New York DOH Finalizes Major CON Rule Changes for Health Projects

If you’ve ever tried to renovate a kitchen in a pre-war building, you know the feeling: you start with “new cabinets,”
and three weeks later you’re negotiating with a plumbing stack from 1939 and a permitting office that closes for lunch
the moment you arrive. In New York healthcare, the equivalent “kitchen remodel” is a construction project under the
state’s Certificate of Need (CON) ruleswhere timelines, thresholds, and review lanes matter as much as bricks and beams.

That’s why the New York State Department of Health (NYSDOH) finalizing major changes to its medical facility construction
CON regulations is a big deal for hospitals, clinics, ambulatory surgery centers, and other Article 28 providers.
The short version: higher cost thresholds, more streamlined review pathways, and clearer “notice-only” or exempt categories
for lower-risk projectswithout taking the state’s hands completely off the steering wheel.

What CON Means in New York (and Why It’s Not Just Paperwork)

A CON is the state’s approval process for certain healthcare facility projectsthink new construction, major renovations,
bed changes, and certain service or equipment moves that affect a facility’s operating certificate. The idea is to balance
access, safety, cost, and system-wide planning. In New York, medical facility construction projects often flow through NYSDOH
review and, for the biggest proposals, a recommendation from the Public Health and Health Planning Council (PHHPC).

In plain English: CON is New York’s way of asking, “Is this project necessary, safe, financially sound, and aligned with how
care is delivered in the state?” Sometimes that’s reassuring. Sometimes it’s… a character-building experience.

The Headline: New York Raised the Dollar Thresholds (Because Construction Costs Did Not Stay in 2017)

One of the most practical changes is also the most obvious: the cost thresholds that trigger CON review were raised. Why?
Because construction, labor, and equipment pricing have been on a long-term upward trend, and thresholds that felt “large”
several years ago can now represent a project that’s big in paperwork but not big in real-world impact.

Key threshold shifts you’ll hear people repeating in meetings

• When a CON application is required (overall trigger): now generally over $30 million for general hospitals and over $8 million for other facilities (up from $15M and $6M, respectively).
• Full Review (PHHPC recommendation involved): now generally triggered above $60 million for general hospitals (or 10% of operating costs, capped) and above $20 million for other facilities (or 10% of operating costs, capped).
• Administrative Review (a middle lane): expanded by aligning with the new thresholds and adding certain categories (including some state grant-funded projects).
• Limited Review (the streamlined lane): expanded in scope and eligible project cost thresholds.

Translation: more projects that used to land in a heavier review lane may now qualify for a lighter processespecially routine
modernization, infrastructure, or service-neutral renovations that don’t meaningfully change what a facility is licensed to do.

How the Review Lanes Now Work: Full, Administrative, Limited, Notice-Only, and Exempt

NYSDOH didn’t just bump up numbers. The finalized changes also reorganize how proposals fit into different levels of review.
The goal is speed where it’s safe, scrutiny where it’s necessary, and fewer “why are we doing this twice?” moments.

1) Full Review: Still the “big-league” lane

Full Review remains the most rigorous track, generally reserved for higher-cost projects, big operational impacts, and certain
services that the regulations treat as inherently significant.

A practical takeaway: the cost threshold for Full Review increased, but Full Review can also be triggered by bed changes.
Under the updated approach, bed changes tend to move to Full Review when the proposal changes more than 10% of existing beds
(for example, adding beds, converting beds to a higher level of care, or otherwise changing bed counts above that threshold).

2) Administrative Review: The “important but not PHHPC-level” lane

Administrative Review continues to cover projects that need real oversight but don’t necessarily require the full PHHPC pathway.
It’s also where NYSDOH has tried to avoid duplicative layers for certain modernization effortsespecially where funding or policy
priorities already put guardrails around the work.

One noteworthy adjustment: projects primarily funded by state grants can be eligible for Administrative Review.
That matters for providers participating in state-supported capital initiativesbecause “state grant + full CON marathon” was never
anyone’s favorite combo.

