Texas presents both tremendous opportunity and significant challenges for home health agencies. The state's senior population is growing faster than any other age group, with the number of Texans 65 and older increasing 3.8% from 2023 to 2024 alone. Texans age 50 and older are projected to number over 11 million by 2030, with the 75-84 age group increasing the fastest.

However, Texas ranks 50th out of 50 states for home health aide salaries, and the state is categorized as "high-risk" on the national caregiving scorecard. The caregiver valuation in Texas is estimated at $62.4 billion, more than four times the size of the state's $15.5 billion cattle industry. More than 80% of Texas counties are designated as mental health professional shortage areas, and workforce shortages are driving agencies to cut services and turn away clients. This guide covers everything agencies need to know about providing home health services in Texas.

Texas Home Health Agency Licensing Requirements

Home health agencies in Texas must obtain a Home and Community Support Services Agency (HCSSA) license from the Texas Health and Human Services Commission (HHSC). The licensing framework is governed by Texas Administrative Code, Title 26, Chapter 558.

License types. The specific type of HCSSA license depends on the services you offer. Categories include Home Health Services (skilled nursing and therapy), Personal Assistance Services, and Hospice. Each license category has distinct requirements and service parameters.

Application process. To become licensed, agencies must complete the pre-survey computer-based training (CBT), properly complete the license application through the Texas Unified Licensure Information Portal (TULIP), upload all required documents, pay the required license fee, be registered and in good standing with the State Comptroller of Public Accounts, be registered with the Secretary of State of Texas, and be approved by the HHS/HCSSA Licensure and Certification Unit.

License fees. The initial HCSSA license fee is $2,625 for a three-year license term. Correct application fees must accompany all license applications, and applications will not be officially accepted until all necessary fees are paid. Fees are non-refundable.

Pre-licensure training. HCSSA providers are responsible for reading and understanding the HCSSA regulations before becoming a licensed provider. The computer-based training covers licensing rules, operational requirements, and compliance standards.

Initial survey requirement. After an initial license is issued, the agency must notify the HHS regional office upon enrolling its first person under their care and request an initial health survey using HHSC Form 2020 (Notification of Readiness for Initial Survey). This survey request must be completed within six months of the issuance of the initial license.

Background check requirements. HHS-regulated facilities and agencies must check an applicant's criminal history and verify the applicant's status on the Nurse Aide Registry (NAR), Medication Aide Registry (MAR), and Employee Misconduct Registry (EMR) via the Employability Status Check Search upon hiring and on an annual basis.

Medicare certification. For agencies seeking Medicare certification in addition to state licensure, you must submit an application through TULIP using Form 2021 (Home and Community Support Services Agency License Application: Initial). Medicare-certified agencies must meet the federal Conditions of Participation in 42 CFR Part 484 and undergo CMS certification surveys.

AlertMedia requirement. As of February 15, 2025, agencies must sign up with AlertMedia for emergency communication purposes. Questions can be directed to [email protected].

Contact information. For licensing and certification questions, contact HHSC at 512-438-2630. For policy and rule interpretations, contact 512-438-3161 or [email protected].

Going deeper on the application package. For a section-by-section walkthrough of Texas Health and Safety Code Chapter 142 and 26 TAC Chapter 558, the line-by-line exhibit list HCSSA analysts work from, the surety bond / contingency fund mechanics, and the most common deficiencies new agencies hit during TULIP review, see our Texas HCSSA licensure forms, fees, and process guide.

Home Health Aide Certification Requirements

Texas follows federal guidelines for home health aide training while maintaining specific state requirements. Understanding these requirements is essential for agencies to build a qualified workforce and maintain compliance.

Training hours. A person who completes an HHA training program will receive at least 75 hours of training. Of these, at least 16 hours must be clinical training. The curriculum must include at least 16 hours of classroom instruction prior to beginning clinical instruction working directly with clients.

Supervision requirements. Training must be conducted by or under the general supervision of a registered nurse (RN) with at least two years of nursing experience, including one year directly related to providing home health care.

Clinical training settings. Clinical hours can take place in several settings including a home, a nursing home, or a hospital. State law allows credit for clinical hours completed in a laboratory setting. Trainees will not work with actual clients until they have completed the prerequisite 16 hours of classroom education.

Competency evaluation. Once the required 75 hours of classroom and lab learning have been completed, candidates must successfully pass a final competency evaluation. The evaluation is performed by a qualified RN and includes written, oral, and observational testing of knowledge and skills. Successful completion makes candidates eligible to be placed on the Texas Nurse Aide Registry.

