North Carolina is experiencing one of the fastest-growing senior populations in the Southeast. With approximately 1.8 million residents aged 65 and older, the state faces substantial demand for home health services. Within the next decade, approximately one in five North Carolina residents will be age 65 or older, with rural areas in the western mountains and eastern coastal plains seeing even higher concentrations of seniors.

This demographic shift creates both tremendous opportunity and significant workforce challenges. North Carolina ranks 50th out of 50 states for home health aide wages, and the state faces a projected shortage of 80,000 healthcare workers by 2030. Additionally, an estimated 186,000 personal caregivers are needed for older adults and people with disabilities. This guide covers everything agencies need to know about providing home health services in North Carolina, from DHSR licensing requirements to Medicaid reimbursement and strategies for building a sustainable caregiver workforce.

North Carolina Home Health Agency Licensing Requirements

Home health agencies in North Carolina are regulated by the Division of Health Service Regulation (DHSR) within the North Carolina Department of Health and Human Services. The state maintains specific licensing requirements for agencies providing home care services.

Regulatory framework. Home care agencies in North Carolina are governed by North Carolina General Statutes 131E-135 through 142 and Title 10A of the North Carolina Administrative Code (10A NCAC 13J). The North Carolina Medical Care Commission has rulemaking authority for home care. Licensure is required for any operating North Carolina Home Care Agency and is issued by the Division of Health Service Regulation.

Application timeline. An applicant must be able to complete all necessary requirements within one year (12 months) from receipt of the initial application and fee date to obtain a license. Each site providing home care services must be separately licensed. Applicants for a home care agency may apply directly for licensure to the Acute and Home Care Licensure and Certification Section.

Application process. The licensing process includes downloading and completing the licensure application with the appropriate fee (payment must be in the form of a check, money order, or certified check payable to the N.C. Division of Health Service Regulation). An email will be sent to the applicant confirming receipt. Subsequently, an email will be sent requesting policies, procedures, and personnel documents. Upon receipt, an initial survey is conducted by reviewing these documents for compliance with licensure requirements. If the initial survey is completed without the need for additional information, an approval letter and license will be mailed to the applicant within 5-10 business days.

Licensing fees. The annual license renewal fee is $510.00. The change of ownership fee is also $510.00.

Agency director qualifications. The agency director must hold a bachelor's degree in health, business, or public administration science and have at least one year of supervisory or management experience in home care or other licensed health care programs. For agencies licensed to provide Companion, Sitter, and Respite services only, the Agency Director shall be a high school graduate or be certified under the GED program.

Background check requirements. According to G.S. 131E-265, within five business days of making a conditional offer of employment, a home care agency shall submit a request to the Department of Public Safety to conduct a State or National criminal history record check. The agency shall not hire any individual either directly or by contract who has a substantiated finding on the North Carolina Health Care Personnel Registry.

Medicare-certified agencies. To operate a Medicare-certified home health agency in North Carolina, an applicant must first consult the State Medical Facilities Plan (SMFP) to determine if there is a projected need for one. If the SMFP does not indicate need for an additional agency, no certificate of need can be issued. If the SMFP indicates need, the applicant must apply for a certificate of need before proceeding with Medicare certification.

Contact information. The Acute and Home Care Licensure and Certification Section can be reached at 919-855-4620 or via email at [email protected]. The office is located at 1205 Umstead Drive, Raleigh, NC 27603.

Home Health Aide Certification Requirements

North Carolina follows federal guidelines for home health aide training while offering additional specialty training programs. Understanding these requirements is essential for agencies to maintain compliance and build a qualified workforce.

Training hours. North Carolina adheres to the federal code Section 484.80 for home health aide training requirements, requiring at least 75 hours of classroom training. Programs must also include a minimum of 16 hours of clinical training providing practical work experience. North Carolina has not set this requirement higher than the federal minimum.

Level III care requirements. For more comprehensive Level III personal care services, aides must complete nurse aide training and successfully pass the evaluation process, resulting in a total of 101 hours of training.

Competency examination. To become certified, candidates must take a certification exam which comprises both a written and a clinical part. A minimum score of 70% is required to pass the certification exam. The National Nurse Aide Assessment Program (NNAAP) exam includes a skills component and a written or oral examination. The oral option is available in English and Spanish.

Registry requirements. You must be listed on the North Carolina Nurse Aide I Registry as a Nurse Aide I before you can be listed on the North Carolina Home Care Specialty Training Program for Nurse Aides Registry.

Continuing education. Home health aides in North Carolina must complete 12 hours of continuing education every 12 months to maintain their certification. The continuing education includes advancements in personal care tasks, infection control, and patient care techniques.

Program costs. Training programs in North Carolina are generally affordable compared to other healthcare certifications. The average cost ranges from $400 to $1,200, depending on the provider, program length, and whether clinical supplies are included.

Salary expectations. The average annual pay for a home health aide in North Carolina is approximately $30,522 a year, which works out to approximately $14.67 per hour. Entry-level positions start at $26,073 per year, while more experienced workers make up to $38,480 per year. According to Indeed, the average hourly rate is $16.69 with $4,000 in overtime annually. North Carolina ranks 50th out of 50 states nationwide for home health aide salaries, presenting significant recruitment challenges.

Certified Nursing Assistant (CNA) Requirements

Certified Nursing Assistants in North Carolina provide a higher level of care and are regulated through the N.C. Nurse Aide I Registry maintained by the Division of Health Service Regulation (DHSR). Many home health agencies prefer or require CNA certification for skilled nursing support roles.

Training requirements. North Carolina requires completion of a state-approved CNA training program with at least 75 hours, including a minimum of 16 hours of supervised clinical practice. CNA programs must receive approval from the North Carolina Department of Health Services.

Registry verification. The N.C. Nurse Aide I Registry is a registry of all people who meet the state and federal training and testing requirements to perform Nurse Aide I tasks. It also has information about substantiated findings of resident abuse, neglect, or misappropriation of resident property. Employers can verify registry listings at the NC HCPR verification portal, which searches the N.C. Nurse Aide I Registry, N.C. Medication Aide Registry, N.C. Geriatric Aide Registry, N.C. Health Care Personnel Registry, and Home Care Aide Specialty Training.

Competency examination. Individuals must pass both a written and skills test within one year of successfully completing a training program. Credentia is the state-contracted provider of Nurse Aide I competency evaluation (testing). The exam includes a Knowledge Test and a Skills Demonstration Test.

Home health settings. CNAs may work in a variety of healthcare settings including hospitals, skilled nursing facilities, adult care facilities, home care, office/ambulatory care practice settings, and various community health environments. Nurse aides working in non-nursing home settings are responsible for making sure their work will qualify and that they can have their employment verified and renewal forms signed by a registered nurse (RN) at the appropriate time for renewal.

Certification renewal. You must complete at least 8 hours of paid work under RN supervision in the 24-month listing period to maintain certification. Private duty and volunteer work do not qualify for renewal purposes.

Contact information. The North Carolina Department of Health and Human Services Health Care Personnel Education and Credentialing Section can be reached at 919-855-3969 from 8:00 a.m. to 12:00 p.m. and 1:00 p.m. to 3:00 p.m. EST.

Medicaid Reimbursement in North Carolina

North Carolina's Medicaid program, NC Medicaid, provides coverage for eligible residents through both fee-for-service and managed care arrangements. The state has undergone significant rate changes and program updates in recent years.

Rate changes in 2025. NC Medicaid implemented provider reimbursement rate reductions effective October 1, 2025, with reductions generally between 3% and 10% impacting doctors, hospitals, and other medical providers. However, effective December 10, 2025, the State announced the reversal of these Medicaid reimbursement rate reductions. NC Medicaid is now taking immediate action to update fee schedules to align with rates in effect September 30, 2025. Updated fee schedules are targeted to be posted by January 5, 2026.

Personal Care Services (PCS). NC Medicaid's Personal Care Services program provides hands-on assistance by paraprofessional aides for the five qualifying activities of daily living (ADLs): eating, dressing, bathing, toileting, and mobility. The amount of approved service is based on an assessment conducted by Acentra Health, the designated independent assessment entity, to determine the beneficiary's ability to perform their ADLs.

PCS reimbursement methodology. Effective January 1, 2025, the unit of reimbursement changed from a 15-minute increment to a daily per diem rate. Reimbursement is no longer based on actual time spent delivering service on a specific day but on a calculated per diem rate based on total units prior-approved by NC Medicaid for PCS services to each specific beneficiary for an authorized period.

Proposed rate increases. NC bill H453 proposes to increase Medicaid reimbursement rates during the 2025-2027 fiscal biennium. For personal care services, the bill appropriates $119.2 million in state funds and $217.8 million in federal funds to raise the rate to $7.50 per 15-minute increment. This would apply to Community Alternatives Programs for Children (CAP/C), Disabled Adults (CAP/DA), and Choice (CAP/CO). The bill also allocates funds to increase private duty nursing services to $16.25 per 15-minute increment.

Fee schedule access. Current NC Medicaid fee schedules are available on the Department's Fee Schedules and Covered Codes Portal. For questions, contact the DHB Provider Reimbursement Team at [email protected].

PCS provider requirements. Agencies providing PCS must comply with PCS Policy and North Carolina Home Care Licensure Rules. The agency must offer ongoing training pertaining to job responsibilities of each employee as well as requirements of Clinical Coverage Policy 3L. This includes skill and competency training for all personal care aides. The agency must keep records of all training activities and staff orientation sessions.

Contact for PCS programs. For additional PCS questions, providers can contact NC Medicaid at [email protected] or call 919-855-4360.

Medicare Home Health Coverage

With North Carolina's rapidly growing elderly population, Medicare remains a crucial payer for home health services. Medicare certification allows agencies to serve beneficiaries and diversify their payer mix beyond Medicaid.

Eligibility requirements. To qualify for Medicare home health coverage, beneficiaries must be homebound (leaving home requires considerable effort due to illness or injury), need skilled nursing care on an intermittent basis or require physical therapy, speech-language pathology services, or continued occupational therapy, have a physician certify the need for home health care and establish a plan of care, and receive services from a Medicare-certified home health agency.

2025 rate updates. CMS's Calendar Year 2025 Home Health Prospective Payment System Final Rule includes a 2.7% home health payment update. This is offset by an estimated 1.8% decrease reflecting the permanent behavior adjustment and an estimated 0.4% decrease reflecting the updated fixed dollar loss ratio. CMS estimates that Medicare payments to HHAs in CY 2025 would increase in the aggregate by 0.5%, or $85 million, compared to CY 2024.

PDGM adjustments. The CY 2025 rule finalized a permanent prospective adjustment of -1.975% to account for the impact of implementing the Patient-Driven Groupings Model (PDGM). The 2.7% market basket update is offset by productivity adjustments and PDGM budget neutrality requirements.

Certificate of Need. Unlike many states, North Carolina requires a Certificate of Need (CON) for Medicare-certified home health agencies. Agencies must consult the State Medical Facilities Plan to determine if there is projected need before applying. This creates a more controlled market for Medicare-certified agencies in the state.

Plan of care requirements. Medicare requires a plan of care signed by a physician that specifies the services needed, frequency, and duration. The plan must be reviewed at least every 60 days.

Labor Laws and Wage Requirements

North Carolina follows federal minimum wage standards and FLSA overtime guidelines. Understanding these requirements is essential for compliance and developing competitive compensation strategies.

Minimum wage. The minimum wage in North Carolina is $7.25 per hour, matching the federal minimum wage. This rate has not changed since 2009, making North Carolina one of the states that still follows the federal minimum wage instead of setting a higher state rate. The low minimum wage contributes to workforce recruitment challenges as caregivers can often earn more in retail or food service positions.

Home health worker protections. Federal laws that went into effect on January 1, 2015 require employers of home health care workers to pay them a wage equal to or higher than the federal minimum wage, as well as overtime pay. Most people who work as in-home caregivers providing home health care services work for home health staffing agencies and are classified as employees.

Companion exemption concerns. There are ongoing concerns about proposals that would allow employers to broadly classify care workers as "companions" who can be paid less than minimum wage and are not eligible for overtime pay. Agencies should stay current on federal rule changes affecting home care worker classifications.

Overtime requirements. Under federal FLSA guidelines, non-exempt employees are entitled to overtime pay at 1.5 times their regular hourly rate for every hour worked beyond 40 hours in a workweek. North Carolina follows these federal standards for home health workers.

Proposed state changes. House Bill 353 (Fair Minimum Wage Act) has been introduced in the North Carolina legislature. This bill would raise the minimum wage to $10 per hour in 2026 and gradually to $18 per hour by 2030. As of current date, this bill has not become law. The current minimum wage remains $7.25 per hour.

North Carolina's Workforce Challenges

North Carolina faces one of the most severe direct care workforce shortages in the nation, driven by its rapidly growing senior population, lowest-in-the-nation wages, and systemic healthcare workforce challenges.

Projected shortages. North Carolina is projected to fall short by 80,000 people who have the necessary degrees and credentials by the year 2030. Within a decade, there could be a need for 21,000 more nurses and more than 186,000 personal caregivers for older adults and for people with disabilities.

Direct care workforce crisis. The direct care sector shows concerning trends, with estimates predicting more than 200,000 job openings through 2032. Additionally, 94 of the state's 100 counties are designated as mental health professional shortage areas, reflecting broader healthcare workforce challenges.

Home health aide projections. Home health and personal care aides represent almost a quarter of the total U.S. healthcare workforce. While nationally there's a projected surplus of workers by 2028, North Carolina is among states projected to have significant deficits rather than surpluses.

Nursing shortage. North Carolina has an anticipated nursing shortage of 15% in 2025, rising to 22% by 2037. Before the pandemic, workforce researchers were predicting a shortage of about 12,500 nurses by 2033. Post-pandemic projections have nearly doubled that estimate.

Home health employment trends. In North Carolina, home healthcare employment has declined each year after an initial peak through 2022. The subsector had only 1% more jobs in 2022 than 2012, compared to more robust growth for physicians' offices (20%), outpatient care centers (36%), and medical and diagnostic laboratories during the same period.

Wage competition. With average HHA wages of $14.67 per hour and North Carolina ranking 50th out of 50 states for home health aide salaries, agencies struggle to compete with retail, food service, and warehouse positions that may offer similar or higher wages with less demanding work.

State workforce initiatives. Governor Roy Cooper signed Session Law 2025-37 on July 1, 2025, allowing associates-degree professionals with relevant experience to practice as Associate or Qualified Professionals, roles that previously required bachelor's degrees. This legislative change significantly expands the pipeline for human services professionals. The NC General Assembly has also appropriated $20 million for a loan repayment program designed to incentivize mental health and substance use providers to serve in underserved counties.

NC Health Talent Alliance. The NC Health Talent Alliance (NC HTA) released its 2025 analysis of annual workforce data for key health occupations. The data collection captures insights from 110 healthcare organizations for nearly 80,000 positions across 1,566 facilities. All 12 nursing programs in the University of North Carolina system and 49 community colleges provided supply data for the analysis.

Strategies for North Carolina Agencies

Given North Carolina's specific market dynamics characterized by lowest-in-the-nation wages, severe workforce shortages, and rapid demographic growth, agencies must adopt targeted strategies to recruit and retain caregivers.

Pay significantly above minimum wage. With North Carolina's minimum wage at $7.25 per hour and average HHA wages around $14.67 per hour, paying at the higher end is essential. Consider offering $16-18 per hour or more in competitive markets like the Research Triangle to attract quality candidates who might otherwise work in retail or food service.

Address training costs. North Carolina's 75-hour HHA training requirement creates a barrier to workforce entry. Consider partnering with training programs to subsidize costs, offer paid training time, or provide signing bonuses that cover training expenses. The relatively lower cost ($400-$1,200) compared to other states provides an opportunity.

Leverage specialty training programs. The North Carolina Home Care Specialty Training Program for Nurse Aides provides additional credentials that can enhance worker skills and marketability. Encourage existing workers to complete specialty training and use it as a recruitment and retention tool.

Build career pathways. Create clear pathways from HHA to CNA and beyond. The 75-hour training requirements for both HHA and CNA create opportunities for stackable credentials. Partner with community colleges (North Carolina has 49 providing healthcare training) to offer tuition assistance tied to employment commitments.

Address benefits gaps. With North Carolina's low wages and high poverty rates among direct care workers, benefits can be a significant differentiator. Even modest offerings such as paid time off, health insurance contributions, or retirement matching can attract caregivers. Same-day pay options can address financial stress among workers living paycheck to paycheck.

Navigate PCS changes. With North Carolina transitioning to per diem reimbursement for Personal Care Services in 2025, ensure your agency understands the new methodology. Train staff on documentation requirements under the new system and adjust scheduling practices as needed.

Focus on retention. Every retained caregiver saves significant replacement costs. With severe statewide shortages, retention is critical. Invest in thorough onboarding, consistent scheduling, supervisor support, and recognition programs. Exit interviews can identify fixable issues driving turnover.

Pursue Medicare certification strategically. North Carolina's Certificate of Need requirement for Medicare-certified agencies creates a controlled market. Research whether your service area has projected need in the State Medical Facilities Plan before investing in Medicare certification. Diversifying payers can improve financial sustainability and allow for more competitive wages.

Target rural and underserved areas. With 94 of 100 North Carolina counties designated as mental health professional shortage areas, rural and underserved communities face severe workforce gaps. Consider travel time reimbursement, mileage payments above the IRS rate, and local community recruiting. The state's $20 million loan repayment program may help attract workers to underserved counties.

Monitor legislative developments. Stay informed on proposals like House Bill 353 (Fair Minimum Wage Act) and ongoing Medicaid rate discussions. The December 2025 reversal of rate reductions shows that advocacy can impact reimbursement. Participate in industry associations like the Association for Home & Hospice Care of North Carolina.

Key Resources and Contacts

Agencies operating in North Carolina should maintain relationships with these key regulatory and support organizations:

NC Division of Health Service Regulation - Acute and Home Care Licensure
Home care agency licensing under 10A NCAC 13J
Phone: 919-855-4620
Email: [email protected]
Address: 1205 Umstead Drive, Raleigh, NC 27603
Website: info.ncdhhs.gov/dhsr/ahc/homecare.html

NC Nurse Aide I Registry
CNA certification and registry
Competency testing through Credentia
Phone: 919-855-3969
Website: ncnar.ncdhhs.gov

NC Medicaid
Provider enrollment and fee schedules
Fee Schedule Portal: ncdhhs.servicenowservices.com/fee_schedules
Reimbursement questions: [email protected]
Website: medicaid.ncdhhs.gov

NC Medicaid Personal Care Services
PCS program information and provider requirements
Phone: 919-855-4360
Email: [email protected]
Website: medicaid.ncdhhs.gov/providers/programs-and-services/long-term-care/personal-care-services-pcs

NC LIFTSS (Acentra Health)
Independent assessment entity for PCS
Provider resources and training
Website: ncliftss.acentra.com

NC Health Care Personnel Registry
Verify registry listings and substantiated findings
Website: ncnar.ncdhhs.gov/verify_listings1.jsp

NC Center on the Workforce for Health
Workforce data, research, and initiatives
NC Health Talent Alliance survey data
Website: workforceforhealth.org

Association for Home & Hospice Care of North Carolina
Industry association and advocacy
Licensure applicant training
Website: ahhcnc.org

The Bottom Line

North Carolina presents both significant challenges and substantial opportunities for home health agencies. The state's 1.8 million seniors and demographic trajectory ensure sustained demand for home health services, but the current workforce crisis with the nation's lowest HHA wages creates immediate operational challenges.

Navigating North Carolina requires careful attention to compliance. The DHSR licensing process under 10A NCAC 13J has specific requirements including agency director qualifications, background check protocols, and documentation standards. Medicare-certified agencies must work within the Certificate of Need framework. The transition to per diem PCS reimbursement requires updated billing and documentation practices.

Workforce challenges in North Carolina are severe. Ranking 50th out of 50 states for home health aide wages means agencies must be creative with compensation, benefits, and career development to attract workers. The projected need for 186,000+ personal caregivers by 2032 represents both a staffing crisis and a market opportunity for agencies that can solve the recruitment puzzle.

Success in North Carolina requires understanding the DHSR licensing framework, leveraging NC Medicaid programs including the new PCS per diem methodology, monitoring ongoing rate and regulatory changes, and investing in competitive compensation significantly above the $7.25 minimum wage. Agencies that address training barriers, build career pathways, and create supportive workplace cultures will be best positioned to serve North Carolina's growing senior population and build sustainable businesses in the Tar Heel State.