Ins & Outs of Medicare Certification for Your Home Health Agency
Becoming a Medicare-certified home health agency (HHA) opens the door to serving a wider range of patients and securing reimbursement for covered home health services. However, the path to certification requires traversing a structured process with specific federal and state requirements. Let’s review the steps to obtaining Medicare certification for your home health agency.
Understand What Medicare Certification Means
Medicare certification is the process through which a home health agency is approved by the Centers for Medicare & Medicaid Services (CMS) to provide and bill for services covered under the Medicare Home Health Benefit. Certification ensures your agency meets the federal Conditions of Participation (CoPs), which govern patient rights, quality of care, documentation, clinical coordination, and administrative operations. Without certification, an agency cannot bill Medicare—even if it provides eligible services.
Prepare and Incorporate Your Agency
Before applying, the agency must be established as a legal business entity in your state. This typically involves:
- Registering your business name and structure (LLC, corporation, etc.)
- Obtaining a National Provider Identifier (NPI)
- Setting up business bank accounts and liability insurance
- Establishing a physical office location that meets state home health regulations
Obtain State Licensure
Most states require home health licensure before an agency can begin operations or apply for Medicare certification. Requirements vary but usually include:
- Submission of an application and licensing fee
- Proof of ownership and management structure
- Criminal background checks for owners and administrators
- Policy and procedure review
- Site inspection
Some states operate under deemed status agreements, where state approval is required before moving forward with CMS.
Develop and Implement Policies and Procedures
Your agency must have comprehensive policies that comply with CMS Conditions of Participation (42 CFR Part 484). These policies cover:
- Patient rights and responsibilities
- Admission and discharge criteria
- Skilled services (nursing, therapy, aide)
- Quality assessment and performance improvement (QAPI)
- Infection control and emergency preparedness
- Clinical documentation standards
Internal systems for scheduling, billing, and compliance should also be established.
Hire Qualified Staff and Begin Operations
Before applying for certification, your agency must be fully operational and have:
- A qualified administrator and clinical director (RN)
- Staff capable of providing skilled nursing and therapy services
- A functional clinical documentation system
- At least one active patient receiving skilled home health care under your supervision (required for the survey process)
Apply for Medicare Certification
You will complete and submit the following forms to your Medicare Administrative Contractor (MAC):
- CMS-855A: Medicare enrollment application
- CMS-1561: Health Insurance Benefit Agreement
- CMS-417: Home Health Agency Request for Certification
Once submitted, your MAC forwards the application to the state survey agency, which will follow up to schedule a Medicare survey.
Pass the State Survey
The initial certification survey is a detailed onsite review to ensure your agency complies with all federal CoPs. Surveyors will:
- Review patient records and policies
- Observe staff performing care
- Evaluate your QAPI and infection control programs
- Verify clinical coordination and documentation accuracy
If deficiencies are found, a Plan of Correction (POC) must be submitted and accepted before CMS moves to grant certification.
Receive CMS Approval and Provider Number
Once your agency passes the survey, CMS will issue a Medicare provider number and effective date. The agency can now bill Medicare for eligible home health services under the Home Health Prospective Payment System (HH PPS) or PDGM model.
Maintain Compliance
Certification is not a one-time event—ongoing compliance is critical. Agencies must:
- Participate in reaccreditation or state surveys
- Maintain up-to-date QAPI programs
- Stay compliant with all CoPs and billing regulations
- Keep staff training and credentials current
Obtaining Medicare certification for your home health agency is a detailed and regulated process, but it ensures your organization is equipped to deliver high-quality, compliant care to patients in need. With proper planning, strong leadership, and adherence to CMS standards, your agency can achieve certification and build a sustainable, trusted presence in the home health industry.
We can help. If your agency is in the process of or interested in obtaining Medicare Certification Proactive is here to assist! Contact us today to learn more.
Written By:
Nichole McClain, RN
Principal Consultant of Home Health Services
Proactive Medical Review
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