New York State Medicaid Update - June 2017 Volume 33 - Number 6

In this issue …

Update on System Editing for: Limiting Initial Opioid Prescribing to a Seven Day Supply for Acute Pain and Emergency 5-Day Supply of Drugs used to Treat Substance Use Disorders in Medicaid Fee-for-Service (Cover)

Pursuant to recently enacted law, the Department has developed a new systematic approach to applying a zero copayment where appropriate for these claim types. The initial interim process as referenced in prior Medicaid Update newsletters published on these topics (July 2016 and December 2016 respectively) will no longer need to be utilized. The new process will be applied effective June 22, 2017, as follows:

Limiting Initial Opioid Prescribing to a Seven Day Supply for Acute Pain

If a prescriber initiates a subsequent prescription for the same pain medication within 30 days of the initial 7-day supply, a zero copayment will be set for claims which meet the criteria systematically.

Emergency 5-Day Supply of Drugs used to Treat Substance Use Disorders

A pharmacist can initiate an emergency 5-day supply of a non-preferred medication for the treatment of a substance use disorder by calling the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week.

If an emergency supply is obtained or is ordered, the pharmacist can utilize a value of "07" Medically Necessary, in Submission Clarification Code (SCC) field 420-DK. Once that is submitted, it flags the claim in our system as an emergency. In turn, subsequent fills for the same medication for the treatment of a substance use disorder within 30 days of the initial 5-day emergency supply will show zero copayment.

Medicaid Managed Care

Managed Care plans will develop and communicate their own processes/procedures to comply with this law.

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Medicaid Pharmacy Prior Authorization Programs Update

On April 27, 2017, 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 June 22, 2017, prior authorization (PA) requirements will change for some drugs in the following PDP classes:

  • Opioids Long Acting
  • Angiotensin Converting Enzyme Inhibitors (ACEIs)
  • HMG-CoA Reductase Inhibitors (Statins)
  • Anticonvulsants – Second Generation
  • Antipsychotics – Second Generation
  • Central Nervous System (CNS) Stimulants
  • Multiple Sclerosis Agents
  • Anti-Fungals - Topical
  • Anti-Infectives - Topical
  • Glucagon-like Peptide-1 (GLP-1 Agonists)
  • Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitors
  • Anticoagulants - Oral
  • Platelet Inhibitors
  • Epinephrine, Self-injected
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) – Ophthalmics
  • Anticholinergics/Chronic Obstructive Pulmonary Disease(COPD) Agents
  • Corticosteroids/Beta-2 Adrenergic Agent (Long Acting) Combinations – Inhaled
  • Corticosteroids - Intranasal

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/meetings/2017/04/summary_durb.pdf.

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.

The following is a link to the most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization programs. This document contains a full listing of drugs subject to PDP, Clinical Drug Review Program (CDRP), DUR Program, Brand Less than Generic program (BLTG), Dose Optimization Program and the Mandatory Generic Drug Program (MGDP):

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf.

To obtain a PA, please call the prior authorization 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 a 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.

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Pharmacy Update on Dose Optimization Program

Effective 07/20/2017, The Medicaid fee-for-service (FFS) program will update the Dose Optimization initiative. Dose optimization can reduce prescription costs by reducing the number of pills a patient needs to take each day. The NYS Department of Health has identified drugs to be included in this program, the majority of which have FDA approval for once-a-day dosing, have multiple strengths available in correlating increments at similar costs and are currently being utilized above the recommended dosing frequency. Prior authorization (PA) will be required to obtain the following medication beyond the following limits:

Dose Optimization Chart- New Additions
Central Nervous System
Antipsychotics- Second Generation
Drug NameDose-Optimization Limitation
Aripiprazole 5mg, 10mg, 15mg 1 daily Tablet In case of dose titration for these medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for three months
Rexulti 0.5mg, 1mg, 2mg 1 daily Tablet
Central Nervous System (CNS) Stimulants
Drug NameDose-Optimization Limitation
Adderall XR 5mg, 10mg, 15mg 1 daily Capsule none
Dextroamphetamine-Amphetamine ER 5mg ,10mg 15mg 1 daily Capsule
Modafinil 100mg 1 daily 1 daily Tablet
Selective-Norepinephrine Reuptake Inhibitors (SNRIs)
Drug NameDose-Optimization Limitation
Trintellix 5mg, 10mg 1 daily Tablet In case of dose titration for these medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for three months
Venlafaxine ER 37.5mg, 75mg 1 daily Capsule
Renal and Genitourinary
Drug NameDose-Optimization Limitation
Urinary tract Antispasmodics
Myrbetriq 25mg 1 daily Tablet none

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.

