For senior living leaders exploring continuing care at home (CCaH), regulatory complexity isn't a reason to hesitate, but it is a reason to do your homework before you start.
A common question we hear from senior living executives exploring continuing care at home (CCaH) programs is some version of this: "What do we actually need to do to operate one of these legally?"
The honest answer is: it depends on your state. The regulatory landscape for CCaH is fragmented, still evolving, and in many markets, largely uncharted. That creates both risk and opportunity for organizations willing to engage it thoughtfully.
Here's what you need to know.
The Starting Point: CCaH Is Not Uniformly Regulated Nationwide
Unlike traditional continuing care retirement communities (CCRCs), which are regulated in the vast majority of states, continuing care at home programs exist in a patchwork regulatory environment. Some states have explicit statutory frameworks for CCaH. Others apply CCRC regulations by extension. And in some states, there is no specific oversight at all.
The number of states with formal CCaH-specific regulatory frameworks remains small. This is both a challenge and, for mission-driven organizations, an opportunity to shape what responsible CCaH regulation looks like in your market.
States With Established CCaH Regulatory Frameworks
Maryland is among the most developed regulatory environments for CCaH. The Maryland Department of Aging oversees both CCRCs and CCaH programs under the state's continuing care statutes, and requires providers to obtain a Certificate of Registration before offering CCaH services. Maryland's regulatory framework includes financial oversight, disclosure requirements, and a Financial Review Committee that monitors providers' financial health this creates meaningful consumer protections that also establish credibility for programs operating within the framework.
North Carolina has also established comprehensive regulation for CCaH programs and Early Advantage programs. The North Carolina Department of Insurance licenses and regulates both CCRCs and CCaH programs under Article 64A of Chapter 58 of the General Statutes which was substantially modernized in recent years to reflect the evolved industry landscape. In North Carolina, a provider must obtain a separate CCaH license before arranging or providing any continuing care at home services, and may only apply for that license if the organization already holds a CCRC license or other qualifying authorization. The state requires disclosure statement filings specific to the CCaH program, and applies multi-stage approval processes with financial viability reviews at each stage.
Pennsylvania has been a notable early mover in CCaH, with more CCRCs offering or exploring at-home programs than most other states. Pennsylvania's continuing care provider regulations under Title 31 of the Pennsylvania Code govern entrance fee escrow requirements, liquid reserve obligations, and investment standards which provides a degree of financial oversight for CCaH programs that operate as extensions of licensed CCRCs. That said, as one legal analysis has noted, most states including Pennsylvania do not regulate at-home programs as standalone insurance products.
Florida regulates continuing care contracts under Chapter 651 of the Florida Statutes, administered by the Office of Insurance Regulation. Florida's framework includes escrow requirements for entrance fees and liquid reserve standards. Florida's framework is detailed and consumer-protective, and organizations exploring CCaH in the Florida market should engage legal counsel familiar with Chapter 651 early in the process.
New York has continuing care regulatory frameworks that extend to CCaH or at-home contract arrangements. New York's regulations, administered through the Department of Health, require CCRCs operating under a certificate of authority to maintain specific reserve liabilities for continuing care at home. However, the current framework has not been conducive to programs opening and operating in the state. There needs to be reform there to make it possible for organizations to be successful in this space.
States Where CCHA Operates in a Gray Zone
In many states, no specific CCaH statute exists. This doesn't mean anything goes, rather it means the legal analysis is more complex, and organizations must carefully evaluate which existing regulatory frameworks may apply.
Depending on the program structure, a CCaH offering could implicate:
- Insurance regulation, if the program's financial structure (entrance fees plus monthly premiums in exchange for a promise of future care) is interpreted as an insurance product or long-term care contract.
- CCRC statutes, if the state's existing continuing care law is broad enough to capture programs that don't require residential occupancy.
- Consumer protection and contract law, which applies in virtually every state regardless of whether a specific CCaH framework exists.
Key Variables That Differ by State
Even within states that regulate CCaH, the specific requirements vary significantly. Here are the dimensions that matter most:
Who oversees the program. Most of the states will house oversight of CCaH programs under the same entity that oversees brick and mortar CCRCs/LPCs. Depending on the state, CCaH programs may fall under the Department of Insurance, the Department of
Reserve requirements. Regulated states typically require CCaH providers to maintain liquid reserves sufficient to cover a defined period of operating expenses or projected future care obligations. The specific formulas and percentages differ by state, and some require actuarial analysis to validate reserve adequacy.
Disclosure requirements. Most regulated states require providers to file and maintain disclosure statements that give prospective members clear information about program costs, services, financial condition, and contract terms.
Who can offer a CCaH program. Some states, like North Carolina and New York, limit CCaH licensure to organizations that already hold a CCRC license. Others are more permissive like Maryland or Pennsylvania. This has significant strategic implications for organizations that are not traditional CCRCs but are exploring CCaH as a standalone or partnership offering.
Practical Guidance for Organizations Exploring CCaH
Given this landscape, here is what I advise organizations to prioritize before building a CCaH:
Do your research early. Before any program design work, understand exactly which regulatory frameworks apply in your state. This includes not just CCRC or CCaH statutes, but insurance law, home health licensure, and consumer protection frameworks. Don't assume that because another organization in a neighboring state has a program, the same approach will work in your market.
Engage your regulator before you're required to. In states where CCaH oversight is established or emerging, a proactive conversation with your regulatory agency builds credibility and often surfaces practical guidance that isn't in the written rules. Regulators who encounter CCaH applications from organizations they've never met are starting from a different posture than those who have had an ongoing dialogue with a provider.
Document your compliance framework. Even in states without specific CCaH regulation, building and maintaining a formal compliance framework such as covering contract terms, disclosure practices, financial reserves, and service delivery standards provides meaningful protection and positions your organization well when regulatory frameworks do arrive.
The Bottom Line
The regulatory landscape for CCaH is not static. Several dynamics are worth monitoring closely:
More states are likely to develop CCaH frameworks. As the model gains visibility and the consumer demand for aging-in-place options grows, state legislatures and insurance regulators will increasingly turn their attention to CCaH programs. Organizations operating in currently unregulated states should anticipate that a framework is coming and consider engaging in that conversation proactively rather than reactively. Early movers who help shape regulation often end up with frameworks that reflect operational reality more accurately than those written without their input.
It is important to leverage consumer demand with regulators and law makers in your state for progress in creating a framework.
Having these regulatory frameworks in your state will protect those consumers and offer them a desired and needed service.
The question isn't whether your organization can afford to deal with regulatory complexity. It's whether it can afford to leave the field to those who are willing to.