Alabama - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The Alabama State Health Planning and Development Agency (SHPDA) controls the expansion of Home Health Services through a strict Certificate of Need (CON) process governed by Ala. Admin. Code r. 410-2-4-.07, which dictates that no more than one new application may be approved in any county showing a statistical need.

Because Alabama explicitly does not issue a state-level operating license for home health agencies, providers must obtain Medicare certification through the Alabama Department of Public Health (ADPH) after securing their CON. Once certified, agencies enroll in the Alabama Medicaid program via the Gainwell Technologies web portal, submitting mandatory Electronic Visit Verification (EVV) attestations to bill for intermittent skilled nursing and therapy.

1. Service Definition and Scope

In Alabama, Home Health Services are defined under Ala. Admin. Code r. 410-2-4-.07 as intermittent skilled nursing and therapeutic services provided in a patient's residence. Services are designed to promote, maintain, or restore health, or maximize independence.

Care is planned and coordinated through centralized professional case management and must be based on an objective patient assessment. Emergency services are explicitly excluded from the scope of home health providers.

• Duration Limit: Each home health visit must be less than four hours in duration.
• Physician Authorization: Any visit made or procedure performed must only be upon a physician's written order.
• Required Services: Providers must offer at least skilled nursing care, personal care, physical therapy, speech therapy, medical social services, and medical supplies.
• Availability: Visits must be scheduled on an intermittent basis and available seven days a week, including weekend and evening provisions.

2. Regulatory and Oversight Agencies

Because Alabama does not have a distinct state licensure category for home health agencies, oversight is divided among health planning, federal certification, and Medicaid enrollment authorities.

SHPDA manages market entry, ADPH ensures clinical quality via federal standards, and the Medicaid Agency handles billing and provider agreements.

• State Health Planning and Development Agency (SHPDA): Administers the Certificate of Need (CON) process and determines county-level need (http://shpda.alabama.gov).
• Alabama Department of Public Health (ADPH): Conducts Medicare certification surveys in the absence of state licensure (https://www.alabamapublichealth.gov).
• Alabama Medicaid Agency: Sets coverage policy and oversees the Medicaid program (https://medicaid.alabama.gov).
• Gainwell Technologies: Operates the Alabama Medicaid Interactive Web Portal for provider enrollment and claims processing (https://medicaidhcp.alabamaservices.org).

3. Gatekeeping Prerequisites: Who Can Even Apply

The Certificate of Need (CON) is the absolute structural precondition for establishing a home health agency in Alabama. SHPDA calculates need using a specific formula for Additional Persons Projected to Need Service (APNS).

If the APNS formula yields a result of 99 or less for a given county, no need is shown, and SHPDA will not approve any additional home health providers for that geographic area.

• Certificate of Need (CON): Mandatory approval from SHPDA required before an agency can be established or certified.
• County Need Determination: SHPDA must identify a statistical need (APNS of 100 or greater) in a specific county before an application can be approved.
• Approval Limits: No more than one application may be approved in any county showing a need during a SHPDA approval cycle.
• New Provider Moratorium: When a new provider is approved, they have 18 months to meet the identified need before any new provider may apply for a CON in that county.

4. Licensure and Certification Requirements

Ala. Admin. Code r. 410-2-4-.07(1)(b) states plainly: "There is no licensure requirement for home health agencies in Alabama." Consequently, providers rely on Medicare certification to demonstrate operational competency.

Agencies must undergo a federal certification survey conducted by ADPH to participate in Medicare and Medicaid.

• State Licensure Exemption: Alabama explicitly does not issue state licenses for home health agencies.
• Medicare Certification: Required as the primary standard of operational approval, surveyed by ADPH.
• Contiguous County Rule: Section 22-21-265 allows an existing agency to accept referrals from a county contiguous to the county where it holds CON authority.
• Charity Care Commitment: SHPDA gives favorable CON consideration to applicants agreeing to achieve the statewide average for Charity Care plus Self Pay (minimum 1%).

5. Medicaid Provider Enrollment

Once CON-approved and Medicare-certified, agencies enroll in Alabama Medicaid through the Gainwell Technologies Interactive Web Portal. Enrollment requires compliance with federal electronic visit tracking mandates.

Providers must complete specific attestations and pay applicable institutional application fees during the initial enrollment and revalidation cycles.

