New York State Medicaid Update - August 2025 Volume 41 - Number 8

In this issue …


Attention Dentists: Billing Guidance for New York State Medicaid Members Who've Received a Pre-Paid Debit Card from Medicare Advantage Plans for Dental Services

New York State (NYS) Medicaid members may have primary coverage for dental services with a Medicare Advantage Plan. Some of these Medicare Advantage Plans have been using a pre-paid debit card as the annual dental benefit that the NYS Medicaid member can use to pay for dental services.

These pre-paid debit cards can be considered private pay agreements with the provider until they are exhausted (the term private pay is being used in this instance "only for billing purposes" and under no circumstances does it reflect the out-of-pocket expenses by NYS Medicaid members). The fee that the provider charges for their service while using the pre-paid debit card is not subject to NYS Medicaid allowable amounts. Once the funds on the debit card have been exhausted, the provider may bill NYS Medicaid, provided that the NYS Medicaid member is eligible on the date of service. The provider must abide by NYS Medicaid allowable amounts for these services. If a balance remains on the debit card that does not fully cover the dental service provided and NYS Medicaid is secondary coverage for the NYS Medicaid member, the provider should report the balance remaining from the debit card on the NYS Medicaid claim in the "Patient Paid Amount" field.

Providers must keep records to identify that the payment was made by the pre-paid debit card and not cash, if the dental service provided is a NYS Medicaid-covered service. NYS Medicaid will pay the difference between the dollar amount reported in the "Patient Paid Amount" field and the NYS Medicaid fee. The claim must be submitted electronically using payer code "16" and the provider should zero fill the Part C payment in the "Coordination of Benefits" section. Partial payments are still subject to prior approval as specified in existing NYS Medicaid policy.

Questions and Additional Information:

  • NYS Medicaid fee-for-service (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 dentalpolicy@health.ny.gov.
  • NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

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New York State Directed Payment Renewal Approved for Labor and Delivery Hospitals to Reduce Low-Risk Cesarean Delivery Rates in State Fiscal Year 2026

The New York State (NYS) Department of Health has received approval from the Centers for Medicare and Medicaid Services to continue the low-risk Cesarean delivery state-directed quality incentive payment for State Fiscal Year (SFY) 2026 (April 1, 2025 to March 31, 2026). Labor and delivery hospitals in NYS may be eligible for a performance payment for reducing their low-risk Cesarean delivery (Nulliparous, Term, Singleton, Vertex) rates to meet their individual measurement year targets in SFY 2026.

For this third year of the incentive payment, the criteria for hospital eligibility are expanded to include hospitals with 400 or more Medicaid Managed Care (MMC) deliveries in SFY 2024. Eligible hospitals will receive a performance payment for achieving a 10 percent reduction of their hospital's specific gap to the statewide performance benchmark goal. Hospitals that have already achieved a very low baseline rate (18 percent or less) will not be expected to lower their rate and will receive performance payment for maintaining a rate within two percent of their SFY 2024 rate. MMC Plans are required to disburse the earned payments to hospitals by March 2027.

Questions

Questions should be directed to MaternalAndChild.HealthPolicy@health.ny.gov.

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Reimbursement for Child Abuse Pediatricians

Effective October 1, 2025, for New York State (NYS) Medicaid fee-for-service (FFS) members, and effective December 1, 2025, for Medicaid Managed Care (MMC) Plan enrollees, NYS Medicaid will reimburse physicians certified by the American Board of Pediatrics (ABP) in Child Abuse Pediatrics a once per NYS Medicaid member lifetime fee. This fee may be billed by a child abuse pediatrician when providing diagnosis and treatment of suspected child maltreatment or when supervising a physician, nurse practitioner (NP), or physician assistant (PA) providing direct care in a child abuse case.

A new specialty code has been created for physicians with Category of Service (COS) "0460" who are ABP-certified in Child Abuse Pediatrics. This specialty code can be added by the physician by completing and submitting the New York State Department of Health Application for Enrollment as a Specialist form. Once the completed application has been reviewed and approved, the newly created COS specialty code "168" will be added to the provider enrollment file.

Billing:

  • The Current Procedural Terminology (CPT) code "G9012", provided in the table below, has been added to the Physician Fee Schedule, located on the eMedNY "Physician Manual" web page, to be billed once per NYS Medicaid member per lifetime by those physicians with specialty code "168".
  • CPT code "G9012" may be billed in addition to an Evaluation and Management service on the same date of service.
  • Physicians should append U2 and U2 modifiers to CPT code "G9012" when submitting a claim for the supervision of a physician, NP, or PA providing direct care in a child abuse case.
  • Physicians should continue to submit claims according to NYS Medicaid policy for all services provided to NYS Medicaid members during evaluation, management and treatment.
CPT Code CPT Code Description Fee Fee with
U2 and U2
Modifier
Combination
G9012 Other specified case management service not elsewhere classified. $400.00 $380.00

Questions and Additional Information:

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New York State Medicaid Coverage of Point of Care Syphilis Testing

Effective immediately, for both fee-for-service (FFS) and Medicaid Managed Care (MMC), New York State (NYS) Medicaid will cover Point of Care (POC) syphilis testing in a physician/nurse practitioner/licensed midwife private office setting. There is currently one Food and Drug Administration (FDA)-approved, Clinical Laboratory Improvement Amendments-waived, rapid syphilis test, Syphilis Health Check™, for the detection of Treponema pallidum antibodies, the bacteria that causes syphilis. If additional tests receive FDA-approval, this same policy will also apply.

According to NYS data, which can be found in the New York State 2023 Sexually Transmitted Infections Surveillance Report, located on the NYS Department of Health "Sexually Transmitted Infections Data and Statistics" web page, (under the "Surveillance Summary Reports" section of the web page), primary and secondary (P&S) syphilis, the most infectious stages of the disease, representing the newest cases reported in NYS, were almost eliminated in the year 2000 when about 132 diagnoses (0.6 cases per 100,000 persons) were reported from a statewide high of 5,688 diagnoses (31.7 cases per 100,000 persons) in 1988 (a reduction of 98 percent in diagnoses and rate*). Since 2000, these diagnoses have been escalating rapidly, and these annual increases have been sustained. In 2023, 2,888 diagnoses were reported, representing a 2,087 percent increase. In 2014, the rate of P&S syphilis in females was 0.5 per 100,000, and in 2023, increased by 800 percent to 4.5 per 100,000. As a result, congenital syphilis diagnoses have also increased from 23 in 2014 to 67 in 2023 as well as 13 associated deaths/stillbirths in the same period. Despite syphilis being a preventable and treatable disease, equitable access to screening and treatment remains a formidable barrier to reaching all populations. For this reason, NYS Medicaid has added coverage of POC syphilis testing. This technology has proven to advance health equity by increasing accessibility and expanding options, particularly for underserved communities disproportionately affected by syphilis.

Additional information regarding syphilis rates in NYS can be found in the New York State 2023 Sexually Transmitted Infections Surveillance Report, located on the NYS Department of Health "Sexually Transmitted Infections Data and Statistics" web page (under the "Surveillance Summary Reports" section of the web page).

FFS Reimbursement for POC Syphilis Testing

For NYS Medicaid FFS POC syphilis testing reimbursement, claims should be submitted using the following Current Procedural Terminology (CPT) code "86780". If the POC syphilis test is positive, confirmatory serological testing must then be performed at a NYS-permitted laboratory to establish definitive diagnosis. A negative result in a high-risk individual should be interpreted cautiously and repeat testing may be necessary if clinical suspicion remains high. This CPT code has been added to the following Fee Schedules:

Questions and Additional Information:

  • NYS Medicaid 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.
  • 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.
  • NYS Medicaid FFS claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid FFS provider enrollment questions should be directed to eMedNY Provider Enrollment at (800)343-9000.

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New York State Medicaid Ambulatory Patient Group Weight Adjustment for Dialysis Clinics to Account for Phosphate Binder Costs

Effective for New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans, for dates of service on or after October 1, 2025, costs related to phosphate binders provided during a dialysis session are included in the Ambulatory Patient Group (APG) payment. The FFS APG weight for APG 168 (dialysis) has increased from 1.3651 to 1.5302. Dialysis patients should not be referred to a pharmacy to obtain phosphate binders.

This change reflects the increased costs incurred by End Stage Renal Disease (ESRD) facilities related to the acquisition and storage of oral phosphate binders. The revised weight accounts for the Average Sales Price or Wholesale Acquisition Cost of the binders, along with monthly operational costs incurred by ESRD facilities for providing phosphate binders.

The update aligns with the Centers for Medicare & Medicaid Services (CMS) policy change under the Transitional Drug Add-on Payment Adjustment (TDAPA), as detailed in the CMS End Stage Renal Disease Prospective Payment System final rule dated November 12, 2024 where CMS finalized its policy to include oral-only phosphate binders in the ESRD Prospective Payment System bundled payment and its mechanism for collecting utilization and price information for these drugs (providers should refer to 89 Federal Register 98822). NYS Medicaid will follow CMS's approach by incorporating these costs into the APG reimbursement through a standard APG claim submission.

Please note: For acute kidney injury (AKI) patients, binders remain covered under Medicare Part D. For NYS Medicaid members with AKI, binders remain covered under the NYS Medicaid pharmacy benefit (NYRx), not through the APG dialysis clinic payment. This policy ensures alignment between Medicare and NYS Medicaid coverage for AKI patients.

Questions and Additional Information:

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

This article updates New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Coronavirus disease 2019 (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 health care professional organizations and are consistent with the scientific evidence supporting their safety and efficacy. Updated recommendations are included below. For additional information regarding the Northeast Public Health Collaborative, providers should refer to the Northeast Public Health Collaborative Recommendations for the 2025-2026 COVID-19 Vaccine document.

COVID-19 Vaccination Recommendations for Adults

Vaccination against COVID-19 is recommended for all adults (18 years of age and older). Additional COVID-19 vaccination recommendations for adults are as follows:

  • All adults 65 years of age and older should be vaccinated.
  • Adults 19 years of age through 64 years of age with risk factors for severe COVID-19 disease (e.g., chronic conditions, immunocompromised status), should be vaccinated. For a list of conditions, provider should refer to Table 1 in the Health Advisory: 2025-2026 COVID-19 Immunization Guidance for Adults.
  • Adults 19 years of age through 64 years of age at higher risk of exposure (e.g., health care workers, congregate care settings) should be vaccinated.
  • Adults 19 years of age through 64 years of age, who are household contacts of persons at high risk of severe disease, should be vaccinated.
  • For adults without underlying conditions, the 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 (six months of age to 18 years of age) are as follows:

  • All children six months of age to 23 months of age should be vaccinated.
  • Children and adolescents two years of age through 18 years of age, who fall within one of the following subgroups, should be vaccinated:
    • high risk for severe COVID-19 (for recommended high risk populations, providers should refer to Table 1, Appendix A of the Health Advisory: 2025-2026 COVID-19 Immunization Guidance for Children;
    • living in a long-term care facility or other congregate setting;
    • have never been vaccinated against COVID-19; and
    • whose household members are at high risk for severe COVID-19.
  • Vaccination may also be provided to children two years of age through 18 years of age, who do not fall into one of the above categories, at the request of their parent/guardian.

COVID-19 Vaccination Recommendations for Pregnant People

COVID-19 vaccination recommendations for all pregnant people are as follows:

  • 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 regarding COVID-19 vaccination recommendations is located on the NYS "COVID-19 Guidance Repository" web page.

NYS Medicaid FFS Billing Instructions

NYS Medicaid FFS 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; Diagnostic and Treatment Centers; local county Health Departments] and School Based Health Centers, should follow the New York State Medicaid Fee-for-Service Coverage for Vaccinations Administered by Providers article published in the October 2024 issue of the Medicaid Update.

As a reminder, providers who provide care to children (zero years of age through 18 years of age) 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 and Additional Information:

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Reminder: NYS Medicaid Telehealth Coverage

The New York State (NYS) Medicaid Telehealth Policy Manual - New York State Medicaid Fee-for-Service Provider Policy Manual, includes detailed coverage policies and billing instructions for NYS Medicaid providers billing for telehealth services. The NYS Medicaid telehealth policy has been unchanged since the manual was last updated in July 2025 and is distinct from Medicare telehealth policy.

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.
  • 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 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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Applied Behavior Analysis Service Updates for Supervision of Unlicensed Individuals and Technicians

Effective October 1, 2025, as authorized by the New York State (NYS) Enacted Budget for fiscal year (FY) 2025-2026, NYS fee-for-service (FFS) Medicaid requires Licensed Behavior Analysts (LBAs) to supervise unlicensed individuals/technicians working as part of an LBA's service delivery team for a minimum of five percent of the hours the unlicensed individual/technician spends providing behavior analysis services each calendar month. Please note: This supervision standard also applies to Medicaid Managed Care (MMC) providers in NYS.

This change aligns NYS Medicaid FFS policy with Behavior Analyst Certification Board (BACB) guidance. LBAs are encouraged to provide direct observation of the unlicensed individual/technician to the fullest extent based on the ability level, clinical experience, and setting in which services are being provided.

Supervision must include at least two face-to-face, real-time contacts per month (i.e., supervision may not occur telephonically, via email or text messaging). The LBA must observe the unlicensed individual/technician providing services in at least one of the monthly meetings. On-site supervision of unlicensed individuals/technicians is preferred; however, supervision may be conducted via a synchronous interactive audio and video telecommunication system, or similar means, consistent with NYS Medicaid FFS telehealth policy.

One of the two face-to-face, real-time contacts per month may occur in a small-group meeting, if preferred. Small-group meetings are interactive sessions involving multiple unlicensed individuals/technicians, including their supervising LBA, who share similar roles and experiences. If other professionals are present during the meeting, their involvement must be limited to ensure that the primary focus remains on supporting the active participation and interaction of the unlicensed individuals/technicians. These meetings must follow all applicable NYS Department of Health regulations and BACB guidelines.

Supervision may include, but is not limited to, the following activities:

  • developing performance expectations;
  • observing, providing behavioral skills training, and delivering performance feedback;
  • modeling technical, professional, and ethical behavior;
  • guiding the development of problem-solving and ethical decision-making capacity;
  • reviewing written materials (e.g., daily progress notes, data sheets);
  • overseeing and evaluating the effects of behavior-analytic service delivery; and/or
  • providing ongoing evaluation of the effects of supervision.

Please note: The five percent minimum supervision requirement may include the use of Current Procedural Terminology (CPT) code "97155" only when the LBA joins the patient and the unlicensed individual/technician during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.

Documentation of supervision should be recorded in the patient file of the NYS Medicaid member. Applied behavior analysis professionals must keep all patient records for a minimum of six years and, for minors, until the patient turns 22 years of age. All MMC providers must keep the patient file a minimum of 10 years.

Reimbursement Reduction for Services Administered by an Unlicensed Individual

As authorized by the NYS Enacted Budget for FY 2025-2026, NYS FFS Medicaid will begin a reduction in the rate paid for adaptive behavior treatment provided by unlicensed individuals/technicians; represented by CPT code "97153". This change in reimbursement methodology ensures providers of ABA services are compensated equitably for their training and experience.

Effective October 1, 2025, the reimbursement rate for procedure code "97153" will be reduced to $16.85/per unit. Effective April 1, 2026, the reimbursement rate for procedure code "97153" will be reduced to $14.45/per unit. Practitioners should refer to the eMedNY Applied Behavior Analysis Policy Manual - New York State Medicaid Provider Policy Manual, for additional program and billing guidance.

Questions and Additional Information:

  • NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid 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.

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New York State Medicaid Evidence Based Benefit Review Advisory Committee Update

A New York State (NYS) Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) meeting was held on July 24, 2025. The NYS Medicaid EBBRAC was established in 2015 pursuant to Chapter 57, Part B, §46-a of the Laws of 2015, as Social Services (SOS) Law §365-d, to make recommendations to the NYS Department of Health regarding NYS Medicaid coverage of health technologies and services.

During the July 24, 2025 meeting, NYS Medicaid EBBRAC reviewed the following topics:

  • "Treatment of Opioid Use Disorder Delivered Exclusively by Telehealth"
  • "Applied Behavior Analysis Therapy Provided via Telehealth"

Meeting materials and reports can be found on the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page.

The next EBBRAC meeting will review the topic: "Hospital at Home for Admission Avoidance or Early Discharge in Adults and Pediatric Patients". Providers should refer to the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page, for details.

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Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Provider Reporting in New York State Training Available Online

The Bureau of Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) Epidemiology recently launched a new online training titled HIV/AIDS Provider Reporting in New York State (2025). This training is available on the New York State (NYS) Department of Health AIDS Institute HIV Education & Training Programs website. It is intended for health care providers and non-clinical staff who assist with HIV/AIDS reporting. The topics covered include:

  • NYS HIV Public Health Laws and regulations that govern reporting by health care providers;
  • the importance of HIV reporting by health care providers;
  • entities required to report and reporting timelines;
  • the Medical Provider HIV/AIDS and Partner/Contact Report Form (DOH-4189); and
  • available reporting options.

To register for the HIV/AIDS Provider Reporting in New York State (2025) training, providers should visit the NYS Department of Health AIDS Institute HIV Education & Training Programs website. Learners must create an account to register for and take this training. Providers are encouraged to share this information with colleagues, contractors, and physician groups who could benefit from this information.

Questions

Questions should be directed to the Bureau of HIV/AIDS Epidemiology by telephone at (518) 474-4284 or by email at bhae@health.ny.gov.

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Apply to Join the Medicaid Advisory Committee and the Beneficiary Advisory Council

The New York State (NYS) Department of Health (DOH) invites NYS residents to contribute their voices and lived experiences by applying to serve on the Medicaid Advisory Committee (MAC) and the Beneficiary Advisory Council (BAC).

The MAC and BAC provide critical input to help guide the development and administration of the NYS Medicaid program and the Child Health Plus (CHPlus). Their collective insight supports the delivery of high-quality, cost-effective care for NYS Medicaid and CHPlus members statewide.

Interested individuals must complete the MAC and BAC Member Application, located on the NYS DOH "Medicaid Advisory Committee (MAC) and Beneficiary Advisory Council (BAC)" web page, which takes approximately five minutes to complete. The MAC members will serve a three-year term and BAC members will serve a two-year term. Providers are encouraged to share this opportunity with their colleagues, patients, caregivers, and community networks who may bring valuable perspectives to this work.

Questions

Questions should be directed to NYS DOH at MAC_BAC@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