New York - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In New York, Skilled Nursing Services delivered in the home (including RN and LPN assessments, medication administration, and skilled treatments) are not typically enrolled as standalone independent nursing practices under Medicaid Home and Community-Based Services (HCBS). Instead, providers must be licensed as a Licensed Home Care Services Agency (LHCSA) or a Certified Home Health Agency (CHHA) under Article 36 of the New York Public Health Law.

The single biggest structural barrier to entry for this service in New York is the Department of Health's Certificate of Need (CON) process and the statutory LHCSA moratorium. Applicants cannot simply submit a license application; they must first pass a rigorous Public Need Review by the Public Health and Health Planning Council (PHHPC) or qualify for a narrow exception to the ongoing moratorium on new LHCSA applications, making market entry highly restricted.

1. Service Definition and Scope

Under New York Medicaid, in-home skilled nursing services encompass preventative, therapeutic, rehabilitative, and palliative care provided by Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). These services must be medically necessary and delivered strictly under the written orders of a physician.

Because New York regulates the agency rather than the individual practitioner for home care billing, the scope of services is dictated by the agency's Article 36 operating certificate. This includes comprehensive patient assessments, wound care, medication administration, and disease management.

• Authorizing Statute: New York Public Health Law (PHL) Article 36 governs all home care services agencies.
• Service Modality: In-home skilled nursing care delivered by RNs and LPNs.
• Physician Orders: Required for all skilled nursing treatments, medication administration, and care plan approvals.
• Assessment Tool: The Uniform Assessment System for New York (UAS-NY) is mandatory for determining patient acuity and care needs.
• Supervision: LPNs must be supervised by an RN in accordance with New York State Education Department (NYSED) Office of the Professions guidelines.

2. Regulatory and Oversight Agencies

Oversight of skilled nursing providers in New York is highly fragmented. The Department of Health handles facility licensure and Medicaid administration, while the Office of the Medicaid Inspector General enforces compliance and program integrity.

Additionally, individual nursing professionals must maintain their credentials through the State Education Department, and billing is processed through the state's centralized MMIS contractor.

• Licensing Authority: New York State Department of Health (NYSDOH) Division of Home and Community Based Services (https://www.health.ny.gov/facilities/home_care/).
• Medicaid Administrator: NYSDOH Office of Health Insurance Programs (OHIP) (https://www.health.ny.gov/health_care/medicaid/).
• Medicaid Enrollment Portal: eMedNY Provider Services Portal (PSP) (https://www.emedny.org/).
• Professional Licensing: New York State Education Department (NYSED) Office of the Professions (https://www.op.nysed.gov/).
• Compliance Oversight: New York State Office of the Medicaid Inspector General (OMIG) (https://omig.ny.gov/).

3. Gatekeeping Prerequisites: Who Can Even Apply

New York imposes severe structural preconditions on new home care agencies. You cannot submit a standard licensure application without first clearing statutory need-review hurdles, which are designed to limit the proliferation of agencies.

The state actively restricts new market entrants through a moratorium and a rigorous Certificate of Need process. Furthermore, because most Medicaid home care is managed, providers must secure network contracts with managed care plans to survive financially.

• LHCSA Moratorium: A statutory moratorium on new LHCSA applications blocks general market entry; applicants must meet specific exception criteria (e.g., affiliation with an Assisted Living Program) to even file.
• Certificate of Need (CON): CHHAs must obtain a CON demonstrating public need, financial feasibility, and character/competence before a license application is accepted.
• Public Health and Health Planning Council (PHHPC): The governing body that must formally approve the establishment of the agency under PHL Article 36 before licensure proceeds.
• Managed Care Contracting: Providers must secure contracts with Managed Long Term Care (MLTC) plans, which often operate closed networks and refuse new providers.
• Financial Feasibility: Applicants must prove sufficient capitalized operating funds (often requiring millions in reserve) to sustain the agency without Medicaid revenue during the initial startup phase.

4. Licensure and Certification Requirements

If an applicant successfully navigates the CON or moratorium exceptions, they must submit a comprehensive licensure application detailing their operational, clinical, and financial frameworks.

This process involves intense scrutiny of the owners' backgrounds and requires the development of extensive policy manuals that meet NYSDOH standards before an Operating Certificate is issued.

• Application System: NYSE-CON (New York State Electronic Certificate of Need) portal is used for submitting all Article 36 applications.
• Required Form: DOH-1056 (or current LHCSA/CHHA application schedules) detailing organizational structure, ownership, and policies.
• Character and Competence Review: Extensive background checks, fingerprinting, and legal disclosures for all owners, operators, and board members.
• Policies and Procedures: Must submit comprehensive manuals covering patient rights, infection control, emergency preparedness, and quality assurance.
• Operating Certificate: Issued by NYSDOH only after a successful pre-opening survey confirms the agency is ready to safely admit patients.

5. Medicaid Provider Enrollment

Once the NYSDOH Operating Certificate is secured, the agency must enroll in the New York State Medicaid program through the eMedNY system. State enrollment grants access to fee-for-service billing and is a prerequisite for managed care credentialing.

Under the 21st Century Cures Act, all providers in a Medicaid managed care network must also be actively enrolled with the State Medicaid agency.

• Enrollment System: eMedNY Provider Services Portal (PSP).
• Category of Service (COS): Typically COS 0260 for CHHAs or COS 0284 for LHCSAs.
• Required Form: ETIN Certification Statement (Form 490501) must be notarized and submitted to establish electronic billing capabilities.
• Application Fee: Subject to the ACA institutional provider application fee (approximately $709) unless waived via existing Medicare enrollment.
• Medicare Enrollment: CHHAs must be Medicare-certified by CMS prior to applying for Medicaid enrollment.
• OMIG Compliance Attestation: Providers must attest to having an active compliance program meeting 18 NYCRR Part 521 requirements during enrollment.

6. Staffing, Training and Background Checks

New York mandates strict credentialing and health screening for all clinical staff entering a patient's home. Agencies are responsible for verifying licenses and maintaining continuous compliance.

The state utilizes a centralized criminal history check system, and agencies face severe penalties if staff provide care before receiving official clearance.

• Professional Licensure: RNs and LPNs must hold active, unencumbered licenses verified through the NYSED Office of the Professions.
• Background Checks: Mandatory fingerprinting and clearance through the NYSDOH Criminal History Record Check (CHRC) program prior to patient contact.
• Exclusion Screening: Mandatory monthly screening of all staff against the OMIG Medicaid Exclusion List and the federal HHS-OIG LEIE.
• Health Assessments: Staff must undergo annual health assessments, including PPD/TB testing and proof of required immunizations (e.g., Rubella, Rubeola).
• In-Service Training: Agencies must provide and document ongoing annual in-service education specific to home care, patient rights, and infection control.

7. Documentation, Policies and Records

Clinical documentation must strictly align with physician orders and state-mandated assessment tools. New York requires robust record-keeping to support both clinical outcomes and billing integrity.

Agencies must also implement electronic systems to track visits and maintain a formal compliance program to prevent fraud, waste, and abuse.

• Plan of Care: Must be established by an RN, signed by a physician, and reviewed/updated at least every 60 days.
• Electronic Visit Verification (EVV): Required for applicable home health services to electronically verify the date, time, and location of care.
• Record Retention: Patient and billing records must be retained for a minimum of six years from the date of service or payment.
• UAS-NY Assessments: Mandatory use of the Uniform Assessment System for New York for determining patient acuity and justifying service authorization.
• Compliance Program: Written policies and a designated compliance officer meeting OMIG standards under Social Services Law Section 363-d.

8. Billing, Rates and Claims

The majority of skilled nursing home care in New York is billed through Managed Long Term Care (MLTC) plans rather than straight Medicaid fee-for-service. Providers must negotiate rates directly with these plans.

For the remaining fee-for-service population, claims are submitted electronically to eMedNY using standardized institutional or professional formats.

• Billing System: eMedNY for Fee-For-Service claims; individual plan clearinghouses for MLTC claims.
• Reimbursement Model: Episodic Payment System (EPS) for CHHAs or negotiated hourly/per-visit rates for LHCSAs under MLTC contracts.
• Prior Authorization: MLTC plans require strict prior authorization for skilled nursing visits, heavily relying on the UAS-NY assessment scores.
• Claim Format: 837I (Institutional) or 837P (Professional) electronic transactions depending on the specific billing entity and payer requirements.
• NPI Requirement: Must use a valid Type 2 (Organizational) National Provider Identifier linked to the eMedNY enrollment profile.

9. Approval Sequence and Timeline

Becoming a licensed and enrolled home care agency in New York is a notoriously lengthy process. Due to the multi-tiered review by PHHPC, DOH, and eMedNY, applicants should expect a multi-year timeline.

Providers cannot bill Medicaid or contract with managed care plans until the entire sequence is complete and the Operating Certificate is in hand.

• Step 1: Submit CON/Public Need application via NYSE-CON (typically 6-12 months for PHHPC review and approval).
• Step 2: Fulfill PHHPC contingencies and submit pre-opening requirements (3-6 months).
• Step 3: NYSDOH Pre-Opening Survey and issuance of the Article 36 Operating Certificate (1-3 months).
• Step 4: Medicare Certification for CHHAs via CMS and State Agency survey (3-6 months).
• Step 5: eMedNY Medicaid Enrollment application processing (60-90 days).
• Step 6: MLTC Network Credentialing and Contracting (90-120 days, running concurrent with or after eMedNY enrollment).

10. Common Denials and Survey Findings

Applications frequently fail at the gatekeeping stage due to an inability to prove public need or due to undisclosed legal issues among the ownership group.

Once operational, agencies face strict unannounced surveys where clinical documentation and infection control are heavily scrutinized.

• Application Denial: Failure to prove public need or financial feasibility during the PHHPC Certificate of Need process.
• Character/Competence Denial: Undisclosed past legal, financial, or regulatory actions against owners, operators, or board members.
• Survey Deficiency: Failure to follow the physician-approved Plan of Care, such as missed nursing visits or unauthorized treatments.
• Survey Deficiency: Incomplete or missing Criminal History Record Checks (CHRC) prior to a nurse's first patient contact.
• Billing Denial: Providing services without an active MLTC prior authorization or failing to match EVV data with submitted claims.

11. Key Contacts and Resources

Prospective providers must utilize official New York State portals for licensure, enrollment, and compliance. Relying on outdated forms or third-party summaries can result in immediate application rejection.

Below are the authoritative state resources required to initiate and maintain a skilled nursing home care agency in New York.

• NYSDOH Home Care Licensure: https://www.health.ny.gov/facilities/home_care/
• eMedNY Provider Enrollment: https://www.emedny.org/info/providerenrollment/
• NYSE-CON Portal: https://www.health.ny.gov/facilities/cons/nysecon/
• OMIG Compliance Resources: https://omig.ny.gov/compliance/compliance
• NYSED Office of the Professions (Nursing): https://www.op.nysed.gov/professions/registered-professional-nurse/laws-rules-regulations

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