New York NY

New York carved pharmacy benefits OUT of MCOs back into state-administered FFS ("NY Medicaid Rx"). Distinct from OH+CA carve-outs because NY pulled drug PA into state operation (not delegated to a private PBM). NYS DOH directly administers.

New York Medicaid (DOH) expresses prior approval ("prior authorization") through eMedNY (Gainwell MMIS, the FFS fiscal agent), NOT a single PA index. The canonical structure is ~50 per-PROVIDER-TYPE Provider Manuals at emedny.org/ProviderManuals/<Type>/. Each manual carries a 'Prior Approval Guidelines' PDF (the actual criteria) plus a 'Procedure Codes & Coverage Guidelines' PDF (which codes require PA) and a shared 'PA Business Location Chart' (routing by provider type). Drug PA: pharmacy carved INTO FFS as NYRx (2023); practitioner-administered (clinician-billed) drugs have a separate FFS clinical-criteria table + per-drug fillable PA worksheets on health.ny.gov. Managed populations (Mainstream MMC / HARP / MLTC / MAP) run PA through their plans, but the FFS criteria are state-published and centrally located on eMedNY. A CMS-0057-F (CMS Interoperability) Prior Approval Changes communication (eff. ~2026) is published across all manuals. Authority: DOH sets policy; eMedNY/Gainwell publishes the operational manuals; managed-care plans administer PA for their enrollees. No bot wall on the PDFs (HEAD 404s for bots but in-page credentialed fetch works).

Centene Corporation operates in NY under the Fidelis Care brand at fideliscare.org. NOT the standard Centene-Ambetter pattern — confirms Centene's pattern of per-state, per-brand subdomain ownership rather than centralized centene.com routing.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: None. Next due: None. Contracts extended through: None.

# NY — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 7 docs. See [[state_shape_NY]]. Correction pass: the model FABRICATED a WISeR expansion ("Workforce Innovation in Self-Sufficiency") — WISeR is actually CMS's "Wasteful and Inappropriate Service Reduction" Medicare PA model, limited to AZ/NJ/OH/OK/TX/WA, and is NOT applicable to NY. Corrected below. ## 1. How NY requires PA New York State (NYS) requires prior authorization (PA) through a structured set of guidelines and provider manuals tailored to different types of providers. The primary mechanism for disseminating these requirements is the eMedNY portal, which hosts approximately 50 per-provider-type Provider Manuals. These manuals detail specific criteria for obtaining PA, such as step-therapy protocols and medical necessity documentation. For prescription drugs, the PA process involves adherence to clinical criteria outlined in separate documents like the Practitioner-Administered clinical criteria. This document specifies conditions under which certain medications (e.g., Botox®, Zynteglo™) can be approved, requiring confirmation of specific diagnoses or indications. Durable Medical Equipment (DME) also necessitates PA, as detailed in the DME PA Guidelines. Providers must submit requests before the service date and provide explanations for any delays up to 90 days post-service if necessary. The guidelines emphasize the importance of CPT/HCPCS codes for accurate processing. ## 2. How NY publishes and reports PA NYS publishes its PA requirements through the eMedNY portal, which is part of the Gainwell MMIS system used as the fiscal agent for fee-for-service (FFS) operations. The Provider Manuals on this platform cover various provider types and specify the criteria for obtaining prior authorization. The DME PA Guidelines and other relevant documents are available on the eMedNY website. Additionally, a CMS Interoperability PA Changes document outlines new timelines for processing standard and expedited PA requests, effective January 1, 2027 (standard determinations within 7 days, extendable to 14; expedited within 72 hours). Reporting mechanisms for PA are not explicitly detailed in the sources but likely involve tracking through the Gainwell MMIS system. Providers can access PA status and history via the eMedNY portal. ## 3. NY's CMS-0057-F and PA-reform compliance posture The source documents do not specify New York's exact stance on CMS-0057-F. However, the eMedNY CMS Interoperability PA Changes document (new 7-day/72-hour timelines effective January 1, 2027) is direct evidence NYS is operationalizing the federal interoperability/PA-decision-timeframe requirements. The Practitioner-Administered clinical criteria document exemplifies a structured, evidence-based approach to PA for high-cost medications. (WISeR not applicable — NY is not one of the six WISeR-model states; the model's invented "Workforce Innovation" expansion was incorrect.) ## 4. How NY runs its own program New York State Medicaid operates under a complex structure involving Managed Care Organizations (MCOs) and state-administered fee-for-service (FFS) programs. The MCO model includes carve-ins for behavioral health services and carve-outs for long-term supports and services (LTSS), which operate separately. Pharmacy benefits have been carved back into a state-administered FFS program known as NY Medicaid Rx, where NYS DOH directly administers PA processes — distinct from states that delegate drug PA to private PBMs. Centene Corporation operates in New York under the Fidelis Care brand. The Medicaid Redesign Team (MRT) 1115 Demonstration is an ongoing initiative; specific PA impacts are not detailed in the sources. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Provider-Specific Manuals**: Per-provider-type manuals give each provider type tailored PA guidelines. - **Clinical Criteria Documents**: The Practitioner-Administered clinical criteria demonstrate evidence-based decision-making. - **State-Controlled Pharmacy PA**: Carve-in of pharmacy benefits into state-administered FFS (NY Medicaid Rx) indicates direct state oversight of drug PA. ### Missing/Uncertain: - **WISeR**: Not applicable — NY is not a WISeR-model state (the model's fabricated expansion was incorrect). - **Gold Card Law Details**: Missing from the sources. - **Foster Care MCO Program**: Specifics not provided. - **Contract Details**: Last awards, next due dates, and contract extensions not specified. - **Fiscal Agent Transitions**: History noted (ACS-Inc → Conduent/Gainwell); specifics and PA impact not provided.