New York State Medicaid Update - July 2025 Volume 41 - Number 7

In this issue …


New York State Patient-Centered Medical Home Program Medical Billing Guidance Manual

The New York State (NYS) Department of Health (DOH) is committed to supporting health promotion and disease prevention with access to high quality care for individuals through the primary care model known as the New York State Patient Centered Medical Home (NYS PCMH) program.

Providers that achieve NYS PCMH recognition are eligible to receive payments provided in the form of either per member per month (PMPM) capitation payments for Medicaid Managed Care (MMC), including mainstream NYS Medicaid, Health and Recovery Plans (HARPs), and Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), and Child Health Plus (CHPlus) members; or as a per-visit "add-on" payment for eligible claims billed for services provided to NYS Medicaid fee-for-service (FFS) members.

To assist Medicaid and CHPlus providers with reimbursement instructions specific to NYS PCMH, NYS Medicaid created the New York State Patient Centered Medical Home (NYS PCMH) Medical Billing Guidance Manual.

Questions and Additional Information:

  • PCMH questions should be directed to pcmh@health.ny.gov.
  • NYS Medicaid FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • MMC reimbursement and billing requirement questions should be directed to the specific MMC Plan of the enrollee.
  • MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee.

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Telehealth Policy Manual Updates

On July 1, 2025, the New York State (NYS) Medicaid program updated the Telehealth Policy Manual. The information in the manual applies to all NYS Medicaid-enrolled providers and Medicaid Managed Care (MMC) Plans. Updates to the manual include:

  • a revised end date for Medicare flexibilities and emphasis that duals are subject to Medicare rules;
  • information for providers, ensuring they meet all elements of a procedure code to bill;
  • a revised teledentistry definition and billing guidance;
  • an Office of Mental Health guidance for audio-only modifier;
  • a clarified remote patient monitoring billing guidance and information about Ambulatory Patient Group reimbursement;
  • an added integrated eConsult rate enhancement guidance; and
  • an added link to the Office of Aging and Long-Term Care latest “Dear Administrator Letter” (DAL 24-03, “Updated Telehealth in Home Health Care and Hospice”).

Providers should visit the NYS Department of Health “New York State Medicaid Telehealth” web page, to access the manual.

Questions and Additional Information:

  • NYS Medicaid fee-for-service (FFS) billing and claims 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.
  • MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee.
  • MMC Plan contact information and plan directory can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

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New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation

Effective October 1, 2025, for New York State (NYS) Medicaid fee-for-service (FFS), and effective November 1, 2025, for Medicaid Managed Care (MMC) Plans, NYS Medicaid will cover Therapeutic Transcranial Magnetic Stimulation (TMS) under Current Procedural Terminology (CPT) codes "90867", "90868" and "90869" for treatment resistant Major Depressive Disorder (MDD). TMS is a non-invasive form of brain stimulation using magnetic pulses on specific areas of the brain. This therapy is used to improve the symptoms of major depressive disorder when conventional treatments have failed. TMS must be performed by a qualified psychiatrist with specialized training and certification.

NYS Medicaid reimbursement for TMS treatment is available for NYS Medicaid members, 18 years of age and older, who are diagnosed with treatment resistant MDD. Treatment resistance is defined as two trials of a therapeutic dose of two different antidepressants for a sufficient duration without achieving a clinically meaningful response. Prior to initiation of TMS treatment, providers must confirm the diagnosis and rule out other etiologies of depressive symptoms that can interfere with medication effectiveness. TMS is not first-line therapy for depression, nor is it indicated for acute suicidality, psychotic depression, or primary neurological disorders. Obsessive-compulsive disorder is currently not an indication for NYS Medicaid reimbursement.

NYS Medicaid FFS Billing

CPT Code CPT Code Description
90867 Therapeutic repetitive TMS initial planning visit; includes initial procedures such as cortical mapping, motor threshold determination, delivery, and management.
90868 Therapeutic repetitive TMS treatment; subsequent delivery and management, per session.
90869 Re-determination of motor threshold during TMS. This code is used for subsequent assessments of the motor threshold, which is the minimum intensity of electrical pulses required to elicit a desired response in brain activity.

*CPT codes "90867", "90868" and "90869" may not be billed on the same date-of-service.


These services are covered for the following conditions when first line treatments have been unsuccessful:

Diagnosis Code Diagnosis Code Description
F32.2 MDD, single episode, severe without psychotic features.
F33.2 MDD, recurrent severe without psychotic features.

MMC Plan Billing

For individuals enrolled in MMC Plans, providers should check with the MMC Plan of the enrollee for implementation details, reimbursement fees and billing instructions. MMC Plan 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.

Questions

NYS Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management at FFSMedicaidPolicy@health.ny.gov.

