How to start a home care agency in North Dakota and reach your first client faster
North Dakota has no state license for nonmedical home care, so new owners think they can open next week. For private pay families, that is close to true. For SPED and Medicaid waiver clients, it is not: agency Qualified Service Provider enrollment with HHS, competency forms for every caregiver, portal screening, required policies, Therap and electronic visit verification come first, and new QSP agencies are paused in Bismarck and Fargo. 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 North Dakota rulesN.D. Admin. Code 75-03-23 and the HHS QSP Agency Handbook
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Updated November 2026 · Reviewed by Christine Ochimas, RN, LMFT, MBA
Answer two questions. See exactly what North Dakota requires.
Nonmedical home care for SPED and Medicaid waiver clients
- State license
- None for nonmedical care; agency Qualified Service Provider (QSP) enrollment with HHS instead (N.D. Admin. Code 75-03-23)
- Who you deal with
- North Dakota Health and Human Services: QSP enrollment, Adult and Aging Services case managers and ND Medicaid
- Must haves
- Type 2 NPI, QSP onboarding orientation and fraud, waste and abuse training, SFN 749 competency for every caregiver, portal screening, compliance and quality improvement policies, WSI and unemployment coverage, Therap and EVV. New agencies are paused in Burleigh and Cass counties.
- Realistic time to first client
- Several months
Orientation for North Dakota only. We confirm your exact path on the free call.
Three places new North Dakota agencies lose months
Each one keeps you paying rent, insurance and payroll while no clients arrive.
Planning a public pay launch in Bismarck or Fargo
Effective June 11, 2026, North Dakota Medicaid paused new QSP agency enrollments in Burleigh and Cass counties for six months, with possible six month extensions. Applications that had not reached final approval by that date were denied. Owners who lease an office and hire staff there before checking the notice can be left with no way to serve SPED or waiver clients.
What it costs: Months of rent and payroll with no public pay clients, or a change of plan to private pay or another county.
Applications returned for small details
The QSP application needs a Type 2 NPI, an organizational chart, job descriptions, ID for every owner and managing employee, proof of WSI, unemployment and Secretary of State registration, training certificates and a bank letter or voided check with preprinted details matching your legal name. The handbook says forms with missing information are not accepted and enrollments close if tasks are not completed.
What it costs: Weeks lost each time a packet goes back, while caregivers you hired wait for work.
Caregivers who cannot start
Each direct service employee needs an SFN 749 competency form signed by a licensed professional, or a current North Dakota CNA, LPN or RN credential, before serving public pay clients. Each one must also be entered in the QSP portal and approved through HHS screening. A CNA cannot sign the form for someone else.
What it costs: A client authorization you cannot staff, and possible repayment if an unapproved worker provided billed services.
What does a delay cost your agency?
Enter your own numbers. Nothing is stored or sent.
Home care vs home health vs hospice in North Dakota
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, companionship, supervision, respite, chore and nonmedical transportation | Skilled nursing plus at least one other therapeutic service, approved by a physician or an allowed practitioner | Palliative and supportive care for people who are terminally ill, and bereavement support for their families |
| State license | None; QSP enrollment for public pay clients | HHS home health agency license (N.D.C.C. 23-17.3; N.D. Admin. Code 33-03-10.1) | HHS hospice program license (N.D.C.C. 23-17.4; N.D. Admin. Code 33-03-15) |
| Certificate of Need | No | No: the Certificate of Need requirement was repealed in 1995 | No: the Certificate of Need law was repealed in 1995, though the older hospice rule still mentions it |
| Main payers | Private pay, SPED, Expanded SPED, Medicaid State Plan Personal Care, Medicaid HCBS waiver | Medicare, ND Medicaid, commercial insurance | Medicare hospice benefit, ND Medicaid, commercial insurance |
| Medicare | Not covered | Survey or accreditation, then Medicare enrollment; check the CMS moratorium | Survey or accreditation, then Medicare enrollment; check the CMS moratorium |
| Key staff | A person who completes the QSP orientation and trains staff; caregivers with SFN 749 competency or a CNA, LPN or RN credential | Qualified administrator, full time RN nurse executive, supervising physician or RN during all hours of operation, trained home health aides | Physician medical director, registered nurse, licensed social worker, counselors, trained volunteers |
| Startup capital | Lowest | Higher: clinical payroll before Medicare or Medicaid revenue | Highest: interdisciplinary team before revenue |
| Time to first client | Weeks (private pay) to months (QSP enrollment) | Longest: licensure, survey, Medicare enrollment, then Medicaid | Longest: licensure, survey, Medicare enrollment, then Medicaid |
Many North Dakota owners start with nonmedical care, build a caregiver team and cash flow, then add home health. Plan the names early: N.D. Admin. Code 33-03-10.1-03 bars using the terms home health agency or home health services without a license, and the QSP handbook also rules out names with nurse or group home. We plan both paths from day one so your policies and hiring grow with you instead of being rewritten.
North Dakota requirements at a glance
| Nonmedical home care license | None. Private pay only agencies do not need QSP enrollment. Public pay clients require agency Qualified Service Provider (QSP) enrollment with HHS. |
|---|---|
| Home health and hospice licensing | North Dakota Health and Human Services, Health Facilities Unit: home health under N.D.C.C. 23-17.3 and N.D. Admin. Code 33-03-10.1; hospice under N.D.C.C. 23-17.4 and N.D. Admin. Code 33-03-15. Licenses expire December 31 each year. |
| Medicaid agency | North Dakota Health and Human Services (ND Medicaid). QSPs enroll through the QSP Enrollment Portal; other providers enroll through the MMIS portal, with enrollment handled by Noridian Healthcare Solutions. |
| Public pay home care programs | SPED and Expanded SPED (state funded), Medicaid State Plan Personal Care and the Medicaid HCBS waiver. A case manager authorizes services and the client chooses the QSP. |
| Enrollment moratorium | No new QSP agencies in Burleigh and Cass counties, effective June 11, 2026, for six months, with possible six month extensions |
| Caregiver competency | SFN 749 Documentation of Competency, signed by a licensed professional and valid five years, or a current ND CNA, LPN or RN credential. Home health aides: 75 hours of training or a competency evaluation. |
| Background screening | HHS screens owners, managing employees and caregivers entered in the QSP portal against court records, sex offender registries, the ND Offenders Against Children list, SAM, the HHS OIG and ND exclusion lists |
| Electronic visit verification | Required for personal care, homemaker, companionship, respite and other in home QSP services, and for Medicaid home health. Therap is the state system at no charge; other systems send data to the Sandata aggregator. |
| Workers' compensation | Workforce Safety and Insurance (WSI) is the only workers' compensation insurer in North Dakota; private carriers cannot write it |
| Medicare (home health, hospice) | State survey or accreditation, then Medicare enrollment. A CMS moratorium on new enrollments began May 13, 2026 for six months. |
Summary of North Dakota requirements as of November 2026. Rules change; confirm with each agency before filing.
Step by step: launching a home care agency in North Dakota
The order matters. Check the county first, because new QSP agencies are paused in Burleigh and Cass counties. Start competency forms and policies early, because the QSP application will not move without them.
Form the business with the Secretary of State
File your LLC or corporation with the North Dakota Secretary of State, get an EIN, register for income tax withholding with the Office of State Tax Commissioner through ND TAP, and open an unemployment insurance account with Job Service North Dakota.
You do this; we give you the checklistDecide your payer mix and counties
Private pay, public pay through QSP enrollment, or both. If you plan public pay clients in Burleigh or Cass county, check the HHS moratorium notice first. Use the path finder above.
Decided on your free consultationGet WSI coverage and other insurance
North Dakota requires workers' compensation from Workforce Safety and Insurance before you hire your first employee, and private carriers cannot sell it. Add general and professional liability, and auto coverage for caregivers who drive clients.
You do this; we specify what is requiredGet your NPI and complete the required trainings
Apply for a Type 2 (organizational) NPI; an individual QSP's NPI cannot be reused. The person who will train your staff completes the QSP Onboarding Orientation and Fraud, Waste and Abuse training, and keeps certificates for the application.
You do this; we give you the checklistWrite policies to the QSP standard
Before enrolling, adopt a compliance program, a process for reporting suspected fraud, waste and abuse, and a quality improvement program with policies on critical incidents, employee screening, supervision, gifts and money, service coverage, confidentiality and complaints, written to N.D. Admin. Code 75-03-23 and the QSP Agency Handbook.
We write this for youBuild the caregiver pipeline
Collect an SFN 749 for each caregiver, signed by a physician, PA, NP, RN, LPN, PT, OT or chiropractor, or a copy of a current ND CNA, LPN or RN credential. HHS approves an agency only when at least two employees show competency. Enter every direct service employee in the portal for screening before they serve public pay clients.
We set up the system and trackerEnroll as an agency QSP
Apply in the QSP Enrollment Portal with ND Login. Upload the organizational chart, job descriptions, owner and board ID, private pay fee schedule if your rates differ from state rates, WSI, unemployment and Secretary of State proof, direct deposit documents and training records.
We prepare and manage itSet up Therap and electronic visit verification
Every agency QSP uses Therap to acknowledge service authorizations and file critical incident reports. For EVV you can use Therap at no charge or your own system that sends data to the state aggregator, Sandata. Only one EVV system at a time.
We walk you through setupGet found by case managers and families
Enrolled agencies can appear on the public QSP list that case managers and clients use to choose a provider, and Provider Navigators may contact you about clients needing services. Pair that with a Google Business Profile for private pay families.
We walk you through setup
Caregiver competency and screening
North Dakota has no training hour requirement for nonmedical caregivers serving private pay clients. For public pay clients, N.D. Admin. Code 75-03-23-07 and the QSP Agency Handbook require written proof that each caregiver is competent in personal care procedures, and HHS screens every owner and caregiver through the QSP portal. Home health aides follow N.D. Admin. Code 33-03-10.1.
- SFN 749 Documentation of Competency: Covers procedures such as infection control, bathing, toileting, transfers, feeding and help with self administered medication. It must be complete before the employee serves public pay clients and is valid for five years.
- Who can sign: A physician, PA, NP, RN, LPN, physical therapist, occupational therapist or chiropractor with a current license. A CNA cannot sign the form for another person.
- Credentials that replace the form: A current North Dakota CNA certificate or LPN or RN license. Check the CNA registry or Board of Nursing for current status and discipline, and upload a copy.
- Portal screening: HHS checks owners, managing employees, contractors and caregivers against ND court records, the national and ND sex offender registries, ND Offenders Against Children, SAM, the HHS OIG list and the ND exclusion list, and keeps screening them while they are on your roster.
- Disqualifying offenses: N.D. Admin. Code 75-03-23-07 lists offenses with a direct bearing on providing care, such as homicide, assault, sexual offenses, robbery and exploitation of a vulnerable adult. Other offenses depend on evidence of rehabilitation.
- Reporting changes: Tell QSP enrollment within five business days when an owner's or employee's conviction history changes. A worker HHS rules ineligible must stop serving public pay clients at once.
- Home health aides: A training and competency evaluation program of at least 75 hours, including 16 classroom hours before 16 hours of supervised practical training, or a competency evaluation, plus 12 hours of inservice education every 12 months.
- Hospice aides and volunteers: Hospice homemakers and aides work only after an organized training program, under written instructions from a registered nurse or therapist. Volunteers complete a training program developed by the hospice.
Six mistakes that slow North Dakota agencies down
We look for every one of these in the first week of an engagement.
Ignoring the Burleigh and Cass moratorium
- What it costs
- An office, staff and a QSP application in a county where new agency enrollments are being denied.
- How we prevent it
- Your first call checks the current HHS notice and maps your counties before you sign a lease.
Calling the business a home health agency
- What it costs
- N.D. Admin. Code 33-03-10.1-03 bars the term without a license, and the QSP handbook will not accept the name.
- How we prevent it
- We check your business name and marketing words against state rules before you file.
Having a CNA sign competency forms
- What it costs
- The SFN 749 is rejected and the caregiver cannot serve public pay clients until a qualified professional signs a new one.
- How we prevent it
- A tracker that records who signed each form, the signer's license check and the five year expiration date.
Sending a caregiver out before portal approval
- What it costs
- Services by an employee who is not approved can be recouped from your agency after an audit.
- How we prevent it
- We build a hiring checklist where portal approval comes before the first shift.
Missing policies the handbook requires
- What it costs
- Policies are not submitted with the application, but HHS can ask for them at any time, and gaps put enrollment at risk.
- How we prevent it
- We write your compliance program, fraud reporting process and quality improvement policies to the QSP Agency Handbook.
Counting on Medicaid before Medicare for home health
- What it costs
- ND Medicaid pays only Medicare certified home health agencies and hospices, so a plan built on Medicaid revenue stalls while Medicare enrollment is paused.
- How we prevent it
- We plan your clinical launch around licensure, survey and the CMS enrollment status, with private pay and nonmedical revenue in the meantime.
In a free 30 minute call we confirm your North Dakota path, flag the mistakes that apply to your plan, and give you a fixed price to handle the rest.
North Dakota 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.
