New York State Medicaid Update - February 2023 Comprehensive Guidance Regarding Use of Telehealth including Telephonic Services After the Coronavirus Disease 2019 Public Health Emergency Special Edition Volume 39 - Number 3

Comprehensive Guidance Regarding Use of Telehealth including Telephonic Services After the Coronavirus Disease 2019 Public Health Emergency

Updates are highlighted in yellow

In this issue …

  1. General Information
  2. Telehealth Definitions
    1. Definition of Telehealth
    2. Originating Site
    3. Distant Site
    4. Telemedicine or Audio-Visual Telehealth
    5. Store-and-Forward Technology
    6. Remote Patient Monitoring
    7. Telephonic (Audio-only)
    8. Expanded 'After Hours' Access
    9. Virtual Check-In
    10. eVisits
    11. Virtual Patient Education
    12. Virtual eTriage
    13. eConsults (Interprofessional Consultations)
  3. Telehealth Providers
  4. Confidentiality
  5. Credentialing and Privileging
  6. Patient Rights and Consents
  7. Billing Rules for Telehealth Services
    1. Payment Parity with In-Person Services
    2. Modifiers to be Used When Billing for Telehealth, Store-and-Forward, and RPM
    3. Place of Service Code to be Used when Billing for Telehealth, Store-and-Forward, and RPM Applicable When Billing Professional Claims
    4. Billing for Teledentistry Services
    5. General Billing Guidelines for Dual Eligible Enrollees
    6. Telephonic (Audio-only) Reimbursement Overview
    7. Store-and-Forward Technology
    8. RPM
    9. After Hours
    10. Virtual Check-In
    11. Virtual Patient Education
    12. Virtual eTriage
    13. FFS Billing for Telehealth by Site and Location
    14. Hospital Inpatient Billing for Audio-Visual Telehealth
    15. Skilled Nursing Facility Billing for Audio-Visual Telehealth
    16. MMC Considerations
  8. Options to Support Members with Limited or Lack of Access to Devices and Services
  9. Useful Links
  10. Questions

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This guidance is intended to clarify the New York State (NYS) Medicaid program telehealth policy, including use of audio-only technology, following the federally declared Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE), which ends on May 11, 2023. Throughout the COVID-19 PHE, NYS Medicaid providers shifted traditional in person care to remote delivery, where possible. Although some barriers still exist and not all services are appropriate for remote delivery, telehealth has been largely beneficial in many service areas. Remote services help address workforce shortages, access to specialists, infection control, transportation issues, and dependent care challenges. In recognition of the changing landscape of healthcare delivery and in preparation for the COVID-19 PHE unwind, the NYS Department of Health (DOH) sought feedback from providers and NYS Medicaid members on their experience with telehealth to inform our post PHE policy.

To support the use of telehealth services, the NYS Medicaid program will continue to cover services delivered via audio-visual telehealth, when appropriate, if such member chooses to receive telehealth services in lieu of an in-person visit. An audo-visual visit must contain all elements of the billable procedure codes or rate codes and all required documentation.

Audio-only services will also continue to be covered when audio-visual services are not available or when the member chooses audio-only services in lieu of audio-visual telehealth or an in-person visit. Audio-only visits must contain all elements of the billable procedure codes or rate codes and all required documentation. Providers must document in the chart of the NYS Medicaid member why audio-only services were used for each audio-only encounter.

This guidance does not change any other NYS Medicaid program requirements, with respect to authorized services or provider enrollment, and does not expand authorization to bill NYS Medicaid beyond service providers who are currently enrolled to bill Medicaid fee-for-service (FFS) or contracted with a Medicaid Managed Care (MMC) Plan.

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I. General Information

Providers may use this guidance to prepare for upcoming policy changes tied to the end of the COVID-19 PHE as it applies to dates of service on or after May 11, 2023. This guidance supersedes guidance issued in June 2021. This guidance outlines policies related to audio-visual telehealth, audio-only telehealth, remote patient monitoring (RPM), Store and Forward, virtual check-ins, virtual patient education, and virtual emergency care.

NYS DOH and its partner state agencies expect full compliance with updates to telehealth modifiers and Place of Service (POS) rules by August 1, 2023. The NYS Office of Medicaid Inspector General (OMIG) will be informed of this date to use for future audits. The Notifications of Enforcement Discretion issued by the U.S. Department of Health and Human Services' Office for Civil Rights (OCR) expired with the end of the COVID-19 PHE. OCR is providing a 90-calendar day transition period for providers to comply with Health Insurance Portability and Accountability Act (HIPAA) rules in their provision of telehealth. The transition period expires on August 9, 2023. More information on HIPAA and telehealth can be found on the U.S. Department of Health and Human Services HIPAA and Telehealth "Expiration of COVID-19 Public Health Emergency HIPAA Notifications of Enforcement Discretion" web page.

The information in this guidance applies to the following NYS Medicaid providers and applies to services delivered via FFS or under contracted MMC Plans:

  • NYS Medicaid-enrolled providers and facilities, including NYS DOH-licensed providers;
  • NYS Office of Addiction Services and Supports (OASAS)-certified or designated providers and facilities;
  • NYS Office of Mental Health (OMH)-licensed or designated providers and facilities; and
  • NYS Office for People With Developmental Disabilities (OPWDD) Article 16 Clinic services (e.g., OT, PT, Speech, Psychology, etc). This guidance does not include Independent Practitioner Services for Individuals with Developmental Disabilities (IPSIDD).

Please note: NYS OMH, OPWDD, and OASAS have issued, or may issue, separate guidance and/or regulations that may supersede or supplement the requirements for telehealth for NYS Medicaid members being served under the authority of those respective agencies and address telehealth delivery for services certified by those agencies under the Mental Hygiene Law (MHL).

Additional programmatic guidance may be published by NYS DOH that specifically allows or prohibits the use of telehealth by type of service.

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II. Telehealth Definitions

A. Definition of Telehealth

Telehealth is defined as the use of electronic information and communiction technologies to deliver health care to patients at a distance. NYS Medicaid covered services provided via telehealth include assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a NYS Medicaid member. This definition includes audio-only services when audio-visual is unavailable, or member chooses audio-only.

