Coverage of Clotting Factor and Non-Clotting Factor Therapeutic Products used in Managing Bleeding Disorder when Administered or Furnished by Hemophilia Treatment Centers

From doh.sm.OMC.Mail <omcmail@health.ny.gov>
Date Thu 7/9/2026 2:26 PM
To doh.sm.OMC.Mail <omcmail@health.ny.gov>

To: Health Plan CEOs, Government Program Liaisons, and Medical Directors

Please share this information with staff as appropriate.

This applies to Medicaid Managed Care (MMC) plans, including Mainstream MMC plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs).

Coverage of Clotting Factor and Non-Clotting Factor Therapeutic Products used in Managing Bleeding Disorder when Administered or Furnished by Hemophilia Treatment Centers (HTCs).

This information is intended to provide added clarification regarding previously distributed New York State (NYS) Department of Health guidance about the coverage of clotting factor and non-clotting factor therapeutic products used in managing bleeding disorders, when administered or furnished by Hemophilia Treatment Centers (HTCs).

MMC plans must contract with at least one HTC per county for provision of clotting factor and non-clotting factor therapeutic products and services. Where contracts do not exist, MMC plans must permit enrollees to access services through out–of–network arrangements. If an out–of–network HTC serves five or more of an MMC plan’s enrollees, the MMC plan must contract with said HTC.

MMC plans are responsible for the reimbursement of all clotting factor and non-clotting factor therapeutic products used in managing bleeding disorders (such as for example, Hemlibra) that are administered or furnished to enrollees by their contracted HTCs and billed via a medical or an institutional claim. MMC plans cannot require pharmacy or NYRx billing regardless of whether the clotting factor or non-clotting factor therapeutic product is administered to the enrollee by the HTC or furnished to the enrollee by the HTC for self-administration.

This guidance is consistent with the intent of Medicaid's policy regarding HTCs, which is to provide continued access and uninterrupted unfragmented care to enrollees who receive care at HTCs.

If you have any questions, please contact the NYS Medicaid Managed Care Program at: omcmail@health.ny.gov.

Thank you,

Division of Health Plan Contracting and Oversight

New York State Department of Health
Office of Health Insurance Programs