New York State Medicaid Update - September 2021 Volume 37 - Number 11

In this issue …

• Policy and Billing Guidance
  • Medicaid Hospital Inpatient Billing Discharge Status Codes
  • Attention: Applied Behavior Analysis Providers
  • Reminder: Existing New York State Medicaid Policy for Drugs, Supplies, and Procedures Used for Sexual or Erectile Dysfunction
• All Providers
  • Medicaid Consumer Fact Sheets Now Available
  • NY State of Health: Higher Income New Yorkers May Now Qualify for Financial Assistance to Lower the Cost of Health Coverage
  • Clozapine Risk Evaluation and Mitigation Strategy Deadline

|top of page|

---

Medicaid Hospital Inpatient Billing Discharge Status Codes

Hospitals must correctly identify and properly code whether patients are transferred or discharged, since this will affect Medicaid hospital inpatient billing and payments. For additional information, providers can refer to the May 2013 issue of the Medicaid Update article titled Medicaid Billing - Patient Status Codes.

Effective August 21, 2021, according to the New York Codes, Rules and Regulations (NYCRR), Title 10, §86-1.15, discharges (in a general hospital acute care setting) shall mean those inpatients whose admission to the facility occurred on or after December 1, 2009, and:

• the patient is released from the facility to a non-acute care setting; or
• the patient dies in the facility; or
• the patient is transferred to a facility or unit that is exempt from the case-based payment system, except when the patient is a newborn transferred to an exempt hospital for neonatal services; or
• the patient is a neonate being released from a hospital (providing neonatal specialty services) back to the community hospital of birth for weight gain.

A transfer patient is defined as a patient who:

• is not discharged, as stated above,
• is not transferred among two or more divisions of merged or consolidated facilities
• is not assigned to a Diagnosis Related Group (DRG) specifically identified as a DRG for transferred patients only, and
• meets one of the following conditions:
  • is transferred from an acute care facility reimbursed under the DRG case-based payment system to another acute care facility reimbursed under the same system; or is transferred to an out-of-state acute care facility; or
  • is a neonate who is being transferred to an exempt hospital for neonatal services.

Hospitals must ensure the accuracy of the patient discharge status coding on correct Medicaid claims.

Additional Information:

• For additional information regarding NYCRR, Title 10, §86-1.15, and transfer payments (NYCRR, Title 10, Part 86-1.21), providers should refer to the NYS Department of Health (DOH) "New York Codes, Rules and Regulations" web site.
• For inpatient billing guidelines, providers should refer to the eMedNY NYS UB-04 Billing Guidelines.

|top of page|

---

Attention: Applied Behavior Analysis Providers

Applied Behavior Analysis (ABA) services provided by New York State (NYS) Medicaid enrolled Licensed Behavior Analysts (LBAs), Certified Behavior Analyst Assistants (CBAAs), or other individuals specified under Article 167 of NYS Education Law working under the supervision of LBAs will be carved out of the Medicaid Managed Care (MMC) benefit package. Effective October 1, 2021, NYS Medicaid enrolled LBAs can bill Medicaid fee-for-service (FFS) for ABA services provided to MMC members until further notice. The ABA Provider Manual and Fee Schedule, published by the NYS Department of Health (DOH) via eMedNY "Applied Behavior Analysts (ABA)" web page, provides coverage policy, billing guidance and fee schedules for ABA services.

Additional Information:

• Additional information regarding ABA services can be found in the article titled Coverage of Applied Behavior Analysis in the July 2021 issue of the Medicaid Update.
• Please note: Current Procedural Terminology (CPT) code "97156" [Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional, with or without the patient present, face-to-face with guardian(s)/caregiver(s), for 15 minutes each] has been added to the published ABA Provider Manual and Fee Schedule.
• CPT code "97156" can only be billed when the service is delivered in concert with care of the patient as part of the patient treatment plan.

|top of page|

---

Reminder: Existing New York State Medicaid Policy for Drugs, Supplies, and Procedures Used for Sexual or Erectile Dysfunction

In accordance with Chapter 645 of the Laws of 2005, the New York State (NYS) Medicaid program does not cover prescription or physician-administered drugs used for the treatment of sexual dysfunction (SD) or erectile dysfunction (ED). Addition, Medicaid does not reimburse any supplies or procedures used to treat SD/ED for persons required to register as sex offenders. Providers must verify that Medicaid members receiving any procedures or supplies which may be used for these indications are not listed as registered sex offenders. There may be limited exceptions where some of these services are covered for members on the sex offender list, if their conditions are not related to SD/ED. These situations will require medical review by NYS Department of Health (DOH) for Medicaid fee-for-service (FFS) and by each impacted Medicaid Managed Care (MMC) Plan.

Medicaid Fee-for-Service

For SD/ED procedures, physician administered drugs or supplies that require Prior Approval (PA), the NYS Department of Health (DOH) will verify if members are registered as sex offenders during the PA process. Prior to performing inpatient procedures related to SD/ED treatment, providers must contact the Bureau of Medical Review at (800) 342‑3005. Outpatient pharmacy services that provide phosphodiesterase type-5 (PDE-5) inhibitors require PA to ensure clinical criteria are met. Specific clinical criteria can be found in the NYS Medicaid Fee-For-Service (FFS) Preferred Drug List. Providers seeking PA can contact the Magellan Clinical Call Center at (800) 343-9000.