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Standing Order for Doula Services Reissued

The New York State (NYS) Commissioner of Health has reissued the standing order titled Non-Patient-Specific Standing Order for the Provision of Doula Services for Pregnant, Birthing and Postpartum Persons, effective June 10, 2025. This standing order fulfills the federal requirements in Title 42 Code of Federal Regulations §440.130(c), for a physician or other licensed practitioner of the healing arts acting within their scope of practice to provide a written order for preventive services. NYS Medicaid members do not need an additional recommendation for doula services beyond this standing order to be eligible for coverage by NYS Medicaid.

Questions and Additional Information:

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Enhanced Rates for Evidence Based Practices within Children and Family Treatment and Support Services

New York State (NYS) is committed to the promotion and support of evidence-based practices (EBPs) within Children and Family Treatment and Support Services (CFTSS) to improve quality of care and outcomes, reduce lengths of stay, and enhance practitioner competencies. As such, NYS has identified three EBPs with demonstrated outcomes for youth and families and developed enhanced rates for their delivery to fidelity:

  • Functional Family Therapy (FFT)
  • Parent-Child Interaction Therapy (PCIT)
  • Multidimensional Family Therapy (MDFT)

Authorization

CFTSS designated agencies providing Other Licensed Practitioner (OLP) and Community Psychiatric Supports and Treatment (CPST) are eligible to offer EBPs through a NYS authorization process. While individual practitioners or teams will be credentialed in an EBP, NYS issues EBP authorization to CFTSS agencies with OLP and CPST designations. Authorization cannot be granted to private practitioners or group practices outside of a CFTSS designated agency. EBP authorization is contingent upon maintenance of OLP and CPST designation and ongoing provision of these services when not delivered via the EBP, by the agency. Agencies must maintain CFTSS licensing/designation in compliance with related state-issued regulations, guidance, or other requirements. Additionally, continued EBP authorization is dependent upon adherence to EBP fidelity measures by the program.

Authorized EBP agencies can be found on the "EBP Approved Provider" tab of the Designated Children's HCBS and CFTSS Providers list, located on the NYS Department of Health (DOH) "Children and Family Treatment and Support Services/Home and Community Based Services" web page, as well as on Exhibit 4, which is shared with Mainstream Medicaid Managed Care (MMC) Plans monthly.

Training

NYS has partnered with specific proprietary organizations to administer EBP training. Given that training availability is limited, EBP authorization is administered in cohorts. Authorized agencies are accepted into a training cohort, allowing them to initiate training and bill the enhanced NYS Medicaid rates upon completion of initial training.

NYS has partnered with the Center for Workforce Excellence (CWE) at McSilver Institute for Poverty Policy and Research at New York University to support the implementation of EBPs in CFTSS. Authorized CFTSS EBP providers are required to collaborate with the CWE to facilitate staff trainings, provide requested data, and ensure access to supportive technical assistance and associated resources. The CWE serves as the conduit between NYS, EBP proprietary organizations and provider agencies. Training for FFT and PCIT launched in October 2023, with a second cohort of each in January 2025. The first MDFT training cohort is anticipated for Summer 2025.

Rates

The enhanced rates supplant existing rate codes for CPST or OLP when EBP services are provided, and providers will submit the same type of rate code claim for both individual and family sessions. Further, when the EBP service is delivered off-site, authorized providers will bill the EBP rate code for the corresponding service per the grid below and the off-site rate code. There is no EBP-specific off-site rate code; the standard off-site code still applies. FFT and PCIT rate codes are effective November 1, 2023, and MDFT rate codes are effective January 1, 2025.

Service Description Rate Code Procedure Code Modifier Billing Unit Unit Limit*
OLP Evidence Based Practice, FFT (Individual and Family) 7981 H0004 U1, UA 15 minutes N/A
OLP Evidence Based Practice, PCIT (Individual and Family) 7982 H0004 U1, UB
OLP Evidence Based Practice, MDFT (Individual and Family) 7984 H0004 U1, UA
CPST Evidence Based Practice, FFT (Individual and Family) 7983 H0036 U1, UA
CPST Evidence Based Practice, MDFT (Individual and Family) 7985 H0036 U1, UA

*While there are no unit limits for CFTSS, all determinations of scope, frequency, and duration must be in accordance with medical necessity and an individualized treatment plan.

To view current rates, providers should refer to the NYS DOH "Children and Family Treatment and Support Services (CFTSS)" web page (under the "RATES" tab).

MMC Plan in NYS-Endorsed EBPs

EBPs are an additional treatment resource for MMC Plans. MMC Plans can help identify MMC enrollees who may benefit from EBPs within CFTSS. Additionally, MMC Plans can educate MMC enrollees on the benefits of EBPs by becoming familiar with EBP appropriateness criteria, as outlined in the NYS Office of Children and Family Services Children and Family Treatment and Support Services (CFTSS) Provider Manual (Appendix C). MMC Plans receive monthly updates through the Exhibit 4 with NYS-endorsed EBP authorized agencies, which includes the authorized EBP(s) and the areas they are approved to serve.

