Why CON programs exist
CON laws were established in the 1970s to slow healthcare cost growth by preventing duplication of services and directing capacity where it's needed most. Federal law originally required states to operate CON programs; the federal mandate was repealed in the 1980s, and states have taken different paths since — some expanded, some narrowed, some repealed their programs entirely.
Reviewable vs non-reviewable services
What triggers CON review depends on the state. The comparison below shows the range of what a typical CON regime does and doesn't reach.
| Category | Typically reviewable | Typically not reviewable |
|---|---|---|
| Facilities | New hospitals; hospital expansions above capital thresholds | Physician offices, dental practices |
| Beds | Acute-care, psychiatric, nursing home beds | Observation beds in some states |
| Equipment | MRI, PET, cardiac cath, linear accelerators | Ultrasound, general radiography, CT in some states |
| Services | Open-heart surgery, transplant, burn units, ASCs (some states) | Urgent care, telehealth |
| Post-acute | Home health, hospice, skilled nursing (varies) | Independent living, personal care |
Category treatment varies by state — always confirm current statute and regulations. [VERIFY.]
How the review process works
Most states operate on a batch cycle: applications are accepted within a defined window, evaluated against statutory criteria and the state health plan, subjected to public comment or hearing, and decided by the agency. Competing applications may be reviewed comparatively. Adverse decisions typically trigger administrative appeal and, sometimes, judicial review.
What makes a strong application
A defensible filing addresses statutory criteria directly, documents need through original methodology, projects financial performance realistically, engages community and stakeholder support, and anticipates opposition. Applications that treat CON as a form-filling exercise almost always underperform.
Frequently asked questions
What is a Certificate of Need?
- A Certificate of Need (CON) is a state approval a healthcare organization must obtain before certain projects — building or expanding a facility, adding beds, acquiring major medical equipment, or offering new services. It requires proving the project is needed in the community.
Which states require a Certificate of Need?
- Roughly three dozen states and Washington, D.C., maintain some form of CON program, though requirements vary widely and change over time. PDA has prepared applications in North Carolina, Connecticut, Delaware, Florida, Georgia, Maryland, Oregon, South Carolina, Utah, and West Virginia. [VERIFY current list.]
How long does the CON process take?
- It varies by state and project, typically several months to over a year including review, public comment, and any appeals. [VERIFY per state.]
What goes into a CON application?
- A demonstration of community need, market and demographic analysis, financial forecasts, competitive analysis, and alignment with the state health plan — plus a strategy to withstand comment and competing applications.