New York - Adult Companion Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The New York State Office for People With Developmental Disabilities (OPWDD) does not fund a distinct service named Adult Companion Services, instead covering non-medical supervision and socialization through Community Habilitation and Respite under its Comprehensive HCBS 1915(c) Waiver. Providers seeking to offer these community-based supports must align their business models with OPWDD's established service definitions, which focus on integrating individuals into the community and providing relief to primary caregivers.

Agencies seeking to provide these socialization and supervision supports must first obtain a Letter of Intent (LOI) approval from the local OPWDD Regional Office before submitting a full provider enrollment application through the eMedNY Provider Services Portal. This regional needs-assessment acts as a structural precondition, meaning no new agency can enroll to bill Medicaid for these services without explicit regional sponsorship.

1. Service Definition and Scope

Because New York does not utilize the term Adult Companion Services, providers must enroll to provide Community Habilitation or Respite. Community Habilitation facilitates community inclusion, socialization, and independent living skills, while Respite provides temporary relief to family caregivers.

These services are delivered in the community or the individual's home, strictly prohibiting the provision of medical or clinical care by the direct support professional.

• Service Proxy 1: Community Habilitation focuses on socialization and skill-building.
• Service Proxy 2: Respite provides non-medical supervision to relieve primary caregivers.
• Waiver Authority: OPWDD Comprehensive HCBS 1915(c) Waiver.
• Setting Limitations: Must be delivered in non-certified, community-based settings compliant with the HCBS Settings Rule.

2. Regulatory and Oversight Agencies

The primary regulatory body for developmental disability services in New York is OPWDD, which dictates service standards and issues operating certificates. The Department of Health (DOH) manages the overarching Medicaid program and the eMedNY billing system.

Additionally, the Office of the Medicaid Inspector General (OMIG) enforces compliance and audits provider billing practices.

• Operating Authority: New York State Office for People With Developmental Disabilities (https://opwdd.ny.gov).
• Medicaid Agency: New York State Department of Health (https://www.health.ny.gov).
• Enrollment Portal: eMedNY Provider Services Portal (https://www.emedny.org).
• Audit Authority: Office of the Medicaid Inspector General (https://omig.ny.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

New York strictly controls the entry of new OPWDD waiver providers through a regional review process. An applicant cannot simply submit a Medicaid enrollment application; they must first be vetted by the state.

The structural precondition is the OPWDD Regional Office Letter of Intent (LOI) and subsequent agency review, which evaluates the applicant's fiscal viability, character and competence, and the regional need for the proposed services.

• Regional Sponsorship: Requires approval from the local OPWDD Developmental Disabilities Regional Office (DDRO).
• Initial Submission: Providers must submit a Letter of Intent (LOI) to the DDRO.
• Character and Competence: Board members and executives must pass a rigorous background and prior conduct review.
• Corporate Structure: Must be established as a legally authorized entity in New York State with a valid FEIN.

4. Licensure and Certification Requirements

While Community Habilitation and Respite do not always require a site-specific operating certificate like a group home, the agency itself must be certified by OPWDD as an approved HCBS waiver provider.

This certification process involves submitting comprehensive policy manuals, emergency plans, and proof of administrative capacity to OPWDD's Bureau of Quality Assurance.

• Agency Certification: OPWDD issues the overarching approval to operate as a waiver provider.
• Policy Review: Applicants must submit comprehensive operational policies for OPWDD review.
• Justice Center Affiliation: Must register with the NYS Justice Center for the Protection of People with Special Needs.
• HCBS Settings Compliance: Must attest to and demonstrate compliance with the federal HCBS Settings Final Rule.

5. Medicaid Provider Enrollment

Once OPWDD authorization is secured, the agency must enroll as a billing provider through the eMedNY Provider Services Portal. This step links the OPWDD certification to the state's Medicaid Management Information System (MMIS).

Providers must submit specific forms, including the ETIN Certification Statement, and pay the required federal application fee.

