Allowed Practitioners (NP, PA, CNS)

Three practitioner types qualify. A nurse practitioner or clinical nurse specialist must be working in accordance with state law, which in many states means a collaborative arrangement with a physician and in others means independent practice. A physician assistant must be practicing under the supervision or collaboration requirements of state law. In every case, state scope of practice controls what the federal rule permits: Medicare opened the door, but a practitioner cannot do for home health what their state license does not allow. The practitioner must also be enrolled in Medicare, since certifying and ordering privileges attach to enrolled, identifiable clinicians.

Since 2020, allowed practitioners can perform essentially the full physician role in home health:

• Certify and recertify Medicare home health eligibility
• Perform the face-to-face encounter
• Establish, sign, and periodically review the plan of care
• Sign orders, including interim verbal order authentication
• Serve as the practitioner responsible for ongoing medical oversight of the patient

Before the CARES Act, agencies had to route every certification and order through a physician even when an NP delivered all the patient's primary care, a detour that delayed starts of care and orders. Removing it was one of the most operationally significant home health changes in years.

The federal change did not standardize practice authority. In full practice authority states, an NP can run home health oversight independently. In restricted states, collaboration or supervision agreements must be in place, and a PA's signing authority follows the state's supervision framework. Multi-state agencies need a state-by-state matrix: who may certify, what collaborative documentation must exist, and how the agency verifies it at intake. Verification belongs in the referral workflow, alongside checking the practitioner's Medicare enrollment in PECOS and screening against the OIG exclusion list, because an order signed by a practitioner without authority is an unbillable order.

The practical wins are speed and access. Referrals from NP-led primary care practices no longer stall while a supervising physician is found to sign the certification, which shortens referral-to-start-of-care time. Orders and plan of care signatures turn around faster when the clinician who actually manages the patient can sign them. In rural markets where physicians are scarce, allowed practitioners are often the only realistic source of home health oversight. Agencies that updated intake scripts, order routing, and physician-facing marketing to include NPs, PAs, and CNSs widened their referral funnel; agencies that still ask every referral source for a physician signature are leaving admissions on the table.