New York - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In New York, intermittent skilled nursing and therapy services provided in a patient's residence under a physician-ordered plan of care are delivered by Certified Home Health Agencies (CHHAs). Governed by Article 36 of the New York Public Health Law, CHHAs are distinct from Licensed Home Care Services Agencies (LHCSAs), which primarily provide personal care and cannot independently bill Medicare or Medicaid for skilled episodic care.

The single biggest structural barrier to entry for becoming a CHHA in New York is the Certificate of Need (CON) process. Unlike many states where licensure is an administrative application, New York requires prospective CHHAs to prove "Public Need" and obtain establishment approval from the Public Health and Health Planning Council (PHHPC) before a license application is even accepted. This process is highly restrictive, often subject to regional moratoria, and requires substantial financial and legal resources to navigate.

1. Service Definition and Scope

A Certified Home Health Agency (CHHA) in New York provides part-time, intermittent health care and support services to individuals who need skilled nursing care, physical therapy, occupational therapy, speech-language pathology, or medical social services in their homes. These services must be prescribed by a physician and delivered under a formal, periodically reviewed plan of care.

CHHAs are authorized to provide both acute post-hospitalization care and long-term intermittent care. They are the only home care entities in New York permitted to bill Medicare directly for home health services and to bill Medicaid under the Episodic Payment System (EPS).

• Skilled Nursing: Intermittent evaluation, care, and treatment provided by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs).
• Therapy Services: Physical, occupational, and speech-language pathology services aimed at rehabilitation and restoring function.
• Medical Social Services: Assessment and counseling provided by a Master of Social Work (MSW) to address social and emotional factors related to the patient's illness.
• Home Health Aide Services: Personal care and assistance with activities of daily living (ADLs) provided as an adjunct to skilled care.
• Medical Supplies and Equipment: Provision or coordination of necessary durable medical equipment (DME) and routine medical supplies.
• Plan of Care: All services must be strictly tied to a CMS-485 (or equivalent) physician-signed plan of care, updated at least every 60 days.

2. Regulatory and Oversight Agencies

The oversight of CHHAs in New York is divided among several state entities that handle establishment, licensure, Medicaid enrollment, and ongoing compliance. Providers must interact with multiple distinct portals and divisions to maintain their operational status.

The primary regulatory body is the New York State Department of Health (NYSDOH), which manages both the initial Certificate of Need process and ongoing surveillance through its regional offices.

• New York State Department of Health (NYSDOH): The primary licensing and regulatory authority for Article 36 agencies (https://www.health.ny.gov).
• Public Health and Health Planning Council (PHHPC): The statutory body that reviews and approves Certificate of Need (CON) applications for the establishment of new CHHAs (https://www.health.ny.gov/facilities/public_health_and_health_planning_council/).
• eMedNY: The Medicaid Management Information System (MMIS) and provider enrollment portal for New York State (https://www.emedny.org).
• Office of the Medicaid Inspector General (OMIG): Conducts audits, compliance reviews, and fraud investigations for Medicaid-enrolled providers (https://omig.ny.gov).
• Centers for Medicare & Medicaid Services (CMS): Federal agency that oversees Medicare certification, which is a prerequisite for CHHA Medicaid enrollment (https://www.cms.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

New York imposes severe structural preconditions on the establishment of new CHHAs. An applicant cannot simply submit a licensure application; they must first successfully navigate the Certificate of Need (CON) process, which acts as a strict gatekeeper to market entry.

The CON process requires applicants to demonstrate a definitive public need for the service in the proposed geographic area. If the state determines that existing CHHAs adequately serve the region, the application will be denied regardless of the applicant's qualifications.

• Certificate of Need (CON) Establishment Approval: Mandatory prior approval from the PHHPC under 10 NYCRR Part 710 before a licensure application can be filed.
• Public Need Methodology: Applicants must prove unmet demand in the target county using NYSDOH's specific statistical need methodologies; applications failing this test are rejected.
• Character and Competence Review: All proposed operators, board members, and owners must undergo a rigorous background review by NYSDOH to prove a history of high-quality care in any previously operated health facilities.
• Financial Feasibility: Applicants must submit certified financial projections proving the agency will be financially viable by its third year of operation without relying on excessive Medicaid utilization.
• Medicare Certification Prerequisite: CHHAs must obtain Medicare certification (Title XVIII) as a condition of operating and enrolling in Medicaid.
• Managed Care Contracting: While not a statutory bar to licensure, new CHHAs must secure contracts with Managed Long Term Care (MLTC) plans to receive Medicaid reimbursement for most dual-eligible patients, as fee-for-service Medicaid is highly restricted.

4. Licensure and Certification Requirements

Once CON approval is granted, the applicant moves into the licensure phase under Article 36 of the Public Health Law. This involves submitting detailed operational policies, architectural plans (if applicable to the office space), and undergoing a pre-opening survey.

The agency must demonstrate full compliance with 10 NYCRR Part 762, which governs the operation of Certified Home Health Agencies, before an Operating Certificate is issued.

• Article 36 Operating Certificate: The official license issued by NYSDOH authorizing the agency to provide CHHA services.
• Pre-Opening Survey: An on-site inspection by NYSDOH regional office staff to verify that the physical office, policies, and personnel files meet state standards.
• Policy and Procedure Manuals: Submission of comprehensive manuals covering patient rights, infection control, emergency preparedness, and quality assurance.
• Governing Authority: Establishment of a formal governing body and a Professional Advisory Committee (PAC) that includes at least one physician and one registered nurse.
• CMS-855A Application: Submission of the Medicare enrollment application to the designated Medicare Administrative Contractor (MAC) concurrent with state licensure.
• Initial Certification Survey: A federal survey conducted by NYSDOH (acting on behalf of CMS) or an approved accrediting organization (e.g., CHAP, ACHC) to grant Medicare certification.

5. Medicaid Provider Enrollment

After obtaining the Article 36 Operating Certificate and Medicare certification, the agency must enroll in the New York Medicaid program through the eMedNY portal. Enrollment is not guaranteed and is subject to OMIG compliance checks.

Providers must enroll under the specific category for Certified Home Health Agencies and must revalidate their enrollment every five years.

• eMedNY Provider Portal: The mandatory online system for submitting the Medicaid enrollment application (https://www.emedny.org/portal).
• Provider Type and Specialty: Must enroll as Provider Type 029 (Home Health Agency) with the appropriate specialty codes for CHHA services.
• Application Fee: Payment of the federal/state Medicaid institutional provider application fee (approximately $709 for 2024, adjusted annually), unless waived due to Medicare enrollment.
• ETIN Certification: Electronic Transmitter Identification Number (ETIN) application and certification statement required to submit electronic claims.
• OMIG Compliance Program: Certification that the agency has implemented a formal corporate compliance program meeting the requirements of NY Social Services Law Section 363-d.
• Revalidation: Mandatory re-enrollment every five years to maintain active Medicaid billing privileges.

6. Staffing, Training and Background Checks

New York enforces strict credentialing and background check requirements for all CHHA personnel. Clinical staff must hold valid New York State licenses, and paraprofessionals must complete state-approved training programs.

All patient-facing staff must be cleared through the NYSDOH Criminal History Record Check (CHRC) process before providing care.

• Professional Licensure: RNs, LPNs, PTs, OTs, and Speech Pathologists must hold current, unencumbered licenses issued by the New York State Education Department (NYSED) Office of the Professions.
• Home Health Aide Certification: HHAs must complete a NYSDOH-approved training program (minimum 75 hours) and be listed in active status on the Home Care Worker Registry.
• Criminal History Record Check (CHRC): Mandatory fingerprint-based background checks through the NYSDOH CHRC system for all unlicensed personnel and aides.
• Health Status and Immunizations: Annual physical exams, PPD/TB testing, and compliance with state mandates for influenza and COVID-19 vaccinations for all patient-facing staff.
• Supervision Requirements: RNs must conduct in-home supervisory visits for Home Health Aides at least once every 14 days.
• In-Service Training: HHAs must complete a minimum of 12 hours of documented in-service training annually.

7. Documentation, Policies and Records

CHHAs must maintain exhaustive clinical and administrative records to support both Medicare and Medicaid billing. Documentation must prove that care is medically necessary, intermittent, and authorized by a physician.

Agencies are required to use the Outcome and Assessment Information Set (OASIS) for all adult patients, which drives both quality reporting and reimbursement rates.

• Physician Orders (CMS-485): The comprehensive plan of care must be signed and dated by the attending physician before final billing, and recertified every 60 days.
• OASIS Assessments: Mandatory completion and transmission of OASIS data at start of care, resumption of care, recertification, and discharge.
• Visit Notes: Contemporaneous clinical notes for every visit, detailing the specific skilled interventions performed and the patient's response.
• Electronic Visit Verification (EVV): Mandatory use of an EVV system to record the date, time, and location of all personal care and home health aide visits.
• Incident Reporting: Mandatory reporting of adverse events, abuse, or neglect to the NYSDOH via the Health Commerce System (HCS).
• Record Retention: Clinical and billing records must be retained for a minimum of six years from the date of payment, per OMIG regulations.

8. Billing, Rates and Claims

Medicaid reimbursement for CHHAs in New York is primarily handled through the Episodic Payment System (EPS) for fee-for-service patients, which pays a base rate for a 60-day episode of care, adjusted for patient acuity.

However, the vast majority of long-term Medicaid home care in New York is managed by Managed Long Term Care (MLTC) plans. CHHAs must negotiate rates and submit claims directly to these MCOs for enrolled members.

• Episodic Payment System (EPS): NY Medicaid's fee-for-service payment model for CHHAs, based on 60-day episodes and adjusted using a state-specific case mix index.
• eMedNY Claims Submission: Fee-for-service claims must be submitted electronically via eMedNY using the 837I (Institutional) format.
• MLTC Contracting: Agencies must secure network contracts with regional MLTC plans (e.g., Fidelis, VNS Health) to serve Medicaid managed care enrollees.
• Prior Authorization: MLTC plans and fee-for-service Medicaid require prior authorization for home health services beyond initial assessment visits.
• Dual Eligibles: For patients with both Medicare and Medicaid, Medicare is the primary payer for skilled episodic care; Medicaid acts as the payer of last resort for copays or non-covered maintenance services.
• Cost Reporting: CHHAs must submit annual statistical and cost reports to NYSDOH, which are used to calculate future EPS base rates.

9. Approval Sequence and Timeline

Establishing a new CHHA in New York is a multi-year endeavor due to the rigorous Certificate of Need process and sequential federal and state approvals.

Applicants should expect a minimum of 18 to 24 months from the initial CON submission to the receipt of an active Medicaid provider number.

• CON Application Submission: Preparation and submission of Schedules 1-24 via the NYSE-CON system (Months 1-3).
• PHHPC Review and Approval: Administrative review, public comment period, and formal PHHPC committee hearings (Months 4-12).
• Pre-Opening Survey and Licensure: Facility inspection and issuance of the Article 36 Operating Certificate (Months 12-15).
• Medicare Initial Survey: CMS or accrediting body survey to achieve Medicare certification (Months 15-18).
• Medicare Tie-In: Issuance of the CMS Certification Number (CCN) by the MAC (Months 18-20).
• Medicaid Enrollment: Submission of the eMedNY application and final activation of the Medicaid provider ID (Months 20-22).

10. Common Denials and Survey Findings

Applications to establish a CHHA are most frequently denied during the CON phase due to an inability to prove public need or financial viability. NYSDOH strictly limits market entry to prevent over-saturation.

During operational surveys, CHHAs are commonly cited for clinical documentation failures, particularly regarding physician orders and care plan adherence.

• CON Denial - Lack of Need: The PHHPC rejects the application because the statistical methodology shows the county is already adequately served by existing CHHAs.
• CON Denial - Financial Infeasibility: Failure to prove the agency has sufficient working capital to survive the initial months of operation before billing revenue stabilizes.
• Survey Deficiency - Care Plan Non-Compliance: Providing services or visit frequencies that do not exactly match the physician-signed CMS-485.
• Survey Deficiency - Missed Visits: Failure to provide scheduled nursing or therapy visits without documented clinical justification and physician notification.
• Survey Deficiency - Inadequate Supervision: RNs failing to conduct and document the required 14-day supervisory visits for Home Health Aides.
• OMIG Audit Findings: Recoupment of Medicaid funds due to missing EVV data, unsigned physician orders, or lack of proof of aide training.

11. Key Contacts and Resources

Prospective CHHA providers must utilize official New York State portals for applications, background checks, and billing. Relying on outdated forms or third-party summaries can result in immediate application rejection.

The following official resources are essential for navigating the licensure and enrollment process in New York.

• NYSDOH Certificate of Need (CON) Program: Official guidance, schedules, and the NYSE-CON portal (https://www.health.ny.gov/facilities/cons/).
• eMedNY Provider Enrollment - Home Health: Enrollment forms, instructions, and moratorium updates for Provider Type 029 (https://www.emedny.org/info/providerenrollment/homehealth/).
• NYSDOH Home Care Registry: Portal for verifying Home Health Aide certification and training status (https://www.health.ny.gov/facilities/home_care/home_care_registry.htm).
• Health Commerce System (HCS): Secure NYSDOH portal required for incident reporting, CHRC background checks, and official state communications (https://commerce.health.state.ny.us).
• Office of the Medicaid Inspector General (OMIG): Resources for compliance program requirements and self-disclosure (https://omig.ny.gov).
• NYS Education Department - Office of the Professions: License verification for RNs, LPNs, and therapists (https://www.op.nysed.gov).

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