• Enrollment Portal: Applications must be submitted electronically via the Gainwell Technologies Web Portal.
• EVV Attestation: Effective January 1, 2024, all Home Health providers must submit an Electronic Visit Verification (EVV) attestation form during enrollment.
• Application Fee: Institutional providers are required to submit a federal application fee unless they have already paid it to Medicare or another state's Medicaid program.
• Revalidation: Providers are subject to periodic revalidation cycles (e.g., the 2026 Off-Cycle Revalidation) managed through the secure portal.

6. Staffing, Training and Background Checks

Staffing qualifications default to Medicare Conditions of Participation due to the lack of state licensure rules. Care must be delivered by qualified professionals under physician direction.

Medicaid enrollment requires background screening for agency owners and managing employees.

• Multidisciplinary Team: Services must be coordinated by a multidisciplinary team or a single qualified health professional.
• Physician Oversight: All care must be delivered under a plan of treatment certified by a physician.
• Background Checks: Fingerprint-based criminal background checks are required for non-criminal justice applicants during the Medicaid enrollment process.
• DEA Registration: Prescribing providers associated with the agency must upload their DEA Registration Certificate to the Medicaid portal.

7. Documentation, Policies and Records

Agencies must maintain comprehensive clinical and administrative records to satisfy Medicare certification standards and Medicaid EVV requirements.

Quality assurance mechanisms are mandated by SHPDA planning policies to ensure patient concerns are addressed.

• Plan of Treatment: Must be written, physician-certified, and detail all appropriate service components.
• Objective Patient Assessment: Services must be justified based on an objective assessment administered by a health professional.
• Quality Assurance: Providers must establish procedures for resolving concerns identified by patients, physicians, or families.
• EVV Compliance Records: Agencies must electronically document visit start and end times to comply with the CMS mandate.

8. Billing, Rates and Claims

Home health claims are processed through the Alabama Medicaid Management Information System (AMMIS). Claims must align with EVV data to be paid.

Providers must also report financial data to SHPDA to maintain their CON standing.

• Claims System: Billed via the AMMIS web portal managed by Gainwell Technologies.
• EVV Integration: Claims for home health services will deny if not supported by compliant Electronic Visit Verification data.
• Visit Definition: Billed visits must strictly adhere to the regulatory definition of being less than four hours in duration.
• Charity Care Reporting: Providers must report Charity Care and Self Pay data to SHPDA (Report HH-11) to demonstrate compliance with CON commitments.

9. Approval Sequence and Timeline

The approval process is strictly sequential, beginning with health planning approval before any clinical certification can occur.

Providers cannot enroll in Medicaid until both SHPDA and ADPH processes are complete.

• Step 1: Verify county need via SHPDA's annual inventory of existing resources and APNS calculations.
• Step 2: Submit a Certificate of Need application to SHPDA and undergo the review and intervention process.
• Step 3: Obtain a Medicare certification survey through ADPH.
• Step 4: Submit the Medicaid enrollment application and EVV attestation via the Gainwell portal.

10. Common Denials and Survey Findings

Market entry is most frequently denied at the CON stage due to a lack of statistical need or opposition from existing providers.

Medicaid enrollment delays often stem from missing mandatory federal attestations.

• CON Denial: Applying in a county where the APNS formula yields 99 or less (no need shown).
• 18-Month Rule Violation: Applying in a county where a new provider was approved less than 18 months prior.
• EVV Attestation Missing: Medicaid enrollment rejected for failing to include the mandatory EVV compliance form.
• Incomplete Survey Data: CON applications deemed incomplete if the applicant fails to submit requested survey information to SHPDA prior to the application date.

11. Key Contacts and Resources

Prospective providers must coordinate with SHPDA for market entry, ADPH for certification, and Gainwell Technologies for Medicaid billing.

Official portals and agency websites are the primary sources for current forms and need projections.

• State Health Planning and Development Agency (SHPDA): Administers the CON process (http://shpda.alabama.gov).
• Alabama Department of Public Health (ADPH): Handles Medicare certification surveys (https://www.alabamapublichealth.gov).
• Alabama Medicaid Provider Enrollment: Managed by Gainwell Technologies, (888) 223-3630 (https://medicaid.alabama.gov).
• Medicaid Interactive Web Portal: For electronic applications and claims submission (https://medicaidhcp.alabamaservices.org).

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