To obtain a prior authorization (PA), please call the prior authorization 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.

Below is a link to the most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs, including the Dose Optimization initiative. 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.

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Reminder: NYS Medicaid Requirements For 340B Claim Identification

As noted the article regarding '340B Claim Identification' in the December 2016 issue of the Medicaid Update, as of 4/1/2017, NYS Medicaid no longer uses the Medicaid Exclusion File (MEF) for 340B claims. NYS Medicaid relies solely on the use of claim level identifiers – the UD modifier for medical claims submitted in 837I or 837P format, and submission clarification code of '20' for pharmacy claims submitted in National Council for Prescription Drug programs (NCPDP) format. In addition, Medicaid fee-for-service (FFS) claims submitted as primary payor via NCPDP format must also be submitted at the entity's acquisition cost, with a basis of cost determination value of '08'.

It is the responsibility of the Covered Entity (CE) and their contracted pharmacies if applicable to correctly identify claims filled with an entity's 340B stock for 340B-eligible Medicaid patients to ensure rebates are not collected for these drugs. If a rebate is received by the Department for a drug obtained via the 340B program due to incorrect or missing claim level identifiers, the CE will be responsible to reimburse the manufacturer the 340B discount.

Claims submitted to Medicaid as a secondary payor also need to include the appropriate claim level identifiers; however, they do not require acquisition cost and Basis of Cost Determination value of '08'.

Another item of note: the removal of the MEF from NYD Medicaid's billing process does not negate the CE's responsibility for providing the federal Health Resources & Services Association (HRSA) with any required information in relation to its determination on whether to use 340B drugs for Medicaid patients. Per HRSA, a CE must include themselves on the MEF if they carve in any 340B drugs, even if their program limits their 340B stock to specific drugs.

Questions/Information:

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Public Health Emergency Response Network Pharmacy Program (PHERN PP)

A message from the New York City Health Department to community pharmacists in New York City

As a community pharmacist, you are among the most accessible and trusted healthcare professionals in your community. We at the New York City Department of Health and Mental Hygiene (DOHMH) recognize that you serve a critical role not only in providing medications but also providing important health information to residents of your communities on a daily basis.

NYC DOHMH is very interested in working with community pharmacists to support them in preparing for and recovering from disasters and other emergencies. However, we currently have no mechanism to communicate effectively with the more than 2,000 independent community pharmacies in New York City.

To address this gap, NYC DOHMH created the Public Health Emergency Response Network Pharmacy Program (PHERN PP), a simple application that allows New York City pharmacies to quickly and easily "register" and provide pharmacy contact and other service information. This information will assist us in engaging in a productive, reciprocal exchange of information that is essential for effective emergency preparedness and response, and will enable us to better support you and your important work ensuring the health and well-being of all New Yorkers.

The registration process is simple and should only take five minutes. Go to: http://on.nyc.gov/phern and scroll down to select the PHERN Pharmacy Program. Questions about the program can be directed to Eric Medina, PHERN PP Coordinator, at: PHERNPP@health.nyc.gov.

Thank you for supporting this important emergency preparedness initiative in New York City!

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Attention: Topical Oxygen Wound Therapy Continues to be Covered Until Further Notice

Providers, Medicaid beneficiaries and Medicaid Managed Care Organizations (MMCOs) were notified in the May 2017 Medicaid Update that the New York State Medicaid Program was eliminating coverage of topical oxygen wound therapy (TOWT) effective July 1, 2017.

This is to notify providers, Medicaid beneficiaries and MMCOs that the May 2017 determination is rescinded. In addition, the Department will present the subject of Topical Oxygen Wound Therapy to its Evidence Based Benefit Review Advisory Committee (EBBRAC) for review and recommendation.

Pending the EBBRAC review and recommendation and until the Department's final determination regarding coverage of Topical Oxygen Wound Therapy, Medicaid fee-for-service and Medicaid Managed Care will continue to cover TOWT in accordance with the Department's existing procedures.

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Office for People with Developmental Disabilities Home and Community Based Services Waiver Respite

Effective July 1, 2017, respite services provided under the Office for People with Developmental Disabilities (OPWDD) Home and Community Based Services (HCBS) Waiver are changing. Prior to July 1, 2017, each agency authorized to deliver respite services utilized a single, agency specific reimbursement rate. As of July 1, 2017, the reimbursement methodology will be configured based on a regional fee structure with various service types which include the following:

  1. In Home Respite (there will be agency supported rate codes to accommodate service provision to individuals self-directing with employer authority)
  2. Site Based Respite
  3. Recreational Respite
  4. Camp Respite
  5. Intensive Respite

Respite services will continue to be billed in quarter hour units unless an individual receives more than 42 overnight respite services between the July 1st – December 31st or the January 1st - June 30th period. When 42 days of overnight respite has been exceeded, any additional claims exceeding the Supervised Individualized Residential Alternative (IRA) regional average will be billed as a per diem. In these instances, the reimbursement will be paid at the specified Supervised IRA regional average fee levels. The limit of 42 overnight respite services is applicable to the In Home and Site Based service models. Further guidance concerning Respite service policy will be made available in both regulation and in an Administrative Memorandum.

Respite services are provided to individuals unable to care for themselves and are provided on a short-term basis because of the absence or need for relief of the individual's unpaid primary caregiver. The table below identifies 9 new rate codes established to accommodate the new categories of respite service for voluntary agencies.

CategorySubmitted When/ForRate CodeDOH RegionLocation Code
In Home Respite Respite services are provided in a person's family home or in another non-certified home (i.e., Guest Respite). 7421 1 117
2118
3119
4120
Site Based Respite Respite services are provided in a Free Standing Respite site, a certified residence, or a community setting (whether certified or not) that the provider owns, leases, or pays property costs or usage fees. 7422 1 121
2122
3123
4124
Recreational Respite Services are provided with a focus on recreational and/or community integration activities and provided in locations that are not owned, rented or leased by the provider. 7423 1 125
2126
3127
4128
Camp Respite Respite services are delivered at a camp that possess a permit under Subpart 7 of the NYS Sanitary Code. 7424 1 129
2130
3131
4132
Intensive Respite Respite services delivered to individuals with high behavioral and/or high medical needs that meet the qualifications for additional staffing supports due to such needs. Intensive Respite can be delivered in any of the defined respite settings. 7425 1 133
2134
3135
4136
In Home Agency Supported Respite services delivered to individuals who have chosen to self-direct the service with employer authority. 7426 1 137
2138
3139
4140
In Home Agency Supported Intensive Respite services delivered to individuals who have chosen to self-direct the service with employer authority and also have high behavioral and/or high medical needs that meet the qualifications for additional staffing supports due to such needs. 7427 1 141
2142
3143
4144
In Home Per Diem Respite services delivered as In-Home when the 42 days of overnight services within the defined time frames has been exceeded. 7428 1 145
2146
3147
4148
Site Based Per Diem Respite services delivered as Site Based when the 42 days of overnight services within the defined time frames has been exceeded. 7429 1 149
2150
3151
4152

Where:

  • DOH Region 1 – New York City, Nassau, Suffolk and Westchester Counties
  • DOH Region 2 – Dutchess, Orange, Putnam, Rockland, Sullivan and Ulster Counties
  • DOH Region 3 – Albany, Erie, Fulton, Genesee, Madison, Monroe, Montgomery, Niagara, Onondaga, Orleans, Rensselaer, Saratoga, Schenectady, Warren, Washington and Wyoming Counties
  • DOH Region 4 – Rest of State

As referenced earlier, OPWDD is finalizing an Administrative Directive Memoranda (ADM) that will outline the service documentation requirements associated with the new respite categories. The ADM will be available at the following link: http://www.opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda.

