Last Updated: January, 2026
Page Contents
- 1 New York Medicaid Fee Schedule 2026
- 2 What Is the Medicaid Fee Schedule?
- 3 2026 Rate Updates & Important Changes
- 4 Sample 2026 Reimbursement Rates
- 5 How to Access Official Fee Schedules
- 6 Fee-for-Service vs. Managed Care Plans
- 7 2026 Medicaid Eligibility & Income Limits
- 8 Important Provider Notes & Reminders
- 9 Frequently Asked Questions
- 9.1 Where can I download the 2026 New York Medicaid fee schedule?
- 9.2 Did New York Medicaid rates increase in 2026?
- 9.3 What is the difference between facility and non-facility rates?
- 9.4 Do managed care plans use the same rates as the fee schedule?
- 9.5 How do I bill New York Medicaid for services?
- 9.6 When do 2026 behavioral health rate increases take effect?
New York Medicaid Fee Schedule 2026
The New York Medicaid Fee Schedule 2026 lists maximum reimbursement rates that providers receive for healthcare services.
It covers physician visits, dental care, lab tests, radiology, and medical equipment.
The New York State Department of Health manages these rates through eMedNY. Most 2026 rates took effect on January 1, 2026.
Quick Summary:
- Physician rates increased 2.5% in January 2026
- Youth behavioral health rates rise 35% on April 1, 2026
- Dental safe-harbor rates decrease on October 1, 2026
- All schedules available free at eMedNY.org
- Rates apply to Fee-for-Service Medicaid only
- Managed care plans may pay different rates
What Is the Medicaid Fee Schedule?
The fee schedule is an official price list for healthcare providers. It shows exactly how much New York Medicaid pays for each medical service, procedure, and supply covered under the program.
Providers use CPT codes or HCPCS codes to bill services. Each code has a set payment amount.
The Medicaid fee schedule in 2026 varies by state, and New York maintains one of the most detailed systems in the country.
Key Terms You Should Know
Understanding the fee schedule requires knowing a few basic terms.
These definitions help providers bill correctly and get paid on time.
Non-Facility Rate: Payment when service happens in a doctor’s office. Covers doctor’s work and office costs.
Facility Rate: Payment when service happens in a hospital. The hospital bills separately for facility costs.
Professional Component: Payment only for the doctor’s work, like reading an X-ray.
BR (By Report): No set fee. Payment decided case-by-case based on medical records.
2026 Rate Updates & Important Changes
New York made several significant changes to Medicaid reimbursement rates in 2026.
These updates reflect budget priorities and workforce investment goals set by the state legislature.
January 1, 2026 Changes
The start of 2026 brought multiple updates across different healthcare sectors.
Most provider types saw some level of rate adjustment or policy change.
Physician Services
- Rates increased 2.5% to match Medicare
- Virtual supervision now allowed for “direct supervision” requirements
- Stricter drug pricing documentation required
Laboratory Services
- New fee schedule effective January 1, 2026
- Downloadable from eMedNY provider manuals
- Updated codes reflect current testing methods
Radiology Services
- Code additions: 78830-78832 added
- Code deletions: 74241 removed
- Updated technical and professional component rates
April 1, 2026 Changes
Mid-year rate increases target specific underserved populations.
The youth behavioral health increase addresses critical access gaps in mental health services.
Youth Behavioral Health
- 35% rate increase for providers serving patients under 21
- Applies to outpatient behavioral health clinic services
- Funded by healthcare stability fund
- Designed to improve access to mental health care
October 1, 2026 Changes
Later in 2026, dental providers will see reimbursement adjustments. These changes reflect ongoing budget balancing efforts.
Dental Services
- Safe-harbor reimbursement floor drops to 5.5%
- May reduce minimum payment rates for some procedures
- Providers should review contracts before October
Sample 2026 Reimbursement Rates
The following tables show actual reimbursement amounts for common procedures.
All rates are effective as of January 1, 2026, unless otherwise noted.
Physician & Surgery Services
| Service | Non-Facility Rate | Facility Rate |
|---|---|---|
| Fine Needle Biopsy (no imaging) | $46.11 | $24.05 |
| Gastrostomy Tube Insertion | $785.10 | Varies |
Radiology Services
| Service | Rate |
|---|---|
| Eye X-Ray (foreign body) | $29.58 |
| MRI (internal auditory canal) | $55.86 |
| Dental X-Ray (single view) | $11.87 |
Vision Care Services
| Service | Rate |
|---|---|
| Eye Exam (new patient) | $76.10 |
| Visual Field Exam | $39.45 |
| Contact Lens Replacement | $65.65 |
Behavioral Health Services
| Service | Enhanced Rate |
|---|---|
| eConsult (Consultative Provider – 99451) | $56.92 |
| eConsult (Treating Provider – 99452) | $53.12 |
All rates effective January 1, 2026. Rates may vary by location and provider type.
How to Access Official Fee Schedules
Finding the right fee schedule is straightforward once you know where to look. The eMedNY website hosts all official provider manuals and rate sheets.
Step-by-Step Guide
Step 1: Visit eMedNY Go to www.emedny.org
Step 2: Choose Your Provider Type Click “Provider Manuals” and select:
- Physician
- Dental
- Laboratory
- Radiology
- DME (Durable Medical Equipment)
- Pharmacy
Step 3: Download Fee Schedule Look for “Fee Schedule” or “Procedure Codes & Fee Schedule” section. Files are Excel or PDF format.
Step 4: Check for Updates Visit the monthly Medicaid Update newsletter on the New York State Department of Health website for latest changes.
Official Download Links
Official Sources:
- Physician/Radiology: eMedNY Physician Fee Schedule
- Laboratory: eMedNY Laboratory Fee Schedule
- DME: eMedNY DME Fee Schedule
Fee-for-Service vs. Managed Care Plans
Understanding the difference between Fee-for-Service and Managed Care is critical for proper billing. These two systems operate completely differently.
Many New York Medicaid patients have Managed Care plans like:
- Fidelis Care
- Healthfirst
- EmblemHealth
- United Healthcare Community Plan
Billing Requirements by Plan Type
If your patient has Fee-for-Service Medicaid:
- Bill eMedNY directly using the fee schedule
- Use rates shown in official eMedNY schedules
- Submit claims electronically through eMedNY portal
If your patient has Managed Care:
- You must bill the managed care plan directly
- Rates may differ from the fee schedule
- Plans often use FFS rates as a starting point
- Some plans negotiate higher rates
- Contract with each plan separately
Always verify patient coverage through ePACES before providing services.
2026 Medicaid Eligibility & Income Limits
Before providers can bill Medicaid, patients must meet eligibility requirements. Income limits determine who qualifies for New York Medicaid coverage in 2026.
Understanding Medicaid eligibility 2026 helps providers verify coverage before rendering services.
New York’s eligibility rules differ from other states, so checking Medicaid income limits by state 2026 can show how New York compares nationally.
Monthly Income Limits (Community Medicaid)
| Household Size | Monthly Income Limit |
|---|---|
| Single person | $1,800 |
| Married couple | $2,433 |
These limits determine eligibility for Aged, Blind, and Disabled Medicaid. Limits stayed the same from 2025 to 2026.
Important Provider Notes & Reminders
Successful Medicaid billing requires attention to detail and staying current with policy changes. Follow these best practices to avoid claim denials.
Always Verify Eligibility
Check patient coverage through ePACES before services. Eligibility can change monthly. A patient covered in January may lose coverage in February.
Know Your Patient’s Plan Type
Fee-for-Service patients: Bill eMedNY directly Managed Care patients: Bill the managed care plan
Mixing up these billing pathways causes immediate claim rejections.
Watch for Policy Updates
Rates and rules change throughout the year. Subscribe to the Medicaid Update newsletter. Check eMedNY quarterly for fee schedule updates.
Submit Proper Documentation
BR (By Report) codes require detailed medical records. Include all necessary documentation with claims. Missing documentation means delayed or denied payment.
Understand Rate Components
Some procedures have separate technical and professional components. Bill both when appropriate. Know which setting (facility vs. non-facility) applies to your service.
Frequently Asked Questions
Where can I download the 2026 New York Medicaid fee schedule?
Visit eMedNY.org and click Provider Manuals. Select your specialty (physician, dental, lab). Download the fee schedule Excel or PDF file. All schedules are free and updated regularly by the Department of Health.
Did New York Medicaid rates increase in 2026?
Yes. Physician rates increased 2.5% on January 1, 2026. Youth behavioral health rates increase 35% on April 1, 2026. Dental safe-harbor rates decrease on October 1, 2026. Not all provider types received increases.
What is the difference between facility and non-facility rates?
Non-facility rates apply when services happen in a doctor’s office. Facility rates apply in hospitals. Non-facility rates are higher because they include office overhead costs like rent, equipment, and staff.
Do managed care plans use the same rates as the fee schedule?
Not always. Managed care plans like Fidelis and Healthfirst negotiate their own rates. They often use fee schedule rates as a baseline but may pay more or less. Check your contract.
How do I bill New York Medicaid for services?
Fee-for-Service patients: Submit claims through eMedNY. Managed Care patients: Bill the patient’s managed care plan directly. Always verify coverage through ePACES first. Use correct CPT or HCPCS codes.
When do 2026 behavioral health rate increases take effect?
Youth behavioral health services get a 35% rate increase on April 1, 2026. This applies to outpatient behavioral health clinic services for patients under age 21. The increase was mandated by Bill S08427.
Official Sources:
- New York State Department of Health eMedNY: www.emedny.org
- NYS Medicaid Update Newsletter: health.ny.gov
This article provides general information only. Always verify current rates and policies through official eMedNY provider manuals and consult with billing specialists for specific questions.