MMC Plans can also play an important role in promoting EBPs to contracted CFTSS agencies to grow their interest in EBP training and authorization. MMC Plans can assist in directing contracted CFTSS agencies to CWE for NYS-endorsed EBP authorization inquiries and share available resources.

Questions and Additional Information:

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Update to Licensure Threshold Guidance

There are a range of preventive and physical health care services that are generally categorized as primary care. This notice is intended to clarify the Updated Licensure Threshold Guidance For Ambulatory Services for New York State Department of Health (DOH), Office of Mental Health (OMH), Office of Addiction Services and Supports (OASAS), and Office for People With Developmental Disabilities (OPWDD) programs, which outlines the newly established licensure thresholds. Threshold services must be delivered within the scope of practice, education, and training of the practitioner, and maintain compliance with clinical guidelines and standards. The following guidance applies to primary care delivered at a licensed or certified Article 16, Article 31, or Article 32 clinic setting.

Dental, surgery, pre-natal care, and all other specialty medical care cannot be provided without licensure from the New York State (NYS) Department of Health and cannot be delivered as licensure threshold services. Licensure threshold limitations outlined in this guidance do not apply to health physicals and monitoring services provided in a licensed Article 31 Mental Health Outpatient Treatment and Rehabilitative Services program. Health physicals and monitoring services are defined in Title 14 New York Codes, Rules and Regulations Part 599.

Article 32 certified providers may continue to deliver physical health care as identified in the OASAS Certified Outpatient Programs - Ambulatory Patient Groups (APG) Clinical and Medicaid Billing Guidance, up to 30 percent of their total annual visits. Article 16 certified providers may continue to bill for medical and health care services, as outlined in the NYS Office for People with Developmental Disabilities Policy and Medicaid Billing Guidance for Ambulatory Patient Groups (APGs) and Standards for Article 16 Clinics - Provider Manual, up to 30 percent of their total annual visits.

Providers who are approaching the 30 percent of total annual visit threshold must coordinate with the appropriate NYS agency to discuss licensing and certification options. Services may not be delivered services above the threshold. Additionally, the NYS Office of Mental Health, Office of Addiction Services and Supports and Office for People with Developmental Disabilities may issue complementary guidance providing more specificity regarding what will be allowable in their settings.

Questions

Questions should be directed to integratedcaremailbox@health.ny.gov, with the subject line "Licensure Thresholds".

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Compound Policy Update

New York State (NYS) Medicaid acknowledges the need for traditional extemporaneous compounding to customize a drug to meet the needs of an individual person prescribed for a NYS Medicaid covered, medically accepted indication. The therapeutic amounts, combinations, and route of administration must be Food and Drug Administration (FDA)-approved, or compendia supported. The compound must have no suitable commercially available product within the drug class. To ensure compliance, NYRx will be implementing system/formulary changes in the near future that may affect pharmacy compound claims/coverage.

Pharmacies that submit compound prescription claims must follow the policy as updated and previously communicated in the NYRx Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines, and the Medicaid Update articles.

Questions and Additional Information:

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New Minimum Needs Requirement for Consumer Directed Personal Care Services, Personal Care Services and Managed Long Term Care Enrollment

Effective September 1, 2025, and in accordance with Social Services Law (SOS) §365-a and SOS §365-f; Title 18 of the New York Codes, Rules, and Regulations (NYCRR) §505.14(b) and Title 18 of the NYCRR §505.28(d); and Public Health Law §4403-f; any individual 21 years of age or older seeking personal care services (PCS), consumer directed personal assistance services (CDPAS), or individuals seeking Managed Long Term Care (MLTC) enrollment through the initial assessment process or any reassessment after an initial assessment that occurred on or after September 1, 2025; must meet the following criteria:

  • need for at least limited assistance with physical maneuvering with more than two activities of daily living (ADLs); or
  • need for at least supervision with more than one ADL if the individual provides a valid diagnosis by a physician of Alzheimer's disease or dementia.

Please note: This is collectively referred to as the "Minimum Needs" requirement.

Individuals seeking PCS, CDPAS, and MLTC enrollment, or reassessed for PCS and CDPAS (that do not have legacy status) and are seeking eligibility based on a diagnosis of Alzheimer's disease or dementia, as well as the need for supervision with more than one ADL, will be required to provide acceptable documentation of Alzheimer's disease or dementia. The only acceptable documentation will be the New York State (NYS) Department of Health (DOH) Alzheimer's Disease and Dementia Diagnosis Verification form (DOH-5821).

