How to start a home care agency in Texas and reach your first client faster
Texas licenses nonmedical personal care, home health and hospice under one Home and Community Support Services Agency license from HHSC. The order is unusual: you are licensed first, then you have six months to admit a client and request your initial survey. Presurvey Training comes before the application, while Medicaid contracts, STAR+PLUS health plans, registry checks and electronic visit verification come after it. We put all of it in the right order for you.
- Guides reviewed by Christine Ochimas, RN, LMFT, MBA
- One fixed price, agreed in writing
- You own 100%. No franchise fees or royalties
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- Christine OchimasRN, LMFT, MBA
- All three care typesNonmedical, home health, hospice
- Written to Texas rules26 TAC Chapter 558 and HHSC contract rules
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Updated November 2026 · Reviewed by Christine Ochimas, RN, LMFT, MBA
Answer two questions. See exactly what Texas requires.
Personal care for STAR+PLUS members
- State license
- HCSSA license, Personal Assistance Services category (26 TAC 558.404)
- Who you deal with
- HHSC, TMHP and each STAR+PLUS health plan in your service area
- Must haves
- HCSSA license, Texas Medicaid enrollment through TMHP, STAR+PLUS health plan contracts, HHSC contract for Primary Home Care, Community Attendant Services and Family Care if you want it, EVV, annual registry checks
- Realistic time to first client
- Several months after the license
Orientation for Texas only. We confirm your exact path on the free call.
Three places new Texas agencies lose months
Each one keeps you paying rent, insurance and payroll while no clients arrive.
The six month survey clock
HHSC issues your license before it surveys you. From the license's effective date you have six months to admit and serve at least one client and send HHSC Form 2020 asking for the initial survey (26 TAC 558.521). Owners who license first and plan marketing later watch the months go by with no client to show the surveyor.
What it costs: Your license itself: HHSC may revoke it or refuse to renew it if the initial survey requirements are not met.
Medicaid only starts after the license
An HHSC contract for Primary Home Care requires an HCSSA license first (26 TAC 52.33), and STAR+PLUS health plans contract and credential you only after Texas Medicaid enrollment through TMHP. Owners who count on a Medicaid client to start the survey clock find the contracts are not ready in time. HHSC has proposed rule text saying that waiting on payer authorization does not excuse the six month deadline.
What it costs: Months of rent and payroll with no billable clients, and a survey deadline you may miss.
The administrator gate before you can apply
The administrator and alternate administrator must complete HHSC Presurvey Training before the application is submitted, plus eight hours of administration training before they are designated. They also need qualifying experience. Owners who name a manager late, or one without the right background, cannot file.
What it costs: Weeks lost before the application, and sometimes a new hire to replace an unqualified administrator.
What does a delay cost your agency?
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Home care vs home health vs hospice in Texas
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 such as bathing, dressing, grooming, feeding, toileting and transfers, plus household help and respite; companion only care is exempt | Skilled nursing, therapy, medical social work and home health aide services | Palliative and supportive care for people who are terminally ill, and their families |
| State license | HCSSA license, Personal Assistance Services category (26 TAC 558.404) | HCSSA license, Licensed Home Health Services, or Licensed and Certified Home Health Services for Medicare | HCSSA license, hospice services category (26 TAC Chapter 558, Subchapter H) |
| Certificate of Need | No | No Certificate of Need step | No Certificate of Need step |
| Main payers | Private pay, STAR+PLUS health plans, HHSC contracts for Primary Home Care, Community Attendant Services and Family Care | Medicare, Texas Medicaid and its health plans, commercial insurance | Medicare hospice benefit, Texas Medicaid hospice (requires Medicare certification) |
| Medicare | Not covered | Accreditation or state survey, then Medicare enrollment; check the CMS moratorium | Accreditation or state survey, then Medicare enrollment; check the CMS moratorium |
| Key staff | Administrator and alternate, a qualified supervisor, attendants who have shown competency | Administrator and alternate, supervising nurse and alternate (RNs with recent experience), clinical staff | Administrator and alternate who are hospice employees, supervising nurse and alternate, medical director, interdisciplinary team |
| Startup capital | Lowest | Higher: clinical payroll before Medicare revenue | Highest: interdisciplinary team before revenue |
| Time to first client | Months: license, first client, then the initial survey | Longest: license, survey, certification, enrollment | Longest: license, survey, certification, enrollment |
In Texas it is one license with categories, not separate licenses. HHSC does not require a second category if the one you hold already covers the services you provide (26 TAC 558.13), and adding a category later is a change reported through the online portal with a $30 fee (26 TAC 558.208). Many owners start with Personal Assistance Services, build cash flow and a caregiver team, then add home health. We plan both from day one so your policies and hiring grow with you instead of being rewritten.
Texas requirements at a glance
| License | Home and Community Support Services Agency (HCSSA) license from the Texas Health and Human Services Commission (HHSC), under Health and Safety Code Chapter 142 and 26 TAC Chapter 558 |
|---|---|
| Nonmedical home care | Personal Assistance Services (PAS) category for any personal care. Sitter companion and chore services with no personal care, health or health related services are exempt (Health and Safety Code § 142.003(a)(15)). |
| Home health and hospice | Same license, with the Licensed Home Health Services, Licensed and Certified Home Health Services or hospice services category |
| License fee and term | $2,625 initial license fee per place of business (26 TAC 558.3), not refunded; an initial license is valid for three years |
| Before you apply | Administrator and alternate complete HHSC Presurvey Training (plus the supervising nurse and alternate for home health or hospice) and eight hours of administration training |
| After the license | Admit at least one client and request the initial survey on HHSC Form 2020 within six months, unless accredited by The Joint Commission, CHAP or ACHC |
| Background screening | DPS criminal history check under Health and Safety Code Chapter 250; Nurse Aide Registry and Employee Misconduct Registry searches before client contact and every 12 months |
| Medicaid | STAR+PLUS health plan contracts, HHSC contracts for Primary Home Care, Community Attendant Services and Family Care, and Texas Medicaid enrollment through TMHP |
| Electronic visit verification | Required for Medicaid personal care and home health visits; HHAeXchange is the state provided system at no cost, or use an approved proprietary system |
| Entity and tax filings | Texas Secretary of State, Texas Comptroller franchise tax report, Texas Workforce Commission |
Summary of Texas requirements as of November 2026. Rules change; confirm with each agency before filing.
Step by step: launching a home care agency in Texas
The order matters. Steps 3 and 7 should start long before step 6, and step 8 has a six month limit from the day your license takes effect, so plan your first client before you file.
Form the business with the Texas Secretary of State
File your LLC or corporation through SOSPortal, get an EIN, register with the Texas Workforce Commission for unemployment tax, and plan for the annual franchise tax report to the Texas Comptroller.
You do this; we give you the checklistDecide your category and payer mix
If caregivers will help with bathing, dressing, toileting or transfers, you need the Personal Assistance Services category. Companion and chore services alone are exempt. Then choose private pay, STAR+PLUS or both. Use the path finder above.
Decided on your free consultationQualify your administrator and supervisor
For a PAS agency, the administrator and alternate need a high school diploma or GED with a year of experience caring for people with functional disabilities, or two years of college in a health field. Both complete Presurvey Training and eight hours of administration training before designation, then 16 more hours within 12 months. The supervisor must be a licensed nurse or meet the college or experience standard.
You do this; we specify what is requiredSet up the office and insurance
Your place of business must be a physical office in Texas where client records are kept. Arrange general and professional liability and auto coverage. Workers' compensation is optional for most Texas employers, but an employer without it must report that to the state.
You do this; we specify what is requiredWrite policies to 26 TAC Chapter 558
Adopt policies for client rights, service agreements, individualized service plans, supervision, staffing and training, registry and criminal history checks, abuse reporting, infection control, emergency preparedness and records. The surveyor reviews all of them.
We write this for youApply for the HCSSA license
Submit the application and the $2,625 fee through HHSC's online licensing portal. HHSC does not review it until payment shows as received, and any missing items must be sent within 30 days of its notice. Do not admit a client until the license is issued.
We prepare the applicationBuild the caregiver pipeline
Run a DPS criminal history check, search the Nurse Aide Registry and Employee Misconduct Registry before first client contact and every 12 months, give each worker the required registry information, and document orientation and competency for every task.
We set up the system and trackerAdmit a client and request your initial survey
Within six months of the license's effective date, serve at least one client and send HHSC Form 2020, Notification of Readiness for Initial Survey. Have the client list, client records, policies and personnel files ready for the surveyor.
We get you ready for the surveyAdd Medicaid and EVV
Enroll in Texas Medicaid through TMHP's PEMS, contract and credential with each STAR+PLUS health plan in your area, apply to HHSC for a Primary Home Care contract if you want those referrals, and set up EVV before your first Medicaid visit.
We prepare every plan's packet
Caregiver training and background checks
Texas does not set a fixed number of training hours for PAS attendants. Under 26 TAC 558.404, personal assistance services may be performed by an unlicensed person who is at least 18 and has shown competency for the tasks the supervisor assigns. Your policies must cover orientation, job specific training and competency checks (26 TAC 558.245), and the background rules come from Health and Safety Code Chapter 250 and 26 TAC 558.247.
- Attendant age and competency: At least 18, or younger if they are a high school graduate or enrolled in a vocational program, and competency shown for each assigned task when education and experience do not establish it.
- Orientation: For HHSC Primary Home Care, Community Attendant Services and Family Care, the supervisor orients each attendant on or before their first day of service and records it on one document (26 TAC 277.25).
- Nursing tasks: Health related tasks need RN delegation under Texas Board of Nursing rules (22 TAC Chapter 225), or an RN decision that delegation is not needed. Gastrostomy tube feeding by unlicensed staff requires a specific training and competency program.
- Home health aides: For home health, aides qualify through a 75 hour training and competency program with at least 16 clinical hours, a competency evaluation, qualifying experience, or a clean Nurse Aide Registry listing (26 TAC 558.701).
- Criminal history: A criminal history check through the Texas Department of Public Safety for unlicensed staff with client contact. Convictions listed in § 250.006 bar employment; other convictions need a documented review. A worker hired pending results may have no direct client contact until cleared.
- Registry searches: Search the Nurse Aide Registry and Employee Misconduct Registry before hire or first client contact and at least every 12 months, keep copies, and discharge anyone listed as unemployable.
- Administrator training: Presurvey Training and eight hours before designation, 16 more hours within the first 12 months, then 12 hours of continuing education every year.
- Coming changes: HHSC proposed Chapter 558 amendments in September 2026 that add a search of the multi agency reportable conduct search engine (SEMARC) and require suspending a worker with a reportable conduct finding during appeals. Watch for the final rule.
Six mistakes that slow Texas agencies down
We look for every one of these in the first week of an engagement.
Calling it companion care while helping with bathing or toileting
- What it costs
- Operating without a license, and a business that cannot use the words "personal assistance services" (Health and Safety Code § 142.002).
- How we prevent it
- Clear service definitions on your first call, and the PAS category from the start if any personal care is likely.
Admitting a client before the license is issued
- What it costs
- 26 TAC 558.11 bars admitting clients or starting services until HHSC issues the initial license.
- How we prevent it
- A launch plan that lines up your first client for the week the license arrives.
Missing the six month survey window
- What it costs
- HHSC may revoke the initial license or deny its renewal, and the fee is not refunded.
- How we prevent it
- A dated plan to admit a client and send Form 2020 well inside six months.
Waiting for Medicaid to supply the first client
- What it costs
- Health plan contracts can take longer than the survey window allows.
- How we prevent it
- A private pay first client plan, with Medicaid enrollment and health plan packets started the day the license is issued.
Checking the registries only at hire
- What it costs
- A survey citation for every worker without a search in the last 12 months.
- How we prevent it
- A tracker that flags Nurse Aide Registry and Employee Misconduct Registry dates for every caregiver.
Naming an administrator who does not qualify
- What it costs
- An application that cannot be filed, or a new administrator to recruit and train.
- How we prevent it
- We check qualifications against 26 TAC 558.244 and schedule Presurvey Training and the first eight hours before you apply.
In a free 30 minute call we confirm your Texas path, flag the mistakes that apply to your plan, and give you a fixed price to handle the rest.
Texas 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.
- Texas path and a dated launch plan
- Policy and procedure manual written to 26 TAC Chapter 558 and HHSC contract rules
- Service agreement, client rights and care plan forms
- Caregiver hiring and screening workflow
- Google Business Profile setup
STAR+PLUS ready agency
Everything in Private pay launch, plus the Medicaid route.
- Policies aligned to STAR+PLUS requirements
- Caregiver training and background check tracker
- Medicaid provider enrollment
- Credentialing packets for each STAR+PLUS health plan in your service area, plus HHSC for Primary Home Care
- Survey and audit readiness
- Texas city pages for local search
Home health and Medicare
For skilled home health. Hospice is scoped separately.
- Staffing and capital timeline
- Policies written to HHSC 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 Texas 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 26 TAC Chapter 558 and HHSC contract rules |
| Medicaid credentialing | One application at a time | Varies by franchisor | Packets for each STAR+PLUS health plan in your service area, plus HHSC for Primary Home Care 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 Texas home care startup checklist
Every Texas 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 license category and payer mix (private pay, STAR+PLUS, or both)
- Form your LLC or corporation with the Texas Secretary of State
- Get an EIN and register with the Texas Workforce Commission for unemployment tax
- Calendar the Texas Comptroller franchise tax report, due May 15 each year
- Lease a physical office in Texas for client records
- and 16 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 Texas
- 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 Texas cities or counties you plan to cover
- Where you are now: idea, business formed or already operating
- Who you expect to pay: families, STAR+PLUS, 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 Texas
| Item | Notes |
|---|---|
| HCSSA license | $2,625 initial license fee per place of business under 26 TAC 558.3, renewed at $2,625 for a three year license. Not refundable if you withdraw or are denied. |
| Branch offices | Each branch office needs its own license, with a $2,625 initial branch fee. |
| Changes after licensing | $30 to report a change of location, name, administrator, category or service area, plus $100 if reported late (26 TAC 558.208). |
| Entity formation | Texas Secretary of State filing fee; check the current fee schedule |
| Administrator training | Eight hours before designation and 16 more in the first year from an academic, association or other qualifying provider, then 12 hours a year |
| Criminal history checks | Per worker, through the Texas Department of Public Safety |
| Insurance | General and professional liability, auto coverage, and workers' compensation if you choose it |
| EVV | The state provided system, HHAeXchange, is free to Medicaid providers; an approved proprietary system is at your cost |
| Accreditation (optional) | Accrediting organization fees if you choose The Joint Commission, CHAP or ACHC; needed for Medicare home health or hospice unless you use the state survey |
| Operating reserve | Covers payroll, rent and insurance while you wait for the license, the survey and health plan contracts |
Fees change. Confirm current amounts with each agency before budgeting.
How long it takes in Texas
A few months. HHSC's rule allows up to 45 days to find the application complete and up to 45 more to issue the license, then you admit your first client.
Several months after the license: Texas Medicaid enrollment through TMHP, then contracting and credentialing with each health plan in your area.
Longest: license, first client, initial survey or accreditation, Medicare certification and enrollment, subject to any CMS moratorium.
Texas is a large state with several big metro areas, including Houston, Dallas and Fort Worth, San Antonio, Austin and El Paso, and long distances between towns in rural and border counties. STAR+PLUS runs in every service area of the state, and members choose among at least two health plans, so contracting with every plan in your area widens your referrals. In rural counties, reliable staffing is your selling point. Families often search by city or county, so a complete Google Business Profile and clear pages for each community you serve matter.
Frequently asked questions
Do you need a license to start a nonmedical home care agency in Texas?
Yes, if caregivers provide personal care such as bathing, dressing, grooming, feeding, toileting or transfers. You need an HCSSA license from HHSC with the Personal Assistance Services category. Sitter companion and chore or household services that involve no personal care, health or health related services are exempt under Health and Safety Code § 142.003(a)(15).
Who licenses home health and hospice agencies in Texas?
HHSC, under the same HCSSA license. Home health uses the Licensed Home Health Services category, or Licensed and Certified Home Health Services for Medicare certified agencies, and hospice has its own category with standards in 26 TAC Chapter 558, Subchapter H.
How much does a Texas HCSSA license cost?
26 TAC 558.3 sets a $2,625 initial license fee for each place of business, and the same amount for each branch office. Fees are not refundable. Budget separately for insurance, administrator training, criminal history checks and any EVV system you buy.
How long does it take to get an HCSSA license?
HHSC's rule allows up to 45 days to decide whether a paid application is complete and up to 45 more days to issue the license. After that, you have six months to admit a client and request the initial survey, so plan for the whole process to take several months.
Do Texas PAS attendants need certification or training hours?
No state certification or fixed hour count is required for PAS attendants. They must be at least 18, with limited exceptions, show competency for their tasks, clear the criminal history check and not be listed as unemployable on the Nurse Aide Registry or Employee Misconduct Registry. Home health aides have separate training rules.
What background checks do Texas home care agencies run?
A criminal history check through the Texas Department of Public Safety under Health and Safety Code Chapter 250, plus Nurse Aide Registry and Employee Misconduct Registry searches before first client contact and at least every 12 months. Certain convictions bar employment outright.
Can I bill Texas Medicaid with a PAS license?
Yes. A PAS licensed agency can enroll in Texas Medicaid through TMHP, contract with STAR+PLUS health plans, and apply to HHSC for a Primary Home Care contract, which also covers Community Attendant Services and Family Care. Medicaid personal care visits must be recorded through electronic visit verification.
Does Texas require a Certificate of Need for home health or hospice?
No. The HCSSA licensing law and rules contain no Certificate of Need or need review. Licensure, the initial survey and, for Medicare, certification and enrollment still apply.
How much does Texas home care consulting cost?
Lunaria charges one fixed price per engagement, based on your path: private pay, STAR+PLUS 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.
Do you only work in Texas?
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 (44)
- 26 TAC § 558.3, license fees (Cornell LII)
- 26 TAC § 558.11, criteria and eligibility for licensing (Cornell LII)
- 26 TAC § 558.12, general application (Cornell LII)
- 26 TAC § 558.13, obtaining an initial license, Presurvey Training and categories (Cornell LII)
- 26 TAC § 558.15, issuance of an initial license (Cornell LII)
- 26 TAC § 558.31, time frames for processing a license (Cornell LII)
- 26 TAC § 558.208, reporting changes and fees (Cornell LII)
- 26 TAC § 558.243, administrative and supervisory responsibilities (Cornell LII)
- 26 TAC § 558.244, administrator and supervising nurse qualifications (Cornell LII)
- 26 TAC § 558.245, staffing policies (Cornell LII)
- 26 TAC § 558.247, verification of employability (Cornell LII)
- 26 TAC § 558.259, initial administrator training (Cornell LII)
- 26 TAC § 558.260, administrator continuing education (Cornell LII)
- 26 TAC § 558.401, licensed home health services (Cornell LII)
- 26 TAC § 558.404, personal assistance services (Cornell LII)
- 26 TAC § 558.503, exemption from a survey for accredited agencies (Cornell LII)
- 26 TAC § 558.521, requirements for an initial survey (Cornell LII)
- 26 TAC § 558.701, home health aides (Cornell LII)
- Texas Register, September 18, 2026: proposed amendments to 26 TAC Chapter 558
- Health and Safety Code § 142.002, license required (Texas Public Law copy)
- Health and Safety Code § 142.003, exemptions from licensing (Texas Public Law copy)
- Health and Safety Code § 250.002, criminal history from DPS (Texas Public Law copy)
- Health and Safety Code § 250.003, verification of employability (Texas Public Law copy)
- 26 TAC § 277.1, Primary Home Care, Community Attendant Services and Family Care contracts (Cornell LII)
- 26 TAC § 277.23, attendant qualifications (Cornell LII)
- 26 TAC § 277.25, attendant orientation (Cornell LII)
- 26 TAC § 52.29, provisional contract application process (Cornell LII)
- 26 TAC § 52.33, license requirements for HHSC community services contracts (Cornell LII)
- 1 TAC § 353.601, STAR+PLUS program (Cornell LII)
- 1 TAC § 353.603, STAR+PLUS enrollment (Cornell LII)
- HHSC STAR+PLUS Handbook 1100, Program Overview
- HHSC STAR+PLUS Handbook 4200, Long Term Services and Supports (Revision 26-1)
- HHSC Electronic Visit Verification Policy Handbook
- TMHP Provider Enrollment (PEMS, LTSS and STAR+PLUS providers)
- Federal Register 2026-09717: nationwide moratorium on Medicare enrollment of home health agencies
- Federal Register 2026-09718: nationwide moratorium on Medicare enrollment of hospices
- Texas Department of Insurance, Division of Workers' Compensation: employer information
- Texas Comptroller, franchise tax
- Texas Secretary of State, business organization forms (SOSPortal)
- Texas Workforce Commission, unemployment tax registration
- 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)
This guide is general information and reflects Texas requirements as we understood them in November 2026. Requirements change. Confirm current rules, fees and procedures with the Texas Health and Human Services Commission, TMHP 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.