Questions regarding service documentation requirements can be directed to OPWDD's Waiver Management Bureau at peoplefirstwaiver@opwdd.ny.gov. Questions regarding the billing changes can be directed to OPWDD's Central Operations Bureau at(518) 402–4333 .

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Further Payment Reductions on Deliveries Prior to 39 Weeks Gestation (C-Section and Induction of Labor)

Medicaid payments for early elective deliveries were subject to a 50% reduction in payment in 2016. Effective July 1, 2017 and September 1, 2017, respectively, Medicaid fee-for-service and Medicaid Managed Care (MMC) will further reduce payment for early elective deliveries. The penalty for early elective deliveries will increase from a 50% reduction to a 75% reduction in reimbursement for claims for early elective deliveries prior to 39 weeks gestation.

This increased penalty reflects the Medicaid Program's commitment to providing high quality prenatal care by ensuring appropriate delivery for both mothers and babies.

Questions regarding Medicaid Managed Care implementation should be directed to the enrollee's MMC plan. Medicaid fee-for-service policy questions may be directed to OHIP Division of Program Development and Management at(518) 473–2160. Claiming questions should be directed to the eMedNY Call Center at(800) 343–9000.

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New York State Medicaid Expansion of Coverage for Colorectal Cancer Screening

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) will expand current colorectal cancer screening methods to include FIT-DNA and computer tomography (CT) colonography, effective June 1, 2017 and August 1, 2017, respectively. This expansion of the types of screening methods available is an effort to increase colorectal cancer screening and align with current United States Preventive Services Task Force (USPSTF) recommendations.

According to the Centers for Disease Control and Prevention (CDC), colorectal cancer is the second leading cause of cancer-related deaths in the United States and the third most common type of cancer. The NYS Cancer Registry estimates that each year, almost 9,200 men and women are diagnosed with colorectal cancer annually and approximately 3,200 men and women die from the disease. Studies show that early detection can increase the five-year survival rate by as much as seventy-five percent. All men and women between the ages of 50-75 years at average risk for colorectal cancer should be screened with one of the recommended screening tests. Screening of individuals at high risk for colorectal cancer should begin earlier than age 50. In 2015, only 60.2 percent of NYS Medicaid patients ages 50 to 75 years of age reported being up to date with colorectal cancer screening according to the brief available here: http://www.health.ny.gov/statistics/brfss/reports/docs/1702_brfss_colorectal_cancer_screening.pdf.

NYS Medicaid providers are encouraged to discuss colorectal cancer screening options with their patients because studies show that patients are more likely to be screened if they are offered test options. Providers, taking patient preference into consideration, may order the most appropriate colorectal cancer screening method from the table below. The recommended frequency listed in the table is for patients considered to be of average risk of developing colorectal cancer and applies to patients with negative findings.

Colorectal Cancer Screening Methods for Patients Considered to be of Average Risk
TestRecommended Frequency
Fecal Immunochemical Test (FIT) or High Sensitivity Fecal Occult Blood Testing (FOBT)once annually
FIT-DNA (e.g. Cologuard)once every three years*
CT Colonography (CTC)once every five years
Flexible Sigmoidoscopy (SIG)once every five years
Double contrast barium enema (DCBE)once every four years
Colonoscopyonce every ten years
SIG with FITonce every ten years (SIG) plus once every year FIT

*Optimal screening interval has not been established

Reminders:

  • In general, screening with colonoscopy is the preferred method for most individuals at high risk for colorectal cancer. However, when medically necessary, the colorectal cancer screening methods included in the table above are reimbursable for individuals considered to be at high risk.
  • Colorectal cancer screening may be considered medically necessary more frequently for individuals considered to be at high risk of developing colorectal cancer.
  • It is important to discuss with patients that a positive result on the screening methods outlined in the above table, other than a colonoscopy, may result in the need for a diagnostic colonoscopy.
  • NYS Medicaid considers colorectal cancer screening by any method not listed above experimental and investigational at this time.

For more information and resources related to colorectal cancer screening, visit the NYS Department of Health website at: http://www.health.ny.gov/diseases/cancer/colorectal/. Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management at (518) 473–2160. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.

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New York State Medicaid Coverage of Zika Testing

As of May 2017, over 1350 cases of Zika virus infection have been reported in New York State (NYS). Nearly 500 of these cases are pregnant women. Zika virus is primarily transmitted by the Aedes aegypti mosquito and may also be transmitted by the related species, the Aedes albopictus. NYS currently does not have the Aedes aegypti mosquito. Aedes mosquitoes also have the potential to transmit several other types of viruses including dengue, chikungunya, and yellow fever. These mosquitoes primarily bite during daytime hours. It is important to educate patients, especially those who are pregnant, on the best ways to prevent the spread of the Zika virus including refraining from unnecessary travel to Zika-affected areas, avoiding unprotected sex with someone who may have been exposed to Zika, and using insect repellant.

Testing to Determine a Zika Diagnosis:

NYS Medicaid covers diagnostic Zika virus testing including, but not limited to, blood and urine screening for members who have been exposed to the Zika virus or with potential exposure as outlined below. Specifically, members meeting the following criteria are eligible for testing:

  • Pregnant women who traveled to a Zika-affected area while pregnant, or within eight weeks prior to conception, regardless if they have Zika virus symptoms;
  • Pregnant women (or within eight weeks prior to conception) who have had unprotected sexual contact with a partner who has traveled to a Zika-affected area, regardless if the partner has Zika virus symptoms;
  • Children, and non-pregnant women and men, who have recently traveled to (or had unprotected sexual contact with a partner who has recently traveled to) an area with an active Zika virus transmission and who present with symptoms consistent with Zika virus or Guillain-Barre syndrome;
  • Infants with microcephaly, intracranial calcifications, or other congenital abnormalities possibly associated with Zika virus and born to women who may have been exposed to Zika virus while pregnant; or
  • Infants who do not have obvious congenital abnormalities at birth and were born to women who were equivocal or positive on Zika virus testing.

The testing criteria outlined above must be met regardless of whether testing is being performed at a public health or commercial laboratory. In addition, pregnant women, who may have been exposed to Zika virus at any stage of their pregnancy are eligible for public health testing at the NYS Department of Health's Wadsworth Center.

Diagnosis of Zika is based on a person's recent travel history, symptoms, and test results. Zika virus ribonucleic acid (RNA) can sometimes be detected early in the course of illness. Real-time reverse transcription-polymerase chain reaction (rRT-PCR) testing should be performed on serum collected during the first two weeks after symptom onset. rRT-PCR should also be conducted on urine samples collected less than 14 days after symptom onset. Testing should be performed as soon as possible and ideally pregnant women should be tested within two weeks of potential exposure even if no symptoms are present. This allows providers the best opportunity to monitor fetal development.

Zika rRT-PCR testing of serum and urine and IgM serology are available from the New York State Department of Health's (NYSDOH) Wadsworth Center, the New York City Department of Health and Mental Hygiene's (NYCDOHMH) Public Health Laboratory (PHL) and some commercial laboratories that are enrolled in NYS Medicaid fee-for-service (FSS) and certain Medicaid Managed Care plans. Please verify both the laboratory's participation with the enrollee's Medicaid Managed Care plan and the specimen requirements prior to obtaining a urine or blood sample that will be sent to a commercial lab.

A negative rRT-PCR result does not exclude Zika virus infection. It may be necessary for laboratories to reflex to serological testing. Plaque reduction neutralization testing (PRNT) and Microsphere Immunofluorescence Assay (MIA), which are serological tests, are only offered at the NYSDOH Wadsworth Center.

Providers can access public health consultation for assistance with interpretation of results by calling the local health department (LHD) located in of the patient's county of residence or at the following:

  • NYSDOH Zika Information Line at(888) 364–4723 weekdays from 9:00 a.m. to 5:00 p.m.
  • NYCDOHMH Provider Access Line at(866) 692–3641 weekdays from 9:00 a.m. to 5:00 p.m.

For more information on testing for Zika virus, test interpretation guidance, and educational materials for your patients, please visit:

Obstetric Ultrasounds

The Centers for Disease Control and Prevention (CDC) recommends that for pregnant women with any laboratory evidence of Zika virus infection (such as Zika virus RNA, antigen, or immunoglobulin) in any body fluid or tissue specimen (e.g., serum, urine, amniotic fluid), serial ultrasounds should be considered to monitor fetal anatomy and growth every 3–4 weeks. In accordance with this recommendation, NYS Medicaid will cover medically indicated serial ultrasounds for pregnant women with laboratory evidence of Zika virus infection (positive or equivocal test results, regardless of symptoms). For more information, please visit NYSDOH and CDC's websites for healthcare providers and updated clinical guidance at the following links:

Infant Testing

The US Department of Health and Human Services in conjunction with the CDC released a report which concluded that only twenty-five percent of infants that need postnatal neuroimaging are being tested (Morbidity and Mortality Weekly Report April 2017). NYS Medicaid provides coverage for testing of infants born to mothers with laboratory evidence of Zika virus infection in accordance with CDC recommendations. This includes but is not limited to the following: laboratory testing to determine congenital Zika virus infection, neurological examinations, postnatal head ultrasounds, and standard newborn hearing screens. In addition, NYS Medicaid covers a comprehensive ophthalmological exam and hearing assessment by auditory brainstem response (ABR) testing for infants with laboratory evidence of congenital Zika virus.

Reminders:

  • NYS Medicaid recently expanded pharmacy benefits to include coverage of mosquito repellent for individuals who intend to travel to, or return from a CDC recognized area of localized Zika transmission. For more information please visit the September 2016 Medicaid Update and CDC's website for areas with risk of Zika at the following links:
  • Providers must maintain documentation of medical indications for testing in the patient's medical record for a minimum of six years for audit purposes.

Providers can access public health consultation for assistance with interpretation of results by calling the LHD located in of the patient's county of residence or at the following:

  • NYSDOH Zika Information Line at(888) 364–4723 weekdays from 9:00 a.m. to 5:00 p.m.
  • NYCDOHMH Provider Access Line at(866) 692–3641 weekdays from 9:00 a.m. to 5:00 p.m.

In addition to diagnostic testing, NYS Medicaid covers most Zika-related testing recommended by the CDC including, but not limited to, testing modalities outlined in this article. For more information regarding the most current CDC guidance please visit the following link: https://www.cdc.gov/zika/index.html. Medicaid fee-for-service (FFS) policy questions may be directed to the Office of Health Insurance Programs' Division of Program Development and Management at(518) 473–2160. Questions regarding Medicaid Managed Care (MMC) reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.

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Breastfeeding Grand Rounds 2017: The Impact of Social and Cultural Values on Breastfeeding Practice and Strategies to Address Disparities

Breastfeeding Grand Rounds (BFGR) is a free, annual webcast sponsored by the University at Albany School of Public Health in partnership with the New York State Department of Health that is available to an international audience. The program draws upon the expertise and experiences of health professionals working in the breastfeeding field, to increase the viewer's knowledge and enhance breastfeeding practices. The 2017 BFGR will focus on specific strategies health care providers can use to help change cultural norms to encourage breastfeeding in the United States (U.S.).

The social context in which a mother gives birth and cares for her child affects whether she initiates and continues breastfeeding. Scholarly and popular literature describes breastfeeding as both a biological and social practice. Health professionals have critically examined the ways biosocial factors shape breastfeeding practices among racial, ethnic, and socioeconomic groups in the U.S. This BFGR will demonstrate how U.S. social values influence breastfeeding practices among mothers from different racial-ethnic and socioeconomic groups. Presenters will describe strategies that have worked to change cultural norms and societal values in ways that positively affect breastfeeding rates among different U.S. groups.

"Breastfeeding Grand Rounds: The Impact of Social and Cultural Values on Breastfeeding Practices and Strategies to Address Disparities" will air on August 3, 2017 from 8:30 a.m. – 10:30 a.m. This webcast is intended for healthcare professionals and paraprofessionals, and will offer CME, CNE, CHES, LCERP or general continuing education credits. For more information, and to view previous years' BFGR webcasts, please visit: http://www.albany.edu/sph/cphce/bfgr.shtml.

