Home Health Agency (HHA) Licensing and Certification Program

Select a topic below for instructions on how to submit the change to the department.  Please notify the department of changes as they occur at the agency.

• Adding Services
  • CMS-1572 (Medicare providers only)
• Adding/Removing Service Area
• Agency address, e-mail, fax, and phone changes
• Medicare Agency Address Change
• Agency closure
• Agency name change (Add “doing business as” (dba) name)
• Agency name change (Legal entity name)
• Medicare Voluntary Termination
• Office Hours
• Staff Changes
  • Agency Staff Change Notification Form
• Stock Transfer

Select a topic below for information related to Branch questions.

• Adding a Branch location
  • Branch Questionnaire for a Home Health Agency
• Branch Closure
• Branch Location
  • Branch Questionnaire for a Home Health Agency

Review all applicable information PRIOR to submission of application to the Department.

Initial Application

To apply for an initial license to operate a home health agency complete the “APPLICATION FOR LICENSE TO OPERATE A HOME HEALTH AGENCY” (SF 4008) and submit with $250.00 licensure fee and other required information to the Indiana Department of Health.

• Initial Licensure Application Instruction Letter
• Application for License to Operate a Home Health Agency (State Form 4008)
  Submit all documentation requested on application.
  • ​PDF Version
  • Word Version

Forms to be completed and returned with the application:

FOR STATE LICENSE AND STATE LICENSE SEEKING MEDICAID:

• Notice of Affiliation
• Home Health Agency Survey Report (CMS-1572)
• Home Health Agency Survey Report State License Only
• Home Health Agencies/Hospice Agencies Geographic Area Served
• Clinical Laboratory Application (HCFA-116).  If applicable.
• Copy of the Articles of Incorporation or Certificate of Assumed Business Name signed by the Secretary of State for doing business in Indiana.
• SS-4 or comparable document from the Internal Revenue Service that reflects the corporation name and EIN number.
• $250.00 Licensure Fee
• Copies of current valid Indiana licenses, limited criminal history checks and resumes on staff. Please refer to Criminal History Check Information.

FOR MEDICARE:

• Initial Certification for Medicare Letter
• CMS LETTER
• Medicare Provider/Supplier Enrollment Applications (Form CMS-855A) Letter
• Process of Initial Medicare Certification
• CMS-Approved Accreditation Organization Contact Information

Medicare Forms:

• Medicare Form Instruction Letter
• Health Insurance Benefit Agreement (Form CMS-1561)
• Civil Rights Certification for Medicare Provider Applicants
  • Please make sure to complete and submit the “Data Request Checklist”
• Medicare Provider/Supplier Enrollment Application (Form CMS-855A)

Change of Ownership Application

To apply for a Change of Ownership for an existing agency complete the “Application for License to Operate a Home Health Agency” (State Form 4008) and submit with the $250.00 licensure fee, applicable purchase agreement, and other required information to the Indiana Department of Health.

• Change of Ownership Application Instruction Letter
• Chow Changes
• Notice of Affiliation
• Home Health Agency Survey Report (CMS-1572)
• Home Health Agency Survey Report State License Only
• Home Health Agencies/Hospice Agencies Geographic Area Served
• Clinical Laboratory Application (HCFA-116) If applicable.
• Copy of the Articles of Incorporation or Certificate of Assumed Business Name signed by the Secretary of State for doing business in Indiana.
• SS-4 or comparable document from the Internal Revenue Service that reflects the corporation name and EIN number.
• $250.00 Licensure Fee
• Copies of current valid Indiana licenses, limited criminal history checks and resumes on new owners, officers, and administrative staff. Please refer to Criminal History Check Information.
• Signed purchase agreement from the buyer and seller with the effective date of transaction.
• Letter of intent from both the buyer/seller on agency letterhead.

For CHOW involving a Medicare CCN please complete the following forms:

Medicare Forms:

• Medicare Form Instruction Letter
• Health Insurance Benefit Agreement (Form CMS-1561)
• Assurance of Compliance (Form HHS-690)
• Civil Rights Certification for Medicare Provider Applicants
  • Please make sure to complete and submit the “Data Request Checklist”
• Medicare Provider/Supplier Enrollment Application (Form CMS-855A)

Laws / Rules

• Home Health Agencies State Statute IC-16-27
• Home Health Agencies State Rules (410 IAC 17)
• State Operations Manual-Appendix B (Federal) 

General Information

• Title 410 IAC--Article 1 Communicable Disease Control Information
• Universal Precautions and Patients Rights Form
• Advance Directives—Your Right to Decide
• Preparation for Survey
• OASIS Information for Medicare and Medicaid Providers

To renew the agency’s license to operate a home health agency complete the Renewal Application for License to Operate a Home Health Agency (SF 48851) and submit with the $250.00 licensure fee to the Indiana Department of Health. In accordance with 410 IAC 17-11-3 an application for renewal of license shall be filed with the department at least sixty (60) days prior, but not sooner than ninety (90) days before, the expiration date of the current license.