3) Limited Review: The “faster, focused” lane gets bigger

Limited Review is the streamlined process for proposals that are lower risk, smaller in scope, or operationally modestbut still
deserve a check to ensure compliance and alignment with licensure requirements. The new rules expand eligibility and raise the cost
thresholds associated with this lane.

Limited Review is where a lot of “normal provider life” projects can now live: facility upgrades, certain relocations, and program
tweaks that don’t radically reshape capacity or services.

4) Notice-only: “Tell NYSDOH, but don’t wait for a full blessing”

The rules also broaden categories that require only written notice to NYSDOH. This matters because “notice-only” can reduce lead time,
simplify filings, and keep projects from stalling on administrative steps when the risk profile is low.

A big change here: non-clinical projects have a higher dollar threshold before notice is requiredmeaning routine infrastructure
and facility upkeep can proceed with fewer regulatory speed bumps (subject to staying within the defined categories).

5) Exempt projects: Some work doesn’t need review at all

The modernized framework recognizes that not all construction is created equal. Some upgrades are essentially safety and maintenance work
that providers must do to functionwithout changing care delivery, licensure scope, or system planning concerns.

Think: certain repairs, maintenance, and “keep the building alive” projects that are necessary but not programmatic.

Specific Changes That Will Hit Project Planning Immediately

Emergency department space no longer automatically routes you into Administrative Review

Emergency departments are busy, space is tight, and demand spikes don’t politely wait for paperwork. One finalized update removes projects
involving emergency room space from requiring Administrative Review by defaultintended to shorten approval timelines and help facilities
respond faster to demand.

Practically, that means some ED renovation or expansion projects may now be evaluated more like other projectsbased on cost thresholds,
bed/service changes, and the overall category of workrather than being automatically bumped into a heavier lane.

Exam rooms: additions and renovations can be “notice-only” in defined situations

The updated rules recognize that exam rooms often present minimal incremental risk when they’re within or adjacent to already certified space.
As a result, adding or renovating exam rooms in qualifying circumstances can be exempt from CON review and require only notice.

Why this matters: exam room work is a common “small but constant” needespecially as providers shift toward more outpatient and ambulatory care.
Making this easier can help facilities adjust capacity without treating every drywall change like a moon landing.

Mobile clinic models get clearer paths

Mobile health is not a futuristic concept anymoreit’s routine access strategy. The finalized approach makes mobile van extension clinics eligible
for Limited Review, reflecting that mobile platforms don’t fit neatly into traditional building-based standards.

Architectural self-certification expands up to larger project sizes

Architectural self-certification lets a licensed architect or engineer certify that a project complies with applicable codes and rules,
reducing the need for NYSDOH to conduct the same level of architectural review for qualifying proposals. The threshold for self-certification
has increased, potentially saving time on projects that are straightforward from a code-compliance perspective.

The “fine print” reality: self-certification is not “do whatever you want.” It’s a different compliance mechanism, and it puts a premium on
disciplined documentation, careful design decisions, and reputable professional oversight.

Service and equipment changes: fewer “special callouts,” more cost-based logic

Previously, certain services and equipment acquisitions were explicitly singled out for specific review levels. The final changes remove references
to some of those service-specific triggerspushing more projects into the general framework based on cost and operating certificate impact.

Examples of items that have been treated with updated logic include acquisitions of MRI machines and CT scanners, as well as
certain service changes that no longer automatically route into a heavier lane just because of the category label. This doesn’t mean “no rules.”
It means the review path is more consistent: cost, scope, bed impact, and licensure implications do the heavy lifting.

Specialized services list is revised: one added, several removed from the automatic Full Review list

The finalized changes update the list of specialized services that automatically trigger Full Review. Notably, lung transplant
services are added. Several services are removed from the “automatic Full Review” listmeaning they may now follow the general thresholds
and criteria rather than being guaranteed a Full Review lane solely by category.

Important nuance: being removed from an “automatic” list does not mean the service is unregulated or casually approved. It means the pathway
can be more proportionaland other licensure, quality, and program requirements still apply where relevant.

