Non-medical home care vs home health: which license your agency needs
A home health agency gives skilled nursing or therapy under a practitioner's plan of care. A non-medical home care agency helps with bathing, dressing, meals and company, with no skilled care. Federal law decides which one Medicare will pay. Each state decides which license you need, and the trigger is usually a short list of tasks: giving medication instead of reminding, wound care, injections, nurse-delegated tasks. This guide shows where the line falls in federal rules and in 12 states, and the order to work through the decision.
Contents8 sections
Key takeaways
- Medicare pays a home health agency only for a homebound patient who needs intermittent skilled nursing, physical therapy, speech-language pathology or continuing occupational therapy, under a practitioner's plan of care. Aide visits are covered only alongside that skilled need.34
- Medicare's test for "skilled" is the task, not the worker: a service that unlicensed staff can safely perform without direct nurse supervision is not skilled even if a nurse does it.3
- Non-medical agency caregivers get no wage exemption. Third-party employers cannot use the FLSA companionship exemption. A DOL proposal from July 2, 2025 to reverse that had not been finalized as of 2026-11-11.1112
- Medication is the most common trigger. Colorado, Minnesota and North Carolina let non-medical staff remind clients to take medication or help with medication someone else set up. Giving or managing the medication needs the skilled tier.20243234
- Some states do not license non-medical home care at all. Michigan and South Dakota say so in writing, and Michigan does not license home health agencies either.373839
- CMS stopped enrolling new home health agencies in Medicare nationwide on May 13, 2026, for six months. As of 2026-11-11 a Federal Register search found no extension notice.13
Quick facts
| Medicare HHA test | Homebound patient, skilled need, plan of care, participating HHA |
|---|---|
| Part-time or intermittent | Under 8 hours a day and 28 or fewer hours a week of nursing and aide care combined |
| Aide training (Medicare HHA) | At least 75 hours, including 16 hours of supervised practical training |
| Medicaid home health | Cannot be limited to homebound beneficiaries |
| Companionship care limit (FLSA) | Hands-on care up to 20% of hours, and agencies cannot claim the exemption |
| Medicare HHA enrollment | Moratorium since May 13, 2026; no extension published as of 2026-11-11 |
Rules as published on 2026-11-11. State license names for every state are on the non-medical home care and home health license pages.
The two businesses side by side
Federal law uses “home health” narrowly. A Medicare home health agency must be primarily engaged in providing skilled nursing services and other therapeutic services. Its policies must be set by a group that includes at least one physician and one registered nurse, and it must keep clinical records on every patient.1 A non-medical agency has no federal definition. It is whatever your state’s licensing law says it is, and in some states it is not licensed at all. The table compares the two. For every state’s license names, use the non-medical home care and home health pages.
| Non-medical home care | Home health (Medicare-type HHA) | |
|---|---|---|
| Core services | Personal care, homemaking, companionship | Skilled nursing, PT, OT, speech therapy, medical social services, aide care 1 |
| Orders | None federally; some states require a service plan | Practitioner’s plan of care, reviewed at least every 60 days 5 |
| Key staff | Aides; training set by the state | RN supervision; aides with at least 75 hours of training 6 |
| Payers | Private pay; Medicaid personal care and waivers 89 | Medicare; Medicaid home health 37 |
| Federal rules | FLSA wage rules (29 CFR 552) 11 | Medicare conditions of participation (42 CFR 484) 15 |
| Example state names | Class B home care agency (CO), home services agency (IL), companion registration (FL) 192023 | Home health agency (FL), Class A home care agency (CO), HCSSA home health category (TX) 151720 |
The federal line: what makes an agency “home health”
The Medicare definition
Medicare home health services are part-time or intermittent nursing care by or under the supervision of a registered nurse, physical or occupational therapy, speech-language pathology, medical social services, and the part-time or intermittent services of a trained home health aide. All of it is furnished under a plan established and periodically reviewed by a physician.1 “Part-time or intermittent” means skilled nursing and aide services combined of less than 8 hours a day and 28 or fewer hours a week. Case by case, Medicare can allow up to 35 hours a week, still under 8 hours a day.1 An agency that sends aides for 10-hour shifts is outside this benefit, whatever its license says.
