How to Start a Home Health Agency in Texas (2026)

Texas licenses home health agencies as home and community support services agencies (HCSSAs), the same license that covers hospice and personal assistance services. Texas Health and Human Services issues it, and the application runs through an online portal called TULIP. Medicare is a second, separate step. As of October 26, 2026, that step is closed.

A note on labels. A CMS rule is a federal regulation or CMS's notice in the Federal Register, and I cite the paragraph. A Texas rule is the Texas Health and Safety Code or the Texas Administrative Code, and I quote the state's own page with the day I read it: October 26, 2026. County counts are Medicare's own files, as our markets pages show them. Texas licenses non-medical home care, which it calls personal assistance services, under the same law. This page covers home health only. For the steps every state shares, see how to start a home health agency in 2026.

The Short Answer

• Medicare is closed to new agencies. As of October 26, 2026, CMS's nationwide moratorium, effective May 13, 2026, stops new home health agencies from enrolling in Medicare unless the Medicare contractor received their application before that date.
• The Texas license is open. You apply to Texas Health and Human Services through TULIP, after your administrator and supervising nurse finish the presurvey training.
• The initial license fee is $2,625 (26 TAC §558.3(a)(1)). A license expires three years after it is issued (Health and Safety Code §142.006(b)), unless HHSC issues a shorter initial term.
• Texas states its clocks. Up to 45 days to process a complete application, 30 days for you to fix a missing item, then 45 days to issue or deny.
• Medicare's survey comes from an accrediting organization. Texas HHS says its survey staff are not doing initial Medicare certification surveys.

The 2026 Medicare Moratorium, in Texas

On May 15, 2026, CMS published a notice in the Federal Register announcing a nationwide moratorium on enrolling home health agencies in Medicare. It says: "This moratorium is effective May 13, 2026." Its scope:

no new HHAs or HHA branches or practice locations will be enrolled into Medicare unless the HHA's enrollment application was received by the applicable Medicare contractor prior to this notice's effective date.

It applies to HHAs "seeking to enroll anywhere in the United States, including all States, territories, and the District of Columbia." On length, the notice says "a temporary enrollment moratorium imposed by CMS remains in effect for 6 months. If CMS deems it necessary, the moratorium may be extended in 6-month increments."

Six months from May 13, 2026 is November 13, 2026. That date is our arithmetic, not a date CMS published. As of October 26, 2026, CMS had published no extension.

Buying an agency is outside the moratorium unless the sale counts as a new enrollment. The notice (section I.A.2.c, under 42 CFR §424.570(a)(1)(iii)) says the moratorium does not apply to "Changes in ownership (except changes in ownership of HHAs, hospices, and suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that would require an initial enrollment)." One sale that does count: buying a majority of an agency within 36 months of its first enrollment counts as a new enrollment, unless an exception applies (42 CFR §424.550(b)). CMS's notice says that rule "requires an HHA undergoing a non-exempt CIMO within 36 months of its initial enrollment (or within 36 months of its most recent CIMO) to enroll in Medicare as a brand new HHA". CIMO is a change in majority ownership. CMS says the moratorium would prohibit such an agency from reenrolling, because "it would constitute an initial enrollment." Medicaid is left to each state: CMS chose to "allow each State to decide whether some form of a home health provider moratorium is appropriate for their respective Medicaid and CHIP programs".

Two Texas details. First, Texas HHS's own page, when I read it on October 26, 2026, still said: "As of January 30, 2019, there are no active Medicare Provider Enrollment Moratoria in Texas." CMS's 2026 notice is the one that governs Medicare enrollment. Second, this is not Texas's first. CMS's notice lists the earlier ones: new agencies in Dallas and Harris Counties and the counties around them from February 4, 2014, statewide from August 3, 2016, until CMS let the moratoria expire on January 30, 2019. Medicare's count of new Texas agencies by year is on the Texas markets page.

Step 1: The Texas License

Who licenses

Texas Health and Human Services. Its page says: "Texas Health and Human Services licenses, certifies and surveys home and community support services agencies for compliance with state and federal laws and regulations." The law is Chapter 142 of the Texas Health and Safety Code. Section 142.002(a), except as Section 142.003 provides, bars anyone from engaging in the business of providing home health services without a home and community support services agency license, and adds: "A certified agency must have a license to provide certified home health services." The rules are 26 TAC Chapter 558, "Licensing Standards for Home and Community Support Services Agencies."

The license categories

26 TAC §558.13(b) lists six. An applicant may ask for one or more:

1. licensed and certified home health services
2. licensed and certified home health services with home dialysis designation
3. licensed home health services
4. licensed home health services with home dialysis designation
5. hospice services
6. personal assistance services

A Medicare-certified agency holds the first. The rule says an applicant for it "must also apply to CMS for certification as a Medicare-certified agency." While CMS decides, Texas "issues an initial license reflecting the category of licensed home health services," and the applicant "must comply with the Medicare conditions of participation for home health agencies in 42 CFR Part 484, as if the applicant were dually certified" (26 TAC §558.13(d)(1)). The statute adds that an applicant not yet certified "must establish that it is in the process of receiving its certification" (Health and Safety Code §142.004(b)). Our reading: while the moratorium lasts, a new agency cannot finish that process. Licensed home health services is the category that does not wait on CMS.

Before you apply: presurvey training

26 TAC §558.13(a): "The following staff must complete the Presurvey Training before submitting an application for a license." For a home health agency that means the administrator and alternate administrator, and the supervising nurse and alternate supervising nurse.

Texas HHS runs the training online. Every participant takes Module 1 and Module 2, then one module for each license category: Module 4 is Licensed Home Health Services, Module 5 is Licensed & Certified Home Health Services. HHS says each module "will take from 30 minutes to an hour to complete." Each participant signs a verification certificate after each module, and a copy goes in with the application. HHS's words: "Application packets will not be accepted without these documents!"

The application

Texas HHS lists what an agency must do to be licensed:

• Complete the pre-survey, computer-based training.
• Properly complete the license application.
• Upload all required documents.
• Pay the required license fee(s).
• Be registered with and be in good standing from the State Comptroller of Public Accounts.
• Be registered with and be in good standing from the Secretary of State of Texas.
• Be approved by HHS/HCSSA Licensure and Certification Unit.

The application is Form 2021, filed in TULIP, the Texas Unified Licensure Information Portal. The statute sets the minimum the rules must ask for (Health and Safety Code §142.004(c)), including documentation that the applicant "has sufficient financial resources to provide the services required by this chapter and by the department during the term of the license," a list of management personnel and their qualifications, a plan for the orderly transfer of clients if the agency cannot keep serving them, and identifying information on the owner, administrator and chief financial officer for criminal background checks.

The fee

26 TAC §558.3(a), read October 26, 2026:

The statute sets the range: the fees "may not be less than $600 or more than $2,625," and "A fee charged under this section is nonrefundable" (Health and Safety Code §142.010). The rule adds: "HHSC does not review an application until the applicant submits the application and the online portal reflects a status of payment received" (26 TAC §558.3(e)). A license "expires three years after the date of issuance" (Health and Safety Code §142.006(b)).

The timeline

Texas HHS, read October 26, 2026:

1. "Upon receipt of a thoroughly complete application in TULIP, the HHS/HCSSA Licensing unit has up to 45 days to process the application."
2. If the application is incomplete, "The applicant must respond with complete and correct information within 30 days from the date of notification or the application will be denied."
3. After that response, "the licensing unit will issue or deny the license within 45 days unless other matters prevent the approval or denial of the application, for example a pending survey or enforcement recommendation."

26 TAC §558.31(b) sets the same two 45-day time frames, and §558.31(c) lets an applicant ask for the fee back if HHSC misses them without good cause.

The first survey

The license comes before the state's first survey. Texas HHS: "After an initial license is issued, the agency must notify the HHS regional office upon enrolling its first person under their care" and request an initial health survey on HHSC Form 2020, Notification of Readiness for Initial Survey. "This survey request must be completed within six months of the issuance of the initial license."

Step 2: Medicare Certification

As of October 26, 2026, this is the step the moratorium closes. The federal steps are the same in every state:

• Enroll on Form CMS-855A. Texas HHS lists it with Form CMS-1561, the Health Insurance Benefit Agreement, and proof of a civil rights clearance. It also says the 855A goes in with "Verification of the application fee in an amount prescribed by CMS," paid through Pay.gov.
• Show initial reserve operating funds. A new agency "must have available sufficient funds, which we term 'initial reserve operating funds,' at the time of application submission and at all times during the enrollment process" up to three months after billing privileges start, "exclusive of actual or projected accounts receivable from Medicare" (42 CFR 489.28(a)). The amount is the average cost per visit of three or more comparable agencies in their first year, times whichever is greater: the visits you project for your first three months, or 22.5% of those agencies' average visit count (42 CFR 489.28(b)).
• Pass a certification survey by the state survey agency or an approved accrediting organization.

In Texas, the survey is the accrediting organization's. Texas HHS: "Due to CMS workload prioritization directives, no initial certification surveys are being performed by HHSC Survey Operations." And: "The application will not be considered completed until verification of an initial certification survey is received from an AO or conducted by HHSC Survey Operations."

Accreditation Options

Texas HHS lists three accrediting organizations:

• Accreditation Commission for Health Care (ACHC)
• Community Health Accreditation Partner (CHAP)
• The Joint Commission

Accreditation can count toward the Texas license too. The statute says the department "may find that a home and community support services agency has satisfied the requirements for licensing if the agency is accredited by an accreditation organization, such as The Joint Commission or the Community Health Accreditation Program," when that organization's standards meet or exceed Texas's (Health and Safety Code §142.006(c)). The license fee is still due.

Where Texas's Agencies Are

Medicare's 2025 county file counts 1,012 home health agencies billing for 186,627 Original Medicare users across Texas. Those are agencies with Medicare volume, not every licensed agency. An agency that serves several counties counts in each. The eight counties with the most users:

Medicare fee-for-service only. CMS does not publish counts under 11. All 254 Texas counties are on the Texas markets page.

Frequently Asked Questions

Can I start a home health agency in Texas right now?

You can apply for the Texas license. Medicare enrollment is the step that is closed. CMS put a nationwide moratorium on Medicare enrollment of new home health agencies, effective May 13, 2026, and it applies "anywhere in the United States, including all States, territories, and the District of Columbia." Six months from May 13, 2026 is November 13, 2026. That date is our arithmetic, not a date CMS published. As of October 26, 2026, CMS had published no extension. Texas licenses home health agencies with or without Medicare certification, as two separate license categories.

How much does a Texas home health agency license cost?

The initial license fee is $2,625, under 26 TAC §558.3(a)(1), read October 26, 2026. The same rule sets $2,625 for each initial branch office license and $2,625 to renew a three-year license. The statute, Texas Health and Safety Code §142.010, says the fee may not be less than $600 or more than $2,625, and that it is nonrefundable. A Texas license expires three years after it is issued. Medicare charges its own application fee with Form CMS-855A, paid through Pay.gov.

Do I need Medicare certification to open in Texas?

Not for the Texas license. The rule lists "licensed and certified home health services" and "licensed home health services" as separate categories (26 TAC §558.13(b)). You need Medicare certification to bill Medicare. An applicant for the certified category must also apply to CMS, and Texas issues the license as licensed home health services while CMS decides (26 TAC §558.13(d)). As of October 26, 2026, CMS's moratorium means a new agency applying now cannot enroll in Medicare.

How long does it take to get a home health license in Texas?

Texas HHS states three clocks. Once a complete application is in TULIP, the licensing unit has up to 45 days to process it. If it is incomplete, you have 30 days from the notice to fix it, or the application is denied. After your response, the unit issues or denies the license within 45 days, unless something such as a pending survey holds it up. After the license is issued, you request the initial health survey on HHSC Form 2020 when you admit your first client, within six months of the license.

Sources

Texas pages, read October 26, 2026:

• Texas Health and Human Services, Home and Community Support Services Agencies (HCSSA)
• Texas Health and Human Services, How to Become a Licensed HCSSA Provider
• Texas Health and Human Services, HCSSA Computer-Based Trainings (presurvey training)
• Texas Health and Human Services, HCSSA Statutes and Rules
• Texas Health and Safety Code, Chapter 142, Home and Community Support Services (§§142.002, 142.004, 142.006, 142.010)
• 26 TAC §558.3, License Fees
• 26 TAC §558.13, Obtaining an Initial License
• 26 TAC §558.31, Time Frames for Processing and Issuing a License

CMS:

• Federal Register notice 2026-09717, 91 FR 27954 (May 15, 2026), Announcement of Nationwide Temporary Moratoria on Enrollment of Home Health Agencies (HHAs)
• Federal Register search for "home health moratorium", newest first (checked October 26, 2026: no extension published)
• 42 CFR §489.28, Special capitalization requirements for HHAs
• 42 CFR §424.550, Prohibitions on the sale or transfer of billing privileges

Medicare data:

• Home health by county in Texas: CMS Market Saturation & Utilization, Home Health, 2025