New York State Medicaid Update - December 2025 Volume 41 - Number 12

In this issue …

  • All Providers
  • Policy and Billing
  • Pharmacy

    Reminder: New York State Medicaid and Child Health Plus Patient-Centered Medical Home Quality Reporting Begins in 2026

    The New York State (NYS) Department of Health is reminding all NYS Patient-Centered Medical Home (PCMH) practices to submit the NYS Department of Health-specified quality measures to the National Committee for Quality Assurance (NCQA) when completing annual renewals in 2026. Reporting on quality measures will be required to receive the incentive enhancement payments.

    In 2024, NYS Medicaid and Child Health Plus (CHPlus) announced a 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, recognized by 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 submitted an attestation confirming social care network (SCN) participation continued to remain eligible for the enhancement.

    As outlined in the New York State Medicaid and Child Health Plus Patient-Centered Medical Home Program Evolution article published in the May 2025 issue of the Medicaid Update, the NYS Department of Health intends to tie the incentive enhancement payment to quality in 2026. 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 complete the following requirements:

    1. Report on select quality metrics: Report these metrics for Measure Year (MY) 2025 (January 1, 2025 through December 31, 2025) to NCQA when applying or renewing in 2026. NCQA will forward the submitted data to the NYS Department of Health. Timeline and payment details are contingent on federal approval.
    2. SCN referral workflow attestations: If you have already submitted an SCN attestation in 2025, you will not have to submit again in 2026. Newly recognized NYS PCMH practices and practices that did not submit an attestation in 2025 will be required to complete the SCN referral workflow attestation to be eligible for the incentive enhancement.

    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; practices seeing children and adults must report all four metrics:

    • 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)

    Please note: Regardless of the numerator and denominator sizes for any of the above quality measures, please submit the data based on the guidance provided by NCQA for quality reporting.

    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 the NYS Department of Health.

    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 for MMC enrollees and CHPlus members 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 for MMC enrollees and CHPlus members by:
    • reporting on prescribed quality metrics for MY 2025 (January 1, 2025 through December 31, 2025) and
    • completing the SCN Referral Workflow Attestation (NEW PCMH practices and practices that did not submit an SCN Referral Workflow Attestation in 2025).
    April 2027 through March 2028 NYS PCMH practices earn an additional $2.00 or $4.00 incentive enhancement for MMC enrollees and CHPlus members by:
    • reporting on prescribed quality metrics for MY 2026 (January 1, 2026 through December 31, 2026) and
    • completing the SCN Referral Workflow Attestation (NEW PCMH practices and practices that did not submit an SCN Referral Workflow Attestation in 2025).
    April 2028 through March 2029 NYS PCMH practices earn an additional $2.00 or $4.00 incentive enhancement for MMC enrollees and CHPlus members by:
    • reporting on prescribed quality metrics for MY 2027 (January 1, 2027 through December 31, 2027);
    • achieving performance benchmarks based on quality data from MY 2026; and
    • completing the SCN Referral Workflow Attestation (NEW PCMH practices and practices that did not submit an SCN Referral Workflow Attestation in 2025).

    Questions and Additional Information:

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    Update to the New York State Medicaid Telehealth Policy Manual

    On January 1, 2026, 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:

    • updated information about Medicare's telehealth waivers;
    • a teledentistry procedure code chart and more detailed billing guidance;
    • a revised description for the remote patient monitoring procedure code "99454" in accordance with the American Medical Association's revision;
    • a new format for "Section 9:16 Clinic Billing by On-Site Presence" based on clinic type; and
    • updated off-site billing guidance for School-Based Health Centers.

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

    Questions and Additional Information:

    • Medicaid fee-for-service (FFS) billing and claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
    • 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 MMC 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 Evidence Based Benefit Review Advisory Committee Update

    On Thursday, November 20, 2025, the New York State (NYS) Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) held its final meeting of 2025. 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. The committee reviewed the topic: "Hospital at Home for Admission Avoidance or Early Hospital Discharge in Adult and Pediatric Patients".

    The meeting materials and reports can be found on the NYS Department of Health "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page.

    The next EBBRAC meeting is planned for Monday, April 16, 2026, where the committee will review the following topic: "Acupuncture for Treatment of Nonspecific Chronic Low Back Pain in Adults". Additional information can be found on the NYS Department of Health "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page.

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    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.

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    Presumptive Eligibility for Pregnant Individuals

    Effective January 1, 2026, qualified entities who screen pregnant individuals for Presumptive Eligibility (PE) will no longer use the paper Medicaid Presumptive Eligibility for Pregnant Individuals Screening form (DOH-5224) or send their PE for Pregnant Individual screenings to their local department of social services (LDSS) or the Human Resources Administration (HRA). Qualified entities include any Article 28 licensed providers offering prenatal care.

    PE for Pregnant Individuals screening will be processed electronically, by qualified entity staff, in the new Medicaid Eligibility and Client Management System (MECM) in the Spring of 2026. During the period between January 1, 2026, and the date MECM is ready to handle PE for Pregnant Individual screenings, staff from qualified entities can assist pregnant patients with accessing New York State (NYS) Medicaid coverage through NY State of Health. If assistance is needed in completing the application in NY State of Health, the pregnant individual can be referred to an assistor or the NY State of Health Customer Service Center at (855) 355-5777. A list of application assistors is included on the NY State of Health website, and can be searched by county. The NY State of Health Customer Service Center can also refer the individual to an application assistor in their county.

    If the DOH-5224 is received by an LDSS or HRA for PE coverage beginning on or after January 1, 2026, it will not be processed by the district or HRA. Instead, the completed DOH-5224 will be forwarded on to NY State of Health to perform outreach to the consumer to start an application. In this situation, there is no guarantee of payment for the date of service. Additionally, there is no way for providers to be notified of the billable Client Identification Number of the patient, other than to contact the patient. If a consumer applies and is determined eligible, coverage will begin the month of application. To avoid delays in coverage for patients and the potential for non-payment of services, providers should not complete PE for Pregnant Individual screenings using DOH-5224 on or after January 1, 2026.

    Questions

    Questions regarding this change should be directed to DEMI.ELIGIBILITY.INQUIRIES@health.ny.gov.

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    Coordination of Benefits Billing Protocols for Providers: Medicaid is the Payer of Last Resort

    The New York State (NYS) Department of Health reminds providers that Medicaid is responsible for paying claims for covered items or services only after all other available payment options have been exhausted. Medicaid is always the payor of last resort; federal regulations require that all other available resources be utilized before Medicaid is responsible for making payment. If a Medicaid member has Medicare, and/or other third-party insurance coverage, the benefits of that coverage must be fully utilized before billing the NYS Medicaid program. Providers should always ask NYS Medicaid members if they have other third-party coverage to ensure the proper coordination of benefits.

    All claims submitted for NYS Medicaid members with Medicare and/or other third-party coverage must accurately reflect payments and denials received from other insurers to allow for the correct calculation of NYS Medicaid reimbursement amounts. The Explanation of Benefits (EOB) and other documentation supporting Medicare and third-party reimbursement amounts must be kept and made available for audit or inspection by NYS Department of Health, NYS Office of the Medicaid Inspector General (OMIG), NYS Office of the State Comptroller (OSC), or other state or federal agencies responsible for audit functions.

    Importance of Submitting Claim Adjustment Reason Codes (CARCs)

    Providers are reminded that NYS Medicaid claims involving third-party liability must include the appropriate CARC from the primary insurance. CARCs are essential to ensure NYS Medicaid to accurately process claims and determine the correct payment amount. Without the correct CARC, claims may be miscalculated, potentially resulting in NYS Medicaid overpayments or underpayments.

    Requirement to Bill Primary Insurance, Even If Not Enrolled

    Providers who are not enrolled with a primary insurance payer must still attempt to submit the claim to that primary insurer before billing Medicaid. This process is crucial for Medicaid's role as the payer of last resort and ensures compliance with third-party liability rules. A formal denial from the primary insurer serves as required documentation to support the Medicaid claim and provides a clear audit trail. If the primary payer issues a CARC with the denial, providers should include this code in their electronic submission to Medicaid, as CARCs are essential for accurate claims processing and helps prevent incorrect payment. If the primary payer will not accept or adjudicate a claim from a non-participating provider, the provider is required to retain clear evidence that the claim submission was first attempted with the primary payer.

    Handling Zero-Fill Claims

    For purposes of this guidance, a "zero fill" claim refers to a claim submitted to a primary payer that was denied as a non-covered benefit and for which no payment was made by the primary insurer. For any claim submitted to Medicaid as a zero fill, the provider must retain documentation that clearly demonstrates the claim was first submitted to the primary payer. This documentation is essential to confirm that all other payment sources were exhausted before billing Medicaid, which aligns with Medicaid's payer-of-last-resort policy.

    Providers must maintain documentation demonstrating that the services rendered are a non-covered benefit by the primary payer. Acceptable documentation includes a claim denial issued within the calendar/benefit year of the claim, verifying that the services are not within the scope of the commercial payer coverage. This documentation may be required for submission to NYS Department of Health to ensure proper processing and payment of claims that were zero-filled. An exception is made for services statutorily not covered by Medicare; in such cases, the provider may bill Medicaid directly without requiring prior submission to Medicare to obtain a claim denial.

    Provider Responsibilities:

    1. Identify Other Payers: Providers must identify all other potential payers for services rendered. This includes, but is not limited to; Medicare, commercial/third-party insurance, Workers' Compensation, Compensation and/or the Medical Indemnity Fund.
    2. Bill All Prior Payers: Providers must bill all identified prior payers and exhaust all available coverage options before submitting a claim to Medicaid. Documentation of these efforts must be maintained and made available upon request.
    3. Submit Corrected Claims: If payments are received from other payers after Medicaid has reimbursed a claim, providers are required to submit corrected claims to Medicaid and refund any overpayments.

    To ensure compliance with Medicaid billing policies, providers should regularly review and update their billing practices, including periodically checking for any changes in statutory non-covered services, to confirm that all available coverage options have been fully utilized before submitting claims to Medicaid. Providers should review, verify, and update any non-coverage information at least annually or whenever significant payer policy changes occur. This process supports Medicaid's role as the payer of last resort by ensuring that only non-covered services are billed to Medicaid.

    Questions and Additional Information:

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    New Requirements: Reimbursement of the Dental Operating Room Facility Fee in Hospital and Freestanding Ambulatory Surgery Centers

    For New York State (NYS) Medicaid members with fee-for-service (FFS) coverage, NYS Medicaid reimburses hospital-based and free-standing Ambulatory Surgery Center (ASC) facilities using CPT code "41899" for Operating Room dental cases. Effective immediately, below the entry of Current Dental Terminology (CPT) code "41899", list CDT codes on subsequent claim lines, for procedures rendered while in the Operating Room, for tracking purposes.

    FFS Billing

    An ASC must submit an Ambulatory Patient Group (APG) claim to NYS Medicaid using CPT code "41899". The anesthesiologist and the treating dentist may also submit separate professional claims to NYS Medicaid for their professional services rendered in an outpatient hospital-based or free-standing ASC, using appropriate procedure codes.

    For ASC billing for NYS Medicaid members with intellectual and/or developmental disabilities, identified by the presence of a RE code "81" or RE code "95" on their NYS Medicaid eligibility response, NYS Medicaid will allow hospital-based and free-standing ASCs to bill multiple units of code "41899". Providers should refer to the Reimbursement Changes for Dental Services article published in the July 2023 issue of the Medicaid Update.

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    New York State Office of Addiction Services and Supports-Certified Programs Excluded from the Recipient Restriction Program Requirement

    This article serves as clarification that detoxification and withdrawal services provided by New York State (NYS) Office of Addiction Services and Supports (OASAS)-certified programs are considered emergency services. As such, the NYS Office of the Medicaid Inspector General (OMIG) has confirmed that these services are exempt from, and not subject to, Recipient Restriction Program (RRP) policies and procedures. In addition, this article affirms that NYS OMIG, in coordination with NYS OASAS, has confirmed that NYS OASAS Part 818 Inpatient Rehabilitation programs are also excluded from, and not subject to, RRP policies and procedures.

    Exempt NYS OASAS-Certified Program Types and Rate Codes

    RRP-identified individuals do not require a referral from their assigned primary care provider to access the following programs:

    OASAS Inpatient and Residential Programs Excluded from RRP Policies and Procedures
    OASAS Certified Program Type Rate Codes
    OASAS Title 14 NYCRR Part 816 Medically Managed 4800, 4801, 4802 and 4803
    OASAS Title 14 NYCRR Part 816 Medically Supervised Inpatient Withdrawal 4220
    OASAS Title 14 NYCRR Part 820 Residential Stabilization 1144
    OASAS Title 14 NYCRR Part 820 Residential Rehabilitation 1145
    OASAS Title 14 NYCRR Part 818 Inpatient Rehabilitation 4213, 4202 and 2957

    Accordingly, all Medicaid Managed Care (MMC) Plans and fee-for-service (FFS) Medicaid providers must ensure that NYS Medicaid members identified under RRP have access to these services without restrictions, edits, authorizations or referral requirements due to the restriction status of the NYS Medicaid member.

    eMedNY Updates

    NYS OMIG has reviewed and, where necessary, updated the eMedNY system to ensure all rates codes listed above are excluded from RRP edits. Going forward, NYS OMIG, in coordination with NYS OASAS, will continue to review and update the file system as necessary.

    Provider and Plan Responsibilities

    All NYS Medicaid MMC Plans and FFS Medicaid must:

    • process claims for inpatient rehabilitation, detoxification, and withdrawal services without applying RRP restrictions; and
    • ensure that claims submitted for inpatient rehabilitation, detoxification, and withdrawal services under the rate codes listed above are not denied due to the RRP status of the NYS Medicaid member.

    Opioid Treatment Program Services Reminder

    As a reminder, Opioid Treatment Program (OTP) services are also fully-exempt from RRP restrictions. OTP services, delivered by programs certified as Article 32 outpatient programs by NYS OASAS, must be covered without additional RRP restrictions, edits, authorizations, or referral requirements; and claims for OTP services must not be denied due to RRP restrictions. For details on OTP rate codes, billing guidance, and additional resources, providers should refer to the Reminder: Recipient Restriction Program and Opioid Treatment Program Services article published in the March 2025 issue of the Medicaid Update.

    Questions and Additional Information:

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    New York State Medicaid Perinatal Care Standards 2026 Update

    The New York State (NYS) Medicaid Perinatal Care Standards are updated and posted to the NYS Department of Health "Medicaid Perinatal Care Standards" web page. This 2026 version of the policy replaces the Medicaid Perinatal Care Standards, issued in 2022.

    The updated standards are effective February 1, 2026, for NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC). This policy is applicable to all NYS Medicaid perinatal care providers who provide prenatal/antepartum care, intrapartum care and/or postpartum care. This includes medical care facilities and public or private not-for-profit agencies or organizations; physicians, licensed nurse practitioners, and licensed midwives practicing on an individual or group basis; and managed care plans that contract with these providers.

    Questions and Additional Information:

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    Reminder: Prescribers May Initiate NYRx Pharmacy Prior Authorizations with CoverMyMeds® or PAXpress®

    On July 15, 2025, NYRx, the Medicaid Pharmacy Program began accepting electronic prior authorization (PA) requests via CoverMyMeds® in addition to the current phone and fax submission methods. Prescribers who do not use CoverMyMeds® may continue to use PAXpress®.

    PAXpress® is a web-based pharmacy PA request/response application designed to help providers determine if a drug will require PA for a specific NYS Medicaid member. The PAXpress® website provides a single point of entry for prescriber access to announcements, documents, and quick links to important program information.

    To use PAXpress®, prescribers must have an active electronic Provider Assisted Claim Entry System (ePACES) account. Providers should visit the eMedNY "Self-Help" web page, for information and to enroll in ePACES.

    Providers can log into PAXpress® and ePACES directly or from the eMedNY homepage, via the buttons on the right-hand side of the web page. The eMedNY PAXpress® User Manual and video tutorials posted on the eMedNY "Provider Training Videos" web page (search "PAXpress" in the search bar) provide additional information about how to use the application.

    Additional information about the NYRx pharmacy programs and PA requirements can be found on the Prime Therapeutics™ NYRx, the Medicaid Pharmacy Program homepage. For a complete list of drugs covered by NYRx see the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.

    Coming soon, in effort to move away from a paper pended claim process, NYRx will offer an additional interface to initiate PAs for Practitioner Administered Drugs (PADs) via PAXpress®. This will allow prescribers to check if PA is required before billing a PAD. Additional information is forthcoming regarding these exciting changes.

    Questions:

    • NYRx policy questions should be directed to NYRx@health.ny.gov.
    • PAXpress® and ePACES application questions should be direct to the eMedNY Call Center at (800) 343-9000.

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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.
    Commissioner
    New York State Department of Health

    Amir Bassiri
    Medicaid Director
    Office of Health Insurance Programs