The agency must also hold the state license where the state licenses agencies of this kind, or be approved as meeting the state’s licensing standards.1 Where a state licenses home health agencies, Medicare certification sits on top of the license. It does not replace it.
The patient tests
A beneficiary qualifies for Medicare home health only if they meet all five tests in 42 CFR 409.42:3
Confined to the home
The Act defines this as a condition that restricts leaving home except with another person’s help or a device such as a cane, walker or wheelchair, or that makes leaving medically contraindicated. The person need not be bedridden, but leaving home must take a considerable and taxing effort.2
Under the care of a physician or allowed practitioner
, meaning a physician assistant, nurse practitioner or clinical nurse specialist, who establishes the plan of care.3
In need of a skilled service
intermittent skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy.3
Under a plan of care
that meets the federal requirements.3 The plan must be individualized, list measurable outcomes and goals, and be established, reviewed and signed by the practitioner.5
Served by a participating HHA,
directly or under arrangements.3
Aide visits ride on the skilled need. Home health aide services are covered only while the patient needs one of the qualifying skilled services. Aide care given after the last qualifying skilled service is not covered, except when an unexpected hospital admission, death or similar event interrupted the plan.4 Medicare never pays for personal care on its own. That is the economic line between the two businesses.
What “skilled” means
Medicare judges the task, not the worker. A service is not skilled merely because a licensed nurse performs or supervises it. If non-licensed staff could perform it safely and effectively without a nurse’s direct supervision, it is not a skilled service, even when a nurse does it.3 The reverse also applies. An unskilled task becomes skilled nursing when the patient’s condition means only a registered nurse can make sure the care is achieving its purpose.3
Aides who work for a Medicare HHA need at least 75 hours of classroom and supervised practical training. At least 16 hours of classroom training must come before at least 16 hours of supervised practical training. They must also pass a competency evaluation before furnishing services.6
Medicaid draws a wider circle
Medicaid home health is broader than Medicare’s. States cannot limit it to homebound beneficiaries. Coverage cannot depend on the person needing nursing or therapy.7 Orders must come from a physician, nurse practitioner, clinical nurse specialist or physician assistant as part of a written plan of care, reviewed every 60 days for nursing, aide and therapy services.7 For home health services to start, an ordering practitioner must document a face-to-face encounter within the 90 days before or the 30 days after the start of care.7 The provider still has to be a “home health agency” that meets the requirements for participation in Medicare, including the capitalization rule in 42 CFR 489.28.7
Non-medical agencies get Medicaid money through two other doors:
- State plan personal care must be authorized by a physician under a plan of treatment or, at the state’s option, under a state-approved service plan. It must be furnished in a home by a qualified person who is not a legally responsible relative.8
- Home and community-based waivers can include homemaker, home health aide, personal care, adult day health, habilitation and respite services, each as the state defines it and CMS approves it.9
The waiver definition is the state’s, so “personal care” in your state’s waiver may require a license tier, an RN assessment or a provider agreement that the federal rule does not mention.
The federal wage rule every non-medical agency meets
Under the Fair Labor Standards Act, “companionship services” means fellowship and protection for an elderly, ill, injured or disabled person. Care (help with dressing, grooming, feeding, bathing, toileting, transferring, meal preparation, light housework or the physical taking of medications) counts as companionship only if it accompanies the fellowship and protection and takes no more than 20% of hours worked per person per workweek.10 Medically related services are never companionship. The test is whether the task typically requires and is performed by trained personnel such as RNs, LPNs or certified nursing assistants, not the worker’s job title.10
That definition matters less for agencies than founders hope. Third-party employers may not claim the companionship exemption from minimum wage and overtime, or the live-in overtime exemption, even when the family is a joint employer.11 DOL proposed on July 2, 2025 to let third-party employers claim both exemptions again.12 As of 2026-11-11 a Federal Register search found no final rule, and the eCFR text of 29 CFR 552.109 still bars agencies from the exemption.11 Price your hourly rates and overtime under the rule in force.
How states draw the line
The federal rules decide who Medicare and Medicaid pay. The state license decides what you may do at all, and states use four structures.
One license with tiers or categories
Texas issues one Home and Community Support Services Agency (HCSSA) license with categories. They are personal assistance services (PAS), licensed home health services, licensed and certified home health services, versions of both home health categories with home dialysis, and two hospice categories.15 PAS covers personal care, health-related services the Texas Board of Nursing does not treat as professional nursing, and health-related tasks delegated by an RN.14 Personal care includes “assisting with self-administered medications”.14 RN delegation is allowed under both the PAS and licensed home health categories, but the agency must employ or contract with the delegating RN.15
Colorado licenses home care agencies in two classes. Class A provides any skilled healthcare service and may also provide personal care. Class B provides only personal care and “shall not provide any skilled healthcare service”.20 The rule lists the skilled services, and medication administration and wound care are both on it.20 Moving from Class B to Class A takes a new initial application and the initial Class A fee.20
Minnesota splits one home care license into basic and comprehensive. A basic license covers help with dressing, grooming, toileting and bathing, standby assistance, and reminders to take regularly scheduled medication. A reminder includes bringing the client previously set-up medication or medication in its original container.24 Nursing, tasks an RN delegates to unlicensed staff, medication management, hands-on help with transfers and mobility, and treatments all require the comprehensive license.24
Washington issues one in-home services agency license with service categories for home care, home health and hospice. The initial 12-month fee is $5,000 for each category, as published on 2026-11-11.27 Home care services are “nonmedical services and assistance”, such as personal care, homemaker help and respite.25 A home health agency provides two or more home health services.25 A home care agency that provides delegated nursing tasks under RCW 18.79.260(3)(e) is not treated as a home health agency for licensing.25 Licensure applies to anyone who employs or contracts with two or more people to provide in-home services.26
A home health license that also covers personal care
Florida has no separate non-medical license. Home health aide services are a home health service, and a home health aide gives hands-on personal care.16 A Florida home health agency license must list the services the agency may perform and say whether each is skilled care. Providing or advertising a service that is not on the license counts as unlicensed activity.17 An agency that does not provide skilled care is exempt from the accreditation and survey that skilled applicants must submit.18 Personal care therefore needs a home health agency license even without nurses, while companion and homemaker services need only a registration (below).
New York has no non-medical tier either. No home care services agency may provide nursing, advanced home health aide, home health aide or personal care services without approval from the Public Health and Health Planning Council and a license.28 The Department of Health states that an organization must be licensed or certified as a home care agency to provide or arrange home care services in the state.29 New Licensed Home Care Services Agency applicants file a certificate of need application with a need report.30
Oklahoma licenses home care agencies for “skilled or personal care services” under one license.31 Skilled care means services performed regularly by a licensed professional such as an LPN, RN or therapist, or by a trained respiratory therapist or technician.31
Separate licenses for skilled and non-medical work
Ohio has two licenses. Nonmedical home health services are home health aide services and personal care services. The aide services are hands-on bathing, help with dressing, walking and toileting, catheter care but not insertion, and meal preparation and feeding.35 Skilled home health services are skilled nursing, physical, occupational and speech therapy, and medical social services.35 Providing nonmedical services through employees requires either license, and skilled services require the skilled license.36
Illinois licenses non-medical home services agencies separately from home health agencies. Its application warns: “As a non-medical service license, this license does not allow for any skilled services to be provided regardless of whether an individual is licensed or certified in their respective discipline.”23 A nurse on your payroll does not change that.
North Carolina separates “home assistance services” from home care. Home assistance means in-home companion, sitter or respite care, and homemaker services provided with those. It is defined as not home care.32 Homemaker services include medication reminders and other tasks that do not require touching the client.32 Both home care agencies and home assistance services providers need a license from the Department.33 Home assistance providers may not bill any health insurer, managed care organization or health plan for services to North Carolina residents.33 In-home aides at licensed home care agencies may not administer medications, only assist with self-administration.34
Companion-only registration or license
Connecticut registers homemaker-companion agencies with the Department of Consumer Protection, not the health department.21 Homemaker services there include help with personal hygiene.21 DCP says the services exclude any medical or nursing service, administering medications or shots, and assessing blood pressure or wound care.22 DCP adds that a DPH-licensed home health care or home health aide agency doing non-medical work should form a separate entity and register it.22
Florida exempts a provider of only companion or homemaker services from home health licensure but requires it to register with AHCA.19 A companion or homemaker may not provide hands-on personal care.16
Oklahoma goes further. Any agency that provides, offers or advertises companion or sitter services must be licensed by the State Department of Health.31 A licensed home care agency may add companion or sitter services under its existing license.31
No state license
Michigan licenses neither type. LARA states that “State licensing is not required for home health agencies”. Agencies that provide skilled nursing may apply for certification to participate in Medicare and Medicaid.37 The Attorney General’s consumer checklist calls non-medical home care “an unregulated industry”.38 South Dakota says non-medical providers of in-home care such as bathing, light housekeeping or meal preparation are not regulated by its Department of Health.39 Wisconsin tells providers of only personal care not to file a home health application.40 Its personal care agencies are certified under DHS 105.17. A successful survey leads to a recommendation for Medicaid certification.41
Many states have no license for private-pay non-medical agencies, and in others only Medicaid-paid agencies are regulated. The non-medical home care page lists which states are in each group. Confirm with the state health department before you open.
Tasks that move you into the skilled license
Across these states the same few tasks decide the tier.
- Medication. Reminding is non-medical almost everywhere. Colorado personal care workers may assist only with medication pre-selected by the client, a family member, a nurse or a pharmacist and stored in containers other than the prescription bottle, such as medication minders.20 Minnesota’s basic license allows reminders and bringing previously set-up medication. Medication management needs the comprehensive license.24 North Carolina aides may assist with self-administration but not administer.34 Texas includes help with self-administered medication in personal care.14
- Wound care and injections. Colorado lists wound care, infusion and medication administration as skilled home health services.20 Connecticut excludes shots and wound care from homemaker-companion work.22
- Nurse delegation. Delegation sits on the non-medical side in some states. Texas allows RN-delegated tasks under the PAS category and Washington under a home care license.1525 Minnesota requires the comprehensive license for any RN-delegated task.24
- Hands-on care at all. In Florida and Connecticut, touching the client is where the line falls. Florida companions may give no hands-on personal care.16 North Carolina’s homemaker definition covers only services that do not require touching the client.32
| State | Non-medical option | Skilled license | What crosses the line |
|---|---|---|---|
| Texas | HCSSA, PAS category 15 | HCSSA, home health category 15 | Nursing and therapy; RN delegation allowed in PAS 1415 |
| Florida | Companion/homemaker registration 19 | Home health agency (lists skilled or not) 17 | Any hands-on personal care 16 |
| Colorado | Class B home care agency 20 | Class A home care agency 20 | Medication administration, wound care 20 |
| Connecticut | DCP homemaker-companion registration 21 | DPH-licensed home health care agency 2122 | Medications, shots, wound care 22 |
| Illinois | Home services agency 23 | Home health agency, same IDPH code 23 | Any skilled service 23 |
| Minnesota | Basic home care license 24 | Comprehensive license 24 | Medication management, delegated tasks, hands-on transfers 24 |
| Washington | Home care category 25 | Home health category 25 | Two or more home health services 25 |
| New York | None for personal care 28 | LHCSA license 28 | Personal care already needs the license 28 |
| Oklahoma | Companion/sitter license 31 | Home care agency 31 | Personal or skilled care 31 |
| North Carolina | Home assistance services license 33 | Home care agency 33 | Touching the client; aides may not administer medications 3234 |
| Ohio | Nonmedical home health license 36 | Skilled home health license 36 | Nursing, therapy, medical social services 35 |
| Michigan | No license 38 | No state license; Medicare/Medicaid certification is optional 37 | Federal certification only 37 |
Scroll the table sideways to see every column.
A decision sequence for founders
List the services you will sell, task by task
Write “medication reminders” or “medication administration”, not “medication help”. Do the same for bathing, transfers, wound care and injections. In Colorado, Minnesota and North Carolina those words decide the tier.202434
Match the list to your state’s tier
Open your state on the non-medical home care and home health pages, then read the state guide. If one task falls in the skilled tier, the agency needs that tier: a Colorado Class B or Illinois home services agency may provide no skilled service at all.2023 In Colorado, moving up later means a new initial application.20
Choose your payers
Medicaid personal care and waiver services are defined by each state within the federal rules, so read the state’s own definition of the service before you bill it.89 Medicare requires a skilled agency that meets every federal condition.13
Check need reviews before you spend
New York requires a certificate of need for new LHCSAs.30 Other states require one for home health. The home health page lists them.
Plan Medicare around the moratorium
CMS imposed a six-month nationwide moratorium on Medicare enrollment of new home health agencies, effective May 13, 2026. It does not apply to applications the Medicare contractor received before that date.13 The first six-month period runs to about November 13, 2026. CMS may extend it in six-month increments and will publish a notice if it does.13 As of 2026-11-11 a Federal Register search found no extension notice. CMS left any Medicaid and CHIP moratorium to each state.13 The business setup guide covers Medicare enrollment, accreditation, capitalization and the 36-month ownership rule.
Set pay under the federal wage rule
Agencies cannot claim the companionship or live-in exemptions from minimum wage and overtime for their aides.11
Sources
- 1
- 2
- 3
- 4 eCFR (National Archives), 42 CFR 409.45, Dependent services requirements Checked 11 Nov 2026 · Back to text ↑
- 5
- 6 eCFR (National Archives), 42 CFR 484.80, Home health aide services Checked 11 Nov 2026 · Back to text ↑
- 7 eCFR (National Archives), 42 CFR 440.70, Home health services (Medicaid) Checked 11 Nov 2026 · Back to text ↑
- 8 eCFR (National Archives), 42 CFR 440.167, Personal care services (Medicaid) Checked 11 Nov 2026 · Back to text ↑
- 9
- 10 eCFR (National Archives), 29 CFR 552.6, Companionship services Checked 11 Nov 2026 · Back to text ↑
- 11 eCFR (National Archives), 29 CFR 552.109, Third party employment Checked 11 Nov 2026 · Back to text ↑
- 12
- 13
- 14
- 15
- 16
- 17
- 18 The Florida Senate, Florida Statutes 400.471, Application for license; fee Checked 11 Nov 2026 · Back to text ↑
- 19
- 20
- 21
- 22
- 23 Illinois Department of Public Health, Home Services Application (form 445104) Checked 11 Nov 2026 · Back to text ↑
- 24
- 25
- 26
- 27 Washington State Legislature, WAC 246-335-990, In-home services agency fees Checked 11 Nov 2026 · Back to text ↑
- 28
- 29 New York State Department of Health, Home Care Checked 11 Nov 2026 · Back to text ↑
- 30
- 31
- 32
- 33 North Carolina General Assembly, N.C. Gen. Stat. 131E-138, Licensure Checked 11 Nov 2026 · Back to text ↑
- 34
- 35
- 36
- 37 Michigan LARA, Bureau of Survey and Certification, Home Health Agencies (HHA) Checked 11 Nov 2026 · Back to text ↑
- 38
- 39 South Dakota Department of Health, Home Health Agencies (HHA) Checked 11 Nov 2026 · Back to text ↑
- 40 Wisconsin Department of Health Services, Home Health Agencies: Application Checked 11 Nov 2026 · Back to text ↑
- 41
Was this information accurate? Report an error
Related guides
- Beyond the state license: the federal and business steps to open a care businessAll states · Business setup
- Texas personal assistance services license: the HCSSA PAS categoryTexas · Non-medical home care agency
- Florida homemaker and companion registration: starting non-medical home careFlorida · Non-medical home care agency
- Colorado Class B home care agency license: opening a non-medical personal care agencyColorado · Non-medical home care agency
- Minnesota basic home care license: starting a non-medical home care agencyMinnesota · Non-medical home care agency
- Washington home care agency license: the in-home services license, home care categoryWashington · Non-medical home care agency