Certificate of Need State Tracker: CON Laws, Thresholds, and Reforms by State (NCSL Data Updated April 29, 2025)
Last updated: October 2026
NCSL counts 35 states and Washington, D.C. as operating Certificate of Need programs, in a page updated April 29, 2025 (NCSL, Certificate of Need State Laws, page opened October 4, 2026). Capital expenditure thresholds, covered services, filing fees, and exemptions vary dramatically by state — and the landscape changes every legislative cycle. This tracker documents the current CON status for each active state, recent 2024-2026 legislative changes, and the strategic implications for healthcare organizations planning new facilities, equipment acquisitions, or service expansions.
CON Landscape at a Glance (NCSL, Updated April 29, 2025)
- 35 states + DC — operate CON programs, per NCSL (updated April 29, 2025)
- 15 states — no CON program (50 states less the 35 NCSL counts)
- 90 days — North Carolina's review period for a CON application, which the Department may extend by up to 60 days (N.C. Gen. Stat. 131E-185, page opened October 4, 2026)
Note: CON laws change through ongoing state legislative cycles. IHS tracks the CON requirements in the states where each client operates. Contact IHS for current status before making project decisions based on this tracker.
States With No CON Program in NCSL's Table (15 States)
NCSL's state table, which lists each state's CON law as of January 2025, shows no facilities regulated under a CON law in the 15 states below (NCSL, Certificate of Need State Laws, page opened October 4, 2026). NCSL notes that Arizona, Minnesota and Wisconsin keep other approval processes that work like CON, and every state still licenses facilities, so check the state's rules before you plan a project.
| State | CON Status | Notes |
|---|---|---|
| Arizona | No CON | No CON program, but NCSL notes other approval processes that work like CON |
| California | No CON | No CON program |
| Colorado | No CON | No CON program |
| Idaho | No CON | No CON program |
| Kansas | No CON | No CON program |
| Minnesota | No CON | No CON program, but NCSL notes other approval processes that work like CON |
| New Hampshire | No CON | Repealed in 2016, per NCSL |
| New Mexico | No CON | No CON program |
| North Dakota | No CON | No CON program |
| Pennsylvania | No CON | No CON program |
| South Dakota | No CON | No CON program |
| Texas | No CON | No CON program |
| Utah | No CON | No CON program |
| Wisconsin | No CON | No CON program, but NCSL notes other approval processes that work like CON |
| Wyoming | No CON | No CON program |
Active CON States: Thresholds, Fees, and Key Provisions
The following table covers the highest-volume and most strategically significant CON states. IHS tracks the CON requirements in the states where each client operates. Contact IHS for state-specific analysis not covered here.
| State | Capital Expenditure Threshold | State Filing Fee | Covered Facility Types | Recent Changes / Key Notes |
|---|---|---|---|---|
| North Carolina | $4,000,000 for a capital expenditure to develop or expand a health service, adjusted each September 30 by the medical care CPI (N.C. Gen. Stat. 131E-176(16)b, page opened October 4, 2026) | $5,000 plus 0.3% of the proposed capital expenditure above $1,000,000, capped at $50,000 (N.C. Gen. Stat. 131E-182(c), page opened October 4, 2026) | Health service facilities as the statute defines them, including hospitals, rehabilitation facilities, nursing homes, adult care homes, kidney disease treatment centers, home health agency offices, diagnostic centers, hospice offices and facilities, and ambulatory surgical facilities (N.C. Gen. Stat. 131E-176(9b), page opened October 4, 2026) | A project must be consistent with the applicable policies and need determinations in the State Medical Facilities Plan (N.C. Gen. Stat. 131E-183(a)(1), page opened October 4, 2026). Confirm the current scope of exemptions with N.C. DHSR (N.C. DHSR, Certificate of Need, page opened October 4, 2026) before planning a project. |
| New York | Review level depends on total project cost and other criteria. Limited review: up to $30 million at hospitals and up to $8 million at other facilities. Full review: above the greater of $60 million or 10% of operating costs at hospitals, and above the greater of $20 million or 10% of operating costs at other facilities, with the 10% figure capped at $150 million for hospitals and $30 million for others. Administrative review sits between limited and full (NYSDOH, 10 NYCRR 710.1 guidance, page opened October 4, 2026) | Varies by project type — contact NYSDOH | Includes hospitals, nursing homes, home care agencies and diagnostic and treatment centers, per NYSDOH (NYSDOH, Certificate of Need, page opened October 4, 2026) | NYSDOH reports that its amendment to 10 NYCRR 710.1 was posted in the State Register on August 6, 2025, and is in effect (NYSDOH, Certificate of Need, page opened October 4, 2026). |
| Illinois | $18,321,164 for hospitals, $10,355,430 for long-term care and $4,779,437 for other projects, effective July 1, 2026 (Illinois HFSRB, Notice of revised thresholds, page opened October 4, 2026) | Contact the Illinois Health Facilities and Services Review Board | Confirm covered services with the Illinois Health Facilities and Services Review Board | The Review Board revised its thresholds on July 1, 2026, a 3.20% adjustment under the Illinois Health Facilities Planning Act (Illinois HFSRB, Notice of revised thresholds, page opened October 4, 2026). |
| Tennessee | Confirm current thresholds with the Tennessee Health Facilities Commission | Contact the Tennessee Health Facilities Commission | Confirm covered services with the Tennessee Health Facilities Commission | The Tennessee Health Facilities Commission runs the state's Certificate of Need program (Tennessee Health Facilities Commission, page opened October 4, 2026). |
