North Carolina certified home health agency: certificate of need, DHSR license and Medicare
In North Carolina a "home health agency" is a home care agency certified for Medicare and Medicaid, and no one may develop a new one without a certificate of need. The 2026 State Medical Facilities Plan shows no need for a new agency anywhere in the state, and the Proposed 2027 Plan shows the same, so as of 2026-10-12 the realistic routes are buying an existing certified agency or petitioning for a county need determination.
Contents14 sections
Key takeaways
- A new Medicare-certified home health agency, or a new office of an existing one, needs a certificate of need (CON), and a CON cannot be issued unless the State Medical Facilities Plan shows need in that county.
- The 2026 Plan and the Proposed 2027 Plan both state there is no need anywhere in North Carolina and schedule no reviews.
- Acquiring an existing agency is exempt from CON review if you give the CON Section prior written notice, but federal rules can block Medicare billing privileges from transferring if the agency enrolled or changed majority hands within the last 36 months.
- After the CON comes a DHSR home care license under 10A NCAC 13J ($510 a year as published on 2026-10-12), then Medicare certification, which DHSR surveys only after the agency is licensed and serving patients.
- NC Medicaid enrolls a home health provider only if it is both Medicare certified and DHSR-licensed for home health.
Quick facts
| Agencies | DHSR Healthcare Planning and CON Section (CON) and DHSR Acute and Home Care Licensure and Certification Section (license and Medicare survey) |
|---|---|
| Certificate of need | Required for a new agency or office; 2026 Plan: no need anywhere in the state |
| CON application fee | $5,000 plus 0.3% of capital cost above $1 million, capped at $50,000, nonrefundable (G.S. 131E-182) |
| State license fee | $510 initial, $510 annual renewal, $510 change of ownership (as published on 2026-10-12) |
| Service area | One county; each of the 100 counties is its own service area |
| License term | One year; all home care licenses expire December 31 |
| Medicare survey trigger | 10 skilled patients served, 7 active, per DHSR |
Fees and need determinations as published on 2026-10-12. The State Medical Facilities Plan is reissued every calendar year.
North Carolina is one of the states where a Medicare-certified home health agency cannot simply apply for a license. The Home Care Licensure Act defines a “home health agency” as a home care agency certified to receive Medicare and Medicaid reimbursement for nursing, therapy, medical social services and home health aide services on a part-time, intermittent basis 124. Each site needs its own certificate of need and its own license 1. The order is fixed: check the State Medical Facilities Plan, win a certificate of need, get the DHSR license, open and serve patients, and only then seek Medicare and Medicaid certification 1.
The certificate of need door is shut for 2026
DHSR says it directly: if the State Medical Facilities Plan (SMFP) does not show need for another agency, “no certificate of need can be issued,” and a certificate cannot be issued “if the SMFP does not show a need for the agency in the county where it is proposed” 1.
Table 12E of the 2026 SMFP, the plan that governs CON reviews in calendar year 2026, reads: “It is determined that there is no need anywhere in the state and no reviews are scheduled” 2. The Proposed 2027 SMFP, posted for reviews beginning in 2027, carries the same sentence in its Table 12E 3. The 2026 Plan counts 208 licensed Medicare-certified agencies or offices in its inventory, and the Proposed 2027 Plan counts 206 23.
The rule covers more than brand-new companies. Under G.S. 131E-176(16), these are all “new institutional health services” that need a CON:
- establishing a new health service facility, and a “home health agency office” is a health service facility 4;
- an existing health service facility starting home health services it has not offered in the previous 12 months 4;
- an existing home health agency opening an additional office, whether inside or outside its service area 4.
So an established agency in Wake County cannot open a branch in Johnston County without its own CON and its own license either 14.
The SMFP is reissued every calendar year. A county can gain a need determination in a later plan, so check the newest final plan and the proposed plan each July before you rule out a de novo agency.
What needs this license, and what does not
The CON law defines home health services as services provided on a visiting basis in the patient’s residence: part-time or intermittent nursing by or under the supervision of a registered nurse; physical, occupational or speech therapy; medical social services and home health aide services; and medical supplies other than drugs 4.
