New York Medicaid Fee Schedule
Current physician rates from the NY Medicaid fee-for-service schedule, compared with other state programs, with the official source.
- Schedule as of
- October 2026
- Codes priced
- 638
Current NY Medicaid rates for common codes
Each amount is the unmodified non-facility rate in the October 2026 schedule. Where a code appears under more than one rate type, it is the state's ordinary statewide rate when its rules name one, and otherwise the median across rate types. Modifier-specific and facility-only rows are listed separately under the service.
| Code | Service | Non-facility rate | Prior auth |
|---|---|---|---|
| 99213 | Office visit, established patient (low complexity) | Not separately priced | |
| 99214 | Office visit, established patient (moderate complexity) | Not separately priced | |
| 99203 | Office visit, new patient (low complexity) | Not separately priced | |
| 99204 | Office visit, new patient (moderate complexity) | Not separately priced | |
| 99285 | Emergency department visit, high severity with threat to function | Not separately priced |
See all 638 NY Medicaid codes, every schedule period, in the platform.
Book a 15-min Medicaid walkthroughSearch a CPT or HCPCS code
Compare any other code across state programs. The free view shows a few states per code; New York's full schedule is in the complete dataset.
What to know about the NY Medicaid fee schedule
- Physician fees are benchmarked to 80% of Medicare, with select office and emergency visits raised to 90% in 2025-26. Medicaid Update, August 2023 Medicaid Update, April 2026
- Nurse practitioners are paid 95% of the physician fee for the same service. Medicaid Update, August 2023
- Enrolled physicians in the MOMS, Preferred Physicians and Children, and HIV programs are paid enhanced fees. Physician Manual Policy Guidelines
- The professional component (modifier 26) pays up to 40% of the maximum fee, and assistant surgeon modifiers 80 and 82 up to 20%. Physician Procedure Codes, Section 1: General Information
NY Medicaid fee schedule FAQ
Does a listed code mean the service is covered by NY Medicaid?
No. A listed NY Medicaid fee is not a coverage, authorization, or payment guarantee. Coverage, prior approval and billing rules are set out in the eMedNY Physician Manual, in its Policy, Billing and Prior Approval Guidelines.
Does this New York rate apply to Medicaid managed-care plans?
Most New York Medicaid enrollees get their care through Medicaid Managed Care plans: CMS reports 72.6% of New York Medicaid enrollees were in some form of managed care in 2024. Plan rates are negotiated with providers and are not published on this fee-for-service schedule. The fee-for-service rates apply when NY Medicaid pays a claim directly.
Why might my actual payment differ from the displayed rate?
These are the October 2026 NY Medicaid rates. A claim can pay a different amount because of the date of service, modifier, place of service, units billed, provider enrollment or taxonomy, bundling with another service, coverage policy, prior authorization, and claim edits.
Why is there no published rate for this code?
New York marks some codes "By Report" (BR): the claim is priced on review, from documentation of what was done and why. When prior approval applies and no fee is listed, the price is set during the prior approval process. A code may also be bundled into another service or priced on a different NY Medicaid schedule. A missing rate does not mean the service is noncovered or pays $0.
Where can I find other NY Medicaid fee schedules?
NY Medicaid publishes separate fee schedules by provider type alongside the NYS Medicaid Physician Manual Fee Schedule, and its provider manual sets the coverage and billing rules.
How does New York set Medicaid physician fees?
Fees are maximums set by the Department of Health and approved by the Director of the Budget. Since October 1, 2023, non-facility fees have been benchmarked to 80% of Medicare, and the FY 2026 budget raised select practitioner and emergency visit codes to 90%: preventive visits (99381-99387, 99391-99397) on October 1, 2025, and office and emergency visits on April 1, 2026.
How do New York Medicaid fees compare to Medicare?
KFF's 2024 Medicaid-to-Medicare fee index put New York at 0.76 of Medicare for all services, 0.68 for primary care and 0.83 for obstetric care, close to the national average of 0.75. That survey predates the 90% benchmark for office, preventive and emergency visits, so New York's primary care ratio should now be higher.
How are nurse practitioners paid relative to physicians in New York Medicaid?
When the Department of Health benchmarked physician fees to 80% of Medicare in October 2023, it also benchmarked nurse practitioners to 95% of the new physician fees. The April 2026 increase to 90% of Medicare updated the physician, nurse practitioner and midwife fee schedules together.
Can physicians bill fee-for-service when working in a hospital or clinic setting in New York?
Yes, in most settings. The Physician Manual carves physician services out of APG and APR-DRG facility payments in hospital outpatient clinics, emergency departments, ambulatory surgery and inpatient settings, so the physician bills separately at the physician fee. The exception is diagnostic and treatment centers (D&TCs), where the professional component is inside the clinic's APG payment.
Do some New York physicians get paid more than the standard fee?
Yes. The Physician Manual says physicians enrolled in the Preferred Physicians and Children Program, the Medicaid Obstetrical and Maternal Services Program or the HIV Enhanced Fees for Physicians Program 'will be paid in accordance with the enhanced fees for those programs.' The fee schedules include a separate MOMS fee column for obstetrical and maternal services.
How are modifiers priced against the New York physician fee?
New York pays modified lines as a share of the maximum fee: the professional component (-26) will not exceed 40% of the maximum fee, and assistant surgeon modifiers (-80, -82) will not exceed 20%. A modified line therefore pays only part of the listed fee. New York announces fee changes like these benchmarking increases in its monthly Medicaid Update.
Neighboring and high-enrollment Medicaid fee schedules
States bordering New York first, then the largest programs.