Certificate of Need State Tracker: CON Laws, Thresholds, and Reforms by State (2026)

CON Landscape at a Glance (2026)

• 35 states + DC — maintain active CON laws
• 15 states — no CON requirements
• 2,500–3,500 — estimated CON applications filed annually across active states
• $150,000–$350,000 — external consulting and legal cost for contested applications
• 6–12 months — unopposed application timeline
• 2–3 years — contested application timeline with appeals

Note: CON laws change through ongoing state legislative cycles. IHS monitors all 35 active states. Contact IHS for current status before making project decisions based on this tracker.

States With No CON Requirements (15 States)

The following states have no Certificate of Need requirements as of 2026. Healthcare organizations can build, acquire, or expand facilities in these states without state market-entry regulatory approval (subject to normal facility licensure and CMS certification requirements):

Active CON States: Thresholds, Fees, and Key Provisions

The following table covers the highest-volume and most strategically significant CON states. IHS provides advisory in all 35 active CON states — contact IHS for state-specific analysis not covered here.

This table covers selected high-volume states. The remaining active CON states include: Arkansas, Delaware, Hawaii, Maine, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, Ohio, Oklahoma, Oregon, Rhode Island, Vermont, West Virginia. Contact IHS for state-specific analysis in any active CON state.

2024–2026 CON Law Changes: What Healthcare Organizations Need to Know

Georgia — HB 1339 (2024): Single-Specialty ASC Exemption

Georgia House Bill 1339 created a significant new exemption for single-specialty ASCs owned by a single medical practice, under specified capital expenditure and operating room thresholds. This opens strategic opportunities for physician-owned ASC development in Georgia that were previously blocked by the CON process. Organizations that previously evaluated Georgia ASC projects and found them CON-required should re-evaluate under HB 1339's exemption criteria.

South Carolina — 2024 Partial Repeal

South Carolina repealed all CON requirements except nursing homes and selective hospital provisions in 2024. For most facility types — ASCs, home health, hospice, diagnostic imaging — South Carolina is now effectively a non-CON state. Organizations planning South Carolina projects previously blocked by CON review should reassess project viability under the post-repeal framework.

New York — 2025 Threshold Modernization

New York doubled the general hospital capital expenditure threshold from $15M to $30M and raised the ASC and clinic threshold from $6M to $8M in 2025. Many projects that previously triggered CON review in New York are now exempt. Health systems and ASC operators with pending or planned New York projects should verify whether the updated thresholds remove their project from CON coverage entirely.

Illinois — July 1, 2025 Threshold Update

Illinois updated its capital expenditure thresholds effective July 1, 2025: hospitals — $17,787,538; long-term care — $10,053,816; all other applicants including major medical equipment — $4,640,230. Projects near the prior thresholds may now fall below review requirements under the updated figures.

North Carolina — December 2025 Constitutional Ruling

North Carolina's December 2025 trial court ruling upheld the constitutionality of the state's CON laws, pausing a near-total repeal that had been scheduled to take effect. The ruling restores regulatory uncertainty for organizations that had been planning North Carolina projects under the assumption that CON would be eliminated. North Carolina currently operates under a 2023 interim policy exempting ASCs and MRI acquisitions in urban counties with populations over 125,000 — a narrower exemption than the full repeal that was anticipated. The litigation continues — IHS monitors and advises on the current state of North Carolina CON law for all project types.

Michigan — January 1, 2026 Threshold CPI Update

Michigan's annual CPI-indexed threshold update brought the capital expenditure threshold for clinical service areas to $4,272,500 effective January 1, 2026. Projects near the prior threshold should confirm whether the updated figure affects their CON requirement.

Iowa, Oklahoma, Washington — Behavioral Health Exemptions

Multiple states have enacted or are considering CON exemptions specifically for behavioral health facilities — psychiatric hospitals, residential treatment centers, and substance use disorder treatment programs — in response to documented mental health crises and inadequate behavioral health capacity. Organizations planning behavioral health facilities should verify current exemption scope before assuming CON review is required.

The CON Application Process: What Every State Requires

Despite state-by-state variation in thresholds, fees, and covered services, the CON application process follows a consistent structure across active states:

1. Pre-Application Strategic Assessment (Months 1–3). Market feasibility analysis; State Medical Facilities Plan (or equivalent) methodology review; competitive landscape assessment; identification of likely opposing applicants. IHS conducts pre-application analysis before any client files an LOI.
2. Letter of Intent (LOI) (Month 4). Formal notification to the state agency and public. LOI deadlines are strict — Tennessee requires LOI filing on the 1st–15th of the month; Georgia requires exactly 25 days before the application. Errors in LOI scope constrain the application.
3. Application Submission (Month 5). Exhaustive application package including epidemiological need analysis, financial projections, architectural schematics, staffing models, patient transfer agreements, and non-refundable state filing fee. Applications that do not match the state's SMFP methodology are categorically denied.
4. Public Comment and Hearing (Months 6–8). Competitors file written opposition. Public hearings allow competing applicants and incumbents to present expert testimony, cross-examine financial projections, and argue need methodology. IHS prepares clients for hearing testimony and manages competing application responses.
5. Agency Decision and Appeals (Months 9+). State agency approves, conditionally approves, or denies. Appeals filed in state courts add 1–2 years to the timeline. IHS coordinates with legal counsel on appeal strategy.
6. Implementation and Licensure Survey (Post-Approval). CON approval is permission to build — not a license to operate. State licensure survey after construction completion issues the facility license. CMS certification follows for Medicare/Medicaid participation.

Frequently Asked Questions

Planning a Healthcare Project in a CON State?

IHS provides CON threshold analysis, pre-application competitive intelligence, full-cycle application support, and hearing preparation for healthcare organizations in all 35 active CON states. Before filing a Letter of Intent — or before concluding your project does not require a CON — schedule a strategy consultation.