If there are changes that occurred at your agency make sure all changes are made on the renewal application.  Include all applicable information with the application.  The application must be approved and licensure fee received PRIOR to issuance of license.

Submit the $250.00 licensure renewal fee with your renewal application (SF 48851).  Make sure check or money order payable to the Indiana Department of Health.  Submit application and $250.00 renewal fee to:

Indiana Department of Health
2 North Meridian Street
Attention: Cashier's Office
Indianapolis, IN 46204

New Test Assessment Submission Process for New HHAs

This notification serves to inform you of the new test assessment submission process that new, not yet certified Home Health Agencies (HHAs) will need to follow in order to fulfill their certification requirements.

Beginning January 1, 2020, new HHAs will need to use the OASIS Validation Utility Tool (VUT), available on the iQIES homepage at https://iQIES.cms.gov/vut to submit test XML files to provide evidence of their ability to submit patient assessments to CMS. Previously, new HHAs used the QIES Assessment Submission and Processing (ASAP) system to submit test XML files.

The OASIS VUT is a software utility that can be used to validate OASIS submission files in XML format. A login to iQIES is not required to access the iQIES OASIS VUT. Upon submission, users will have the option to download a validation report displaying their submission results that can be provided to the surveyor as part of the pre-certification process.

Note: It is recommended that users access iQIES using Chrome or an Internet browser alternative to Internet Explorer. If there are any questions regarding the use of the VUT, users can contact the service desk at: help@qtso.com or by phone: 800-339-9313.

Home Health Quality Reporting Program

OASIS Data Sets

OASIS User Manuals

Spotlights and Announcements

Home Health Quality Reporting Training

For HH QRP and OASIS Guidance related questions email: homehealthqualityquestions@cms.hhs.gov.

For Technical Help related to Data Submission & Certification and Survey Provider Enhancement Reports (CASPER): Quality Improvement and Evaluation System (QIES) Technical Support Office (QTSO) Help Desk Contact:

Phone: 1-800-339-9313
Email: help@qtso.com
Website: https://qtso.cms.gov
OASIS Help: Oasishelp@health.IN.gov

• Survey Reporting System Quick Guide

To add personal services to an existing home health agency license, please provide the items and/or documentation listed below.

A letter on your agency's letterhead to include the following:

• The agency's license number. The number is located on agency's license.
• Your request to add personal services.
• The date the service is intended to be offered - the effective date.

Ensure you meet the requirements of IC 16-27-4-16 and provide the following:

• Copy of a basic attendant care provider job description as well as
• An updated training and evaluation policy that includes the following:
  • A method of determining competency and provides a passing score for the attendants;
  • Describe your determination of competency methods: i.e., how you evaluate, train, and
    retrain, if needed
• In addition, please submit page 2 of an Initial Home Health Agency application with Section E
  completed.

Once the above-mentioned documents are submitted and approved, the IDOH will update our database to reflect the changes and send a confirmation letter to the agency. A home health agency may not offer additional services until it has received approval form IDOH.

Please submit your change request to HCBC@health.IN.gov.

• 42 CFR 484
• Appendix B  State Operations Manual
• Code of Federal Regulations (CFR) Homepage

• Home Health Agency Statute
• Home Health Agency Rules
• Indiana Law and Rules Homepage
• Indiana Register

• Indiana Association for Home and Hospice Care

• Accreditation Commission for Health Care, Inc. (ACHC)
• Community Health Accreditation Program (CHAP)
• Joint Commission on Accreditation of Hospital Organizations

Quality Improvement Organization Information - A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.  QIOs work under the direction of the Centers for Medicare and Medicaid Services (CMS) to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries of the Medicare Trust Fund.

• Indiana Public Access Counselor
• Indiana Secretary of State
• Office of Medicaid Policy and Planning (FSSA)

• Agency for Healthcare Research and Quality (AHRQ)
• Americans with Disabilities Act (ADA)
• Centers for Disease Control and Prevention (CDC)
• Centers for Medicare and Medicaid Services (CMS)
• National Government Services
• National Patient Safety Foundation
• Office of Civil Rights
• U.S. Small Business Administration