Home Health OTs and the Patient's State

For home health OTs, the license you need is the one for the state where the patient lives, not the state where your agency is based. The OT Compact's model law states the general rule: practice "occurs in the State where the patient/client is located at the time of the patient/client encounter." An agency in one state that sends you across a river or a county line to see patients needs you authorized in that second state too, by license or, where both states issue them, by compact privilege.

Why does this come up so often in home health?

Because metro areas ignore state lines and home health follows the patient. A clinic OT treats everyone in one building in one state. A home health OT may cover a caseload across two or three states in a single week, and a new referral can arrive from an address you have no authority to visit. Medicare's home health conditions of participation also require the OT to be licensed by "the state in which practicing" (42 C.F.R. § 484.115(f)), so the agency has its own reason to check.

Where does the compact help, and where does it not?

The compact helps only between states that are both issuing privileges. As of October 2026, ten are: Minnesota, Ohio, West Virginia, Indiana, Virginia, Maryland, Tennessee, Wisconsin, Arkansas and Mississippi. A few metro examples show how uneven that is:

• Memphis: Tennessee, Mississippi and Arkansas all issue privileges, with Arkansas and Mississippi starting October 5, 2026. An OT who lives in any of the three and holds that state's license can now seek privileges in the other two.
• Cincinnati: Ohio and Indiana issue privileges, but Kentucky has only enacted the compact and is not issuing yet. Northern Kentucky patients still need a Kentucky license.
• Washington, DC: Maryland and Virginia issue privileges; the District of Columbia is not a member. DC patients need a DC license.
• Philadelphia: Pennsylvania has enacted the compact but is not issuing, and New Jersey is not a member. Both sides need licenses for now.
• Kansas City: Missouri and Kansas have both enacted the compact; neither is issuing. Licenses on both sides.

Statuses change as states open applications, so check the Commission's map before you plan. See which states are issuing privileges.

Does the privilege route depend on where you live?

Yes, and home health OTs who live on one side of a metro sometimes miss it. Your home state is your primary residence, and it must be issuing privileges. An OT who lives in Kentucky and works in Cincinnati cannot use the compact today, even though Ohio issues privileges, because Kentucky is not issuing. That OT needs an Ohio license. If you move across the line, your home state changes too. See your home state and the OT Compact.

Which state's practice rules apply in the home?

The patient's state's, for everything: scope, documentation, OTA supervision and modalities. A privilege holder "shall function within the laws and regulations of the Remote State" (OT Compact, Section 4.C). OTAs on a privilege must be supervised by an OT licensed or holding a privilege in that state (Section 4.D), which matters when an agency pairs OTs and OTAs across a state line. See OTA supervision rules.

What do Medicare's home health rules add?

Beyond the licensing requirement, the conditions of participation set what an OT may do at the start of care. Under 42 C.F.R. § 484.55, a registered nurse normally conducts the initial and comprehensive assessments, but when rehabilitation therapy is the only service ordered, the therapist may. For Medicare patients, the rule says an OT "may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility," and similarly for the comprehensive assessment.

Enrollment and billing are a separate track from licensure, and the agency, not the OT, enrolls as the home health provider. For enrollment questions, see our sister site's guide to enrolling in Medicare through PECOS and our post on Medicare for OTs.

How should an agency plan coverage?

1. Map the service area by state, and by compact status for each state.
2. For each OT and OTA, list where they live and where they are licensed or hold privileges.
3. Route referrals by authority, not only by geography.
4. Apply for licenses ahead of need in states that are not issuing privileges; endorsement takes weeks, not days.
5. Remind staff that each OT completes and pays for their own compact privilege; the Commission says employing agencies "may not legally complete the application on behalf of licensees."

Physical therapists face the same map; our sister site covers it in home health PT across a metro state line.

How do we help home health OTs and agencies?

We sort out which states need a license and which can use a privilege, file endorsement applications ($599 per state for OTs, $499 for OTAs), and run guided privilege sessions where each OT completes their own application. See also licensing for OT staffing and contract companies and the state license index.