By Brett Kaufman. 8 years using relationships to build sales pipelines, from political fundraising to a 7 figure business to running matchmaking for two communities. Over 1,000 introductions facilitated.

If you want to know how to buy a home health agency, start with two things: where the target sits on the CMS 36 month clock, and the people who hear first, like discharge planners, referring physicians, cost report preparers and healthcare attorneys. State licensing rules vary, and I am not a lawyer.

Here is the scene. A hospital case manager calls an agency director about a discharge. The director says the owner is worn out by survey prep and staffing and has started asking what the agency might be worth.

When someone asks the case manager for a buyer, she names the one who checked in most recently.

Who hears first when a home health owner is ready to sell?

The people inside the agency’s referral and compliance routine hear first. Here is my map. It is a framework, not data.

Person	What they see	When	How you show up
Hospital discharge planners and case managers	Which agencies are stretched	Every discharge	Be known, be useful, never pitch
Physicians who sign plans of care	The owner’s capacity and mood	Every referral	Meet the practice managers
SNF administrators	Agencies taking or turning down patients	Every week	Ask who is slowing down
The cost report preparer	Owner pay, cost report history	Every year	The person who knows the clock
Healthcare attorneys and lenders	Owners asking about exits	When planning starts	Be the buyer they trust
State home care association peers	The owner’s own plans	At meetings	Listen first
Brokers	The listing	Last	Keep them warm too

The owners are the targets. The other rows are how you hear early.

What is the CMS 36 month rule?

It decides whether the Medicare billing privileges come with the agency. CMS explains it in chapter 10 of the Medicare Program Integrity Manual, section 10.6.1.1.5. I am not a lawyer, so read this as a map for your questions to counsel.

Under 42 CFR § 424.550(b)(1), CMS says that if there is a change in majority ownership of a home health agency by sale “within 36 months after the effective date of the HHA’s or hospice’s initial enrollment in Medicare or within 36 months after the HHA’s or hospice most recent change in majority ownership, the provider agreement and Medicare billing privileges do not convey to the new owner.” The buyer must enroll as a new agency and obtain a state survey or accreditation.

A change in majority ownership means acquiring more than 50 percent direct ownership, including through the cumulative effect of asset sales, stock transfers, mergers or consolidations. CMS gives an example: a 40 percent owner who buys another 15 percent has made a change in majority ownership.

How do you tell if the 36 month rule applies?

Run the four steps CMS gives its contractors in the same section. This is a summary for your attorney, not a ruling.

Step	Question	If yes	If no
1	Will you get more than 50% direct ownership?	Go to step 2	Rule not triggered
2	Is the sale within 36 months of initial enrollment or the last majority change?	Go to step 3	Rule not triggered
3	Does an exception apply?	Normal processing	Go to step 4
4	No exception	New enrollment and new survey or accreditation

The exceptions CMS lists in step 3:

1. The agency has submitted 2 consecutive years of full cost reports since initial enrollment or the last change in majority ownership. Low or no utilization cost reports do not count.
2. The parent company is undergoing an internal corporate restructuring, such as a merger or consolidation.
3. The agency is changing business structure and the owners remain the same.
4. An individual owner dies.

CMS also says the rule does not apply to indirect ownership changes. And it says providers and their attorneys “shall contact their local MAC with any questions” about whether the rule applies. Do that before you talk price.

What happens to the provider agreement in a change of ownership?

In a change of ownership under 42 CFR § 489.18, CMS says in the same chapter, section 10.6.1.1.1, that “the existing provider agreement is automatically assigned to the new owner unless the new owner rejects assignment.” Automatic assignment “means the new owner is subject to all the terms and conditions under which the existing agreement was issued.”

You keep billing, and you inherit the history: survey results, overpayment demands, the cost report record.

State rules sit on top of all this. CMS’s home health agency page says an agency must be “licensed pursuant to State or local law.” Licensing and change of ownership notices differ from state to state. Ask a healthcare attorney in that state.

How to buy a home health agency in 90 days

Here is how I would run it, for one region.

1. Days 1 to 14: settle the rules. Hire a healthcare attorney in the state. Learn the state licensing and change of ownership steps.
2. Days 15 to 30: talk to three lenders that finance home health deals, and two cost report preparers. Ask which agencies might come up.
3. Days 31 to 60: meet the referral side. Discharge planners at two hospitals, two SNF administrators, and the practice managers at physician groups that sign plans of care.
4. Days 61 to 90: one coffee a week with an owner or administrator. Attend a state home care association meeting. End every conversation with “who else should I know?”
5. Day 90 onward: keep a note per person with what they told you, plus each target’s enrollment date and last change of ownership, so you know where it sits on the 36 month clock.

What should you text?

Short and specific. Each of these is under 40 words.

To a cost report preparer:

“[Name], thanks for the time today. If an agency owner you work with starts thinking about an exit, I would value a quiet intro. I keep the staff and the name.”

To a hospital case manager:

“[Name], good to meet you. If an agency you work with ever needs a steady owner behind it, I would like to hear. Patients first, always.”

To an owner you met at an association meeting:

“[Name], enjoyed meeting you at the association meeting. You mentioned survey prep wearing you down. No agenda, I would like to hear how you are thinking about the next few years. Coffee next month?”

What does a worked example look like?

Illustrative, not a real deal. Say you track 30 people in one metro: three lenders, two cost report preparers, two attorneys, six discharge planners, four SNF administrators and thirteen owners. You note each target agency’s enrollment date.

A preparer mentions an owner who wants out. Your note says the agency’s last change in majority ownership was 26 months ago, inside the window. You ask your attorney about the cost report exception before anyone talks price.

For the owners and connectors already in your phone, see how to find owner direct business deals in your network. The same approach for dentists is in how to buy a dental practice. The full map is at deal flow for business buyers.

Where does this break?

Between visits. Another deal eats your next four months. The preparer hears the owner wants out and names the buyer who texted last week. If that was not you, the coffee did not count.

That is the job I built FRONT OF MIND for. At the meeting, say a name and a sentence out loud, snap a business card or badge, or take a selfie together, and it is filed under the event. Then it opens on your 10 minutes for today. Each person has a one line reason why today: they posted, their agency was in the news, you met weeks ago and never followed up, or they are going cold. Every draft is a text style message, 40 words max. Nothing sends without your tap, and it learns from your edits. Ask Liala “who do I know that is a discharge planner” and get the right people with why.

It runs in your phone’s browser and can be saved to your home screen. There is no native iPhone app yet. Your contacts are encrypted. No one on our team looks at them. Export or delete anytime.

Start free with your first 25 contacts and see which home health contact comes up first.

See how it works