With the New York Medicaid Program facing scrutiny by the U.S. Department of Health and Human Services (HHS) for a perceived lack of oversight and compliance integrity involving certain types of providers (including personal care and home health providers), the New York Department of Health (DOH) recently announced certain program administrative measures that seem designed to help address these concerns.
First, in compliance with an April 2026 directive from the Centers for Medicare & Medicaid Services (CMS) mandating that all state Medicaid Programs revalidate their providers within 24 months, DOH published requirements relating to its revalidation program.[1] DOH stressed that the revalidation requirement “is not new” and that “federal law has always required it at least every 5 years,” further commenting that it is “a routine compliance activity” and that “no individual provider is being singled out, and this isn’t an indication of fraud, waste, or abuse suspicion.”[2] Even so, DOH specifically acknowledged the April 2026 directive from CMS as a “change” and also announced certain changes to the provider risk designations, which determine “screening intensity at enrollment and revalidation.”[3]
All providers must undergo standard screening, which includes: (1) Verification of provider identity and credentials; (2) Confirmation of practice location and contact information; (3) National Provider Identifier (NPI) validation; and (4) Submission of all required documentation through the Provider Services Portal (PSP). However, higher-risk providers are subjected to additional screening requirements and have shorter deadlines for revalidation. DOH announced that, among other providers, Licensed Home Care Services Agencies (LHCSAs) would be added to the “High-Risk Providers” category, which means that in addition to the standard screening requirements, this class of providers must undergo a pre- and post-enrollment site visit, a fingerprinting background check for all owners having at least a 5% ownership interest, and revalidation every three years, instead of every five years.[4]
Moreover, the risk levels of individual providers can change based on various factors, including: (1) payment suspension based on a credible allegation of fraud, waste or abuse; (2) an unreported Medicaid overpayment of at least $1,500; (3) prior exclusion of a provider that has been reinstated; (4) the passing of six months following the lifting of a temporary moratorium for a particular provider type that was impacted by the moratorium; (5) billing anomalies; (6) referral by the Office of Medicaid Inspector General (OMIG); and (7) change in ownership (CHOW) in specific provider classes.[5]
Second, DOH imposed a temporary moratorium on new enrollments for certain provider classes. This, too, according to DOH, was in response to a CMS communication encouraging that state Medicaid programs “implement temporary enrollment moratoriums for provider classes identified as posing a higher risk of fraud, waste, or abuse.”[6] The provider categories subject to the moratorium include: (1) Laboratory; (2) Durable Medical Equipment; (3) Applied Behavior Analysis; (4) Licensed Home Care Services Agencies; and (5) Pharmacy. Additionally, Managed Long Term Care Plans have been instructed to place a moratorium on Social Adult Day Care contracting and credentialing. Each moratorium will remain in effect for at least six months and no CHOWs or pending applications will be processed during that period.
If you have any questions about this article or the impact of these new measures, you may contact the author at Geoffrey.Kaiser@rivkin.com or (516) 357-3161.
Sign up to receive Rivkin Rounds at www.RivkinRounds.com.
[1] https://health.ny.gov/health_care/medicaid/integrity/docs/2026-08-06_medicaid_provider_revalidation_webinar.pdf
[2] Id. at p. 4.
[3] Id. at p. 5.
[4] Id.
[5] Id.
[6] Id. at 7.