Medicare AdvantageReimbursementHigh impact
Provider Updates for September 2026
Healthfirst·NY·Provider Update
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Healthfirst updated its reimbursement policy for E/M services billed with preventive medicine visits, effective September 1, 2026. E/M services (CPT 99202-99215) billed with Modifier 25 on the same date as preventive services will now be reimbursed at 50% of the contracted allowable amount instead of full payment. The policy also introduces new coverage for complexity add-on code G2211 for Medicaid members ages 0-20 years in pediatric primary care, reimbursable once per week per patient.
Action Required
By August 31, 2026: Billing team must update billing system and encounter forms to implement the 50% reimbursement reduction for E/M codes (99202-99215, 99341-99350, 99304-99316) when billed with Modifier 25 on the same date of service as preventive medicine codes (99381-99397, G0402, G0438, G0439). For Medicaid members ages 0-20 years, enable billing of G2211 add-on code with E/M services, limited to once per week per patient for pediatric primary care providers and eligible subspecialties. Providers must ensure documentation clearly distinguishes between preventive and problem-oriented services and supports the medical necessity and level of E/M service billed, or claims will be denied. Update denial management protocols to reflect the 50% payment reduction for properly documented E/M services with Modifier 25 rather than outright denials.