Medicaid Guidance to New York State Planned Parenthood Providers and Payors
Background:
On July 4, 2025, H.R.1 was signed into law under the Trump Administration which included Section 71113 (Federal Payments to Prohibited Entities) that prohibits Medicaid payments to certain prohibited entities for one year. On July 7, 2025, a complaint was filed by the Planned Parenthood Federation of America in Massachusetts against the action resulting in the Federal District Court Judge issuing a temporary restraining order (TRO) which stopped implementation of this section. Additionally, on July 21st and July 28th, the Federal District Court issued two separate Preliminary Injunctions (PIs) which modified the TRO.
On September 11, 2025, the First Circuit of the U.S. Court of Appeals put on hold both PIs which allows Section 71113 to take effect. Bill text for H.R.1, including the criteria for determining a “Prohibited Entity” as defined by Section 71113, can be found here: https://www.congress.gov/119/plaws/publ21/PLAW-119publ21.pdf
Medicaid Claim Submission:
- New York State (NYS) Medicaid providers that do not meet the definition of “Prohibited Entity” should continue to submit fee-for-service (FFS) claims as normal through the eMedNY system as well as Medicaid Managed Care (MC) claims for payment through Managed Care Organizations (MCOs).
- NYS Medicaid providers that do meet the definition of “Prohibited Entity” should also continue to submit FFS and MC claims as normal for dates of service on or before July 3, 2024. These claims will be processed as normal.
- Additionally, providers that meet the definition of “Prohibited Entity” and were included under the July 21st and July 28th PIs should continue to submit all FFS and MC claims for all services with a date of service (DOS) from July 4, 2025 through September 10, 2025. These claims will also be processed as normal.
- FFS and MC claims submitted with a DOS on or after September 11, 2025 by “Prohibited Entities” will be pended by eMedNY and MCOs and modified to be paid with State dollars only to comply with H.R.1.
The NYS Department of Health (DOH) recognizes that this is a rapidly evolving situation and will make the required changes to comply with H.R.1 and applicable court orders. Additional information will be made available as necessary as we continue to monitor the situation. NYS DOH is committed to ensuring all essential health benefits are available to Medicaid beneficiaries while also adhering to Federal requirements.
