Florida - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The Florida Agency for Health Care Administration (AHCA) licenses providers of in-home RN and LPN care as Home Health Agencies under Chapter 400, Part III, Florida Statutes, and funds these services primarily through the Statewide Medicaid Managed Care (SMMC) Long-Term Care (LTC) program. Florida does not issue a standalone "Skilled Nursing Services" license; instead, agencies must obtain a standard Home Health Agency license to deliver skilled nursing, physical therapy, and home health aide services.

Approval to bill Florida Medicaid for skilled nursing requires securing active network contracts with the specific Managed Care Organizations (MCOs) awarded SMMC contracts in the provider's AHCA region. Because Florida operates a nearly universal managed care system for Medicaid long-term care, an agency holding a valid license and an active Medicaid provider ID cannot be reimbursed for services unless it successfully negotiates a contract and completes credentialing with the recipient's assigned health plan.

1. Service Definition and Scope

In Florida's SMMC LTC program, skilled nursing is defined as Intermittent and Skilled Nursing or Private Duty Nursing delivered in the recipient's home or community setting. These services must be ordered by a physician and provided by a Florida-licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) under the direction of an RN.

The scope of practice is governed by the Florida Nurse Practice Act (Chapter 464, F.S.) and includes comprehensive assessments, medication administration, wound care, tube feedings, and other skilled treatments that exceed the scope of a home health aide or personal care assistant.

• Service Name: Intermittent and Skilled Nursing (under SMMC LTC).
• Provider Type: Home Health Agency (HHA) or Nurse Registry.
• Prescription Requirement: Services must be ordered by a Florida-licensed physician, advanced practice registered nurse (APRN), or physician assistant (PA).
• RN Duties: Initial assessment, care plan development, complex skilled treatments, and supervision of LPNs and aides.
• LPN Duties: Routine skilled nursing tasks, medication administration, and patient monitoring under RN supervision.
• Setting: Delivered in the recipient's private residence or an approved community-based setting, excluding inpatient facilities.

2. Regulatory and Oversight Agencies

The Florida Agency for Health Care Administration (AHCA) is the single state agency responsible for both facility licensure and Medicaid administration. AHCA's Division of Health Quality Assurance (HQA) handles the licensure and surveying of Home Health Agencies.

The AHCA Division of Medicaid oversees the Statewide Medicaid Managed Care (SMMC) program, while the actual day-to-day authorization and payment of skilled nursing services are managed by the contracted MCOs operating in Florida's 11 Medicaid regions.

• Licensing Authority: AHCA Division of Health Quality Assurance (https://ahca.myflorida.com/health-quality-assurance).
• Medicaid Authority: AHCA Division of Medicaid (https://ahca.myflorida.com/medicaid).
• Managed Care Oversight: Statewide Medicaid Managed Care (SMMC) Program (https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care).
• Enrollment Portal: Florida Medicaid Management Information System (FLMMIS) (https://portal.flmmis.com/FLPublic).
• Background Screening: Care Provider Background Screening Clearinghouse (https://apps.ahca.myflorida.com/SingleSignOnPortal).

3. Gatekeeping Prerequisites: Who Can Even Apply

Florida requires all entities providing skilled nursing to first obtain a Home Health Agency license from AHCA HQA before applying for Medicaid enrollment. Florida does not require a Certificate of Need (CON) for standard Home Health Agencies, meaning the market is open to new applicants who meet the financial and structural requirements.

To participate in Medicaid, the agency must navigate the SMMC closed network system. Medicaid enrollment itself does not guarantee patient volume; the agency must secure a contract with at least one SMMC health plan in their region, and plans may close their networks if they determine they have adequate capacity.

• Licensure Prerequisite: Must hold an active, unencumbered Florida Home Health Agency license under Chapter 400, Part III, F.S.
• Managed Care Contracting: Must secure a network agreement with an SMMC MCO (e.g., Sunshine Health, Humana, Simply Healthcare) to receive authorizations and payments.
• Director of Nursing (DON): Must employ a Florida-licensed RN with at least one year of supervisory experience as the DON prior to licensure.
• Financial Viability: Must submit proof of financial ability to operate (PFA) during the initial licensure process, demonstrating sufficient funds to operate for the first year.
• Accreditation/Medicare Certification: While not strictly required for basic licensure, many SMMC plans require Joint Commission, ACHC, or CHAP accreditation, or Medicare certification, for network inclusion.

4. Licensure and Certification Requirements

Home Health Agency licensure is processed entirely through the AHCA Online Licensing System. Applicants must submit AHCA Form 3110-1011, along with comprehensive policies, personnel records, and financial disclosures.

Agencies are subject to an initial unannounced survey by AHCA field office staff to verify compliance with Rule 59A-8, Florida Administrative Code, before the license is issued.

• Application Form: AHCA Form 3110-1011 (Home Health Agency Licensure Application).
• Submission Method: Mandatory electronic submission via the AHCA Online Licensing System.
• Licensure Fee: $1,705 biennial licensure fee, plus a $300 biennial assessment for the Health Care Trust Fund.
• Governing Regulation: Rule 59A-8, Florida Administrative Code (F.A.C.).
• Initial Survey: An on-site inspection by AHCA to verify the physical office, patient records system, and administrative compliance.
• Administrator Qualifications: Must be a licensed physician, RN, or individual with at least one year of supervisory experience in health care.

5. Medicaid Provider Enrollment

Once licensed, the agency must enroll in Florida Medicaid via the FLMMIS portal. Home Health Agencies enroll under Provider Type 65.

Florida enforces a strict 21-day deficiency window for Medicaid applications. If an application is submitted with missing or incorrect information, the provider has exactly 21 days to correct it upon notification, or the application is denied and the process must restart.

• Enrollment Portal: FLMMIS Provider Services (https://portal.flmmis.com/FLPublic).
• Provider Type: Type 65 (Home Health Agency).
• Risk Category: Home Health Agencies are typically categorized as High Risk, requiring fingerprint-based criminal background checks and site visits.
• Application Fee: Must pay the federal Medicaid application fee (approx. $709 for 2024) unless already paid to Medicare.
• Deficiency Window: 21 days to correct any application errors after AHCA notification.
• Processing Time: AHCA processes complete applications in 60 days or less.

6. Staffing, Training and Background Checks

All personnel with direct patient contact must clear a Level 2 background screening through the AHCA Care Provider Background Screening Clearinghouse prior to employment. This includes fingerprinting and a search of state and national criminal databases.

Clinical staff must hold active, unencumbered Florida licenses. The agency must maintain detailed personnel files proving ongoing compliance with continuing education and CPR requirements.

• Background Screening: Level 2 screening via the AHCA Clearinghouse is mandatory for all patient-facing staff and owners.
• Director of Nursing: Must be a Florida-licensed RN with at least 1 year of supervisory experience.
• Nursing Staff: RNs and LPNs must hold active licenses from the Florida Board of Nursing.
• CPR Certification: All clinical staff must maintain current CPR certification.
• In-Service Training: Agencies must provide and document ongoing in-service training specific to the needs of the LTC population.
• Employee Verification: Must verify licenses through the Florida Department of Health portal prior to hire and upon renewal.

7. Documentation, Policies and Records

Florida Rule 59A-8 dictates strict clinical and administrative record-keeping standards. Every patient must have a comprehensive Plan of Care signed by a physician, updated at least every 60 days.

Agencies must also maintain a Comprehensive Emergency Management Plan (CEMP) approved by the local county emergency management agency, detailing how patients will be cared for during hurricanes or other disasters.

• Plan of Care: Must be established by the physician and RN, and reviewed/signed by the physician every 60 days (CMS-485 or equivalent).
• Clinical Notes: Must be written and incorporated into the patient's record within 7 days of the visit.
• CEMP: Comprehensive Emergency Management Plan must be updated annually and approved by the county.
• Quality Assurance: Must maintain a continuous quality assurance program reviewing at least 10% of active records quarterly.
• Record Retention: Clinical records must be retained for at least 5 years following the patient's discharge.
• Electronic Visit Verification (EVV): Must utilize an AHCA-compliant EVV system to document the exact time and location of in-home service delivery.

