New York - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

New York Medicaid does not cover a distinct Home and Community-Based Services (HCBS) waiver service named "Skilled Respite." When a waiver participant's care needs exceed the scope of an unlicensed caregiver and require licensed nursing tasks, the state authorizes the service as hourly nursing (RN/LPN) delivered by a Licensed Home Care Services Agency (LHCSA) under Article 36 of the Public Health Law, or as specialized medical respite under the Children's Waiver or OPWDD Comprehensive Waiver.

Approval requires navigating the Department of Health (DOH) Certificate of Need (CON) process for a LHCSA license, followed by Medicaid enrollment through eMedNY. Applicants must secure Public Health and Health Planning Council (PHHPC) establishment approval before DOH will accept a licensure application, requiring a demonstrated public need for additional nursing-level home care capacity in the target counties.

1. Service Definition and Scope

Because New York does not utilize a standalone "Skilled Respite" service code, providers must be licensed to deliver standard nursing services or designated to provide waiver-specific respite that incorporates medical care. Under the Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) waivers, this is billed as hourly nursing.

Under the Children's Waiver, agencies can be designated for Planned Respite or Crisis Respite, utilizing licensed staff to manage complex medical needs during the caregiver's absence. The scope of practice is strictly governed by the New York State Education Department's nursing regulations.

• Service Name: Hourly Nursing (RN/LPN) or Designated HCBS Respite.
• Governing Authority: Article 36 of the New York State Public Health Law (for LHCSAs).
• Delivery Setting: The participant's home or an approved community setting.
• Target Population: TBI, NHTD, OPWDD, and Children's Waiver participants requiring medication administration, tube feeding, or ventilator care.
• Scope of Practice: Nursing tasks must be performed by an RN or an LPN under RN supervision.

2. Regulatory and Oversight Agencies

The New York State Department of Health (DOH) is the primary licensing body for any agency providing nursing-level care in the home. For agencies serving specific waiver populations, additional oversight is provided by the respective state offices.

Medicaid enrollment and claims processing are managed centrally through the eMedNY system, which acts as the state's Medicaid Management Information System (MMIS).

• Licensing Agency: NYS Department of Health (DOH) [https://www.health.ny.gov/facilities/home_care/]
• Waiver Authority (Developmental Disabilities): Office for People With Developmental Disabilities (OPWDD) [https://opwdd.ny.gov/]
• Waiver Authority (Children): NYS Children's Provider Designation Review Team [https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/]
• Medicaid Enrollment: eMedNY [https://www.emedny.org/]
• Compliance Oversight: Office of the Medicaid Inspector General (OMIG) [https://omig.ny.gov/]

3. Gatekeeping Prerequisites: Who Can Even Apply

New York heavily regulates the entry of new home care agencies through a Certificate of Need (CON) framework. A prospective provider cannot simply submit a license application; they must first pass a public need methodology review.

For waiver-specific respite, agencies must obtain designation from the state review team or OPWDD before eMedNY will allow them to enroll for those specific rate codes.

• Establishment Approval: Public Health and Health Planning Council (PHHPC) approval is required before a LHCSA licensure application is accepted.
• Public Need Methodology: DOH must determine a quantitative need for new LHCSAs in the requested county; moratoria on new LHCSAs are frequently enacted.
• Children's Waiver Designation: Requires submission of the HCBS Provider Attestation to the State Review Team within 30 days of the designation letter.
• OPWDD Letter of Intent: Required for new OPWDD provider agencies before submitting a full certification application.
• Managed Care Contracting: Providers must secure contracts with Medicaid Managed Care Organizations (MCOs) to receive referrals, as most NY Medicaid populations are mandatorily enrolled in managed care.

4. Licensure and Certification Requirements

Agencies seeking to provide nursing-level respite must complete the DOH-1056 Application for Home Care Licensure. This application requires extensive disclosures regarding the applicant's financial health and the background of its operators.

The application must be submitted in quadruplicate to the Bureau of Project Management in Albany, and must include a detailed program analysis and quality assurance plan.

• Application Form: DOH-1056 (Application for Home Care Licensure).
• Submission Location: Bureau of Project Management, Division of Health Facility Planning, ESP, Corning Tower, Room 1842, Albany NY 12237.
• Financial Feasibility: Must include a summary of operating costs, projected budget, and proof of capitalization.
• Character and Competence: Requires a 10-year affiliation disclosure for all owners, board officers, directors, and controlling persons.
• Board Resolution: Corporate applicants must attach a board resolution authorizing the application.

5. Medicaid Provider Enrollment

Once licensed or designated, the agency must enroll as a billing provider through the eMedNY Provider Services Portal (PSP). The enrollment process requires specific forms to link the agency's tax ID to the Medicaid system.

Providers must also attest to having an active compliance program that meets state standards, particularly if they expect to bill over a certain threshold.

• System: eMedNY Provider Services Portal (PSP).
• Application Fee: $750 for institutional providers, unless a waiver applies.
• Required Form: ETIN Certification Statement (EMEDNY-490602 for new enrollments).
• Financial Setup: Electronic Funds Transfer (EFT) Authorization is required.
• Compliance Attestation: Must certify adoption of an effective compliance program pursuant to NYS Social Services Law section 363-d and 18 NYCRR Part 521.

6. Staffing, Training and Background Checks

Because this service involves skilled nursing tasks, all direct care staff providing the intervention must hold active New York State nursing licenses. Unlicensed personnel cannot perform these duties.

Agencies must conduct rigorous background checks through state systems before allowing any staff member to have direct contact with vulnerable waiver participants.

• Nursing Qualifications: Staff must hold an active NYS Registered Nurse (RN) or Licensed Practical Nurse (LPN) license.
• Supervision: LPNs must practice under the direction and supervision of an RN or physician.
• Background Checks: Must clear the Justice Center Staff Exclusion List (SEL) and complete a Criminal Background Check (CBC).
• Training: Staff must complete state-mandated training on incident reporting, rights and dignity, and the HCBS Settings Rule.
• Health Clearance: Staff must have an annual health assessment and PPD/TB screening.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records that justify the need for nursing-level care during the respite period. DOH and OMIG auditors frequently review these records for compliance.

Agencies designated under the Children's Waiver must also maintain the signed 11-page HCBS Provider Attestation on file.

• Quality Assurance: Must submit a QA program description with the DOH-1056 application.
• Service Plans: Nursing care plans must be signed by a physician and updated at least every 60 days.
• Attestation: Children's Waiver providers must sign and adhere to the Designated HCBS Provider Attestation.
• Record Retention: All Medicaid claims and supporting clinical documentation must be retained for a minimum of 6 years.
• Incident Reporting: Must maintain policies for reporting to the NYS Justice Center for the Protection of People with Special Needs.

8. Billing, Rates and Claims

Claims for nursing-level respite are submitted to eMedNY for fee-for-service participants, or directly to the participant's Managed Care Organization (MCO). Rates are established regionally by DOH.

Prior approval is strictly enforced. Effective September 1, 2026, due to federal interoperability rules, eMedNY is updating its prior approval change request process, limiting changes to existing approved PAs.

• Billing System: eMedNY MMIS or MCO clearinghouse.
• Prior Approval: Required for nursing hours; change requests are limited by 2026 interoperability rules.
• Rates: Regional fee-for-service rates are published on the DOH and OPWDD websites.
• Claim Format: Institutional claims use the UB-04 format or 837I electronic transaction.
• Referral Requirement: Only the designated agency providing the service can bill; subcontracting agencies cannot bill directly if they are not the designated provider.

9. Approval Sequence and Timeline

The pathway to becoming a licensed and enrolled provider of nursing-level home care in New York is lengthy, primarily due to the PHHPC review process. Applicants should expect a multi-year timeline from initial concept to first billable claim.

Waiver designation processes (like the Children's Waiver) run parallel to or after licensure, adding additional review steps before eMedNY enrollment can be finalized.

• Step 1: PHHPC Establishment Review (typically 6-12 months).
• Step 2: DOH-1056 Licensure Application Review (typically 4-6 months).
• Step 3: Waiver Designation Application (if applicable, 2-4 months).
• Step 4: eMedNY Provider Enrollment (60-90 days).
• Step 5: MCO Credentialing and Contracting (90-120 days).

10. Common Denials and Survey Findings

Applications are most frequently rejected at the CON stage because the applicant cannot prove a quantitative public need for a new LHCSA in their target county. DOH strictly enforces need methodologies.

During post-enrollment surveys, OMIG frequently recoups funds for missing physician signatures on nursing care plans or lapsed background checks.

• Need Methodology: Denial of the DOH-1056 due to lack of demonstrated public need in the requested region.
• Character/Competence: Rejection due to undisclosed past affiliations or regulatory violations in other states.
• Incomplete Attestations: Revocation of Children's Waiver designation for failure to return the attestation within 30 days.
• Financials: Denial for inadequate capitalization shown in the DOH-1056 budget.
• Survey Finding: Recoupment for billing nursing hours that exceed the prior authorization limit.

11. Key Contacts and Resources

Prospective providers must interact with multiple state divisions depending on the specific waiver population they intend to serve. The DOH Bureau of Project Management is the starting point for LHCSA licensure.

For enrollment and billing technical assistance, eMedNY provides regional representatives and a dedicated call center.

• DOH Bureau of Project Management: [email protected]
• eMedNY Provider Enrollment: [https://www.emedny.org/info/providerenrollment/]
• OPWDD Provider Registration: [https://opwdd.ny.gov/providers/register-provider]
• OMIG Compliance Information: [https://omig.ny.gov/compliance/compliance]
• Children's Waiver Designation: [https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/]

See all New York services · New York Medicaid consulting · book a consultation.