2026-27 FY Budget Priorities

Strengthen Home Care Workforce Operations -  

Streamline training, onboarding, and administrative function

Overview

New York’s home care system continues to face persistent workforce shortages, high administrative costs, and caregiver retention challenges. Individual agencies are currently responsible for duplicative onboarding, training, credentialing, and compliance functions—creating inefficiencies, inconsistent standards, and unnecessary costs that ultimately affect patient care access.

This proposal consists of a pilot program in partnership with the Department of Health (DOH), to serve as a unified workforce infrastructure supporting home care agencies and workers statewide. The model expands on existing DOH-managed systems—such as the Criminal History Record Check (CHRC) and Home Care Registry—by centralizing additional workforce functions through a shared, technology-enabled platform.

Policy Problem

• Agencies duplicate onboarding, training, and credential verification at significant cost
• Workforce records are fragmented across employers, limiting portability and efficiency
• Caregivers face inconsistent training pathways and limited professional development
• Administrative burden contributes to agency strain and worker turnover

These structural inefficiencies weaken workforce stability and reduce care continuity for patients.

Policy Solution

The centralized ecosystem would function as a shared service hub, responsible for:

• Standardized Onboarding & Credentialing
• Centralized hiring intake, credential verification, and compliance tracking
• Workforce registry maintaining credentials, training history, and regulatory status
• Training & Professional Development
• State- and federally compliant standardized training programs
• Technology-Driven Administration
• Centralized HR, compliance, and credential management systems
• Real-time data sharing among agencies, the ecosystem, and DOH
• Modeled after existing CHRC and DOH registry infrastructure
• Caregiver Health Benefit Integration
• Hybrid health coverage model providing primary and limited acute care benefits
• Medicaid remains available for emergency or higher-level care
• Reduces reliance on Medicaid for routine services and supports preventive care
  
  

Expected Outcomes

• Workforce Stability: Reduced turnover and improved retention
• Operational Efficiency: Lower administrative costs through shared services and automation
• Improved Job Quality: Clear career pathways, consistent training, and health supports
• Quality of Care: More reliable, well-trained workforce delivering consistent care statewide

Live-In Home Care Reform -
Aligning DOH and DOL Standards

Policy Problem

New York’s live-in home care system is governed by conflicting Department of Health (DOH) and Department of Labor (DOL) standards. DOH permits agencies to pay 13 hours of a 24-hour live-in shift when aides receive required sleep and breaks. DOL interpretations and court decisions have nevertheless required payment for all 24 hours—even when agencies comply with DOH rules.

At the same time, unclear DOH supervision rules conflict with federal DOL requirements for duty-free, uninterrupted meal and rest breaks, creating legal exposure and operational confusion.

Current impact on home care providers:

• Widespread litigation and escalating legal costs
• Reduced availability of live-in services
• Increased risk of institutional placement for medically fragile patients
• Provider withdrawal from 24-hour home care
  
  

Policy Solution

Create one clear, enforceable statewide standard that aligns DOH and DOL requirements that protects compliant providers from duplicative wage claims and preserves access to 24-hour home-based care.

• Codify the 13-Hour Rule: Define live-in care as 13 compensable hours within a 24-hour shift (including required sleep and breaks).
• Preempt Conflicting Interpretations: Statutory clarity that supersedes inconsistent DOL guidance or judicial interpretations.
• Safe-Harbor Protections: Liability protection for agencies with verifiable compliance records (e.g., EVV, time logs).
• Curb Abusive Litigation: Direct the Attorney General to address duplicative or bad-faith class actions.

Required Regulatory Clarification

Direct DOH to clarify that supervision requirements do not apply during federally protected, duty-free meal and rest breaks, during which aides are not required to remain on-site or under employer control.

Fiscal Impact

• Budget neutral
• Potential indirect savings from reduced litigation, administrative burden, and avoidable institutional placements

Streamline Nursing Assessments
Reducing Duplication, Accelerating Care, and Modernizing Home Care Oversight

Overview

The FAIR Access Initiative proposes the Universal Nursing Assessment. This proposal is not a new program—it is a structural correction. By aligning existing tools, modernizing data sharing, and eliminating unnecessary duplication, UNA strengthens New York’s home care system while protecting patients, workers, and taxpayers.

Policy Problem

New York’s home and community-based care system requires multiple duplicative nursing assessments for the same individual across programs—often within days or weeks of one another. Licensed Home Care Services Agencies (LHCSAs), Managed Long Term Care plans (MLTCs), PACE programs, Health Homes, and primary care providers each conduct overlapping assessments using similar data but different formats.

This fragmentation delays access to care, increases administrative costs, and contributes to nurse and care manager burnout. The delays also frustrate patients with repetitive evaluations. Moreover, duplicative assessments waste substantial state Medicaid resources without improving outcomes.

Policy Solution: Universal Nursing Assessment (UNA)

The FAIR Access Initiative proposes the Universal Nursing Assessment (UNA) as a single, standardized, nurse-led clinical assessment that is completed once at the point of care and shared securely across authorized providers.

Key Features

• Built on the existing Uniform Assessment System–New York (UAS-NY)
• Completed by a Registered Nurse or qualified care manager
• Shared in real time via SHIN-NY / Qualified Entities
• Serves as the authoritative clinical baseline for a defined validity period (e.g., 90 days)
• Allows targeted program-specific addenda—not full reassessments

UNA eliminates duplicative base assessments while preserving clinical oversight, patient choice, and program integrity.

