NYS Medicaid APG Weight Adjustment for Dialysis Clinics

Inclusion of Phosphate Binder Costs

Effective January 1, 2026, the New York State (NYS) Medicaid program, including both Feefor-Service (FFS) and Medicaid Managed Care (MMC) plans, will incorporate the costs of phosphate binders provided during dialysis sessions into the Ambulatory Patient Group (APG) payment.

This change accounts for the acquisition, storage, and dispensing costs of oral phosphate binders provided to patients during dialysis sessions.

Key Updates

• The APG weight for APG 168 (Dialysis) has increased from 1.3651 to 1.5302 to reflect the additional costs associated with providing phosphate binders.
• Dialysis patients should not be referred to a pharmacy to obtain phosphate binders. These costs are now included in the dialysis APG payment rate.
• Providers not contracted for APG reimbursement will be reimbursed at their contracted rate.

Coverage Clarifications

• For ESRD patients, phosphate binders are included in the APG dialysis clinic payment.
• For acute kidney injury (AKI) patients, phosphate binders remain covered under the NYS Medicaid pharmacy benefit (NYRx) and not through the dialysis clinic APG payment.
• This ensures consistency between Medicare and NYS Medicaid coverage policies for AKI patients.

Action Required

• Providers that are reimbursed based on APG should ensure billing systems and claims submissions reflect the updated APG weight for dialysis services effective January 1, 2026.
• Do not bill separately for phosphate binders provided during dialysis sessions.

Alignment with CMS Policy

This update aligns with the Centers for Medicare & Medicaid Services (CMS) policy change under the Transitional Drug Add-on Payment Adjustment (TDAPA) finalized in the CMS End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule, published November 12, 2024 (89 Federal Register 98822). CMS now includes oral-only phosphate binders in the ESRD bundled payment, and NYS Medicaid will follow this approach by incorporating these costs into the APG reimbursement.

More Information

• ESRD Prospective Payment System, Furnished to Individuals with Acute Kidney Injury

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.