Update to the New York State Medicaid Telehealth Policy Manual

On July 29, 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 Medicare flexibility expiration date;
• updated telehealth parity expiration date;
• a revised description of eTriage to include Treatment in Place;
• added guidance for newly created CPT codes "99445" and "99470";
• reorganized Remote Patient Monitoring (RPM) procedure code table into categories;
• updated rate information for CPT code "99407";
• updated information for "D9991";
• revised teledentistry billing grid by site and location;
• added a teledentistry with collaborative practice Registered Dental Hygienist (RDH) model billing grid;
• relabeled for section 9.16.2 Article 28 Clinic Billing by On-Site Presence billing grid categories; and
• updated restrictions for adult day health care, Home Health Care and hospice.

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

Questions and Additional Information:

• NYS Medicaid fee-for-service (FFS) billing and claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS telehealth coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at telehealth.policy@health.ny.gov .
• 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.

NYRx Compound Policy and Proper Billing Practices

NYRx, the New York State (NYS) Medicaid Pharmacy program, recognizes the need for traditional extemporaneous compounding to meet the specific clinical needs of a NYS Medicaid member when no suitable commercially available Food and Drug Administration (FDA)-approved drug exists. Compounded products will only be reimbursed when the final compounded product is produced to meet the specific clinical needs of an individual patient that cannot be met by a commercially available FDA-approved drug and when the ingredients are compendia-supported for the intended route of administration and indication.

To qualify for NYS Medicaid reimbursement, compounded products must:

• be compendia-supported for the prescribed route of administration and indication;
• address a specific clinical need of an individual patient that cannot be met by a commercially available FDA-approved product; and
• not be produced to replace commercially available products unless there is a documented sensitivity or contraindication to dyes, preservatives, or fillers or lack of availability. Sensitivities or contraindications must be documented on the prescription.

Medications are not covered when the prescribed use is not for a medically accepted indication; is for a NYS Medicaid excluded indication as per the Social Security Act §1927(d)(2), or is made by reconstituting commercially available products. Following a review by the Drug Utilization Review Board in September 2015, it was determined that the following ingredients, when used in topical compounds, are excluded from formulary coverage:

• anticonvulsants,
• non-steroidal anti-inflammatory drugs (NSAIDS),
• skeletal muscle relaxants,
• tricyclic antidepressants,
• combinations of two or more antifungals,
• foot baths or soaks,
• other soaks or irrigations, and
• any ingredient not FDA-approved, not compendia-supported, or otherwise excluded from NYS Medicaid coverage.

For all routes of administration, the final compounded product should always align with NYRx clinical criteria, formulary exclusions, or other limitations within the NYS Medicaid. Providers should review the resources below for additional information on billing for compounded products on NYRx.

Please note: Utilizing the Submission Clarification Code (SCC) "08" to receive reimbursement on a compounded product made with an excluded ingredient, or for an excluded indication, violates NYS Medicaid policy. The NYS Department of Health will continue monitoring the use of SCC "08" to ensure appropriate utilization.

Questions and Additional Information:

• Billing questions should be directed to the eMedNY Call Center at (800) 343-9000
• Providers should refer to the NYRx, Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines (section "4.0 Basis of Payment," "Compounded Prescriptions"), for additional information.
• Providers should refer to the NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders article published in the January 2025 issue of the Medicaid Update, for additional information.
• For information regarding compounding kits, providers should refer to the Compound Coverage Clarification article published in the August 2022 issue of the Medicaid Update.
• Providers should refer to the Reminder: Compounded Prescriptions Policy article published in the January 2026 issue of the Medicaid Update.
• Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.

Update to the New York State Medicaid Patient Centered Medical Home Billing Guidance Manual

Effective July 29, 2026, the New York State (NYS) Medicaid program updated the New York State Patient Centered Medical Home Billing Guidance. The information in this manual applies to all NYS Patient Centered Medical Home (PCMH)-recognized providers and Medicaid Managed Care (MMC) Plans. Updates to the manual include:

• additional detail about the medical home file that is posted on the Health Commerce System (HCS);
• a reminder about the responsibility of the provider to keep their practice information updated;
• clarification about third-party insurance;
• clarification about MMC enrollee assignment to a provider and their specific site;
• information about the current phase of quality reporting and a table listing the required quality metrics; and
• PCMH payment tables for fee-for-service, MMC, Child Health Plus (CHPlus), Adirondack program, and the full NYS PCMH payment structure.

Providers should visit the NYS Department of Health "New York State Patient-Centered Medical Home (NYS PCMH)" web page, to access the manual.

Questions and Additional Information:

• Questions related to the NYS PCMH program and attestation should be directed to PCMH@health.ny.gov.
• Questions related to Social Care Networks (SCNs) should be directed to NYHER@health.ny.gov. Additional information regarding SCNs can be found on the NYS Department of Health "Social Care Networks (SCN)" web page.
• Questions related to CHPlus should be directed to CHPlus@health.ny.gov.
• Additional NYS Medicaid and CHPlus NYS PCMH incentive enhancement information can be found in the Reminder: New York State Medicaid and Child Health Plus Patient-Centered Medical Home Quality Reporting Begins in 2026 article published in the December 2025 issue of the Medicaid Update.
• Providers should refer to the NYS Department of Health "PCMH Attestation: Frequently Asked Questions (FAQ's)" web page, for frequently asked questions and answers.
• Questions related to quality reporting should be directed to the My NCQA website.

New York State Medicaid Coverage of Hyperbaric Oxygen Therapy

This article provides comprehensive policy and billing guidance pertaining to New York State (NYS) Medicaid coverage of hyperbaric oxygen therapy (HBOT). HBOT is used to increase the delivery of oxygen to the body by providing pure oxygen in an enclosed, pressurized space. For purposes of this policy, the definition of HBOT mirrors that used by the Undersea and Hyperbaric Medical Society. Use of protocols, devices, equipment, or oxygen concentrations not consistent with this definition are not considered a covered service under NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC). HBOT must be provided in an Article 28 hospital-based setting including hospital outpatient departments (OPDs) and Diagnostic and Treatment Centers (D&TCs) and performed by a physician, nurse practitioner or physician assistant.

NYS Medicaid reimbursement for HBOT is limited to the following conditions:

• acute carbon monoxide intoxication with or without concomitant cyanide poisoning;
• decompression illness;
• gas embolism; and
• gas gangrene.

And as adjunctive therapy for:

• acute traumatic peripheral ischemia;
• crush injuries;
• reattachment of severed limbs;
• progressive necrotizing infections (necrotizing fasciitis);
• acute peripheral arterial insufficiency;
• preparation and preservation of compromised skin grafts;
• chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management;
• osteoradionecrosis;
• actinomycosis; and
• diabetic wounds of the lower extremities in patients who meet the following criteria:
  • patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
  • patient has a wound classified as Wagner grade III or higher; and
  • patient has failed an adequate course of standard wound therapy.

The use of HBOT for diabetic wound healing is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Patient specific standard wound care in patients with diabetic wounds may include:

• assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible;
• optimization of nutritional status;
• optimization of glucose control; debridement by any means to remove devitalized tissue;
• maintenance of a clean, moist bed of granulation tissue with moist dressings;
• pressure reduction (off-loading); and
• necessary treatment to resolve any infection that might be present.

Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBOT. Continued treatment with HBOT is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

Examples of non-covered conditions include but are not limited to:

• pediatric developmental disorders, including autism;
• cutaneous, decubitus, and stasis ulcers;
• chronic peripheral vascular insufficiency;
• anaerobic septicemia and infection other than clostridial;
• skin burns (thermal);
• senility;
• myocardial infarction;
• cardiogenic shock;
• sickle cell anemia;
• acute thermal and chemical pulmonary damage (i.e., smoke inhalation with pulmonary insufficiency);
• acute or chronic cerebral vascular insufficiency;
• hepatic necrosis;
• aerobic septicemia;
• nonvascular causes of chronic brain syndrome (pick’s disease, Alzheimer’s disease, Korsakoff’s disease);
• tetanus;
• systemic aerobic infection;
• organ transplantation;
• organ storage;
• pulmonary emphysema;
• exceptional blood loss anemia;
• multiple sclerosis;
• Arthritic diseases; and
• acute cerebral edema.

Please note: This list is not exhaustive of all non-covered conditions.

NYS Medicaid FFS Billing

Clinic Billing Instructions
Clinics should submit claims using the Healthcare Common Procedure Coding System code "G0277" (Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval) for each 30-minute interval of HBOT.

Physician Billing Instructions
A separate claim for the reimbursement of professional services may be submitted by a physician attending and supervising the HBOT when the therapy is provided in an Article 28 hospital-based setting including hospital OPDs and D&TCs.

Physicians should submit claims using Current Procedural Terminology (CPT) code "99183" (Physician attendance and supervision of HBOT, per session) to account for the physicians’ professional time, expertise and management of the treatment. Please note: A physician may report Evaluation and Management services performed on same date of service as HBOT with modifier "25", if a physician performs unrelated, significant, and separately identifiable services.

Questions and Additional Information:

• FFS claim 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 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.

New York State Medicaid Coverage of Nucleic Acid Amplification Testing for the Purpose of Bacterial Vaginosis and Sexually Transmitted Infection Diagnosis and Treatment

This article serves as a reminder to providers regarding New York State (NYS) Medicaid fee-for service (FFS) and Medicaid Managed Care (MMC) coverage of nucleic acid amplification tests (NAATs) for the diagnosis and treatment of bacterial vaginosis and sexually transmitted infections (STIs), outlining current coverage and billing requirements to support appropriate reimbursement and compliance with Medicaid policy. NYS Medicaid-enrolled clinical laboratories performing the testing are able to bill NYS Medicaid directly for reimbursement for the testing performed. Practitioners may bill for an Evaluation and Management (E&M) service for an encounter in which a NAAT test is ordered when all required elements for that specific E&M code are met.

NAAT testing will be reimbursed when one or more of the following criteria are met:

• All sexually active women younger than 25 years of age should be tested for gonorrhea and chlamydia every year; women 25 years or age and older with risk factors should be tested for gonorrhea and chlamydia every year. Risk factors include having new partners, multiple partners, or a partner who has an STI.
• Universal screening is recommended for all pregnant women at the first prenatal visit; rescreening should be completed in the third trimester if risk factors persist.
• All sexually active persons 15 to 44 years of age should be offered syphilis screening if living in counties where the primary/secondary syphilis rate among females exceeds 4.6 per 100,000.
• Sexually active men who are gay or bisexual and men who have sex with men should be tested for syphilis, chlamydia, and gonorrhea at least once a year; those with multiple or anonymous partners should be tested more frequently (e.g., every three to six months).
• Persons who have receptive vaginal sex should be screened for trichomonas at the initial visit and at least annually using vaginal/cervical NAAT.
• The U.S. Preventive Services Task Force recommends against routine serologic screening for genital herpes in asymptomatic individuals; type-specific PCR (polymerase chain reaction) testing of a lesion is preferred when symptomatic.
• Transgender/gender-diverse persons should be screened based on current anatomy and sexual behaviors.

NAAT testing may be billed using the following Current Procedural Terminology (CPT) codes:

* CPT code "81513" was added to the NYS Medicaid Laboratory Fee Schedule, effective July 1, 2026.

Questions and Additional Information:

• 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 FFS billing/claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• 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 can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
• Additional laboratory information and billing guidance is available in the eMedNY New York State Medicaid Program Fee-for-Service Laboratory Procedure Codes and Coverage Guidelines Manual.

Reimbursement Change for Unlicensed Individuals Providing Applied Behavior Analysis Services

As authorized by the New York State (NYS) Enacted Budget for Fiscal Year 2026-2027, NYS Medicaid fee-for-service (FFS) will decrease the fee paid for Applied Behavioral Analysis (ABA) services provided by unlicensed individuals/technicians represented by Current Procedural Terminology (CPT) code "97153". This change in reimbursement methodology ensures providers of ABA services are compensated equitably for their training and experience.

Effective October 1, 2026, the reimbursement for CPT code "97153" will be reduced to $9.63/per unit. Providers should refer to eMedNY "Applied Behavior Analysts (ABA)" web page, for current fee schedule and policy guidelines.

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.

Spread the Word: New York State Medicaid Advisory Committee and Beneficiary Advisory Council

The New York State (NYS) Department of Health has launched two new boards, the Medicaid Advisory Committee (MAC) and the Beneficiary Advisory Council (BAC), and assistance is requested to spread the word.

Promotional flyers are available in multiple languages to facilitate reaching a broader audience and ensuring that as many NYS Medicaid and Child Health Plus members as possible can learn about these boards and participate.

Providers are encouraged to take a moment to share these flyers with family, friends, colleagues, community groups, networks, and any other interested individuals. Support in distributing these flyers is invaluable and plays a vital role in reaching individuals who can benefit from the information and discussions at these meetings.

Appreciation is extended for this continued support. For additional information and to access the flyers, providers are encouraged to visit the NYS Department of Health "Medicaid Advisory Committee (MAC) and Beneficiary Advisory Council (BAC)" web page.