February 2009    Volume 25, Number 2  

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Dear Medicaid Provider,

Welcome to the February 2009 edition of the Medicaid Update. This month's issue features several important policy bulletins and pharmacy updates. The Department has also compiled an extensive update on Ambulatory Care Payment Reform. Please see our cover story for highlights.

We continually look for additional ways to keep you informed. If you have any ideas or comments about this publication, please e-mail us: medicaidupdate@health.state.ny.us

The Medicaid Update is a monthly publication of the New York State Department of Health and contains information regarding the care of those enrolled in the Medicaid program.

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In this issue....

Policy and Billing Guidance

Ambulatory Care Payment Reform
Wheeled Mobility Bases Enrollees
Oxygen Concentrator Update
Automatic Blood Pressure Machines Update

PHARMACY UPDATES

PART D Transition Supply Policy Reminder
Facilitated Enrollment for Duals
Inhaler Update

NEWS FOR ALL PROVIDERS

Important Change With IRS Form 1099
Smoking Cessation
Provider Services

Did you know?

The Medicaid Update, indexed by subject area, can be accessed on-line at: http://www.health.state.ny.us/health_care/medicaid/program/update/main.htm

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Physician Fee Increases

Effective January 1, 2009, New York State Medicaid fees for physicians and other practitioners are indexed to the 2008 Medicare physician fee schedule. This payment reform initiative is financed by a historic investment of $120 million, resulting in a projected 50% increase in payments for physician and practitioner services. The updated physician fee schedule can be viewed at the following link: http://www.emedny.org/ProviderManuals/Physician/index.html

Also effective January 1, 2009, physician offices serving Medicaid patients in health professional shortage areas (HPSAs) are receiving an additional 10% enhancement to their reimbursement. Both of these reform initiatives are designed to expand access to primary and preventive care for Medicaid beneficiaries.

Certified Asthma and Diabetes Educators

Effective January 1, 2009, New York State Medicaid began covering asthma and diabetes self-management services (ASMT and DSMT), provided by a New York State licensed, registered or certified health care professional, who is also certified as an educator by the National Asthma Educator Certification Board (CAE) or the National Certification Board for Diabetes Educators (CDE).

If you're a New York State Medicaid enrolled fee for service (office based) provider and are a CAE and CDE you only need to complete the CAE or CDE Employment Certification and Enrollment Questionnaire forms available on the eMedNY Website: http://www.emedny.org/info/ProviderEnrollment/index.html

Hospitals

The Ambulatory Patient Group (APG) payment methodology has been successfully implemented for hospital outpatient departments, ambulatory surgery units and emergency departments. Thousands of claims with APG rate codes are being processed daily by eMedNY and nearly all affected hospitals have successfully submitted claims using the new APG rate codes.

To save providers from having to submit adjustment claims for dates of service on or after the effective dates for APG implementation, eMedNY automatically reprocessed 120,000 outpatient clinic, ambulatory surgery, and emergency department claims received and paid prior to January 25, 2009, using the new APG rate codes. This reprocessing resulted in upward adjustments of $3.2 million to hospitals for outpatient services based on the APG payment methodology.

Diagnostic and Treatment Centers Including Free-standing Ambulatory Surgery Centers

While scheduled for March 1, 2009, implementation of APGs in Diagnostic and Treatment Centers (D&TCs) including free-standing ambulatory surgery centers will not begin until federal approval is received. The Department is responding to CMS' request for additional information on the State Plan Amendment authorizing federal financial participation for APG payments. Discussions with CMS are ongoing and approval is anticipated soon. D&TCs were notified by letter of the process that should be followed pending CMS approval.

For additional information on APGs please visit the Department's APG Webpage at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/index.htm

The Department and eMedNY have also established an "APG Known Issues List." This list is frequently updated and includes important announcements, new issues, active issues and recently closed issues. Please visit the following Websites to access the list. http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_known_issues.pdf or http://www.nyhipaadesk.com

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Unlike most services, certain customized or specialized wheeled mobility bases are eligible for an Advance Determination of Medicare Coverage (ADMC) review prior to provision of service. When Medicare decides that the beneficiary does not meet Medicare coverage criteria established for the base equipment, Medicaid will review a prior approval request.

The request must include a copy of the ADMC and all the supporting documentation required by and submitted to Medicare.*

When a particular item is eligible for ADMC, all options and accessories ordered by the physician for that patient, along with the base HCPCS code, are eligible for ADMC.

