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

Last reviewed: 2026-09-09

The Hawaii State Department of Health (DOH), Office of Health Care Assurance (OHCA) licenses Home Health Agencies under Hawaii Administrative Rules (HAR) Title 11, Chapter 97 to provide intermittent skilled nursing and therapeutic services. Agencies seeking to serve Medicaid beneficiaries enroll as institutional providers through the Department of Human Services (DHS) Med-QUEST Division.

Before submitting a licensure application to OHCA, prospective providers must obtain an approved Certificate of Need (CON) from the State Health Planning and Development Agency (SHPDA). This statutory requirement mandates a public hearing process to prove community need before any state license or federal certification application can be accepted.

1. Service Definition and Scope

In Hawaii, a home health agency is defined as a public, proprietary, or private nonprofit organization primarily engaged in providing skilled nursing and therapeutic services to homebound patients.

The requirement for licensure is based on meeting the definition of the service, regardless of the source of reimbursement or the volume of clients served.

• Definition: Direct or indirect skilled nursing services and other therapeutic services under a physician's direction on a part-time or intermittent basis.
• Therapeutic Services: Includes physical, occupational, and speech therapy, as well as medical social services.
• Setting: Services must be provided in a place used as the individual's home.
• Service Delineation: Agencies providing both home health and home care services must clearly delineate the separate clientele, especially for Medicare billing.

2. Regulatory and Oversight Agencies

Oversight of Home Health Agencies in Hawaii is divided between health planning, facility licensing, and Medicaid financing divisions.

Providers must interact with multiple state departments to achieve full operational and billing status.

• Licensing Agency: Hawaii Department of Health, Office of Health Care Assurance (OHCA) (https://health.hawaii.gov/ohca)
• Health Planning Authority: State Health Planning and Development Agency (SHPDA) (https://health.hawaii.gov/shpda)
• Medicaid Authority: Department of Human Services, Med-QUEST Division (MQD) (https://medquest.hawaii.gov)
• Waiver Operating Agency: DOH Developmental Disabilities Division (DDD) (https://health.hawaii.gov/ddd)

3. Gatekeeping Prerequisites: Who Can Even Apply

Hawaii enforces strict health planning laws that block new home health agencies from opening without state approval of need.

An applicant cannot simply submit a license application to OHCA; they must first clear the SHPDA health planning process.

• Certificate of Need (CON): Required from SHPDA before OHCA will accept a licensure application for Medicare/Medicaid participation.
• CON Public Hearing: The CON approval involves a formal public hearing process to prove community need and financial feasibility.
• SHPDA Exemption Letter: If an applicant is strictly private pay and not pursuing federal certification, they must still obtain a formal letter from SHPDA indicating no CON is necessary.
• Business Registration: Must be a registered business in the State of Hawaii through the Department of Commerce and Consumer Affairs (DCCA).

4. Licensure and Certification Requirements

Once the CON prerequisite is met, agencies apply for a state license through OHCA, which also conducts Medicare certification surveys on behalf of CMS.

Operating without a valid Chapter 97 license subjects an agency to civil money penalties and cease-and-desist orders.

• Regulation: Governed by Hawaii Administrative Rules (HAR) Title 11, Chapter 97.
• Application Submission: Written request submitted to OHCA at 601 Kamokila Boulevard, Room 395, Kapolei, Hawaii 96707.
• Required Documents: Must submit the SHPDA CON approval (or exemption letter), legal name, tax ID, DBA, and physical location details.
• Initial Survey: OHCA schedules an initial onsite survey after reviewing submitted policies; due to contractual obligations, scheduling may take several months.

5. Medicaid Provider Enrollment

Medicaid enrollment is managed by the Med-QUEST Division (MQD) in accordance with Affordable Care Act screening requirements.

Home Health Agencies are classified as institutional providers and are subject to specific fees and site visits.

• Application Form: DHS 1139 Medicaid Provider Application, required initially and every five years.
• Application Fee: $500 fee collected from institutional providers, including HCBS providers.
• Risk Screening: Providers are screened at high, moderate, or limited risk levels under 42 CFR Part 455.
• Site Visit: MQD conducts on-site visits for high and moderate risk providers to verify DHS 1139 accuracy.

6. Staffing, Training and Background Checks

Agencies must employ qualified personnel and ensure all staff and owners pass comprehensive state and federal background checks.

Med-QUEST imposes strict background screening requirements for agency owners.

• Administrator: Must designate an administrator responsible for the organization's daily operations.
• Background System: Checks are processed through the Hawaii Background Check System (HI-BCS).
• Fingerprinting: High-risk Medicaid providers require fingerprint-based criminal background checks for anyone with 5% or more ownership.
• Clearances: Fitness determinations include Adult Protective Services (APS) and Child Abuse and Neglect (CAN) screenings.

7. Documentation, Policies and Records

OHCA requires a comprehensive review of agency policies and procedures before scheduling the initial licensing survey.

These documents are reviewed off-site and returned during the on-site inspection.

• Policy Manuals: Must include Governing Body, Personnel, Patient Care, Emergency and Disaster Plan, and Infection Control.
• Program Evaluation: An Overall Facility Program Evaluation Plan must be submitted.
• Contracts: Copies of contracts for any services not provided through salaried employees must be provided.
• Operating Hours: A formal copy of the agency's days and hours of operation is required.

8. Billing, Rates and Claims

Home health services are billed to Med-QUEST contracted managed care plans or directly to the state for fee-for-service populations.

Agencies must maintain proper state tax licensing to receive Medicaid disbursements.

• Tax Requirement: Must possess a General Excise Tax (GET) license from the Hawaii Department of Taxation.
• Reimbursement Basis: Licensure and billing eligibility are based on meeting the service definition, not the frequency of visits.
• Managed Care: Most Medicaid claims are processed through Med-QUEST contracted health plans rather than the state MMIS.
• Medicare/Medicaid Delineation: Agencies must separate home health and home care services for accurate Medicare and Medicaid billing.

9. Approval Sequence and Timeline

The approval process in Hawaii is strictly sequential, beginning with health planning and ending with Medicaid enrollment.

Delays at the CON or initial survey stages can significantly extend the timeline.

• Step 1: Obtain CON approval or a formal exemption letter from SHPDA.
• Step 2: Submit a written licensure request and policy manuals to OHCA.
• Step 3: OHCA conducts a document review and schedules the initial onsite survey (often delayed by several months).
• Step 4: Submit the DHS 1139 application and $500 fee to Med-QUEST for Medicaid enrollment.

10. Common Denials and Survey Findings

Applications are most frequently blocked at the health planning stage or delayed due to incomplete policy submissions.

Failure to maintain continuous compliance results in severe state sanctions.

• CON Denial: Inability to prove community need during the SHPDA public hearing process blocks the application entirely.
• Unlicensed Operation: Operating without a Chapter 97 license results in cease and desist orders and civil money penalties.
• Policy Deficiencies: Incomplete manuals for Infection Control or Emergency Plans delay the OHCA survey scheduling.
• Background Check Failures: Owners failing the APS, CAN, or fingerprint screenings result in Med-QUEST enrollment denial.

11. Key Contacts and Resources

Prospective providers should consult the official state division websites for the most current forms, fee schedules, and rule chapters.

Direct communication with SHPDA and OHCA is required before initiating any application.

• OHCA Medicare Section: https://health.hawaii.gov/ohca/home/medicare-section/
• SHPDA (Certificate of Need): https://health.hawaii.gov/shpda
• Med-QUEST Provider Enrollment: https://medquest.hawaii.gov
• Hawaii Administrative Rules Chapter 97: https://health.hawaii.gov/opppd/files/2015/06/11-97.pdf

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