New York State Medicaid Update - November 2015 Volume 31 - Number 12

In this issue...

ALL PROVIDERS POLICY AND BILLING GUIDANCE PHARMACY UPDATE PROVIDER DIRECTORY
ALL PROVIDERS

Mandatory Electronic Prescribing in New York State

Effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances will be required in New York State.

⇒In order to process electronic prescriptions for controlled substances (EPCS), a prescriber must select and use a certified electronic prescribing computer application that meets all federal requirements. Each unique certified computer application used to electronically prescribe controlled substances must first be registered by the practitioner with the New York State Department of Health, Bureau of Narcotic Enforcement (BNE).

⇒Prescribers who have certified EPCS software and have completed the registration process are highly encouraged to begin electronically prescribing instead of using paper. This will allow for time to resolve technical or workflow issues prior to the mandate's effective date.

⇒Please be aware that implementation timelines for EPCS software vary and may be lengthy. If you have not already begun this process, it is recommended that you begin immediately.

⇒ The laws regarding issuing and dispensing prescriptions for controlled substances, from paper to the electronic method, have not changed. Only the format has changed.

For downloadable information to help patients better understand electronic prescribing, please click on the following link:
http://www.health.ny.gov/publications/1098.pdf

Other useful information related to electronic prescribing, including frequently asked questions and information regarding the EPCS registration process, can be found on BNE's website at: http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Record (EHR) Incentive Program provides financial incentives to eligible professionals and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011 over $728 million in incentive funds have been distributed within 21,429 payments to New York State Medicaid providers.

21,429 Payments.

$728+ Million Paid.

Are you eligible? For more information, visit www.emedny.org/meipass

Modifications to Meaningful Use 2015 Through 2017

On 10/16/2015, the Centers for Medicare and Medicaid Services (CMS) published a final rule that sets new criteria for eligible professionals (EPs) and eligible hospitals (EHs) participating in the EHR Incentive Programs. Key points of the modified meaningful use criteria (known as Modified Stage 2) that impact providers in 2015 include:

  • Calendar-based EHR reporting for all providers, including an extended period for EHs in 2015 (October 1, 2014 to December 31, 2015)
  • 90-day EHR reporting period for all providers in 2015
  • Single set of required objectives and measures (10 for EPs, 9 for EHs), including accommodations for Stage 1 providers in 2015

Modified Stage 2 is effective December 15, 2015. Providers who attest prior to this date must comply with the previous meaningful use requirements.

For more guidance, please review the CMS tip sheets:

We also encourage providers to register for our live webinars to learn about meaningful use and public health reporting requirements. Registration is available at www.emedny.org/meipass/info/Events.aspx.

Announcements will be made on the NY Medicaid EHR Incentive Program website and LISTSERV when providers may attest for Modified Stage 2 for 2015.

Questions? Contact hit@health.ny.gov for program clarifications and details.

The New York Medicaid Management Information System (NYMMIS) Update

The New York State Department of Health and Xerox Healthcare, LLC are continuing work on the design and development of NYMMIS.

In early 2016, all new provider enrollments (enrollments for providers who are not currently enrolled in the New York State Medicaid program), will be handled by NYMMIS. Other functionality and activities will be added in releases throughout 2016 and 2017.

In order for providers and all interested parties to stay up-to-date on process changes related to NYMMIS, all are being encouraged to sign up for the ListServ on the Interim NYMMIS website: http://www.interimnymmis.com/. In addition, training opportunities for NYMMIS are now available. Information on training sessions can also be obtained on the interim website.

Certification of Compliance with Section 6032 of the Deficit Reduction Act of 2005, Section 1902 of the Social Security Act, and Title 42 of the United States Code Section 1396a (a)(68)

Reminder of December 2015 Certification Obligation

THIS IS A REMINDER FROM THE NEW YORK STATE OFFICE OF THE MEDICAID INSPECTOR GENERAL (OMIG) FOR ALL PROVIDERS WHO ARE SUBJECT TO THE REQUIREMENTS UNDER TITLE 42 OF THE UNITED STATES CODE SECTION 1396a (a)(68), [42 USC§1396a (a)(68)].

