New York State Medicaid Coverage for COVID-19 Vaccinations Administered by Providers

  • Guidance is also available in Portable Document Format (PDF)

This article updates New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) COVID-19 vaccine coverage policy to align with recommendations issued by the NYS Commissioner of Health, the New York City (NYC) Department of Health and Mental Hygiene and the Northeast Public Health Collaborative. Coverage policies of COVID-19 vaccines and guidance for administration of those vaccines follow the recommendations of healthcare professional organizations and are consistent with the scientific evidence supporting their safety and efficacy. Updated recommendations are included below.

COVID-19 Vaccination Recommendations for Adults

Vaccination against COVID-19 is recommended for all adults (>18 years).

  • All adults 65 years and older should be vaccinated
  • Adults 19-64 years with risk factors for severe COVID-19 disease (e.g., chronic conditions, immunocompromised status) should be vaccinated (For a list of conditions please see Table 1 in the Health Advisory: 2025-2026 COVID-19 Immunization Guidance for Adults, found here.
  • Adults 19-64 years at higher risk of exposure (e.g., healthcare workers, congregate care settings) should be vaccinated
  • Adults 19-64 who are household contacts of persons at high risk of severe disease should be vaccinated
  • For adults without underlying conditions, vaccination remains recommended as it reduces the risk of symptomatic infection, severe illness, and death

COVID-19 Vaccination Recommendations for Children and Adolescents

COVID-19 vaccination recommendations for children and adolescents (defined as ages 6 months to 18 years) are as follows.

  • All children ages 6-23 months should be vaccinated.
  • Children and adolescents ages 2-18 years who fall within one of the following subgroups should be vaccinated:
    • At high risk for severe COVID-19 (For recommended high risk populations, please see Table 1, Appendix A in the Health Advisory: 2025-2026 COVID-19 Immunization Guidance for Children, found here.
    • Living in a long-term care facility or other congregate setting
    • Have never been vaccinated against COVID-19
    • Whose household members are at high risk for severe COVID-19
  • Vaccination may also be provided to children ages 2-18 years who do not fall into one of the above categories, at the request of their parent/guardian.

COVID-19 Vaccination Recommendations for Pregnant People

All pregnant people should be vaccinated against COVID-19.

  • Vaccination may occur in any trimester.
  • All individuals in the postpartum period should be vaccinated against COVID-19.
  • All lactating individuals should be vaccinated against COVID-19. There is no need to stop or delay breastfeeding.
  • All individuals contemplating pregnancy or actively trying to conceive should be vaccinated against COVID-19. There is no need to delay pregnancy following a COVID- 19 vaccine.

Additional information on COVID-19 vaccination recommendations can be found here.

FFS Billing Instructions

New York State fee-for-service billing policies for COVID-19 vaccinations provided by NYS Medicaid-enrolled office based practitioners, ordered ambulatory providers, Article 28 outpatient facilities [including hospital outpatient departments, Federally Qualified Health Centers (FQHCs), Diagnostic and Treatment Centers (D&TCs), Local County Health Departments (LCHDs)] and School Based Health Centers (SBHCs) should follow guidance previously issued in the October 2024 Medicaid Update found here.

As a reminder, providers who provide care to children between the ages of 0 and 18 years will be reimbursed for the cost of the vaccine and the administration fee when medically necessary pediatric vaccines are not included in the Vaccines For Children program.

Questions:

  • Fee-for-service claim questions should be directed to the eMedNY Call Center at (800) 343-9000
  • Fee-for-service coverage and policy questions should be directed to the Office of Health Insurance Program’s (OHIP) Division of Program Development and Management at (518) 473-2160 or FFSMedicaidPolicy@health.ny.gov
  • Medicaid Managed Care reimbursement, billing, and/or documentation requirement questions should be directed to the specific Medicaid Managed Care Plan of the enrollee. Medicaid Managed Care Plan contact information is available in the eMedNY New York State Medicaid Program Information for All Providers – Managed Care Information document at: https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Provid ers_Managed_Care_Information.pdf