Certification status. Texas does not require HHAs to hold a state license, but they must complete a certified training program. Certification is required to work with Medicare or Medicaid-funded agencies.

Continuing education. Texas requires HHAs to complete 12 hours of continuing education every 12 months to maintain their certification and keep up with healthcare practices and standards.

Alternative pathways. There are alternative pathways into the home health aide field, including nursing school attendance, prior home health experience, and CNA certification. An individual who has provided home health services in the recent past may qualify as a Texas home health aide based on competency evaluation alone, though requirements are stringent.

Salary expectations. The average hourly pay for a home health aide in Texas is $15.04 an hour, with salaries ranging from $8.96 to $20.83. Texas ranks 50th out of 50 states nationwide for home health aide salaries. In Dallas-Fort Worth, the average salary is approximately $36,899 per year ($18/hour), while Houston averages $36,234 per year ($17/hour). Both are below the national average.

Certified Nursing Assistant (CNA) Requirements

Certified Nursing Assistants in Texas provide a higher level of care and are regulated through the Texas Nurse Aide Registry maintained by HHSC. Many home health agencies prefer or require CNA certification for skilled nursing support roles.

Training requirements. Texas requires completion of a state-approved nurse aide training program consisting of 60 hours of classroom training and 40 hours of clinical training, for a total of 100 hours. The state does not impose a minimum education requirement, though some training schools may require a high school diploma or GED.

Computer-based training option. Candidates may complete the HHSC computer-based training (CBT) 60-hour online classroom training, followed by 40 hours of clinical training with a state-approved nurse aide training and competency evaluation program.

Application process. As of July 5, 2023, nurse aides and applicants for nurse aide certification must apply via the Texas Unified Licensure Information Portal (TULIP). Students who have successfully completed a training program must submit a New Nurse Aide by Examination Application in TULIP.

Competency examination. To be certified on the Texas Nurse Aide Registry, candidates must pass both a skills demonstration examination and a written or oral examination. Written and oral exams may be taken remotely or at testing sites, while skills exams are in-person only. Candidates have 24 months and three attempts per test. If unsuccessful after three attempts, retraining is required.

Background check requirements. Applicants must pass a background check based on requirements in Texas Health and Safety Code 250.006 and must not be listed on the Employee Misconduct Registry.

Texas Nurse Aide Registry. HHSC maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities. The registry records certification status, exam results, and any substantiated findings of abuse, neglect, or misappropriation of resident property.

Renewal requirements. A nurse aide renewing certification must complete at least 24 hours of in-service education every two years, including training in geriatrics and care of residents with dementia disorders. Verification of qualifying employment is required for renewal.

Reciprocity. If you hold an active CNA certification in another U.S. state, you may request Texas certification through reciprocity without retraining or testing. TULIP requires uploading criminal history results, the nurse aide certificate from the other state, and valid identification.

Contact information. Military personnel, their spouses, and veterans interested in nurse aide certification may call 512-438-2050 for additional information.

Medicaid Reimbursement in Texas

Texas Medicaid provides coverage for eligible residents through both fee-for-service and managed care arrangements. The Texas Health and Human Services Commission Provider Finance Department (PFD) is responsible for setting Medicaid reimbursement rates.

Reimbursement methodology. For Texas Medicaid (Title XIX) Home Health Services, the reimbursement methodology for home health nursing and aide services delivered by home health agencies uses statewide visit rates. Rates are established through the Provider Finance Department.

Fee schedule access. Current Texas Medicaid fee schedules are available through the Texas Medicaid & Healthcare Partnership (TMHP) Online Fee Lookup. The lookup provides fee information for Texas Medicaid, Texas Health Steps (THSteps), the HHSC Family Planning Program, and the CSHCN Services Program. Providers can search by procedure code, and static fee schedules are available as Excel spreadsheets or PDF files from the TMHP website.

Rate tables. The HHSC Provider Finance Department maintains provider reimbursement rate tables as a transparent resource about reimbursement levels for various Medicaid and non-Medicaid services. These are available at pfd.hhs.texas.gov/rate-tables.

2025 rate updates. Effective September 1, 2025, TMHP implemented reimbursement rate changes and updates for certain procedure codes following the public rate hearing held in May 2025. Providers should check the current fee schedules for updated rates.

Managed care considerations. Managed care organizations (MCOs) and dental plans are not required to follow the Texas Medicaid fee schedules, so there may be differences in reimbursement based on decisions made by individual health plans. Agencies should verify rates with each contracted MCO.

Provider manual. The Texas Medicaid Provider Procedures Manual is available on TMHP.com and contains detailed information on reimbursement methodology, billing procedures, and covered services. The manual is updated monthly.

Billing requirements. Providers must submit claims following Texas Medicaid guidelines including proper coding, documentation, and authorization requirements. Claims should be submitted to TMHP for fee-for-service or to the appropriate MCO for managed care members.

Medicare Home Health Coverage

With Texas'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.

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 home health agencies 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.

Certification process. New home health providers seeking Medicare certification should submit an application through TULIP using Form 2021. The certification process includes meeting the federal Conditions of Participation in 42 CFR Part 484 and passing a state survey.

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

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

Minimum wage. Texas adopts the federal minimum wage rate of $7.25 per hour. The Texas Minimum Wage Act has not changed since 2009, keeping the state's minimum wage at the federal level. As of January 1, 2025, there has been no law passed to increase Texas minimum wage beyond the federal minimum.

Home care worker protections. Federal laws effective 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 in-home caregivers work for home health staffing agencies and are classified as employees entitled to these protections.

Companionship services exemption. Under the FLSA, certain domestic service workers are exempt from minimum wage and overtime requirements. Workers providing "companionship services" (fellowship and protection for elderly or disabled individuals) may be exempt, but this exemption is limited to 20% of total work hours per week. If the companion spends more than 20% of their work week providing care services, they are entitled to minimum wage and overtime pay.

Agency vs. private employer distinction. Wage and hour rules vary significantly depending on whether a person or an agency hires the caregiver. Agency-employed caregivers are generally covered by FLSA protections regardless of the services they provide.

Overtime requirements. Workers putting in over 40 hours weekly qualify for overtime compensation at one and a half times their standard hourly wage. The federal Fair Labor Standards Act and the Texas Labor Code enforce overtime protections.

Healthcare 8/80 rule. In Texas, hospitals and residential care facilities may use a fixed work period of 14 consecutive days rather than the traditional 40-hour workweek. Under this exception, employers pay 1.5x the regular rate for all time over eight hours in a workday or eighty hours in a 14-day work period.

Wage claims. Workers can file wage claims with the Texas Workforce Commission (TWC) or file a lawsuit in civil court. Claims must be filed no later than 180 days after the wages were due. The Department of Labor has recovered significant unpaid wages for Texas home health workers, including over $1 million for workers in the Pharr, San Juan, and Laredo areas.

Texas Workforce Challenges

Texas 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 gaps.

Demographic pressures. In 2020, Texas had 9 million people age 50 and older, and that population is projected to grow 82% to 16.4 million by 2050. The number of Texas seniors 65 and older is expected to more than double from 3.9 million in 2020 to 8.3 million by 2050. This increase creates substantial demand for home health services.

High-risk caregiving state. Texas is categorized as "high-risk" on the national caregiving scorecard. The caregiver valuation in Texas is estimated at $62.4 billion, reflecting the massive scope of unpaid family caregiving that formal services must increasingly supplement.

Healthcare professional shortages. Texas has well-documented shortages of primary care physicians and specialists, including psychiatrists. More than 80% of Texas counties are designated as mental health professional shortage areas, and about 40% of Texas counties' primary care health needs are not currently being met.

Direct care workforce crisis. Workforce shortages are occurring due to turnover, limited qualified staff entering the workforce, and burnout. In October 2022, more than three-quarters of service providers were not accepting new clients and more than half had cut services because of direct care workforce shortage.

Regional nursing assistant shortages. Texas is projected to face a shortage of 12,000 nursing assistants by 2028. This shortage compounds the broader home health workforce crisis.

Wage competition. With Texas ranking 50th out of 50 states for home health aide salaries at an average of $15.04 per hour, agencies struggle to compete with retail, food service, and warehouse positions that may offer similar or higher wages with less demanding work. The $7.25 minimum wage creates a low baseline that depresses wages across the care sector.

Rural challenges. 76 out of 254 Texas counties have more elders than children, predominantly rural places young people left to seek job opportunities elsewhere. These rural communities face the most acute workforce shortages.

National context. Nationally, demand for direct care workers is projected to increase by 48% for nursing assistants, 43% for personal care aides, and 42% for home health aides between 2020 and 2035. Turnover rates of 75-80% across the industry exacerbate recruitment challenges.

Strategies for Texas Agencies

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

Pay significantly above minimum wage. With Texas's minimum wage at $7.25 per hour and average HHA wages around $15 per hour, paying at the higher end is essential. Consider offering $16-18 per hour or more in competitive markets like Dallas-Fort Worth and Houston to attract quality candidates.

Address training costs. The 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.

Leverage CNA pathways. The 100-hour Texas CNA training program offers a clear career advancement path. Encourage HHAs to pursue CNA certification and provide tuition assistance tied to employment commitments.

Target military communities. Texas has significant military populations. HHSC provides dedicated resources for military personnel, spouses, and veterans interested in nursing aide careers. Partner with military transition programs and leverage these pathways.

Address benefits gaps. With Texas having the highest levels of uninsured residents in the nation, benefits can be a significant differentiator. Even modest offerings such as health insurance contributions, paid time off, or retirement matching can attract caregivers. Same-day pay options address financial stress.

Navigate managed care. With most Texas Medicaid members in managed care, develop strong relationships with MCOs and understand their specific reimbursement rates and requirements. Diversify payer contracts to improve financial stability.

Focus on retention. Every retained caregiver saves significant replacement costs. With statewide shortages, retention is critical. Invest in thorough onboarding, consistent scheduling, supervisor support, and recognition programs.

Target rural and underserved areas. With 76 of 254 Texas counties having more elders than children, rural communities face severe workforce gaps. Consider travel time reimbursement, mileage payments above the IRS rate, and local community recruiting.

Pursue Medicare certification. Medicare certification diversifies payer mix and often provides higher reimbursement than Medicaid. This can support more competitive wages and improve agency financial sustainability.

Stay compliant with AlertMedia. Ensure your agency has registered with AlertMedia by the required deadline. Maintain current emergency communication protocols.

Key Resources and Contacts

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

HHSC HCSSA Licensure and Certification
Home health agency licensing under TAC Title 26, Chapter 558
Phone: 512-438-2630
Policy questions: 512-438-3161 / [email protected]
Website: hhs.texas.gov/providers/long-term-care-providers/home-community-support-services-agencies-hcssa

Texas Unified Licensure Information Portal (TULIP)
License applications, renewals, and nurse aide certification
Website: txhhs.my.site.com/TULIP

Texas Nurse Aide Registry
CNA certification and registry verification
Competency testing through Prometric
Phone: 512-438-2050 (military personnel and veterans)
Website: hhs.texas.gov/business/licensing-credentialing-regulation/long-term-care-credentialing/nurse-aide-registry

Texas Medicaid & Healthcare Partnership (TMHP)
Fee schedules, claims, and provider enrollment
Online Fee Lookup: public.tmhp.com/FeeSchedules
Provider Procedures Manual: tmhp.com
Website: tmhp.com

HHSC Provider Finance Department
Medicaid and non-Medicaid reimbursement rates
Rate Tables: pfd.hhs.texas.gov/rate-tables
Rate Packets: pfd.hhs.texas.gov/rate-packets

Texas Workforce Commission
Wage claims and labor law compliance
Website: twc.texas.gov

Texas Association for Home Care & Hospice (TAHCH)
Industry association and advocacy
Regulatory information and resources
Website: tahch.org

The Bottom Line

Texas presents both significant challenges and substantial opportunities for home health agencies. The state's 3.9 million seniors today and projected 8.3 million by 2050 ensure sustained and growing demand for home health services. However, the current workforce crisis with the nation's lowest HHA wages creates immediate operational challenges.

Navigating Texas requires careful attention to compliance. The HCSSA licensing process through TULIP has specific requirements including pre-survey training, background checks, and initial survey timelines. The $2,625 three-year license fee and ongoing compliance requirements demand operational discipline. Medicare-certified agencies face additional federal requirements.

Workforce challenges in Texas 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 shortage of 12,000 nursing assistants by 2028 represents both a staffing crisis and a market opportunity for agencies that can solve the recruitment puzzle.

Success in Texas requires understanding the HHSC licensing framework, leveraging TMHP resources for Medicaid billing and reimbursement, monitoring managed care relationships, and investing in competitive compensation significantly above the $7.25 minimum wage. Agencies that address training barriers, build CNA career pathways, target military communities, and create supportive workplace cultures will be best positioned to serve Texas's growing senior population and build sustainable businesses in the Lone Star State.