Consolidated applications: you can’t “slice the salami” anymore

A major operational change is the expectation that programmatically related CON applications be submitted together.
In other words, projects that are part of the same planfunctionally linked renovations, phased expansions, coordinated service movesshould be
presented as a unified package rather than staggered filings designed to fall below thresholds or avoid scrutiny.

For providers, this can be a win (one integrated narrative, one coordinated review). But it also forces better internal alignment:
finance, facilities, clinical leadership, compliance, and architects have to agree on the “whole story” earlier.

What These Changes Mean for Health Project Strategy in 2026 and Beyond

1) Timelines may improvebut planning discipline becomes even more valuable

With expanded Limited Review and broader notice-only categories, many projects may spend less time waiting for process steps that don’t add meaningful
safety or planning value. But the flip side is that providers must be sharper about classification, documentation, and total project cost calculations.
Misclassify a project and you can lose timefast.

2) “Total project cost” math becomes a board-level topic

These rules put real weight on total project cost thresholds. That means project scoping, budgeting, and the definition of what’s “in” the project
are not just finance exercisesthey determine your regulatory lane. If you’re doing construction, equipment, and enabling infrastructure as one integrated
effort, treat it like one integrated effort in your regulatory planning too.

3) Bed changes remain a “watch this like a hawk” trigger

Even with higher dollar thresholds, bed additions or conversions can pull a project into Full Review when they cross the defined percentage threshold.
Providers planning capacity shifts should model regulatory impact earlybefore design is locked and procurement timelines are set.

Real-World Examples: How Projects Might Route Under the New Rules

Example A: Emergency department renovation + waiting room expansion (General hospital)

A hospital plans a $22 million emergency department refresh: new triage layout, upgraded imaging alcove, expanded waiting, and improved staff work areas.
Under the updated approach, ED work is no longer automatically routed into Administrative Review by category alone. If there’s no major bed change and the
total project cost stays within the Limited Review threshold for a general hospital, the project may qualify for a more streamlined path.

Example B: CT scanner acquisition + suite renovation (Article 28 diagnostic/treatment center)

A D&TC plans a $7.5 million CT replacement and suite upgrade. Previously, CT acquisition could trigger a specific review lane regardless of cost.
With service-specific callouts reduced, the project’s review path is more likely to be determined by overall project cost and operating certificate impacts.
For many facilities, that can mean a lighter pathwayassuming no broader service expansion is bundled in.

Example C: Adding 25 beds to a 160-bed facility

A facility proposes adding 25 beds. That’s roughly 15.6% of existing capacityabove the 10% trigger. Even if the construction budget is modest relative to
other projects, the bed change itself can push the proposal into Full Review territory. This is exactly the kind of system-impact change the state still wants
a closer look at.

Example D: $10.8 million HVAC + fire alarm upgrades (non-clinical infrastructure)

A facility plans major HVAC replacement and fire alarm modernization. Under the expanded approach to non-clinical work, projects under the $12 million threshold
may be exempt from review or require only minimal notice depending on category and context. This helps providers address safety and infrastructure needs without
converting essential building upkeep into a multi-month regulatory event.

Practical Checklist: How to Approach a New Health Project Under the Finalized Rules

Step 1: Define the project scope like you’re going to defend it

• List every major component: construction, equipment, enabling infrastructure, IT, temporary relocations, and contingencies.
• Confirm what counts toward total project cost and avoid “phantom phases” that look separate on paper but are one plan in reality.

Step 2: Map the project to a review lane early

• Does it exceed the CON application threshold?
• Does it trigger Full Review by cost, bed change percentage, or specialized service category?
• Could it qualify for Administrative or Limited Review?
• Is it notice-only or exempt (and if so, are you meeting the exact conditions)?

Step 3: Separate “construction review” from “operating certificate impact”

The new rules encourage cost-based consistency, but operating certificate implications still matter. A project that looks like “just construction” can become
a regulatory event if it changes licensed services, capacity, or certified space parameters.