The CON requirement attaches to Medicare certification. The 2026 SMFP’s CON review category lists “new Medicare-certified home health agencies or offices” 2, and DHSR’s home care FAQ states that Medicare certification requires a CON 13. Nursing is also a “home care service” under G.S. 131E-136 24, and 10A NCAC 13J sets the rules for any licensed home care agency that offers nursing 10. An agency that sends nurses or aides into homes without seeking Medicare certification is licensed as a home care agency with no CON. That route, with its training, staffing and Medicaid personal care rules, is covered in the North Carolina home care agency guide.
Hospices are a separate CON category entry and a separate license; this guide does not cover them 2.
How a county earns a need determination
The need formula in Chapter 12 of the SMFP decides whether the door opens anywhere. As written in the 2026 Plan:
- Service area. Each county is its own service area; there are 100 2.
- Data. Patient origin and visits come from the license renewal applications agencies file with DHSR each year 2.
- Projection. The model projects patients three years past the reporting year. The 2026 Plan projects to 2027 and the Proposed 2027 Plan projects to 2028 23.
- Threshold. A county needs a new agency or office when its projected unmet need is 325 patients or more, and each 325-patient deficit produces one need determination 2.
- New-agency credit. For three annual plans after a need-based agency is certified, the model counts it as serving at least 325 patients, even if it serves fewer 2.
Neither plan changed the methodology. Both say Chapter 12 “contains no substantive changes from the previous SMFP” 23.
Petitioning for an adjusted need determination
When the standard formula shows no need, the SMFP’s route to creating one for a specific county is a summer petition to the State Health Coordinating Council. (Spring petitions exist too, but they ask for statewide changes to policies or need methodologies, not a county adjustment 2.) The Proposed SMFP is posted on or about July 1, the Council holds public hearings in July, and petitions asking for an adjusted need determination are due by 5:00 p.m. on the date of the last July hearing 2. A petition must argue that “special attributes of a service area or institution” create needs the standard methodology misses 2. A two-week comment period follows, then committee review, and any approved adjustment appears in the final plan for the next year 2. Healthcare Planning encourages petitioners to talk with its staff before filing 2; the Medical Facilities Planning Section is at 919-855-3865 1.
If a need determination appears: the CON application
Home health falls in CON review Category F. In 2026, Category F reviews could begin March 1, May 1, July 1 or November 1, but each need determination gets only one review date, set in the chapter’s need table, and no review is held where there is no need 2. Application deadlines are absolute: filings are due by 5:00 p.m. on the deadline date 2.
What the application must show. Under 10A NCAC 14C .2003 (readopted January 1, 2023), an applicant for a new Medicare-certified agency must project utilization for each of its first three full fiscal years, show it will serve at least 325 residents of the proposed county in the third full year, and give the assumptions and method behind those numbers 7. The SMFP’s basic principle also encourages applicants to offer a wide scope of services, seven-day service where patients need it, and service to special needs populations 2.
Form and fee. The CON Section uses one application form and fee sheet for all non-dialysis services; you can request it by email with the information required by 10A NCAC 14C .0203(c), and the Section asks applicants to check with the project analyst assigned to their county 9. The application fee is $5,000 plus 0.3% of any proposed capital expenditure above $1,000,000, capped at $50,000, and it is not refunded even if the CON is denied 5.
The review clock, as DHSR describes it 1:
| Point in review | What happens |
|---|---|
| Days 1-30 | Anyone, including competing applicants, may file written comments |
| Days 30-50 | CON Section holds a local public hearing; the applicant responds to comments |
| By day 150 | CON Section approves or denies |
| 35 days after approval | Certificate issued if no contested case petition is filed |
The CON Section’s mailing address is 2704 Mail Service Center, Raleigh, NC 27699-2704, phone 919-855-3873 8.
