New York Medicaid Fee Schedule 2026

Last Updated: January 30, 2026

New York’s Medicaid fee schedule for 2026 determines payment rates for healthcare providers.

The state allocated $1.4 billion for provider rate increases effective January 2026.

These updates affect physicians, hospitals, dentists, and other healthcare professionals serving Medicaid patients.

Quick Summary:

• Physician fee schedule increased by $50 million
• Hospital outpatient rates enhanced by $305 million
• Most fee schedules updated January 1, 2026
• ABA therapy rates reduced for unlicensed providers
• Telehealth payment parity extended through April 2026
• All schedules are available on eMedNY.org

Key 2026 Updates & Effective Dates

Jan 1, 2026

Dental Policy Update: New 2026 Dental Policy and Procedure Code Manual takes effect. Specific reimbursement adjustments for preventive and restorative services are detailed in the eMedNY Dental Manual.

Jan 9, 2026

Pharmacy Prescriber Update: Unlicensed interns, residents, and foreign physicians in training programs are now officially authorized prescribers for Medicaid members, resolving previous claim rejection issues.

Apr 1, 2026

Behavioral Health Proposal (Pending): Proposed legislation (Bill S08427/A08600) seeks a 35% rate increase for outpatient behavioral health services for youth (under 21). This is tied to the State Fiscal Year budget and is currently under legislative review.

What Is the New York Medicaid Fee Schedule?

The New York Medicaid fee schedule sets payment amounts for medical services.

It tells healthcare providers how much they’ll receive for treating Medicaid patients.

New York maintains separate schedules for different provider types. Each schedule lists specific procedure codes and payment rates.

The state updates these schedules throughout the year.

The Department of Health manages all fee schedules. They publish updates on the eMedNY website. Providers must check regularly for rate changes.

2026 Fee Schedule Updates by Provider Type

The state updated most fee schedules on January 1, 2026. Some received additional updates in mid-January.

Here’s what changed for each provider category.

Physician Services

Medicine, Surgery, and Radiology Physician fee schedules received a $50 million boost. This brings Medicaid rates closer to Medicare levels. The state historically paid 30-40% less than Medicare.

Updates went live on January 2, 2026 for most specialties. Surgical procedures got an additional update on January 26, 2026. Radiology and imaging codes also increased.

Understanding New York Medicaid eligibility 2026 helps providers know which patients qualify for these updated rates.

Anesthesia and Drug Administration Anesthesia service rates updated January 2, 2026. Provider-administered drug reimbursement also changed. These updates affect hospital-based and office-based providers.

Dental Services

The dental schedule received major updates on January 6, 2026. The state deleted code D9248 and added replacement codes. New prior authorization requirements apply to dental implants.

Dentists must now use the Evaluation of Dental Implant Patient Form. This form determines medical necessity before implant procedures. The prior authorization checklist also changed.

Hospital and Clinic Services

Outpatient Services Hospital outpatient departments received $305 million in rate increases. The state updated Ambulatory Patient Group (APG) rates. Ordered ambulatory services changed on January 2, 2026.

Critical Access Hospitals get additional payments:

• $118-$354 per clinic visit
• $886-$2,658 per emergency department visit

Safety net hospitals receive add-ons through March 31, 2026. Financially distressed hospitals also qualify for supplemental payments.

FQHCs and Community Health Centers Federally Qualified Health Centers updated rates on January 5, 2026. The state increased funding from $20 million to $40 million. Diagnostic and Treatment Centers also received rate boosts.

These centers serve low-income communities. They must pass network adequacy standards. Many patients check New York Medicaid income limits 2026 before visiting.

Mental Health and Therapy Services

Clinical psychology rates updated January 13, 2026. This affects mental health counseling and therapy services. Providers should review the updated procedure codes.

Rehabilitation services changed on January 2, 2026. This includes physical therapy and occupational therapy. Speech therapy rates also adjusted.

Other Provider Categories

Nursing and Home Health: Private duty nursing has new claim submission requirements. Edit 02304 now applies to all claims. This affects billing procedures and documentation.

Rural home health providers may see increases. Assembly Bill A9679 proposes rate hikes. The bill aims to cover actual delivery costs.

Vision and Laboratory Vision care rates updated January 2, 2026. This includes eye exams and optical services. Laboratory fee schedules changed January 6, 2026.

Podiatry services also received updates. Foot care procedures now pay different rates. Midwife services adjusted for OB/GYN care.

Major Rate Changes and Funding Sources

New York funded rate increases through a new MCO Provider Tax. Managed Care Organizations now pay taxes that support provider rates. This generates $1.4 billion annually.

Physician Payment Enhancements

The $50 million physician investment addresses a longstanding gap. Medicaid traditionally pays much less than Medicare. This creates access problems for Medicaid patients.

The 2026 Medicare fee schedule increased 3.26-3.77%. New York’s investment helps narrow this difference. Providers may accept more Medicaid patients.

Hospital Payment Improvements

Hospitals received the largest share at $305 million. APG weights changed for many outpatient procedures. Capital rate add-ons decreased slightly.

Safety net hospitals serve vulnerable populations. They treat more uninsured and Medicaid patients. Extra payments help these facilities remain open.

Long-Term Care Funding

Nursing homes received $200 million in rate increases. Assisted living programs also got boosts. Hospice programs saw enhanced payments.

The state discontinued Managed Long-Term Care Quality Pool funding. Regular rates now include these amounts. This simplifies billing for providers.

Important Rate Reductions and Exceptions

Not all rates increased in 2026. Some services face significant cuts. Providers must prepare for revenue impacts.

Applied Behavior Analysis (ABA) Rate Cuts

ABA services for autism treatment saw major changes. Code 97153 applies to unlicensed technicians. This code faces two rate reductions:

• October 1, 2025: Reduced to $16.85 per unit
• April 1, 2026: Further reduced to $14.45 per unit

The state wants equitable pay based on training. Licensed providers keep higher rates. Unlicensed individuals earn less per unit.

Revenue impact: 14-20% reduction for ABA providers. Many agencies employ both licensed and unlicensed staff. Budget planning is essential.

Telehealth Payment Changes

Telehealth currently pays the same as in-person visits. This parity extends through April 1, 2026. After that date, rates may change.

The legislature may extend payment parity. No decision has been made yet. Providers should monitor for updates.

Documentation requirements remain strict. Providers must record:

• Medical necessity
• Visit type (phone or video)
• Patient location
• Patient consent

Dialysis Payment Adjustments

Dialysis rates changed October 1, 2025. The APG weight increased from 1.3651 to 1.5302. This covers oral phosphate binders.

These medications are now bundled into dialysis payments. Pharmacies no longer dispense them separately. Acute kidney injury patients have different rules.

How to Access Current Fee Schedules

All fee schedules are available online. The state posts updates promptly. Providers should bookmark key resources.

Primary Resources

eMedNY Provider Portal Visit eMedNY.org for all provider manuals. Each manual contains the relevant fee schedule. Downloads are available in Excel and PDF formats.

The “What’s New” page lists recent updates. Check this page weekly. It shows exact effective dates for changes.

NYS Department of Health The DOH maintains hospital and nursing home rates. Visit health.ny.gov/health_care/medicaid/rates/ for:

• Hospital APG rates
• Nursing facility rates
• Long-term care payments
• FQHC prospective payment rates

Specialty Fee Schedules

Different providers need different schedules. Find your specialty area first. Then download the current rate file.

Common schedule locations:

• Physician services: eMedNY provider manuals
• Dental services: Updated January 6, 2026
• Hospital rates: DOH APG rate page
• FQHC rates: Updated January 5, 2026

Providers serving multiple specialties need multiple schedules. Keep all relevant files updated. Quarterly drug rate updates also occur.

Billing and Compliance Requirements

Rate changes come with new billing rules. Providers must follow updated requirements. Non-compliance may result in claim denials.

Documentation Standards

Dental Prior Authorization Implant services now require prior approval. Submit the Evaluation of Dental Implant Patient Form. Include clinical justification for medical necessity.

The prior authorization checklist changed. Review all requirements before submitting. Incomplete forms cause delays.

Private Duty Nursing Edit 02304 applies to all claims. This “Zero-Fill” edit checks specific fields. Ensure claim forms are complete.

Record retention rules remain strict:

• Fee-for-service: 6 years minimum
• Managed care: 10 years minimum

ABA Services Document supervision of unlicensed technicians. Show training and credential verification. Maintain service logs with provider signatures.

Managed Care vs Fee-for-Service

All rate increases apply to fee-for-service Medicaid. Managed Care Organizations may negotiate different rates. However, certain add-ons are mandatory.

Safety net hospital add-ons must pass through MCOs. This requirement appears in the Managed Care Model Contract. MCOs cannot reduce these payments.

Network adequacy standards apply to all MCOs. They must maintain sufficient provider networks. Patients need access to covered services.

Many beneficiaries qualify through Medicaid income limits by state 2026. Providers should understand both FFS and managed care rules.

Federal Policy Context

New York’s rates relate to federal Medicare rates. Understanding this relationship helps providers. It also explains why gaps exist.

Medicare Comparison

Medicare’s 2026 Physician Fee Schedule increased 3.26-3.77%. Non-participating providers get 3.26%. Advanced Alternative Payment Model participants get 3.77%.

New York Medicaid historically pays 30-40% below Medicare. The $50 million investment narrows this gap. However, significant differences remain.

Why rates differ:

• Federal vs. state funding
• Different patient populations
• Budget constraints
• Political priorities

Federal Transparency Requirements

Federal law requires online fee schedule posting. All states must publish current rates. Updates must appear promptly.

New York complies through eMedNY. The system automatically posts updates. Providers access schedules 24/7.

The national Medicaid fee schedule 2026 varies significantly by state. Each state sets its own rates within federal guidelines.

Revenue Impact for Providers

Rate changes affect provider finances. Understanding the impact helps with planning. Different specialties see different effects.

Winners and Losers

Significant Increases:

• Physicians (all specialties): Moderate revenue boost
• Hospital outpatient departments: Large increase
• Critical Access Hospitals: Substantial add-ons
• FQHCs and community health centers: Enhanced rates
• Long-term care facilities: $200 million boost

Rate Reductions:

• ABA providers (unlicensed staff): 14-20% decrease
• Hospital capital add-ons: Slight reduction

Uncertain:

• Telehealth providers: Depends on post-April policy
• Rural home health: Pending legislative action

Planning Considerations

Providers should review their payer mix. Calculate Medicaid revenue percentage. Apply rate changes to estimate impact.

Consider these factors:

• Percentage of Medicaid patients
• Services most commonly billed
• Licensed vs. unlicensed staff ratios
• Geographic location (urban vs. rural)

Budget planning requires current data. Download your specialty’s fee schedule. Compare the 2026 rates to the 2025 rates.

Frequently Asked Questions

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Need help with New York Medicaid? Visit your local Department of Social Services office or apply online through NY State of Health. Check your eligibility using the current income guidelines and start receiving benefits today.