On December 1, 2015, OMIG will make available on its website, the Federal Deficit Reduction Act (DRA) of 2005 DRA Certification Form (Certification Form) for 2015. Frequently asked questions (FAQs) pertaining to the December 2015 Certification Obligation will also be posted.

Additionally, OMIG has posted on its website a webinar that provides information about and guidance on completing the new 2015 certification form. The webinar is available at:
https://www.omig.ny.gov/resources/webinars

42 USC §1396a provides in relevant part that:
(a) A State plan for medical assistance must-
(68) provide that any entity that receives or makes annual payments under the State plan of at least $5,000,000, as a condition of receiving such payments, shall-
(A) establish written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the False Claims Act established under sections 3729 through 3733 of title 31, United States Code, administrative remedies for false claims and statements established under chapter 38 of title 31, United States Code, any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs (as defined in section 1320a-7b(f) of this title);
(B) include as part of such written policies, detailed provisions regarding the entity's policies and procedures for detecting and preventing fraud, waste, and abuse; and
(C) include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), the rights of employees to be protected as whistleblowers, and the entity's policies and procedures for detecting and preventing fraud, waste, and abuse; ...

OMIG addresses this mandate by monitoring a provider's certification of compliance status and conducting compliance program reviews of required providers.

Questions on the December 2015 Certification Obligation should be directed to OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address compliance@omig.ny.gov.

Mandatory Compliance Program Certification Requirement under 18 NYCRR §521.3(b)

Reminder of December 2015 Certification Obligation

THIS IS A REMINDER FROM THE NEW YORK STATE (NYS) OFFICE OF THE MEDICAID INSPECTOR GENERAL (OMIG) FOR ALL MEDICAID REQUIRED PROVIDERS WHO ARE SUBJECT TO THE NYS SOCIAL SERVICES LAW SECTION 363-d MANDATORY COMPLIANCE PROGRAM REQUIREMENT.

If you are a required provider as defined in 18 NYCRR 521, you are required to certify each December on OMIG's website at www.omig.ny.gov, that you have a compliance program in place that meets the requirements of the applicable law and regulations.

If you need assistance in determining if you are a required provider, please see the Compliance landing page on OMIG's website and complete the questions on the "Are you required to have a compliance program?" survey. The law, regulation, and guidance documents related to the mandatory compliance program requirements are also available on this page.

Additionally, OMIG has posted on its website a webinar that provides information about and guidance on completing the new 2015 certification form. The webinar is available at: https://www.omig.ny.gov/resources/webinars.

On December 1, 2015, OMIG will make available on its website, the NYS Social Services Law Compliance Program Certification Form (Certification Form) for 2015. The Certification Form for 2014 will remain active on OMIG's website until December 1, 2015 for newly enrolling and revalidating Medicaid providers.

Please note that the NYS Department of Health (DOH) is revalidating Medicaid providers' enrollment in the medical assistance program. As part of the DOH's revalidation process, required providers will be asked to submit evidence that they met the December certification obligation. Certifying in December and retaining a copy of the certification confirmation and/or confirmation emails will help those Medicaid providers who are required to have a compliance program when they complete the revalidation process.

The regulation and Frequently Asked Questions (FAQs) are available on the OMIG website. OMIG's listserv subscribers will be notified when the new forms are posted.

It is the responsibility of required providers to determine:

a. if it has a compliance plan that meets the requirements of SSL § 363-d subsection 2 and 18 NYCRR § 521.3 (c);

b. if its compliance program is effective; and

c. if they are required to certify annually.

Questions on the December 2015 certification obligation should be directed to OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address compliance@omig.ny.gov.

Questions regarding the enrollment and revalidation process should be directed to the Bureau of Provider Enrollment within the Office of Health Insurance Programs at (518) 402-1278.

-Reminder-

POLICY AND BILLING GUIDANCE

PCMH Incentive Change Implementation Date January 1, 2016

Patient Centered Medical Home Statewide Program Incentive Payments

On January 1, 2016, the reimbursement for PCMH incentive payments will be updated to reflect the program changes that were originally published in the February 2015 Medicaid Update. Incentives for providers recognized at level 2 or level 3 under the National Committee for Quality Assurance's (NCQA's) 2011 standards will be reduced and incentives for providers recognized at level 2 or level 3 under NCQA's 2014 standards will be increased. Table 1 summarizes the Medicaid Managed Care (MMC) per member per month (PMPM) payment and the Medicaid fee-for-service (FFS) 'add-on' amounts by provider type and recognition status, which will be begin on January 1, 2016.

Table 1: PCMH Statewide Incentive Payment Program PMPM and 'Add-on' Amounts
Effective January 1, 2016
NCQA Level 2
2011/2014 Standards		 NCQA Level 3
2011/2014 Standards
MMC - PMPM $2.00 / $6.00 $4.00 / $8.00
FFS Per Visit
Institutional $7.75 / $23.25 $12.50 / $25.25
Professional $6.75 / $20.50 $14.50 / $29.00

Table 2 summarizes the current MMC PMPM payment and the Medicaid FFS 'add-on' amounts by provider type and recognition status which will remain in effect through December 31, 2015.

Table 2: Statewide PCMH Incentive Payment Program PMPM and 'Add-on' Amounts
Terminating December 31, 2015
NCQA Level 1, 2, or 3* 2008 Standards NCQA Level 2 2011 or 2014 Standards NCQA Level 3 2011 or 2014 Standards
MMC - PMPM $0.00 PMPM $4.00 PMPM $6.00 PMPM
FFS Per Visit
Institutional $0.00 $11.25 $16.75
Professional $0.00 $14.25 $21.25

*NCQA Level 1 payments for all standard years were discontinued on January 1, 2013.
**NCQA Level 2 payments for 2008-recognized providers were discontinued on July 1, 2013.
***NCQA Level 3 payments for 2008-regcognized providers were discontinued on April 1, 2015.

For more information on FFS claim eligibility, please see page 13 of the February 2015 Medicaid Update article.

New York Medicaid providers participating in the Adirondack Medical Home Demonstration Project are not eligible for enhanced payment through the Statewide PCMH Program.

Questions/Information:

For more information on how to achieve NCQA PCMH recognition, providers may contact NCQA at (888) 275-7585 or visit NCQA's website at www.ncqa.org.

MMC PCMH questions may be directed to the Division of Health Plan Contracting and Oversight at 518-474-5050, or the eMedNY Call Center at (800) 343-9000 or pcmh@health.ny.gov regarding Medicaid FFS questions.

For more information on claim eligibility please contact eMedNY at (800) 343-9000.

Reporting of Third Party Health Insurance Information
-Reminder-

Providers are reminded that pursuant to the billing procedures, all nursing home claims including Hospice must contain the Third Party Health Insurance Information.

To ensure proper payment, providers should follow these guidelines when billing Medicaid fee-for-service as well as billing Medicaid Managed Care plans.

For Medicaid fee-for-service billing guideline questions, please contact the eMedNY Call Center at 1-800-343-9000.

Medicaid Managed Care billing and reimbursement inquiries should be directed to the enrollee's Medicaid Managed Care plan.

Medicare Part B Providers
-Reminder-

Pursuant to 2015 changes to Social Services Law, the NYS Department of Health is revising the Medicaid reimbursement methodology for claims containing Medicare Part B services/supplies. Effective January 1, 2016, Medicaid will no longer reimburse partial Medicare Part B coinsurance amounts when the Medicare payment exceeds the Medicaid fee or rate for that service. This change is retroactive to July 1, 2015 and applies to Medicare Part B services.

These changes will also apply to claims submitted by pharmacies for certain drugs and supplies. Additional information on the effective date specific to pharmacy claims will be forthcoming.

Additional information is also contained in the July 2015 Medicaid Update article entitled, Clarification on Medicaid Reimbursement of Medicare Part B Services Including Pharmacy Items.

Pharmacy Update

New York State Medicaid Pharmacy Prior Authorization Programs Update

On September 17, 2015, the New York State Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy Prior Authorization (PA) programs. The Commissioner of Health has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program. Effective November 19, 2015 PA requirements will change for some drugs in the following PDP classes:

  • Agents for Actinic Keratosis
  • Anabolic Steroids - Topical
  • Antipsychotics - Second Generation
  • Insulin - Rapid Acting

The PDP has also expanded to include one additional drug class. Non-preferred drugs in the following class will require PA:

  • Inhaled Antibiotics

Also effective November 19, 2015 the FFS pharmacy program will implement the following parameters recommended by the DUR Board:

  • Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
  • Diagnosis Requirement: Familial Hypercholesterolemia (heterozygous or homozygous) or Atherosclerotic Cardiovascular Disease
  • Require trial of statin therapy at maximum tolerated dosage
  • Require concurrent statin therapy

For more detailed information on the above DUR Board recommendations, please refer to the meeting summary at: http://www.health.ny.gov/health_care/medicaid/program/dur/

Please note that PA requirements are not dependent on the date a prescription is written. New prescriptions and refills on existing prescriptions require PA even if the prescription was written before the date the drug was determined to require PA.

Below is a link to the most up-to-date information on the Medicaid FFS PA Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs: https://newyork.fhsc.com/downloads/providers/NYRX_PDP_PDL.pdf

To obtain a PA, please call the PA clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain PA.

Medicaid enrolled prescribers with an active e-PACES account can initiate PA requests through the web-based application PAXpress®. The website for PAXpress is https://paxpress.nypa.hidinc.com/. The website may also be accessed through the eMedNY website at: http://www.eMedNY.org as well as Magellan Medicaid Administration's website at http://newyork.fhsc.com.

New York State Medicaid Fee-for-Service Pharmacy Changes for Behavioral Health Medications

In an effort to align NYS Medicaid fee-for-service (FFS) coverage with the pharmacy changes associated with the NYC Behavioral Health transition to Medicaid Managed Care (MMC) plans, effective October 1, 2015, course limitations on smoking cessation medications have been removed.

Additionally, members who currently have Medicaid FFS pharmacy benefit, with no managed care component for pharmacy, can obtain atypical long-acting injectables, as well as injectable naltrexone extended release (Vivitrol®) as both a medical and pharmacy benefit.

The chart below provides guidance for those members who have MMC pharmacy benefits to help determine coverage (MMC vs. FFS) for risperidone microspheres (Risperdal Consta(®), paliperidone palmitate (Invega Sustenna(®)and Invega Trinza (®), olanzapine (Zyprexa Relprevv(™), aripiprazole (Abilify Maintena(®), aripiprazole lauroxil (Aristada(™) and naltrexone (Vivitrol(®) as of 10/1/2015.

Member Qualified for
Social Security
Income
(SSI) or is SSI
Related 		Member's Geographic
Location		 Age Coverage
Provided By		 Available
through the
Medical
Benefit		 Available
through the
Pharmacy
Benefit
No Entire State All Ages MMC Plan Yes Yes
Yes New York City 21 or older MMC Plan Yes Yes
Yes New York City 20 or younger Medicaid FFS Yes No*
Yes Outside of New
York City		 All Ages Medicaid FFS Yes No*

*Note- The Department is working on implementing system changes to allow for atypical long-acting injectables, as well as injectable naltrexone extended release (Vivitrol(®)) to be covered as a pharmacy benefit for those members with MMC who continue to access these medications through Medicaid FFS (as shown above). More information will be communicated on this as we continue to make progress.

Prescribers should continue to use their professional judgement to determine the best method of accessing injectable medications that require the administration of a health care practitioner. Likewise, pharmacists should continue to use their professional judgement when providing such medications directly to the enrollee. Medicaid policy for appropriate delivery of medications, including adherence to signature requirements should also be followed.

For additional information on Medicaid FFS delivery requirements for prescription drugs, see page 11 of the September 2011 issue of the Medicaid Update, titled "New York Medicaid Pharmacy Services Signature Requirement", as well as page 15 of the January 2013 issue of the Medicaid Update, titled "Important Reminder to Pharmacies and DME Providers".

New York State Medicaid Managed Care Pharmacy Benefit Information Center Behavioral Health Update
http://pbic.nysdoh.suny.edu/

The New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center web site has been updated to include additional information regarding the drug classes affected by the Behavioral Health Transition.

As referenced in the October 2015 Medicaid Update, this web site has been updated to provide a link (highlighted below), from the HOMEPAGE, that will direct you to a MMC Plan's specific information regarding its coverage of relevant drug classes.

General Pharmacy Benefit Information
Medicaid Covered Drugs
Prior Authorization Form
Behavioral Health Transition
Drug Look-Up

This site also provides a "drug look-up" option, and functionality to view coverage for selected therapeutic classes; e.g., Atypical Antipsychotics, Smoking Cessation Agents and Drugs to Treat Chemical Dependence.

From the DRUG LOOK-UP page select the Mental Health Quicklist tab to find the recently added Injectable Antipsychotics list.

Select the Therapeutic Classes, Other tab and find the recently added Smoking Cessation and Drugs to Treat Chemical Dependence lists.

Once you select a drug list to view there is additional information below the list about the transition as well as a link to the FAQ page.

DRUG LOOK-UP(PDF, 2pg)

The New York State MMC Pharmacy Benefit Information Center is updated frequently. Visit the site for the most up-to-date information. http://pbic.nysdoh.suny.edu/

For More information on the Behavioral Health Transition see the September 2015 issue of the Medicaid Update. http://www.health.ny.gov/health_care/medicaid/program/update/2015/sept15_mu.pdf

Important Information for Prescribers to Assist in Expediting the
Medicaid Prior Authorization (PA) Process

When contacting the Clinical Call Center to request a PA, the provider or an authorized agent will need to provide the following information:

  • Prescriber name and NPI
  • Beneficiary's diagnoses
  • Requested medication, quantity, number of refills and prescribing information
  • Clinical rationale supporting the use of the requested medication
  • Previous medication trials

It is very helpful to have any/all medical records available before calling to ensure that you will be able to provide the above information.

Please note: If, for any reason, the PA cannot be approved by the technician, the actual prescriber (not the prescriber's agent) will be required to have a clinical discussion with the pharmacist.

Fax Process

When faxing a PA request to the Clinical Call Center, please ensure the following information is clearly written on the form:

  • Beneficiary's name, date of birth and Client Identification Number (CIN)
  • Prescriber's National Provider Identification (NPI) number, name, specialty and contact information
  • Requested medication, quantity, number of refills and prescribing information
  • Beneficiary's diagnoses
  • Clinical rationale that supports the use of the requested medication
  • Any medical trials

Please be sure the form is signed before faxing to the Clinical Call Center.
Clinical Call Center Fax # 800-268-2990
Clinic Call Center Telephone # 877-309-9493

Consult the New York State Medicaid fee-for-service (FFS) Pharmacy Program document from the following link for the most up-to-date information on the Medicaid FFS Pharmacy PA Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs and will give you an idea of what information will be needed to obtain the PA. https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

Additional information, such as the Medicaid Standardized PA form and clinical criteria for the Preferred Drug Program (PDP) and Clinical Drug Review Program (CDRP), is available from the following website: https://newyork.fhsc.com/providers/PA_forms.asp

To obtain a PA, please contact the PA clinical call center at (877) 309-9493, 24 hours per day, 7 days per week. Pharmacy technicians and pharmacists will work with you, or your agent, to quickly obtain a PA.

Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress(®) is a web-based pharmacy PA request/response application accessible through the button "PAXpress" located on eMedNY. https://www.emedny.org/

Provider Directory

Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit www.omig.ny.gov.

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at: www.emedny.org.

Providers wishing to listen to the current week's check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount).

Do you have questions about billing and performing MEVS transactions?
Please call the 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 e-mail: emednyproviderrelations@csc.com.

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites: http://www.health.ny.gov/health_care/medicaid/program/prescriber_education/presc-educationprog and http://nypep.nysdoh.suny.edu/home

Need to change your address? Does your enrollment file need to be updated because you have experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit http://www.emedny.org/info/ProviderEnrollment/index.aspx and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.).

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Amy Siegfried, at medicaidupdate@health.ny.gov

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
Governor
State of New York

Howard A. Zucker, M.D., J.D.
Commissioner
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs