MedicaidCoverageHigh impact
Coverage for Annual Well-Child Visits
EmblemHealth·Pediatrics, Family Medicine, General Practice·Provider News
We identified it
Jun 20, 2026
Summary
Medicaid members under 21 can now receive annual well-child visits without waiting 12 months from their last visit, and providers can bill for both a sick visit and preventive wellness visit on the same day using Modifier 25. This allows for more frequent preventive care and additional billing opportunities.
Action Required
Immediately: Update billing workflows to allow same-day billing of sick visits and well-child visits for Medicaid members under 21. Train billing staff to add Modifier 25 when both services are provided on the same day. Update scheduling system to allow annual wellness visits even if 365 days haven't passed since the last visit in the prior calendar year. Ensure providers document all components properly to support both CPT and E/M codes billed.