B. Originating Site

The originating site is where the NYS Medicaid member is located at the time health care services are delivered to the individual by means of telehealth. On professional claims, POS "02", "10", or "11" must be coded to document the location of the NYS Medicaid member during the telehealth visit.

C. Distant Site

The distant site is the site where the telehealth provider is located while delivering health care services by means of telehealth. Any secure site within the fifty United States (U.S.) or U.S. territories, is eligible to be a distant site for delivery and payment purposes, includeing Federally Qualified Health Centers (FQHCs) and providers homes, for NYS Medicaid-enrolled patients. To receive reimbursement from NYS Medicaid, providers submitting telehealth claims or encounters must be NYS-licensed and enrolled in NYS Medicaid. The enrollment requirement is applicable only to enrollable provider types, including pharmacies and most licensed practitioners.

D. Telemedicine or Audio-Visual Telehealth

Telemedicine, or audio-visual telehealth, uses two-way synchronous electronic audio-visual communications to deliver clinical health care services to a patient at an originating site by a telehealth provider located at a distant site. Telemedicine includes teledentistry. Teledentistry, an alternative method of delivering care, can provide a convenient and accessible platform for urgent dental problems, virtual consultations, monitoring of patients, and assistance in making referrals. By improving access to care using teledentistry, long transportation barriers in rural areas to see dental providers and visits to urgent care facilities and emergency rooms for dental-related problems may be avoided. Teledentistry also makes in-office appointments more available for patients who need them.

E. Store-and-Forward Technology

Store-and-forward technology involves the asynchronous, electronic transmission of health information of a NYS Medicaid member, in the form of patient-specific pre-recorded videos and/or digital images from a provider at an originating site to a telehealth provider at a distant site. Store-and-forward technology aids in diagnoses when live video contact is not readily available or not necessary. Additionally, pre-recorded videos and/or static digital images (e.g., pictures) must be specific to the condition of the NYS Medicaid member, as well as be adequate for rendering or confirming a diagnosis or a plan of treatment.

F. Remote Patient Monitoring

Remote patient monitoring (RPM) uses digital technologies to collect medical data and other personal health information from the NYS Medicaid member in one location and can electronically transmit that information to health care providers in a different location for assessment and recommendations. Monitoring programs can collect a wide range of health data from the point of care, such as vital signs, blood pressure, heart rate, weight, blood sugar, blood oxygen levels and electrocardiogram readings. RPM may include follow-up on previously transmitted data conducted through communication technologies or by telephone.

Medical conditions that may be treated/monitored by means of RPM include, but are not limited to, congestive heart failure, diabetes, chronic obstructive pulmonary disease (COPD), wound care, polypharmacy, mental or behavioral problems, and technology-dependent care such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding. RPM may be used during pregnancy and postpartum, as outlined in the New York State Medicaid Expansion of Remote Patient Monitoring for Maternal Care article published in the September 2022 issue of the Medicaid Update.

G. Telephonic (Audio-only)

Telephonic service uses two-way electronic audio-only communications to deliver services to a patient at an originating site by a telehealth provider. For complete billing instructions for telephonic services, providers can refer to "VII. Billing Rules for Telehealth Services", "F. Telephonic (Audio-only) Reimbursement Overview" of this issue.

NYS Medicaid is expanding coverage of remote services to include audio-only visits, to increase access to services, eliminate barriers, supplement oversight of chronic conditions, and improve outcomes. Decisions on what type of visit the NYS Medicaid member receives should be based on their best interest, not that of the provider nor for the convenience of the provider. Providers must use professional judgment to determine whether audio-only services meet patient needs and whether a visit is eligible for audio-only based on criteria below. NYS DOH anticipates only rare occasions when audio-only visits are appropriate for non-behavioral health (BH) services. For example, during weather emergencies when the patient is unable to use audio-visual technologies or when the visit could otherwise not occur unless provided via audio-only telehealth. NYS DOH will monitor audio-only billing and take steps to limit overuse and prevent misuse of audio-only services. This new policy will be monitored following the COVID-19 PHE to determine if additional guidance is necessary.

NYS Medicaid covers audio-only visits for NYS Medicaid members when all the following conditions are met:

  • audio-visual telehealth is not available to the patient due to lack of patient equipment or connectivity (see "VIII. Options to Support Members with Limited or Lack of Access to Devices and Services" and "IX. Useful Links" of this issue, for connectivity resources) or audio-only is the preference of the patient;
  • the provider must make either audio-visual or in-person appointments available at the request of the patient;
  • the service can be effectively delivered without a visual or in-person component, unless otherwise stated in guidance issued by the NYS DOH (this is a clinical decision made by the provider); and
  • the service provided via audio-only visits contains all elements of the billable procedures or rate codes and meets all documentation requirements as if provided in person or via an audio-visual visit.

Additional programmatic guidance may be published that specifically allows or prohibits the use of audio-only telehealth by type of service. For example, when specific Community Based Long Term Care Services and Supports will have allowable telephonic billing available, it will be defined in program-specific guidance. Additional agency-issued guidance outlines the appropriateness of audio-only visits for their specific populations.

H. Expanded 'After Hours' Access

An add-on payment is available for visits that occur on evenings, weekends, and holidays. An evening visit is one which is scheduled for and occurs after 6 p.m. A weekend visit is one that is scheduled for and occurs on Saturday or Sunday. A holiday visit is one that is scheduled for and occurs on a designated holiday. When the after hours visit is completed via telehealth, the appropriate telehealth modifier must be used (see "VII. Billing Rules for Telehealth Services" of this issue for specific guidance).

I. Virtual Check-In

Virtual check-ins are brief medical interactions between a physician or other qualified health care professional and a patient. Virtual check-ins may be especially helpful for patients with ongoing chronic conditions that would benefit from recurring check-ins with their provider. A virtual check-in can be conducted via several technology-based modalities, including communication by telephone or by secure text-based messaging, such as electronic interactions via patient portal, secure email, or secure text messaging. Communication must be HIPAA compliant and don't relate to an Evaluation and Management (E&M) visit the patient had within the past seven days, nor lead to a related E&M visit within 24 hours (see "VII. Billing Rules for Telehealth Services" of this issue for specific information on code and modifiers).