Medicaid Managed Care Plans

Prior to approving requests for any SD/ED related drugs, supplies, or procedures, MMC Plans [including mainstream MMC Plans, HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs), as well as Health and Recovery Plans (HARPs)] are required to submit requests for information regarding enrollee status on the sex offender registry to the NYS DOH, through the Health Commerce System (HCS) Erectile Dysfunction Verification System (EDVS), each time there are requests for these services.

Questions and Additional Information:

• Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management by phone at (518) 473‑2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343‑9000.
• MMC general coverage questions may be directed to OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by phone at (518) 473‑1134.
• MMC reimbursement and/or billing requirements questions should be directed to the enrollee's MMC plan. Providers can refer to the NYS Medicaid Program Information for All Providers: Managed Care Information document.
• PA questions may be directed to the OHIP Division of Operations and Systems (DOS) at (800) 342‑3005.

|top of page|

---

Medicaid Consumer Fact Sheets Now Available

Following a recommendation from the Medicaid Redesign Team (MRT) II, the New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) created Medicaid consumer fact sheets focused on chronic health conditions. Each fact sheet provides information regarding how a condition can be prevented or managed, as well as relevant Medicaid benefits that can be used to help members stay healthy. Topics include sickle cell disease, diabetes, high blood pressure, asthma control, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), and smoking cessation. Fact sheets can be found on the NYS DOH "MRT II Policies and Guidance" web page, and are available in English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali, and Korean. The most recently added Sickle Cell Disease fact sheet is also available in Simplified Chinese, Polish, Yiddish, Arabic, and Italian.

|top of page|

---

NY State of Health: Higher Income New Yorkers May Now Qualify for Financial Assistance to Lower the Cost of Health Coverage

New federal financial assistance is now available through NY State of Health to qualifying, higher-income individuals. This financial assistance is being implemented as part of the American Rescue Plan Act (ARPA) signed into law on March 11, 2021.

Nearly 120,000 enrollees with income below 400 percent federal poverty level (FPL) are already receiving enhanced tax credits and nearly 18,000 higher-income enrollees are eligible for these federal tax credits for the first time. Higher-income individuals enrolled outside of NY State of Health and uninsured individuals may also be eligible for enhanced tax credits available through NY State of Health. Before the ARPA, tax credits were not available to higher-income individuals and their families (i.e., those earning more than $51,040 and families of four earning more than $104,800). Through the ARPA, these federal tax credits are available to these individuals and their families when enrolling in a health plan through NY State of Health.

Individuals with low and moderate incomes (i.e., those earning up to $51,040 and families of four earning up to $104,800) who were previously eligible for tax credits are now eligible for higher tax credits. NY State of Health automatically applied higher tax credits without enrollees needing to take any action. Enrollees can make changes to their account by logging into their NY State of Health account, contacting an Enrollment Assistor, and/or calling NY State of Health at (855) 355–5777.

To allow as many individuals as possible to access these enhanced tax credits, the 2021 Open Enrollment Period has been extended through December 31, 2021. Individuals and families can apply for coverage through the NY State of Health website, by phone at (855) 355‑5777, or by connecting with a free enrollment assistor via the NY State of Health "Find a Broker/Navigator" search tool.

Additional Information

To read more about how NY State of Health enrollees benefit from the ARPA, providers can visit the How NY State of Health Enrollees Benefit from the American Rescue Plan web page.

|top of page|

---

Clozapine Risk Evaluation and Mitigation Strategy Deadline

Effective immediately, all providers and pharmacies that prescribe or dispense clozapine must re-certify in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) by November 15, 2021. Clozapine is Food and Drug Administration (FDA)-approved for treatment-resistant Schizophrenia and to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. Clozapine is associated with severe neutropenia [absolute neutrophil count (ANC) less than 500/μL], and as part of Clozapine REMS, patient ANCs must be submitted monthly via Patient Status forms.

For prescribers, re-certification is required regardless of outpatient or inpatient setting. Providers and pharmacies that fail to re-certify cannot prescribe or dispense clozapine. Providers/pharmacies must also re-enroll their patients in the Clozapine REMS by November 15, 2021. Patients who are not re-enrolled by their providers into Clozapine REMS cannot receive clozapine.

The modifications to the Clozapine REMS, which include the prescribing, dispensing, and receiving of clozapine into a single-shared program, were approved on July 29, 2021 by the FDA and can be found on the FDA "Clozapine Risk Evaluation and Mitigation Strategy (REMS) requirements will change on November 15, 2021" web page. Providers and pharmacies can re-certify or re-enroll their patients into the program by visiting the "Clozapine REMS" home page.

|top of page|

---

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

Kathy Hochul
Governor
State of New York

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

Brett R. Friedman
Acting Medicaid Director
Office of Health Insurance Programs