8. Billing, Rates and Claims

Because skilled nursing is delivered through the SMMC program, providers do not bill AHCA directly for most services. Instead, claims are submitted to the specific MCO that authorized the care.

Rates are not strictly fixed by the state; they are negotiated between the Home Health Agency and the MCO, though they generally align with the Florida Medicaid fee schedule baseline. Providers must use standard HCPCS codes and comply with EVV mandates to ensure claim payment.

• Billing Entity: Claims are submitted to the SMMC Managed Care Organization (e.g., Humana, Sunshine Health), not FLMMIS.
• Procedure Codes: Typically billed using HCPCS codes such as G0299 (RN services) and G0300 (LPN services), or T1002/T1003 for Private Duty Nursing.
• Rate Setting: Rates are negotiated directly with the MCOs during the contracting phase.
• Prior Authorization: All skilled nursing visits must be prior-authorized by the MCO based on the physician's order.
• EVV Requirement: Claims will be denied if not supported by matching Electronic Visit Verification data.
• Timely Filing: Dictated by the MCO contract, typically ranging from 90 to 180 days from the date of service.

9. Approval Sequence and Timeline

Becoming a fully operational, billing provider is a sequential process that typically takes 6 to 9 months. The agency must first secure its physical location, hire a DON, and pass the AHCA HQA licensure process.

Only after the license is in hand can the agency enroll in FLMMIS. Once the Medicaid ID is issued, the agency begins the lengthy process of credentialing and contracting with regional SMMC plans.

• Step 1: Entity Formation and Local Approvals (2-4 weeks).
• Step 2: AHCA HQA Licensure Application and Initial Survey (60-90 days).
• Step 3: FLMMIS Medicaid Enrollment (up to 60 days).
• Step 4: SMMC MCO Credentialing and Contracting (90-120 days).
• Step 5: EVV System Integration and Training (concurrent with MCO contracting).
• Step 6: Receipt of first MCO authorizations and commencement of billable services.

10. Common Denials and Survey Findings

Licensure applications are frequently delayed or denied due to incomplete financial projections or failure of the DON to meet the strict one-year supervisory experience requirement. During initial surveys, AHCA inspectors heavily scrutinize personnel files and the physical office setup.

On the Medicaid enrollment side, the most common reason for denial is missing the 21-day deficiency window. Providers who fail to upload a requested document within this exact timeframe must restart the entire FLMMIS application.

• DON Qualifications: Rejection due to inability to prove the Director of Nursing has one full year of supervisory experience.
• Deficiency Window: FLMMIS application denial for missing the 21-day deadline to correct errors.
• Background Screening: Citations for allowing staff to begin training or work before the Level 2 Clearinghouse result is "Eligible".
• CEMP Rejection: Failure to secure county approval for the Comprehensive Emergency Management Plan prior to survey.
• Financial Proof: Licensure denial due to inadequate Proof of Financial Ability to Operate (PFA) documentation.
• MCO Closed Networks: Inability to secure patients because regional MCOs declare their home health networks adequate and refuse new contracts.

11. Key Contacts and Resources

Providers should rely on the official AHCA portals for all regulatory and enrollment activities. The AHCA Health Quality Assurance page contains all current licensure forms and survey guidelines.

For Medicaid enrollment and managed care information, the FLMMIS portal and the SMMC program pages are the authoritative sources for policy updates and health plan contact information.

• AHCA Health Quality Assurance: https://ahca.myflorida.com/health-quality-assurance
• AHCA Online Licensing System: https://apps.ahca.myflorida.com/SingleSignOnPortal
• FLMMIS Provider Portal: https://portal.flmmis.com/FLPublic
• SMMC Program Information: https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care
• Florida Board of Nursing: https://floridasnursing.gov
• Background Screening Clearinghouse: https://apps.ahca.myflorida.com/SingleSignOnPortal

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