New York State Medicaid Update - April 2026 Volume 42 - Number 5

In this issue …

Continued Development of the New York State Medicaid Provider Services Portal: New Enrollment for All Provider Types Now Available

As previously shared in the Modernization of the New York State Medicaid Provider Enrollment Process article published in the September 2025 issue of the Medicaid Update, 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).

All providers who have never been enrolled in NYS Medicaid before should now use the NYS Medicaid PSP when applying for new enrollment, except group practices with only one NYS Medicaid-enrolled practitioner. Group practices with only one NYS Medicaid-enrolled practitioner should continue to submit paper applications until July 2026 at which time all paper applications will be discontinued. All other provider types should refer to the NYS Medicaid PSP. This second major release enables organizational provider types, including groups, institutions, and businesses, to enroll. Credentialing staff can also use the online portal to support new provider enrollment.

A future release will allow existing NYS Medicaid providers to use the NYS Medicaid PSP for revalidation, reporting a change of ownership, applying for reinstatement and maintaining their provider ID, all online. Details for the roll-out of upcoming phases will continue to be communicated to the provider community via Medicaid Update, eMedNY Listservs, and the MRT Listserv. Providers must ensure their correspondence and email addresses are current on provider files so that important information is not missed. Providers who need to update their correspondence address or email address must download the correct form on the eMedNY "Change of Address for Enrolled Providers" web page, and submit as soon as possible.

With this modernization, the paper enrollment process will be phasing out in the coming months. Providers who choose to submit a paper application, while still available, should be sure to use the most recent version of the form which is available on eMedNY.org. Applications submitted on older versions of the form will be rejected.

To support the complex transition from a paper application process to a web-based enrollment process, eMedNY.org has been updated to include quick reference materials and on-demand training videos. Additionally, live training webinars are offered on a recurring basis. To view the training schedule and/or register for training on the NYS Medicaid PSP, providers should refer to the eMedNY Provider Training web page. 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.

The eMedNY Provider Training calendar, also located on the eMedNY Provider Training web page, is updated as trainings become available. To access the NYS Medicaid PSP, providers must first spend a few minutes creating a NY.gov Business Account. Providers should visit the eMedNY NY.GOV ID Account Overview document for step-by-step instructions to create a NY.gov Business Account. Account creation only needs to be done once and can be done from a desktop, laptop, tablet or phone.

Questions

Questions related to enrollment through the NYS Medicaid PSP should be directed to the eMedNY Call Center at (800) 343-9000.

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Reminder: Disenrollment Rules and Recovery Rules for Mainstream Medicaid Managed Care, Health and Recovery Plans, and Special Needs Plans

The New York State (NYS) Department of Health and NYS Office of the Medicaid Inspector General would like to remind Contractor health plans (health plans) of the retroactive recovery rules established by The MMC Model Contract, "Medicaid Managed Care (MMC), Family Health Plus, Human Immunodeficiency Virus-Special Needs Plans, Health and Recovery Plan Model Contract" (MMC Model Contract).

Contract Guidance on Disenrollment

The MMC Model Contract provides disenrollment rules and guidance, outlined in Appendix H, New York State Department of Health Requirements for the Processing of Enrollments and Disenrollments in the MMC. Enrollment determinations are made by NY State of Health (the Marketplace) or the local Department of Social Services (LDSS) and communicated to the health plan via 834 file or retroactive disenrollment notification. Most disenrollments are prospective; in some circumstances, retroactive disenrollment and recovery is appropriate. For those retroactive disenrollment scenarios, the contract outlines the effective date of disenrollment for each scenario.

As stated in Appendix H §7(b)(ii) "Contractor Responsibilities," the health plan will make a good faith effort to identify cases which may be appropriate for an NY State of Health or LDSS-initiated disenrollment. Within five business days of identifying such cases and following NY State of Health or LDSS procedures, the Contractor will, in writing or electronically, refer cases which are appropriate for an NY State of Health or LDSS-initiated disenrollment and will submit supporting documentation to NY State of Health or LDSS. This includes changes in status for its enrollees that may impact eligibility for enrollment, including, but not limited to address changes, incarceration, death, exclusion from the MMC program MMC Plan, the apparent enrollment of a member in the contractor’s MMC product under more than one Client Identification Number, or the availability of Third-Party Health Insurance to the MMC enrollee.
If the health plan determines the MMC enrollee meets the requirements of a retroactive disenrollment, the health plan must refer to the case, then wait for the LDSS or NY State of Health to make a determination on the referral before taking any action to disenroll the MMC enrollee. As stated in Appendix H §7(b)(ii) of The MMC Model Contract, consistent with other health plan-initiated disenrollments, the health plan will "not consider an enrollee disenrolled without confirmation from the NY State of Health or LDSS as described in Section 5 of this Appendix."

NYS Department of Health, NYS Office of the Medicaid Inspector General and NYS Office of the Attorney General Right to Recover

As stated in the MMC Model Contract, Appendix H (7)(a)(xiv): "Failure by the NY State of Health, Enrollment Broker, or LDSS to notify the Contractor of a disenrollment does not affect the right of the SDOH to withhold or recover capitation payment(s) as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment." Therefore, the right to recover capitation payments remains regardless of whether the health plan receives a notice of disenrollment from the LDSS.

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Obstetric Billing Changes for Prenatal Services Related to Upcoming Global Obstetric Fee Changes

Effective immediately, New York State (NYS) Medicaid fee-for-service (FFS) directs all NYS Medicaid-enrolled providers of antepartum, postpartum, labor and delivery services to use the below for services provided to individuals that initiate prenatal care on or after June 1, 2026, and/or have an estimated due date on or after January 1, 2027:

  • Evaluation and Management (E/M) Common Procedure Terminology (CPT) codes with a TH modifier;
  • pregnancy-related O or Z International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes for all prenatal visits; and
  • initial prenatal visits must include the Category II CPT code "0500F".

For services provided to NYS Medicaid members who have established prenatal care prior to June 1, 2026, current billing guidance applies through December 31, 2026.

E/M CPT codes are to be used for prenatal services in place of global/bundled obstetric CPT codes (noted in table below) in anticipation of January 1, 2027 comprehensive changes to obstetric-related services per the American Medical Association (AMA). The AMA obstetric billing guidance can be found in the AMA/Specialty Society RVS Update Process RUC Recommendations for CPT 2027 – January 2026 Meeting document.

Medicaid Managed Care (MMC) Plans are required to:

  • prepare systems and provider agreements/contracts, as needed, to align with the use of E/M codes with a TH modifier as well as pregnancy-related O or Z ICD-10 diagnostic codes for all new prenatal visits that occur for the above population by June 1, 2026; and
  • prepare systems and provider agreements/contracts to fully implement AMA billing code changes by January 1, 2027.

Bundled/Global CPT codes that will be deleted and unavailable when service dates include dates on or after January 1, 2027:

CPT Code CPT Description
59400 Vaginal delivery with antepartum and postpartum care
59425 Antepartum care only; four to six visits
59426 Antepartum care only; seven or more visits
59510 Cesarean delivery with antepartum and postpartum care
59610 Vaginal birth after cesarean delivery with antepartum and postpartum care
59618 Cesarean delivery after attempted vaginal delivery with antepartum and postpartum care

CPT E/M codes available to identify routine antepartum care:

CPT Code CPT Description Modifier
99202 Office Or Other Outpatient Visit for New Patient TH modifier to be used for all routine prenatal visits initiated on or after June 1, 2026.
99203 Office Or Other Outpatient Visit for New Patient
99204 Office Or Other Outpatient Visit for New Patient
99205 Office Or Other Outpatient Visit for New Patient
99211 Office Or Other Outpatient Visit for Established Patient
99212 Office Or Other Outpatient Visit for Established Patient
99213 Office Or Other Outpatient Visit for Established Patient
99214 Office Or Other Outpatient Visit for Established Patient
99215 Office Or Other Outpatient Visit for Established Patient
99341 Residence Visit For New Patient With Straightforward
99342 Residence Visit For New Patient With Low Level
99344 Residence Visit For New Patient With Moderate Level
99345 Residence Visit For New Patient With High Level
99347 Residence Visit For Established Patient With Straightforward
99348 Residence Visit For Established Patient With Low Level
99349 Residence Visit For Established Patient With Moderate Level
99350 Residence Visit For Established Patient With High Level
99417 Prolonged Outpatient Service, Each 15 Minutes

As of January 1, 2027, additional CPT codes used for billing obstetric services will be revised and deleted. Further guidance will be released by the AMA for obstetric-related services, and the NYS Department of Health will release further Medicaid Update articles.

Additional Resources:

NYS Medicaid FFS Information:

MMC Information

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.

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Submission of Secondary Claims to New York State Medicaid and Use of Claim Adjustment Reason Codes

A recent review of secondary claims submitted to New York State (NYS) Medicaid has identified a recurring billing practice that does not comply with NYS Medicaid billing requirements or established Coordination of Benefits (COB) standards.

Prohibited Practice

COB standards for billing secondary claims require the communication of the exact Group Code returned by the primary payer. It has been identified that some claims are being submitted to NYS Medicaid with adjustment codes that differ from those returned on the Explanation of Benefits (EOB) or remittance advice issued by the primary payer. Specifically, the Group Code was altered from CO (Contractual Obligation) to PR (Patient Responsibility) prior to submission to NYS Medicaid.

Under no circumstances may adjustment codes be changed or substituted, (e.g., from CO to PR) for the purpose of altering NYS Medicaid reimbursement or liability. Any code modification constitutes a misrepresentation of the primary payers’ adjudication and is prohibited. All claims submitted for NYS Medicaid members with Medicare and/or other third-party insurance must accurately reflect payments, adjustments and denials received from other insurers to allow correct calculation of NYS Medicaid reimbursement amounts.

Financial Impact

Changing adjustment codes improperly can result in NYS Medicaid overpayments. Any overpayments resulting from this practice are subject to recoupment and must be promptly reported and returned in accordance with applicable federal and state regulations. Providers should refer to the Self-Disclosure Obligation Reminder article published in the January 2026 issue of the Medicaid Update, for guidance on returning overpayments.

Enforcement

Failure to follow this policy may lead to corrective action, fund recoupment, and other remedies under NYS Medicaid rules and law. Providers must maintain accurate and compliant billing practices consistent with NYS Medicaid COB requirements.

Questions and Additional Information:

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Updates to Fee Schedules for Physician, Nurse Practitioner and Midwife Services

As part of the New York State (NYS) enacted budget for fiscal year (FY) 2026, the NYS Department of Health was authorized to benchmark NYS Medicaid fee-for-service reimbursement rates to 90 percent of Medicare reimbursement rates for select non-facility practitoner services and emergency visit codes. This investment in the physician and primary care workforce is expected to improve access to primary and preventative care for NYS Medicaid members.

Effective October 1, 2025, fees for the following procedure codes have increased:

Code Description
99381 Evaluation and Management (E/M) Preventive Medicine: New patient initial comprehensive age (under one year of age)
99382 E/M Preventive Medicine: New patient initial comprehensive age (one to four years of age)
99383 E/M Preventive Medicine: New patient initial comprehensive age (five to 11 years of age)
99384 E/M Preventive Medicine: New patient initial comprehensive age (12 to 17 years of age)
99385 E/M Preventive Medicine: New patient initial comprehensive age (18 to 39 years of age)
99386 E/M Preventive Medicine: New patient initial comprehensive age (40 to 64 years of age)
99387 E/M Preventive Medicine: New patient initial comprehensive age (65 years of age and older)
99391 E/M Preventive Medicine: Established patient (one year of age and younger)
99392 E/M Preventive Medicine: Established patient (one to four years of age)
99393 E/M Preventive Medicine: Established patient (five to 11 years of age)
99394 E/M Preventive Medicine: Established patient (12 to 17 years of age)
99395 E/M Preventive Medicine: Established patient (18 to 39 years of age)
99396 E/M Preventive Medicine: Established patient (40 to 64 years of age)
99397 E/M Preventive Medicine: Established patient (65 years of age and older)

Effective April 1, 2026, fees for the following procedure codes have increased:

Code Description
69210 Removal impacted cerumen requiring instrumentation, unilateral
90471 Immunization administration, one vaccine
90472 Immunization administration, each additional vaccine
90473 Immunization administration by intranasal or oral route, one vaccine
90474 Immunization administration by intranasal or oral route, each additional vaccine
90480 Immunization administration by intramuscular injection, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine, first or only component of each vaccine administered
92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report
93040 Rythm electrocardiogram, one to three leads; with interpretation and report
99202 Office or other outpatient visit for the E/M of a new patient, 15 minutes or more
99203 Office or other outpatient visit for the E/M of a new patient, 30 minutes or more
99204 Office or other outpatient visit for the E/M of a new patient, 45 minutes or more
99205 Office or other outpatient visit for the E/M of a new patient, 60 minutes or more
99211 Office or other outpatient visit for the E/M of an established patient that may not require the presence of a physician or other qualified health care professional
99212 Office or other outpatient visit for the E/M of an established patient, straightforward, 10 minutes or more
99213 Office or other outpatient visit for the E/M of an established patient, low level, 20 minutes or more
99214 Office or other outpatient visit for the E/M of an established patient, moderate level, 30 minutes or more
99215 Office or other outpatient visit for the E/M of an established patient, high level, 40 minutes or more
99342 Home or residence visit for the E/M of a new patient, low level, at least 30 minutes
99348 Home or residence visit for the E/M of an established patient, low level, 30 minutes or more
99349 Home or residence visit for the E/M of an established patient, moderate level, 40 minutes or more
99350 Home or residence visit for the E/M of an established patient, high level, 60 minutes or more
99407 Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes
99281 Emergency department (ED) visit for the E/M of a patient that may not require presence of a physician or other qualified health care professional
99282 ED visit for the E/M of a patient, straightforward medical decision making
99283 ED visit for the E/M of a patient, straightforward medical decision making
99284 ED visit, for the E/M of a patient, moderate level of medical decision making
99285 ED visit, for the E/M of a patient, high level of medical decision making

Please note: Procedure codes appearing on multiple fee schedules will be updated on each fee schedule.

The following impacted fee schedules include:

  • NYS Medicaid Physician Medicine Services Fee Schedule
  • NYS Medicaid Physician Drug and Drug Administration Services Fee Schedule
  • NYS Medicaid Physician Surgery Services Fee Schedule
  • NYS Medicaid Nurse Practitioner Services Fee Schedule
  • NYS Medicaid Midwife Services Fee Schedule

Providers can refer to the eMedNY "Provider Manuals" web page, for updated fee schedules and select a category within the "Select a Provider Manual" section.

Questions

Questions regarding the updated fees should be directed to the NYS Department of Health at FFSMedicaidPolicy@health.ny.gov.

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Coverage of Healthcare Common Procedure Coding System "G2211": Add-On Code for Complex Pediatric Care

Effective April 1, 2026, New York State (NYS) Medicaid will reimburse Healthcare Common Procedure Coding System (HCPCS) code "G2211". Medicaid Managed Care (MMC) Plans must comply with this coverage by June 1, 2026.

Add-on HCPCS code "G2211" recognizes the establishment and maintenance of an ongoing clinician-patient relationship. It provides additional reimbursement for visits with greater complexity than a typical Evaluation and Management (E/M) service. It is intended for situations where the clinician:

  • serves as the focal point for all needed health care services; and
  • provides ongoing care related to a single, serious condition or a complex condition of a patient.

Visit complexity for HCPCS code "G2211" is related to the additional effort of providing longitudinal care. It is not based on specific diagnoses or the level of medical decision making. HCPCS code "G2211" may not be reported for acute or routine care. Clinicians must document the medical complexity and ongoing care that justify the use of HCPCS code "G2211", including how the visit fits within a patient centered plan of care.

Eligibility

Population

NYS Medicaid coverage of HCPCS code "G2211" is limited to NYS Medicaid members from birth to 20 years of age.

Billing Providers

HCPCS code "G2211" may be billed by physicians and nurse practitioners in pediatric primary care and pediatric subspecialties. Providers should refer to Table 1 for eligible specialty codes.

Table 1: Specialty Codes Eligible to Bill HCPCS code "G2211"

Specialty Code Specialty Description
055 ADOLESCENT MEDICINE: FAMILY MEDICINE
056 ADOLESCENT MEDICINE: PEDIATRICS
059 PEDIATRIC RHEUMATOLOGY
061 PEDIATRIC INFECTIOUS DISEASE
073 PEDIATRIC DERMATOLOGY
076 PEDIATRIC REHABILITATION
150 PEDIATRICS
151 PEDIATRIC CARDIOLOGY
152 PEDIATRIC HEMATOLOGY – ONCOLOGY
154 PEDIATRIC NEPHROLOGY
156 PEDIATRIC ENDOCRINOLOGY
157 PEDIATRIC PULMONOLOGY
163 PEDIATRIC GASTROENTOLOGY
305 PEDIATRIC SPECIALTY – ALL EXCEPT PRIMARY CARE
936 PEDIATRIC GENERAL MEDICINE- CLINIC SPECIALTY
937 PEDIATRIC ALLERGY- CLINIC SPECIALTY
938 PEDIATRIC NEUROLOGY- CLINIC SPECIALTY

Billing Guidance and Reimbursement

HCPCS code "G2211" must be billed in conjunction with an E/M procedure code, which may include preventative visit codes, on the same date of service. Clinicians should not report independently. Clinicians may bill HCPCS code "G2211" once per week per patient.

Clinicians should report HCPCS code "G2211" with Place of Service code "02", "10", "11" or "22" on professional claims. Reimbursement for HCPCS code "G2211" is allowable when the service is delivered via telehealth. Clinicians should refer to the NYS Department of Health Telehealth Policy Manual, for detail on telehealth modifiers and billing instructions.

HCPCS Code Description NYS Medicaid Rate
G2211 Visit complexity inherent to E/M associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a single, serious condition or a complex condition of a patient.
(Add-on code, list separately in addition to home or residence or office/outpatient evaluation and management service, new or established)		 $14.83

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 primary care 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 pcmh@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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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