New York State Medicaid Update - April 2017 Volume 33 - Number 4

In this issue …

Patient Centered Medical Home Statewide Incentive Payment Program: Revised Incentive Payments and Updated Billing Guidance

Effective July 1, 2017, in accordance with the 2017-2018 enacted State budget, New York State (NYS) Medicaid is changing the reimbursement amounts for providers working at practices that are recognized as a Patient Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). The revised policy applies to both Medicaid Managed Care (MMC) and Medicaid Fee-For-Service (FFS). Since its inception, this program has significantly grown and NYS Medicaid continues to make every effort to reward primary care providers (PCPs) who seek to achieve PCMH recognition and provide high quality of care to NYS Medicaid enrollees.

The subsequent summarizes, by provider type and recognition status, the MMC per member per month (PMPM) amounts and the FFS 'add-on' amounts for visits with qualified evaluation and management codes. Level 2 providers recognized under the 2014 standards will receive MMC incentive payments of $3.00 PMPM, and FFS add-on amounts will be $ 20.50 and $23.25 for professional and institutional claims, respectively. Level 3 providers recognized under the 2014 standards will receive MMC incentive payments of $7.50 PMPM, and the FFS add-on amounts will be $29.00 and $25.25 for professional and institutional claims, respectively. All incentive payments for PCMH-recognized providers under NCQA's 2011 standards will be eliminated for both MMC and FFS.

PCMH Statewide Incentive Payment Program
MMC-PMPM and FFS 'Add-on' Amounts
Effective July 1, 2017
Provider 2011 Standards
NCQA Level 2		 2011 Standards
NCQA Level 3		 2014 Standards
NCQA Level 2		 2014 Standards
NCQA Level 3
MMC-PMPM$0.00$0.00$3.00$7.50
FFS Add-on Per Visit: Professional$0.00$0.00$20.50$29.00
FFS Add-on Per Visit: Institutional$0.00$0.00$23.25$25.25

On April 3, 2017 NCQA released the next iteration of their PCMH recognition program, which includes annual updates to the standards. Practices and their providers who have achieved NCQA PCMH recognition under the NCQA's redesigned version released in April 2017 will receive payments equivalent to NCQA 2014 Level 3 standards.

Updated Fee-For-Service Billing Guidance

Office-based Practitioners: Office-based practitioners will receive the add-on payment amount when they meet the following criteria:

  1. The billing provider within the servicing practitioner's practice must be designated as PCMH (Level 2 or Level 3 2014 NCQA standards or recognized under the NCQA's redesigned version released in April 2017);
  2. In a practitioner group practice the group National Provider Identifier (NPI) and the billing practitioner NPI must be designated as a PCMH (Level 2 or Level 3 under 2014 NCQA standards or recognized under the NCQA's redesigned version released in April 2017);
  3. The claim must contain, and service provided must be consistent with, one of the following Evaluation and Management codes: 99201-99205, 99211-99215; or one of the following Preventive Medicine codes: 99381-99386, 99391-99396;
  4. The place of service code on the claim must be office (POS'11');
  5. The claim must include the 9-digit zip-code of the designated practice's physical location, as reported to NCQA.

Article 28 Clinics - Outpatient Departments, Diagnostic and Treatment Centers, and Federally Qualified Health Centers

The PCMH designation will be associated with each clinic on a site-specific basis. Clinics will receive the PCMH add-on when they fulfill the following requirements:

  1. The billing clinic (site-specific) must be designated as a PCMH (Level 2 or Level 3 under 2014 NCQA standards or recognized under the NCQA's redesigned version released in April 2017);
  2. Claims must contain, and the service provided must be consistent with, one of the following Evaluation and Management codes 99201-99205, 99211-99215; or one of the following Preventive Medicine codes 99381-99386, 99391-99396;
  3. The submitted rate code must be one of the following 1400, 1407, 1422, 1425, 1432, 1435, 1444, 1447, 1450, 1453, 2887, 2888, 2889, 2940-2942, 2945, 2985, 2987, 4012, 4013; and
  4. The claim must include the 9-digit zip-code of the designated practice's physical location, as reported to NCQA.

In the event that both a practitioner working in a clinic (who submits a professional claim) and the clinic have a PCMH designation, only the clinic will receive the enhanced payment.

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

Policy discussions are underway regarding alignment of PCMH incentive payments with value based principles and policies.

Questions/Information:

  • MMC PCMH questions may be directed to the Division of Health Plan Contracting and Oversight at 518-474-5050.
  • Medicaid FFS questions may be directed to the eMedNY Call Center at 1-800-343-9000. Inquires on FFS claim eligibility can also be directed to the eMedNY Call Center.
  • Policy questions or any additional questions related to the New York State Medicaid PCMH Incentive Payment Program may be directed to pcmh@health.ny.gov.

New York State Medicaid 2017 Drug Testing Update

This article updates the coverage and reimbursement policy by New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) for drug testing. The coding changes and guidance in this article are effective April 1, 2017 for FFS and July 1, 2017 for MMC plans unless otherwise indicated.

NYS Medicaid drug testing policy consists of a screen (presumptive) and confirm (quantitative) testing structure. Presumptive drug class screening using CPT codes 80305, 80306 or 80307 is the first step in the process. Only substances that return a positive result on a screen (presumptive) or are inconclusive or inconsistent with clinical presentation are reimbursable for confirmation (quantitative) testing using CPT codes 80320 – 80377 listed on the fee schedule. Definitive or direct confirmation testing using CPT code G0480 is only reimbursable when no screening method is available.

Drug or drug classes being tested must be ordered by the provider and should be considered based on the patient's medical history and/or current clinical presentation. Medical records must support the need for each drug or drug class being tested and be kept on file for a minimum of six years for audit purposes.

Presumptive Drug Class Screening:

Replacement CPT codes effective January 1, 2017
CPT CodeDescription
80305(Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service)
80306(Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures, (e.g., immunoassay) read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service)
80307(Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service)

Testing of the following drug/drug classes are included in screening by NYS Medicaid:

  • Alcohol
  • Amphetamines
  • Barbiturates
  • Benzodiazepines
  • Buprenorphine
  • Cocaine metabolites
  • Heroin metabolites
  • Methadone
  • Methadone metabolites
  • Methamphetamine
  • Methaqualone
  • Methylenedioxymethamphetamine
  • Opiates
  • Oxycodone
  • Phencylicine
  • Propoxyphene
  • Tetrahyrdrocannabional (THC) metabolites (marijuana)
  • Tricyclic Antidepressants.

The fee for codes 80305, 80306 and 80307 covers screening of one specimen for all drugs listed above. These codes should only be billed once irrespective of the number of drug class procedures or results on any date of service.

Screening by a broad-spectrum chromatographic procedure, which detects multiple drug classes, should be billed using code 80307. Each step in the sequential development of a chromatograph is not considered a separate procedure. Only when an analytical condition, e.g., column temperature or flow rate, is changed such that additional controls must be run, is subsequent analysis of the same specimen for additional drug(s) considered a separate procedure for billing purposes.

Screening for drugs using immunoassay or enzyme assay using multichannel chemistry analyzers should be billed using code 80307. Use 80307 once to report single or multiple procedures performed, irrespective of the number of procedures, classes, or results on any date of service.

Confirmatory Drug Testing:

Billing for confirmatory testing using CPT Codes 80320 through 80377 is allowable when the code is listed on the fee schedule and one or more of the following conditions are met:

  • a presumptive positive drug screen is found using codes 80305, 80306, 80307 or
  • a screen result is inconclusive or inconsistent with clinical presentation

For confirmation testing, bill the appropriate code related to the drug/drug class. If there is no screening method available for a drug class, refer to Definitive Drug testing guidance.

Definitive Drug Testing:

Definitive Testing (G0480) may be billed for testing of drugs or drug classes when there is no screening method available. NYS Medicaid covers definitive drug testing using this code for up to 7 drug classes. CPT code G0480 is reimbursable once per date of service, up to a maximum of 6 times within 365 days. CPT code G0480 cannot be billed in conjunction with CPT codes 80305, 80306 or 80307 for drug/drug classes listed above included in the screening codes.

CPT CodeDescription
G0480Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed.

Questions:

Policy questions regarding Medicaid fee-for-service may be directed to OHIP, Division of Program Development and Management at(518) 473–2160 . Questions on billing or claims regarding Medicaid fee-for-service should be directed to Computer Sciences Corporation at 1-800-343-9000. Questions regarding Medicaid Managed Care billing and reimbursement should be directed to the enrollee's Medicaid Managed Care Plan.

Reminder: Medicare Part C Providers

Pursuant to 2016 changes to Social Services Law*, the New York State Department of Health has revised the Medicaid reimbursement methodology for claims containing Medicare Part C (Medicare Advantage or Medicare managed care) co-payment and/or co-insurance liabilities. Retroactive to July 1, 2016, Medicaid will no longer reimburse the full Medicare Part C copay or coinsurance amount.

The 2016 change to Social Services Law regarding Medicaid payment of Medicare Part C copay or coinsurance will:

  • Be implemented on or about May 25, 2017 by NYS Medicaid;
  • Reimburse 85% of the copay or the coinsurance;
  • Affect both institutional and professional claims, as well as pharmacy claims for drugs and supplies when submitted via an NCPDP transaction or as a professional claim; and
  • Will be retroactive to July 1, 2016.

At the time of implementation, providers will be informed via eMedNY, and eMedNY will begin reprocessing claims retroactively to July 1, 2016, using the new methodology. There will be no change to the reimbursement of the Medicare Part C deductible. Medicaid will continue to reimburse the full deductible. There will be no change to Medicare Part C inpatient claims.

Providers exempt from the 85% Part C reimbursement: There is no change to the current reimbursement methodology of Medicare Part C copayment and coinsurance amounts for ambulance providers and psychologists. Medicaid will continue to reimburse these providers the full Medicare Part C copayment and coinsurance amounts.

Note: The provider is required to accept the Medicare Part C health plan payment and any Medicaid payment as payment in full for the service. The member may not be billed for any Medicare Part C copayment or coinsurance amount that is not reimbursed by Medicaid. Refer to the Centers for Medicare and Medicaid Services (CMS) publication, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1128.pdf.

* A new subparagraph (iv) was added to paragraph (d) of subdivision 1 of Section 367-a of the Social Services Law.

FIDA Program Expanded to Suffolk and Westchester Counties

The New York State Department of Health (NYSDOH) has been partnering with the Center for Medicare and Medicaid Services (CMS) to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience. Under the demonstration, known as "Fully Integrated Duals Advantage" (FIDA), NYSDOH and CMS contract with Medicare-Medicaid Plans to coordinate the delivery of covered Medicare and Medicaid services for participating enrollees.

The FIDA Demonstration started in New York City and Nassau County on January 1, 2015. In November of 2016, CMS and NYSDOH announced plans to extend the program through December 2019. Starting March 1, 2017, the program expanded to Suffolk and Westchester Counties.

Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as "dual-eligible individuals" – is a priority. Through the demonstrations approved under the Financial Alignment Initiative, CMS and NYSDOH provide Medicare-Medicaid enrollees with a better care experience by offering a participant-centered, integrated care initiative and seamless access 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 enrollees have multiple or severe chronic conditions and could benefit from better care coordination and management of health and long-term supports and services.

FIDA fully integrates Medicare and Medicaid benefits in a way not previously available in New York State. NYSDOH and CMS are committed to providing maximum integration of care to dual eligibles to help ensure all medically necessary services are provided, to promote care in the community, and to reduce avoidable hospitalizations and nursing facility stays.

Andrew Segal, Director of the Division of Long Term Care of the NYS Office of Health Insurance Programs said of the extension: "We are very pleased with the experience we are seeing so far with this program and anticipate that over time the impact will continue to be positive. We are committed to growing the program and to making refinements and enhancements, as necessary, as we move ahead."

The first plan to be approved to operate in Suffolk and Westchester Counties has already started enrolling FIDA plan members. Pending final review of the Medicare provider networks, CMS and NYSDOH will be approving additional managed care plans over the next several months.

New York State Awards Contract for Medicaid Transportation Management in New York City

The New York State Department of Health (NYSDOH) has announced the award of a contract to Medical Answering Services LLC (MAS). Effective April 23, 2017, MAS will be the new Medicaid transportation manager for the New York City region, which includes: New York County (Manhattan), Kings County (Brooklyn), Bronx County (Bronx), Richmond County (Staten Island), and Queens County (Queens).

In New York City, MAS will be responsible for administering, prior approving, and coordinating non-emergency medical transportation for Medicaid fee-for-service and mainstream managed care enrollees at the most medically appropriate, cost effective mode of transport.

MAS is currently the NYSDOH transportation manager for the Hudson Valley, Finger Lakes, Northern New York and Western New York regions and has been providing services to over 2,000,000 Medicaid enrollees in 55 counties. As the transportation manager, MAS has maintained working relationships with thousands of medical providers and hundreds of transportation vendors.

The MAS contact information is below.
Telephone:1-844-666-6270 (NYC specific)
Telephone:1-800-850-5340 (General)
Fax:1-315-299-2786
Website:https://www.medanswering.com/
Mailing Address:
Medical Answering Services, LLC
PO Box 12000
Syracuse, NY 13218

Free Online Opioid Prescriber Training Program Available Which Meets the Mandatory Prescriber Opioid Education Requirements in New York State

Prescribers licensed under Title Eight of the Education Law in New York to treat people and who have a Drug Enforcement Administration (DEA) registration to prescribe controlled substances, as well as medical residents who prescribe controlled substances under a facility DEA registration number, must complete at least three (3) hours of course work or training in pain management, palliative care and addiction. The course work or training must be completed by July 1, 2017, and once every three (3) years thereafter, pursuant to Public Health Law (PHL) §3309-a(3).

The course work or training may be live or online and must include the following eight (8) topics:

  1. New York State and federal requirements for prescribing controlled substances;
  2. Pain management;
  3. Appropriate prescribing;
  4. Managing acute pain;
  5. Palliative medicine;
  6. Prevention, screening and signs of addiction;
  7. Responses to abuse and addiction; and
  8. End-of-life care.

Specific guidance from the Bureau of Narcotic Enforcement related to the Mandatory Prescriber Opioid Education can be found at: https://www.health.ny.gov/professionals/narcotic/mandatory_prescriber_education/. Prescribers must notify the New York State Department of Health (NYSDOH) that they have completed the educational requirement by attesting through their Health Commerce Account. Information on how to do this is now available on the Bureau of Narcotic Enforcement website at: http://www.health.ny.gov/professionals/narcotic/mandatory_prescriber_education/neat.htm.

Pursuant to the new requirements, development of an online Opioid Prescriber Training Program was established collaboratively with the State University of New York (SUNY) at Buffalo School of Pharmacy and Pharmaceutical Sciences and NYSDOH. The online program was developed through cooperative agreement number 5 U16 CE002614-03 with the Centers for Disease Control and Prevention (CDC) and NYSDOH. The content does not necessarily represent the official views of the CDC. The Opioid Prescriber Training Program is available at no charge to prescribers and is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for practitioners. The program will cover all eight (8) topics required per legislation.

Prescribers must create an account to register for the Training Program and to receive a CME accreditation certificate. The online Opioid Prescriber Training Program is located on the SUNY Buffalo School of Pharmacy & Pharmaceutical Sciences Website at: https://www.pharm.buffalo.edu/CE/index.php.

In addition to the online Opioid Prescriber Training Program, the New York State Medicaid Provider Education Program (NYSMPEP) provides on-site educational sessions for prescribers serving Medicaid members, as well as educational information resources. NYSMPEP was established with the goal to promote better health outcomes for all NYS Medicaid members by engaging prescribers with information on evidence based, unbiased pharmacotherapy. The NYSMPEP is a partnership between NYSDOH and the SUNY. Academic educators hold Doctorate of Pharmacy (PharmD) degrees and are trained to provide educational sessions to prescribers throughout New York. An educational session with a PharmD educator consists of either one-on-one sessions, small group sessions, or large group settings, such as a grand rounds platform. More information regarding the NYSMPEP and available resources is located at: https://nypep.nysdoh.suny.edu/.

Gender Reassignment Surgery Update

This article modifies the June 2015 Medicaid Update article, New York State Medicaid Updates Regulations, regarding when the Sterilization Consent Form (LDSS-3134) must be completed.

The New York State Department of Health (Department) has determined that the LDSS-3134 is only required when the procedure being performed is solely for the purpose of rendering the individual incapable of reproducing. This form is not required where sterilization is an ancillary result of a procedure, such as gender reassignment surgery.

However, if a hysterectomy is being performed, regardless of the purpose, an LDSS-3113, "Acknowledgement of Receipt of Hysterectomy Information," is required. (The LDSS-3113 may also be referred to in Department publications as the "Hysterectomy Receipt of Information Form".)

In addition, surgical practices required by the practitioner's institution and professional protocols and standards of care, including obtaining a patient's informed consent, should always be followed. Health care professionals treating individuals for gender dysphoria should discuss the risks, consequences, and options of any treatment prior to the initiation of the treatment, including sterilization and other reproductive considerations.

Further information regarding the LDSS-3113 can be found in the New York State Medicaid General Billing Guidelines, pages 44-48 at: https://www.emedny.org/ProviderManuals/AllProviders/General_Billing_Guidelines_Professional.pdf.

For questions regarding Medicaid policy, providers should contact the Division of Program Development and Management at(518) 473–2160. For questions regarding Medicaid Managed Care, providers should could contact the member's health plan.

Payment Error Rate Measurement (PERM) Upcoming Request for Medicaid Provider Documentation

The Centers for Medicare & Medicaid Services (CMS), in partnership with the New York State Office of the Medicaid Inspector General (OMIG), will be measuring improper payments in the Medicaid and State Child Health Insurance programs under the Payment Error Rate Measurement (PERM) program. This will be the fourth time New York State will be participating. The State last participated in federal fiscal year 2014.

CMS, along with their contractor, and OMIG have the authority to collect this information under sections 1902(a)(27) and 2107(b)(1) of the Social Security Act. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) statutes and regulations require the provision of such information upon request, and the information can be provided without patient consent.

Documentation for medical review of randomly selected claims will be requested by Chickasaw Nation Industries (CNI) Advantage, LLC, the new CMS review contractor. If claims you submitted are selected, the CMS contractor will request from you, in writing, documentation to substantiate claims paid in federal fiscal year 2017 (October 1, 2016 - September 30, 2017). Your cooperation and a timely response are requested. Please submit copies of the specific medical documents for the patient, as requested in the letter you receive from the CMS contractor, directly to the CMS contractor with a second copy to OMIG at the following address:

Office of the Medicaid Inspector General
800 North Pearl Street
First Floor
Albany, NY 12204
Attention: PERM Project Staff

Requests for documentation will start in May 2017. The sampled claims will be claims paid between October 1, 2016 and September 30, 2017. Requests and subsequent receipt or non-receipt of documentation will be tracked. Failure to provide requested records will result in a determination of erroneous payment and OMIG will pursue recovery.

Questions? Please contact PERM Project staff at(518) 402–7041,(518) 474–3499 or via email at: PERMNY@omig.ny.gov.

NY Medicaid EHR Incentive Program Update

The New York Medicaid Electronic Health Records (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 $786 million in incentive funds have been distributed within 24,599 payments to New York State Medicaid providers.

24,599
Payments

$786+
Million Paid

Are you eligible? For more information, visit http://www.health.ny.gov/ehr

MEIPASS Open for Meaningful Use

The NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) is now open and is accepting attestations for 2015 and 2016 meaningful use (MU) and 2016 Adopt, Implement, Upgrade (AIU). The final deadlines have been extended and are listed below.

  • 2016 AIU deadline: 5/31/17
  • 2015 MU deadline: 6/30/17
  • 2016 MU deadline: 9/15/17

Resources

The New York Medicaid EHR Incentive Program website (http://www.health.ny.gov/health_care/medicaid/redesign/ehr/) now has recorded video tutorials available for on-demand assistance. The interactive tutorials are instructor-led with step-by-step guidance to assist with completing your MU attestation. Visit the Tutorials page here: http://www.health.ny.gov/health_care/medicaid/redesign/ehr/tutorials.htm, to access these videos.

Preparing to Attest

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.

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