Fiscal Impact (Public-Info-Based Estimate)

Using CMS-reported NY LTSS enrollment (~289,500 users) and conservative RN labor cost proxies:

• Estimated annual gross savings:
  $40 million – $175 million per year
• Savings driven by eliminating 1–2 duplicative RN assessments per LTSS user annually
• Does not include downstream savings from faster care initiation or reduced institutional utilization

Integrated Home Care Ecosystem
A Sustainable Alternative to New York’s Current Home Care System

Overview

New York’s home care system is facing significant fiscal and workforce pressures that threaten access to care for seniors, people with disabilities, and medically complex patients. Across-the-board reimbursement cuts risk destabilizing providers, worsening workforce shortages, and increasing avoidable hospitalizations and institutional care. The FAIR Access Initiative proposes the Integrated Home Care Ecosystem as a sustainable, cost-effective alternative that achieves savings through coordination and efficiency—not service reductions—while strengthening quality, access, and continuity of care.

Policy Problem

• Home care agencies operate under Medicaid reimbursement rates that do not adjust to rising labor and operating costs.
• Fragmentation across providers, payers, and care managers leads to duplicative services, poor coordination, and higher downstream costs.
• Workforce instability and agency closures threaten patient access and continuity of care.
• Cuts to home care risk shifting costs to more expensive settings such as hospitals and nursing homes.

Policy Solution: Integrated Home Care Ecosystem

The Integrated Home Care Ecosystem aligns key partners across the care continuum to deliver coordinated, patient-centered home care services. Participating entities include:

• Licensed Home Care Service Agencies (LHCSAs)
• Primary care practices
• Health Homes and care management organizations
• Managed care organizations and other payers
• Community-based and supportive service providers

Through formal coordination, shared accountability, and data-driven care planning, the model improves outcomes while controlling costs.

Fiscal & System Impact

• Reduces avoidable hospital admissions, emergency department use, and institutional placements.
• Preserves access to home care while mitigating long-term Medicaid costs.
• Strengthens provider viability and protects the home care safety net statewide.

Modernize Home Care Funding
Aligning Fair Pay with Sustainable Medicaid Funding

Overview

New York State has long championed fair wages, workers’ rights, and equitable access to care. Home care agencies and caregivers support efforts to raise the minimum wage and establish a livable wage for the workforce serving the State’s most vulnerable residents.

However, unlike other industries, home care agencies cannot adjust prices or negotiate reimbursement to absorb rising labor costs. Caregiver wages are funded entirely through Medicaid reimbursement rates set by Managed Care Organizations (MCOs) under State oversight.

When wage mandates increase without corresponding reimbursement adjustments, agencies face an untenable choice: comply and risk insolvency, or reduce services and quality to remain operational. The FAIR Access Initiative calls for aligning wage policy with reimbursement policy to ensure fair pay for workers and sustainable access to care for patients.

Policy Problem

• Wage mandates rise without funding alignment: State minimum wage increases are not automatically reflected in Medicaid reimbursement rates.
• Agencies lack rate-setting authority: Licensed Home Care Services Agencies (LHCSAs) rely on MCO-negotiated rates that often fall below the true cost of care.
• Inconsistent and inequitable MCO practices: Some MCO incentives favor volume or referrals, disadvantaging smaller and independent agencies regardless of quality outcomes.
• Data-driven methodologies are underutilized: MCO rates frequently fail to reflect Department of Health (DOH) Cost Reports and regional cost data used by the State in rate-setting.

Absent reform, these structural imbalances will continue to drive agency closures, workforce attrition, and reduced patient access—particularly in rural and underserved communities.

Fiscal Reality

A $1.00/hour wage increase results in $1.64/hour in total employer cost once mandated payroll taxes, benefits, and administrative expenses are included—representing a 64% increase beyond the wage itself.

• Per caregiver (30 hours/week): ≈ $2,560 annually
• 750 caregivers: ≈ $1.92 million annually
• 1,000 caregivers: ≈ $2.56 million annually

With approximately 250,000 caregivers statewide, even modest wage increases create substantial unfunded liabilities when reimbursement is not adjusted proportionally, threatening agency solvency and continuity of care.

Policy Solution

The FAIR Access Initiative proposes aligning wage policy and Medicaid reimbursement through the following reforms:

• Automatic Rate Adjustment
• Statutorily require Medicaid reimbursement rates to automatically adjust with any State-mandated wage increase.
• Apply a standardized multiplier (e.g., 1.64×) to reflect the full employer cost of wage increases.
• Review and update the multiplier biennially.
• Cost-of-Living Adjustment (COLA) Indexing
• Incorporate regular COLAs into home care reimbursement rates to prevent recurring inflation-driven funding gaps.
• Transparency and Pass-Through Enforcement
• Require MCOs to demonstrate compliance with State-directed rate increases through provider-level reporting and auditable verification that funds reach direct care staff.
• Data-Driven Base Rate Methodology
• Mandate use of DOH Cost Reports and regional cost data in MCO rate negotiations to ensure consistent, evidence-based reimbursement.
• Administrative Transition Support
• Provide temporary implementation funding to support necessary updates to billing, payroll, and contract systems.

Policy Impact

• Advances New York’s livable wage goals in a fiscally responsible manner.
• Protects patient access to Medicaid-funded home care statewide.
• Stabilizes the caregiving workforce and prevents provider attrition.
• Promotes transparency, accountability, and data-driven oversight.
• Strengthens collaboration among providers, MCOs, and the State.