New York State Medicaid Update - November 2016 Volume 32 - Number 11

In this issue …

FIDA Demonstration Extended through December 31, 2019

The Fully Integrated Duals Advantage (FIDA) Demonstration was originally approved to run January 1, 2015 through December 31, 2017. Last year, the Centers for Medicare & Medicaid Services (CMS) offered states an opportunity to extend their demonstrations through December 2019. After previously submitting a non-binding letter of intent to extend the demonstration, New York State Department of Health (NYSDOH) has now formally accepted the opportunity from CMS, and has officially committed to the two-year extension.

On August 26, 2013, the CMS announced that NYSDOH would partner with CMS to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience. Under the demonstration, NYSDOH and CMS would contract with Medicare-Medicaid Plans to coordinate the delivery of covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.

Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees is a priority for both CMS and NYSDOH. FIDA sought to provide Medicare-Medicaid enrollees with a better care experience by offering a participant-centered, integrated care initiative that provided a more easily navigable and seamless path to all covered Medicare and Medicaid services. Outside of this demonstration, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers. Many Medicare-Medicaid enrollees have multiple or severe chronic conditions and could benefit from enhanced care coordination and management of health and long-term supports and services. FIDA provides maximum integration of care to dual eligibles to ensure the provision of all medically necessary services, promote care in the community, and reduce avoidable hospitalizations and nursing facility stays. FIDA fully integrates Medicare and Medicaid benefits in a way not previously available in New York State.

While there have been many success stories of how FIDA has improved the lives of its participants, the first round of preliminary data from the independent evaluation is still likely at least six months away. The two-year extension will allow more time to assess the impact of FIDA on quality and cost of care. It will also allow time to maximize experience with fully integrated care through the demonstration while engaging stakeholders in planning for the future of integrated care in New York State when the demonstration comes to an end in 2019.

The FIDA Demonstration has been operating in New York City and Nassau County. Pending final review of the Medicare provider networks, NYSDOH anticipates rolling out FIDA to Region 2 (Westchester and Suffolk Counties) in 2017.

For more information, please visit the FIDA website at http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.

Mandatory Compliance Program Certification Requirement under Title 18 of the New York Codes, Rules and Regulation (NYCRR) Section 521.3(b)

Reminder of December 2016 Certification Obligation

This is a reminder from the New York State Office of the Medicaid Inspector General (OMIG) for all Medicaid required providers who are subject to the New York State Social Services Law Section 363-d Mandatory Compliance Program Requirement. If you are a required provider as defined in 18 NYCRR 521, each December you are required to certify 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.

OMIG will make the New York State Social Services Law 2016 Certification forms available on its website starting on December 1, 2016. Please note, there are some changes to the Certification form from 2015. Additionally, on or before December 1, 2016, OMIG will post on its website a webinar that provides information about and guidance on completing the new 2016 certification form. The webinar will be available at: https://www.omig.ny.gov/resources/webinars.

Questions on the December 2016 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.

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 2016 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 Section 1396a (a)(68)].

On December 1, 2016, OMIG will make available on its website, the Federal Deficit Reduction Act (DRA) of 2005 DRA Certification Form (Certification Form) for 2016. Frequently asked questions (FAQs) pertaining to the December 2016 Certification Obligation will also be posted. Additionally, on or before December 1, 2016 OMIG will post on its website a webinar that provides information about, and guidance on, completing the new 2016 Certification Form. The webinar will be available at: https://www.omig.ny.gov/resources/webinars.

OMIG Publishes Compliance Program Review Guidance

On October 26, 2016, the NYS OMIG published its Compliance Program Review Guidance. The Guidance is available at https://www.omig.ny.gov/images/stories/compliance/compliance_program_review_guidance.pdf.

The Guidance describes what OMIG looks for when it conducts compliance program reviews of providers that are subject to the mandatory compliance program requirements established in New York State Social Services Law Section 363-d subsection 2 and Title 18 of the New York Codes of Rules and Regulations at Section 521.3(c). Providers subject to the mandatory compliance program obligation of those sections can refer to the Guidance to identify the types of questions OMIG will ask when it conducts compliance program reviews.

Anyone with questions on the Compliance Program Review Guidance, or any compliance obligation in New York State Social Services Law Section 363-d or 18 NYCRR Part 521, can contact 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.

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 $783 million in incentive funds have been distributed within 24,287 payments to New York State Medicaid providers.

24,287
Payments

$783+
Million Paid

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

Did you know?

2016 is the last year that eligible professionals (EPs) may begin participation in the NY Medicaid EHR Incentive Program. An EP may receive up to $63,750 over the course of six years for the adoption and meaningful use of certified EHR technology. All adoption or meaningful use activities for payment year 2016 must be completed within the 2016 calendar year.

MEIPASS Availability

The NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) is currently closed due to important maintenance being performed on the system for meaningful use attestations for payment year 2015 and beyond. Program support will continue to be available by phone at 877-646-5410.

We thank you for your patience. Launch of the new MEIPASS system has been delayed due to issues found during testing. We want to make sure that the system operates smoothly for the provider community and for our team at the Department of Health. Please sign up for our LISTSERV to receive notification about when we will be accepting attestations again.

Preparing to Attest

Visit https://ehrincentives.cms.gov/hitech/login.action to register for the program.

Verify your system is complete and certified at http://chpl.healthit.gov/ on the Certified Health IT Product List.

Utilize NY Medicaid EHR Incentive Program support services:

  • Numerator Request: EPs may request a summary of their Medicaid claims as guidance for calculating Medicaid patient volume.
  • Pre-validation: Individual and group EPs who have already determined their Medicaid patient volume may submit data to NY Medicaid prior to attesting.

Questions? Contact NY Medicaid EHR Incentive Program Support at hit@health.ny.gov.

Need Assistance?

In addition to the NY Medicaid EHR Incentive Program Support Team, who can be reached via phone at 877-646-5410 or via email at hit@health.ny.gov, there are two Regional Extension Centers (RECs) available to assist you.

EPs in New York City can contact NYC REACH at 347-396-4888 or pcip@health.nyc.gov.

EPs outside of New York City can contact NYeC at 646-619-6400 or hapsinfo@nyehealth.org.

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

Revised Dental Policy and Procedure Code Manual and Dental Fee Schedule Available

A revised "Dental Policy and Procedure Code Manual" and "Dental Fee Schedule" are available on the eMedNY web site at https://www.emedny.org/ProviderManuals/Dental/index.aspx. The new manuals are effective for dates of service on or after November 1, 2016.

The 2016 "Dental Policy and Procedure Manual" and "Dental Fee Schedule" must be referenced for full details as well as a complete listing of all the changes. Reminder: the change to reimbursement methods for dental anesthesia codes and the one radiographic code were effective beginning on January 1, 2016.

The Following Codes Were End Dated December 31, 2015 and Have Been Removed:

  • D9220 (Deep sedation/general anesthesia – first 30 minutes)
  • D9221 (Deep sedation/general anesthesia – each additional 15 minutes)
  • D9241 (Intravenous moderate (conscious) sedation/analgesia – first 30 minutes)
  • D9242 (Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes)
  • D0260 (Extra-oral – each additional radiographic)

The Following New Codes Were Added and are Effective January 1, 2016:

Current Dental Terminology (CDT) Procedure CodeOffice-Based
Dental Practitioners
D0251 Extra-oral posterior dental radiographic image $12.00
D9223 Deep sedation/general anesthesia – each 15-minute increment) – replaces D9220 and D9221 $76.00
D9243 (Intravenous moderate (conscious) sedation/analgesia – each 15-minute increment) – replaces D9241 and D9242 $76.00

The Dental Provider Manual Changes Listed Below are Effective beginning November 1, 2016:

The Fee-For-Service (FFS) Dental Program has added the Following Codes: All of the following CDT Procedure Codes require prior approval (PA) and may be used for any date of service on or after November 1, 2016. Refer to the Dental Manuals located on the eMedNY.org website for guidance on obtaining prior approval.

CDT Procedure CodeOffice-Based
Dental Practitioners
D2794 Crown – Titanium$500.00
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth)$560.00
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth)$560.00
D6214 Pontic - titanium$400.00
D6245 Pontic - porcelain/ceramic$400.00
D6740 Retainer crown - porcelain/ceramic$500.00
D6781 Retainer crown - ¾ cast predominately base metal$400.00
D6782 Retainer crown - ¾ cast noble metal$400.00
D6783 Retainer crown - ¾ porcelain/ceramic$400.00
D6794 Retainer crown – titanium$500.00

D1999 Unspecified preventative procedure, by report is now an active CDT Procedure Code that may be used (see below) for any date of service on or after November 1, 2016.

Dental prophylaxis is reimbursable once per six-month period. However, an additional prophylaxis may be considered within a twelve month period for those individuals identified with a recipient exception code of RE 81 ("TBI Eligible") or RE 95 ("OMRDD/Managed Care Exemption"). The additional prophylaxis should be submitted using procedure code D1999. Documentation supporting necessity must be submitted with the claim. Reimbursement will not be considered if performed within a four-month interval of D1110, D1120, D1999 (used as an additional prophylaxis), or D4910.

Changes to Frequency Limitations Effective November 1, 2016:

  1. D0350 – 2D Oral/facial photographic image obtained intra-orally or extra-orally. Frequency reduced from two (2) times within three (3) months to two (2) times within six (6) months.
  2. D7210 – Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated. Frequency without prior approval (PA) reduced from six (6) to four (4) times within twelve (12) months from date of first surgical extraction.

Change to Age Limitation in Manuals to More Accurately Reflect Current Policy:

  1. D3220 – Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament, D2933 – Prefabricated Stainless steel crown with resin window, and D3330 - Endodontic therapy – molar (excluding final restoration): Maximum age has been updated on the fee schedule. The correct maximum age is twenty (20) years inclusive (not twenty-one (21) years).
  2. D5953 – Speech aid prosthesis, adult. Minimum age updated. The correct minimum age is twenty-one (21) years.

Change to Procedure Code Site Designation Requirement Effective November 1, 2016:

D5610 – Repair resin denture base. The site designation requirement has changed from quadrant (QUAD) to arch (ARCH).

Change to Prior Approval (PA) or By Report (BR) Requirement Effective November 1, 2016:

  1. D7413 – Excision of malignant lesion up to 1.25 cm, D7471 – Removal of lateral exostosis (maxilla or mandible), D7490 – Radical resection of maxilla or mandible, D7540 – Removal of reaction-producing foreign bodies – musculoskeletal system, D7550 – Partial ostectomy / sequestrectomy for removal of non-vital bone, are all now "By Report" codes and claims must be submitted on paper. There is no longer a set fee.
  2. D5911 – Facial moulage (sectional), D5912 – Facial moulage (complete), D5915 – Orbital prosthesis, D5916 – Ocular prosthesis, D5923 – Ocular prosthesis, interim, D5937 – Trismus appliance (not for TMD treatment), D5951 – Feeding aid, D7285 Biopsy of oral tissue – hard (bone, tooth), D7286 – Biopsy of oral tissue – soft, D7410 Excision of benign lesion up to 1.25 cm, D7450 – Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm, D7460 Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm, D7510 – Incision and drainage of abscess – intraoral soft tissue are all now "By Report" codes and claims must be submitted on paper.
  3. D7350 – Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachments, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) is no longer a "By Report" (BR) code. Vestibuloplasty (procedure code D7350) requires prior approval (PA).
  4. D8010, D8020, D8030, D8040, D8050, and D8060 are no longer "By Report, PA optional" codes. These codes require prior approval (PA).
  5. D9920 – Behavior management is no longer a "By Report" code and claims can be submitted without supporting documentation. Exception code on recipient file identifies claim that may be considered.

Policy Clarification:

Denture adjustments (procedure codes D5410, D5411, D5421, and D5422) within 6 months of the delivery of the prosthesis are considered part of the payment for the prosthesis. Adjustments (procedure codes D5410, D5411, D5421, and D5422) are not reimbursable on the same date of service as the initial insertion of the prosthetic appliance or; on the same date of service as any repair, rebase, or reline procedure code (procedure codes D5510, D5520, D5610, D5620, D5630, D5640, D5650, D5660, D5710, D5711, D5720, D5721, D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761).

For questions about this update, please contact the Bureau of Dental Review at 1-800-342-3005, or by email at dental@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