Starting a care business in Missouri

Any home that gives 24-hour care and protective oversight to three or more unrelated adults is a licensed facility, whatever its size. Relatives within the fourth degree do not count toward the three, and Missouri has no adult family home or adult foster home license, so a three-bed house and a large building choose between the same two licenses. The test is evacuation, not size. A residential care facility may only admit people who can reach safety on their own within five minutes of an alarm, and it needs no licensed administrator. An assisted living facility may keep residents who need minimal help to get out (more, under the ALF** designation), and its administrator must be licensed by the Missouri Board of Nursing Home Administrators. DHSS charges both $100 for 3 to 24 residents, and both rules were amended in 2026.

Before DHSS licenses either one, the applicant needs a certificate of need or a written determination from the Certificate of Need Program that none is required. A new facility costing $600,000 or more needs a full application to the Missouri Health Facilities Review Committee. A smaller project files a Letter of Intent (Form MO 580-1860) for a non-applicability letter, even if the project cost is $0. Home health agencies are outside the certificate of need law.

In-home care turns on a count of services. An agency that provides two or more of six home health services, one of them skilled nursing, in intermittent visits needs a home health agency license: $600 a year, an office outside a private residence, and the Medicare Conditions of Participation even if it never bills Medicare. DHSS says companies offering a single service, or nurse and aide shifts of four hours or more, get no license and no government oversight; state-paid homemaker, personal care and respite runs on a Medicaid contract through Missouri Medicaid Audit and Compliance (MMAC). New agencies also face a nationwide Medicare enrollment moratorium that began May 13, 2026; the Missouri license itself is not frozen.

Child care needs a DESE license once you care for more than six children, or more than three under age 2, at one address; school-age children who live in your home do not count. A family child care home takes up to 10 children. A group child care home takes up to 20 and a child care center any number, both away from the provider's living quarters and both covered in the center guide. Nursery schools, church-controlled programs and other exempt programs lose the exemption if they take state or federal child care money other than food program funds. Since July 1, 2026, DESE no longer pays for fingerprinting, and under Executive Order 25-15 it is rewriting the child care rulebooks; as of October 12, 2026 its pages did not say when new rules take effect.

Daytime care for adults is licensed separately. An adult day care program serving five or more functionally impaired adults for more than two but less than 24 hours a day needs a DHSS license; a program caring for four or fewer unrelated people is exempt. The license fee runs from $25 to $100 by capacity, and the rule has not changed since 2005. Medicaid pays through two waivers, and only after the program is licensed and each location has enrolled with MMAC, which DHSS says takes about six months on average.