Buying an existing certified agency
With no need determination available, acquisition is the practical way in. G.S. 131E-184(a)(8) requires the Department to exempt from CON review the acquisition of an existing health service facility, “including equipment owned by the health service facility,” if the buyer gives prior written notice explaining why it is required 6. A home health agency office is a health service facility under G.S. 131E-176 4. The CON Section’s website lists a “No Reviews and Exemptions” report among its public records 8. Neither it nor DHSR publishes a processing time for exemption notices.
The state license does not transfer. A 13J license is issued “for the premises and persons named in the application and shall not be transferable” 10. The licensee must notify DHSR in writing at least 30 days before a change of ownership or name, the agency must be in compliance with all statutes and rules before the change, and a Medicare-certified agency must also comply with the CON statutes in G.S. 131E Article 9 10. DHSR’s change of ownership fee is $510 as published on 2026-10-12 12.
Federal rules decide whether the Medicare enrollment comes with the purchase:
- 36-month rule. If majority ownership of a home health agency changes hands by sale, including asset sales, stock transfers and mergers, within 36 months of its initial Medicare enrollment or its last majority ownership change, the provider agreement and billing privileges do not convey to the buyer unless a listed exception applies; the buyer must instead enroll as a new home health agency and obtain a state survey or an accreditation 17. Check the target’s enrollment and ownership dates before you sign.
- Both parties file. The seller and buyer must both submit Medicare enrollment applications before the change of ownership closes 17.
- Enhanced oversight. A certified provider going through a change of ownership counts as a “new provider” for CMS’s provisional period of enhanced oversight, which starts when the first claim is submitted 18.
- Capital reserve. If the change of ownership results in a new provider number, the federal capitalization rule below applies to the buyer as well 16.
The DHSR license after the certificate of need
Once the certificate is issued, you contact the Acute and Home Care Licensure and Certification Section (919-855-4620) and request a licensure application 1. Because a certified agency provides more than one home care service, DHSR uses a multi-purpose application and may issue a multi-program license 1.
Owner training. Under 10A NCAC 13J .0903(a), if the applicant has never owned or operated a home care agency, DHSR will not issue a license until the applicant completes DHSR-approved training on licensure requirements, the process and the operating rules 10. DHSR does not run this training itself; it lists approved trainers 14.
Agency director. 13J .1001(b) requires a director who is a health care practitioner under G.S. 90-640(a), or has two years of supervisory or management experience in home care or another provider licensed under G.S. 131E or 122C, or holds a bachelor’s degree in health, business or public administration with one year of supervisory or management experience in home care or another licensed health program 10. Each type of service needs a designated supervisor, who may also be the director 10. If the director’s position becomes vacant, DHSR must be told in writing within five working days 10.
Written policies. 13J .1001(a) lists the policies DHSR will look for: scope of services, admission and discharge, personnel supervision, plan of care development and updates, emergencies in the home, timeframes for returning service records, personnel qualifications, an organizational chart, program evaluation, confidentiality, and coordination with other community agencies 10. Agencies that give medications or treatments also need policies on staff accountability for side effects, toxic and allergic reactions, and when to call the physician 10.
Deemed status or survey. If the agency is accredited by a body named in G.S. 131E-138, it is deemed to meet the licensure rules and the license is issued without further review 111. Otherwise DHSR schedules an initial licensure survey. If the agency is in substantial compliance, it gets a survey report and a license. If not, DHSR says at the survey what is missing and may consult with the agency, and it denies the license if those efforts fail 1. DHSR’s home care FAQ says it cannot set timeframes for initial licensure 13.
The license is for one year and is posted in a prominent place at the office, with a sign bearing the agency name at the public door 10.
Staffing to two rulebooks
A certified agency must meet the state home care rules and the federal Medicare conditions of participation at the same time. NC Medicaid’s home health policy also requires staff to meet the federal qualifications in 42 CFR 484.115 22.
| Topic | North Carolina (10A NCAC 13J) | Federal (42 CFR Part 484) |
|---|---|---|
| Leadership | Agency director meeting .1001(b); supervisor for each service 10 | Administrator who is a physician, RN or degree holder with at least 1 year of supervisory or administrative home health or related experience; clinical manager who is a physician, PT, SLP, OT, audiologist, social worker or RN 19, available during all operating hours 23 |
| Nursing | By or under an RN; LPN duties delegated by the RN; on-call nursing 24 hours a day, 7 days a week, with schedules kept one year 10 | Initial assessment within 48 hours of referral; RN comprehensive assessment, including OASIS, within 5 calendar days of start of care 21 |
| Therapy and social work | PT by or under a licensed PT; social work by or under a medical social worker 10 | Qualifications by discipline in 484.115 19 |
| Aides | Background check consent as a condition of hire, with fingerprints if the person has lived in NC less than 5 years 15 | 75 hours of training, including at least 16 classroom hours before 16 supervised practical hours; 12 in-service hours every 12 months 20 |
| Aide supervision | Health care practitioner reviews the plan of care every 90 days and makes a supervisory visit to each in-home aide client’s residence every 90 days and annually 10 | Supervisory assessment at least every 14 days when skilled services are provided; RN onsite visit every 60 days for aide-only patients 20 |
For Medicaid patients, aides must be listed as Nurse Aide I on the DHSR Nurse Aide Registry or as Nurse Aide II on both that registry and the Board of Nursing registry 22.
Medicare certification: what DHSR runs after you open
DHSR’s procedure page puts certification after licensure. A licensed agency holding a home health CON contacts the section for the federal forms, and the Medicare contractor must approve the agency’s Form CMS-855 before the initial Medicare survey 1.
The patient threshold. The agency notifies the section in writing when it is ready. Per DHSR, it must have served 10 skilled care patients, with 7 active at the time, before requesting the on-site survey 1. That means operating as a licensed agency and treating non-Medicare patients first.
Funding the gap. Federal rules require a new home health agency to hold “initial reserve operating funds” from the time it applies through three months after Medicare billing privileges are granted, not counting Medicare receivables 16. CMS sets the amount from the first-year cost per visit of at least three comparable agencies, multiplied by your projected first-quarter visits, or 22.5% of the comparison agencies’ average visits, whichever is greater 16.
Survey and effective date. The initial survey is unannounced. If deficiencies are cited, certification takes effect on the latest date the agency signs a plan of correction 1. DHSR then sends the file to CMS, which assigns the provider number and notifies the Medicare contractor 1. New enrollees are also subject to CMS’s provisional period of enhanced oversight starting with the first claim 18.
DHSR’s procedure page was last modified October 15, 2008, and still refers to a “fiscal intermediary” and the CMS Atlanta Regional Office 1. The page does not say which Medicare contractor now reviews the Form CMS-855 or how the certification packet now reaches CMS, and no other official source consulted settles it. Ask the section at 919-855-4620 which contractor to file with and in what order before you submit.
Medicaid enrollment
Under NC Medicaid Clinical Coverage Policy 3A (amended July 1, 2026), an agency can enroll as a Medicaid home health provider only if it is Medicare certified and licensed by DHSR to provide home health services. All services must be delivered by its own employees or contractors 22. It must also sign the DHHS Provider Administrative Participation Agreement 22 and run a quality assessment and performance improvement program and an infection control program under 42 CFR 484.65 and 484.70 22. Home health visits fall under electronic visit verification: the agency must register with the state’s EVV system or use an alternate system that meets the 21st Century Cures Act 22. DHSR licenses home care agencies; the Division of Health Benefits (formerly DMA) runs Medicaid, and an agency that lets its license lapse can be referred to it 13. Ownership, address or agency director changes must be reported to DHSR in writing before they take effect 13.
Fees as published on 2026-10-12
| Fee | Amount | Source |
|---|---|---|
| CON application | $5,000 + 0.3% of capital expenditure above $1,000,000; max $50,000; nonrefundable | G.S. 131E-182(c) 5 |
| Initial home care license | $510, nonrefundable | DHSR fee schedule 12; G.S. 131E-138 11 |
| Annual renewal | $510, nonrefundable | 12 |
| Change of ownership | $510 | 12 |
The federal capital reserve in 42 CFR 489.28 is a separate cash requirement, not a fee 16.
Renewal, inspections and reporting
All home care licenses expire at midnight on December 31. A renewal received after January 1 takes effect on the date DHSR receives it, and in the meantime the agency is operating without a license 13. The renewal application matters beyond licensure: its patient and visit data feed the SMFP need formula 2. Under 13J .1002, a certified agency keeps statistical data that includes total charges and visits by payer, and keeps records at least three years 10.
DHSR inspects home care agencies every three years, and inspections and complaint investigations are unannounced 13. Adding a service category requires written notice to DHSR at least 30 days before serving any client with it 10. Reducing or ending a client’s services requires at least 48 hours’ notice to the client, with limited exceptions 10.
The sequence, start to finish
Read the plans
Check Table 12E in the final SMFP for the calendar year and in the Proposed SMFP posted around July 1. As of 2026-10-12 both show no need anywhere 23.
Choose a route
Petition for an adjusted need determination by the last July public hearing 2, wait for a county need determination, or find an existing certified agency to buy 6.
For a new agency, file the CON
Submit by 5:00 p.m. on the deadline in the need table, with the fee and three-year projections reaching at least 325 county residents in year three 257.
For an acquisition, file the exemption notice and screen the 36-month rule
Give the CON Section prior written notice 6, confirm the target’s Medicare enrollment and ownership history 17, and give DHSR 30 days’ written notice of the ownership change 10.
Complete owner training
if you have never owned or operated a home care agency 1014.
Apply for the DHSR license
Use the multi-purpose application, then pass the initial licensure survey or qualify for deemed status through accreditation 111.
Open and serve patients
Build up 10 skilled patients, 7 of them active, while holding the federal capital reserve 116.
Get Medicare certification
File the federal forms, have the CMS-855 approved, pass DHSR’s unannounced survey and wait for CMS to assign the provider number 1.
Enroll in NC Medicaid
as a Medicare-certified, DHSR-licensed home health provider and set up EVV 22.
Renew by December 31 each year
and report ownership, director or address changes before they take effect 1013.
North Carolina also uses certificate of need for new adult care home beds with 7 or more residents, so the SMFP process will look familiar if you are planning across care types.
Sources
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- 11
- 12 NC DHHS, Division of Health Service Regulation, Fee Schedules: Home Care Checked 12 Oct 2026 · Back to text ↑
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- 14 NC DHHS, Division of Health Service Regulation, Home Care Provider Training Checked 12 Oct 2026 · Back to text ↑
- 15 North Carolina General Assembly, G.S. 131E-265: criminal history record checks Checked 12 Oct 2026 · Back to text ↑
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Related guides
- North Carolina home care agency license: in-home aide and companion servicesNorth Carolina · Non-medical home care agency
- North Carolina adult care home license: certificate of need, DHSR steps and feesNorth Carolina · Assisted living facility
- North Carolina adult day care certification: county DSS study, DAAS rules and day healthNorth Carolina · Adult day care
North Carolina and neighboring states
Compare all 51| State | License | Who needs it | State fee |
|---|---|---|---|
| North Carolina (this guide) | Home Care Agency license for a Medicare/Medicaid-certified home health agency (plus certificate of need) | Medicare/Medicaid-certified agency; certificate of need required | $5,000 plus 0.3% of capital cost above $1 million, capped at $50,000, nonrefundable (G.S. 131E-182) |
| Virginia | Home Care Organization (HCO) license, home health services | Any organization sending health professionals into homes; no minimum size | $1,500 initial or renewal; $50 late renewal; $250 reissue; $75 exemption |
| Tennessee | Home Care Organization Providing Home Health Services license | Own nurses or therapists in homes; certificate of need required | $2.25 per $1,000 of project cost, $3,000 minimum, $45,000 maximum |
| Georgia | Home Health Agency license | Skilled home health; certificate of need required first | $300 application processing + $1,000 a year |
| South Carolina | Home Health Agency license | Any agency offering skilled nursing plus another home health service | $100 + $50 per county, initial and renewal |
Shortened from each state's guide and our 51-state table, as of each guide's last review. Fees are the state's own; local permits and background checks cost extra.