Reimbursement for Hospital Based & Free-Standing Behavioral Health Clinics Claims for Dually Eligible Members

  • Memo is also available in Portable Document Format (PDF)


To:             New York State Medicaid Managed Care Plans (MMCPs), Health and Recovery Plans (HARPs) and HIV Special Needs Plans (HIV-SNPs)

From:         New York State Department of Health (DOH); Office of Mental Health (OMH), Office of Addiction Services and Supports (OASAS)

Date:         December 1, 2021 (Reissued - Original guidance release date: May 14, 2021)

Subject:     Duals Reimbursement in MMC

Dear Health Plan Administrators,

Enrollees who become eligible for Medicare have remained in their Medicaid Managed Care Plan (MMCP) during the public health emergency, unless opting to change their enrollment. Some of these enrollees have enrolled in their Medicaid Managed Care Plan’s aligned Medicare D-SNP and remained in their Medicaid Managed Care Plan through the Integrated Benefits for Dually Eligible Enrollees program.

This is a reminder that Chapter 57 of 2019 of the Laws of New York and Section 21.19 (f) of the Medicaid Managed Care/HIV Special Needs Plans/Health and Recovery Plan Model Contract requires that MMCPs reimburse hospital-based and free-standing behavioral health clinics at an amount equivalent to the payments established for such services under New York State’s Medicaid ambulatory patient group (APG) rate-setting methodology. Therefore, when processing claims for dual eligibles for services provided by behavioral health clinics:

  1. MMCPs are required to coordinate benefits with Medicare primary coverage when applicable, and
  2. MMCPs are to ensure reimbursement to such behavioral health clinics is configured to pay up to the higher of the Medicaid APG payment amount or the Medicare rate.

This represents total reimbursement to the provider; members in MMCPs should not experience Medicare cost sharing responsibility outside of the pharmacy benefit.

If you have any questions, please contact

Thank you.

44 Holland Avenue, Albany NY 12229 |
1450 Western Avenue, Albany, NY 12203 |
Empire State Plaza, Corning Tower, Albany, NY 12237 |