New York State Medicaid Update - September 2025 Volume 41 - Number 9
In this issue …
- All Providers
- Policy and Billing
- Update to School-Based Health Center Medicaid Telehealth Off-Site Billing Guidance
- Reminder to Vision Care Providers: Pediatric Eye and Vision Exams
- New York State Medicaid Coverage of Tumor Treatment Field Therapy
- Submission of Prenatal and Postpartum Service Claims for Pregnancy-Related Visit and Timely Postpartum Visit Incentive
- New York State Medicaid Coverage of Magnetic Resonance Image Guided High Intensity Focused Ultrasound for Essential Tremor
- Pharmacy
Health Navigation Services: Clarification of Coverage Under Community Health Worker Services Benefit and Social Care Network
Effective January 1, 2024, the New York State (NYS) Medicaid program covers Community Health Worker (CHW) services provided in accordance with 42 Code of Federal Regulations (CFR) §440.130(c). CHWs foster trusting relationships with the populations they serve, function as a link between health care providers and patients, reduce barriers to care, and provide health advocacy, health education, and health navigation services. These services aim to improve health knowledge and self-sufficiency and to support a reduction in maternal mortality, violence retaliation, injury, illness or the progression thereof. CHW services include health advocacy, health education, and health navigation supports aimed at improving health outcomes and overall health literacy and preventing the development of adverse health conditions, injury, illness or the progression thereof.
Under the 1115 New York Health Equity Reform Waiver, Medicaid Managed Care (MMC) enrollees are eligible for navigation to existing resources, and those who meet specific criteria are eligible to receive health-related social needs services. Therefore, screening, navigation and referral for social care services of MMC enrollees should be covered under the regional Social Care Network (SCN). Information regarding payment through the SCNs is located on the NYS Department of Health "Social Care Networks (SCN)" web page. CHWs can be reimbursed under the SCN for the screening and navigation of NYS Medicaid members when contracted directly with the regional SCN.
Social care navigation services provided to MMC enrollees are covered under the SCN and are not billable outside of the SCN. Other CHW services provided to NYS Medicaid members not related to those explicitly available under the SCN, such as health education and advocacy, are billable outside of the SCN.
Providers should refer to the following resources for additional policy and billing guidelines pertaining to NYS Medicaid coverage of CHW services:
- Community Health Worker Services Policy Manual - eMedNY New York State Medicaid Provider Policy Manual
- Community Health Worker Services for Pregnant and Postpartum People article published in the September 2023 issue of the Medicaid Update
- Expanded Eligibility for Community Health Worker Services article published in the December 2023 issue of the Medicaid Update
- Federally Qualified Health Centers and Rural Health Centers Reimbursement for Community Health Worker Services article published in the October 2024 issue of the Medicaid Update
Reminder: Sign Up for eMedNY Training Webinars
eMedNY offers various types of training webinars for providers and their billing staff, which can be accessed via computer and telephone (no travel is necessary). Valuable provider webinars offered include:
- New! Provider Services Portal - Practitioner
- ePACES for: Dental, DME, Doula, Free-Standing and Hospital-Based Clinics, Institutional, Physician, Private Duty Nursing, Professional Real-Time, Transportation and Vision Care.
- ePACES Dispensing Validation System (DVS) for DME
- eMedNY Website Review
- Medicaid Eligibility Verification System (MEVS)
- Medicaid Revalidation for Practitioners
- New Provider / New Biller
Webinar registration is fast and easy. To register and view the list of topics, descriptions and available session dates, providers should visit the eMedNY "Provider Training" web page. Providers are reminded to review the webinar descriptions carefully to identify the webinar(s) appropriate for their specific training needs.
Questions
Questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343-9000.
Modernization of the New York State Medicaid Provider Enrollment Process
The New York State (NYS) Medicaid program is modernizing the provider enrollment process with the phased roll-out of an online provider enrollment portal known as the New York State Medicaid Provider Services Portal (PSP). The portal is separate and distinct from the current Provider Enrollment Maintenance Portal (maintenance portal) that allows currently enrolled practitioners to update their enrollment file. Providers who have never been enrolled in NYS Medicaid before can now apply for enrollment via the NYS Medicaid PSP.
The modernization effort will include a series of phased releases over the coming months beginning with the current announcement of this capability for new enrollment for individual providers. Credentialing staff at facilities will be able to support new provider enrollment using the online portal. Each roll-out phase will be communicated to the provider community via the Medicaid Update and NYS DOH listservs.
Development of an online portal is a complex undertaking involving many stakeholders, types of providers, and transactions. To support this transition, eMedNY will be offering live training webinars on a recurring basis. To view the training schedule and/or register for training regarding the NYS Medicaid PSP, providers can visit the eMedNY "Provider Training" web page. NYS Medicaid PSP training sessions will orient providers to the NYS Medicaid PSP and the steps necessary to apply for enrollment, including:
- creating a NY.gov Business Account to access the NYS Medicaid PSP;
- navigating NYS Medicaid PSP features and functions;
- understanding available transaction types and associated instructions within the screens; and
- monitoring submission status.
Similar to the way in which creating a NY.gov Personal Account to use MyDMV is convenient and saves time, a few minutes creating NY.gov Business Account to use the NYS Medicaid PSP will streamline the process and improve application turnaround time down the road. Providers should visit the eMedNY NY.GOV ID Account Overview document, for step-by-step instructions to create an account. Account creation only needs to be done once and can be done from a desktop, laptop, tablet and phone.
The eMedNY Provider Training calendar, located on the eMedNY "Provider Training" web page, will be updated with additional information and trainings as they become available.
Questions
Questions related to enrollment through the NYS Medicaid PSP should be directed to the eMedNY Call Center at (800) 343-9000.
Update to School-Based Health Center Medicaid Off-Site Billing Guidance
Effective immediately, School-Based Health Centers (SBHCs) must bill according to the guidance below for telehealth services rendered to New York State (NYS) Medicaid members.
This update clarifies that the provider must be located at a SBHC for the service to be considered school-based and eligible to bill under SBHC rate codes. When the provider is located at the facility of the operator and delivers services to the student via telehealth, they must bill according to the operator facility type guidance and rate codes outlined in the Telehealth Policy Manual - New York State Medicaid Fee-for-Service Provider Policy Manual (under section 9.16).
| Facility/Clinic Type | On-Site Presence | Billing Instructions |
|---|---|---|
| Federally Qualified Health Centers (FQHCs) Article 28 SBHCs that have not opted into Ambulatory Patient Group (APG) | Only the provider is on-site. | If the provider is located at an SBHC, the provider must bill FQHC SBHC rate codes "4014", "4015" and "4016". If the provider is located at the facility of the operator, the provider must bill under the operator facility type guidance and rate codes. |
| Only the NYS Medicaid member is on-site. | If the provider is located at a different SBHC than the student, the provider must bill FQHC SBHC rate codes "4014", "4015" and "4016". If the provider is located at the facility of the operator, the provider must bill under the operator facility type guidance and rate codes. |
|
| Neither the provider nor the NYS Medicaid member is on-site. | Not billable. | |
| Article 28 SBHCs opted into APGs | Only the provider is on-site. | If the provider is located at an SBHC, the provider must bill SBHC rate codes "1444", "1450", "1447", "1453", "3257", "3258" and "3259". If the provider is located at the facility of the operator, the provider must bill under the operator facility type guidance and rate codes. |
| Only the NYS Medicaid member is on-site. | If the provider is located at a different SBHC than the student, the provider must bill SBHC rate codes "1444", "1450", "1447", "1453", "3257", "3258" and "3259". If the provider is located at the facility of the operator, the provider must bill under the operator facility type guidance and rate codes. |
|
| Neither the provider nor the NYS Medicaid member is on-site. | Not billable. |
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.
Reminder to Vision Care Providers: Pediatric Eye and Vision Exams
New York State (NYS) Medicaid fee-for-service (FFS) policy allows for providers to bill for complete ophthalmologic and optometric eye examination at frequencies recommended by the American Academy of Pediatrics, American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus.
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.
- Medicaid Managed Care (MMC) 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 Coverage of Tumor Treatment Field Therapy
Effective October 1, 2025, for New York State (NYS) Medicaid fee-for-service (FFS), and effective December 1, 2025, for Medicaid Managed Care (MMC) Plans, NYS Medicaid will cover Tumor Treatment Field Therapy (TTFT) under Healthcare Common Procedure Coding System (HCPCS) code "E0766" for treatment of Glioblastoma Multiforme. TTFT are alternating electric fields produced by a pulse generator and transmitted by ceramic transducers placed on the head of the patient. TTFT uses alternating electric fields to target cancer cells and disrupt cancer cell division.
NYS Medicaid reimbursement for TFFT treatment is available for NYS Medicaid members when all the required criteria are met, as outlined on the eMedNY "DME Manual" web page.
NYS Medicaid FFS Billing
| HCPCS Code | HCPCS Code Description |
|---|---|
| E0766 | Electrical stimulation device used for cancer treatment, includes all accessories, any type. |
If criteria are met, initial prior approval will be given for three months. Additional FFS billing guidelines can be found on the eMedNY "DME Manual" web page.
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 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 at FFSMedicaidPolicy@health.ny.gov.
- Durable medical equipment procedure codes and coverage guidelines regarding new codes, descriptions, and fees can be found on the eMedNY "DME Manual" web page.
- Questions regarding prior approval for HCPCS code "E0766" for the coverage of TTFT for NYS Medicaid FFS members should be directed to the DME program by telephone at (800) 342-3005 or by email at OHIPMEDPA@health.ny.gov.
Submission of Prenatal and Postpartum Service Claims for Pregnancy-Related Visit and Timely Postpartum Visit Incentive
This update clarifies the requirement to submit Category II Current Procedural Terminology (CPT) codes for pregnancy-related visits and provides an update to the Timely Postpartum Visit Incentive Payment.
Effective for service delivered as of July 1, 2024, providers using bundled/global procedure codes for billing of perinatal (prenatal and postpartum) services are also required to submit separate claims for non-payment Category II CPT codes for perinatal service to New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC). A separate claim with the Category II CPT code must be submitted for each perinatal service provided to the NYS Medicaid member. These Category II CPT code claims are to be billed as separate claims from the global or bundled code claims at the time perinatal services are rendered. The following CPT codes must be used:
| CPT Code | CPT Code Description |
|---|---|
| 0500F | INITIAL PRENATAL VISIT |
| 0502F | SUBSEQUENT |
| 0503F | POSTPARTUM VISIT |
Claims for NYS Medicaid FFS members must be submitted directly to NYS Medicaid. Claims for MMC enrollees must be submitted to the MMC Plan of the enrollee. MMC Plans are required to submit this information, alongside other encounter data, to NYS Medicaid via the Original Source Data Submitter system. Category II CPT codes are non-reimbursable but can be submitted with a $.01 charge if provider or MMC Plans require a payment amount to generate/accept the claim.
As a reminder, the Timely Postpartum Visit Incentive article published in the December 2024 issue of the Medicaid Update, the 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 MMC enrollees for deliveries that occurred from July 1, 2024 through March 31, 2025.
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.
To ensure that all MMC Plans have configured their systems to accept Category II CPT codes and give providers the opportunity to submit any previously denied claims, the claims runout end date has been adjusted to the following:
| Performance Year One (July 2024 to March 2025) | ||
|---|---|---|
| Date of Delivery | Comprehensive Postpartum Visit Period End Date | Claims Runout End Date |
| July 1, 2024 to March 31, 2025 | June 23, 2025 | December 23, 2025 |
Questions
Questions should be directed to MaternalandChild.HealthPolicy@health.ny.gov.
New York State Medicaid Coverage of Magnetic Resonance Image Guided High Intensity Focused Ultrasound for Essential Tremor
Effective January 1, 2026, for New York State (NYS) fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans, NYS Medicaid will cover Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) under Current Procedural Terminology "61715" MRgFUS thalamotomy is a noninvasive treatment option for medication refractory Essential Tremor (ET) that affects the ability of a person to perform routine activities. NYS Medicaid reimbursement for MRgFUS is available for NYS Medicaid members 22 years of age or older, meeting all of the criteria below:
- Presence of medication refractory ET defined as refractory to at least two trials of pharmaceutical treatment, including at least one first-line agent (i.e., propranalol or primidone);
- Presence of a moderate to severe postural or intention tremor [defined by a score greater than or equal to two on the clinical rating score for tremor (CRST) or another nationally accepted clinical measure of tremor severity] of the dominant hand;
- The tremor is disabling (defined by a score of greater than or equal to two on any of the eight items in the disability subsection of the CRST or another nationally accepted clinical measure of tremor severity); and
- The recipient is not a candidate for deep brain stimulation (e.g., advanced age, anticoagulant therapy, surgical comorbidities, or has failed DBS, but has no retained cranial implants).
Questions and Additional Information:
- FFS billing and claims 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.
- 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.
NYRx, the New York State Medicaid Pharmacy Program: Prior Authorization Update
On May 15, 2025, the New York State (NYS) Medicaid Drug Utilization Review Board (DURB) recommended changes to NYRx, the NYS Medicaid Pharmacy program. The Commissioner of Health has reviewed the recommendations of the DURB and has approved the following changes.
The following drug classes were reviewed, and effective November 6, 2025, prior authorization (PA) requirements may change in the following Preferred Drug Program (PDP) drug classes:
- Anti-Virals - Oral
- Beta Blockers
- Antimigraine Agents -Other
- Antipsychotics - Second Generation
- Sedative Hypnotics / Sleep Agents
- Glucagon Agents
- Insulin - Rapid-Acting
- Colony Stimulating Factors
- Hemophilia Agents - Other
- Platelet Inhibitors
- Prostaglandin Agents - Ophthalmic
- Alpha Reductase Inhibitors for BPH
- Urinary Tract Antispasmodics
- COPD Agents
Effective December 1, 2025, coverage will change for the over-the-counter products containing Aluminum Chloride, and will be removed from the Medicaid Pharmacy List of Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.
For additional information about the DURB, pharmacists should refer to the NYS Department of Health "Drug Utilization Review (DUR)" web page. For additional information regarding NYRx PA criteria, pharmacists should refer to the NYRx, the Medicaid Pharmacy Program Preferred Drug List. To review a list of preferred products that generally do not require a PA when prescribed according to Food and Drug Administration labeling (unless otherwise indicated), pharmacists should refer to the NYRx Preferred Drug Quick List. For a complete list of drugs covered by NYRx, pharmacists should refer to the Medicaid Pharmacy List of Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.
For practitioner-administered drug Clinical Criteria Worksheets, pharmacists should refer to the New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance.
To request a PA, pharmacists should contact the NYRx Clinical Call Center by telephone at (877) 309-9493 or fax the completed form to (800) 268-2990, 24 hours a day, seven days a week. Electronic PA requests are now accepted by NYRx via CoverMyMeds®. Consider this alternative option as an effective and efficient way to request a PA other than by telephone or by fax. For additional information, pharmacists should contact the NYRx Education & Outreach at NYRxEO@primetherapeutics.com.
Resources:
- Prime Therapeutics™ NYRx, the Medicaid Pharmacy Program website
- eMedNY website
- New York State Department of Health "Welcome to NYRx, the Medicaid Pharmacy Program" web page
- New York State Department of Health website
- Prime Therapeutics™ NYRx, the Medicaid Pharmacy Program "NYRx Education & Outreach" web page)
Questions and Additional Information:
- The NYRx Education and Outreach Call Center is available 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.
- The NYRx Education and Outreach team hosts virtual office hours every week for stakeholders to ask questions related to NYRx and care coordination. Pharmacists should visit the Prime Therapeutics™ NYRx, the Medicaid Pharmacy Program "NYRx Education & Outreach" web page, for more information.
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.
Commissioner
New York State Department of Health
Amir Bassiri
Medicaid Director
Office of Health Insurance Programs
