How to start a home care agency in Missouri and reach your first client faster
Missouri has no state license for nonmedical home care, but serving MO HealthNet participants is not quick. MMAC wants a complete In-Home Services proposal, a designated manager who has passed its quarterly test, an RN supervisor, set insurance limits and a site visit, and it estimates about nine months before provider numbers arrive. Caregivers need Family Care Safety Registry and disqualification list checks, and every visit must match EVV data. Home health and hospice add DHSS licensing and Medicare. We put all of it in the right order for you.
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- Christine OchimasRN, LMFT, MBA
- All three care typesNonmedical, home health, hospice
- Written to Missouri rules19 CSR 15-7.021, 13 CSR 70-91.010 and the MMAC In-Home Services Proposal for Contract
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Updated November 2026 · Reviewed by Christine Ochimas, RN, LMFT, MBA
Answer two questions. See exactly what Missouri requires.
Nonmedical In-Home Services for MO HealthNet participants
- State license
- None for nonmedical care; an MMAC In-Home Services participation agreement under 19 CSR 15-7.021 instead
- Who you deal with
- MMAC (contract and Medicaid enrollment), DHSS Division of Senior and Disability Services (authorizes each participant), MO HealthNet Division (pays claims)
- Must haves
- Complete proposal, MMAC certified designated manager, Missouri licensed RN supervisor, administrative supervisor, $1 million per occurrence and $3 million aggregate liability coverage, employee dishonesty bond, EVV contract, FCSR, criminal background and EDL screening, MMAC site visit
- Realistic time to first client
- Several months: MMAC estimates about nine months from proposal to provider numbers
Orientation for Missouri only. We confirm your exact path on the free call.
Three places new Missouri agencies lose months
Each one keeps you paying rent, insurance and payroll while no clients arrive.
The nine month MMAC queue
MMAC says it takes approximately nine months from a submitted proposal until provider numbers are issued and services can start, and longer when the proposal is weak or answers are slow. If MMAC asks for more information, you get 30 days to answer, and it grants no extensions. A missed deadline means a denied proposal and a fresh start.
What it costs: Most of a year of rent, insurance and salaries before the first MO HealthNet participant, and another year if the proposal is denied.
A manager certificate that runs on MMAC's calendar
Every In-Home Services provider needs a designated manager who has passed MMAC's certification test, and the proposal asks for that certificate. The free, open book test is given once per calendar quarter, with 40 questions and an 80% passing score, and results come by mail within two weeks. Owners who learn this late wait for the next quarter.
What it costs: Up to three months added before the proposal can even be mailed.
Screening that has to be proven three ways
Caregivers must be registered with the Family Care Safety Registry, have a criminal background check before any participant contact, and be checked against the Employee Disqualification List, with dates and outcomes on file. Some findings need a Good Cause Waiver, and DHSS listed a review time of 5 to 7 weeks in October 2026.
What it costs: A caregiver you cannot schedule for weeks, and recouped payments if the file is missing a check.
What does a delay cost your agency?
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Home care vs home health vs hospice in Missouri
The three sound alike and are regulated differently. The one you choose decides your regulator, staffing, startup capital and timeline.