J. eVisits

eVisits are patient-initiated communications with a medical provider through a text-based and HIPAA-compliant digital platform, such as a patient portal. eVisits are a type of Virtual Check-In which occur through asynchronous communication; the exchange is neither real-time nor face-to-face. They are intended to remotely assess non-urgent conditions and prevent unnecessary in-person visits. Coverage of eVisits reimburses providers for the problem-focused communication and medical decision-making conducted outside of their normal visits. NYS Medicaid intends to cover eVisits on or after October 1, 2023, and will release guidance outlining coverage policies once approved. eVisits are not currently a covered service in NYS Medicaid FFS.

K. Virtual Patient Education

Virtual patient education means education and training for patient self-management by a qualified health care professional via telehealth. Virtual patient education delivers health education to patients, their families, or caregivers, and is reimbursable only for services that are otherwise reimbursable when delivered in-person and when the provider meets certain billing requirements.

The National Diabetes Prevention Program (NDPP) is reimbursable when provided as a live/synchronous program (using code "0403T") and is now also reimbursable when provided as an on-demand/asynchronous program (using code "0488T"). NDPPs must meet Centers for Disease Control and Prevention (CDC) requirements and adhere to previously published guidance.

L. Virtual eTriage

In accordance with The CMS Emergency Triage, Treat, and Transport Model with the Department of Health Parallel Model article published in the November 2021 issue of the Medicaid Update, authorized ambulance services responding to 911 calls may facilitate telehealth encounters where appropriate when providing "treatment in place". The visit should be reported by both the ambulance service [as an Emergency Triage, Treat, and Transport (ET3) claim] and the telehealth provider (as a telehealth claim). This model mirrors the Centers for Medicare and Medicaid Services (CMS) ET3 Model and will only be allowable while the CMS program is active, and only to ambulance services participating in the national model. The CMS ET3 program is scheduled to end December 31, 2023. A future Medicaid Update issue regarding treatment in place and alternative destinations will provide additional guidance for ambulance providers.

M. eConsults (Interprofessional Consultations)

eConsults, or interprofessional consultations between a treating/requesting provider and a consulting provider, are intended to improve access to specialty expertise by assisting the treating practitioner with the care of the patient without patient contact with the consulting practitioner. CMS announced in a "Coverage and Payment of Interprofessional Consultation in Medicaid and the Children´s Health Insurance Program (CHIP)" letter on January 5, 2023, that coverage of interprofessional consultations is now permissible and that State Medicaid programs may seek CMS approval to reimburse consulting providers for eConsults. NYS Medicaid intends to request approval of eConsult coverage from CMS and will release guidance outlining coverage policies once approved. eConsults are not currently a covered service in NYS Medicaid FFS.

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III. Telehealth Providers

"Telehealth provider" is defined in Public Health Law (PHL) §2999-cc, and, per NYS regulations, Title 18 of the New York Codes, Rules and Regulations (NYCRR) Part 538, shall also include:

  1. Voluntary foster care agencies certified by the NYS Office of Children and Family Services (OCFS) and licensed pursuant to Article 29-I of PHL, as well as providers employed by those agencies.
  2. Providers licensed or certified by the New York State Education Department (NYSED) to provide Applied Behavioral Analysis (ABA) therapy.
  3. Radiologists licensed pursuant to Article 131 of the Education Law and credentialed by the site from which the radiologist practices.
  4. All NYS Medicaid providers and providers employed by NYS Medicaid facilities, or provider agencies who are authorized to provide in-person services, are authorized to provide such services via telehealth if such telehealth services are appropriate to meet the needs of the patient and are within the scope of practice of the provider.

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IV. Confidentiality

Services provided by means of telehealth must be in compliance with HIPAA and all other relevant laws and regulations governing confidentiality, privacy, and consent, including, but not limited to 45 Code of Federal Regulations (CFR) Parts 160 and 164 [HIPAA Security Rules]; 42 CFR, Part 2; PHL Article 27-F; and MHL §33.13. All providers must take steps to reasonably ensure privacy during all patient-practitioner interactions.

The Notifications of Enforcement Discretion issued by the U.S. Department of Health and Human Services' Office for Civil Rights (OCR) expired with the end of the COVID-19 PHE. OCR is providing a 90-calendar day transition period for providers to comply with HIPAA rules in their provision of telehealth. The transition period expires on August 9, 2023. More information on HIPAA and telehealth can be found on the U.S. Department of Health and Human Services website.

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V. Credentialing and Privileging

Physicians
NYS hospitals acting as originating sites are required to ensure that physicians who are providing consultations via telehealth at distant sites are appropriately credentialed and privileged. Pursuant to previously published NYS DOH letter released September 22, 2006, and Expanded Coverage of Telemedicine article published in the September 2011 issue of the Medicaid Update, a hospital facility, including one that is acting as a telehealth originating site, may enter into a contract with an outside entity to carry out all or part of the professional application and verification process (physician credentialing). This includes activities associated with the collection and verification of information specific to credentials and prior affiliations/employment. A hospital originating site may therefore enter into a contract with the distant site to receive and collect credentialing information, perform all required verification activities, and act on behalf of the originating site hospital for such credentialing purposes regarding those physicians who will be providing patient consultations via telehealth. Such contracts must establish that the originating site hospital retains ultimate responsibility for the physician credentialing. Distant site hospitals may not delegate, through a contract, their responsibility for peer review, quality assurance/quality improvement activities and decision-making authority for granting medical staff membership or professional privileges (physician privileging).

Certified Asthma Educators (Verification Requirements)
The hospital, Diagnostic and Treatment Centers (D&TCs) or office serving as the originating site is responsible for ensuring that the Certified Asthma Educator (CAE) providing self-management training services via telehealth, is a NYS licensed, registered, or certified health care professional, who is also certified as an educator by the National Asthma Educator Certification Board NAECB and CBDCE educators are expected to practice within the scope of practice that is appropriate to their respective discipline, as defined by the NYSED Office of the Professions.

Certified Diabetes Educators
Certification through the Certification Board for Diabetes Educators (CBDCE) is no longer required. Registered dieticians can enroll as NYS Medicaid providers and deliver diabetes self-management training via telehealth.

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VI. Patient Rights and Consents

The practitioner shall confirm the identity of the NYS Medicaid member and provide the NYS Medicaid member with basic information about the services that they will be receiving via telehealth. Written consent by the NYS Medicaid member is not required, but the provider must document informed consent in the chart of the patient before or during the first visit in which telehealth services are provided. Telehealth sessions/services shall not be recorded without the consent of the member.

Informed consent means that telehealth practitioners provide members with sufficient information and education about telehealth to assist them in making an informed choice to receive telehealth services. This must include the following:

  1. The telehealth provider must confirm that the NYS Medicaid member is aware of the potential advantages and disadvantages of telehealth, be given the option of not participating in telehealth services and information regarding their right to request a change in service delivery mode at any time.
  2. The telehealth provider must inform NYS Medicaid members that they will not be denied services if they do not consent to telehealth devices or request to receive services in-person.
  3. Where the NYS Medicaid member is a minor, consent shall also be provided by the parent/guardian or other person who has legal authority to consent to health care on behalf of the minor.

Informed consent shall be obtained through a process of communication between the telehealth provider and NYS Medicaid member. Although some providers may choose to document informed consent to receive telehealth services using a form, it is not necessary to use a specific form. Informed consent processes should be specified in the policies and procedures of the provider.

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VII. Billing Rules for Telehealth Services

A. Payment Parity with In-Person Services

Under NYS Law Chapter 45 Article 29-G §2999-DD, healthcare services delivered by means of telehealth are entitled to reimbursement on the same basis, at the same rate, and to the same extent the equivalent services, as may be defined in regulations promulgated by the commissioner, are reimbursed when delivered in person. Exceptions are in place for certain costs, including facility fees in instances when such costs were not incurred in the provision of telehealth services because neither the originating nor the distant site occurring within the facility or clinic setting for Article 28 licensed facilities. This law is effective until April 1, 2024.

B. Modifiers to be Used When Billing for Telehealth, Store-and-Forward, and RPM

Modifiers Description Note/Example
95 Synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system.  
GT Via interactive audio and video telecommunication systems. Please note: Per CMS, the GT modifier is allowed on institutional claims from Critical Access Hospitals (CAH)
GQ Via asynchronous telecommunications system. Please note: The GQ modifier is for use with Store-and-Forward technology.
25 Significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day as a procedure or other service. Example: The NYS Medicaid member has a psychiatric consultation via telemedicine on the same day as a primary care E&M service at the originating site. The E&M service should be appended with the 25 modifier.
93 Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system. The 93 modifier must be used for mental health services provided via audio-only telecommunications.

Providers can refer to the CMS "List of Telehealth Services" web page, for additional information.
FQ A telehealth service was furnished using real-time audio-only communication technology.  
FR A supervising practitioner was present through a real-time two-way, audio/video communication technology.  

C. POS Code to be Used when Billing for Telehealth, Store-and-Forward, and RPM Applicable When Billing Professional Claims

POS Code Description (as of April 1, 2022)
02 Telehealth provided other than in the home of the patient.
10 Telehealth provided in the home of the patient (which is a location other than a hospital or other facility where the patient receives care in a private residence).
11 Telehealth provided in a private practice or office setting (other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF)). Providers who would report POS 11 if the visit had been in person should report POS 11 on the telehealth claim to ensure proper reimbursement.

D. Billing for Teledentistry Services

NYS Medicaid reimburses for teledentistry and telephonic services. For additional information, dental providers can refer to the February 2019 Expansion of Telehealth Special Edition issue of the Medicaid Update.

The types of teledental (audio-visual) encounters are synchronous (real time) encounters and asynchronous (Store and Forward) encounters. Synchronous ("D9995") encounters are live, two-way encounters between a patient or caregiver and provider. These types of encounters may include urgent visits, follow-up visits or new patient screenings with the use of audio-visual technology. Additionally, synchronous teledental encounters may also occur between a patient or caregiver along with their dental provider and a specialist, such as an endodontist or oral surgeon. For example, a patient presents for an in-person visit to their dental provider for tooth pain. The dental provider determines through radiographs and examination that the tooth in question requires an extraction by an oral surgeon. While the patient is still present, the dental provider then initiates a teledental encounter with an oral surgeon. The oral surgeon conducts a consultation with the dental provider along with the patient. This results in the patient scheduling an appointment for an extraction with the oral surgeon, thereby eliminating the need to schedule an in-person consultation on a different day.

By contrast, asynchronous ("D9996") encounters involve the transmission of recorded health information such as charting, radiographs, digital impressions and video to a dental provider who assesses the information for treatment needs at a later time. For example, a hygienist who is employed by an Article 28 facility and has a collaboration arrangement with a dentist also employed by the same facility, can be in a remote location such as a School-Based Health Center (SBHC). From there the hygienist can perform dental hygiene services for the patient, including gathering information that will be sent to the dentist for further review. The dentist can then review the information at a later time, such as during last-minute cancellations or no-show appointments in their schedule.

When billing for teledentistry services, modifiers cannot be used by dentists. Additional general billing guidance was issued in the Billing Telehealth as a Teledental Encounter article published in the January 2020 issue of the Medicaid Update, which allows for both dental codes ("D9995" and "D9996") to be used in place of modifiers. Both dental codes ("D9995" and "D9996") along with "Q3014" were added to the dental fee schedule as published in the Billing Telehealth as a Teledental Encounter article published in the January 2020 issue of the Medicaid Update. Telephonic (audio only) services use two-way electronic audio only communications to deliver services to a patient at on originating site by a telehealth provider located at a distant site. This service is billed utilizing Current Dental Terminology (CDT) code "D9991".

Dental telehealth services shall adhere to the standards of appropriate patient care required in other dental health care settings, including but not limited to appropriate patient examination and review of the medical and dental history of the patient. For additional information, providers can refer to NYS Law Chapter 45 Article 29-G §2999-DD.

E. General Billing Guidelines for Dual Eligible Enrollees

Pursuant to federal law, Medicaid is the payer of last resort, which means Medicaid will make payments only after all other sources of reimbursement have been exhausted. Therefore, potential third-party reimbursement sources including Medicare, must be billed prior to billing Medicaid. For additional information, providers can refer to the following NYS Medicaid billing guidance for dual enrollees:

For dually enrolled Medicare and NYS Medicaid members, if Medicare covers the telehealth encounter, NYS Medicaid will reimburse the Part B coinsurance and deductible to the extent permitted by NYS law. For benefits covered by Medicare, any telehealth restrictions set by Medicare apply to dually-enrolled members unless otherwise stated in policy, located on the CMS "List of Telehealth Services" web page.

The Performance Enhancement Reform Act, or omnibus budget for federal fiscal year (FY) 2023, included several provisions that extend telehealth flexibilities for federal programs through December 31, 2024. Several flexibilities apply to Medicare´s coverage of telehealth, including suspending geography-based telehealth requirements, allowing audio-only telehealth, patient homes as originating sites, FQHCs and RHCs to continue to offer telehealth, and delaying in-person visit requirements prior to delivering mental health services via telehealth. When such flexibilities end, NYS Medicaid coverage of some services via telehealth for those dually enrolled may be impacted. For additional information, providers can refer to the Congress "House Committee Print 117-59 - RULES COMMITTEE PRINT 117-59 TEXT OF H.R. 4040, THE ADVANCING TELEHEALTH BEYOND COVID-19 ACT OF 2021 [Showing the text of H.R. 4040, as introduced, with modifications.]" web page.

F. Telephonic (Audio-only) Reimbursement Overview

  1. Following the COVID-19 PHE, when audio-only telehealth is used in accordance with the policy outlined in "II. Telehealth Definitions", "G. Telephonic (Audio-only)" of this issue, providers may bill NYS Medicaid as they would for an in-person or audio-visual telehealth visit (using the appropriate procedure or rate code).
    • Services provided via audio-only visits shall contain all elements of the billable procedures or rate codes and must meet all documentation requirements as if provided in person or via an audio-visual visit.
    • Audio-only rate codes used during the COVID-19 PHE will be retired. FQHCs can bill the Prospective Payment System (PPS) rate code "4012" or "4013", depending on on-site presence as outlined in "VII. Billing Rules for Telehealth Services", "M. FFS Billing for Telehealth by Site and Location" of this issue. Wrap payments are available for any telehealth services, including telephonic services reimbursed by an MMC Plan, under qualifying PPS and off-site rate codes.
    • Audio-only E&M procedure codes "99441" through "99443" will continue to be billable, though as of the date of this guidance, 151-days post COVID-19 PHE, Medicare will no longer cover codes "99441" through "99443".
  2. All audio-only claims and encounter must include the 93 or FQ modifier unless modifiers are not allowable (e.g., teledentistry). The UA modifier should no longer be used to indicate the service as delivered via audio-only.
  3. When a POS is allowable on a claim or encounter, providers should report POS "02" for telehealth provided other than in patient's home, "10" or telehealth provided in the home of the patient, except in cases where POS "11" is typically submitted (private practice or office setting); POS "11" providers should continue to report POS "11" and use telehealth modifiers on the claim or encounter to identify it as telehealth.

MMC Plans may have separate detailed billing guidance that supplements the billing guidance outlined in this issue, but cover all services appropriate to deliver through telehealth, including audio-only telehealth. Further detail on FFS code coverage is provided in specialized guidance for mental health, substance use and NYS OPWDD services (see "IX. Useful Links" of this issue).

G. Store-and-Forward Technology:

  • Reimbursement will be made to the consulting distant-site practitioner when billed with an appropriate procedure code.
  • The consulting distant-site practitioner must provide the requesting originating-site practitioner with a written report of the consultation in order for payment to be made.
  • The consulting practitioner should bill the CPT code for the professional service appended with the telehealth GQ modifier.

H. RPM:

  1. Telehealth services provided by means of RPM should be billed using CPT code "99091" [collection and interpretation of physiologic data (e.g., Electrocardiography (ECG), blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training and licensure/regulation (when applicable) requiring a minimum of 30 minutes of time].
  2. A fee of $48.00 per month will be paid for RPM.
  3. Providers are not to bill "99091" more than one time per member per month.
  4. Maternity RPM services:
    1. In an effort to reduce maternal and infant morbidity and mortality, an additional allowance may be reimbursable for RPM equipment provided by enrolled providers to pregnant and postpartum NYS Medicaid members using CPT codes "99453" and "99454" with HD modifier. Additional information can be found in the New York State Medicaid Expansion of Remote Patient Monitoring for Maternal Care article published in the September 2022 issue of the Medicaid Update.
    2. Please note: "99091" and "99454" are both intended to be billed once monthly, but cannot be billed on the same day. This replaces the guidance for billing these codes that was included in the September 2022 issue of the Medicaid Update that stated, "CPT Code "99454" is billed along with CPT Code "99091".
  5. FQHCs that have opted out of Ambulatory Patient Groups (APGs) are unable to bill for RPM services at this time.

I. After Hours

An add-on payment is available for visits that occur on evenings, weekends, and holidays. An evening visit is one that is scheduled for and occurs after 6 p.m. A weekend visit is one that is scheduled for and occurs on Saturday or Sunday. A holiday visit is one that is scheduled for and occurs on a designated holiday. When the after hours visit is completed via telehealth, the appropriate modifier from the table below must be used. Providers should use the following CPT codes as appropriate:

Procedure Codes Procedure Description Appropriate Telehealth Modifiers NYS Medicaid Rate
99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service. 95, GT, 93, or FQ $7.07
99051 Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service. 95, GT, 93, or FQ $7.07

Please note: "99050" and "99051" can be used in conjunction with E&M codes only.

