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

Last reviewed: 2026-09-09

The California Department of Public Health (CDPH) Centralized Applications Branch (CAB) licenses Home Health Agencies (HHAs) under California Code of Regulations, Title 22, Section 74652 to deliver intermittent skilled nursing and therapy. Funding for these services is administered by the Department of Health Care Services (DHCS) through the Medi-Cal State Plan and specific Home and Community-Based Services (HCBS) waivers, such as the In-Home Operations (IHO) and Nursing Facility/Acute Hospital (NF/AH) waivers.

Approval requires securing the state license, obtaining Medicare certification via a federal survey, and subsequently enrolling through the DHCS Provider Application and Validation for Enrollment (PAVE) portal. The mandatory Medicare certification sequence dictates that applicants must first operate and treat patients to pass the initial federal survey before Medi-Cal will issue a provider number for billing.

1. Service Definition and Scope

In California, a Home Health Agency provides skilled nursing services, physical therapy, occupational therapy, speech-language pathology, and home health aide services on a part-time or intermittent basis. These services are delivered in the patient's temporary or permanent place of residence.

All care must be delivered under a physician-ordered plan of care that is reviewed and updated at least every 60 days. Entities providing or arranging for the provision of skilled nursing services must obtain an HHA license.

• Skilled Nursing: Services provided by and within the scope of practice of a registered nurse (RN) or licensed vocational nurse (LVN) under CCR Title 22 § 74652.
• Home Health Aide: Services provided by an individual defined in Health and Safety Code § 1727(c) and CCR Title 22 § 74624.
• Plan of Care: Must be established and periodically reviewed by the ordering, referring, or prescribing (ORP) physician.
• Setting: Services must be provided in the patient's home or place of residence, not in a hospital or skilled nursing facility.

2. Regulatory and Oversight Agencies

The California Department of Public Health (CDPH) is the primary regulatory body responsible for licensing HHAs and conducting certification surveys on behalf of CMS. The Centralized Applications Branch (CAB) processes the initial licensure packets.

The Department of Health Care Services (DHCS) manages the Medi-Cal program, with the Provider Enrollment Division (PED) handling the enrollment of licensed HHAs into the Medicaid system.

• California Department of Public Health (CDPH): https://www.cdph.ca.gov
• CDPH Centralized Applications Branch (CAB): https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/CAB.aspx
• Department of Health Care Services (DHCS): https://www.dhcs.ca.gov
• DHCS Provider Enrollment Division (PED): https://www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
• Provider Application and Validation for Enrollment (PAVE): https://pave.dhcs.ca.gov
• Centers for Medicare & Medicaid Services (CMS): https://www.cms.gov

3. Gatekeeping Prerequisites: Who Can Even Apply

California explicitly does not require a Certificate of Need (CON) for Home Health Agencies, meaning there are no state-imposed caps on the number of agencies that can open in a given county. However, structural prerequisites exist regarding Medicare certification.

To enroll as a standard HHA in Medi-Cal, the agency must first achieve Medicare certification. This requires the agency to obtain its initial state license, admit a minimum number of patients, and pass a federal certification survey before DHCS will process the Medi-Cal enrollment.

• Certificate of Need: Genuinely none exists; California does not utilize a CON process for Home Health Agencies.
• Medicare Certification: Required by DHCS as a precondition for standard Medi-Cal HHA enrollment.
• Initial Patient Census: Applicants must admit and provide skilled care to a minimum number of patients (typically 10) to undergo the initial Medicare certification survey.
• Capitalization: Applicants must possess sufficient operating capital to sustain the agency through the licensing, census-building, and survey phases before any Medi-Cal billing can occur.

4. Licensure and Certification Requirements

Prospective HHAs must submit a comprehensive Initial Application Packet to the CDPH Centralized Applications Branch. This packet includes detailed organizational, financial, and operational disclosures.

Once the application is deemed complete, CDPH will issue an initial license, allowing the agency to begin operations and prepare for the certification survey.

• Application Form: Form HS 200 (Licensure and Certification Application).
• Designee Form: Form CDPH 328 (Notice of Designee).
• Administrative Organization: Form HS 309 (Administrative Organization and Organizational Structure).
• Fire Clearance: Form STD 850 (Fire Safety Inspection Request) required for the administrative office location.

5. Medicaid Provider Enrollment

After obtaining the CDPH license and Medicare certification, the HHA must enroll in Medi-Cal through the DHCS Provider Application and Validation for Enrollment (PAVE) portal. PAVE is the mandatory electronic system for fee-for-service enrollment.

Pursuant to W&I Code § 14043.26(a), all ordering, referring, and prescribing (ORP) physicians associated with the HHA's plans of care must also be enrolled in Medi-Cal.

• Enrollment Portal: PAVE (Provider Application and Validation for Enrollment).
• NPI Requirement: The agency must obtain a Type 2 National Provider Identifier (NPI) from NPPES prior to applying.
• Application Fee: Providers must pay the Medi-Cal application fee (aligned with the CMS institutional fee) unless proof of payment to Medicare or another state's Medicaid program is provided.
• ORP Enrollment: Physicians ordering home health services must be actively enrolled in Medi-Cal as participating or ORP providers.

6. Staffing, Training and Background Checks

California imposes strict qualification standards for HHA leadership and clinical staff. The agency must designate qualified individuals for key administrative and clinical oversight roles.

All owners, administrators, and key personnel must undergo criminal background checks prior to licensure.

• Administrator: Must be a licensed physician, RN, or an individual with at least one year of supervisory or administrative experience in home health care or a related health program.
• Director of Patient Care Services (DPCS): Must be a Registered Nurse (RN) with at least one year of experience in an HHA or related community health program.
• Home Health Aides: Must hold a valid Home Health Aide certificate issued by CDPH.
• Background Checks: Department of Justice (DOJ) Live Scan fingerprinting is required for all owners with a 5% or greater interest and the Administrator.

7. Documentation, Policies and Records

HHAs must maintain comprehensive clinical records for every patient, documenting all assessments, interventions, and physician orders. Policies must align with both state Title 22 regulations and federal Conditions of Participation.

Agencies are also required to maintain robust emergency preparedness plans and collect standardized patient assessment data.

• Plan of Care: The CMS-485 form or equivalent must be used to document the physician-ordered plan of care.
• Clinical Records: Must be retained for a minimum of seven years following the patient's discharge.
• OASIS Data: Agencies must collect and transmit the Outcome and Assessment Information Set (OASIS) for adult patients as required by CMS.
• Emergency Preparedness: Must maintain a comprehensive emergency preparedness program in compliance with CMS Appendix Z.

8. Billing, Rates and Claims

Medi-Cal fee-for-service claims are processed by the California MMIS Fiscal Intermediary. Services provided under HCBS waivers require prior authorization.

Providers must ensure that all billed services match the approved authorization and the physician's plan of care.

• Prior Authorization: A Treatment Authorization Request (TAR) is required for HCBS waiver services, generating an 11-digit TAR number for the claim.
• Claim Format: Institutional claims are submitted using the UB-04 claim form or the 837I electronic equivalent.
• Fiscal Intermediary: Claims are submitted to and processed by the California MMIS Fiscal Intermediary.
• Rate Publication: Medi-Cal fee-for-service rates are published and updated on the Medi-Cal Provider Portal rate tables.

9. Approval Sequence and Timeline

The pathway to becoming a fully billing Medi-Cal HHA is a multi-stage process that spans several months to over a year, depending on survey readiness and application volumes.

Agencies must sequence their applications carefully, as Medi-Cal enrollment cannot be finalized until the CDPH license and Medicare certification are secured.

• Step 1: Submit the Initial Application Packet to CDPH CAB (review typically takes 3-6 months).
• Step 2: Receive initial state license and begin admitting patients to build the required census.
• Step 3: Undergo the initial Medicare certification survey conducted by CDPH or an approved Accreditation Organization (AO).
• Step 4: Submit the Medi-Cal enrollment application via the PAVE portal (DHCS PED processing can take 90-180 days).

10. Common Denials and Survey Findings

Licensure applications are frequently delayed due to incomplete forms or missing background check clearances. During surveys, deficiencies often center on clinical documentation and supervision.

Failure to adhere strictly to the physician's orders is a primary cause for both survey citations and claim denials.

• Care Plan Deviations: Providing services at a frequency or duration that differs from the physician-signed plan of care.
• Incomplete Background Checks: Owners or administrators failing to complete Live Scan fingerprinting prior to submitting the application.
• Inadequate Supervision: RNs failing to conduct and document the required on-site supervisory visits for Home Health Aides every 14 days.
• OASIS Inaccuracies: Failure to accurately complete or timely transmit OASIS assessments to the state repository.

11. Key Contacts and Resources

Providers should rely on official state portals and manuals for the most current forms, regulations, and billing instructions.

The CDPH and DHCS websites provide the authoritative guidance for licensure and Medi-Cal enrollment.

• CDPH HHA Initial Application Packet: https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AppPacket/HHA-Initial.aspx
• DHCS Provider Enrollment Division: https://www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
• Medi-Cal PAVE Portal: https://pave.dhcs.ca.gov
• Medi-Cal Provider Manual (HCBS): https://mcweb.apps.prd.cammis.medi-cal.ca.gov

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