Step 4: Treat consolidated applications as a planning tool, not a punishment

If the state expects programmatically related filings together, use that to your advantage: build one narrative, one rationale, one coherent community benefit story,
and one integrated schedule. It’s usually easier to defend a unified plan than a patchwork of “unrelated” projects that share the same hallway.

Step 5: Build your timeline around the slowest compliance lever

Even with streamlined lanes, don’t assume instant approvals. Design, procurement, workforce constraints, and code compliance can be the real bottlenecks.
The best strategy is not “hope for speed,” it’s “plan for certainty.”

Bottom Line

NYSDOH’s finalized CON rule changes modernize the medical facility construction process by raising thresholds, expanding streamlined pathways, and clarifying
notice-only and exempt categories for lower-risk work. For providers, the opportunity is real: fewer unnecessary delays for routine modernization and faster
movement on projects that support today’s care delivery models.

But the new world also demands better project disciplineespecially around total project cost, bed-change math, operating certificate impacts, and consolidated
application strategy. The smartest teams will treat the rules like a project design constraint: understand them early, plan around them, and avoid late-stage
surprises that turn a simple renovation into a regulatory thriller.

Experiences Related to New York DOH Finalizes Major CON Rule Changes for Health Projects (Composite, Real-World Scenarios)

The most common “experience” project teams describeespecially in New Yorkis that CON planning feels like running two projects at once: the building project
and the regulatory project. Facilities leaders will tell you the construction itself can be the easy part (famous last words), while the hardest part is
predicting what the state will consider the true scope. Under the newly finalized rules, that conversation gets better, but it doesn’t disappear.

One scenario that pops up again and again is the “routine upgrade that didn’t feel routine on paper.” A facilities director might plan an HVAC overhaul and fire
alarm modernization because the building is aging and the work is overdue. Under older thresholds, the team could find themselves assembling filings that felt
disproportionate to the clinical impactbecause the project was expensive, even though it didn’t change services, beds, or patient-facing operations. With the
higher thresholds and expanded exempt/notice-only categories, teams often describe a sense of relief: they can focus on safety and infrastructure first, and
paperwork second. Not zero paperworkthis is still New Yorkbut more proportional paperwork.

Another common experience comes from ambulatory settings adapting to outpatient growth. Leaders talk about how quickly exam rooms become the “currency of access.”
You don’t always need a brand-new wing; sometimes you need three new rooms, better flow, and less chaos at check-in. Under the revised approach, the idea that
certain exam room renovations or additions in already certified or adjacent space can be handled with notice rather than full CON review matches what providers
say they need: the ability to adjust capacity without treating every exam table like a regulated technology platform.

Project managers also describe how “total project cost” discussions can become unexpectedly emotional. Finance teams want accurate budgets; clinical leaders want
the right space; architects want enough contingency to avoid change orders; and everyone wants the regulatory lane that won’t derail the schedule. The new rules
raise thresholds, which helps, but the real-life lesson remains: define scope early and document assumptions. Teams that do this well tend to avoid the panic
moment when someone asks, “Waitare we actually over the threshold if we include enabling infrastructure and temporary swing space?”

Consolidated applications are another lived reality that can feel annoying at first and helpful later. People often describe a short-term pain: you can’t keep
“Phase 2” in a separate drawer if it’s truly part of the same plan. But in practice, teams that lean into consolidation often end up with a cleaner narrative:
one integrated rationale, one set of drawings that actually match the operational plan, and fewer internal contradictions. It also forces alignment between
departments that don’t always talk earlyclinical leadership, compliance, IT, and facilitiesso the project is less likely to implode at 80% design when someone
realizes the operating certificate implications weren’t addressed.

Finally, a lot of teams describe the emotional win of faster movement on emergency department changes. EDs are where the system shows its stress first. When
demand increases, the experience on the ground isn’t abstract: it’s hallway beds, strained staff, and patients waiting too long. The idea that ED-space projects
won’t automatically be routed into a heavier review lane resonates with what teams experience dailybecause when your ED is crowded, “see you next quarter” is not
a plan. The revised rules won’t magically solve capacity issues, but they can reduce friction so providers can act sooner.