Individuals who are authorized for PCS and CDPAS, and/or continuously enrolled in a MLTC Plan before September 1, 2025, will not need to meet the Minimum Needs requirement to continue receiving their services or to remain enrolled. Additionally, individuals who have a valid Community Health Assessment (CHA) for PCS and CDPAS signed and finalized one year prior to September 1, 2025, and are authorized for services within a year of their CHA, will not need to meet Minimum Needs Requirements. These individuals have "Legacy" status. Please note: There are two types of "Legacy" status:

  • PCS/CDPAS Service Legacy
  • MLTC Plan Legacy

"Service Legacy" refers to PCS and CDPAS. All individuals authorized for PCS and CDPAS prior to September 1, 2025, will have "Service Legacy" status. Individuals who are granted "Service Legacy" status will not have to meet the Minimum Needs requirements if their services end after September 1, 2025 and they come back for services at a future date. They will continue to be assessed using the criteria in place prior to September 1, 2025.

"MLTC Plan Legacy" refers to individuals enrolled in a MLTC Plan. All individuals enrolled in MLTC prior to September 1, 2025, will have both PCS and CDPAS "Service Legacy" and "MLTC Plan Legacy" status. Individuals who are disenrolled from MLTC after September 1, 2025 will lose their MLTC Plan "Legacy" status and will need to meet the new Minimum Needs eligibility criteria to re-enroll at a future date. However, they will retain their PCS and CDPAS "Service Legacy" status. Individuals with Program of All-Inclusive Care for the Elderly (PACE) will be granted "Plan Legacy" status and "Service Legacy" status following the same process as other MLTC Plans. PACE is not subject to the Minimum Needs requirement for enrollment.

Questions and Additional Information:

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Reminder: NYRx Allows 90-Day Prescribing for Most Maintenance Medications and OTC Drugs

NYRx, the New York State (NYS) Medicaid pharmacy program, would like to remind stakeholders including prescribers, pharmacists, NYS Medicaid members, and other caregivers that 90-day supplies of most maintenance medications and over the counter (OTC) drugs, are covered by NYRx. This benefit applies, but is not limited to, NYRx-covered OTC medications such as aspirin, acetaminophen, ibuprofen, antihistamines, covered vitamins and minerals such as prenatal vitamin, vitamin B, vitamin D, calcium, fluoride and iron preparations. For a complete list of medications covered by NYRx, stakeholders should refer to the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.

90-day supplies offer numerous benefits:

  • For patients, cost savings with less copays, convenience of less trips to the pharmacy, improved medication adherence, and reduced risk of missing refills.
  • For prescribers, increased patient adherence equals easier monitoring, reduced administrative burden, increased patient satisfaction, and a more streamlined process for chronic disease management.
  • For pharmacies, increased patient adherence, improved operational efficiency leading to more time for additional services such as immunizations and medication therapy management (MTM), and enhanced customer satisfaction resulting in a stronger patient-pharmacy relationship.

Prescribers should consider writing for a 90-day supply and pharmacistsshould work with prescribers to switch to a 90-day supply, once it is determined the patient is on a stable dose of a maintenance medication or OTC drug. Furthermore, pharmacists must submit for package size quantities that closely represent the fiscal order of the prescriber. For instance, if a prescriber writes for a quantity of 90 tablets and the closest package size is 100 tablets, that can be utilized. Prescribers and pharmacies should remind patients to store medications, including over the counter medications, safely and out of the reach of children.

Questions

Questions should be directed to NYRx by email at NYRx@health.ny.gov or by telephone at (518) 486-3209.

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NYRx Now Accepts Electronic Prior Authorization Requests via CoverMyMeds®

Effective July 15, 2025, NYRx now accepts prior authorization (PA) requests via CoverMyMeds®, in addition to the current phone and fax submission methods. The CoverMyMeds® electronic prior authorization (ePA) request submission portal allows pharmacy providers to initiate ePA requests to the prescriber, where the prescriber then completes and submits the ePA request. CoverMyMeds® streamlines the PA process by prompting prescribers to respond to required clinical questions which can lead to real-time approval when criteria are met. Over 98 percent of prescribers who have requested a PA from NYRx are enrolled with CoverMyMeds®. Pharmacy providers who utilize CoverMyMeds® can initiate PA requests on behalf of the NYS Medicaid member for completion by the prescriber. Additional information and how to create an account with CoverMyMeds can be found here:

Questions:

  • Questions or technical support related to CoverMyMeds® should be directed to the CoverMyMeds® Call Center by telephone at (866) 452-5017 or by live chat, located on the CoverMyMeds® homepage (refer "Chat With Support" box in bottom righthand corner), from 8 a.m. to 8 p.m. ET, Monday through Friday, excluding holidays.
  • Questions related to NYRx should be directed to the NYRx Education and Outreach Call Center by telephone at (833) 967-7310 or by email at NYRxEO@primetherapeutics.com, from 8 a.m. to 5 p.m. ET, Monday through Friday, excluding holidays.

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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