New York State Medicaid Update - May 2025 Volume 41 - Number 4
In this issue …
- Policy and Billing
- Timely Postpartum Visit Incentive Coding
- Attention: Federally Qualified Health Centers and Clinics Receiving a Prospective Payment System Rate or Threshold Payment for Dental Encounters
- Remote Patient Monitoring Expansion: New Reimbursement in an Outpatient Setting
- Reminder: Billing for Hospitals Reporting Newborn Claim Information
- New York State Medicaid and Child Health Plus Patient-Centered Medical Home Program Evolution
- All Providers
Timely Postpartum Visit Incentive Coding
As announced in the Timely Postpartum Visit Incentive article published in the December 2024 issue of the Medicaid Update, the New York State (NYS) Medicaid program has received approval from the Centers for Medicare & Medicaid Services to provide an additional payment to the current NYS Medicaid reimbursement for comprehensive, timely postpartum visits provided to Medicaid Managed Care (MMC) enrollees.
This incentive payment will apply to postpartum visits for deliveries that occurred from July 1, 2024, through March 31, 2025.
Perinatal clinicians (e.g., obstetrician/gynecologist physicians, midwives and family practice physicians) who deliver a person-centered comprehensive postpartum visit (as outlined by the American College of Obstetricians and Gynecologists clinical guidelines), and postpartum depression screening to MMC enrollees, within 12 weeks of the date of delivery, will receive an additional payment of $208.55. One incentive is available per MMC enrollee/delivery combination.
Comprehensive postpartum visits are identified for the additional payment by CPT code "59430" - Postpartum Care Only (Separate Procedure) or if billing the bundled/global procedures codes ("59400" , "59410" , "59510" , "59515" , "59610" , "59614" , "59618" , "59622" , "59426" , and "59425" ), Category II CPT code "0503F" - Postpartum Care Visit from the encounter data provided to the NYS Department of Health by the MMC Plans.
Earned payments will be distributed following claim reconciliation to confirm a postpartum visit that meets the guidelines stated above was performed, based on the dates provided in the table below. Providers will receive payment from contracted MMC Plans within six months following the claims runout end date to allow time to complete the reconciliation and process the payments.
| Performance Year One (July 2024 to June 2025) | ||
|---|---|---|
| Date of Delivery | Comprehensive Postpartum Visit Period End Date | Claims Runout End Date |
| July 1, 2024 to September 30, 2024 | December 23, 2024 | June 23, 2025 |
| October 1, 2024 to December 31, 2024 | March 25, 2025 | September 25, 2025 |
| January 1, 2025 to March 31, 2025 | June 23, 2025 | December 23, 2025 |
Questions
Questions should be directed to MaternalandChild.HealthPolicy@health.ny.gov.
Attention: Federally Qualified Health Centers and Clinics Receiving a Prospective Payment System Rate or Threshold Payment for Dental Encounters
Safety net clinics are undeniably valuable to our program, New York State (NYS) Medicaid members, and the communities being served. For Federally Qualified Health Centers and clinics receiving threshold payments, quarterly utilization reviews are in place.
This notice serves as a reminder that "unbundling" of procedures does not meet the standards of the NYS Medicaid program, as indicated on page 12 of the Dental Policy and Procedure Code Manual.
Additionally, routine recall visits should include a cleaning, radiographic images (if required), as well as a dental examination (or screening), with rare instances of exception. Screening of a patient [Current Dental Terminology (CDT) code "D0190" ] is not a standalone procedure. Topical application of fluoride (CDT codes "D1206" and "D1208" ) is not a standalone procedure. All CDT codes performed at each patient encounter must appear on the claim.
Remote Patient Monitoring Expansion: New Reimbursement in an Outpatient Setting
Effective July 1, 2025 , hospital Outpatient Departments (OPDs), freestanding Diagnostic and Treatment Centers (D&TCs), and Federally Qualified Health Centers (FQHCs) that have opted into the Ambulatory Patient Group (APG) reimbursement methodology will be eligible for reimbursement of the remote patient monitoring (RPM) Current Procedural Terminology (CPT) code "99457" through the APG fee schedule in an outpatient clinic setting.
RPM Services Delivered by Clinical Staff
RPM services may be delivered by clinical staff; however, the service must be ordered by a physician or other qualified health care professional. Clinical staff includes individuals under the direction of a physician or qualified health care professional who do not independently bill professional services, such as pharmacists and some registered dieticians. Providers delivering RPM services must confirm that they operate within their scope of practice. Clinical staff may not order nor modify prescriptions. This service is not intended for retail pharmacists.
CPT code "99457" requires a live, interactive communication with the patient/caregiver. The interactive communication contributes to the cumulative time, but it does not need to represent the entire cumulative reported time of the treatment management services. Providers are not to bill CPT code "99457" more than one time per New York State (NYS) Medicaid member, per 30-day period.
Fee-for-Service Billing
An Article 16, Article 28, Article 31, or Article 32 OPD or D&TC may submit an APG claim to NYS Medicaid for RPM services. Claims for RPM services delivered by clinical staff should utilize the CPT code referenced in the table below to ensure appropriate billing and reimbursement.
| CPT Code | Description | NYS Medicaid Rate |
|---|---|---|
| 99457 | Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes. | $41.80 |
Clinical staff should refer to the New York State Medicaid Fee-for-Service Provider Policy Manual – Telehealth Policy Manual, for additional information about RPM and telehealth billing guidance.
Questions and Additional Information:
- NYS Medicaid fee-for-service (FFS) billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- NYS Medicaid FFS telehealth coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at telehealth.policy@health.ny.gov.
- Medicaid Managed Care (MMC) enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee. MMC Plan contact and plan directory information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
Reminder: Billing for Hospitals Reporting Newborn Claim Information
The New York State (NYS) Department of Health reminds hospitals to accurately report newborn birth weights and diagnosis codes on inpatient claims. Pursuant to the inpatient billing procedures for All Patient Refined Diagnostic Related Groups (APR DRGs) shown in the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital document, claims for newborns, 28 days or younger, must accurately contain the birth weight in grams of the newborn. This includes claims where the newborn is transferred to another health care facility. The birth weight is reported using Value Code "54" in the "Value Information" segment. Errors in reporting, such as incorrect birth weight or diagnosis code on newborn and maternity claims, can result in NYS Medicaid overpayments and may be subject to review and recovery by the Office of the Medicaid Inspector General.
To ensure proper payment when billing NYS Medicaid fee-for-service (FFS), providers should follow the billing guidelines detailed in the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital document (see "2.3.1.2 Acute APR DRG Payment Calculation", "Rule 3 - Newborns").
Questions and Additional Information:
- FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- FFS coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
- Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee.
- MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers – Managed Care Information document.
New York State Medicaid and Child Health Plus Patient-Centered Medical Home Program Evolution
In 2024, New York State (NYS) Medicaid and Child Health Plus (CHPlus) announced a New York State Patient-Centered Medical Home (NYS PCMH) Medicaid Managed Care (MMC) incentive enhancement in the New York State Patient-Centered Medical Home Program article published in the October 2024 issue of the Medicaid Update. The enhancement allows providers in a NYS PCMH, for which is recognized by the National Committee for Quality Assurance (NCQA), to earn additional NYS PCMH dollars for MMC enrollees and CHPlus members assigned to them. From April 1, 2024, through March 31, 2025, all NYS PCMH-recognized providers were eligible for the incentive enhancement, as well as the NYS PCMH base payment of $6.00/per member per month (PMPM) (or $7.00/PMPM for Adirondack Medical Home providers). As of April 1, 2025, providers who completed an attestation about social care network (SCN) referral processes continued to be remained eligible for the enhancement.
To continue to incentivize quality improvement within the NYS PCMH program, the NYS Department of Health (DOH) intends to tie the incentive enhancement payment to quality in upcoming years. The following program changes are forthcoming:
- SCN referral workflow attestations will transition to the NCQA PCMH application/renewal system, after which attestations will no longer be collected directly by the NYS DOH via survey. The NYS DOH survey will continue to be available until this transition occurs (additional details on the timeline will be announced at a later date).
- NYS PCMH practices wishing to continue to earn the "incentive enhancement" (an additional $2.00 or $4.00 per month for each MMC enrollee or CHPlus member assigned to them) must report on select quality metrics.
- These measures will be reported to NCQA during the NYS PCMH transformation or annual reporting process. It is recommended that practices applying or renewing for the remainder of 2025 report on these metrics for Measure Year (MY) 2024. While not a requirement for MY 2024, this recommendation is intended to prepare practices for reporting in future years; the incentive enhancement will not be contingent on MY 2024 reporting. Practices applying or renewing in 2026 will report on these metrics for MY 2025. Only practices that submitted MY 2025 data for the required quality metrics will continue to earn the incentive enhancement.* Timeline and payment details are contingent on federal approval and a more detailed timeline will be released in a future update.
*Practices that do not complete the SCN referral attestation or do not report on the required quality metrics will forfeit the incentive enhancement but will still qualify for the NYS PCMH base payment of $6.00/PMPM (or $7.00/PMPM for Adirondack Medical Home providers), if all NYS PCMH eligibility criteria are met.
Required Quality Measures
The metrics below, also known as the required quality measures, were selected from the NCQA PCMH Standardized Measurement list. Pediatric practices report two of the four; adult practices must report three of the four):
- Childhood Immunization Status – Combination 10 (pediatric practices must report)
- Colorectal Cancer Screening (adult practices must report)
- Diabetes HbA1C Poor Control – Greater than nine percent (adult practices must report)
- Screening for Depression and Follow-Up Plan (pediatric and adult practices must report)
Performance goals will be set by NYS DOH for each required quality metric. In State Fiscal Year 2028 (April 1, 2027 through March 31, 2028), only practices reporting quality measures and achieving a NYS DOH-prescribed performance standard will continue to be eligible for the enhancement.
The following table outlines the intended NYS Medicaid and CHPlus MMC payment evolution for NYS PCMH recognized practices. Timeline and payment details are contingent on federal approval and are subject to change; any changes will be communicated by NYS DOH.
| Payment Period | NYS PCMH Base PMPM | NYS PCMH Incentive Enhancement |
|---|---|---|
| April 2025 through March 2026 | All NYS PCMH practices earn $6.00/PMPM for MMC enrollees and CHPlus members ($7.00/PMPM for Adirondack practices). | NYS PCMH practices earn an additional $2.00 or $4.00 incentive enhancement by completing an SCN Referral Workflow Attestation. |
| April 2026 through March 2027 | NYS PCMH practices earn an additional $2.00 or $4.00 incentive enhancement by:
|
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| April 2027 through March 2028 | NYS PCMH practices earn an additional $2.00 or $4.00 incentive enhancement by:
|
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| April 2028 through March 2029 | NYS PCMH practices earn an additional $2.00 or $4.00 incentive enhancement by:
|
Questions and Additional Information:
- Questions regarding the NYS PCMH program and attestation should be directed to PCMH@health.ny.gov.
- Questions related to SCNs should be directed to NYHER@health.ny.gov. Additional information regarding SCNs can be found on the NYS DOH "Social Care Networks (SCN)" web page.
- Questions related to CHPlus should be directed to CHPlus@health.ny.gov.
- Additional NYS Medicaid and CHPlus NYS PCMH incentive enhancement information can be found in the New York State Patient-Centered Medical Home Program article published in the October 2024 issue of the Medicaid Update.
- Providers should refer to the NYS DOH "PCMH Attestation: Frequently Asked Questions (FAQ's)" web page.
New York State Medicaid Evidence Based Benefit Review Advisory Committee Meeting on July 24, 2025
On Thursday, July 24, 2025, from 10:30 a.m. to 3:30 p.m., the New York State (NYS) Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) will hold its second in-person meeting of 2025. The meeting will take place at the Empire State Plaza, Concourse Meeting Room #6, Albany, NY 12242. At this meeting, the committee will review two topics: “Treatment of Opioid Use Disorder Exclusively by Telehealth” and “Applied Behavior Analysis Therapy Provided via Telehealth.” Additional information can be found on the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page.
Background
NYS Medicaid EBBRAC was established in 2015 pursuant to Chapter 57, Part B, §46-a of the Laws of 2015, as Social Services Law §365-d, to make recommendations to the NYS DOH regarding NYS Medicaid coverage of health technologies and services.
Additional Information
Providers should refer to the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page, or email EBBRAC@health.ny.gov, for additional information regarding NYS Medicaid EBBRAC.
New York State Department of Health "Social Care Networks: Opportunities for Provider Participation and Impact" Webinar Held on July 14, 2025
The New York State Department of Health (NYS DOH) invites health, behavioral and social care providers to attend the "Social Care Networks: Opportunities for Provider Participation and Impact" webinar on July 14, 2025, from 11 a.m. to noon. Providers are encouraged to register for the "Social Care Networks: Opportunities for Provider Participation and Impact" webinar.
What information will be covered?
The "Social Care Networks: Opportunities for Provider Participation and Impact" webinar will include an overview of the Social Care Network (SCN) program and provide insight into key operational aspects for providers who may be interested in participating, such as onboarding and contracting with an SCN and ways to connect to the SCN Information Technology platform through your regional Qualified Entity.
Who should attend?
The "Social Care Networks: Opportunities for Provider Participation and Impact" webinar is for health care and behavioral health providers and leaders involved in population health, social care, or care management from hospitals, health systems, primary care practices, behavioral health organizations, and community health centers, including federally qualified health centers.
Feedback
The "Social Care Networks: Opportunities for Provider Participation and Impact" webinar will be informed by participants questions and concerns. To provide your input, providers must take the five-minute Social Care Network (SCN) Program Survey.
Additional Information
Additional information about the NYS DOH SCN program can be found on the NYS DOH "Social Care Initiatives" web page.
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
