How to start a skilled nursing facility in District of Columbia

District of Columbia requires a Nursing home (nursing facility) license from DC Health, Health Care Facilities Division (licensure); State Health Planning and Development Agency (CON) to operate a skilled nursing facility. Fee: License fee not stated in the sources used. CON application fee: 3% of the proposed capital expenditure, minimum $5,000 and maximum $300,000. Processing time: CON: 60-day wait between letter of intent and application (waivable for good cause); allow about six months from letter of intent to SHPDA decision.

License required

Yes

License

Nursing home (nursing facility) license

Issuing agency

DC Health, Health Care Facilities Division (licensure); State Health Planning and Development Agency (CON)

Fee

License fee not stated in the sources used. CON application fee: 3% of the proposed capital expenditure, minimum $5,000 and maximum $300,000.

Processing time

CON: 60-day wait between letter of intent and application (waivable for good cause); allow about six months from letter of intent to SHPDA decision.

Certificate of need

Required

Medicare certification

Separate from the state license. The state survey agency runs an unannounced standard health survey, a Life Safety Code survey and an emergency-preparedness survey against 42 CFR Part 483 Subpart B. For a Medicare SNF the state certifies and the CMS Location decides Medicare participation; for a Medicaid-only NF the state's certification is final and the state Medicaid agency decides participation.

Regulation

D.C. Code §44-401 et seq. (CON); 22-B DCMR Ch. 32 (nursing facilities)

1. File a CON letter of intent through SHPDA's online system
2. After the 60-day waiting period, file the CON application with the fee
3. Submit the DC Health nursing home licensure application package (including ownership disclosure and Clean Hands certification)
4. Pass the DC Health licensure inspection
5. For Medicare/Medicaid, complete the federal certification survey and enroll with DHCF

Program

DC Medicaid (Department of Health Care Finance)

Enrollment portal

DC Medicaid Provider Data Management System (PDMS)

Fiscal agent

Gainwell Technologies (fiscal agent and claims vendor since March 2, 2026, replacing Conduent)

Application fee

DHCF has collected the institutional application fee at enrollment and re-enrollment since May 1, 2015, under the District's Medicaid provider screening, enrollment and termination rule. Federal rule (42 CFR 455.460): the state must collect the CMS application fee from institutional providers that are newly enrolling or re-enrolling; individual physicians and non-physician practitioners are exempt, as are providers already enrolled in (or that already paid the fee to) Medicare or another state's Medicaid/CHIP. CMS set the fee at $750 for calendar year 2026.

Fingerprinting

Federal rule (42 CFR 455.434, 455.450(c)): providers the state places in the 'high' categorical risk level, and anyone owning 5% or more of such a provider, must submit fingerprints for a criminal background check.

Site visit

Federal rule (42 CFR 455.432, 455.450(b)-(c)): the state must do site visits before and after enrollment for providers in the 'moderate' or 'high' risk levels, and any enrolled provider must allow unannounced on-site inspections.

Revalidation

Federal rule (42 CFR 455.414): every enrolled provider must be revalidated at least once every 5 years.

Full District of Columbia Medicaid enrollment guide →

For this business

Required (licensing source)

CON program

Yes

Program

Certificate of Need

Agency

State Health Planning and Development Agency (SHPDA), DC Health

Services covered

• hospitals (general, psychiatric, rehabilitation, specialty)
• skilled nursing facilities
• intermediate care facilities
• ambulatory care centers / clinics
• ambulatory surgical facilities
• kidney disease treatment / freestanding hemodialysis
• diagnostic health care facilities
• home health agencies
• hospice
• new health services by facilities with operating budgets of $500,000+
• capital expenditures of $6M+ (hospitals) or $3.5M+ (other facilities)
• major medical equipment ($3.5M hospitals / $2M other facilities / $350,000 single physician-owned unit)
• bed relocations and redistribution

Moratoria

SHPDA may impose a moratorium of up to 120 days on CONs for a specific service while it develops review standards; the same service cannot be placed under moratorium more than once in 12 months (D.C. Code §44-418). No standing moratorium identified.

District of Columbia certificate of need details →

State minimum wage

$18.40 an hour

Effective

2026-07-01

Scheduled increases

Adjusted each July 1 by formula (US DOL); the July 2027 rate was not yet published in the sources reviewed.

Direct-care wage floor

For FY2026, DC must pay direct care service providers a rate that supports direct care professional pay at the highest of: 117.6% of the DC living wage in effect on 2025-07-01, the current DC minimum wage, or the current DC living wage. DHCF's supplemental payment program requires eligible HCBS providers to pay their direct care workforce, on average, at or above the target wage.

Rate pass-through

Supplemental payments must fund wages, salaries and benefits of direct care professionals (DHCF Transmittal 25-03).

HCBS 80/20 rule

Federal baseline: 42 CFR 441.302(k) requires the state to show that each provider spends at least 80% of Medicaid payments for homemaker, home health aide and personal care services under 1915(c) waivers on direct care worker pay and benefits. Compliance starts 2030-07-09 (for managed care, the first rating period starting on or after that date); annual payment-adequacy reporting under 441.311(e) starts 2028-07-09. A state may set a lower share for state-defined small providers and exempt providers facing hardship, each only through a public notice-and-comment process. The eCFR text has not changed since 2024-07-09. No state-published 80/20 implementation step (small-provider criteria, hardship exemption or reporting guidance) was found for this state in the official sources reviewed.

Skilled nursing facilities — active organization NPIs (NPPES)

43 (as of Sep 13, 2026)

Medicare/Medicaid-certified nursing homes (CMS Care Compare)

17 (as of Aug 1, 2026)

Total Medicaid and CHIP enrollment (latest reported month)

237,170 (as of Jun 1, 2026)

All District of Columbia Skilled nursing Medicaid rates, ranked →