These CPT codes are not payable if they are the only CPT procedure(s) listed on the claim. They are reimbursed only when accompanied by a valid CPT code that represents an in-office or remote medical service/procedure. The entire visit must occur outside of normal hours. Services occurring after hours due to office/provider delays are not eligible for this supplemental payment. Additional information on after hours billing can be found in the Enhanced payment for expanded 'after hours' access article published in the October 2008 issue of the Medicaid Update.

J. Virtual Check-In

Virtual check-ins must be patient-initiated and allow patients to communicate with their provider in order to avoid an unnecessary visit; however, practitioners may need to inform and educate beneficiaries on the availability of the service prior to patient initiation. A parent or caregiver may initiate a virtual check-in on behalf of a patient. The patient must consent to receive virtual check-in services and the provider must document the consent of the patient in their chart at least once annually while the patient receives virtual check-in services. A virtual check-in can be conducted via several technology-based modalities, including communication by telephone or by secure text-based messaging, such as electronic interactions via patient portal, secure email, or secure text messaging. Communication must be HIPAA-compliant and must not originate from a related E&M visit within seven days, nor lead to a related E&M visit within 24 hours.

Expanding on previous policy, NYS Medicaid-enrolled providers (physician or other qualified health care professional who report E&M services) can bill CPT codes "G2012" or "G2252" for reimbursement for virtual check-ins. The virtual check-in must be reported on the claim with the appropriate telehealth modifier (93, 95, FQ, GT, and GQ). Communications reported with a virtual check-in CPT code must meet the criteria outlined below.

CPT Code Description Appropriate Telehealth Modifiers NYS Medicaid Rate
G2012 Brief communication technology-based service by a physician or other qualified health care professional who can report E&M services, not originating from a related E&M service provided within the previous seven days nor leading to a E&M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion. 93, 95, FQ, GT, and GQ $17.30
G2252 Brief communication technology-based service by a physician or other qualified health care professional who can report E&M services, not originating from a related E&M service provided within the previous seven days nor leading to a E&M service or procedure within the next 24 hours or soonest available appointment; 11 to 20 minutes of medical discussion. 93, 95, FQ, GT, and GQ $21.47

Additional agency-issued guidance may be available for specific populations. NYS OPWDD, OASAS, and OMH providers should review their respective guidance to ensure compliance.

K. Virtual Patient Education

Virtual patient education means education and training for patient self-management by a qualified health care professional via telehealth. Virtual patient education delivers health education to patients, their families, or caregivers, and is reimbursable only for services that are otherwise reimbursable when delivered in person and when the provider meets certain billing requirements.

Synchronous audio-visual telehealth may meet the definitions found under CPT codes "98960" through "98962", specifying "face-to-face" education and training. The virtual patient education must be reported on the claim with the appropriate telehealth 95 or GT modifier.

CPT Code Description Appropriate Telehealth Modifiers NYS Medicaid Rate
98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient 95 and GT $20.20
98961 Two to four patients 95 and GT $11.11
98962 Five to eight patients 95 and GT $11.11
0403T Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day 95 and GT $22.22
0488T Preventive behavior change, online/electronic structured intensive program for prevention of diabetes using a standardized diabetes prevention program curriculum, provided to an individual, per 30 days. Coaches must be able to track participant progress through online modules. To bill, the patient must complete a minimum of three sessions per month and adhere to the CDC guidelines regarding coaching support (no less than once per week first six months and no less than once per month next six months) Not applicable $49.00
G0108 Diabetes outpatient self-management training services, individual, per 30 minutes. 95 and GT $42.74
G0109 Diabetes outpatient self-management training services, group (two to eight patients), per 30 minutes. 95 and GT $12.09
99406 Intermediate Smoking Cessation Counseling (SCC), three to ten minutes (billable only as an individual session). 95 and GT $11.97
99407 Intensive SCC, greater than 10 minutes (billable as an individual or group session; using the HQ modifier to indicate a group SCC session, up to eight patients in a group). 95 and GT $22.02
D1320 Tobacco counseling for the control and prevention of oral disease. Billable only as an individual session, greater than three minutes. 95 and GT $10.10

Additional agency-issued guidance may be available for specific populations. NYS OPWDD, OASAS, and OMH providers should review their respective guidance to ensure compliance.

L. Virtual eTriage

Emergency treatment in place via telehealth in response to 911 calls is allowable under the CMS ET3 Model for participating providers. For additional billing information, providers can refer to The CMS Emergency Triage, Treat, and Transport Model with the Department of Health Parallel Model article published in the November 2021 issue of the Medicaid Update. The CMS ET3 program is scheduled to end December 31, 2023. A future Medicaid Update issue regarding treatment in place and alternative destinations will provide additional guidance for ambulance providers.

M. FFS Billing for Telehealth by Site and Location

When services are provided via telehealth to a member located at an originating site, the servicing provider should bill for the telemedicine encounter as if the provider saw the member in-person using the appropriate billing rules for services rendered. The CPT or rate code for the encounter must be appended with the applicable modifier (see "VII. Billing Rules for Telehealth Services", "B. Modifiers to be Used When Billing for Telehealth, Store-and-Forward, and RPM" of this issue). This section describes billing rules when telehealth services are permissible. Refer to agency-specific guidance to determine permissibility of services.

Facility/Clinic Type On-Site Presence During COVID-19 PHE Post COVID-19 PHE
Article 16 OPWDD Clinic Only the provider is on-site. Provider submits APG claim for services provided (when telehealth is permissible). APGs (+Capital Component), if and as appropriate.
Only the NYS Medicaid member is on-site. Provider submits APG claim for services provided (when telehealth is permissible). APGs (+Capital Component), if and as appropriate.
Only the NYS Medicaid member is on-site. Provider submits APG claim for services provided (when telehealth is permissible). Not billable [with exception for dual enrollees when Medicare Part B covers the service when delivered via telehealth].
Article 28 Hospital OPDs and EDs Only the provider is on-site. Provider submits APG claim for services provided.

Professional Component can be billed by physician.
Provider submits APG claim for services provided.

Professional Component can be billed by physician.
Only the NYS Medicaid member is on-site. Provider submits APG claim for services provided (when telehealth is permissible). Provider submits APG claim for services provided. If the off-site provider delivering service is not employed or contracted by the facility, submit APGs for CPT code "Q3014" as originating site fee.

Professional Component can be billed by physician.
Neither the provider nor the NYS Medicaid member is on-site.* Provider submits APG claim for services provided. Professional Component can be billed by physician. Physician can bill for Professional Component only.
Article 28 D&TCs and FQHCs opting into APGs Only the provider is on-site. Provider submits APG claim for services provided. Provider submits APG claim for services provided.
Only the NYS Medicaid member is on-site. Provider submits APG claim for services provided. Provider submits APG claim for services provided. If the off-site provider delivering service is not employed or contracted by the facility, submit APGs for CPT code "Q3014" as originating site fee.
Neither the provider nor the NYS Medicaid member is on-site. Provider submits APG claim for services provided. Physician can bill for Professional Component only.**
Article 31 OMH Part 599 Only the provider is on-site. Provider submits APG claim for services provided. No facility fee - no professional component. Provider submits APG claim for services provided. No facility fee - no professional component.
Only the NYS Medicaid member is on-site. Provider submits APG claim for services provided. No facility fee - no professional component. Provider submits APG claim for services provided. If the off-site provider delivering service is not employed or contracted by the facility, submit APGs for CPT code "Q3014" as originating site/ facility fee.
Neither the provider nor the NYS Medicaid member is on-site. Provider submits APG claim for services provided. No facility fee - no professional component. Provider submits APG Claim for services provided. No bill for facility fee - no professional component.
Article 32 OASAS Clinic Only the provider is on-site. Provider submits APG claim for services provided. Provider submits APG claim for services provided.
Only the NYS Medicaid member is on-site. Provider submits APG claim for services provided. Provider submits APG claim for services provided.
Neither the provider nor the NYS Medicaid member is on-site. Provider submits APG claim for services provided. Provider submits APG claim for services provided.
FQHC Operated Article 28 that have not opted into APGs Only the provider is on-site. PPS Rate PPS Rate
Only the NYS Medicaid member is on-site. PPS Rate PPS Rate
Neither the provider nor the NYS Medicaid member is on-site. PPS Rate Off-site ("4012") rate
FQHC Operated Article 31 (OMH Part 599) that have not opted into APGs Only the provider is on-site. Provider submits Article 31 rate coded claim for PPS rate (e.g., "4301", "4303") with appropriate telehealth modifier (i.e., 95, GT). Provider submits Article 31 rate coded claim for PPS rate (e.g., "4301", "4303") with appropriate telehealth modifier (i.e., 95, GT, 93).
Only the NYS Medicaid member is on-site. Provider submits Article 31 rate coded claim for PPS rate (e.g., "4301", "4303") with appropriate telehealth modifier (i.e., 95, GT). Provider submits Article 31 rate coded claim for PPS rate (e.g., "4301", "4303") with appropriate telehealth modifier (i.e., 95, GT, 93).
Neither the provider nor the NYS Medicaid member is on-site. Provider submits Article 31 rate coded claim for PPS rate (e.g., "4301", "4303") with appropriate telehealth modifier (i.e., 95, GT). Provider submits Article 31 rate coded claim for PPS rate (e.g., "4301", "4303") with appropriate telehealth modifier (i.e., 95, GT, 93).
FQHC Operated Article 32 (OASAS Clinic) that have not opted into APGs Only the provider is on-site. Provider submits Article 32 rate coded claim for PPS rate (e.g., "4273" through "4275", "4214" through "4216") with appropriate telehealth modifier (i.e., 95, GT). Provider submits Article 32 rate coded claim for PPS rate (e.g., "4273" through "4275", "4214" through "4216") with appropriate telehealth modifier (i.e., 95, GT, 93).
Only the NYS Medicaid member is on-site. Provider submits Article 32 rate coded claim for PPS rate (e.g., "4275", "4214" through "4216") with appropriate telehealth modifier (i.e., 95, GT). Provider submits Article 32 rate coded claim for PPS rate (e.g., "4275", "4214" through "4216") with appropriate telehealth modifier (i.e., 95, GT, 93).
Neither the provider nor the NYS Medicaid member is on-site. Provider submits Article 32 rate coded claim for PPS rate (e.g., "4275", "4214" through "4216") with appropriate telehealth modifier (i.e., 95, GT). Provider submits Article 32 rate coded claim for PPS rate (e.g., "4275", "4214" through "4216") with appropriate telehealth modifier (i.e., 95, GT, 93).

* Article 31 and 32 facilities operated by FQHCs should follow guidance from OMH and OASAS and should bill according to the guidance outlined under the Article 31/32 sections of the above grid.

* * 42 CFR §440.90 defines clinic services as those occurring within the clinic's four walls. NYS Medicaid does not currently have a mechanism to allow freestanding clinics / diagnostic and treatment centers to bill when there is no on-site presence at the clinic.

N. Hospital Inpatient Billing for Audio-Visual Telehealth

When a telehealth consult is being provided by a distant-site physician to a NYS Medicaid member who is an inpatient in the hospital, payment for the telehealth encounter may be billed by the distant-site physician. Other than physician services, all other practitioner services are included in the All Patient Revised - Diagnosis Related Group (APR-DRG) payment to the facility.

O. Skilled Nursing Facility Billing for Audio-Visual Telehealth

When the services of the telehealth practitioner are included in the nursing home rate, the telehealth practitioner must bill the nursing home. If the services of the telehealth practitioner are not included in the nursing home rate, the telehealth practitioner should bill NYS Medicaid as if practitioner saw the NYS Medicaid member in-person. The CPT code billed should be appended with the applicable telehealth modifier. Practitioners providing services via telehealth should confirm with the nursing facility whether their services are in the nursing home rate.

P. MMC Considerations

  1. MMC Plans are required to cover, at a minimum, services that are covered by NYS Medicaid FFS and included in the MMC benefit package, when determined medically necessary and must provide telehealth coverage as described in this guidance. MMC Plans may establish claiming requirements (e.g., specialized coding) that vary from FFS billing instructions in this guidance. To allow DOH to adequately track telehealth use, MMC Plans must ensure claims allow the use of the telehealth modifiers established in this guidance, and may establish additional claiming requirements beyond those set out in the FFS billing instructions in this guidance.
  2. MMC Plans must adhere to the payment parity requirements outlined in "VII. Billing Rules for Telehealth Services", "A. Payment Parity with In-Person Services" on page 8 of this issue.
  3. MMC Plans may not limit enrollee access to telehealth/telephonic services to solely the MMC Plan telehealth vendors and must cover appropriate telehealth/telephonic services provided by other network providers.
  4. Questions regarding MMC reimbursement or documentation requirements should be directed to the MMC Plan of the enrollee.

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VIII. Options to Support NYS Medicaid Members with Limited or Lack of Access to Devices and Services

The following is a list of helpful resources compiled for emergency assistance:

  • Affordable Connectivity Program
    The Affordable Connectivity Program (ACP) is a U.S. government program run by the Federal Communications Commission (FCC) to help low-income households pay for internet service and connected devices like a laptop or tablet. For more information on ACP and to apply online for ACP-related services, providers can refer to the FCC "Affordable Connectivity Program" web page.

    A household is eligible for ACP if the household income is at or below 200 percent of the federal Poverty Guidelines or if a NYS Medicaid member of the household participates in or is eligible for a variety of assistance programs, including:
    • Supplemental Nutrition Assistance Program (SNAP), NYS Medicaid, Federal Public Housing Assistance (Section 8), Supplemental Security Income (SSI), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or Lifeline; and
    • tribal specific programs, such as the Bureau of Indian Affairs (BIA) General Assistance, Tribal Temporary Assistance for Needy Families (TANF) or Food Distribution Program on Indian Reservations (FDPIR); and
    • the National School Lunch Program (NSLP) or the School Breakfast Program (SBP), including through the United States Department of Agriculture (USDA) Community Eligibility Provision (CEP); and
    • recipients of a Federal Pell Grant during the current award year.
    If your household is eligible, you could receive:
    • up to a $30.00/month discount on your internet service;
    • up to a $75.00/month discount if your household is on qualifying Tribal lands;
    • a one-time discount of up to $100.00 for a laptop, tablet, or desktop computer (with a co-payment of more than $10.00 but less than $50.00); and/or
    • a low-cost service plan that may be fully covered through ACP*.
    *Only one monthly service discount and one device discount is allowed per household. To receive the connected device discount, consumers need to enroll in ACP with a participating provider that offers connected devices.
  • ConnectALL
    Governor Hochul announced the $1+ billion ConnectALL initiative - the largest ever investment in New York's 21st century infrastructure - as part of her 2022 State of the State. This initiative will deliver affordable internet access to millions of New Yorkers, bolster digital equity, and transform the state's digital infrastructure through new investments.

    Under the new ConnectALL initiative, New York State will use over $1 billion in public and private investments to connect New Yorkers in rural and urban areas statewide to broadband. For more information about ConnectALL, refer to the NYS "ConnectALL" web page.
  • Lifeline
    Lifeline is a federal program dedicated to making phone and internet service more affordable for low-income households. This benefit provides eligible consumers with a monthly discount of up to $9.25. Consumers living on Tribal lands are eligible for an enhanced discount of up to $34.25 per month. For more information, refer to the Universal Service Administrative Co. Lifelife Support website.

    To quality for Lifeline services, the income of the consumer must be 135 percent or less than the federal Poverty Guidelines, or the subscriber (or someone in their household) participates in one of the following programs:
    • SNAP;
    • NYS Medicaid;
    • Supplemental Security Income (SSI);
    • Federal Public Housing Assistance (FPHA); and
    • Veterans Pension and Survivors Benefit.
    Tribal Assistance Programs include the following:
    • BIA General Assistance
    • Tribal Head Start (only households meeting the income qualifying standard);
    • Tribal TANF; and
    • Food Distribution Program on Indian Reservations (FDPIR).
  • SafeLink Wireless
    SafeLink Wireless is a program provided by TracFone Wireless, Inc. serving eligible households. To participate in the SafeLink Wireless service, certain eligibility requirements must be met, which are set by each State where the service is provided. Service is limited to one person per household. To quality for SafeLink Wireless services, the consumer must have either an income that is at or below 135 percent of the federal Poverty Guidelines, or participate in one of the following assistance programs:
    • NYS Medicaid;
    • SNAP;
    • SSI;
    • Federal Public Housing Assistance (Section 8); and
    • Veterans and Survivors Pension Benefit.
    Some states have additional eligibility under the following Tribal programs:
    • BIA General Assistance;
    • Tribally administered TANF;
    • Tribal Head Start (only those households meeting its income qualifying standard); and
    • FDPIR.
  • Spectrum Internet 100
    Charter recently launched Spectrum Internet 100, a high-speed, low-cost broadband service with 100 megabits per second (Mbps) download and 10 Mbps upload speeds available to households qualifying for the ACP. Eligible new households can receive Spectrum Internet 100, including free self-installation, at no-monthly cost. For more information, providers can refer to the Spectrum Internet® "Affordable Connectivity Program" web page, or call (877) 959-1748.

  • Spectrum Internet Assist Program
    Originally launched in 2016, the Charter Spectrum Internet Assist (SIA) program provides eligible low-income households with discounted 30/4 Mbps high-speed internet, along with Security Suite and an internet modem at no additional charge. The SIA program is available to eligible families for less than $20.00 per month, allowing new eligible households who qualify for ACP to receive internet access at no monthly cost. For more information, providers can refer to the Spectrum Internet® Assist web page.

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X. Questions:

  • Medicaid FFS telehealth/telephonic/teledental coverage and policy questions may be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) at (518) 473-2160 or via email at Telehealth.Policy@health.ny.gov.
  • Questions regarding MMC reimbursement and/or documentation requirements should be directed to the MMC Plan of the enrollee.
  • Questions regarding FFS claiming should be directed to the eMedNY Call Center at (800) 343-9000.

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
Governor
State of New York

James McDonald, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs