health agencies only when the Department of Health issues a CN call. DOH cancelled the July 1, 2022 call after finding no need for more home health services ⁠60. On July 21, 2025 it postponed the call scheduled for July 1, 2025, and said a future call would be published if it decides one is appropriate ⁠61. New assisted living residences go through CON on DOH’s expedited review form, CN-19 ⁠59⁠58. See the New Jersey home health guide and the assisted living residence guide.

Tennessee, Arkansas, Missouri, Hawaii, Washington and Vermont

  • Tennessee. A home care organization providing home health needs a CON before it is established, licensed or certified. Agencies that serve only patients under 18, or only EEOICPA beneficiaries, are excepted ⁠76. The filing fee is $2.25 per $1,000 of project cost, with a $3,000 minimum and a $45,000 maximum ⁠87. The need standard estimates home health use at 1.5% of a county’s population ⁠77. Assisted-care living facilities are not among the healthcare institutions the Commission lists as needing a CON ⁠76.
  • Arkansas. The Health Services Permit Agency issues Permits of Approval for home health and hospice agencies, assisted living facilities and residential care facilities ⁠18. Applications are accepted on February 1, May 1, August 1 and November 1, with a $3,000 review fee ⁠19. Since July 1, 2005, Arkansas has not accepted applications to build new residential care facilities or add beds. Replacement facilities of 16 beds or fewer are allowed if they do not add beds ⁠20.
  • Missouri. Every facility licensed under chapter 198, including residential care and assisted living facilities, falls under CON ⁠52. Home health agencies are not on that list, and the definition of a new institutional health service excludes home health services offered within a health care facility ⁠52⁠12. The application fee is $1,000 or 0.1% of the project cost, whichever is greater ⁠1. See the Missouri assisted living guide.
  • Hawaii. A new home health agency that will bill Medicare or Medicaid goes through SHPDA’s CON process with a public hearing; otherwise SHPDA issues a letter saying no CON is needed. Either answer goes to OHCA with the license request ⁠14. A freestanding adult day health center follows the same first step ⁠29.
  • Washington. The CN Program covers home health agencies that are, or intend to become, Medicare or Medicaid certified ⁠13. Serving a new county on a regular basis counts as developing a new agency ⁠81. DOH tells licensed agencies to contact the CN Program before submitting the Medicare CMS-855A ⁠88. Since October 10, 2026, the application fee is 1.15% of the estimated capital expenditure, with a $25,000 minimum and an $80,000 maximum, or $25,000 in a designated rural area ⁠89.
  • Vermont. A CON is required to offer any home health service ⁠78. Act 87 of 2024 bars granting a CON for a new home health agency or home health services, including hospice, through January 1, 2030, unless lifted sooner ⁠79.

Repeals and changes since 2023

  • South Carolina, May 16, 2023. Act 20 narrowed the general CON requirement in section 44-7-160 to nursing homes, plus hospitals until that part is repealed on January 1, 2027 ⁠75. Home health was not freed: section 44-69-75 still requires a home health agency to obtain a CON before licensure ⁠7. See the South Carolina home health guide.
  • Georgia, 2024-2025. HB 1339, signed April 19, 2024, revised the CON process and added exemptions. DCH accepted letters of determination under it from July 1, 2024, and updated rules took effect January 13, 2025 ⁠27.
  • North Dakota, August 1, 2025. Basic care beds may not be added to licensed capacity until July 31, 2029. The exceptions cover nursing-bed conversions, transferred capacity, a showing that basic care is not readily available, and a few other listed cases. Approved beds must be licensed within 48 months ⁠68. North Dakota had already repealed its home health CON in 1995 ⁠67.
  • Rhode Island, 2026. Until June 12, 2026, Rhode Island’s CON law covered home nursing-care and home-care providers ⁠73. Article 12 of the FY2027 budget, enacted June 12, 2026 as P.L. 2026, ch. 84, struck “home nursing-care provider” and “home-care provider” from the CON definition of a healthcare facility, effective on passage ⁠74[107]. The statute page posted online still showed the old wording on November 11, 2026 ⁠73, and RIDOH’s rule still describes a CON step, so ask RIDOH which process it applies before filing.

Moratoriums and need reviews that work like a CON

  • California home health (SB 164). From June 29, 2026, CDPH may not issue a new home health agency license, except that it may grant an exception on a written finding that the applicant has shown unmet need in its proposed service area. The freeze lasts until no later than 90 days after CDPH’s revised home health regulations take effect, and it also covers branch offices and changes of service area ⁠21. Every applicant must also prove unmet need for home health in its service area, including after the freeze ends. CDPH may not approve a change of ownership within five years of a license’s initial issue, except for extenuating circumstances it accepts ⁠21. See the California home health guide.
  • Louisiana home health. Louisiana has no CON, but R.S. 40:2116.32(F)(1) bars new home health licenses until LDH publishes a rule certifying it has the money for initial licensure surveys. The only exception is a survey eligible for federal priority funding under guidelines in effect June 1, 1995 ⁠39. LDH’s home health page still points to this “moratorium” language ⁠40. Louisiana’s Facility Need Review separately gates personal care attendant, respite, supervised independent living and monitored in-home caregiving providers, with a $200 non-refundable fee ⁠41. Adult residential care providers licensed on or after August 1, 2022 no longer need FNR approval ⁠42. See the Louisiana home health guide.
  • Minnesota adult day and foster care. DHS imposed a licensing moratorium on new adult day centers from February 1, 2026, expected to last 24 months, to January 31, 2028 ⁠49. The statute lets DHS impose such a pause for up to 24 months when applications outgrow need ⁠50. DHS may not issue an initial adult foster care license for a home that will not be the license holder’s primary residence, nor an initial community residential setting license, with listed exceptions ⁠50. See the Minnesota adult day guide.
  • North Dakota Medicaid. ND Medicaid stopped enrolling new Qualified Service Provider agencies in Burleigh and Cass counties on June 11, 2026, for six months with possible extensions ⁠69.
  • Massachusetts adult day health. MassHealth began a six-month Medicaid provider enrollment moratorium on May 19, 2026. DPH says it does not affect initial licensure ⁠46. Adult day health programs do not need Determination of Need review ⁠47.
  • Maine nursing-bed conversions. Converting nursing facility beds to residential care beds does not need a CON, but MaineCare and other public funds may not pay for the converted beds unless the department approves the conversion ⁠43.
  • New Hampshire. The RSA 151:2 moratorium covers new nursing homes, skilled nursing, intermediate care and rehabilitation facilities, not assisted living or home health ⁠57.

The federal home health enrollment moratorium

CMS imposed a nationwide moratorium on Medicare enrollment of new home health agencies, effective May 13, 2026, and published it on May 15, 2026 ⁠90. It covers new agencies and new branches or practice locations in every state, unless the Medicare contractor received the application before May 13 ⁠90. CMS left Medicaid and CHIP home health moratoriums to each state ⁠90.

The notice states that the moratorium “remains in effect for 6 months” and may be extended in 6-month increments, with any extension published in the Federal Register ⁠90. It gives the length, not a calendar end date. Six months from May 13, 2026 is November 13, 2026. As of November 11, 2026, CMS has not announced an extension in the Federal Register: a search of documents published since May 16, 2026 finds no extension notice, and the newest related document is the CY 2027 home health payment final rule of November 9, 2026 ⁠91. Check the Federal Register again before you file a CMS-855A.

The two layers stack. In North Carolina, Washington or Hawaii, a Medicare-bound agency needs the state CON and, after it, a Medicare enrollment that is frozen nationally until the moratorium ends. In states with no CON and no licensing freeze, the federal moratorium is the only supply limit on new Medicare home health agencies. For how the Medicare and Medicaid steps fit after the license, see beyond the state license.

Getting a written answer before you spend money

Some agencies decide in writing whether a project needs a CON, and a few require you to ask first. Hawaii’s SHPDA answers with a CON or a no-CON letter, and Georgia’s Office of Health Planning answers with a letter of determination (see above). In Connecticut, a new residential care home starts with a letter of intent to DSS; if DSS decides a CON is needed, it sends the application and you have 180 days to file it ⁠23. West Virginia’s assisted living exemption must be claimed through an exemption application ⁠84.

If your state has no CON program or is “None found” in the table, your gates are the license itself, local zoning and, for home health, Medicare enrollment. Each state’s license for home health, assisted living, small residential care and adult day is on the license type pages. In Georgia the CON reaches home health but not a private home care provider license ⁠92, so the line drawn in non-medical home care vs home health also decides whether you face a review.

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