New York State Medicaid Update - February 2025 Volume 41 - Number 2

In this issue …

New York State Patient-Centered Medical Home Program

Primary care providers who missed the March 31, 2025 deadline can still submit an attestation for the New York State Patient-Centered Medical Home Provider (NYS PCMH), Medicaid Managed Care (MMC) and Child Health Plus (CHPlus) incentive enhancement.

Effective April 1, 2025, primary care providers recognized under the NYS PCMH program are entitled to an incentive enhancement of $4.00/per member per month (PMPM) for MMC enrollees and CHPlus members under 21 years of age, and $2.00/PMPM for NYS Medicaid members 21 years of age and older, in addition to the current $6.00/PMPM payment.

To receive this enhanced incentive payment, in addition to the $6.00/PMPM, providers will be required to develop a workflow to refer NYS Medicaid members to a Social Care Network (SCN) and submit an attestation confirming their SCN participation. It is best practice for primary care providers to document their referral workflow and attestation survey response, for their own records.

The NYS PCMH incentive enhancement will be paid in addition to the current $6.00/PMPM payment. Additionally, NYS Medicaid health plans, Health and Recovery Plans, Human Immunodeficiency Virus-Special Needs Plans, and CHPlus Plans will be instructed to calculate and pay the NYS PCMH incentive enhancement. Practices submitting attestations after April 1, 2025, will forfeit monthly incentive enhancement payments until the attestation is received. Practices will continue to receive the current $6.00/PMPM.

Practice(s) must complete the NYS Department of Health (DOH) password protected attestation. All currently recognized NYS PCMH providers have received the link to the attestation using the email address(es) associated with recognized primary care providers and practices, as transmitted to the NYS DOH by the National Committee for Quality Assurance (NCQA). Primary care providers who have not received the password for the attestation should email pcmh@health.ny.gov.

SCN Program

The SCN program is part of the 1115 New York Health Equity Reform Waiver. SCNs will help address health disparities and social needs by connecting NYS Medicaid members to nutritional services, housing supports, transportation, and other social services that can impact the health of an individual. For individuals not enrolled in NYS Medicaid, and therefore, ineligible for the SCN program, including CHPlus members, the goal of NYS DOH is to provide these individuals with appropriate services to pre-existing state, federal, and local programs to address health-related social needs. When completing the attestation, providers are allowed to make more than one selection related to their practice workflow with designated SCNs, as shown below:

  1. Connect patients to the regional SCN for NYS Medicaid members via referral provided to the patient.
  2. Connect directly with the SCN platform or through a regional Qualified Entity to submit Accountable Health Communities Health-Related Social Needs (HRSN) screenings and referrals for NYS Medicaid members.
  3. Connect with the regional SCN in another agreed upon way.

Reminder

Only practices that complete the attestation survey will be eligible for the MMC and CHPlus NYS PCMH program incentive enhancement of $2.00/PMPM or $4.00/PMPM. The drop-down list of practices available on the attestation survey is updated monthly as new practices earn NYS PCMH recognition. All new practices must complete the attestation to be eligible for the $2.00/PMPM or $4.00/PMPM incentive enhancements.

Questions and Additional Information:

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Public Health Emergency Unwind

The Consolidated Appropriations Act of 2023 required states to begin the process of redetermining Medicaid eligibility for its members, which New York State (NYS) began in April 2023. This process is also referred to as the Public Health Emergency Unwind. States must conclude the entire Unwind process by December 31, 2025, in accordance with recent guidance issued by the Centers for Medicare and Medicaid Services.

Beginning in mid-February 2025, the New York City (NYC) Human Resources Administration will include updated language in its renewal packages informing NYS Medicaid members that their cases will be closed if the renewal packet is not returned by the due date. Renewal notices for NYS Medicaid members enrolled through a local social services district outside of NYC will include similar language indicating coverage will be closed if the renewal packet is not returned by the due date. Please note: In some cases, a NYS Medicaid member may be administratively renewed based on data sources. In that case, the NYS Medicaid member will not receive a renewal packet but will instead receive a notice confirming a successful administrative renewal.

Providers can assist in this effort by informing their patients of this requirement and encouraging them to complete and return their renewal packet by the due date so their NYS Medicaid eligibility can be redetermined.

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Enhanced Reimbursement for Integrated eConsultations, Physical Health and Behavioral Health eConsults

Effective June 1, 2025, New York State (NYS) will enhance reimbursement rates for a period of five years for eConsultations between eligible physical health and behavioral health practitioners. For instance, a primary care physician may seek a consultation with a psychiatrist to determine the most suitable antidepressant medication for a patient diagnosed with major depressive disorder, who also has complex comorbidities including heart disease, hypertension, and diabetes. This collaborative approach ensures a comprehensive evaluation of treatment options that address both the mental health needs and the medical complexities of the patient, promoting safer, more effective care.

The following practitioners may engage in eConsults: physicians (including psychiatrists), physician assistants, nurse practitioners (NPs) (including psychiatric NPs), and midwives. Eligible eConsults will be reimbursed at 200 percent for the initial two years of the enhanced reimbursement period and both providers engaged in the eConsult will be entitled to the enhanced rate. Following this initial period, reimbursement will adjust according to a scheduled reduction as outlined in the table below.

Current Procedure
Terminology (CPT) Code		 Provider Type Established Rate
Effective January 1, 2025		 Enhancement Rate
Effective June 1, 2025
through
December 31, 2026
(200 percent)		 Enhancement Rate
Effective January 1, 2027
through
December 31, 2028
(150 percent)		 Enhancement Rate
Effective January 1, 2029
through
December 31, 2029
(125 percent)
99451 Consultative Provider $28.46 $56.92 $42.69 $35.58
99452 Treating/Requesting Provider $26.56 $53.12 $39.84 $33.20

Billing

Article 16, Article 28, Article 31, or Article 32 Hospital Outpatient Departments or freestanding Diagnostic and Treatment Centers, and Federally Qualified Health Centers that have opted into the Ambulatory Patient Group (APG) reimbursement methodology may submit an APG claim to NYS Medicaid for eConsult services, provided that either the treating/requesting provider and/or the consulting provider is an eligible practitioner employed by the clinic. Claims for eConsult services should utilize one of the designated CPT codes referenced above with the modifier outlined in this guidance to ensure appropriate billing and reimbursement. To identify these collaborative eConsult visits, a new modifier combination, "U1, U1", has been established. This combination must be appended to the claim line to qualify for the enhanced reimbursement rate. This modifier must also be appended to claims submitted by private practice providers to eMedNY in order to receive the enhanced reimbursement for integrated eConsultations.

Please note: Medicaid Managed Care (MMC) Plans are required to pay the government rate for eConsults collaborations involving Article 31 and 32 clinics.

Providers should refer to the eConsults article published in the January 2024 issue of the Medicaid Update, including as to consent, record and documentation requirements. Additional information regarding eConsults in APGs can be found in the eConsult Expansion: New Reimbursement in an Outpatient Setting article published in the December 2024 issue of the Medicaid Update.

Questions and Additional Information:

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New York State Medicaid Doula Provider Enrollment Update: Doula Group Enrollment

Effective immediately, a doula-only group can now enroll in the New York State (NYS) Medicaid program as a doula services provider and bill NYS Medicaid directly for doula services. A NYS Medicaid-enrolled doula provider can now affiliate with a multi-professional group. Doula services may be provided through a NYS Medicaid-enrolled individual provider, a doula-only group or a multi-professional group. The individual doula in a doula-only group or multi-professional group must be enrolled as an individual NYS Medicaid provider.

Resources:

Questions and Additional Information:

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Transition of Doula Services into Medicaid Managed Care

Coverage of doula services by Medicaid Managed Care (MMC) Plans was delayed to April 1, 2025. Doula services provided to MMC enrollees between March 1, 2024 and March 31, 2025, will continue to be billed to New York State (NYS) Medicaid fee-for-service (FFS). Effective April 1, 2025, doula services are covered by MMC Plans [inclusive of mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans, as well as Health and Recovery Plans].

NYS Medicaid FFS Policy and Billing:

Providers should refer to the following resources for NYS Medicaid FFS policy and billing guidelines pertaining to NYS Medicaid coverage of doula services:

MMC Billing

For dates of service (DOS) on or after April 1, 2025, a doula, doula-only group, or multi-professional group that has a contract with an MMC Plan will be reimbursed by the MMC Plan for all eligible doula services. If a MMC enrollee is receiving services prior to April 1, 2025, MMC Plans are required to cover the doula services and continue the NYS Medicaid FFS equivalent until 12 months after the end of the pregnancy, regardless of pregnancy outcome.

The doula, doula-only group, or multi-professional group is required to begin billing the MMC Plan of the enrollee for DOS on or after April 1, 2025. The MMC Plan is required to ensure continuity of care for these services for MMC enrollees, even if the doula, doula-only group, or multi-professional group is not contracted with the MMC Plan as of April 1, 2025.

The MMC Plan will reimburse no less than the NYS Medicaid FFS equivalent until 12 months after the end of the pregnancy, regardless of pregnancy outcome. Please note: This requirement only applies if the MMC enrollee was receiving services from the billing doula prior to April 1, 2025.

If an MMC enrollee has not received services prior to April 1, 2025, doula services will be reimbursed by the MMC Plan only if:

  • the doula is enrolled as a NYS Medicaid FFS provider;
  • the doula, doula-only group, or multi-professional group has contracted with the individual MMC Plan, in which the NYS Medicaid member is enrolled; and
  • the doula is billing the MMC Plan.

For NYS Medicaid members enrolled in MMC, providers must contact the MMC Plan of the enrollee for billing instructions that apply on and after April 1, 2025. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

Questions and Additional Information:

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Transition of School-Based Health Center Services Benefit and Population into Medicaid Managed Care

Effective April 1, 2025, School-Based Health Center (SBHC) and SBHC-Dental (SBHC-D) services will be incorporated into the mainstream Medicaid Managed Care (MMC) and Human Immunodeficiency Virus-Special Needs Plan benefit package. MMC Plans will be responsible for reimbursing SBHC operators for SBHC/SBHC-D services provided to MMC enrollees. For further details about covered services, refer to the Transition of School-Based Health Center Benefit and Population into Medicaid Managed Care document.

Billing and Reimbursement

To receive reimbursement for services provided to MMC enrollees, contracts must be executed between the Article 28 facilities that operate the SBHCs and the MMC Plans in their service area. For benefits managed by subcontractors, such as dental health, the operator may be required to contract with those subcontractor(s) identified by the MMC Plan. Federally Qualified Health Centers are encouraged, but not required, to contract with all MMC Plans in their service area. Billing and reimbursement for services provided by SBHCs and SBHC-Ds to MMC enrollees will occur in accordance with the NYS Mainstream Medicaid Managed Care and School-Based Health Center Billing Guidance and the Ambulatory Patient Group (APG) Provider Manual. Contemporaneous documentation as to the provision of services should be created and maintained.

Questions and Additional Information:

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Continuous Coverage for Children from Birth to Six Years of Age

Effective January 1, 2025, children eligible for New York State (NYS) Medicaid and Child Health Plus (CHPlus) will be given continuous coverage until six years of age, per federal approval granted via the 1115 Medicaid Redesign Team waiver amendment. Previously, most NYS Medicaid and CHPlus-eligible children would receive 12-months of continuous coverage starting from the month in which they were determined or redetermined fully eligible. This change will help keep most young children continuously enrolled in NYS Medicaid or CHPlus up until the end of the month in which they turn six years of age. Uninterrupted access to health insurance will keep children connected to coverage and essential care during their formative years, including important preventive and primary care services that are detrimental if missed. The loss of health coverage is particularly problematic for young children, since events in the early years of a child's life can significantly impact future health and social outcomes.

Children will have their eligibility reviewed each year during their renewal period; however, children under six years of age, will not have their coverage terminated because of a change in income, a change in household composition, or for failing to complete a renewal. Children will have their eligibility redetermined at the end of their continuous period when they turn six years of age. There are a few reasons why the coverage of a child may end prior to the end of their continuous coverage period, which include death, no longer being a resident of NYS, voluntary termination, or if coverage was found to be granted erroneously or fraudulently.

Similarly to 12-month continuous coverage, continuous coverage to six years of age is only available once a child is found fully NYS Medicaid or CHPlus eligible. Children who have not had their eligibility determined due to outstanding verification of eligibility factors such as citizenship, immigration status or income, are not eligible for continuous coverage. Additionally, children who have obtained their NYS Medicaid coverage through meeting a spenddown; presumptive eligibility; or waiver-enrolled children who are determined eligible for NYS Medicaid with only their own income are not eligible for continuous coverage.

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Electronic Submission of Health Care Transactions

The New York State (NYS) Medicaid program offers several electronic options for submitting health care transactions as the preferable alternative to manual submission of paper-based health care transactions. Please note: The eMedNY system accepts submissions 24/7.

Electronic Method Description Inbound Transactions Supported Resources
electronic Provider Assisted Claim Entry System (ePACES) ePACES is a free to use web-based Direct Data Entry system to enter health care transactions, one by one, into eMedNY for processing. This connection is available on the eMedNY website. Claims, claim status, eligibility, prior authorization (PA)/Dispensing Validation System requests, and PA attachments.
eMedNY eXchange eMedNY eXchange is a web-based application where transactions are uploaded manually and one at a time.

Providers must be enrolled in ePACES to use this protocol.		 All X12 and National Council for Prescription Drug Programs (NCPDP) D.0 Health Insurance Portability and Accountability Act (HIPAA) regulated transactions, and eMedNY proprietary transactions. eMedNY "Frequently Asked Questions (FAQ)" web page
eMedNY Simple Object Access Protocol File Transfer Service This protocol is designed to be used in place of the manual upload and download capabilities in the eMedNY eXchange. This protocol requires the user to develop, maintain, and operate their own connectivity application.

Providers must be enrolled in ePACES to use this protocol.		 All X12 and NCPDP D.0 HIPAA-regulated transactions, and eMedNY proprietary transactions. eMedNY SOAP FTS (File Transfer Service) User Guide
CORE Web Services Both batch and real time transactions sent in a secure protocol over the internet. This protocol requires the user to develop, maintain, and operate their own connectivity application.

Providers must be enrolled in the WEB Portal to use this protocol.		 270/271, 276/277, 820, 820S, 834, 835, and 835S. eMedNY CORE Web Services Connectivity Guide v.2.1

Additional Information and Questions

For detailed information about the submission protocols, providers should refer to the eMedNY "Self Help" web page or contact the eMedNY Call Center at (800)343-9000.

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Attention Pharmacy Providers: Options Available for Reproductive Health for New York State Medicaid Members

New York State (NYS) Medicaid members have a wide variety of options available to them for reproductive health. Traditionally, a NYS Medicaid member could seek reproductive health and family planning services at their enrolled health care practitioner office. NYRx, the NYS Medicaid pharmacy program, additionally reminds enrolled pharmacies of the following services:

Reminders:

  • An order from the practitioner for hormonal contraception or pharmacist dispensed self-administered hormonal contraception, may be dispensed up to a year supply at the time of dispensing.
  • There is no copay for family planning services.
  • Additional medical benefit services are available to NYS Medicaid members. These services are outlined in the Reminder: Medicaid Billing Rules for Family Planning and Reproductive Health Services article published in the November 2022 issue of the Medicaid Update.

Resources:

Questions:

  • Billing questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • Questions regarding this guidance should be directed to the Medicaid Pharmacy Policy Unit at NYRx@health.ny.gov.

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Attention Pharmacy Providers: Pregnant New York State Medicaid Members are Copay-Exempt

As communicated in the March 2023 and June 2023 Medicaid Update issues and in accordance with New York State (NYS) law, NYS Medicaid eligibility for pregnant consumers was extended from 60 days to 12 months postpartum. Additional information regarding this change can be found in the following Medicaid Update articles:

Pharmacy providers are reminded that pregnant consumers are exempt from paying pharmacy copayments. Due to timing of eligibility changes to address the pregnancy status of the NYS Medicaid member, the system may inadvertently apply a copay. In addition, a NYS Medicaid member may state they do not pay copayments due to pregnancy or because the NYS Medicaid member is within their 12-month postpartum period.

Pharmacies may use the following override to remove the copayment for these scenarios:
In the National Council for Prescription Drugs Program field 461-EU, enter a value "04" (Exempt Copay and/or Coinsurance). Providers may also refer to the following resources:

Questions:

  • Billing questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • Questions regarding this guidance should be directed to the Medicaid Pharmacy Policy Unit at NYRx@health.ny.gov.

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
Governor
State of New York

James McDonald, M.D., M.P.H.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs