DOH Medicaid Update September 2001 Vol.16, No.9

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Family Health Plus "is a bold, new innovative health care program that will provide nearly 620,000 uninsured New Yorkers with comprehensive health care coverage."

--Governor George E. Pataki

Family Health Plus is New York State's health insurance program for adults who do not have health insurance-either on their own or through their employers-but have incomes too high to qualify for Medicaid. Family Health Plus is available to single adults, couples without children, and parents with low income, who live in New York State and are United States citizens or fall under one of many immigrant categories.

There is no cost to participate in Family Health Plus. Unlike Medicaid, there are no asset or resource tests involved in determining if you are eligible for Family Health Plus.There are no co-payments, deductibles or contributions once you are enrolled.

To apply for Family Health Plus, people will need to complete an application, provide proof of certain information, select a health plan, and have a personal interview. Beginning September 1, 2001, interested persons can call this toll free telephone number, Family Health Plus Hotline 1-877-9-FHPLUS (1-877-934-7587), and ask about locations near their home where they can apply for Family Health Plus and other New York State health insurance programs for them and their family. Help in filling out an application will be available at these locations. More information on the Family Health Plus program can also be found at our website, http://www.health.ny.gov/health_care/family_health_plus/.

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Effective September 4, 2001, local social service districts will begin accepting applications for Family Health Plus (FHPlus), with managed care enrollments effective as early as October 1, 2001. FHPlus enrollees will have managed care coverage only. All medical services covered under FHPlus are provided by the managed care plan chosen by the enrollee. These medical services include pharmacy and family planning services. FHPlus enrollees are exempt from any utilization thresholds and co-pays.

No Medicaid cards will be issued to FHPlus enrollees. Enrollees will be issued a managed care plan identification card that shows their CIN (client identification number).

Participating hospitals and eligible federally qualified health centers who will be billing the State for graduate medical education and "wraparound" payments not covered through the FHPlus capitation rates will use the CIN to claim those amounts.

Providers will be able to verify FHPlus status using the CIN, but there will be no ability to "swipe" a benefit card to access this information. Methods for accessing eligibility information will be limited to the telephone, verifone, and CPU methods. There may be FHPlus enrollees who previously had Medicaid coverage and present a Medicaid card. Providers will not be able to verify FHPlus status by "swiping" an old Medicaid card, even though the CIN is the same.

All providers need to be aware of the new messages that will be returned by the Electronic Medicaid Eligibility Verification System (EMEVS) for FHPlus enrollees. EMEVS will return the following message for people with FHPlus coverage:

ARU (telephone):	FAMILY HEALTH PLUS
POS VERIFONE TERMINAL:	FAM HEALTH PLUS
CPU/PC/RJE:	Table 1 Response code 017 (Family Health Plus)
DVS TRANSACTIONS	FHP DENIAL (via the POS verifone)
(Dispensing Validation System)	Denial Code 722 (Family Health Plus Denial) (via other access methods)
NCPDP TRANSACTIONS	Table 7 RX Denial Code 722 (Family Health Plus Denial) and
(Pharmacy)	NCPDP Reject Code 65(Patient Not Covered)

Note: NCPDP Eligibility ONLY transactions will receive Code 017 although the code will be changed to 722 at a later time.

Please note that some individuals will be determined to be eligible for the FHPlus Program, but will be awaiting coverage to be provided by a participating managed care plan. Services delivered to these pending FHPlus individuals will not be reimbursed by any managed care plan or the Medicaid Program. EMEVS will return the following message for people with pending FHPlus coverage:

ARU (telephone):	NO COVERAGE:PENDING FAMILY HEALTH PLUS
POS VERIFONE TERMINAL:	NO COVERAGE PENDING FHP
CPU/PC/RJE:	Table 2 denial code 103 (No Coverage:Pending Family Health Plus)
DVS TRANSACTIONS	Table 2 denial code 103 (No Coverage:Pending Family Health Plus)
NCPDP TRANSACTIONS	Table 2 denial code 103 (No Coverage:Pending Family Health Plus) NCPDP Reject Code65 (Patient Not Covered)

Note: Table 2 Denial Code 103 will also be returned for NCPDP Eligibility ONLY Transactions

If you have any questions related to this article, please contact MaryKim Bauer at (518) 486-6342.

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November 15, 2001

It's never too late to think about "kicking the habit." The American Cancer Society's volunteers and staff hold the Great American Smokeout every year to help smokers quit tobacco use for at least one day. More people quit smoking on this day than any other day of the year. Health care professionals have the ability to help patients stop tobacco usage.

• The Great American Smokeout is an opportunity for Americans to renew their commitment to a tobacco-free environment for themselves and family members.
• Smoking is an addiction and health care professionals can be very influential when they suggest smoking cessation to their patients.
• Please take time to mention this event as the first day towards a healthier lifestyle.

Encourage your patients to take part in the Great American Smokeout on November 15, 2001.

For more information on tobacco cessation contact:

New York State Medicaid Program is committed to assisting all Medicaid recipients who would like to stop tobacco use. Medicaid covers both prescription and over-the-counter smoking cessation agents. For more information on Medicaid's Smoking Cessation policy, contact (518) 474-9219.

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The New York State Smokers' Quitline is offering free posters"New York State Medicaid Covers Stop Smoking Medications." The colored posters come in 2 sizes; 11" x 17" and 22" x 28" and are available in English or Spanish.

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The first and most important step in treating tobacco use and dependence is to systematically identify tobacco users at each office or clinic visit. Effective identification of tobacco use status not only opens the door for successful interventions (e.g. physician advice), but also guides clinicians to identify appropriate interventions based on patients' tobacco use status and willingness to quit.

For patients not willing to make a quit attempt, clinicians should use a brief intervention designed to promote the motivation to quit. Motivational interventions built around the five "Rs":relevance, risks, rewards,roadblocks and repetition can give the clinician an opportunity to educate, reassure and motivate patients.

Relevance	Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation, health concerns, age, gender and other important patient characteristics.
Risks	The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g. smokeless tobacco, cigars and pipes) will not eliminate these risks. Examples of risks are: Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility and increased serum carbon monoxide. Long-term risks:Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability and need for extended care. Environmental risks: Increased risk of lung cancer and heart disease in spouses; higher rates of smoking by children of tobacco users; increased risk for low birth weight, SIDS, asthma, middle ear disease and respiratory infections in children of smokers.
Rewards	The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards follow: Improved health Improved sense of smell Save money Home, car, clothing, breath will smell better Set a good example for children Have healthier babies and children Not worry about exposing others to smoke Food will taste better Feel better about yourself Can stop worrying about quitting Perform better in physical activities Feel better physically Reduced wrinking/aging of skin
Roadblocks	The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers. Typical barriers might include: Withdrawl symptoms Fear of failure Weight gain Lack of support Depression Enjoyment of tobacco
Repetition	The motivational intervention should be repeated every time an unmotivated patient visits the clinic/office setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.

New York State Medicaid covers both prescription and non-prescription smoking cessation agents. For more information on Medicaid's smoking cessation policy, contact the Pharmacy Policy & Operations Unit at (518) 486-3209.
You can also access the NYS Quitline Quitsite www.nysmokefree.com

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According to a November 2000 report in the American Journal of Medicine, cigarette smoking has been associated with a substantial increase in the incidence of type II diabetes mellitus. Smoking increases blood glucose levels after an oral glucose challenge and may impair insulin sensitivity, which is one of the reasons why there may be a causal association between smoking and diabetes. Populations at high risk for type II diabetes should be considered for special targeted smoking interventions.

Other increased health risks associated with smoking in the diabetic population have been identified. Smoking may contribute to the cardiovascular burden and the microvascular complications associated with diabetes. All persons with diabetes should be urged to not start smoking or to quit smoking. The following information is provided to help you assist your diabetic patients. Additional information regarding smoking and diabetes can be found at the American Diabetes Association (ADA) website www.diabetes.org

Assessment of Smoking Status and History

• Systematic documentation of a history of tobacco use should be obtained from all adolescent and adult individuals with diabetes.

Smoking Prevention and Cessation

• The Agency for Health Care Policy and Research has guidelines regarding smoking cessation which are available at www.ahcpr.gov. All health care providers should be aware and familiar with these guidelines.
• All health care providers should advise individuals with diabetes not to initiate smoking. This advice should be consistently repeated to prevent smoking and other tobacco use among children and adolescents with diabetes under age 21 years.
• Smokers should be advised, as a routine component of diabetes care, to quit smoking. Every smoker should be urged to quit in a clear, strong, and personalized manner that describes the added risks of smoking and diabetes.
• Every diabetic smoker should be asked if he or she is willing to quit at this time.

Smoking Cessation Follow-up

• Follow-up procedures designed to assess and promote quitting status should be arranged for all diabetic smokers.

Reminder: As a commitment to provide assistance to Medicaid recipients who want to stop smoking, Medicaid now covers prescription and non-prescription smoking cessation agents.We appreciate your participation in helping to make New Yorkers healthier.

If you would like more information about the Medicaid Program's Smoking Cessation Initiative, please contact the Bureau of Program Guidance at (518) 474-9219.

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Over the past decade, there has been a steady rise in the prevalence of drug-resistant Streptococcus pneumoniae. Current resistance rates in the Rochester area are 17%, the Capital Region 23%, and the New York City area 26%! Resistant infections are accompanied by increased and prolonged morbidity.

New York State has become increasingly involved in efforts to control antibiotic resistance. Some of these initiatives include the Capital Region Otitis Project of 1997-1999 and the ongoing New York Region Otitis Project of 1999-2001. Further information is available through our website:

The New York State Upper Respiratory Project is a new committee formed to combat the rising prevalence of drug-resistant bacteria. This coalition, begun in the Fall of 2000, is composed of leading clinicians, public health practitioners, researchers, health plans, pharmacists, and public health educators, as well as staff from the Office of Medicaid Management. The coalition is organizing an interactive conference as part of a nationwide effort

The committee has asked us to extend an invitation to practitioners and stakeholders to be a part of this First Annual Statewide Conference on Antibiotic Resistance. The conference will be held on April 17, 2002 from 4:30 - 9:00 PM at the Bulmer Conference Center at Hudson Valley Community College, Troy, New York.

Primary care physicians, nurse practitioners, physician assistants and midwives in ambulatory settings who see children and adults with upper respiratory infections including bronchitis, pharyngitis, sinusitis, and otitis, should be especially interested in participating. All practitioners, however, are welcome.

Stakeholders invited are groups or organizations who have already developed operating judicious antibiotic use projects, those who are contemplating developing a project, and those wishing to familiarize themselves with the issues.

The conference goal is to lay the foundation for a better understanding of the emergence and epidemiology of antibiotic resistance and to evaluate strategies for control of this epidemic in the State of New York.

Mark your calendar for this event! Consider developing a project in your community! Share your results at the conference!

For further information call Richard Propp, M.D., Medical Consultant at (518) 473-5876; Denise Spor, R.N., at (518) 473-0185; or Elizabeth Villamil, M.P.H., Project Administrator at (518) 473-5499

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Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

• Overview of MMIS
• Explanation of MMIS Provider Manual
• Discussion of Medicaid Managed Care
• Overview of Billing Options
• Explanation of 90-day Regulation
• Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend:

November 6, 2001 - 10 AM
Franklin County Department of Social Services
Courthouse Building, Kitchen Conference Room
Malone, NY

November 13, 2001 - 10 AM
Lockport Public Library (rear entrance)
East Avenue
Lockport, NY

Additional seminars may be scheduled as new programs are implemented or changes to exsisting billing procedures are announced.

Please register early to attend sites marked with (*) because seating is limited. Each seminar will last approximately two hours.

If the seminar address is not listed above, a CSC representative will contact you at least 2 weeks prior to the seminar date to confirm attendance and provide seminar address information

To register, please mail this completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

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The Office of Medicaid Management (OMM) is working collaboratively with the Upstate Asthma Coalitions. The American Lung Association of Central New York (ALA of CNY), a member of the upstate coalition network, is holding their first annual community asthma educational fair. The ASTHMA FAIR will take place at the New York State Fair Art and Home Center in:

• Raise awareness of asthma
• Reinforce the importance of keeping asthma under control
• Know the dangers of undiagnosed and mismanaged asthma
• How to recognize the signs of an asthma attack
• Know the symptoms of asthma
• How to reduce absenteeism from work and school
• How to reduce emergency room visits
• How to reduce the cost of medications
• How to reduce the financial burden of asthma

The fair includes an array of FREE educational activities, including:

• Educational Seminars
• Pulmonary Function Testing
• Educational Games and Activities

Educational Activities Include:

• Learn about symptoms, causes, triggers, asthma induced exercise
• How to treat asthma
• Medications, what's a controller, what's a rescuer
• What's the latest and greatest news about asthma
• What support groups are available
• Attend workshops, seminars and demonstrations about exercise induced asthma, pediatric care, hypnotism and asthma, medications, rescuers and controllers, general asthma, and triggers, allergies and asthma.
• Learn about personal asthma action plans
• Learn about foods that affect asthma
• Ask the doctor questions about asthma

OMM encourages providers to apprise their asthma patients of this special event. For more information, call (315) 422-6142.

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Influenza and pneumococcal diseases are responsible for approximately 60,000 deaths each year in the United States. More deaths are attributable to influenza and pneumonia than acquired immuno deficiency syndrome (AIDS), breast cancer, all U.S. motor vehicle accidents, diabetes or Alzheimer disease. In response to this, the New York State Department of Health is promoting an Adult Immunization Campaign with a goal of increasing both influenza and pneumococcal vaccination rates in New York State.

Current projections predict that there will be approximately 79 million doses of influenza vaccine available in the United States this year. 48 million doses or roughly 61% of the supply will be delivered to health care providers before the end of October. However, the remaining 31 million doses may not be completely distributed until some time in November or December. As health care providers have traditionally received all of their influenza vaccine by the end of October, this represents a delay of a month or more. Supplies of pneumococcal vaccines should not be a problem. Providers should take steps to ensure that individuals for whom a pneumococcal vaccination is recommended receive that vaccination when they obtain their flu shot.

To ensure availability of influenza vaccine for high-risk patients, providers are advised to contact their local health department, if:

• they have not already ordered influenza vaccine, or
• they are experiencing difficulties placing an order for influenza vaccine, or
• they have not yet received their influenza vaccine order.

As the influenza vaccine becomes available in September and October, providers should concentrate on vaccinating patients age 65 and older, and high-risk individuals. In addition, the Office of Medicaid Management recommends that priority be given to vaccinating high-risk individuals anticipating out of state travel. Community immunization efforts should not begin until November, or at such time as it becomes clear that sufficient flu vaccine supplies will be obtainable.

As a guide, the Department has developed the Flu Vaccination Prioritization Plan for the 2001-2002 Season. Please refer to the charts following this article which summarize risk categories of those persons who should be vaccinated.

Medicaid Reimbursement Is Available

Reimbursement for influenza virus vaccine and pneumococcal vaccine under Medicaid may be billed by a clinic as a threshold visit.

Physicians and nurse practitioners may claim different procedure codes, based upon the age of the patient. For a complete list of immunization injections, please refer to the procedure code section of your Physician Medicaid Management Information System Provider Manual.

If you would like more information or have questions on New York State's Adult Immunization Campaign, you may call (518) 473-4437 or visit the website at http://www.flu.state.ny.us.

Risk Category 1

Groups at highest risk for serious influenza-related complications and health care workers, including:

• Adults at or over 65 years of age
• Residents and staff of nursing homes and other chronic-care facilities that care for people of any age who have chronic medical conditions
• Adults and children with chronic cardiovascular or pulmonary disorders, including asthma
• Adults and children with chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, immunosuppressive or immunodeficiency disorders, including HIV
• Children and teenagers, 6 months to 18 years old, receiving long-term aspirin therapy (could develop Reyes syndrome after influenza infection)
• Physicians, nurses and other personnel in both hospitals and outpatient-care settings, including emergency response workers
• Healthy women who will be in their 2nd or 3rd trimester of pregnancy during flu season
• Pregnant women with underlying medical conditions regardless of the stage of pregnancy
• Travelers to areas where influenza activity exists or when traveling among people from areas of the world where there is current influenza activity

Risk Category 2

Those persons at increased risk for serious influenza-related complications and others, including:

• Adults 50-64 years of age
• Household members, including children, of people in risk category 1
• Students and other persons in institutional settings (e.g., college students in dormitories)
• Employees of health care facilities who do not provide direct patient care
• Persons, other than health care workers, who provide essential community services

Risk Category 3

Otherwise healthy adults and children age 6 months and older who wish to reduce their likelihood of becoming ill with influenza, such as:

• Healthy persons in the workplace
• Anyone who wishes to reduce the likelihood of becoming ill with influenza

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Month	Local Health Unit Mass Immunizers	Health Care Providers	General Public
July/August	Develop contingency plan in response to delay or possible shortage of vaccine
September	Finalize Campaign plans (except for worksites) for late October and November	Actively target risk category 1 persons.	Risk category 1 persons should actively seek vaccination from health care provider.
October	Conduct immunization campaigns targeting risk category 1.	Actively target risk category 1 persons.	Risk category 1 persons should continue to seek vaccination
November	Conduct immunization campaigns targeting risk category 1 & 2 persons Mid-month, begin worksite immunizations	Continue to vaccinate all risk category 1 persons and target risk category 2 Mid to later in month, begin to offer vaccine to risk category 3 persons	All risk category 1 & 2 persons should actively seek vaccination Mid-month, risk category 3 persons may begin seeking vaccination
December	Continue to conduct immunization campaigns	Continue to vaccinate all risk categories.	All risk category 1 & 2 and otherwise healthy persons should continue to seek vaccination
January	Continue to vaccinate all risk category persons since the flu season may peak this month or later	Continue to vaccinate all risk category persons since the flu season may peak this month or later	All risk category 1 & 2 and otherwise healthy persons should continue to seek vaccination

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The New York State Department of Health is pleased to announce an increase in certain rates for the Home and Community-Based Services/Traumatic Brain Injury Waiver (HCBS/TBI Waiver), Category of Service 0263, effective April 1, 2000, and April 1, 2001:

Service Coordination, initial (Rate Code 9850):

• effective April 1, 2000, from $400 to $450 per initial billing
• effective April 1, 2001, from $450 to $464 per initial billing

Service Coordination, monthly (Rate Code 9851):

• effective April 1, 2000, from $267 to $330 per month
• effective April 1, 2001, from $330 to $340 per month.

Structured Day Programs, half-day (Rate Code 9870):

• effective April 1, 2000, from $25 to $38 per half-day
• effective April 1, 2001, from $38 to $39 per half-day.

These increases are retroactive to April 1, 2000 and April1, 2001. Checks reflecting the retroactive payment will be sent to affected providers through the usual retroactive rate process with an accompanying retroactive remittance statement.

If you have any questions related to this article, or the Traumatic Brain Injury Waiver program, please contact Bruce Rosen, Bureau of Long Term Care, at (518)474-6580

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Effective July 1, 2001, the costs of certified social workers who provide mental health services to foster care children become an allowable cost in the Medicaid per diem rate methodology for voluntary child (foster) care agencies. These costs must be reported in the child care agency cost report. Reporting instructions will be issued shortly from the New York State Department of Health's Division of Health Care Financing.

Current Medicaid policy, as reflected in the Child Care Agency Medicaid Management Information System Provider Manual (Page 2-57), indicates that the salaries of social workers are not Medicaid reimbursable. This policy change aligns Medicaid reimbursement policy for child care agencies with existing Medicaid reimbursement of Article 28 (Department of Health) clinics and Article 31 (Office of Mental Health) clinics in coverage of certified social worker services. The new policy will improve the ability of child care agencies to provide needed mental health interventions for foster care children served by the child care agencies, in addition to the mental health services of psychiatrists and psychologists already included in the Medicaid per diem rates.

Questions related to this new policy should be directed to Gail Charlson, Bureau of Maternal and Child Health, at (518) 486-6562. Questions related to cost reporting should be directed to the Division of Health Care Financing at (518) 474-1792.

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The Department of Health has found that many laboratories do not hold a permit in Genetic Testing and are billing for molecular diagnostic procedures (procedure codes 83890 - 83912

• Molecular diagnostics codes are reimbursable for DNA-based genetic testing only. These codes are not reimbursable for non-genetic applications such as microbial detection or quantification, or testing for acquired changes in genetic material.
  Laboratory providers should refer to the procedure code section of the Medicaid Management Information System Provider Manual (MMIS) for Laboratories, rule number 14, for instructions on the proper use of procedure codes 83890 - 83912.
• When billing for organism specific antibody teststests use procedure codes in the 86000 series.
• When testing involves infectious agent detection by nucleic acid (DNA or RNA), use procedure codes 87449 - 87798. These codes include all steps of testing and reporting.
• Reimbursement for laboratory testing is limited to those procedures listed in the procedure code section of the MMIS Provider Manual for Laboratories
• It is an unacceptable practice to bill Medicaid for tests actually performed by another laboratory, and/or to bill Medicaid for procedures or categories of procedures that are not included on your laboratory permit. (See the MMIS Provider Manual for Laboratories, page 2-46.)

If you have any questions related to this article, or on the proper use of laboratory procedure codes, please telephone the Bureau of Policy Development and Agency Relations at (518) 473-5873.

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us)

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm