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

Last reviewed: 2026-08-16

In Pennsylvania, Home Health Services provide intermittent, short-term, or ongoing skilled nursing and therapeutic care in a patient's residence under a physician-ordered plan of care. The service is strictly regulated by the Pennsylvania Department of Health (DOH) under 28 PA Code Chapter 601 and requires both state licensure and, typically, federal Medicare certification to enroll as a Medicaid provider.

The single biggest structural barrier to entry in Pennsylvania is securing network contracts with Community HealthChoices (CHC) Managed Care Organizations (MCOs). While Pennsylvania does not require a Certificate of Need (CON) to open a home health agency, enrolling in the state's PROMISe Medicaid system does not guarantee MCO network inclusion. MCOs frequently close their networks to new home health providers based on regional network adequacy, effectively blocking new agencies from serving the majority of the state's Medicaid population.

1. Service Definition and Scope

Home Health Services in Pennsylvania encompass clinical care delivered in the home on a part-time or intermittent basis. Unlike non-medical home care, these services require strict clinical oversight, a physician's order, and adherence to federal Conditions of Participation (CoPs).

Approved agencies must be staffed and equipped to provide skilled nursing care and at least one other therapeutic service to qualify for licensure under state definitions.

• Skilled Nursing: Wound care, intravenous (IV) therapy, medication administration, and chronic disease monitoring provided by RNs or LPNs.
• Physical Therapy (PT): Post-operative rehabilitation, mobility improvement, and fall prevention strategies.
• Occupational Therapy (OT): Activities of Daily Living (ADL) skill-building and adaptive equipment training.
• Speech Therapy (ST): Communication, cognitive, and swallowing therapy.
• Medical Social Services: Counseling, care coordination, and connecting patients with community resources.
• Home Health Aides: Assistance with ADLs performed under the direct, documented supervision of a registered nurse or licensed therapist.

2. Regulatory and Oversight Agencies

Oversight of home health agencies in Pennsylvania is divided among state health regulators, state human services departments, and federal authorities. Providers must maintain compliance with all three tiers to operate and bill Medicaid.

The Department of Health handles physical licensure and surveys, while the Department of Human Services manages the financial and enrollment aspects of the Medicaid program.

• Pennsylvania Department of Health (DOH) - Division of Home Health: Licenses Home Health Agencies, conducts pre-licensure inspections, and performs state surveys (https://www.pa.gov/agencies/health/facilities/out-patient-healthcare-facilities/home-health/licensure).
• Pennsylvania Department of Human Services (DHS): Manages the Medical Assistance program and the PROMISe provider enrollment system (https://www.pa.gov/agencies/dhs/resources/for-providers/promise/promise-provider-enrollment).
• Office of Long-Term Living (OLTL): A division of DHS that coordinates Medicaid-funded home health services and waivers through the Community HealthChoices (CHC) program (https://www.pa.gov/agencies/dhs/about/departments-program-offices/office-of-long-term-living).
• Centers for Medicare & Medicaid Services (CMS): Enforces federal Conditions of Participation (CoPs) under 42 CFR Part 484, which PA agencies must meet for Medicare and Medicaid certification (https://www.cms.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania explicitly does not require a Certificate of Need (CON) for home health agencies, removing a major regulatory barrier found in many other states. However, structural prerequisites still dictate market entry and operational viability.

Before an agency can successfully bill Medicaid, it must navigate federal certification prerequisites and managed care gatekeeping, which often act as de facto moratoria in saturated counties.

• Certificate of Need (CON): None required in Pennsylvania; applicants do not need to prove regional need to the DOH to obtain a license.
• Medicare Certification Prerequisite: State licensure as a home health agency is a strict prerequisite for federal Medicare certification, which is subsequently required for full Medicaid enrollment.
• MCO Network Adequacy (Closed Networks): Enrollment in PA Medicaid (PROMISe) does not guarantee a contract with Community HealthChoices (CHC) MCOs; MCOs frequently enforce closed networks based on regional adequacy, blocking new providers from receiving referrals.
• Business Registration: Applicants must be formally registered with the Pennsylvania Department of State before submitting a DOH licensure application.
• Physical Location: Agencies must maintain a physical office in Pennsylvania equipped to securely maintain patient records and coordinate clinical care.

4. Licensure and Certification Requirements

Agencies must obtain a Home Health Agency License from the PA DOH under 28 PA Code Chapter 601. The application process requires both digital submission of forms and physical mailing of fees.

Because Medicaid requires Medicare certification for home health providers, agencies must simultaneously apply for federal certification, often utilizing deemed status through an approved accrediting organization.

• State Regulation: Agencies must comply with 28 PA Code Chapter 601, which governs clinical standards, staffing, and patient rights.
• Initial Application: Providers must submit the Initial Home Health Application (PDF) via email to ra-dhhhandhosinitial@pa.gov.
• Application Fee: The required licensure fee must be physically mailed to the DOH; applications are not reviewed until the physical check is received.
• Medicare Certification Forms: Applicants must submit CMS Form 1572(a), CMS Form 690, and CMS Form 1561 directly to the PA Division of Home Health.
• Accreditation: Most new agencies achieve Medicare certification via deemed status from accrediting bodies like ACHC, CHAP, or the Joint Commission.
• Pre-Licensure Inspection: The DOH conducts an initial on-site survey to verify compliance with state regulations before issuing the formal license.

5. Medicaid Provider Enrollment

Once licensed by the DOH and certified by Medicare, providers must enroll in Pennsylvania's Medical Assistance program. This is executed through the PROMISe (Provider Reimbursement and Operations Management Information System) portal.

Enrollment in PROMISe establishes the agency's fee-for-service billing capability and is a mandatory prerequisite before an agency can apply for credentialing with any CHC MCO.

• System: The PROMISe Provider Portal is the mandatory state system for PA Medicaid enrollment and claims processing.
• Provider Type: Applicants must select the specific Home Health Agency provider type and applicable specialty codes during the PROMISe application.
• Identifiers: Enrollment requires an Employer Identification Number (EIN) and a Type 2 (Organizational) National Provider Identifier (NPI).
• Application Fee: Agencies are subject to the ACA institutional provider application fee unless they can prove the fee was already paid during Medicare enrollment.
• Service Locations: Each physical branch or service location must be enrolled separately in PROMISe with its own application.
• MCO Contracting: After PROMISe approval, providers must independently contact and contract with CHC MCOs (e.g., UPMC, Keystone First, PA Health & Wellness).

6. Staffing, Training and Background Checks

Staffing requirements for home health agencies are strictly governed by 28 PA Code Chapter 601 and federal CoPs. Agencies must ensure all clinical staff hold active Pennsylvania licenses.

Background checks are heavily scrutinized during state surveys. Pennsylvania law mandates strict criminal history clearances for any employee with direct patient contact.

• Administrator: Must be a licensed healthcare professional or possess specific, documented management experience in health care administration.
• Clinical Staff: Agencies must employ or contract with registered nurses (RNs) and therapists (PT, OT, ST) who hold active, unencumbered Pennsylvania licenses.
• Background Checks: Act 169 of 1996 (Older Adults Protective Services Act) requires PA State Police criminal history checks for all patient-facing staff before they begin work.
• FBI Clearance: An FBI criminal history check is required for any employee who has not been a Pennsylvania resident for the two consecutive years prior to employment.
• Home Health Aide Training: Aides must complete a minimum of 75 hours of training and pass a competency evaluation in accordance with federal CoPs.
• Tuberculosis (TB) Screening: Required for all direct care staff prior to initial patient contact and annually thereafter.

7. Documentation, Policies and Records

Agencies must maintain a comprehensive Policy & Procedure Manual that aligns with both PA DOH regulations and CMS Conditions of Participation. Documentation is the primary focus of state and federal surveys.

Clinical records must demonstrate continuous physician oversight and justify the medical necessity of the intermittent skilled services provided.

• Plan of Care: Agencies must maintain physician-ordered plans of care (CMS-485 or equivalent) that are reviewed and signed by the physician at least every 60 days.
• Policy Manual: Must include detailed protocols for admission/discharge criteria, infection control, emergency preparedness, and medication administration.
• Consumer Disclosure: Agencies must provide written consumer disclosure notices and patient rights documents to the patient before service initiation.
• Clinical Records: Must maintain secure, HIPAA-compliant electronic or physical charting of all visit notes, assessments, and care coordination efforts.
• Quality Assessment: Agencies must implement and document an ongoing Quality Assessment and Performance Improvement (QAPI) program as required by CMS.

8. Billing, Rates and Claims

Billing for Medicaid home health services in Pennsylvania is bifurcated. Services for managed care enrollees are billed to the respective CHC MCO, while fee-for-service claims go through the state system.

Providers must adhere to strict prior authorization rules and utilize electronic verification systems where mandated by federal law.

• Claims Portal: Fee-for-service Medicaid claims are submitted directly via the PROMISe system.
• MCO Billing: Managed care claims must be submitted to the specific CHC MCO's clearinghouse (e.g., UPMC or PA Health & Wellness).
• Prior Authorization: Most skilled therapy visits and ongoing nursing care require prior authorization from the MCO or OLTL before services are rendered.
• Electronic Visit Verification (EVV): Required for personal care and home health aide services under the 21st Century Cures Act; PA uses the DHS-provided EVV system or approved alternate vendors.
• Revalidation: Providers must revalidate their PROMISe Medicaid enrollment at least every 5 years to maintain active billing status.

9. Approval Sequence and Timeline

The end-to-end process from business formation to billing Pennsylvania Medicaid can take 6 to 12 months. The timeline is heavily dependent on Medicare certification surveys and MCO credentialing.

Providers cannot expedite the DOH licensure process, and applications are processed in the order they become fully complete, including the receipt of mailed fees.

• Business Formation: Registering the entity with the PA Department of State typically takes 1-2 weeks.
• DOH Licensure: Takes 60-90 days from the submission of a complete application to the pre-licensure inspection and license issuance.
• Medicare Certification: Achieving deemed status through an accrediting body (CHAP/ACHC) can add 3-6 months depending on survey schedules.
• PROMISe Enrollment: Processing takes 30-60 days once the application is submitted with DOH and Medicare approvals attached.
• MCO Credentialing: Contracting with CHC MCOs takes an additional 90-120 days, strictly subject to the MCO's network need and open enrollment windows.

10. Common Denials and Survey Findings

Applications and state surveys frequently fail due to administrative oversights or failure to adhere to strict clinical oversight rules. The DOH is unforgiving regarding incomplete applications.

During operations, the most common citations involve lapses in physician orders or background check violations.

• Application Rejection: Failing to physically mail the application fee to the DOH; email submissions alone are considered incomplete and will stall the process.
• Background Check Violations: Allowing staff to provide care before Act 169 background checks and FBI clearances are fully returned and cleared.
• Plan of Care Lapses: Providing services without a current, signed physician order or failing to update the plan of care every 60 days.
• Incomplete PROMISe Apps: Missing ownership disclosure forms or failing to enroll each physical service location separately in the portal.
• MCO Network Denials: Receiving rejections from CHC MCOs because the regional network is deemed adequate, preventing the agency from serving managed care patients.

11. Key Contacts and Resources

Prospective home health providers should rely on official Commonwealth of Pennsylvania resources and federal CMS guidelines to navigate the licensure and enrollment process.

Direct communication with the Division of Home Health and the PROMISe enrollment broker is essential for resolving application holds.

• PA DOH Division of Home Health: ra-dhhhandhosinitial@pa.gov | https://www.pa.gov/agencies/health/facilities/out-patient-healthcare-facilities/home-health/licensure
• PROMISe Provider Portal: https://www.pa.gov/agencies/dhs/resources/for-providers/promise/promise-provider-enrollment
• PA Department of Human Services (DHS): https://www.pa.gov/agencies/dhs
• Community HealthChoices (CHC) OLTL: https://www.pa.gov/agencies/dhs/about/departments-program-offices/office-of-long-term-living/community-healthchoices
• CMS Medicare Enrollment: https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers

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