• System: eMedNY Provider Services Portal (PSP).
• Application Fee: $750 federal Medicaid enrollment fee (subject to annual CMS adjustment).
• Required Form: ETIN Certification Statement for New Enrollments (EMEDNY-490602).
• Required Form: Electronic Funds Transfer (EFT) Authorization.

6. Staffing, Training and Background Checks

Direct Support Professionals (DSPs) providing Community Habilitation or Respite must meet strict background check and training mandates enforced by OPWDD and the Justice Center.

Agencies are responsible for maintaining training records and ensuring all staff complete required modules before providing unsupervised care.

• Background Checks: Mandatory fingerprinting and screening through the NYS Justice Center.
• Exclusion Screening: Staff must be checked against the OMIG Medicaid Exclusion List and federal LEIE.
• Initial Training: DSPs must complete OPWDD-mandated orientation, including abuse prevention and incident reporting.
• Ongoing Training: Annual compliance and person-centered planning training required.

7. Documentation, Policies and Records

New York requires robust documentation to support Medicaid claims, governed by OPWDD regulations and OMIG compliance standards. Providers must maintain detailed service records, known as Staff Action Plans.

Agencies must also implement a formal Corporate Compliance Program if they meet specific billing thresholds.

• Service Plans: Must maintain individualized Staff Action Plans detailing goals and interventions.
• Session Notes: Contemporaneous documentation of service delivery, including start/stop times and activities.
• Compliance Program: Must adopt an effective compliance program pursuant to NYS Social Services Law section 363-d.
• Record Retention: Medicaid records must typically be retained for a minimum of six years.

8. Billing, Rates and Claims

Claims for OPWDD waiver services are submitted electronically to eMedNY. Rates for Community Habilitation and Respite are established by the DOH and OPWDD, often varying by geographic region (Upstate vs. Downstate).

Providers utilize the ePACES system or approved clearinghouses to submit HIPAA-compliant 837I or 837P transactions.

• Billing System: eMedNY via ePACES or direct EDI.
• Rate Setting: Regional fee-for-service rates published by DOH/OPWDD.
• Prior Authorization: Services must be authorized in the individual's Life Plan and approved by the DDRO.
• Remittance: Electronic Remittance Advice (ERA) or PDF remits delivered via eMedNY eXchange.

9. Approval Sequence and Timeline

The pathway to becoming a billing provider in New York is sequential and lengthy. It begins with the regional LOI and ends with eMedNY enrollment.

Providers should anticipate a timeline of 9 to 18 months from initial concept to first billable claim, depending on OPWDD review queues.

• Step 1: Submit Letter of Intent to OPWDD DDRO.
• Step 2: Complete OPWDD Character and Competence review.
• Step 3: Obtain OPWDD programmatic approval and authorization letter.
• Step 4: Submit eMedNY enrollment application with $750 fee.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete eMedNY submissions or failure to properly align corporate documents with OPWDD requirements.

During post-enrollment audits, OMIG frequently cites providers for missing contemporaneous session notes or failing to verify staff background checks.

• Enrollment Denial: Missing or mismatched FEIN on the IRS SS-4 assignment letter.
• Enrollment Delay: Failure to upload the required OPWDD authorization letter in the PSP.
• Audit Finding: Billing for services without a finalized, signed Staff Action Plan.
• Audit Finding: Failure to complete the annual OMIG Provider Compliance Certification.

11. Key Contacts and Resources

Prospective providers must utilize official state portals for accurate manuals, forms, and policy updates. The eMedNY portal is the central hub for enrollment forms.

OPWDD's website provides the necessary regulatory guidance and regional office contact information.

• eMedNY Provider Enrollment: https://www.emedny.org/info/providerenrollment/
• OPWDD Provider Resources: https://opwdd.ny.gov/providers
• NYS OMIG Compliance: https://omig.ny.gov/compliance/compliance
• eMedNY Call Center: 1-800-343-9000

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