ICYMI: NYS Medicaid Updates Telehealth Policy; Stops Short of Payment Parity for Article 28 Clinics

Summary Points

• The New York State (NYS) Medicaid program updated its to clarify and add new guidance related to billing and delivery of health care services via telehealth.
• Notable updates include new language aimed at limiting providers’ use of audio-only/telephone (particularly for medical visits) and expanding providers eligible to conduct remote patient monitoring (RPM) and e-consults.
• NYS may make broader telehealth policy changes for both Medicaid and commercial payers during the 2025–2026 legislative session, including extending payment parity beyond its current sunset date of April 1, 2026.

NYS has been a national leader in expanding access to telehealth. The COVID-19 pandemic to enable access to care via telehealth, and NYS was an of COVID-era temporary flexibilities for commercial and Medicaid coverage. NYS Medicaid went on to memorialize telehealth policy expansions to allow broad coverage of a wide range of telehealth modalities, services, and provider types without geographic limitations. Following passage of the , telehealth services across all payors, including Medicaid, are reimbursed at the as in-person services through April 1, 2026.

In late December 2024, the NYS Medicaid program published an updated version of its with some notable changes, outlined below.

What Notable Policy Changes Should You Be Aware Of?

No Payment Parity for Article 28-Licensed Federally Qualified Health Centers (FQHCs)

• Context: NYS Medicaid currently requires all Article 28-licensed facilities, many of which are FQHCs, to have either the provider or patient physically on-site at the clinic in order to bill the full prospective payment system (PPS) rate for services delivered via telehealth. Article 28-licensed FQHCs that have not opted into Ambulatory Patient Groups (APGs) are instructed to bill their “off-site” rate for a telehealth visit when both the provider and patient are off-site, which effectively reduces payment in these circumstances by an of the full PPS payment rate. Lack of payment parity for Article 28-licensed FQHCs has been debated within the state legislature for , and research that this inequitable payment structure has forced providers back into the office, even when their patients aren’t there. The situation has exacerbated existing FQHC workforce shortages as staff, particularly mental health providers, leave clinics in search of more flexible jobs.
• Policy Change: The updated Manual instructs Article 28 facilities to bill a different off-site code (4012 instead of 4013) but makes no other changes to ensure equitable payment for those providers when both the patient and provider are outside of the clinic during a telehealth visit.  

Reining in Audio-Only (Telephonic) Coverage

• Context: NYS Medicaid added permanent coverage for audio-only, (i.e., telephonic) services in response to the COVID-19 pandemic and to ensure access to care for geographic areas and populations that face barriers to participating in a video visit (e.g., access to broadband internet).
• Policy Change: NYS Medicaid made some important changes to audio-only policy language that will effectively rein in use among providers, specifically, the updated Manual:
  • Expressly states that provider preference or convenience are not relevant when selecting a telehealth modality.
  • Emphasizes that providers must use professional judgment to determine: 1) whether audio-only services meet the patient’s needs; and 2) whether a visit is eligible for audio-only services based on the state’s criteria (e.g., audio-only is the preference of the patient, the service can be delivered without a visual or in-person component, etc.).
  • Signals that there are limited occasions when audio-only visits are appropriate for medical visits (e.g., non-behavioral health or community health worker services), such as when there are weather emergencies that limit access to video or in-person care.
  • Removed two audio-only evaluation and management current procedural terminology (CPT) codes (99441-99443), in accordance with from the American Medical Association CPT Editorial Panel.

Expanding RPM Coverage

• Context: RPM involves use of digital technologies to collect medical data and other personal health information from the member in one location and electronically transmit that information to health care providers in a different location for assessment and recommendations.  
• Policy Change: NYS Medicaid added coverage for a new CPT code (99457) to enable clinical staff to connect with a patient or caregiver via a live, interactive communication to discuss RPM monitoring and treatment services. Clinical staff includes individuals under the direction of a physician or qualified health care professional who do not independently bill professional service (e.g., pharmacists, some registered dieticians). The service must: 1) be ordered by a physician or other qualified health care professional; 2) be at least 20 minutes long; and 3) may not be billed more than once every 30 days.  

Enabling E-Consults for Dentistry

• Context: E-consults are a synchronous or asynchronous virtual consultation between health care providers to discuss clinical questions about a patient's care and are frequently used to streamline access to specialty services. NYS Medicaid first coverage for e-consults in April 2024.
• Policy Change: NYS Medicaid added coverage for e-consults in dental settings through code D9311, which allows a treating dentist to consult with a health care provider regarding medical issues that may impact a patient’s planned dental treatment. The updated Manual also clarifies that providers (e.g., FQHCs, hospital outpatient departments) that have opted into the APG reimbursement methodology are eligible to bill for e-consults (codes 99451 and 99452) through the APG fee schedule in an outpatient clinic setting.

Our Take

These policy changes are likely unremarkable for larger health systems and telehealth providers, but impactful for smaller provider groups, such as Article 28-licensed FQHCs who continue to advocate for payment parity, dentists who can now enhance their care via e-consults with other medical professionals who care for their patients, and medical providers who have become accustomed to use of audio-only over the past few years.

During the 2025–2026 legislative process, NYS may implement further telehealth policy changes for Medicaid and commercial payers, for example, by determining whether to extend payment parity beyond April 1, 2026 and/or enabling Article 28 facilities to bill the full PPS rate for telehealth services when the provider and patient are off-site.

We’ll be keeping an eye out for further developments—stay tuned for updates.

For more information on NYS telehealth policy and trends, see this published by the New York Health Foundation in July 2024.