MedicaidCoverageHigh impact
Reimbursement Change for Unlicensed Individuals Providing Applied Behavior Analysis Services
NY Medicaid·NY · Pharmacy, Wound Care, General Practice +1 more·Claims & Billing
Effective date
Jul 29, 2026
We identified it
Sep 18, 2026
Summary
New York State Medicaid updated four major policy manuals effective July 29, 2026: the Telehealth Policy Manual (with updated CPT codes 99445, 99470, and rate changes for 99407), the NYRx Compound Policy (clarifying reimbursement restrictions for compounded medications with excluded ingredients), the Patient Centered Medical Home Billing Guidance (with updated payment tables and quality metrics), and Hyperbaric Oxygen Therapy coverage policy (limiting HBOT to specific medical conditions in Article 28 hospital-based settings). These changes require immediate review and potential updates to billing workflows, documentation practices, and claim submission processes.
Action Required
By July 29, 2026: (1) Billing Team - Update telehealth billing system to reflect new CPT codes 99445 and 99470 rates and 99407 rate changes in the telehealth module. (2) All Providers and Billing Staff - Download and review the updated NYS Medicaid Telehealth Policy Manual from the NYS Department of Health website and implement any changes to telehealth service site requirements and billing grids. (3) Pharmacy Billing Staff - Implement stricter review process for compounded medication claims to ensure excluded ingredients (anticonvulsants, NSAIDs, skeletal muscle relaxants, tricyclic antidepressants, multiple antifungals) are not billed; DO NOT use Submission Clarification Code (SCC) 08 for excluded ingredients or indications, as this violates policy and triggers NYS monitoring. (4) PCMH-Recognized Providers - Verify practice information is current in Health Commerce System (HCS); review updated payment tables for FFS, MMC, CHPlus, and Adirondack programs; ensure quality metrics reporting is configured for 2026. (5) Facilities Providing HBOT - Verify treatment site is Article 28 hospital-based (hospital OPD or D&TC); confirm treating provider is physician, nurse practitioner, or physician assistant; implement pre-authorization process for HBOT claims to document medical necessity for covered indications (acute carbon monoxide poisoning, decompression illness, gas embolism, gas gangrene) or adjunctive uses with required documentation (e.g., Wagner grade III+ diabetic wounds with 30+ days failed standard therapy). Contact eMedNY Call Center (800-343-9000) for billing questions or telehealth.policy@health.ny.gov for coverage questions. Claims that do not comply with updated manual requirements will be denied.