DOH Medicaid Update January 2002 Vol.17, No.1

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There is clear evidence that smoking and tobacco cessation will lead to better health, thus reducing health care costs.

During 2001, the Medicaid Program has encouraged providers to assist our Medicaid population in stopping their smoking and tobacco use. The following 2001 Medicaid Update articles were printed and made available for you to use as a resource for you and your patients. These articles can be located:

• on the Department of Health website at: http://www.health.state.ny.us/health_care/medicaid/index.htm

• or by request, by emailing your address to: MedicaidUpdate@health.state.ny.us.

Secondhand Smoke General Information (January)
Secondhand Smoke Information for Patients (February)
Smoking Cessation and Pregnancy (March)
Tobacco Use and Teens (April)
Asthma And Secondhand Smoke (May)
Medicaid Coverage of Smoking Cessation (June)
Smokeless Tobacco: Dip, Chew and Snuff (July)
Smoking Cessation: How Practitioners Can Help: Part 1 (August)
Motivating Patients To Stop Tobacco Use: Part 2 (September)
Diabetes and Smoking (September)
Smoking Cessation: How Practitioners Can Help: Part 3 (October)
Smoking and Pharmacotherapy: Part 4 (November)
Stop Smoking and Prevent Relapse: Part 5 (December)

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Persons of all racial and ethnic backgrounds are vulnerable to tobacco addiction. However, according to the 1998 Surgeon General's Report, Tobacco Use Among U.S. Racial/Ethnic Minority Groups, some alarming trends have been noted.

• In the four racial/ethnic groups studied (African-American, American Indians/Alaska Natives, Asian Americans/Pacific Islanders and Hispanics) African-American men bear one of the greatest health burdens of the four ethnic groups, with death rates from lung cancer that are 50 percent higher than those of Caucasian men.
• Rates of tobacco related cancers (other than lung cancer) vary widely among members of racial/ethnic groups and they are particularly high among African-American men.
• Tobacco use among adolescents from racial and ethnic minority groups has begun to increase rapidly, threatening to reverse the progress made against lung cancer among adults in these minority groups. Cigarette smoking among African-American teens has increased 80 percent over the last six years-three times as fast as among white teens.
• The high level of tobacco product advertising in racial/ethnic publications is problematic because the editors and publishers of these publications may limit the level of tobacco use prevention and health promotion information included in their publications.

• Ask, Advise and Assist all patients with tobacco cessation. There is a critical need to deliver effective tobacco dependence interventions to ethnic and racial minorities.
• Use smoking cessation interventions developed for the general population that have been effective with racial and ethnic minority participants. Studies have demonstrated the efficacy of a variety of smoking cessation interventions (including screening, clinician advice, self help materials and the nicotine patch) in minority populations.
• Be culturally appropriate, reflecting the targeted racial/ethnic groups' cultural values. This may increase the smoker's acceptance of treatment.
• Convey cessation counseling or self-help materials in a language understood by the smoker.

Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD:U.S. Department of Health and Human Services. Public Health Service. June 2000.

US Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups, Report of the Surgeon General. Washington (DC): US Department of Health and Human Services, Centers for Disease Control and Prevention, 1998.

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Many asthmatics have little or no symptoms with routine daily activities for decades before disease progression actually catches up with them. This lag period between symptom development and often-irreversible lung disease is difficult to assess without measurable parameters. One of the simplest and more accurate assessment tools for both diagnosis and follow-up is spirometry.

Spirometry typically measures the maximal volume of air forcibly exhaled from the point of maximal inhalation (forced vital capacity, FVC) and the volume of air exhaled during the first second of the FVC (forced expiratory volume in 1 second, FEV₁). Spirometry measurements before and after the patient inhales a short-acting bronchodilator should be undertaken for patients in whom the diagnosis of asthma is being considered. This helps determine whether there is airflow obstruction and whether it is reversible over the short term.

Many asthmatics can have subtle abnormalities on their spirometry while they are still asymptomatic. This is very important since early diagnosis can improve long-term outcome and provide guidance with decisions on medications, dosage and management plans. Physicians who care for asthma patients should have access to spirometry, which is useful in both diagnosis and periodic monitoring. Spirometry should be performed using equipment and techniques that meet standards developed by the American Thoracic Society.

Spirometry is a covered Medicaid procedure. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.

Source: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda, MD): National Institutes of Health, National Heart, Lung and Blood Institute, NIH Institute: 1997.

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According to the New England Journal of Medicine, the majority of cases of type 2 diabetes in middle aged women could be prevented by weight loss, regular exercise, modification of diet, abstinence from smoking and the consumption of limited amounts of alcohol. Findings include:

• Women who are overweight are eight times more likely to be diagnosed with the disease than lean women. Obese women are 20 times more likely.
• Women who do at least seven hours a week of brisk walking, jogging, heavy gardening or housework, or other activities "vigorous enough to build up a sweat" have a 30 percent lower risk than women who exercise less than half an hour a week.
• Women who eat the most high-fiber cereals and breads (rather than sweets, potatoes, and other refined carbohydrates) and the most polyunsaturated fats (rather than saturated and trans fats) have half the risk.

Practitioners are encouraged to educate their patients on the importance of weight loss and regular exercise. Excess body fat is the single most important determinant of type 2 diabetes. Exercise has also been found to reduce the risk of diabetes even if the patient does not have significant weight loss. It is important to note that the public generally does not recognize the connection between being overweight or obese and diabetes.

For further information regarding type 2 diabetes in women, please refer to "Information for Providers" on the Department's website at: http://www.health.state.ny.us/ or the following websites: http://www.niddk.nih.gov/ and http://www.diabetes.org/diabetes-statistics/women.jsp

For additional information regarding Medicaid payment on medically necessary care, services and supplies for the diagnosis and treatment of diabetes, please contact the Bureau of Program Guidance at (518) 474-9219.

Source: New England Journal of Medicine, September 13, 2001, Vol. 345, No. 11, pp. 790-797.

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Effective August 1, 2001, new reimbursement amounts have been established for ambulette transports of New York City Medicaid recipients. The following questions and answers are designed to facilitate the ordering of appropriate ambulette services under the new structure.

Effective for ambulette/wheelchair van transports occurring on or after August 1, 2001, the following reimbursement structure is in effect:

¹ The common medical marketing area (CMMA) means the geographic area from which a community customarily obtains its medical care and services. In New York City, the CMMA is five (5) miles from one's residence.

• Your only consideration when ordering ambulette transportation is the distance traveled by the Medicaid recipient.
  • If the recipient will travel no more than five miles then use procedure code 66101 when ordering the transport.
  • If the recipient will travel more than five miles then use procedure code 66103 when ordering the transport.
• There is no separate reimbursement of an escort of a recipient. Necessary escorts are to be transported by the ambulette service with no additional charge.
• There is no enhanced reimbursement for a person traveling in a wheelchair, or a person needing to be carried down steps. The only decision you must make is whether the recipient is traveling more or less than five miles.

Previous orders of ambulette transportation do not need to be changed

What is the responsibility of the ordering practitioner?

As an ordering practitioner, you are responsible for ordering only necessary Medicaid transportation within the recipient's CMMA, the geographic area from which a community customarily obtains its medical care and services. In New York City, the CMMA is five (5) miles from one's residence.

Recipients who have reasonable access to a mode of transportation used for normal activities of daily living, such as shopping and recreational events, should also use this mode to travel to and from medical appointments when that mode is available to them.

Medicaid may not pay for transportation expenses outside of the CMMA, or reimburse for a mode of transportation which the recipient does not use for normal activities of daily living, unless the recipient can demonstrate circumstances justifying such payment. Medicaid may restrict payment for the transportation if it is determined that the recipient chose to go to a medical provider outside of the CMMA when services were available within the CMMA, or the recipient could have taken a less expensive form of transportation and opted to take the more costly transportation.

As the medical practitioner requesting livery, ambulette, or ambulance services, you are also responsible for ordering the appropriate mode of transportation for the Medicaid recipient. A basic consideration for this should be the recipient's current level of mobility and functional independence. The transportation provided should be the least specialized mode required based on the recipient's current medical condition. For example, if you feel the recipient does not require personal assistance but cannot walk to public transportation, you should order livery service, not ambulette service.

Due to the extensive network of mass transportation in New York City, recipients should use mass transportation for travel to and from medical appointments unless a specific condition contraindicates such use.

What are the specific guidelines for ordering ambulette transportation?

Ambulette transportation may be ordered if any one of the following conditions exist:

1. The recipient needs to be transported in a recumbent position and the ambulette service ordered has stretcher-carrying capacity; or
2. The recipient is wheelchair bound and is unable to use a livery service or bus; or
3. The recipient has a disabling physical condition which requires the use of a walker or crutches and is unable to use a livery service, bus or subway; or
4. The recipient has a disabling physical condition other than one described above or a disabling mental condition, either of which requires the personal assistance provided by an ambulette service, and the ordering practitioner certifies that the recipient cannot be transported by a livery service, bus or subway and requires transportation by ambulette service; or
5. An otherwise ambulatory recipient requires radiation therapy, chemotherapy, or dialysis treatment which results in a disabling physical condition after treatment and renders the recipient unable to access transportation without the personal assistance provided by an ambulette service.

What does the Department of Health consider an ambulette service?

As defined in Department regulations (Title 18 New York Code of Rules and Regulation 505.10), an:

Ambulette service means an individual, partnership, association, corporation, or any other legal entity, which transports the invalid, infirm or disabled by ambulette to or from facilities which provide medical care. An ambulette service provides the invalid, infirm or disabled with personal assistance as defined in this subdivision (italics added).

Regulations define personal assistance as:

...the provision of physical assistance by a provider of ambulette services or the provider's employee to a [Medicaid] recipient for the purpose of assuring safe access to and from the recipient's place of residence, ambulette vehicle and Medicaid covered health service provider's place of business. Personal assistance is the rendering of physical assistance to the recipient in walking, climbing or descending stairs, ramps, curbs or other obstacles; opening or closing doors; accessing an ambulette vehicle; and the moving of wheelchairs or other items of medical equipment and the removal of obstacles as necessary to assure the safe movement of the recipient. In providing personal assistance, the provider or the provider's employee will physically assist the recipient which shall include touching, or, if the recipient prefers not to be touched, guiding the recipient in such close proximity that the provider of services will be able to prevent any potential injury due to a sudden loss of steadiness or balance. A recipient who can walk to and from a vehicle, his or her home, and a place of medical services without such assistance is deemed not to require personal assistance.

If personal assistance is not required, what should I order?

If personal assistance is not required, you should order livery service.

Most ambulette providers who work with you will transport livery-eligible recipients in the same vehicle as ambulette-eligible recipients. You should order one of the two procedure codes below:

How do I document the need for a particular mode of transportation?

The Human Resources Administration form (MAP 2015) Livery, Ambulette and Non-Emergency Ambulance Services Medicaid Transportation Prior Approval, should be used as a record of your decision to order Medicaid transportation.

Requests for the form MAP 2015, Livery, Ambulette and Non-Emergency Ambulance Services Medicaid Transportation Prior Approval, should be directed to the Human Resources Administration's Division of Medicaid Transportation at (212) 630-1513.

Questions regarding the ordering of transportation should be directed to the same Human Resources Administration number, or to the New York State Department of Health Provider Resource Unit at (518) 474-9219.

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Please Note: This article first appeared in the July 2001 Medicaid Update. Information has been added to the second table, Table of Medicaid Recipients Who Are Exempt From The Co-Payment Program. The changes to the table are underlined. The entire article is reprinted for your benefit

Medicaid co-payments have been in effect since November 1993. This article reiterates co-payment policy. Please share this information with your staff and/or employees and with patients and/or customers when they have questions about Medicaid co-payments. The Department of Health Co-Payment Hotline at 1 (800) 541-2831 is available for questions Monday through Friday between 8:30 am and 5:00 pm.

• Health care providers have an obligation to provide services and goods regardless of a recipient's ability to pay co-payments. The legislation enacting co-payments provides that a provider may not deny services to an eligible recipient based on a recipient's (or his/her agent's) statement that he/she cannot afford the co-payment. You may not refuse to provide services to otherwise eligible recipients who cannot afford to pay the co-payment.To refuse to provide services is an unacceptable practice.
• You may:
  • request the co-payment each time a recipient needs services or goods;
  • ask a recipient for outstanding co-payments the next time he/she comes in;
  • send the recipient bills; or,
  • use other legal means to collect the co-pay due.
• You must not reduce the amount charged on a Medicaid claim by the co-payment that is collected from a Medicaid recipient. Each claim that requires a co-payment will have the co-paymentautomatically deducted from the final payment when the claim is approved for payment.
• Some recipients become eligible for Medicaid by spending part of their monthly income on medical care. Since co-payments paid or incurred can be used toward satisfying the spenddown (overage) in the following month, itemized bills or receipts for co-payments should be provided to recipients when requested
• When eligibility is verified and a service authorization, if appropriate, is obtained on the date of service through the Electronic Medicaid Eligibility Verification System (EMEVS), you are required to enter co-payment information for each recipient, regardless of whether recipients pay or do not pay the co-payment.There is a $100 maximum per recipient for all co-payments incurred per year. Entering co-payment information will help to ensure that EMEVS accurately indicates when co-payments are no longer due from recipients and should not be deducted from your claims for the remainder of the current co-payment year. The co-payment year starts April 1^st and ends March 31^st.
• When a recipient reaches the $100 annual co-pay maximum, EMEVS will tell you that no co-payment is due from the recipient. The recipient will automatically receive a letter confirming the date on which the co-pay maximum was met and exempting the recipient from a co-payment until the end of the current co-payment year.
• For help with entering co-payment data on EMEVS, please call the EMEVS Helpline at 1-800-343-9000. To order an EMEVS Provider Manual, contact Computer Sciences Corporation, our fiscal agent, at one of the following telephone numbers:

• You should become familiar with what services or items have a co-payment or are exempt from co-payments and what groups of recipients are exempt from co-payments. Please see the following two (2) tables.
• If you have questions or concerns about Medicaid's co-payment policy, contact the toll-free Co-Payment Hotline at 1-800-541-2831 for assistance.

Service or Item	AMOUNT	DETAILS ABOUT CO-PAY	NO CO-PAY FOR THESE SERVICES
Clinic Visits	$3.00	Outpatient clinics in hospitals or freestanding clinics such as Community Health Centers	Mental Health Clinics Family Planning/Prenatal Services Alcohol, Drug Abuse Methadone Clinic Tuberculosis Directly Observed Therapy Developmental Disability/Mental Retardation Clinics
Brand Name Prescription	$2.00	One co-payment charge for each new prescription or fiscal order and for each refill	NO CO-PAY FOR: drugs to treat mental illness (psychotropic) Birth Control Tuberculosis Drugs
Generic Drug Prescription and Over-the-counter Medications	$.50	One co-payment charge for each new prescription or fiscal order and for each refill	NO CO-PAY FOR: drugs to treat mental illness (psychotropic) Birth Control Tuberculosis Drugs
Lab Tests	$.50	Several co-pays may be charged for one blood test because each test procedure has a co-pay	NO CO-PAY FOR: pregnancy or prenatal tests
X-Rays	$1.00	X-rays in hospital clinics, free-standing clinics, and community health clinics	NO CO-PAY FOR: x-rays in private doctors or dentists offices or for x-rays for emergencies
Medical Supplies	$1.00	Syringes,bandages,gloves,sterile irrigation solutions, incontinent pads (diapers), ostomy bags,heating pads,hearing aid batteries,nutritional supplements,etc.	NO CO-PAY FOR: for birth control supplies,condoms,diaphragms,contraceptive creams
Overnight Hospital Stays	$25.00 on the last day	One $25 co-payment for each hospitalization of any length involving at least one overnight stay	NO CO-PAY FOR: hospital stays for childbirth, miscarriage, family planning services, prenatal care or an emergency condition
Emergency Room	$3.00	Co-pay is only for non-urgent or non-emergency services	NO CO-PAY FOR: Urgent of emergency services received in an emergency room
Private Doctor's or Dentist's office	No Co-pay	No Co-pay	NO CO-PAY FOR: services provided in a private doctor or dentist's office

Under the Legislation, recipients who are eligible for both Medicare and Medicaid, and/or receive SSI (Supplemental Security Income) payments, are not exempt from Medicaid co-payments, unless they also fall under one of the following categories of people that are exempt.

CATEGORY OF PEOPLE EXEMPT FROM MEDICAID CO-PAYS	HOW TO KNOW A RECIPIENT IS EXEMPT FROM MEDICAID CO-PAYS
Children and teenagers under 21 years old	Medicaid Benefit card shows date of birth. If the card has the wrong birth date, contact the recipient, who then must contact his/her caseworker.
Pregnant women are exempt during the pregnancy and for 60 days postpartum after the month in which the pregnancy ends.	Recipient must have a doctor's note OR look pregnant OR the pregnancy is obvious from the type of service or prescription OR you can call the recipient's doctor to verify the pregnancy
Anyone enrolled in a Health Maintenance Organization or another Managed Care Program, including Family Health Plus	An insurance code on EMEVS indicates the recipient is in an HMO or other managed care program
Anyone enrolled in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program	An exception code* on EMEVS Indicates a recipient is in a CMCM or Service Coordination Program
Nursing Home residents	The code NH appears on EMEVS
Residents of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD)	An exception code* on EMEVS indicates that the recipient lives in an ICF
Residents of OMH (Office of Mental Health) certified community residences (CR), residential care centers for adults (RCCA), and family care homes (FC). This category does not include adult homes	Residential staff must give residents proof of residence (a letter to show the pharmacist, clinic and other providers). A letter must be used on a monthly basis. You must indicate the appropriate co-pay exemption code on your claim.
Recipients enrolled in the OMRDD Home and Community Based Services (HCBS) Waiver.	An exception code* on EMEVS tells providers that the person is a HCBS Waiver participant
Recipients enrolled in the Department of Health (DOH) Home and Community Based Services (HCBS) Waiver Program for Persons with Traumatic Brain Injuries (HCBS/TBI Waiver).	An exception code* on EMEVS tells providers that the recipient is an HCBS/TBI Waiver participant

*Please see the billing section of your Provider Manual to find instructions for entering the appropriate co-payment exception code on your claim, or contact CSC at one of the following numbers:

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This is to remind providers that useful information about the New York State Medicaid Program is available on the Department's web site at:
http://www.health.state.ny.us/health_care/medicaid/index.htm

Among the items posted is the Medicaid pamphlet "Need Help Paying for Medical Care? How Medicaid Helps You & Your Family," that may be accessed at: http://www.health.state.ny.us/health_care/medicaid/. Medicaid Income and Resource Levels providing consumers a benchmark in the eligibility process, as well as guidance for consumers on how to apply for Medicaid are included at this site.

Applications for Medicaid are made at the Local Department of Social Services in the applicant's county of residence. To assist your consumers the complete listing of county offices, including address and telephone number, may be found at:
http://www.health.state.ny.us/health_care/medicaid/ldss.htm

If the applicant resides in New York City, the New York City Human Resources Administration's web site will link the individual to the Medicaid offices in New York City at: http://www.nyc.gov/html/hra/pdf/medicaid_offices.pdf

Applicants must provide documentation of all available or potentially available income and resources and other eligibility requirements when applying for Medicaid. A review by Local Department of Social Services staff of the documentation determines whether an applicant qualifies for Medicaid.
Consumers are welcome to write to us . Questions may be submitted to the Medicaid Mailbox at: medicaid@health.state.ny.us
(Please note that this Department will not make a determination as to anyone's eligibility for assistance. The Local Department of Social Services in the applicant's county of residence makes this determination.)

Both providers and consumers can make use of the Department's listing of Important Telephone Numbers at: http://www.health.state.ny.us/health_care/medicaid/program/contact.htm  Included are the toll free numbers to report Medicaid fraud, inquire about co-payment requirements or Medicaid managed care issues, or to receive help on Medicaid billing questions.

Family Health Plus information, including application assistance sites, participating health plans, and qualifying income levels can be found at:
http://www.health.ny.gov/health_care/family_health_plus/

We encourage providers to visit this site for useful information and encourage you to share information with your consumers.

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Beginning February 1, 2002, remittances for Comprehensive Medicaid Case Management claims will no longer be returned from Computer Science Corporation (CSC) with edit 1120, "Claim Information Does Not Match Restricted Recipient File." Three new edits will be implemented, so that the remittance reason for the pend/denial is clearer. The new edits are:

• EDIT 01338: "Recip not on the Rest Recip File" (The Recipient is not on the Restriction/Exception Recipient file)
  This means that there is no Exception Code on file for this recipient. If you have not sent an enrollment to your local Social Services District (LDSS), send the enrollment. If the enrollment has been sent previously, call the LDSS to check on the progress of the enrollment.
• EDIT 01339: "Recip not Authorized for CMCM on SVC DT" (Recipient not Authorized for Case Management Services on the Service Date)
  This means that the recipient has been enrolled with the exception code, but the date of service on the claim does not fall within the enrollment dates on the file. Verify the accuracy of the enrollment dates with your LDSS contact.
• EDIT 01340: "Claim Prov not Equal Rest Recip File Prov" (Claim provider is not equal to the Restriction/Exception Recipient file provider)
  This means that the provider on the claim does not match the provider enrolled on the Restriction/Exception file. The client is enrolled to a different provider for the date of service for which you are billing. Contact the LDSS to inquire about the procedure for disenrolling the previous provider and enrolling the recipient to your provider identification number.

Claims will continue to be processed the same way they process currently. The only change is to the message you will receive when the claim pends or denies.

¹ If you are an Office of Mental Retardation And Developmental Disabilities (OMRDD) Medicaid Service Coordination provider, you must continue to contact the OMRDD Central Operations unit at (518) 402-4333.

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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