30-Day Public Comment Period Opened for the 1115 Medicaid Redesign Team Waiver Extension Application

The New York State (NYS) Department of Health is requesting a five-year extension of the existing Section 1115(a) Medicaid Redesign Team (MRT) demonstration, which is scheduled to expire March 31, 2027.

In accordance with 42 CFR 431.408(a)(1), the NYS Department of Health will hold one in-person and one virtual public hearing to provide an overview of the proposed extension and receive public comment. The second hearing will also serve as the Annual 1115 Public Forum.

The 30-day public comment period is now open and will close August 21, 2026. During this time, members of the public may submit written comments on the extension request.

Public Hearing updates will be shared through the MRT Listserv. To subscribe for the MRT Listserv, individuals are encouraged to sign up via the NYS Department of Health "Medicaid Redesign Team (MRT) LISTSERV" web page. Individuals can also refer to the New York State Medicaid Redesign Team (MRT) Waiver: 1115 Waiver Extension Request, for additional information.

Public Hearing Schedule

First Public Hearing (Held)
Location: Empire State Plaza, Meeting Room 2, Albany, NY 12242
Date and time: Friday, July 31, 2026, from 1 p.m. to 4 p.m.

The hearing was also available via live webcast and is now available via recording. Webcast details were shared through the MRT Listserv on July 28, 2026. Individuals who wished to provide public comment could email 1115waivers@health.ny.gov to be added to the speaker list or register upon arrival. Speakers were called in the order they registered, and comments were limited to five minutes per speaker to allow time for all participants. American Sign Language (ASL) interpretation was available during the hearing as well.

Second Public Hearing and Annual 1115 Public Forum
Location: Virtual*
Date and time: Tuesday, August 11, 2026, from 1 p.m. to 4 p.m.

This webinar is virtual and will be hosted on WebEx. Pre-registration is required for all attending, as well as for those who wish to provide comments. Individuals who wish to provide comment must register using the online registration form, include "SP" before their name (e.g., "SP Jane Doe") and email 1115waivers@health.ny.gov by 4 p.m. on Monday, August 10, 2026, to confirm their registration. Speakers will be called in the order they register. To ensure all voices are heard, comments are limited to five minutes per speaker. ASL interpretation will be available as well as closed captioning, provided by the Webex platform.

In accordance with Special Terms and Conditions (STC) 14.16, the December 27, 2024 New York State Medicaid Redesign Team (MRT) Waiver Section 1115 Fourth Quarter and Annual Report is available for review. Under updated Centers for Medicare & Medicaid Services guidance, the next annual report is due September 2026, making the December 27, 2024 report the most recently filed report.

Goals and Objectives of the Extension

The goals and objectives of this demonstration extension are intended to continue, maintain, and operationalize the approved and current Section 1115(a) demonstration, including:

• improving access to health care for the NYS Medicaid population;
• improving the quality of health services delivered;
• expanding coverage with resources generated through managed care efficiencies to additional low-income New Yorkers; and
• addressing upstream drivers of health, advancing population health and supporting the delivery of Health-Related Social Needs (HRSN) services.

The proposed extension seeks to continue core waiver and expenditure authorities necessary to sustain initiatives that have been fully implemented through the waiver, allow recently approved initiatives to be fully implemented and demonstrate outcomes, and maintain continuity of coverage and services for NYS Medicaid members, as follows:

Initiatives to Continue Without Amendments

NYS Department of Health is proposing to continue the following initiatives without amendment:

• Mainstream Medicaid Managed Care: Mainstream Medicaid Managed Care (MMC) is a NYS program that provides health insurance benefits to most NYS Medicaid members through contracted managed care organizations that coordinate care via a primary care provider across three plan types: mainstream managed care*, Health and Recovery Plans (HARPs), and human immunodeficiency virus-Special Needs Plans (HIV-SNPs).
  *Mainstream managed care is the NYS standard mainstream managed care system, whereas HARP and HIV-SNPs are specialized programs.
• Managed Long Term Care: Managed Long Term Care (MLTC) is the NYS managed care delivery system for individuals with chronic illness, disability, or functional limitations who need ongoing community-based long-term services and support.
• Facilitated enrollment services: One-on-one assistance to help New Yorkers apply for and renew their NYS Medicaid, Child Health Plus, the Essential Plan (EP), and Qualified Health Plans through NY State of Health (the Marketplace).
• Community Oriented Recovery and Empowerment: Community Oriented Recovery and Empowerment (CORE) is person-centered, recovery-oriented mobile behavioral health (BH) supports delivered in homes and communities to adult NYS Medicaid beneficiaries (21 years of age and older) with serious mental illness or substance use disorders (SUDs).
• Residential and inpatient treatment for individuals with SUD: NYS Medicaid reimbursement for residential and inpatient treatment services for adults and children with opioid and other SUD. The purpose of this request is to strengthen statewide treatment infrastructure, preserve residential treatment capacity, improve coordination across the continuum of SUD care, and support ongoing reductions in avoidable emergency department use, inpatient admissions, overdose deaths, and other adverse health outcomes. This extension waives the Institution for Mental Diseases Exclusion. This will allow continued federal funding of facilities with more than 16 beds specializing in psychiatric or SUD care, thereby enabling NYS Department of Health to provide adequate institutional care to its NYS Medicaid members. Combined with the broader continuum, Institutions for Mental Disease help ensure individuals receive care in the most appropriate setting.
• Designated State Health Programs: NYS Department of Health makes three requests concerning Designated State Health Programs (DSHPs) funding:
  • to rollover $1.5 billion* of already-drawn DSHP funds that the NYS Department of Health projects will remain unspent by the end of the demonstrations for continued use on the DSHP-funded initiatives approved in the current demonstration, including HRSN services, the HERO and workforce initiatives into the extension period;
  • to continue expenditure authority to draw down federal financial participation for $672 million of unclaimed DSHP funds up to the already approved total $3.9 billion in total computable in the current demonstration** to be spent on the DSHP-funded initiatives; and
  • for the workforce initiatives, to exercise the time-limited close-out expenditure authority referenced in the current STCs demonstration. STCs Section 12.7.d permits NYS Department of Health to pay administrative costs and monitor remaining service obligations associated with the Student Loan Repayment for Qualified Providers (also known as the Healthcare Access Loan Repayment [HEALR] program) and Career Pathways Training (CPT) programs from April 1, 2027 until March 31, 2031, as the programs phase out.
    *DSHP preliminary financial projections summary, total expenditures, as of June 1, 2026.
    **DSHP preliminary financial projections summary, unclaimed DSHP funds, as of June 1, 2026.

Initiatives Proposed to Be Amended

NYS Department of Health is requesting amendments to the following initiatives as part of the five-year extension of its Section 1115(a) Medicaid Redesign Team (MRT) demonstration:

• Demonstration-eligible populations: NYS Department of Health requests to continue waiver authority for all existing, demonstration-eligible populations with the exception of Demonstration Population 2 (Temporary Assistance for Needy Families [TANF] adults). For a full description of the TANF adult discontinuation, providers should refer to the "Initiatives Proposed to Be Discontinued" section below.
• Workforce initiatives: NYS Department of Health proposes to close out current workforce initiatives which include:
  • HEALR or in STCs as Student Loan Repayment for Qualified Providers; and
  • CPT programs with continued, time-limited expenditure authority for close-out activities consistent with approved STCs. NYS Department of Health is not seeking new workforce authority under this extension.
• HRSN services: NYS Department of Health proposes to amend and continue its HRSN services initiative. The amendment would maintain the full scope of HRSN services and eligible populations approved in the current demonstration, while making limited refinements to improve program alignment and sustainability.

Specifically, NYS Department of Health proposes to:

• Continue coverage of approved HRSN services, which include:
• Care Management:
  • Level One Care Management (Navigation Services)
  • Level Two Care Management (Enhanced Population)
• Housing:
  • Home accessibility and safety modifications
  • Home remediation service
  • Asthma remediation
  • Medical respite (recuperative care)
  • Rent/temporary housing
  • Utility setup/assistance
  • Pre-tenancy services and housing navigation
  • Community Transitional Supports (CTS)
  • Tenancy sustaining services
• Nutrition supports:
  • Nutrition counseling and education
  • Medically tailored meals or clinically appropriate home delivered meals
  • Medically tailored or nutritionally appropriate food prescriptions
  • Fresh produce and non-perishable groceries (pantry stocking)
• Cooking supplies
• Transportation services
• Maintain delivery of HRSN services through Social Care Networks
• Remove coverage of real estate brokerage fees associated with housing services due to changes in State law and limited program utilization
• Update the definition of enhanced HRSN populations to align with the enters for Medicare & Medicaid services-approved HRSN Implementation Plan* and to group child populations together:
  • juvenile justice involved youth, foster care youth, and those under kinship care
  • children under six years of age
  • children under 18 years of age with one or more chronic conditions to be "High-Risk Children under 18 years of age"
  *Providers should refer to the Attachment J of Special Terms and Conditions.
• Maintain non-risk payments for HRSN services for one additional year, prior to transitioning to risk-based funding** in April 2028; this additional year will allow NYS Department of Health to collect sufficient encounter, utilization, and cost data to support actuarially sound rate development and ensure compliance with managed care rate setting requirements.
  **Capitated payments are fixed, pre-paid, per-person payments for providing contracted services.
• Health Equity Regional Organization: NYS Department of Health requests to continue the remaining $78.00 million in expenditure authority for the Health Equity Regional Organization (HERO) initiative. The purpose of this request is to build upon existing infrastructure and information gathered during the initial demonstration period and transition to an advanced analytics platform to better support program operations and program integrity. Evolving those functions of the HERO would enable NYS to be at the forefront of Medicaid data analytics and program administration, including enabling real-time feedback to inform decision-making. In addition to supporting evidence-based policy decisions based on observed metrics of success, it would leverage predictive modeling, machine learning, and anomaly detection to help serve as an early warning system for outlier programmatic, billing, or referral patterns before they become material, enabling reforms and referrals to be implemented quickly as issues arise. By improving the speed and quality of data analysis and decision-making, this new capability will help improve program design and operations, while ensuring continued access to care for those who need it most.
• Medicaid Hospital Global Budget Initiative: NYS Department of Health is requesting NYS Medicaid authority for hospital global budgets (HGB) in accordance with the Achieving Healthcare Efficiency through Accountable Design (AHEAD) model requirements. NYS continues to prioritize hospital transformation efforts and readiness for the AHEAD model by working across the AHEAD project team and the Section 1115(a) demonstration team, coordinating closely with stakeholders, and making strides developing the Medicaid HGB methodology. NYS Department of Health also continues to work with Centers for Medicare and Medicaid Services (CMS) and to hone the details of each Medicaid hospital global budget adjustment and baseline inclusion rules to ensure alignment with CMS criteria and the overall needs of the participating hospitals and Medicaid population impacted. NYS Department of Health will work to develop the HGB baseline through discussions with CMS, but the request is that the Medicaid HGB initiative funding will be maintained in the HGB baseline calculation for eligible hospitals.

Initiatives Proposed to Be Discontinued

NYS Department of Health proposes to discontinue the following initiatives by the end of the current demonstration period:

• HRSN infrastructure: NYS Department of Health projects it will reach the expenditure cap for HRSN infrastructure by the end of the current demonstration and therefore does not request continuing expenditure for this initiative.
• Demonstration services for BH provided under Mainstream MMC: NYS Department of Health implemented select BH services for MMC enrollees under the current Section 1115(a) demonstration. As these services have transitioned to State Plan authority and become standard components of the NYS Medicaid benefit package, NYS Department of Health proposes to discontinue this authority upon extension.
• Self-direction pilot: Neither the Adult Self-Direction Pilot nor the Child Self-Direction Pilot has drawn down Medicaid federal financial participation under the Section 1115(a) demonstration. The Adult Self-Direction Pilot will continue to operate under state authority where appropriate. It has been funded exclusively with state funds and does not require extension of federal demonstration approval. The Child Self-Direction Pilot authorized under the current 1115 demonstration was never implemented, and NYS Department of Health does not anticipate implementing the pilot at this time*. Since this authority will not impact services delivered, NYS Department of Health does not intend to develop a transition plan.
  *Separate from the NYS 1115 authority for the Child Self-Direction Pilot, the NYS 1915(c) authority to provide Financial Management Services to assist NYS Medicaid members in purchasing Adaptive and Assistive Technology, Environmental Modifications, and Vehicle Modifications will continue under the Children's Waiver. These services are authorized through the 1915(c) waiver and therefore do not depend on the Section 1115(a) demonstration authority that New York is requesting to discontinue.
• BH Home and Community-Based Services: NYS Department of Health proposes an amendment to phase out remaining BH Home and Community-Based Services (HCBSs) while continuing CORE services. CORE services replaced the majority of adult BH HCBS in 2022 and are now the primary rehabilitation service model for eligible NYS Medicaid members. Prior to the transition to CORE services, the utilization of BH HCBS services was low. Utilization began to decrease further each month following the CORE implementation in 2022. NYS Department of Health intends to fully transition remaining participants to CORE or other appropriate State Plan BH services, ensuring continuity of care and no disruption of services.
  
  Final timing for the BH HCBS phase-out will be coordinated with the 1115 waiver extension timeline and public notice process to allow sufficient stakeholder engagement and implementation planning. By the end of the current demonstration, NYS Department of Health will issue formal notifications to NYS Medicaid members eligible for or receiving BH HCBS via Mainstream Managed Care Plans. Every individual currently receiving BH HCBS will receive an individualized transition plan and will be connected to appropriate alternative services, including CORE services and other State Plan BH services. The transition will be completed by the end of the current demonstration and will preserve continuity of care with no service interruption.
• Demonstration Population 2 (Temporary Assistance for Needy Families adult): Individuals currently eligible based on Temporary Assistance for Needy Families (TANF) status will instead undergo a full NYS Medicaid eligibility determination under State Plan rules. This amendment is intended to align demonstration eligibility with standard NYS Medicaid eligibility processes. NYS Department of Health will work to transition members by January 1, 2027.
• Continuous eligibility for children up to six years of age: To comply with the July 2025 CMS guidance, Section 1115(a) Demonstration Authority for Continuous Eligibility initiatives, specifying that CMS does not anticipate extending existing Section 1115(a) demonstration authority for expanded continuous eligibility initiatives, NYS Department of Health has discontinued continuous eligibility for children up to six years of age. Affected children will be returned to standard renewal processes and evaluated for ongoing eligibility under NYS Medicaid or other insurance affordability programs. By July 1, all individuals will be re-enrolled in NYS Medicaid if they remain eligible or transitioned to another program if they no longer qualify.
• Twelve-month continuous eligibility for adults: To comply with the July 2025 CMS guidance, Section 1115(a) Demonstration Authority for Continuous Eligibility initiatives, specifying that CMS does not anticipate extending existing Section 1115(a) demonstration authority for expanded continuous eligibility, NYS Department of Health has discontinued Twelve-Month Continuous Eligibility. Pregnant individuals and those up to 12 months postpartum will still be eligible for 12-month continuous eligibility. Adults who maintained eligibility under this authority will be redetermined through standard renewal processes and assessed for eligibility for NYS Medicaid, the EP, or other coverage options, with appropriate notice provided. By July 1, all individuals will either be re-enrolled in NYS Medicaid if they remain eligible or transitioned to another program if they no longer qualify.

Eligibility Requirements, Benefits, and Cost Sharing Changes

This Section 1115(a) extension request primarily continues existing NYS Medicaid eligibility rules, benefits, and cost sharing requirements. For most individuals currently enrolled in NYS Medicaid, this extension will not result in changes to eligibility or covered benefits. Consistent with updated federal guidance and the maturation of certain demonstration initiatives, the extension reflects a limited set of changes described in the table below.

In addition to the initiative-level impacts to eligibility requirements, benefits, cost sharing, and delivery system identified in table 1 below, NYS Department of Health is actively preparing for the operational updates needed to comply with the September 30, 2025 CMS State Medicaid Director #25-003 titled, Medicaid Managed Care Payments and Emergency Medical Condition Coverage for Aliens Ineligible for Full Medicaid Benefits. NYS Department of Health will continue to work with CMS to evaluate whether modifications to existing authorities are required, including as they relate to Section 1115(a) managed care authorities.

Table 1: Impact on Eligibility Requirements, Benefits, Cost Sharing, or Delivery System

Submission and Review of Public Comments

A draft of the New York State Medicaid Redesign Team (MRT) Waiver: 1115 Waiver Extension Request is available for review. Individuals with limited online access and who require special accommodation to access paper copies should contact (518) 473-0868.

Prior to finalizing the proposed extension application, NYS Department of Health will consider all written and verbal comments received. These comments will be summarized in the final submitted version. NYS Department of Health will post a transcript of the public hearings on the NYS Department of Health "New York State Medicaid 1115 Waiver" web page.

Additionally, the notice for this application can be found through the Full Public Notice: Department of Health Medicaid Redesign Team (MRT) Section 1115(a) Demonstration Extension Request.

Questions

Questions should be directed to 1115waivers@health.ny.gov. Written comments will be accepted by email at 1115waivers@health.ny.gov or by mail at:

All comments must be postmarked or emailed by August 21, 2026.

New York State Department of Health Announces Modernized Medicaid Provider Revalidation Process

On Tuesday, August 4, 2026, New York State (NYS) Department of Health announced improvements to NYS Medicaid oversight and the modernization of the provider enrollment and revalidation process. The plan includes an updated provider revalidation schedule and reflects Governor Hochul's commitment to working with our federal partners to address waste, fraud and abuse and ensure program integrity.

This message is to inform providers about these important updates regarding the NYS Medicaid provider revalidation process. All providers serving NYS Medicaid members are now required to enroll and revalidate through the new NYS Medicaid Provider Services Portal (PSP).

To help providers navigate this transition, an official press release was published, detailing the new risk-based, phased revalidation schedule running through June 2028. Additionally, providers can attend the New York State Department of Health Medicaid Provider Revalidation webinar via WebEx, for a walk through the new NYS Medicaid PSP and answer your questions.

What You Need to Do:

• Register for the webinar: Register via WebEx for the New York State Department of Health Medicaid Provider Revalidation webinar, held on Thursday, August 6, 2026, from 3 p.m. to 4 p.m., to learn how to access the NYS Medicaid PSP.
• Review the press release: The press release is now available and contains the complete details on the phased rollout.
• Update your contact information: Ensure your email and mailing addresses are current in our system so you receive your official notification when it is your turn to revalidate. To update your contact information, please contact the eMedNY Help Desk at (800) 343-9000.

Guidance for Centers for Medicare and Medicaid Services Cell and Gene Therapy Access Model

In reference to the Casgevy™ (exagamglogene autotemcel) and Lyfgenia® (lovotibeglogene autotemcel): Centers for Medicare and Medicaid Services Cell and Gene Therapy Access Model article published in the October 2025 issue of the Medicaid Update, the New York State (NYS) Department of Health is now a participant in the Centers for Medicare and Medicaid Services (CMS) Cell and Gene Therapy (CGT) Access Model. The model is voluntary for State Medicaid programs and manufacturers and will test whether a CMS-led approach to developing outcomes-based agreements for cell and gene therapies increases access for NYS Medicaid beneficiaries to innovative treatment, improve health outcomes, and reduces health care costs to State Medicaid programs. The initial focus of the model is on gene therapies for people living with sickle cell disease, inclusive of Casgevy™ (exagamglogene autotemcel) and Lyfgenia® (lovotibeglogene autotemcel).

As provided in the article referenced above, NYS Medicaid providers should be aware of the following:

• Casgevy™ and Lyfgenia® will be reimbursed by the NYS Medicaid fee-for-service (FFS) program for Medicaid Managed Care (MMC) enrollees and NYS Medicaid FFS members.
• For MMC enrollees, consideration of approval for treatment-related medical care will be determined by the individual MMC Plan.
• Gene therapy coverage will be in accordance with Food and Drug Administration-approved labeling.
• The CMS CGT Access Model also includes a fertility preservation provision provided by the manufacturers of Casgevy™ and Lyfgenia®.

Drug Claim Submission:

• Facilities and pharmacies enrolled with NYS Medicaid will be reimbursed for the cost of Casgevy™ and Lyfgenia®.
• Pharmacy providers must have an "0442" category of service to submit the Medical Assistance Health Insurance Claim Form (eMedNY 150003), to NYS Department of Health. Pharmacy providers should refer to the following for enrollment information on the eMedNY "Provider Enrollment & Maintenance" web page, for additional information.
• Providers will submit claims using the medical professional claim format with the Paper Claim Form 150003 - Instructions for Drugs Billed Separately, that includes both of the following:
  • the assigned Healthcare Common Procedure Coding System code along with the National Drug Code associated with the drug; and
  • a copy of the drug invoice showing the actual acquisition cost of the drug, dated within six months prior to the date of service and/or should include the expiration date of the drug.

Providers may not use 340B inventory for the CGT Access Model drugs. Additional information regarding billing can be found in the eMedNY New York State Medicaid General Billing Guidelines – Professional.

Drug Administration Claim Submission:

• For NYS Medicaid FFS members, payment for drug administration will be made through the outpatient Ambulatory Patient Groups payment when administered in a clinic setting or, if administered on an inpatient basis, following the All Patient Refined-Diagnosis Related Groups.
• For MMC enrollees, payment for drug administration will be made through the MMC Plan. Providers should check with the MMC Plan regarding specific medical coverage criteria, and reimbursement.
• MMC Plan contact and plan directory information is located on the NYS Department of Health "Medicaid Managed Care Plan Information" web page.

Questions and Additional Information:

• NYS Medicaid FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS drug coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.

Standing Order for Doula Services Reissued

The New York State (NYS) Commissioner of Health has reissued the standing order titled Non-Patient-Specific Standing Order for the Provision of Doula Services for Pregnant, Birthing and Postpartum Persons, effective June 10, 2026. This standing order fulfills the federal requirements in Title 42 Code of Federal Regulations §440.130(c), for a physician or other licensed practitioner of the healing arts acting within their scope of practice to provide a written order for preventive services. NYS Medicaid members do not need an additional recommendation for doula services beyond this standing order for the services to be eligible for coverage by NYS Medicaid.

Questions and Additional Information:

• Providers should refer to the eMedNY New York State Medicaid Provider Policy Manual – Doula Services Benefit Policy Manual, for policy and billing guidelines pertaining to NYS Medicaid coverage of doula services.
• NYS Medicaid FFS coverage and policy questions should be directed to MaternalandChild.HealthPolicy@health.ny.gov.
• NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• 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.