New York State Medicaid Update - May 2020 Volume 36 - Number 10

In this issue …

Billing Reminder for Fee-for-Service Institutional Patient-Centered Medical Homes and Advanced Primary Care Program Providers

The following article provides a Medicaid fee-for-service (FFS) billing reminder to Article 28 clinics recognized under either the Patient-Centered Medical Home (PCMH) or Advanced Primary Care (APC) Programs.

Billing Reminder

Article 28 clinics are reminded that since PCMH- and APC-recognition is site specific, the Medicaid FFS institutional claim must include the United States Postal Service (USPS) ZIP+4 code of the recognized clinic's site-specific physical location where services were rendered to the Medicaid member. The ZIP+4 code submitted on the claim must reflect the actual service location where services were rendered, and not the ZIP+4 code associated with the main facility or health system to which Medicaid payments are made.

Article 28 clinics are reminded to accurately code their FFS Medicaid claims with the following:

  • The National Provider Identifier (NPI) for both the PCMH- or APC-recognized clinic and the attending primary care provider;
  • The appropriate Ambulatory Patient Group (APG) rate code; and
  • The correct ZIP+4 code associated with the locator code where services were rendered to the Medicaid member.

New System Edit on FFS PCMH and APC Claims

A new system edit was implemented into the eMedNY claiming system as of January 23, 2020 for all Medicaid FFS institutional claims. This edit withholds the PCMH or APC incentive payment in situations where the ZIP+4 code submitted on the claim was not located on the provider's rate file for the submitted rate code. The inability for the eMedNY system to locate the submitted ZIP+4 code on the provider's rate file causes the claim to trigger edit "02068" (Provider Rate Found Without Matching ZIP/Locator Code). The PCMH or APC incentive payment will be withheld from any FFS institutional claim that triggers edit "02068". The FFS institutional claim will still adjudicate as normal; however, the PCMH or APC incentive payment will be withheld. Providers are responsible for reviewing their remit statements to ensure payment of the PCMH or APC incentive. Providers must resubmit a claim adjustment to Medicaid with the correct ZIP+4 code that reflects the actual service location to be eligible to receive the incentive payment.

Questions and Additional Information:

  • Questions regarding Medicaid FFS incentive payments (including but not limited to missing incentive payments, claim add-on incentive payment amounts, and/or practice/provider recognition dates) should be directed to: the eMedNY Call Center at (800) 343‑9000 or via email at emednycallctr@csra.com.
  • Providers seeking assistance with FFS policy should contact the Office of Health Insurance Programs (OHIP) at (518) 473‑2160.
  • Additional information can be found at: https://www.emedny.org/.

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Attention Patient-Centered Medical Home and Advanced Primary Care Program Providers: Telehealth has Been Added as an Acceptable Modality Eligible to Receive Incentive Payments During the COVID-19 State of Emergency

This guidance is no longer applicable.

The following article pertains to Medicaid fee-for-service (FFS) clinis and practitioners that achieved recognition as either Patient-Centered Medical Homes (PCMH) by the National Committee for Quality Assurance (NCQA) or Advanced Primary Care (APC) programs.

This guidance is effective for dates of service on or after March 1, 2020 and shall remain in effect for the remainder of the disaster emergency declared by Executive Order No. 202, or until the issuance of subsequent guidance by the NYSDOH prior to the expiration of such state disaster emergency declaration.

In response to the COVID-19 State of Emergency, New York State (NYS) Medicaid broadly expanded the ability of Medicaid providers to use a wide variety of communication methods to deliver services remotely via telehealth where face-to-face visits may not be recommended, and it is appropriate for the member. For purposes of the State of Emergency, the definition of telehealth was expanded to include telephonic communications, telemedicine, store and forward, and remote patient monitoring.

The following temporary revisions have been implented into the eMedNY claiming system to allow PCMH/APC-recognized clinics and practitioners billing FFS Medicaid for telehealth claims to be able to receive the PCMH/APC incentive for those primary care or preventative medicine services that would have otherwise been rendered to the member face-to-face:

  • For practitioner claims:
    • The Place of Service (POS) "02" was added as an acceptable location to allow practitioners to receive the PCMH/APC incentive payment. POS "02" is the service location that is used to indicate that health services and health-related services are provided via telemedicine, store-and-forward, and remote patient monitoring services. Providers must bill with POS code "02" and append the applicable modifier "95", "GT", or "GQ". The code POS "02" is not used when billing for telephonic services.