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OMIG Webinar: Retroactive Disenrollment Notification Process

The New York State Office of the Medicaid Inspector General (OMIG) has posted on its website a webinar entitled "Retroactive Disenrollment Notification Process". Posted in May 2017, this webinar provides a comprehensive and detailed review of OMIG's retroactive disenrollment notification process. It also introduces the electronic retroactive disenrollment notification form and submission instructions that must be used by New York's Local Departments of Social Services (LDSS or local districts), New York State of Health (NYSoH), and New York City's Human Resources Administration (HRA) to notify Medicaid managed care plans and OMIG of an enrollee's retroactive disenrollment.

These retroactive disenrollment notifications play an important role in ensuring the integrity of the Medicaid Program. OMIG is committed to assisting the local districts, NYSoH and HRA staff in meeting their responsibility to retroactively disenroll Medicaid managed care enrollees as needed and to report these actions in the required form and format. The webinar is available on OMIG's website at: https://omig.ny.gov/resources/webinars/1050-omig-webinar-37-retroactive-disenrollment-process.

OMIG staff are available to assist should help be needed to successfully submit the retroactive disenrollment notifications. Questions regarding the retroactive disenrollment notification process may be submitted to: retrodata@omig.ny.gov.

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Reminder: 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)

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)].

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 annual Deficit Reduction Act (DRA) Form performance and by conducting reviews of providers' compliance with the DRA requirements. On December 1, 2017, OMIG will make available on its website the Federal DRA of 2005 DRA Certification Form (Certification Form) for 2017.

Additionally, in November 2017, OMIG will post a webinar on its website that will explain the new Certification Form for 2017. OMIG will issue communications via its listserv and social media channels when the webinar is posted. To subscribe to OMIG's listserv, please visit: https://omig.ny.gov/omig-email-list-subscriptions.

The Certification Form and Frequently Asked Questions (FAQs) will be available on the OMIG website. OMIG's listserv subscribers will be notified when the new forms are posted. If you have any questions, please contact OMIG's Bureau of Compliance at(518) 408–0401 or compliance@omig.ny.gov.

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Reminder: Mandatory Compliance Program Certification Requirement under Title 18 of the New York Codes, Rules and Regulations (NYCRR) §521.3(b)

This is a reminder from the New York State Office of the Medicaid Inspector General (OMIG) for all required providers who are subject to the New York State (NYS) Social Services Law Section 363-d (SSL §363-d) Mandatory Compliance Program Requirement. OMIG is an independent entity created within the NYS Department of Health (Department) to promote and protect the integrity of the Medicaid program.

On December 1, 2017, OMIG will make available on its website, the NYS Social Services Law Compliance Program Certification Form (Certification Form) for 2017. The Certification Form for 2016 will remain active on OMIG's website until December 1, 2017 for newly enrolling and revalidating Medicaid providers.

Additionally, in November 2017, OMIG will post a webinar on its website that will explain the NYS Social Services Law Certification Form for 2017. OMIG will issue communications via its listserv and social media channels when the webinar is posted. To subscribe to OMIG's listserv, please visit: https://omig.ny.gov/omig-email-list-subscriptions.

OMIG has actively monitored providers' adherence to SSL §363-d and Part 521, of Title 18 of the New York Codes, Rules and Regulations (NYCRR) since 2009. The regulation mandates all required providers under the Medicaid program in the categories listed below to certify in December of each year that they have adopted, implemented, and maintain an effective compliance program. If you are required to have a compliance program, you are also required to certify on OMIG's website at: https://www.omig.ny.gov.

  • persons subject to the provisions of Article 28 or 36 of the NYS Public Health Law;
  • persons subject to the provisions of Article 16 or 31 of the NYS Mental Hygiene Law;
  • other persons, providers or affiliates who provide care, services or supplies under the Medicaid program, or persons who submit claims for care, services or supplies for or on behalf of another person or provider for which the Medicaid program is or should be reasonably expected by a provider to be a substantial portion of their business operations.

Under 18 NYCRR §521.2 (b), "substantial portion" of business operations means any of the following:

  1. (1) when a person, provider or affiliate claims or orders, or has claimed or has ordered, or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from the Medical Assistance Program;
  2. (2) when a person, provider or affiliate receives or has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period directly or indirectly from the Medical Assistance Program; or
  3. (3) when a person, provider or affiliate who submits or has submitted claims for care, services, or supplies to the Medical Assistance Program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.

Each compliance program must contain the eight elements required under SSL §363-d and 18 NYCRR §521.3 (c). Upon applying for enrollment in the medical assistance program, and during the month of December each year thereafter, 18 NYCRR §521.3 (b) requires those providers who are subject to the mandatory compliance program obligation to certify to the Department that a compliance program meeting the requirements of the regulation is in place. For those Medicaid providers required to have a compliance program and to certify in December 2017, OMIG recommends that providers test the operation of their compliance program and make any adjustments necessary so that in December, the Medicaid provider is prepared to certify that its compliance program meets the requirements of SSL §363-d and 18 NYCRR §521.3 (c).

Please note that the Department is revalidating Medicaid providers' enrollment in the medical assistance program. As part of the revalidation process, required providers will be asked to submit evidence that they met the December SSL certification obligation. Certifying in December and retaining a copy of the SSL Certification Confirmation and/or confirmation emails will help Medicaid required providers 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 a required provider to determine if:

  1. they have a compliance plan that meets the requirements of SSL § 363-d and 18 NYCRR § 521.3 (c);
    and
  2. the compliance program is effective.

Required providers must assess their compliance programs to determine whether they can certify that they do or do not have a compliance program in place that meets the requirements of SSL § 363-d and 18 NYCRR Part 521.

The Compliance Program Review Guidance published on OMIG's website in the Compliance Library on October 26, 2016 is a comprehensive outline of what OMIG uses when it conducts compliance program reviews of required providers' compliance programs and is one of several resources available on OMIG's website.

OMIG recommends visiting its website to review compliance-related information and resources; please see:https://omig.ny.gov/compliance. The Compliance Library provides copies of current forms, publications and other resources that are helpful in conducting a self-assessment. If you have any questions, please contact OMIG's Bureau of Compliance at(518) 408–0401 or compliance@omig.ny.gov.

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NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Records (EHR) Incentive Program provides financial incentives to eligible professionals (EPs) 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 $794 million in incentive funds have been distributed within 25,026 payments to New York State Medicaid providers.

25,026
Payments

$794+
Million Paid

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

Last Chance to Participate

The deadline to report 2016 Meaningful Use (MU) for the New York State Medicaid Electronic Health Records (EHR) Program is September 15, 2017. Incentive payments to EPs are disbursed over the course of 6 participation years. EPs may receive up to $21,250 for the first participation year and $8,500 for each remaining participation year.

2016 MU Deadline: September 15, 2017
Last Chance to Join the MU Program
Total Incentives: $63,750

To participate in the EHR Incentive Program, you must have a certified EHR system, be enrolled as a fee-for-service New York Medicaid provider, and be registered with CMS.

Incentive payments continue until 2021, but new EPs must be registered and able to report 2016 EHR measures by September 15, 2017.

writing iconPrerequisites

computer icon Next Steps

Tutorials

The NY Medicaid EHR Incentive Program website (http://www.health.ny.gov/health_care/medicaid/redesign/ehr/) 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. Tutorials are being added frequently. To access these videos, visit the Tutorials page here: http://www.health.ny.gov/health_care/medicaid/redesign/ehr/tutorials.htm.

Webinars

The NY Medicaid EHR Incentive Program has several instructor-led webinars available on a variety of topics to assist in the meaningful use attestation process. Webinars are offered at different times, including 7 a.m., to accommodate many schedules. To register for a session, visit the Webinar Calendar page at: http://www.health.ny.gov/health_care/medicaid/redesign/ehr/calendar/.

phone icon Contact us at 877-646-5410 option 2 or hit@health.ny.gov
Questions? We have a dedicated support team that will guide you through the registration and attestation process.

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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