| Topic | Nonmedical home care | Home health (skilled) | Hospice |
|---|---|---|---|
| What your staff do | Personal care, homemaker, chore, respite, companionship | Two or more of nursing, therapy, home health aide or medical social services under a written plan of treatment | Palliative and supportive care for people who are terminally ill, and their families |
| State license | None. MO HealthNet work needs an MMAC In-Home Services participation agreement | DHSS home health agency license (sections 197.400 to 197.475, RSMo; 19 CSR 30-26.010) | DHSS hospice certificate (sections 197.250 to 197.280, RSMo) |
| Certificate of Need | No | No Certificate of Need step | No Certificate of Need step |
| Main payers | Private pay, MO HealthNet State Plan personal care and the Aged and Disabled Waiver (authorized by DSDS), Social Services Block Grant | Medicare, MO HealthNet, MO HealthNet Managed Care plans, commercial insurance | Medicare hospice benefit, MO HealthNet |
| Medicare | Not covered | Accreditation or state survey, then Medicare enrollment. A CMS moratorium on new enrollment took effect May 13, 2026. | Accreditation or state survey, then Medicare enrollment. A CMS moratorium on new enrollment took effect May 13, 2026. |
| Key staff | MMAC certified designated manager, Missouri licensed RN, administrative supervisor, trained aides | Administrator, clinical manager and clinical staff under 42 CFR Part 484 | Administrator, medical director, RN coordinator, interdisciplinary team |
| Startup capital | Lowest for private pay; MO HealthNet needs staff and an office through the MMAC review | Higher: clinical payroll before Medicare revenue | Highest: interdisciplinary team before revenue |
| Time to first client | Weeks (private pay) to about nine months (MO HealthNet) | Longest: licensure, survey, enrollment | Longest: certification, survey, enrollment |
Many Missouri owners start with private pay nonmedical care while the MMAC proposal is under review, then add MO HealthNet In-Home Services and later home health. Missouri's home health rule already requires licensed agencies to meet the Medicare Conditions of Participation, so a state only home health agency is built to Medicare standards from day one. We plan both from the start so your policies and hiring grow with you instead of being rewritten.
Missouri requirements at a glance
| Nonmedical home care license | None. Private pay needs no state approval; serving MO HealthNet participants needs an MMAC In-Home Services participation agreement. |
|---|---|
| In-Home Services rules | 19 CSR 15-7.021 (In-Home Service Standards) and 13 CSR 70-91.010 (personal care), both last amended effective August 30, 2023 |
| Home health licensing | Department of Health and Senior Services (DHSS), Bureau of Home Care and Rehabilitative Standards, under sections 197.400 to 197.475, RSMo, and 19 CSR 30-26.010; $600 license fee, renewed every year |
| Hospice | DHSS hospice certificate under sections 197.250 to 197.280, RSMo, and 19 CSR 30-35.010; fee on a sliding scale from $250 to $750, renewed at least every 12 months |
| Medicaid route | MO HealthNet Division pays, MMAC contracts and enrolls providers, and the DHSS Division of Senior and Disability Services (DSDS) assesses and authorizes services: State Plan personal care and the Aged and Disabled Waiver |
| Caregiver training | 12 hours of orientation within 30 days of hire (6 before first participant contact), including Alzheimer's and dementia; 5 hours of in service training a year after the first year |
| Background screening | Family Care Safety Registry registration, criminal background check before participant contact, Employee Disqualification List check, Good Cause Waiver where required (section 192.2495, RSMo) |
| Electronic visit verification | Required for personal care and home health under 13 CSR 70-3.320. Open model: you choose a vendor that sends visits to the state aggregator. Claims without a matching visit have been denied since April 1, 2026 for DSDS authorized services. |
| Certificate of Need | Not required for home health or hospice. Missouri's law covers long term care facilities and hospitals. |
| Entity filing | Missouri Secretary of State; tax registration with the Missouri Department of Revenue |
Summary of Missouri requirements as of November 2026. Rules change; confirm with each agency before filing.
Step by step: launching a home care agency in Missouri
The order matters. The designated manager test, the RN supervisor and the caregiver screening process (steps 3 to 6) must be in place before step 7, because MMAC reviews a complete proposal only and gives you 30 days to fix anything it asks for.
Form the business with the Missouri Secretary of State
File your LLC or corporation, get an EIN, register with the Department of Revenue for withholding (MMAC asks for your Missouri employer number and a Vendor No Tax Due letter), set up state unemployment insurance, get your city or county business license and enroll in the federal employment eligibility program that sections 285.525 to 285.530, RSMo, require of state contractors.
You do this; we give you the checklistDecide your payer mix
Private pay, MO HealthNet In-Home Services or both. In-Home Services is the agency model; Consumer Directed Services is a separate vendor program with its own proposal, and MMAC paused new CDS vendor enrollments from August 1, 2026. Use the path finder above.
Decided on your free consultationGet your designated manager certified
19 CSR 15-7.021 requires a designated manager who passes MMAC's certification test. The test is free, given once per calendar quarter online, and the certificate goes into your proposal, so register for the next date early.
You do this; we specify what is requiredLine up your RN, supervisor, office and insurance
Hire or contract a Missouri licensed RN with at least one year of relevant direct care experience and an administrative supervisor who is at least 21 and qualified under the rule. Secure an office lease, an NPI as an organization, an EVV vendor quote, general and professional liability of $1 million per occurrence and $3 million aggregate, and an employee dishonesty bond.
You do this; we specify what is requiredWrite the proposal policies and training plans
MMAC's Proposal for Contract asks for a business plan with a startup budget, aide orientation, advanced personal care and in service training plans, and 17 policies, each on its own page, in the same order and numbering as the form. MMAC does not review policies before you submit.
We write this for youBuild the caregiver screening and training system
Register every caregiver with the Family Care Safety Registry, run the criminal background check and Employee Disqualification List check before any participant contact, request Good Cause Waivers where needed, and deliver 12 hours of orientation with dementia training.
We set up the system and trackerSubmit the proposal and pass the site visit
Mail the complete proposal to MMAC Provider Contracts. Answer any request for more information within 30 days. If the written proposal is approved, MMAC visits and interviews your director, designated manager and RN supervisor.
We prepare and manage itSign the agreement, enroll and start on time
Sign the participation agreement MMAC mails you, complete MO HealthNet enrollment, connect your EVV system to the state aggregator, then accept DSDS authorizations. Services must begin within 10 calendar days of an authorization or its start date.
We walk you through setup
Aide training and background screening
19 CSR 15-7.021 and 13 CSR 70-91.010 set the rules for aides who provide In-Home Services to MO HealthNet participants. Missouri does not require certification for basic personal care aides, but every hour of training and every screening must be documented in the personnel file.
- Who can be an aide: At least 18, able to read, write and follow directions, and not an immediate family member of the participant.
- Orientation: 12 hours within 30 days of hire, with at least 6 hours completed before the first day of participant contact and at least 2 hours on agency protocols and emergencies. Some hours may be waived for documented recent training or licensed staff.
- Dementia training: Orientation must include an overview of Alzheimer's disease and related dementias under section 192.2000, RSMo, and this part cannot be waived. In service training must include dementia updates.
- Annual in service: 5 hours a year after the first 12 months. After three years and 15 in service hours, this may drop to 2 hours of refresher training.
- Advanced personal care: Aides need at least 6 more hours of training and observed competency before advanced tasks, unless they are a Missouri LPN or CNA or recently worked as an advanced aide. An RN visits each advanced personal care participant at least every six months.
- Family Care Safety Registry: Every employee must be registered. The registration fee is $16.00 from October 1, 2026. Screen through the registry at hire and before any participant contact.
- Criminal background and EDL checks: Section 192.2495, RSMo, requires the criminal background check before a new hire has contact with a participant, plus a check of the DHSS Employee Disqualification List. Anyone on the list cannot be employed.
- Good Cause Waiver: Certain felony findings and registry listings bar employment unless DHSS grants a Good Cause Waiver. DHSS reported a 5 to 7 week review time in October 2026.
- Supervision: The administrative supervisor reviews worker records against care plans every month, and each aide gets a written evaluation with an in home visit at least once a year. Missing evaluations can lead to recouped payments.
Six mistakes that slow Missouri agencies down
We look for every one of these in the first week of an engagement.
Mailing the proposal before the manager is certified
- What it costs
- The proposal is incomplete, and the next test date may be months away.
- How we prevent it
- Your first call sets the order: manager test, RN, office, then the proposal.
Policies that do not match the Proposal for Contract
- What it costs
- MMAC denies proposals that skip items, change the order or use the wrong legal name.
- How we prevent it
- We write every policy to 19 CSR 15-7.021, 13 CSR 70-91.010 and MMAC's numbering, one item per page.
Missing the 30 day response window
- What it costs
- MMAC grants no extensions. A late or incomplete answer means denial and starting over.
- How we prevent it
- We prepare every answer and track each MMAC deadline for you.
Letting a caregiver work before all three checks clear
- What it costs
- A misdemeanor exposure under section 192.2495, RSMo, and payments MMAC can recoup.
- How we prevent it
- A tracker that records FCSR, criminal background and EDL results with dates for every caregiver.