THE CURRENT LIST OF CODES AVAILABLE FOR ADMC ARE:

Manual wheelchairs described by codes: E1161, E1231-E1234, K0005, and K0009;

Group 2, 3, 4 or 5 Single Power Option or Multiple Power Options wheelchair (K0835-K0843, K0856-K0864, K0877-K0891)- whether or not a power seating system will be provided at the time of initial issue. Group 3 or 4 No Power Option wheelchair (K0848-K0855, K0868-K0871) that will be provided with an alternative drive control interface at the time of initial issue.

Group 3 or 4 No Power Option wheelchair (K0848-K0855, K0868-K0871) that will be provided with an alternative drive control interface at the time of initial issue.

Effective January 2009, for powered wheeled mobility bases that are not listed on the ADMC list and intended only for use outside of the home, Medicaid will review a prior approval request without requiring a claims denial from the DME MAC.

This exception will facilitate faster ordering and delivery of the wheeled mobility base.

*Refer to the DME Medicare Administrative Contractor (DME MAC) Supplier Manual at: http://www.medicarenhic.com/dme/dmemaca_sm_ch10-rev2008-07.pdf

For more information please refer to eMedNY.org, DME Provider Communications. Prior Approval for Dually Eligible, August 2007: http://www.emedny.org/providermanuals/DME/communications.html

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Portable oxygen concentrators are reimbursable effective for dates of service on and after January 1, 2009. Please make the changes, noted below, in your DME Procedure Code section:

• E1392 Portable oxygen concentrator, rental
  • The monthly rate for code E1392 is $195.00 and includes all oxygen needs: stationary, portable and emergency gaseous supply in place for a power outage, malfunction of the concentrator, or other emergency situations.
  • Code E1392 is not reimbursable in conjunction with any other oxygen system (codes E1390, E0424, E0431, E0434 or E0439).
  • Do not report modifier 'RR' with code E1392, unless the 'RR' was used when billing Medicare or other insurances.

Billing instructions for home fill systems:

• Providers billing E1390 Oxygen concentrator (stationary) which feature oxygen home fill systems may bill code E0431 portable gaseous oxygen in conjunction. The combined payment includes all oxygen needs: stationary, portable and emergency gaseous supply in place for a power outage, malfunction of the concentrator, or other emergency situations.

NOTE: The monthly payment for all oxygen systems includes all necessary equipment, delivery, maintenance and repair costs, parts, supplies, any type oxygen tank holder and services for equipment set-up, maintenance and replacement of worn essential accessories or parts.

Questions? Please call the Division of Provider Relations and Utilization Management at (800) 342-3005.

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Effective for dates of service on or after January 1, 2009, automatic blood pressure machines are reimbursable when prior approved and billed using the code A4670 Automatic blood pressure monitor (semi or fully automatic).

Blood pressure machines will be covered when ordered by a qualified practitioner as part of a comprehensive treatment plan for patient monitoring and recording in the home.

Semi-automatic (hand cuff inflation, contraction of bulb) machines will be approved when the beneficiary has a hearing or visual impairment, or when the beneficiary can not be taught to use a manual monitor due to low literacy skills or learning impairment. The maximum reimbursement is $31.00

Fully-automatic (push button operation) machines are covered when the beneficiary meets the criteria for semi-automatic, and has Arthritis or other motor disorders involving the upper extremities. The maximum reimbursement is $65.00

For information on obtaining prior approval visit: www.emedny.org/ProviderManuals/DME/PDFS/DME_PA_Guidelines.pdf or call the eMedNY Call Center at (800) 343-9000.

Questions on coverage criteria may be referred to the Division of Provider Relations and Utilization Management at (800) 342-3005.

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Medicare prescription drug plans are required to have an appropriate transition process for patients that switch plans.

Plans must cover at least a 30 day transition supply of medication during the first 90 days of the beneficiary's enrollment. In the long term care setting, plans must cover at least a 31 day supply plus all necessary refills throughout the first 90 days of enrollment.

Pharmacists are encouraged to review any special messaging they may receive through the claims processing system. Some of these messages may include information regarding the need for prior authorization or the need to take some other action (i.e., calling a plan's hotline to ensure the processing of a transition supply of drug).

The pharmacist must also provide information to the enrollee regarding the exception and appeal process if a drug is not covered by the plan. Pharmacists may be asked by the enrollee to assist them with this process.

Prescribers are encouraged to take action to ensure that enrollees will continue with their necessary drug regimen. This may entail switching an enrollee to a covered formulary drug or initiating step therapy, if appropriate, or obtaining an exception authorization through the prescription drug plan. Contact the enrollee's plan for more information.

Questions about Medicaid pharmacy policy? Contact the Bureau of Pharmacy Policy and Operations at (518) 486-3209.

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The Point of Sale Facilitated Enrollment (POS FE) process was designed to ensure that individuals with both Medicare and Medicaid (dual eligibles), who are not enrolled in a Medicare Part D prescription drug plan are still able to obtain services immediately at the pharmacy when a pharmacist believes that an individual has provided the Best Available Evidence of having both Medicare and Medicaid coverage.

The following four steps provide a quick reference guide for using the POS FE process:

• STEP 1 Ask for the Patient ID Card or other plan enrollment confirmation. Once the information is provided;
• STEP 2 Submit an E1 Transaction to identify possible plan enrollment. If no plan enrollment is found;
• STEP 3 Confirm Medicare/Medicaid/LIS Eligibility. Once eligibility is confirmed;
• STEP 4 Submit claims following the POS FE Process. Once all claim edits are satisfied, the claim is paid. CMS will facilitate enrollment into a zero-premium plan for individuals receiving the full subsidy.

If you require further information regarding the POS FE process, please visit the NextRx Provider portal at: http://www.wellpointnextrx.com/wps/portal/wpo/provider/home

Additional information available on the CMS Website: http://medicaidprovider.hhs.mt.gov/pdf/posfefoursteps041808.pdf

Questions about Medicaid pharmacy policy? Contact the Bureau of Pharmacy Policy and Operations at (518) 486-3209.

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Effective February 18, 2009, the preferred albuterol HFA inhaler for NYS Medicaid is Ventolin HFA. As of this date, Proventil HFA will be non-preferred and new prescriptions will require prior authorization. You will find the most up-to-date Quicklist, with a full listing of preferred drugs for all drug categories subject to the Preferred Drug Program at: http://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDLquicklist.pdf. Additional information can be found on-line at: http://www.nyhealth.gov and http://newyork.fhsc.com

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Computer Sciences Corporation (CSC), the eMedNY contractor for the Department of Health (DOH), issues IRS (Internal Revenue Service) Form 1099 to providers at the beginning of each year for the previous year's Medicaid payments.

In previous years, a 1099 would be issued for each Medicaid Provider Number. However, beginning in January 2009, 1099s will be issued by taxpayer identification number (TIN). Therefore, if multiple provider identifiers (Medicaid Provider Numbers or National Provider Identifiers) share a common TIN, only one 1099 will be issued.

As with previous years, please note that the IRS 1099 amount is not based on the date of the checks; rather, it is based on the date the checks were released to providers.

Due to the two-week check lag between the date of the check and the date the check is issued, the IRS 1099 amount will not correspond to the sum of all checks issued for your provider identification number during the calendar year.

The IRS 1099 that will be issued for the year 2008 will include the following:

• Check dated 12/17/07 (Cycle 1582) released on 01/02/2008 through;
• Check dated 12/15/08 (Cycle 1634) released 12/31/08.

Additionally, in order for group practice providers to direct Medicaid payments to a group identification number and corresponding IRS 1099, providers are reminded that they must submit the group identification number in the appropriate field on the claim (paper or electronic).

Claims that do not have the group identification number entered will cause payment to go to the individual provider and his/her IRS 1099.

Please note that 1099s are not issued to providers whose yearly payments are less than $600.00.

IRS 1099s for the year 2008 will be mailed no later than January 31, 2009.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

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Missing Issues?
The Medicaid Update, indexed by subject area, can be accessed online at:
http://www.nyhealth.gov/health_care/medicaid/program/update/main.htm

Office of the Medicaid Inspector General: http://www.omig.state.ny.us (518) 473-3782

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS transactions?
Please contact eMedNY Call Center at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:
http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email: emednyproviderrelations@csc.com

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

Address Change?
Questions should be directed to the eMedNY Call Center at: (800) 343-9000.

Fee-for-Service Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-Based/Institutional Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlack, at: medicaidupdate@health.state.ny.us

Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.