New York - Respite Care Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In New York, Respite Care provides short-term relief to unpaid primary caregivers, ensuring the care recipient maintains supervision and support. New York does not issue a standalone "Respite Care License." Instead, respite is an authorized service covered under specific Medicaid Home and Community-Based Services (HCBS) waivers, such as the Office for People With Developmental Disabilities (OPWDD) Comprehensive Waiver, the Nursing Home Transition and Diversion (NHTD) Waiver, and the Children's Waiver. To offer this service, a provider must first hold an underlying agency license (such as a Licensed Home Care Services Agency, or LHCSA) or a specific state agency certification, and then apply to add the respite service line.

The single biggest structural barrier to entry for a new respite provider in New York is the dual requirement of state programmatic designation and managed care network affiliation. A provider cannot simply submit a Medicaid enrollment application to bill for respite; they must first pass a gatekeeping review by a designating entity (such as the NYS Children's Provider Designation Review Team or a regional Regional Resource Development Center). Even after state Medicaid enrollment is achieved, the provider must secure credentialing and active contracts with regional Medicaid Managed Care Organizations (MCOs), which control the actual patient authorizations and network access.

1. Service Definition and Scope

In New York, Respite Care is defined as scheduled or emergency short-term relief provided to unpaid primary caregivers. It is delivered in hourly increments or 24-hour blocks, primarily in the participant's home, a certified Family Care home, or an approved community facility. The service ensures the participant's health and safety while the caregiver steps away.

The exact scope, duration, and setting of the service are dictated by the specific Medicaid waiver authorizing the care. For example, the NHTD waiver generally caps respite at 30 days per year, while the Children's Waiver includes specialized crisis respite requiring advanced trauma-informed care capabilities.

• Authority: authorized under 1915(c) HCBS Waivers, including NY.0444 (NHTD) and the OPWDD Comprehensive Waiver.
• Setting Limits: provided in the participant's home, an approved foster/family care home, or a certified community facility; it cannot be provided in an acute care hospital.
• Duration Caps: the NHTD waiver limits respite to 30 days per year unless prior authorization is granted by the regional gatekeeper.
• Service Exclusions: respite cannot duplicate or replace services otherwise available through the Medicaid State Plan, IDEA, or private insurance.
• Target Populations: tailored to specific waiver populations, including individuals with developmental disabilities (OPWDD), traumatic brain injuries (TBI), physical disabilities (NHTD), or behavioral health needs (Children's Waiver).

2. Regulatory and Oversight Agencies

Oversight of respite services in New York is fragmented across multiple state agencies, depending on the target population of the waiver. The New York State Department of Health (DOH) oversees the overarching Medicaid program and directly manages the NHTD and TBI waivers.

Other specialized agencies manage provider certification and designation for their respective populations. Providers must comply with the rules of the specific agency administering the waiver under which they are billing, as well as the state's centralized Medicaid enrollment contractor.

• NYS Department of Health (DOH): administers the Medicaid program and oversees the NHTD and TBI waivers (https://www.health.ny.gov).
• Office for People With Developmental Disabilities (OPWDD): certifies agencies and Family Care providers for I/DD respite services (https://opwdd.ny.gov).
• Office of Mental Health (OMH): co-manages the Children's Waiver HCBS designation process and reviews behavioral health respite providers (https://omh.ny.gov).
• NYS Office of Children and Family Services (OCFS): regulates foster care and certain youth respite settings (https://ocfs.ny.gov).
• eMedNY: operates the state's Medicaid Management Information System (MMIS) and the Provider Services Portal for enrollment (https://www.emedny.org).

3. Gatekeeping Prerequisites: Who Can Even Apply

New York strictly gates access to respite provider enrollment. You cannot apply directly to eMedNY for a respite billing number without first securing a programmatic designation or certification from the relevant state waiver authority. This structural precondition blocks any standalone Medicaid application.

Furthermore, because most New York Medicaid populations have transitioned to managed care, holding a state Medicaid ID is insufficient to receive patients. Providers must secure network contracts with Medicaid Managed Care Organizations (MCOs) or regional gatekeepers to actually operate.