Visits that do not match EVV
- What it costs
- Since April 1, 2026, claims for DSDS authorized services with no matching visit in the state aggregator are denied.
- How we prevent it
- EVV vendor setup before your first authorization and a weekly aggregator review, as 13 CSR 70-3.320 requires.
Drifting into skilled care without a DHSS license
- What it costs
- Exposure to enforcement under sections 197.400 to 197.475, RSMo, and problems with every payer.
- How we prevent it
- Clear service definitions so aides stay within basic and advanced personal care tasks.
In a free 30 minute call we confirm your Missouri path, flag the mistakes that apply to your plan, and give you a fixed price to handle the rest.
Missouri launch packages
Three fixed price packages, matched to the path you choose. Your exact price is quoted in writing after your free call, before any work starts.
Private pay launch
For nonmedical agencies serving families who pay privately.
- Missouri path and a dated launch plan
- Policy and procedure manual written to 19 CSR 15-7.021, 13 CSR 70-91.010 and the MMAC In-Home Services Proposal for Contract
- Service agreement, client rights and care plan forms
- Caregiver hiring and screening workflow
- Google Business Profile setup
MO HealthNet In-Home Services ready agency
Everything in Private pay launch, plus the Medicaid route.
- Policies aligned to MO HealthNet In-Home Services requirements
- Caregiver training and background check tracker
- Medicaid provider enrollment
- Credentialing packets for MMAC through an In-Home Services participation agreement
- Survey and audit readiness
- Missouri city pages for local search
Home health and Medicare
For skilled home health. Hospice is scoped separately.
- Staffing and capital timeline
- Policies written to DHSS rules and the Medicare Conditions of Participation
- License application and inspection readiness
- Accreditation survey preparation
- Medicare and Medicaid enrollment support
Every package: one fixed price agreed in writing · you own 100% of your agency · no franchise fees or royalties.
On your own vs a franchise vs Lunaria
| Topic | On your own | Home care franchise | With Lunaria |
|---|---|---|---|
| Who owns the business | You | You, under the franchisor's brand and rules | You, 100% |
| Ongoing fees | None | Royalties and brand fees, usually a share of revenue | None. One fixed project fee |
| Knowing what Missouri requires | Pieced together from manuals and forums | A national playbook, adapted | Confirmed on your first call, then in writing |
| Policy manual | A template, often from another state | The franchisor's standard manual | Written to 19 CSR 15-7.021, 13 CSR 70-91.010 and the MMAC In-Home Services Proposal for Contract |
| Medicaid credentialing | One application at a time | Varies by franchisor | Packets for MMAC through an In-Home Services participation agreement prepared together |
| Your brand and marketing | Up to you | The franchisor's brand, with territory limits | Your brand, plus local search set up for you |
The Missouri home care startup checklist
Every Missouri step in order: business setup, your payer path, policies, caregiver screening and training, Medicaid enrollment and getting found. The items to start first are starred.
- Choose your care type and payer mix (private pay, MO HealthNet In-Home Services, or both)
- Form your LLC or corporation with the Missouri Secretary of State
- Get an EIN, register with the Department of Revenue and request a Vendor No Tax Due letter
- Set up state unemployment insurance and enroll in federal employment eligibility checks for new hires
- Get your city or county business license and sign an office lease
- and 15 more steps
Christine Ochimas, RN, LMFT, MBA
Christine founded Lunaria Care Consulting to give nurses and caregivers a direct route from "I want my own agency" to a compliant business with clients. She reads state requirements the way a reviewer does and writes policies the way a nurse would actually use them.
- We serve owners in all 50 states and DC, with a plan written for Missouri
- We help through enrollment and survey readiness, not just the application
- We tell you what we cannot promise: no one can guarantee a state or health plan decision
Have these ready for your consultation
- The care you want to provide and the clients you want to serve
- The Missouri cities or counties you plan to cover
- Where you are now: idea, business formed or already operating
- Who you expect to pay: families, MO HealthNet In-Home Services, Medicare
- Your target opening month and rough budget
No client or patient records. We never need them for a first call.
What it costs to start a home care agency in Missouri
| Item | Notes |
|---|---|
| State license | None for nonmedical care or In-Home Services. DHSS home health license: $600 at application and $600 each yearly renewal. Hospice certificate: a DHSS fee on a sliding scale from $250 to $750. |
| MO HealthNet application fee | MMAC lists $750 for new and revalidating institutional providers. It is waived if you paid the fee to Medicare or another state Medicaid program in the past two years. Confirm with MMAC whether it applies to your enrollment. |
| Designated manager certification | No charge for MMAC's training and test |
| Family Care Safety Registry | $16.00 per registration from October 1, 2026, plus any background check or fingerprinting costs |
| Insurance and bond | General and professional liability of at least $1 million per occurrence and $3 million aggregate, plus an employee dishonesty bond |
| RN and supervisor | Salaried or contracted time for the RN supervisor, administrative supervisor and designated manager |
| Office | Lease or deed required in the MMAC proposal; home health offices cannot be in a private residence |
| EVV and scheduling software | Paid by the agency; the vendor must be approved and send visits to the state aggregator |
| Accreditation (home health, hospice) | Accrediting organization application and survey fees |
| Operating reserve | Covers payroll, rent and insurance during the MMAC review or Medicare enrollment |
Fees change. Confirm current amounts with each agency before budgeting.
How long it takes in Missouri
Weeks, once the business, insurance and screening process are in place.
MMAC estimates approximately nine months from proposal to provider numbers, longer if the proposal needs work. Add the time to certify your designated manager before you submit.
Longest: DHSS licensure or certification survey, then a certification survey and Medicare enrollment, which is paused while the CMS moratorium lasts.
Demand follows population, so the St. Louis and Kansas City metro areas have the most families and the most agencies competing for them, followed by Springfield, Columbia and Joplin. In rural counties distances are long, and an agency that can cover a whole service area reliably stands out, since the MMAC rule expects staff in every part of the area you commit to. Agencies near St. Louis or Kansas City should know that clients across the river in Illinois or across State Line Road in Kansas fall under those states' rules. Many families search for care for a parent from out of state, so a strong Google Business Profile and clear pages for each city and county you serve matter.
Frequently asked questions
Do you need a license to start a nonmedical home care agency in Missouri?
No. Missouri does not license nonmedical home care agencies. Private pay agencies need business and tax registration and insurance. To serve MO HealthNet participants, you need an In-Home Services participation agreement with MMAC and must meet 19 CSR 15-7.021 and 13 CSR 70-91.010.
How do I become a MO HealthNet In-Home Services provider?
Submit a complete proposal to MMAC Provider Contracts that follows its Proposal for Contract, with your manager's certificate, RN, insurance, business plan, training plans and policies. If MMAC approves the written proposal, it conducts a site visit, then sends a participation agreement. After MO HealthNet enrollment, DSDS sends authorizations for participants.
How long does MMAC approval take?
MMAC says it takes approximately nine months after a proposal is submitted before provider numbers are issued, and longer depending on the quality of the proposal, MMAC's workload and how fast you answer its questions. You have 30 days to answer any request for information.
Who licenses home health and hospice agencies in Missouri?
The Department of Health and Senior Services, through its Bureau of Home Care and Rehabilitative Standards. Home health agencies are licensed under sections 197.400 to 197.475, RSMo, and 19 CSR 30-26.010. Hospices hold a DHSS certificate under sections 197.250 to 197.280, RSMo, and follow 19 CSR 30-35.010.
Does Missouri require a Certificate of Need for home health or hospice?
No. Missouri's Certificate of Need law applies to long term care facilities licensed under chapter 198, long term care beds and hospitals, not to home health agencies or hospices. Licensure or certification, survey and Medicare enrollment still apply.
What training do Missouri home care aides need?
For In-Home Services, 12 hours of orientation within 30 days of hire, with 6 hours before first participant contact and a dementia overview, then 5 hours of in service training each year after the first year. Advanced personal care needs at least 6 more hours and observed competency unless the aide is an LPN or CNA.
What background checks does Missouri require for home care workers?
In-Home Services and home health agencies must register each worker with the Family Care Safety Registry, complete a criminal background check before participant contact and check the Employee Disqualification List. Some findings require a DHSS Good Cause Waiver before the person can work.
Can a new home health agency or hospice enroll in Medicare right now?
CMS imposed a nationwide moratorium on new Medicare enrollment of home health agencies and hospices effective May 13, 2026, for six months, which it can extend in six month steps. Applications received before that date continue to be processed. It was due to run until about November 13, 2026, so check its current status with CMS before you plan on Medicare revenue.
How much does Missouri home care consulting cost?
Lunaria charges one fixed price per engagement, based on your path: private pay, MO HealthNet In-Home Services or home health and Medicare. You receive the price in writing after a free 30 minute consultation. There are no hourly charges, and you own 100% of your agency with no franchise fees or royalties.
Do you only work in Missouri?
No. Lunaria works with owners in all 50 states and DC, so you can expand into Illinois or Kansas with the same team.
Sources checked for this guide (41)
- 19 CSR 15-7.021, In-Home Service Standards (Cornell LII)
- 13 CSR 70-91.010, Personal Care Program (Cornell LII)
- 13 CSR 70-3.320, Electronic Visit Verification (Cornell LII)
- 19 CSR 30-26.010, Home Health Licensure Rule (Cornell LII)
- 19 CSR 30-35.010, Hospice Program Operations (Cornell LII)
- MMAC IHS and CDS Proposal Information (nine month estimate, 30 day response, site visit)
- MMAC In-Home Services Proposal for Contract
- MMAC In-Home Services General Information (services, funding, governing laws)
- MMAC Home and Community Based Services provider enrollment
- MMAC IHS Designated Manager and CDS Manager Training/Testing
- MMAC Application Fee ($750 for institutional providers)
- MMAC FCSR for In-Home and Consumer Directed Services (Good Cause Waiver findings)
- MMAC EVV Hard Launch, Phase I on April 1, 2026
- MMAC home page: DME and CDS Temporary New Enrollment Moratoria (July 24, 2026)
- MO HealthNet Division, Electronic Visit Verification
- MO HealthNet Division, Aged and Disabled Waiver
- DHSS Family Care Safety Registry ($16.00 fee from October 1, 2026; Good Cause Waiver review time)
- DHSS Home Care and Rehabilitative Standards
- DHSS Home Care Applications and Forms
- DHSS Hospice
- DHSS Certificate of Need Program
- Section 197.400, RSMo, home health definitions
- Section 197.410, RSMo, home health license application and $600 fee
- Section 197.254, RSMo, hospice certificate application and fee
- Section 197.256, RSMo, hospice certificate renewal
- Section 197.366, RSMo, health care facilities under the Certificate of Need law
- Section 290.600, RSMo, paid sick leave (repealed by H.B. 567, effective August 28, 2025)
- Section 192.2495, RSMo, criminal background checks (FindLaw copy)
- Section 197.252, RSMo, hospice certificate required (FindLaw copy)
- Missouri Department of Revenue, Business Tax Registration
- Missouri Department of Labor, Minimum Wage ($15.00 for 2026)
- CMS Home Health and Hospice Nationwide Moratorium Q&As (revised 7/09/26)
- CMS Provider Enrollment Moratoria
- Federal Register 2026-09717, nationwide home health agency enrollment moratorium (govinfo)
- Federal Register 2026-09718, nationwide hospice enrollment moratorium (govinfo)
- CMS accreditation and approved accrediting organizations
- CMS-855A Medicare enrollment application, institutional providers
- 42 CFR Part 484, home health Conditions of Participation (Cornell LII)
- 42 CFR Part 418, hospice care (Cornell LII)
- Home State Health EVV provider notice, July 2026 (Missouri open model, Sandata aggregator; health plan document)
- AAHomeCare Medicaid program integrity page (secondary, pointer only)
This guide is general information and reflects Missouri requirements as we understood them in November 2026. Requirements change. Confirm current rules, fees and procedures with the Missouri Medicaid Audit and Compliance Unit, the Department of Health and Senior Services, the MO HealthNet Division and CMS before filing. Lunaria Care Consulting provides professional consulting services and does not provide legal advice.
Other states: see all state guides. What we do: licensing, compliance, Medicaid enrollment and local search marketing.