| Georgia | Confirm current thresholds with the Georgia Department of Community Health | Contact the Georgia Department of Community Health | Confirm covered services with the Georgia Department of Community Health | NCSL summarizes HB 1339 (2024) as revising Georgia's CON review (NCSL, Certificate of Need State Laws, page opened October 4, 2026). Check the current rules with the Georgia Department of Community Health. |
| Washington State | Confirm current thresholds with the Washington State Department of Health | Contact the Washington State Department of Health | Confirm covered services with the Washington State Department of Health | Check current review rules with the Washington State Department of Health. |
| Maryland | Confirm current thresholds with the Maryland Health Care Commission | Contact the Maryland Health Care Commission | Confirm covered services with the Maryland Health Care Commission | Check current review rules with the Maryland Health Care Commission. |
| Michigan | Confirm the current figure with the Michigan Department of Health and Human Services | Contact the Michigan Department of Health and Human Services | Hospitals, psychiatric hospitals and units, nursing homes and hospital long-term care units, freestanding surgical outpatient facilities and HMOs, per NCSL | NCSL lists a covered capital expenditure above the state's threshold among Michigan's CON triggers (NCSL, Certificate of Need State Laws, page opened October 4, 2026). |
| Kentucky | Confirm current thresholds with the Kentucky Cabinet for Health and Family Services | Contact the Kentucky Cabinet for Health and Family Services | Confirm covered services with the Kentucky Cabinet for Health and Family Services | Check current review rules with the Kentucky Cabinet for Health and Family Services. |
| Iowa | Confirm current thresholds with Iowa's Certificate of Need agency | Contact Iowa's Certificate of Need agency | Confirm covered services with Iowa's Certificate of Need agency | Check current review rules with Iowa's Certificate of Need agency. |
| Florida | Confirm current thresholds with Florida's Certificate of Need agency | Contact Florida's Certificate of Need agency | Confirm covered services with Florida's Certificate of Need agency | Check current review rules with Florida's Certificate of Need agency. |
| Alabama | Confirm current thresholds with the Alabama State Health Planning and Development Agency | Contact the Alabama State Health Planning and Development Agency | Confirm covered services with the Alabama State Health Planning and Development Agency | Check current review rules with the Alabama State Health Planning and Development Agency. |
| Connecticut | Confirm current thresholds with the Connecticut Office of Health Strategy | Contact the Connecticut Office of Health Strategy | Confirm covered services with the Connecticut Office of Health Strategy | Check current review rules with the Connecticut Office of Health Strategy. |
| Virginia | Confirm current thresholds with the Virginia Department of Health | Contact the Virginia Department of Health | Confirm covered services with the Virginia Department of Health | Check current review rules with the Virginia Department of Health. |
Agency names follow each agency's own Certificate of Need page or rules. The North Carolina, New York, Illinois and Tennessee agency names follow the agency pages the table cites (NC Division of Health Service Regulation, Healthcare Planning and Certificate of Need Section, New York State Department of Health, Certificate of Need, Illinois Health Facilities and Services Review Board and Tennessee Health Facilities Commission, pages opened October 6, 2026). Georgia, Washington, Maryland, Michigan, Kentucky, Alabama, Connecticut and Virginia: (Georgia Department of Community Health, Certificate of Need, page opened October 4, 2026), (Washington State Department of Health, Certificate of Need, page opened October 4, 2026), (Maryland Health Care Commission, Certificate of Need, page opened October 4, 2026), (Michigan Department of Health and Human Services, Certificate of Need, page opened October 4, 2026), (Kentucky Cabinet for Health and Family Services, Division of Certificate of Need, page opened October 4, 2026), (Alabama State Health Planning and Development Agency, Certificate of Need Rules and Regulations, page opened October 4, 2026), (Connecticut Office of Health Strategy, Certificate of Need, page opened October 4, 2026) and (Virginia Department of Health, Certificate of Public Need Program, page opened October 4, 2026).
This table covers selected high-volume states. NCSL's state table also lists a Certificate of Need law for Alaska, Arkansas, Delaware, Hawaii, Indiana, Louisiana, Maine, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Vermont, West Virginia and the District of Columbia (NCSL, Certificate of Need State Laws, page opened October 6, 2026). Contact IHS for state-specific analysis in any of these states.
2024–2026 CON Law Changes: What Healthcare Organizations Need to Know
Georgia — HB 1339 (2024)
NCSL's summary of Georgia's HB 1339, enacted in 2024, lists changes that include removing the $10 million review threshold set in 2019 and adding exemptions for some psychiatric and substance use inpatient programs, rural perinatal services and certain rural hospitals (NCSL, Certificate of Need State Laws, page opened October 4, 2026). Organizations that ruled out a Georgia project under the earlier rules should check it against the current law with the Georgia Department of Community Health.
South Carolina — Repeal Legislation
NCSL reports that South Carolina repealed all of its CON requirements except those for nursing homes and a few that relate to hospitals (NCSL, Certificate of Need State Laws, page opened October 4, 2026). Organizations planning South Carolina projects should check which requirements still apply to their project.
New York: 2025 Amendment to 10 NYCRR 710.1
NYSDOH reports that its amendment to 10 NYCRR 710.1, which sets the CON review process for health facility construction projects, was posted in the State Register on August 6, 2025, and is now in effect (NYSDOH, Certificate of Need, page opened October 4, 2026). Its guidance sets the level of review by total project cost and other criteria, with higher limits for hospitals than for other facilities (NYSDOH, 10 NYCRR 710.1 guidance, page opened October 4, 2026).
Illinois: July 1, 2026 Threshold Update
The Illinois Health Facilities and Services Review Board revised its CON review thresholds on July 1, 2026, to $18,321,164 for hospitals, $10,355,430 for long-term care and $4,779,437 for other projects (Illinois HFSRB, Notice of revised thresholds, page opened October 4, 2026). Projects near the prior thresholds may now fall below review requirements under the updated figures.
North Carolina: Current Exemptions
Confirm the current scope of North Carolina's CON exemptions with N.C. DHSR (N.C. DHSR, Certificate of Need, page opened October 4, 2026) before planning a project. IHS advises each client on the current state of North Carolina CON law for its project.
Michigan — Capital Expenditure Threshold
Michigan's CON law covers a capital expenditure above the state's threshold, along with new facilities, bed changes and covered clinical services (NCSL, Certificate of Need State Laws, page opened October 4, 2026). Projects near the threshold should confirm the current figure with the Michigan Department of Health and Human Services.
Behavioral Health Exemptions
Some states exempt certain behavioral health facilities from CON review. NCSL's summary of Georgia's HB 1339, for example, lists exemptions for some psychiatric and substance use inpatient programs (NCSL, Certificate of Need State Laws, page opened October 4, 2026). Organizations planning behavioral health facilities should check the current exemption scope with the state's CON agency 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:
- Pre-Application Strategic Assessment. 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.
- Letter of Intent (LOI). Formal notification to the state agency and public. Each state sets its own LOI deadlines and requirements, so check the state's rules before you file.
- Application Submission. Exhaustive application package including epidemiological need analysis, financial projections, architectural schematics, staffing models, patient transfer agreements, and non-refundable state filing fee.
- Public Comment and Hearing. 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.
- Agency Decision and Appeals. State agency approves, conditionally approves, or denies. In North Carolina, the statute sets a 90-day review period for applications, which the Department may extend by up to 60 days (N.C. Gen. Stat. 131E-185, page opened October 4, 2026). IHS coordinates with legal counsel on appeal strategy.
- 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
Do all states require a CON for home health agencies?
No. CON requirements for home health agencies vary by state. In North Carolina, a new home health agency must obtain a certificate of need before it is developed (N.C. DHSR, Certificate of Need, page opened October 4, 2026). Coverage in other states differs, so check each state's CON law for the service you plan. IHS provides state-specific home health CON analysis for operators planning new agency locations.
Can incumbents block a competitor's CON application?
Yes. In states with competitive or comparative review processes, incumbent hospitals, health systems, and competing applicants can file formal opposition, submit expert testimony, and challenge the applicant's need analysis at public hearings. Incumbents have a strong financial incentive to oppose independent ASC and specialty facility applications — particularly when commercially insured patient volume is at stake. IHS prepares CON applications specifically to withstand incumbent opposition: the need analysis is built to anticipate and address competitor arguments, not to react to them after the fact.
What does a CON review look at?
Each state's review criteria differ, so read the criteria for the state where you plan to file. In North Carolina, a proposed project must be consistent with the applicable policies and need determinations in the State Medical Facilities Plan (N.C. Gen. Stat. 131E-183(a)(1), page opened October 6, 2026). IHS builds need analyses from the state methodology first, then supplements with supporting data.
Is a CON required to acquire an existing healthcare facility?
It depends on the state and the nature of the transaction. Most states distinguish between capital expenditures for new construction or new services (typically covered) and ownership transfers of existing facilities (coverage varies significantly). In some states, a change of ownership triggers CON review; in others, it does not. IHS conducts CON threshold analysis for acquisition transactions before any purchase agreement is executed.
Which CON states does IHS work in?
IHS tracks the CON requirements in the states where each client operates. The table above covers North Carolina, New York, Illinois, Tennessee, Georgia, Washington State, Maryland, Michigan, Kentucky, Iowa, Florida, Alabama, Connecticut and Virginia. Thomas G. Goddard, JD, PhD supports contested CON applications as a consultant and advisor to the applicant's counsel, including expert testimony support where appropriate.
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 the states where each client operates. Before filing a Letter of Intent — or before concluding your project does not require a CON — schedule a strategy consultation.