• Underlying Licensure: applicants typically must already hold a valid NYS license, such as a Licensed Home Care Services Agency (LHCSA) under 10 NYCRR Article 36, or an OPWDD agency certification.
• Children's HCBS Designation: agencies must be approved by the NYS Children's Provider Designation Review Team before an eMedNY application is accepted.
• RRDC Approval: for NHTD/TBI waivers, providers must be interviewed and approved by the regional Regional Resource Development Center (RRDC).
• MCO Contracting: providers must successfully credential and contract with regional MCOs (e.g., Fidelis Care, Healthfirst) to receive patient authorizations.
• Fiscal Viability: designation applications require proof of organizational fiscal viability and established quality management policies.

4. Licensure and Certification Requirements

New York does not issue a specific "Respite Agency License." Instead, respite is an authorized service line added to an existing organizational license or certification. For medical or personal care respite, a LHCSA license is the standard underlying requirement.

For non-medical or behavioral respite, agencies must complete the specific waiver's certification process. For example, individuals providing respite in their own homes for OPWDD participants must pass rigorous safety inspections and complete the Family Care certification process.

• Corporate Registration: the business entity must be registered and in good standing with the New York Department of State.
• OPWDD Certification: requires completion of the LS-22 Application for Certification and a subsequent safety inspection for Family Care homes.
• LHCSA Licensure: requires compliance with 10 NYCRR Part 766 for agencies providing personal care or nursing tasks during respite.
• NPI Requirement: agencies must obtain a Type 2 (Organizational) National Provider Identifier (NPI) from the NPPES registry.
• Physical Plant Standards: facility-based respite locations must meet HCBS Settings Final Rule requirements and local fire/safety codes.

5. Medicaid Provider Enrollment

Once designated by the appropriate state agency, providers must enroll in the New York State Medicaid program via the eMedNY Provider Services Portal (PSP). The application data must perfectly match the provider's state designation records and IRS documents.

Enrollment requires paying an application fee and submitting detailed ownership disclosures. For Children's HCBS, providers enroll under a specific Category of Service (COS) and must notify the designation team once their MMIS number is issued.

• Portal Access: applications are submitted exclusively through the eMedNY Provider Services Portal (PSP) (https://www.emedny.org/portal/).
• Category of Service: designated Children's HCBS providers must enroll using Category of Service (COS) 0268.
• Application Fee: an institutional application fee (approximately $709 for 2024/2025) is required unless a federal waiver is granted.
• Ownership Disclosure: providers must complete the Ownership and Controlling Interest Disclosure (42 CFR 455.104) for anyone with 5 percent or more direct or indirect interest.
• Post-Enrollment Notification: newly enrolled providers must email their MMIS number to the Provider Designation Team to finalize system linkage.

6. Staffing, Training and Background Checks

Respite staff must meet stringent background check and training requirements mandated by the NYS Justice Center for the Protection of People with Special Needs and the specific waiver authority.

Agencies must maintain a master credentialing file for all staff. Training must be completed prior to service delivery and includes state-mandated modules on abuse prevention, mandated reporting, and population-specific care.

• Justice Center Checks: all staff must clear the NYS Central Register for Child Abuse and Maltreatment (SCR) and the Staff Exclusion List (SEL).
• Criminal History: fingerprint-based criminal history record checks (CBC) are mandatory for all patient-facing staff and household members over 18 in Family Care settings.
• Driver Monitoring: all staff transporting participants must be enrolled in the License Event Notification System (LENS).
• Mandated Training: staff must complete Mandated Reporter training and trauma-informed care training prior to delivering services.
• Medicaid Exclusion: agencies must screen all employees against the NYS Medicaid Exclusion List and federal LEIE monthly.

7. Documentation, Policies and Records

Respite providers must maintain comprehensive documentation to support both their agency designation and individual claims. Policies must align with the HCBS Settings Final Rule and state cultural competency guidelines.

Participant records must clearly document the primary caregiver's absence, the duration of the respite service, and the specific activities provided to ensure the participant's health and welfare during the block of time.

• Service Plans: respite must be explicitly authorized in the participant's individualized service plan (e.g., Life Plan for OPWDD participants).
• Session Notes: contemporaneous documentation must include start and stop times, location, and a description of the participant's status.
• Quality Management: agencies must maintain written quality management and reporting policies as required for HCBS designation.
• Cultural Competency: providers must maintain written policies demonstrating adherence to state cultural competency and trauma-informed care guidelines.
• Record Retention: all Medicaid service and billing records must be retained for a minimum of six years from the date of payment.

8. Billing, Rates and Claims

Respite services are billed either directly to eMedNY for fee-for-service participants or to the contracted Medicaid Managed Care Organization (MCO) for enrolled members. Rates vary significantly by waiver, region, and whether the service is hourly or per diem.

Providers must ensure that their taxonomy codes and NPIs match exactly on all claims. Electronic Visit Verification (EVV) may be required for in-home respite services depending on the specific personal care tasks performed.

• Billing System: fee-for-service claims are submitted via the eMedNY Medicaid Management Information System (MMIS).
• MCO Claims: managed care claims are submitted directly to the MCO according to their specific clearinghouse rules.
• Rate Structure: reimbursed in 15-minute increments for short-term relief or in 24-hour per diem blocks for overnight care.
• EVV Compliance: in-home respite involving personal care tasks must comply with NYS Electronic Visit Verification (EVV) requirements.
• Duplication Prohibition: claims will be denied if billed concurrently with other Medicaid State Plan services or during an inpatient hospital stay.

9. Approval Sequence and Timeline

Becoming a fully operational respite provider in New York is a multi-stage process that typically takes 9 to 18 months. The sequence must be followed strictly, as eMedNY will reject applications lacking prior state designation.

After state Medicaid enrollment, the MCO credentialing phase adds significant time. Providers cannot bill for managed care patients until both the state and the individual MCOs have approved their applications.

• Step 1: obtain underlying licensure (e.g., LHCSA) or agency incorporation (Timeline: 6-12 months).
• Step 2: submit designation application to the specific waiver authority, such as the Children's Designation Team or OPWDD (Timeline: 60-90 days).
• Step 3: submit Medicaid enrollment application via eMedNY PSP (Timeline: 45-90 days; applications delete if not submitted within 45 days of starting).
• Step 4: complete MCO credentialing and contracting for the target service area (Timeline: 90-120 days per plan).
• Step 5: receive participant referrals and authorizations from Care Managers or RRDCs prior to initiating service.

10. Common Denials and Survey Findings

Applications for respite designation and Medicaid enrollment are frequently delayed or denied due to administrative errors or failure to meet strict gatekeeping prerequisites. eMedNY is particularly strict about data matching.

During post-enrollment audits by the Office of the Medicaid Inspector General (OMIG) or DOH, providers often face recoupments for failing to properly document the caregiver's absence or exceeding authorized service limits.

• Application Rejection: eMedNY rejections often stem from incorrect signatures, incomplete ownership sections, or EFT upload errors.
• Data Mismatches: denials occur when the provider's name, NPI, or address on the eMedNY application does not perfectly match IRS and state licensing records.
• Audit Finding: billing for respite while the participant is receiving another Medicaid service (e.g., day habilitation) simultaneously.
• Audit Finding: missing contemporaneous session notes or failure to document the specific start and stop times of the respite shift.
• Credentialing Failure: losing an MCO network slot because the provider failed to maintain active NYS Medicaid fee-for-service enrollment.

11. Key Contacts and Resources

Navigating New York's complex waiver system requires direct communication with the specific state agencies and regional gatekeepers responsible for the target population.

Providers should regularly check the eMedNY portal and specific agency websites for updates to HCBS manuals, billing guidelines, and designation requirements.

• eMedNY Provider Enrollment: portal for Medicaid enrollment and PSP access (https://www.emedny.org/info/ProviderEnrollment/).
• NYS DOH HCBS Guidance: policy manuals and designation rules for Children's HCBS (https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/).
• OPWDD Provider Resources: certification and Family Care information for I/DD services (https://opwdd.ny.gov/providers).
• OMH Children's Designation Team: email for submitting MMIS numbers and designation questions (OMH-Childrens-Designation@omh.ny.gov).
• Fidelis Care (MCO): example of a major NY Medicaid Managed Care plan for credentialing (https://www.fideliscare.org).
• Healthfirst (MCO): example of a major NY Medicaid Managed Care plan for credentialing (https://healthfirst.org).

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