- North Dakota path and a dated launch plan
- Policy and procedure manual written to N.D. Admin. Code 75-03-23 and the HHS QSP Agency Handbook
- Service agreement, client rights and care plan forms
- Caregiver hiring and screening workflow
- Google Business Profile setup
Medicaid waiver ready agency
Everything in Private pay launch, plus the Medicaid route.
- Policies aligned to Medicaid waiver requirements
- Caregiver training and background check tracker
- Medicaid provider enrollment
- Credentialing packets for North Dakota Health and Human Services, as an agency Qualified Service Provider (QSP)
- Survey and audit readiness
- North Dakota city pages for local search
Home health and Medicare
For skilled home health. Hospice is scoped separately.
- Staffing and capital timeline
- Policies written to the HHS Health Facilities Unit 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 North Dakota 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 N.D. Admin. Code 75-03-23 and the HHS QSP Agency Handbook |
| Medicaid credentialing | One application at a time | Varies by franchisor | Packets for North Dakota Health and Human Services, as an agency Qualified Service Provider (QSP) 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 North Dakota home care startup checklist
Every North Dakota 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, payer mix and counties, and check the QSP moratorium for Burleigh and Cass
- Form your LLC or corporation with the North Dakota Secretary of State
- Get an EIN and register for income tax withholding through ND TAP
- Open an unemployment insurance account with Job Service North Dakota
- Get WSI workers' compensation coverage before your first hire
- 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 North Dakota
- 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 North Dakota cities or counties you plan to cover
- Where you are now: idea, business formed or already operating
- Who you expect to pay: families, Medicaid waiver, 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 North Dakota
| Item | Notes |
|---|---|
| State license | None for nonmedical care. Home health agencies and hospice programs pay a license fee set by HHS; check current fees with the Health Facilities Unit. |
| QSP enrollment | The January 2026 QSP Agency Handbook lists no enrollment fee |
| Entity formation | North Dakota Secretary of State filing and annual report fees |
| Workers' compensation and unemployment | WSI premiums and Job Service North Dakota unemployment taxes, based on payroll |
| Competency evaluations | A licensed professional's time to complete SFN 749 forms, renewed every five years |
| Insurance | General and professional liability, plus auto coverage for transportation services |
| EVV and scheduling software | Therap EVV is free to providers; a different EVV system and devices are at your cost |
| Accreditation (home health, hospice) | Accrediting organization application and survey fees, if you choose accreditation |
| Operating reserve | Covers payroll, rent and insurance while QSP enrollment, licensure or Medicare enrollment is pending |
Fees change. Confirm current amounts with each agency before budgeting.
How long it takes in North Dakota
Weeks, once the business, WSI coverage, insurance and hiring process are in place.
Several months: policies, competency forms and screening, QSP enrollment, then a case manager's authorization. HHS publishes no standard processing time.
Longest: HHS licensure and inspection, certification survey and Medicare enrollment before ND Medicaid. The CMS moratorium may add time.
North Dakota's public pay home care runs through Qualified Service Providers that clients choose themselves, so being on the QSP list in the counties you serve matters as much as marketing. With new QSP agencies paused in Burleigh and Cass counties, new public pay agencies look to Grand Forks, Minot, Williston, Dickinson, Jamestown and rural counties, where long drives make reliable staffing the selling point. HHS publishes a rural differential rate with its QSP rate sheet. Many families search for care for a parent from out of state, so a strong Google Business Profile and clear city pages help private pay growth.
Frequently asked questions
Do you need a license to start a nonmedical home care agency in North Dakota?
No. North Dakota licenses only home health agencies and hospice programs. A nonmedical agency serving private pay clients needs business registration, WSI coverage and other employer registrations. To serve SPED or Medicaid waiver clients, it enrolls with HHS as an agency Qualified Service Provider.
What is a QSP in North Dakota?
A Qualified Service Provider is an individual or agency approved by North Dakota Health and Human Services to provide services it pays for, such as personal care, homemaker, companionship, respite and supervision. Eligible clients choose among available QSPs, and a case manager authorizes the services.
Can I enroll a new QSP agency in Bismarck or Fargo?
Not right now. Effective June 11, 2026, North Dakota Medicaid paused new QSP agency enrollments in Burleigh and Cass counties for six months, and it may be extended in six month periods. Agencies already enrolled are not affected. Check the HHS Provider Enrollment Moratoria notice for the current status.
Who licenses home health and hospice agencies in North Dakota?
The Health Facilities Unit of North Dakota Health and Human Services. Home health agencies are licensed under N.D.C.C. 23-17.3 and N.D. Admin. Code 33-03-10.1, and hospice programs under N.D.C.C. 23-17.4 and N.D. Admin. Code 33-03-15. Both licenses are renewed every year.
Does North Dakota require a Certificate of Need for home health or hospice?
No. North Dakota repealed its Certificate of Need law, including the home health requirement, in 1995. Licensure, inspection and Medicare certification still apply.
Do North Dakota caregivers need certification?
Not for private pay work. For public pay clients, each caregiver needs an SFN 749 Documentation of Competency signed by a licensed professional, or a current ND CNA, LPN or RN credential, and must pass HHS screening in the QSP portal. Home health aides need 75 hours of training or a competency evaluation.
Can I open a Medicare home health agency or hospice in North Dakota right now?
CMS put a nationwide moratorium on new Medicare enrollment of home health agencies and hospices from May 13, 2026, for six months, so it was due to run out around November 13, 2026. It may have ended or been extended by the time you read this. You can still pursue the state license, then apply to Medicare once new applications are accepted.
Is a franchise a better way to start a home care agency in North Dakota?
A franchise gives you a brand and playbook in exchange for fees and ongoing royalties. Starting independently with Lunaria costs one fixed price, and you own 100% of your agency with no franchise fees or royalties.
How much does North Dakota home care consulting cost?
Lunaria charges one fixed price per engagement, based on your path: private pay, QSP enrollment or home health and Medicare. You receive the price in writing after a free 30 minute consultation. There are no hourly charges.
Do you only work in North Dakota?
No. Lunaria works with owners in all 50 states and DC, so you can expand into a second state with the same team.
Sources checked for this guide (31)
- ND HHS QSP Agency Handbook, January 2026
- ND HHS Qualified Service Providers page (portal, revalidation, QSP Hub, rate sheet)
- ND Medicaid Provider Enrollment Moratoria (effective June 11, 2026)
- ND Medicaid Provider Enrollment (Noridian, MMIS portal, QSP exception)
- N.D. Admin. Code chapter 75-03-23, HCBS under SPED and the Medicaid waiver (QSP standards)
- N.D.C.C. chapter 23-17.3, home health agency licensure
- N.D. Admin. Code chapter 33-03-10.1, home health agencies (amended October 1, 2025)
- N.D.C.C. chapter 23-17.4, hospice programs
- N.D. Admin. Code chapter 33-03-15, hospice programs
- N.D.C.C. chapter 23-17.2, certification of need (repealed by S.L. 1995, ch. 254)
- N.D. Admin. Code chapter 75-04-01, licensing of developmental disabilities programs
- ND HHS Health Facilities Unit, Home Health Agencies
- ND HHS Health Facilities Unit, Hospice Programs
- ND HHS Electronic Visit Verification (EVV) System and FAQ
- ND HHS Home and Community-Based Long Term Care (SPED, Ex-SPED, State Plan Personal Care, HCBS waiver)
- ND HHS Medicaid Waivers (HCBS waiver effective January 1, 2026)
- ND Medicaid Billing and Policy Manual: Home Health Services (April 2026)
- ND Medicaid Billing and Policy Manual: Hospice Services (July 2026)
- ND HHS Medicaid provider manuals page (Medicaid Expansion through Blue Cross Blue Shield of ND)
- ND HHS Criminal Background Checks (online system from November 3, 2025)
- Workforce Safety and Insurance FAQ (sole provider of workers' compensation)
- WSI employers page
- ND Office of State Tax Commissioner, income tax withholding registration
- CMS Provider Enrollment Moratoria (last updated 08/27/2026)
- CMS QSO-26-11-HHA & Hospice, six month national moratoria (May 20, 2026)
- CMS home health and hospice moratorium FAQs (revised 7/09/26)
- Federal Register 2026-09717: nationwide moratorium on Medicare enrollment of home health agencies
- Federal Register 2026-09718: nationwide moratorium on Medicare enrollment of hospices
- 42 CFR Part 484, home health Conditions of Participation (Cornell LII)
- 42 CFR Part 418, hospice care (Cornell LII)
- Home Health Care News, October 2026, on a possible CMS extension (secondary, pointer only)
This guide is general information and reflects North Dakota requirements as we understood them in November 2026. Requirements change. Confirm current rules, fees and procedures with North Dakota Health and Human Services (QSP enrollment, ND Medicaid and the Health Facilities Unit) 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.