      Note:Physicians, physician assistants and registered nurse practitioners that are included on the PCMH/APC recognized provider list that are billing for telephonic communication services via Lane 1 referenced in the May 1, 2020 Comprehensive Guidance Regarding Use of Telehealth including Telephonic Services During the COVID-19 State of Emergency should reflect the POS location where the service would have been rendered to the member face-to-face (e.g., office POS "11".)
    • The Evaluation and Management (E&M) telephonic services procedure codes "99441" – "99443" referenced in Lane 1 of the May 1, 2020 Guidance referenced above were added as acceptable procedure codes that are eligible to receive incentive payments.
    • The procedure code for Remote Patient Monitoring (RPM) "99091" was added as an acceptable procedure code that is eligible to receive incentive payments.
  • For institutional claims: The telephonic service rate codes "4012", "4015", "7961" – 7962", referenced in Lanes 3, and 4 of the May 1, 2020 Guidance referenced above were added as acceptable rate codes that are eligible to receive incentive payments.

Any professional or institutional claims that were previously adjudicated for dates of service on or after March 1, 2020 that are eligible to receive an incentive payment based on the requirements referenced above will be systematically identified, and automatically reprocessed within the eMedNY system to add the PCMH/APC incentive payment. Providers and institutions do not need to resubmit a claim adjustment to receive any missed incentive payments.

This guidance replaces any previously issued guidance or provider communications issued regarding payment of the PCMH/APC incentive on claims fpr telehealth and telephonic services rendered during the COVID-19 State of Ememergency. All other PCMH/APC policy and billing guidelines remain unchanged. Please refer to the November 2018 issue of the Medicaid Update for additional information.

Questions and Additional Information:

  • Questions regarding Medicaid FFS incentive payments (including but not limited to missing incentive payments, claim add-on incentive payment amounts, and/or practice/provider recognition dates) should be directed to Computer Sciences Corporation (CSC a/k/a CSRA) at(800) 343‑9000 or via email to emednycallctr@csra.com.
  • Additional information can also be found on the eMedNY website at: https://www.emedny.org/.
  • Providers seeking assistance with FFS Policy should contact pcmh@health.NY.gov.

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Medicaid Taxi/Livery Reimbursement Fee Reduction

The Enacted 2020-2021 State Budget and Medicaid Redesign Team II (MRTII) initiative will decrease Medicaid Taxi/Livery base and mileage fees by 7.5 percent effective June 1, 2020. The updated fees effective for dates of service on or after June 1, 2020 are posted at: https://www.emedny.org/ProviderManuals/Transportation/index.aspx.

Questions

Questions regarding this policy should be directed to the Office of Health Insurance Programs (OHIP), Bureau of Medicaid Transportation at (518) 473‑2160 or medtrans@health.ny.gov.

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Medicaid Eligibility for Pregnant Women and COVID-19

This guidance is no longer applicable.

During the period of the COVID-19 emergency, Medicaid coverage will be continued for anyone who had Medicaid coverage on March 18, 2020. This includes all pregnant women, regardless of their immigration status. This means a pregnant woman may have coverage beyond her typical 60-day post-partum period or her typical twelve (12) months continuous Medicaid coverage period, depending on the duration of the disaster period.

Under ordinary circumstances many, if not most, pregnant women receive coverage beyond the 60-day post-partum period because they are eligible for twelve (12) months of continuous Medicaid coverage. Most Modified Adjusted Gross Income (MAGI) consumers receive twelve (12) months of Medicaid coverage from their eligibility determination or redetermination, regardless of changes in circumstance.

Some pregnant women are not eligible for twelve (12) months of continuous Medicaid coverage due to their immigration status. These pregnant women are eligible to move to Essential Plan (EP) after their 60-day post-partum period. EP has a plan/provider overlap of approximately 97 percent, which ensures continuity of care for women who change programs. During the COVID-19 emergency period, pregnant women who would ordinarily move to EP after their 60-day post-partum period will have continued Medicaid coverage. Eligibility redeterminations and any resulting program changes will take place after the emergency period is over.

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New York State Medicaid Fee-for-Service Policy and Billing Guidance for crizanlizumab-tmca (ADAKVEO®): New Coverage Criteria and "J" Code

Effective July 1, 2020, New York State (NYS) Medicaid fee-for-service (FFS) will begin utilizing criteria to determine the approval of crizanlizumab-tmca (ADVAKVEO®) for members with sickle cell disease to reduce the frequency of vasoocclusive crises when the member meets the criteria outlined in this policy. ADAKVEO® was approved by the U.S. Food and Drug Administration (FDA) for use on November 15, 2019.

NYS FFS Coverage Policy

In accordance with FDA indications, FFS will reimburse for ADVAKVEO® when the following criteria are met:

  • The patient must have a confirmed diagnosis of sickle cell disease
  • The patient must be sixteen (16) years of age and older

FFS Billing:

  • Payment for the drug's administration will be made through the outpatient Ambulatory Patient Groups (APG) payment when administered in a clinic setting.
  • Facilities administering ADVAKVEO® will be reimbursed for the cost of the drug using the ordered ambulatory fee schedule. The ordered ambulatory claim should be submitted on paper (using the eMedNY 150003 claim form) and should include the facility's actual acquisition cost by invoice. Documentation of medical necessity that includes the criteria listed above must accompany the claim. Ordered ambulatory billing guidelines can be found at: https://www.emedny.org/ProviderManuals/OrderedAmbulatory/PDFS/OrderedAmbulatory_Billing_Guidelines.pdf.
  • The following documentation must be included with the claim:
    • Manufacturer's invoice showing the acquisition cost of the biologic, including all discounts, rebates or incentives;
    • Documentation of the medication administration; and
    • Documentation of the criteria listed under the NYS FFS Coverage Policy section above.
  • Healthcare Common Procedure Coding System (HCPCS) code "J0791" (injection, crizanlizumab-tmca, 5mg) should be used to bill for "ADVAKVEO®". The associated National Drug Code (NDC) must be included on the claim.
  • Actual reimbursement will be calculated based on the actual acquisition cost, per the submitted invoice. Providers should report actual acquisition cost in the allowed amount field. Reimbursement will be at the acquisition cost on the provider's invoice.
  • Missing or incomplete documentation submissions will result in denials of the claim and delay the processing claims payment.

Reminders

Providers are reminded that any off-invoice discounts or rebates received from the manufacturer must be passed back to Medicaid. Storage and handling charges are included in the APG outpatient payment and will not be reimbursed separately.

Medicaid Managed Care (MMC) Billing

Providers participating in MMC should check with the individual health plans to determine their billing policies and how each MMC plan will apply this FFS policy.

Questions:

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Updated Criteria for HCPCS Code "A4670" - Automatic Blood Pressure Monitor

Effective July 6, 2020, fee-for-service (FFS) coverage criteria and reimbursement for Healthcare Common Procedure Coding System (HCPCS) code "A4670" will be updated and may be dispensed without prior approval. The new coverage criteria will be as follows:

CodeFeeMax Unit/Frequency
A4670$50.001 every 5 years

"A4670" - Automatic Blood Pressure Monitor Coverage Criteria:

  • The monitor must be ordered by a qualified practitioner as part of a comprehensive treatment plan that requires member monitoring and recording of blood pressure readings in the home.
  • Replacement due to other factors not covered by the manufacturer's warranty requires prior approval. Documentation of use and compliance to the physician treatment plan for monitoring blood pressure in the home must be submitted with the request.

Questions:

  • Questions regarding this guidance should be directed to (800) 342‑3005 or via email to OHIPMEDPA@health.ny.gov.
  • Medicaid Managed Care (MMC) questions regarding policy should be directed to the member's MMC plan.

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Pharmacy Update on Dose Optimization Program

Effective February 27, 2020, the New York State (NYS) Medicaid fee-for-service (FFS) program will update the Dose Optimization initiative with the drugs listed below. 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 Food and Drug Administration (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
CARDIOVASCULAR AGENTS
Antiarrhythmics
Drug Name, StrengthDose Optimization Limitations
amiodarone 100mg1 dailyTabletIn case of dose titration for these medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for loading dose for 30 days
CENTRAL NERVOUS SYSTEM AGENTS
Anticonvulsants
Drug Name, StrengthDose Optimization Limitations
Aptiom® 200mg, 400mg1 dailyTabletNone
Fycompa® 4mg, 6mg1 dailyTabletNone
topiramate ER 100mg1 dailyCapsuleNone
Lamictal XR® 50mg1 dailyTabletIn case of dose titration for these medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for 90 days
Oxtellar XR® 300mg1 dailyTabletIn case of dose titration for these medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for 90 days
Central Nervous System (CNS) Stimulants
Drug Name, StrengthDose Optimization Limitations
Vyvanse® 10mg, 40mg1 dailyCapsuleNone
GASTROINTESTINAL AGENTS
Proton Pump Inhibitors
Drug Name, StrengthDose Optimization Limitations
Nexium® 10mg, 20mg1 dailyPacketNone
HEMATOLOGIC AGENTS
Anticoagulants – Oral
Drug Name, StrengthDose Optimization Limitations
Xarelto® 10mg1 dailyTabletNone

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 a PA. To obtain a PA, providers may contact the Clinical Call Center at (877) 309‑9493. The Clinical Call Center is available 24 hours per day, seven days per week and staffed with pharmacy technicians and pharmacists available to assist providers in quickly obtaining a PA.

Current information on the Medicaid FFS Pharmacy PA Programs, including the Dose Optimization initiative, can be found at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf. This document contains a full list of drugs subject to the NYS Medicaid FFS Pharmacy Programs.

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Reminder: Substance Use Disorder Drug Treatment: Medicaid Managed Care and Fee-for-Service Coverage

Important Legislation Regarding Drugs to Treat Substance Use Disorders:

  • Medicaid policy requires Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) to provide at least five days' coverage for emergencies, without prior authorization, for medications used to treat substance use disorders. This includes medication associated with the management of opioid withdrawal and/or stabilization as well as medication used for opioid overdose reversal.
  • As published in the August 2016 issue of the Medicaid Update, New York State Social Services Law §364-j and Public Health Law §273, prohibit prior authorization under Medicaid FFS and MMC for initial or renewal prescriptions for preferred or formulary forms of buprenorphine or injectable naltrexone when used for detoxification or maintenance treatment of opioid addiction. The frequency, quantity, and/or duration limits supported by the Food and Drug Administration (FDA) and Compendia may continue to be applied.

Plan Contacts and Formulary Resource

The New York State MMC Pharmacy Benefit Information Center website contains information that can assist providers in identifying which medications are included on the NYS MMC formularies. The NYS MMC Pharmacy Benefit Information Center can be found at: https://mmcdruginformation.nysdoh.suny.edu/.

A comprehensive listing of Drugs to Treat Chemical Dependence, showing formulary coverage by plan, can be found on the "DRUG QUICKLISTS" page of the NYS MMC Pharmacy Benefit Information Center by selecting the "Therapeutic Classes, Other" tab. The list can be downloaded and printed.

The NYS MMC Pharmacy Benefit Information Center formulary coverage is updated quarterly. The website also includes a link to each individual plans' website, with their contact information and formulary, in order to access more in-depth information about each plan.

Additional information on substance use disorder drug coverage in FFS is available within the New York State Medicaid FFS Preferred Drug List at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf.

Frequently Asked Questions (FAQ):

Q1. What if the pharmacy does not have the medication in stock or not enough medication in stock?

A. The pharmacist can work with the prescriber to determine another pharmacy that has the medication in stock and send a new prescription to that pharmacy. If the pharmacy has limited stock, they can partially fill the prescription and dispense the remainder when the product is received according to applicable NYS law.

Q2. What if the wholesaler is limiting the amount of medication a pharmacy can receive?

A. Pharmacies should contact their wholesaler to determine if there is a shortage issue or a limit being imposed on the product in question. If the wholesaler imposed a limit, the pharmacy can work with the wholesaler to increase that limit. This may include providing additional information regarding their dispensing patterns.

Q3. What if the generic product is not available and the brand product is available and in stock?

A. The pharmacist can contact the insurance plan to authorize a pharmacy override to allow the brand medication to be dispensed when the generic is unavailable due to a marketplace shortage or when the product is temporality unavailable.

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New York Medicaid EHR Incentive Program

Distribution to Eligible Professionals & Eligible Hospitals Since the Start of the Program in 2011*
Number of Payments:Distributed Funds:
43,558$1,010,583,699

*As of 5/22/2020

Through the New York (NY) Medicaid Electronic Health Record (EHR) Incentive Program, eligible professionals (EPs) and eligible hospitals (EHs) in New York who adopt, implement, or upgrade certified EHR technology (CEHRT) and subsequently become meaningful users of CEHRT, can qualify for financial incentives. The Centers for Medicare and Medicaid Services (CMS) is dedicated to improving interoperability and patient access to health information. The NY Medicaid EHR Incentive Program is a part of the CMS Promoting Interoperability Program, but will continue to operate under the current name, NY Medicaid EHR Incentive Program.

Updated Payment Year (PY) 2019 Program Deadlines

To allow providers the opportunity to focus on patient care during this difficult time, the NY Medicaid EHR Incentive Program has extended all program deadlines for PY 2019 by one month. The new PY 2019 deadlines are as follows:

  • PY 2019 Attestation Deadline - June 4, 2020
  • Attestation Deadline Extension (ADE) Request Period Begins - May 20, 2020
  • ADE Request Period End (Last Day to Submit ADE) - June 22, 2020
  • Final PY 2019 Attestation Submission Deadline with Approved ADE - July 8, 2020

Attestation Deadline Extension (ADE)

The ADE Request Period is now open. Providers that are unable to complete their attestation by the deadline of June 4, 2020 may be granted an ADE upon request. To submit an ADE Request, providersdiers must fill out the ADE template which requires basic personal information and a reason for the request. The template is available for download at: https://www.health.ny.gov/health_care/medicaid/redesign/ehr/repository/docs/attestation_ext.xls. Completed templates should be sent to attestation@health.ny.gov for review.

Providers should contact the NY Medicaid EHR Incentive Program support desk with any questions or concerns regarding the new deadlines or the ADE process. The support desk is still operating during normal business hours and the contact information is available in the Questions section below.

Program Discussion Webinars

The NY Medicaid EHR Incentive Program will be hosting quarterly Program Discussion Webinars on a variety of topics identified by support staff and the provider community. Providers who would like to submit a particular topic for discussion may do so via the Program Satisfaction Survey available at: https://www.surveymonkey.com/r/NY_EHR.

The schedule and registration information for all webinars, including Program Discussions, Stage 3, Security Risk Analysis, Public Health Reporting, Patient Engagement, and Health Information Exchange can be found at: https://www.health.ny.gov/health_care/medicaid/redesign/ehr/calendar/.

LISTSERV Communications

As the COVID-19 situation continues to develop and change, additional information and program changes may be announced. The NY Medicaid EHR Incentive Program utilizes a LISTSERV messaging system to quickly communicate any changes or updates and recommends that providers and administrators subscribe in order to best be kept up to date.

Information and instructions on how to subscribe can be found on the NY Medicaid EHR Incentive Program LISTSERV webpage at: https://www.health.ny.gov/health_care/medicaid/redesign/ehr/listserv/index.htm. Providers who experience any difficulty when attempting to subscribe should contact the support team for assistance.

Check Participation Status

At minimum*, a provider must have completed and received an incentive payment for one payment year in PY 2016 or earlier to participate for future years. Providers uncertain about their participation status are encouraged to reach out to the NY Medicaid EHR Incentive Program support team for assistance. Program participation status can be verified and reviewed using the provider's National Provider Identifier (NPI) and may assist in determining a provider's ability to attest in PY2019-2021. Providers who wish to check their participation status should contact the support team at (877) 646‑5410 (Option 2) or via email at: hit@health.ny.gov.

*Providers must also meet all other relevant program requirements and metrics to be eligible to participate in the NY Medicaid EHR Incentive Program.

New York State (NYS) Regional Extension Centers (RECs)

NYS RECs offer free support to help providers achieve Meaningful Use (MU) of CEHRT. Support provided by NYS RECs includes, but is not limited to, the following:

  • Answers to questions regarding the program and requirements
  • Assistance on selecting and using CEHRT
  • Help meeting program objectives

NYS RECs offer free assistance for all practices and providers located within New York.

For Providers Located: Inside the five boroughs of NYC Outside the five boroughs of NYC
Contact:
NYC REACH
Phone: (347) 396‑4888
Website: https://www.nycreach.org.
MU Direct: https://www.nycreach.org/qi-services/#meaningful-use
Email: nycreach@health.nyc.gov.
New York eHealth Collaborative (NYeC)
Phone: (646) 619‑6400
Website: https://www.nyehealth.org
MU Direct: https://www.nyehealth.org/services/meaningful-use/
Email: ep2info@nyehealth.org

Questions

The EHR Incentive Program has a dedicated support team ready to assist. Please contact the program at (877) 646‑5410 (Option 2) or via email at hit@health.ny.gov.

Please Complete the New York Medicaid EHR Incentive Program Customer Satisfaction Survey

The NY Medicaid EHR Incentive Program values provider insight. The survey can be found at: https://www.surveymonkey.com/r/NY_EHR.

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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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs