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HealthfirstMedicaid · Reimbursement · Provider Update · NYHigh impact

Provider Updates for September 2026

Effective date
Jan 1, 2027
Identified
Sep 2, 2026

Summary

Effective November 1, 2026, Healthfirst bundles G2211 into the E/M service for HARP, Essential Plan and Qualified Health Plan members, and treats G0545, the listed counseling, screening and vision codes, and prolonged service codes 99415 through 99418 as inclusive to the associated E/M or preventive service for Medicaid Managed Care, Child Health Plus, HARP, Essential Plan and Qualified Health Plan members. Effective January 1, 2027, G0545 and the listed counseling, screening and vision codes are not separately reimbursable with an E/M or preventive medicine service for Medicare Advantage and CompleteCare (MAP) members, and CPT 99415 through 99418 are non-covered for those plans. Claims with G2211, G2212 or G0545 billed with an E/M service appended with modifier 25 will be denied, and G2211 is not separately reimbursable for Healthfirst Medicaid members age 21 and older.

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What to do

Action · 9 steps
01Already effective November 1, 2026: For HARP, Essential Plan and Qualified Health Plan members, bill G2211 and G0545 as inclusive to the E/M service, since they are not separately reimbursable.
02Effective January 1, 2027: For Medicare Advantage and CompleteCare (MAP) members, bill G0545 and the listed counseling, screening and vision codes with an E/M or preventive medicine service only as inclusive services, and expect CPT 99415 through 99418 to be non-covered.
03Do not append modifier 25 to G2211, G2212 or G0545, because claims with those codes billed with an E/M service appended with modifier 25 will be denied.
04Do not bill G2211 for Healthfirst Medicaid members age 21 and older, because claims for those members will be denied.
05For Medicaid members ages 0 to 20, G2211 may be billed once per week per patient with POS 02, 10, 11 or 22, and telehealth services require modifier 93, 95 or GT on the qualifying E/M service.
06Document the medical complexity and ongoing care that justify G2211, including how the visit supports a patient-centered plan of care.
07Report G2212 only when total time exceeds the maximum time threshold of the primary E/M service, in 15-minute units, and do not report G2212 on the same date of service as 99358, 99359, 99415 or 99416.
08When a preventive medicine exam and a separately identifiable E/M are on the same date, bill both on the same claim with modifier 25 on the E/M, which is reimbursed at 50 percent of the contracted allowable.
09For Medicaid Managed Care and Child Health Plus members under 21, CPT 99401 and 90483 follow PO-RE-175, Childhood Vaccine Counseling.

Codes mentioned

G2211G2212G05459938199382993839938499385993869938799391993929939399394993959939699397G0402G0438G043999202992039920499205992119921299213992149921599341993429934499345993479934899349993509930499305993069930799308993099931099315993169940199404994069940799408994099941199412G0296G0396G0397G0443G0445G0446G0473G2011H0005S0257S94709048399415994169941799418G0102Q009199172991739935899359

Original notice

Provider Updates for September 2026
hfproviders.org · Always check the source before changing claims.
View original ↗

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Related policy hubs

Healthfirst policiesNY policy changesCode G2211Code G2212Code G0545Code 99381Code 99382Code 99383Code 99384Code 99385Code 99386Code 99387Code 99391Code 99392Code 99393Code 99394Code 99395Code 99396Code 99397Code G0402Code G0438Code G0439Code 99202Code 99203Code 99204Code 99205Code 99211Code 99212Code 99213Code 99214Code 99215Code 99341Code 99342Code 99344Code 99345Code 99347Code 99348Code 99349Code 99350Code 99304Code 99305Code 99306Code 99307Code 99308Code 99309Code 99310Code 99315Code 99316Code 99401Code 99404Code 99406Code 99407Code 99408Code 99409Code 99411Code 99412Code G0296Code G0396Code G0397Code G0443Code G0445Code G0446Code G0473Code G2011Code H0005Code S0257Code S9470Code 90483Code 99415Code 99416Code 99417Code 99418Code G0102Code Q0091Code 99172Code 99173Code 99358Code 99359

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