Attention Dental Providers: Fragmenting Care and Private Pay Agreements

As a reminder, New York State (NYS) Medicaid providers must accept as payment in full the amounts paid by the NYS Medicaid agency or Medicaid Managed Care Plan for all components of a comprehensive treatment plan. Some component dental services, including but not limited to:

• rubber dam placement;
• local anesthesia;
• interim restorations;
• core buildup;
• socket or healing enhancing material;
• case presentation, and treatment planning; and
• endodontic regenerative or biological technologies.

These dental services are considered part of another covered service and cannot be billed separately. Additional reimbursement for component services cannot be claimed from NYS Medicaid, and it is a violation of federal law and NYS Medicaid policy for NYS Medicaid providers to charge or collect any payment from the NYS Medicaid member, even under a private pay agreement, if NYS Medicaid is billed for the visit.

For additional information, providers should refer to the federal regulation 42 Code of Federal Regulations § 447.15. Likewise, NYS Medicaid providers are prohibited from breaking up a treatment plan into phases for purposes of charging or collecting any direct payment from the NYS Medicaid member for covered services, if the provider is billing NYS Medicaid for any procedure in the treatment plan.

Dental Benefit Expansion of Criteria for Topical Application of Fluoride Varnish

Topical application of fluoride varnish is a covered service for New York State (NYS) Medicaid members when professionally administered in accordance with appropriate standards. Effective October 1, 2026, topical application of fluoride varnish is reimbursable in the dental setting under Current Dental Terminology (CDT) code "D1206", once per six months for NYS Medicaid members 21 years of age and older with documented moderate-to-high caries risk.

For reimbursement on NYS Medicaid members 21 years of age and older, providers must document moderate-to-high risk by using a Caries Risk Assessment tool, such as:

• ADA Caries Risk Assessment Form Completion Instructions;
• UCSF "CAMBRA: Proven method for preventing tooth decay" web page, or similar* performed within the previous 12 months.

The Caries Risk Assessment form must be signed by a licensed dental provider and kept in the chart of the patient; a corresponding CDT code ("D0602" and/or "D0603") must be on the claim**.
*Caries Risk Assessment tool must include written assessment of contributing conditions, clinical conditions, disease indicators, biological risk factors, and protective factors. CAMBRA: © 2003, 2010, 2011, 2019–2021 The Regents of The University of California. CAMBRA® is a trademark of The Regents of the University of California. © American Dental Association, 2009, 2011.
**Caries Risk Assessment is not separately reimbursed; reimbursement is included in routine evaluation and treatment planning.

This is an expansion of service. Topical application of fluoride varnish CDT code "D1206" remains reimbursable in a dental setting from eruption of first tooth for NYS Medicaid members under 21 years of age. Topical application of fluoride varnish is reimbursed through six years of age in a non-dental setting with CPT code "99188".

Topical application of fluoride varnish is reimbursable once per three-month period for NYS Medicaid members 21 years of age and older when identified with a Restriction Exception code of RE 81 ("TBI Eligible" or RE 95 ("OPWDD/Managed Care Exemption") or in cases where salivary gland function has been compromised through surgery, radiation, or disease under CDT code "D1206".

Questions and Additional Information:

• NYS Medicaid fee-for-service (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 dentalpolicy@health.ny.gov.
• Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the specific 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.
• NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

1915(c) Children's Waiver Home and Community Based Services

This information is relevant for providers treating children who are at risk of hospitalization or institutionalization due to a complex medical condition or mental health condition or treating children in foster care with developmental disabilities.

For children under 21 years of age who have a medical condition, developmental disability, and/or serious mental health disorder that is currently impacting their daily functioning and that places them at imminent risk of hospitalization or institutionalization, or results in the need for supports to return safely home and to their community after discharge from an institutional level of care, New York State (NYS) Medicaid and Child Health Plus (CHPlus) offers coverage of non-clinic home and community based support services.

Children's Waiver Home and Community Based Services (HCBS) are community-based support services for children/youth to prevent the need for institutional care such as psychiatric hospitalization, residential treatment, or nursing home admission, or to assist children/youth to return to their home and community after discharge from an institutional level of care.

The Children's Waiver services complement and/or supplement the clinical services that are available to participants through NYS Medicaid, CHPlus, and other federal, state and local public programs as well as the supports that families and communities provide.

The Children's Waiver offers an array of supportive services that assist NYS Medicaid members to live in the community and avoid institutionalization. As of April 1, 2026, the following services are available to children/youth that meet the diagnostic and functional criteria of HCBS and each service which includes:

• adaptive and assistive technology;
• caregiver/family advocacy and support services;
• community habilitation;
• environmental modifications;
• non-medical transportation;
• palliative care:
  • counseling and support services;
  • expressive therapy;
  • massage therapy;
  • pain and symptom management;
• prevocational services;
• respite (both planned and crisis);
• supported employment;
• transitional care coordination;
• transitional services; and
• vehicle modifications.

Determining Eligibility and Care Management

Children/youth who are already enrolled in NYS Medicaid who are believed to be eligible for and in need of Children's Waiver HCBS may contact or be referred to their local children's Health Home to receive an HCBS eligibility determination. Health Home locations and contact information can be found on the NYS Department of Health "Find a Health Home Tool" web page.

Children/youth who do not have active NYS Medicaid may be referred to the Children and Youth Evaluation Services (C-YES) for an HCBS eligibility determination, and assistance with obtaining NYS Medicaid. Effective January 1, 2026, Children's Waiver C-YES functions and services are coordinated by the NYS Department of Health, or the Office of Mental Health (OMH)/Children Single Point of contact (C-SPOA). To make a referral to C-YES for children/youth in need of HCBS who are not already enrolled in NYS Medicaid, families, providers, and other stakeholders may use the secure C-YES Online Referral, or call NYS Department of Health C-YES to complete the referral form over the telephone at (518) 408-5358 (local) or (833) 861-4467 (toll free).

All children/youth who have been determined to be eligible for and enrolled in the Children's Waiver must have access to care management. Participants have a choice of comprehensive care management through a Health Home care management agency, or basic care coordination by a qualified individual identified by the state (QIIS).

Please note: A Health Home provides comprehensive care management and supports all services for the needs of the child/youth, including health care services, mental health services, community support, and HCBS. A QIIS provides HCBS-only care coordination for Children's Waiver participants who have opted out of comprehensive Health Home care management.

Resources:

• To obtain additional information, resources, and online referral form for NYS Department of Health C-YES, providers should refer to the NYS Department of Health "The Department of Health (DOH) Children and Youth Evaluation Services (C-YES)" web page.
• To obtain additional information and resources about Children's Waiver Home and Community Based Services, providers should refer to the NYS Department of Health "1915(c) Children's Waiver and 1115 Waiver Amendments" web page.
• To obtain eligibility and enrollment information regarding the Children's HCBS Waiver, providers should refer to the NYS Department of Health "Children's Home and Community Based Services (HCBS) Waiver Eligibility and Enrollment Policy #CW0005" web page.
• To obtain information on Children's HCBS Waiver service definitions and necessity criteria, providers should refer to the NYS Department of Health "HCBS Service Definition and Necessity Criteria Policy #CW0020" web page.

Questions:

• General inquiries related to C-YES should be directed to NYS Department of Health C-YES by email at CYESConnect@health.ny.gov and/or by telephone at (518) 408-5358 (local) or (833) 861-4467 (toll free).
• Questions related to Children's Waiver HCBS should be directed to the NYS Department of Health Children's Waiver team by email at BH.Transition@health.ny.gov or by telephone at (518) 473-5569.

Stay Covered: Preparing for Federal Policy Changes

The federal H.R.1 law makes big changes that go beyond just updating policies — it creates real challenges for the health care system that millions of New Yorkers depend on. To help protect as many New Yorkers as possible from losing their health coverage, New York State is working with community partners to share information about what's changing and what people need to do through the Stay Covered campaign.

Many communication tools are available for partners and stakeholders on the Implementing H.R.1 Communications Tool Kit, including educational materials in 27 languages and Frequently Asked Questions for partners to provide information about what is changing and how they can help. The Implementing H.R.1 Communications Tool Kit also includes these recent additions:

• Quick Guide for Partners on the Stay Covered campaign
• Messages by Month for Work Requirements for Medicaid Coverage
• New Social Media Video in English and Spanish: "Don't Miss Important Information about Medicaid Work Requirements"
• Demographic ZIP Code Report of NY State of Health H.R.1 Impacted Medicaid Enrollees

This Implementing H.R.1 Communications Tool Kit will continue to be updated with the latest news and available resources.

New York State Medicaid to Introduce Work Requirements Starting January 1, 2027

Starting January 1, 2027, some people who have New York State (NYS) Medicaid coverage will need to show they are working, going to school, helping out in the community, or participating in job training to keep their health coverage.

This is a new federal rule called Work Requirements for Medicaid Coverage. If someone is subject to work requirements for NYS Medicaid coverage, NY State of Health will send them a notice by mail (or email if they chose electronic notices). NYS Medicaid members potentially subject to these new work requirements began receiving these notices in mid-August through September 30, 2026.

Read more about work requirements for NYS Medicaid coverage, as well as a timeline of other changes coming to the NYS Medicaid program on the NY State of Health "Changes to Medicaid Coverage" web page.

NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders

The New York State (NYS) NYS Department of Health has enhanced claims editing for products not covered by NYRx. The following information provides details of these edits.

Claim Edit Details

NDC Not Covered
When a National Drug Code (NDC) does not appear on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, the pharmacy should review the list for a covered option or discuss possible alternatives with the prescriber. This has been the subject of numerous past articles, including the Medicaid Pharmacy List of Reimbursable Drugs article published in the June 2020 issue of the Medicaid Update. Claims billed to NYRx with an NDC that is not covered will be rejected with the following claims edit:

Drugs Without Federal Rebate Agreement
Pursuant to Social Security Act (SSA) § 1927(a), drug manufacturers are required to participate in the Medicaid Drug Rebate Program (MDRP) for coverage. Drugs manufactured without MDRP participation are not covered. Providers should consult the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, for a list of covered alternatives. Additional information regarding this limitation can be found in the Medicaid FFS Removing NDCs article published in the October 2018 issue of the Medicaid Update. Providers should also refer to the NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders article published in the January 2025 issue of the Medicaid Update. Claims billed to NYRx that do not participate in the MDRP will be rejected with the following claims edit:

Drug Efficacy Study Implementation Drugs
The Food and Drug Administration (FDA) Drug Efficacy Study Implementation (DESI) program requires new drugs be proven safe and effective. Drugs that are identified by the FDA with DESI codes five and six are not available for reimbursement, and will be rejected with the following claims edit:

NDC Excluded from State Plan Coverage
NYS Medicaid reimburses for drugs included on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page. The following are examples of drugs/drug uses which are not reimbursable by NYS Medicaid in accordance with policy and/or state or federal legislation:

• Drugs used for the treatment of anorexia, weight loss or weight gain pursuant to SSA § 1927(d)(2).
• Drugs for the treatment of sexual dysfunction pursuant to SSA § 1927(d)(2), and Social Services Law § 365-a(4)(f).
• Drugs indicated for cosmetic use or hair growth pursuant to SSA § 1927(d)(2).
• Any contrast agents, used for radiological testing (these are included in the fee of the radiologist).
• Drugs packaged in unit doses for which bulk product exists.

Claims billed to NYRx with an NDC that is excluded from State Plan coverage will be rejected with the following claims edit:

Medical Supplies and Durable Medical Equipment
The Healthcare Common Procedure Coding System (HCPCS) code should be submitted in the 11-digit NDC field with leading zeros for Medical Supplies billed to NYRx. For additional information, refer to the Medical Supply Procedure Codes & Coverage Guidelines. Pharmacies and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers that submit claims using an NDC number, will be rejected with the following claims edit:

Termination Dates
NYRx routinely receives termination data when NDCs have been discontinued by the manufacturer. Drugs identified as terminated by the manufacturer are not covered. Providers should refer to the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, for alternative NDCs. Claims billed to NYRx that have a terminated NDC number will be rejected with the following claims edit:

Frequently Rejected Drugs as of September 2026

For more information on NYRx drug coverage criteria, drug coverage limitations, and claims processing prescribers should refer to NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders article published in the April 2025 issue of the Medicaid Update.

Resources:

• eMedNY Edit/Error Knowledge Base (EEKB) Search Tool
• NYRx Pharmacy Rejections – How to Identify and Resolve document
• New York State eMedNY Billing Guidelines – Pharmacy (located on the eMedNY "Pharmacy Manual" web page)
• NYRx, The Medicaid Pharmacy Program: Top Edit Resource

Questions:

• Questions regarding this guidance should be directed to NYRx@health.ny.gov.
• NYRx billing/claims question should be directed to the eMedNY Call Center at (800) 343-9000. The eMedNY Call Center hours are Monday through Friday from 7 a.m. to 10 p.m., and Saturday through Sunday from 8:30 a.m. to 5:30 p.m.

NYRx Medicaid Drug Program Update: NY Select Drug List for Practitioner Administered Drugs

The New York State (NYS) Medicaid fee-for-service (FFS) program has established a NY Select Drug List, for high-cost practitioner administered drugs (PADs), including certain gene therapies and Chimeric Antigen Receptor (CAR) T-cell therapies. These drugs are carved out of the inpatient rate or All Patient Refined Diagnosis Related Group (APR-DRG) and must be billed separately from the inpatient rate. The NY Select Drug List includes drugs that are billed and reimbursed separately from the inpatient rate.

This list will be updated periodically and supersedes any previous Medicaid Update articles that identify gene therapies or CAR-T cell therapies as eligible for separate reimbursement. Providers may not utilize 340B inventory for drugs listed on the NY Select Drug List. Claims submitted with 340B modifiers for drugs on the NY Select Drug List are not payable and will return edit 00927: Procedure code is inconsistent with the modifier use.

Billing Guidance and Additional Resources

A separate claim must be submitted to receive reimbursement for a drug administered from the NY Select Drug List. Certain drugs that are designated "By Report" ("BR") must be submitted on the Medical Assistance Health Insurance Claim Form. If the drug is not listed with "BR", the claim can be submitted electronically (837-P transaction).

Prescribers should refer to the eMedNY New York State Medicaid General Billing Guidelines, for professional claims. Providers will be reimbursed for these drugs in compliance with the Reimbursement for Medicaid Fee-for-Service Professional Drug Claims document.

Questions and Additional Information:

• Policy guidance for an inpatient drug reimbursed separately is in the New York State Medicaid Program Inpatient Policy Guidelines.
• Providers needing assistance should refer to the eMedNY Edit/Error Knowledge Base (EEKB) Search Tool.
• NYS Medicaid FFS billing/claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• For PAD clinical criteria and billing guidance, prescribers should visit the NYS Department of Health "Policies and Billing Guidance for Practitioner Administered Drugs" web page.
• NYS Medicaid FFS drug policy questions should be directed to NYRx telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
• Providers should check with the Medicaid Managed Care (MMC) Plan regarding specific medical coverage criteria, and reimbursement. MMC Plan contact and plan directory information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
• NYS Medicaid 340B policy questions should be directed to NYRx@health.ny.gov.