Essential Plan: What Providers Must Know about Newborn Enrollment

Essential Plan Newborn Coverage Requirements

• What the Essential Plan Covers: Medically necessary newborn services from birth through initial hospital discharge only if the newborn has no other active coverage at delivery.
• Coverage Limitation: After initial discharge, EP is no longer responsible for newborn claims.
• Retroactive Coverage: If newborn coverage (Medicaid, CHPlus, or Commercial) is later found retroactive to birth, that plan becomes the payor of record. Providers should rebill under the newborn’s active coverage.

Provider Action Required

To ensure compliance and prevent avoidable recoupments:

• Providers must ensure they bill the correct payor: If the pregnant member/patient is enrolled in a Medicaid Managed Care Plan, then providers should bill the appropriate Medicaid Managed Care Plan for the newborn’s hospital stay.
• Rebill the newborn’s identified payor when retroactive coverage is identified.
• It is the provider's responsibility to rebill the appropriate payor if a newborn is retroactively enrolled in Medicaid FFS, Medicaid Managed Care, CHPlus, or Commercial after payment was received.
• Educate patient-facing teams and remind EP pregnant members/patients to enroll newborns as soon as possible and no later than 60 days after birth to ensure continuity of care and correct payment.

Why This Matters

• Ensures seamless access to care for newborns
• Supports accurate and timely claim adjudication
• Reduces financial impact on hospitals and the plan
• Maintains compliance with NYSDOH reporting and billing requirements

More Information

Please refer to these DOH materials for the complete newborn reporting and billing procedures, including CIN capture and billing responsibilities when the pregnant member/patient is enrolled in a Medicaid Managed Care Plan (MMCP):

• New York State Medicaid Update - March 2024 Volume 40 - Number 3
• New York State Medicaid Update - March 2021 Volume 37 - Number 3

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am–5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).

February 2026