Does New York Medicaid Cover TMS? Criteria and Plan-by-Plan Rules

Yes. New York State Medicaid covers TMS for adults with treatment-resistant major depression. Coverage began October 1, 2025 for fee-for-service Medicaid and November 1, 2025 for Medicaid Managed Care plans such as Healthfirst, Fidelis Care, MetroPlusHealth and UnitedHealthcare Community Plan. The state's rule is short: you must be 18 or older, have tried two antidepressants at a therapeutic dose for long enough without a meaningful response, and have severe depression without psychotic features.

Each managed care plan then runs its own prior authorization process, and not every plan has published its version. Below is what the state requires, what each major New York plan has put in writing, and how to get the rules from a plan that has not. Confirm current criteria with your plan before starting, because these documents are revised often.

What New York Medicaid requires

The source is the NYS Department of Health's Medicaid Update of July 2025 (Vol. 41 No. 7), which the state revised with new highlighted text on September 30, 2026. Its criteria:

• Age 18 or older, with treatment-resistant MDD.
• Treatment resistance means "two trials of a therapeutic dose of two different antidepressants for a sufficient duration without achieving a clinically meaningful response."
• Covered diagnoses are F32.2 and F33.2, severe major depression without psychotic features, "when first line treatments have been unsuccessful."
• The provider must confirm the diagnosis and rule out other causes of depressive symptoms that can interfere with medication.
• TMS must be ordered by, and given under the direct supervision of, a qualified psychiatrist or a psychiatric nurse practitioner who can practice independently, with specialized training and certification. The nurse-practitioner wording was added in the September 2026 update; earlier versions said psychiatrist only.

Two things are notably absent. The state text does not require a failed psychotherapy trial, and it does not require the two antidepressants to come from different drug classes. That makes the state rule simpler than Medicare's, which requires both a psychotherapy trial and agents from two classes (see Medicare coverage for TMS in New York).

The state is equally clear about limits. "TMS is not first-line therapy for depression, nor is it indicated for acute suicidality, psychotic depression, or primary neurological disorders." And: "Obsessive-compulsive disorder is currently not an indication for NYS Medicaid reimbursement." Ruling out medical causes first is part of good care regardless of insurance; the reasoning is in ruling out medical causes before TMS.

The update does not state a session limit, a fee, or a prior authorization rule for fee-for-service. Managed care members are directed to their plan for billing and reimbursement. You can read the state's Medicaid Update directly.

Plan by plan: what has been published

If you have Medicaid through a managed care plan, that plan, not the state, reviews the request. Here is what each plan's own public documents said when this page was last checked (October 2026). A plan that has not published a TMS document may still have internal criteria; that is the gap to close with a phone call.

MetroPlusHealth

MetroPlusHealth's provider notice lists TMS as covered from November 1, 2025 for its Medicaid, SNP, HARP, CHP, QHP, Essential Plan, Gold and Gold Care lines, with prior authorization required. Its policy BMD-110 replaces InterQual criteria with the state standard for the Medicaid line. The authorization package includes attestations about device training, psychiatrist supervision, a psychiatric evaluation ruling out acute suicidality, psychotic depression and neurological disorders, and at least two therapeutic-dose antidepressant trials. Retreatment "may be considered for members that have relapsed, 6 months after the most recent treatment." Requests that do not meet criteria go to a behavioral health medical director.

Fidelis Care

Fidelis added TMS (CPT 90867, 90868 and 90869) to its Medicaid, Medicare, Essential Plan and Ambetter authorization grids effective October 1, 2024, a year before the state mandate. Its published summary asks for "failure to respond to a combination of multiple trials of medication and evidence-based psychotherapy treatment during the current episode of illness." That psychotherapy language is stricter than the later state rule. Because the notice predates the state's 2025 policy, ask Fidelis which criteria it applies now.

Healthfirst

Healthfirst has not published a TMS policy, criteria or prior authorization rule; none could be found when this page was checked. Because Healthfirst is a Medicaid Managed Care plan, its Medicaid members fall under the state coverage that began November 1, 2025. What its own review process asks for is not public. To get it, call the member services number on your Healthfirst card and ask for the medical necessity criteria and prior authorization requirements for CPT 90867 and 90868, in writing. Ask, too, which criteria set its reviewers use and whether a behavioral health company manages TMS requests on its behalf. Write down the date, the representative's name and the reference number of the call.

Child Health Plus and the Essential Plan

Optum's New York criteria extend the same TMS rules to Child Health Plus (from November 1, 2025) and to the Essential Plan from November 1, 2026. The state Medicaid criteria themselves start at age 18. Teenagers covered by Child Health Plus should not assume TMS is available to them; ask the plan directly.

How to get your plan's rules in writing

1. Find the plan name and member services number on your card. Medicaid Managed Care, HARP, Child Health Plus and Essential Plan are different products even within one company.
2. Ask whether TMS for depression requires prior authorization, and ask for the written criteria. The billing codes are 90867 (initial session with mapping), 90868 (each later session) and 90869 (session with motor threshold re-determination).
3. Ask whether the TMS clinic you are considering participates with your plan. Network participation affects whether the plan pays at all, so this question matters as much as the clinical criteria.
4. Ask your psychiatrist to document the two antidepressant trials with names, doses, dates and outcome, and the evaluation that ruled out other causes.

A general walk-through of the request process is in TMS prior authorization, step by step.

Timelines and appeals

Since January 1, 2026, federal rules require Medicaid fee-for-service and Medicaid managed care to decide prior authorization requests within 7 calendar days (standard) or 72 hours (urgent), and to give a specific reason for any denial. If the plan's final answer is a denial as not medically necessary or experimental, New York's external appeal is available. The external appeal fee is waived for Medicaid, Child Health Plus and Family Health Plus enrollees. Patients have 4 months from the final adverse determination to file. How parity law can support an appeal is covered in New York parity law and TMS claims.

If you have Medicare and Medicaid

If you have both, ask the clinic how the claim will be billed. New York Medicare's own policy has stricter criteria than the state Medicaid rule, including a failed psychotherapy trial documented with rating scales. A record that satisfies only the Medicaid checklist may not satisfy Medicare, so ask the clinic to check your history against both policies before the first session.

Where TMS fits

The state's definition of treatment resistance, two failed antidepressant trials, is the threshold most often studied; what STAR*D tells us explains that evidence and its limits. Coverage is not a reason to skip other options. Every option for treatment-resistant depression compares TMS with medication changes, psychotherapy, esketamine and ECT, and the TMS guide covers the rest of the process. The TMS therapy page has the practice's current TMS information.

TMS is not used for acute suicidality under the state policy, and safety comes first. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.

Frequently asked questions

Do I need to have tried therapy before New York Medicaid covers TMS?

The state's Medicaid Update does not list a psychotherapy requirement. Some plans' own documents, such as Fidelis Care's 2024 notice, mention psychotherapy, so ask your plan for its current written criteria.

Does Medicaid cover TMS for teenagers in New York?

The state criteria cover members 18 and older, and MetroPlusHealth's policy calls TMS under 18 experimental. Ask the plan directly before assuming any coverage for a teenager.

Is TMS for OCD covered by New York Medicaid?

No. The state's policy says obsessive-compulsive disorder is currently not an indication for NYS Medicaid reimbursement.

How many TMS sessions does Medicaid allow?

The state Medicaid Update does not set a session limit. Your managed care plan sets the number it authorizes, so ask for it in writing with the approval.

Does Healthfirst cover TMS?

Healthfirst's Medicaid members fall under the state coverage that began November 1, 2025, but Healthfirst has not published its own TMS criteria. Call member services and ask for the criteria and prior authorization rules for CPT 90867 and 90868.

Sources

1. New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (Medicaid Update, July 2025, Vol. 41 No. 7). NYS Department of Health, 2025. healthweb-back.health.ny.gov
2. Repetitive Transcranial Magnetic Stimulation (TMS) - Policy and Procedure (BMD-110). MetroPlusHealth, 2025. metroplus.org
3. Medicaid Update - New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (provider notice). MetroPlusHealth, 2025. metroplus.org
4. Fidelis Care Authorization Grids Effective October 1, 2024. Fidelis Care, 2024. fideliscare.org
5. New York Medicaid and Essential Plan: Transcranial Magnetic Stimulation (TMS) - Medicaid, Child Health Plus and Essential Plan (BH803NYTMS122025). Optum Behavioral Health Solutions, 2026. providerexpress.com
6. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet. Centers for Medicare & Medicaid Services, 2024. cms.gov
7. File an External Appeal. NY Department of Financial Services, n.d.. dfs.ny.gov
8. Transcranial Magnetic Stimulation for Treating Physical Health Conditions (Medical Policy 2026T0536W; CPT code descriptors). UnitedHealthcare, 2026. uhcprovider.com
9. LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal, CMS Medicare Coverage Database, 2026. cms.gov

Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.