Medicaid agency: NY DOH
New York Medicaid covered 5,056,572 enrollees per CMS's most recent managed care enrollment data, report year 2024, delivered mostly through managed care across several distinct product types: mainstream Medicaid Managed Care, Health and Recovery Plans (HARP) for members with significant behavioral health needs, Managed Long Term Care (MLTC) for LTSS, Medicaid Advantage Plus and FIDA-IDD for integrated dual-eligible care, and PACE for frail elderly duals.
New York delivers most Medicaid through mainstream Medicaid Managed Care, operated by roughly 15 competing comprehensive MCOs statewide and regionally, the largest being Fidelis Care and Healthfirst. Health and Recovery Plans (HARP) are a specialized line of business operated by the same MCOs for members with significant mental health or substance use needs, integrating physical and behavioral health care under one plan rather than a separate carve-out entity.
Most LTSS is delivered through Managed Long Term Care (MLTC), a set of nearly 20 competing plans covering home care, adult day care, and other community-based services for dual-eligible and other qualifying members; the two largest by enrollment are Anthem Blue Cross and Blue Shield HP and Centers Plan for Healthy Living. Medicaid Advantage Plus and FIDA-IDD combine MLTC-style LTSS with full Medicaid (and, for MAP/FIDA, Medicare) acute care under one plan; PACE is a separate, smaller, fully integrated LTSS model for frail elderly duals.
Partially integrated into managed care
Behavioral health is not carved out to a separate vendor; non-specialty mental health services are a standard Medicaid Managed Care benefit, and members with significant behavioral health needs are served through Health and Recovery Plans (HARP), a specialized line of business operated by the same mainstream MCOs rather than a distinct carve-out entity.
Carved in
Dental benefits are carved into Medicaid Managed Care plans, each of which subcontracts its own dental network rather than the state contracting a single statewide vendor. DentaQuest serves Fidelis Care, Healthfirst, MetroPlus, and MVP members, while Liberty Dental serves Molina Healthcare members, among other plan-specific arrangements.
Pharmacy benefits were carved out of Medicaid Managed Care into NYRx, the Medicaid Pharmacy Program, effective April 1, 2023, for mainstream Medicaid Managed Care, HARP, and HIV Special Needs Plan enrollees (Managed Long Term Care, PACE, and Medicaid Advantage Plus were not included in the transition). NYRx pays pharmacies directly through the state's own eMedNY claims system; clinical services including prior authorization and the Preferred Drug Program are administered under contract by Prime Therapeutics.
Medical Answering Services (MAS), LLC was designated New York's single statewide Medicaid non-emergency medical transportation broker effective August 1, 2023, consolidating a system previously split among several regional managers; all Medicaid members, including Managed Care and MLTC enrollees, were required to arrange trips through MAS by March 1, 2024.
The eMedNY Medicaid Management Information System, which processes Medicaid fee-for-service and NYRx pharmacy claims and payments, is operated by GDIT (General Dynamics Information Technology) as the state's fiscal agent.
44 agency updates tracked for New York. Available with Pro.
See them with ProAn owner of Brooklyn-based Happy Family Social Adult Day Care Center, Family Social Adult Day Care Center, and Responsible Care Staffing, a home health fiscal intermediary operating under New York's Consumer Directed Personal Assistance Program (CDPAP), pleaded guilty earlier this month to defrauding Medicaid of approximately $65 million. The scheme involved billing for social adult day care and home health services that were never actually provided to beneficiaries. The case was reported by Rivkin Radler LLP.
In a client alert, Sheppard Mullin examines New York's recent Medicaid enrollment changes, arguing that attention has focused too narrowly on the state's temporary enrollment moratoriums and their effect on provider transactions. The firm highlights additional enrollment-related changes providers and transaction parties should account for beyond the moratorium itself. The piece is directed at healthcare providers, investors, and counsel navigating New York Medicaid provider enrollment and deal structuring. Specific details of the broader changes are drawn from the firm's analysis of state Medicaid enrollment policy.
In a President's Column commentary, David Sandman of the New York Health Foundation argues that New York must strengthen primary care and community-based approaches to finish eliminating HIV/AIDS. He cites a new NYHealth analysis showing nearly one in four New Yorkers living with HIV in 2024 were not receiving optimal care, new infections rose 23% from 2023 to 2024, and stark racial disparities persist, with Black and Hispanic New Yorkers accounting for 78% of new diagnoses but only 21% of PrEP use. Sandman points to data showing routine checkups correlate with higher HIV testing rates, while testing among 25-to-34-year-olds fell 22% since 2016, and calls for HIV testing, PrEP, and PEP prescribing to become standard parts of primary care delivered by physicians, pharmacists, nurses, and community health workers.
On The Dose podcast, NYC Health Commissioner Dr. Alister Martin discusses what city government can do to protect residents' access to care if federal Medicaid funding or eligibility rules are rolled back. The conversation focuses on local strategies to mitigate the impact of reduced federal support rather than announcing a specific new city policy or program. Martin frames the discussion around the city's role as a backstop when federal safety-net protections weaken. No specific city policy, funding commitment, or regulatory action is detailed in the segment.
New York has notified CMS of plans to exempt Bronx County Medicaid members from new federal work requirements, citing the county's high unemployment rate. Under HR 1, members are exempt if they live in a county with unemployment at or above 8% or 1.5 times the national rate, whichever is lower, and the Bronx is currently the only New York county meeting that threshold. About 200,000 Bronx residents would otherwise have been subject to the rules. The broader work requirements take effect January 1, requiring adults ages 19-64 to show work, schooling, job training, or volunteering to keep coverage, unless another exemption applies.
22 active waivers tracked for New York. Available with Pro.
See them with Pro1 active solicitations tracked for New York. Available with Pro.
See them with Pro11 managed care contracts tracked for New York. Available with Pro.
See them with Pro207 bills tracked for New York. Available with Pro.
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