New York State Medicaid Update - February 2022 Volume 38 - Number 2

In this issue …

• Policy and Billing
  • Medicaid Members are Exempt from Copayments for COVID-19-Related Treatment and Services
  • Change to Dental Clinic Billing in Ambulatory Patient Group
  • Updated COVID-19 Vaccine Counseling Coverage
• All Providers
  • Office of Health Insurance Programs Announces Launch of 2022 Medicaid Accelerated eXchange (MAX) Workshop Series
  • Medicaid Consumer Fact Sheets Now Available
  • Update to Upcoming eMedNY Provider Enrollment Portal
  • Driver's License Requirements
  • Parking and Toll Reimbursement for All Non-Emergency Medical Transportation Providers
• Pharmacy
  • Updated Statewide Formulary for Opioid Dependence Agents and Opioid Antagonists

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

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Medicaid Members are Exempt from Copayments for COVID-19-Related Treatment and Services

This guidance is outdated. Please refer to the September 2024 Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 Services Special Edition issue of the Medicaid Update, for current COVID-19 billing and coverage guidance.

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) covers Coronavirus Disease 2019 (COVID-19) testing, evaluation, and treatment without copayments, including preventive therapies and specialized equipment. This coverage also includes treatment for post-acute-COVID conditions, which may be described as "long COVID". Long COVID includes a range of symptoms that can last weeks or months after infection. NYS Medicaid FFS and MMC also cover, without copayments, treatments for conditions that may seriously complicate the treatment of COVID-19 for individuals who have, or are presumed to have, COVID-19. This includes immunizations, monoclonal antibody infusions, and all lab tests, as well as other treatments provided.

Professional claims submitted for COVID-19 related testing, evaluation, and treatment should be identified as emergencies by reporting with Emergency Indicator = "Y". Institutional providers [Emergency Department (ED), hospital outpatient/Diagnostic and Treatment Centers (D&TCs), Federally Qualified Health Centers (FQHCs), and hospital inpatient] should report Type of Admission Code = "1" to indicate emergencies when the purpose of the encounters are related to COVID-19. Previous guidance was provided in the March 2020 Special Edition of the Medicaid Update guidance titled New York State Medicaid Coverage and Reimbursement Policy for Services Related to Coronavirus Disease 2019 (COVID-19).

Pharmacy claims submitted for COVID-19-related testing, evaluation, and treatment that do not adjudicate with a zero copayment can be systematically adjusted by utilizing National Council for Prescription Drug Programs (NCPDP) field 461-EU (Prior Authorization Type Code) using a value of "04" = exempt copay. This instruction can be found in the NCPDP D.0 Companion Guide, located on the eMedNY "5010/D.0 Transaction Instructions" web page. Similar guidance can be found in the May 2020 COVID-19 guidance titled New York State (NYS) Medicaid Fee-for-Service (FFS) Policy and Billing Guidance for COVID-19, Testing and Specimen Collection at Pharmacies As of 12/16/2021.

Questions and Additional Information:

• FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

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Change to Dental Clinic Billing in Ambulatory Patient Group

Effective January 1, 2022, New York State (NYS) Medicaid fee-for-service (FFS) Clinic Billing reimbursement will be provided for "D1354" interim caries arresting medicament application per tooth by unit(s) versus by line item(s). When billing "D1354" under the Ambulatory Patient Group (APG) payment methodology:

• Reimbursement is $15.00 per tooth/unit.
• "D1354" should be indicated on one claim line with the number of units performed.
• "D1354" can be billed for up to five teeth/units on the same date of service. More teeth can be considered in exceptional circumstances; however, documentation supporting necessity must be submitted with the claim.
  • Example: If three teeth are being treated, "D1354" should be billed on one claim line with three units.

Questions and Additional Information:

• Medicaid Dental Policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development (DPDM) by phone at (518) 473-2160 or by email at dentalpolicy@health.ny.gov.
• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Updated COVID-19 Vaccine Counseling Coverage

This guidance is outdated. Please refer to the September 2024 Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 Services Special Edition issue of the Medicaid Update, for current COVID-19 billing and coverage guidance.

Effective December 1, 2021, New York State (NYS) Medicaid fee-for-service (FFS), Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, Health and Recovery Plans (HARPs), and HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs)], provides reimbursement for Coronavirus Disease 2019 (COVID-19) vaccination counseling to unvaccinated Medicaid members to encourage the administration of the COVID-19 vaccine. MMC Plans must configure their payment systems no later than February 7, 2022 to pay claims for dates of service on or after December 1, 2021.

The following coverage criteria supersedes the coverage criteria published in the November 2021 Medicaid Update article titled COVID-19 Vaccine Counseling Coverage. Changes made in March 2022 are highlighted below in yellow.

The provider types listed below may bill for COVID-19 vaccine counseling:

• Physicians
• Nurse Practitioners (NPs)
• Licensed Midwives
• Pharmacists
• Article 28 clinics billing ordered ambulatory
• Federally Qualified Health Centers (FQHCs)
• Other qualified rate-based providers

Updated Coverage Criteria

Providers may bill for COVID-19 vaccine counseling provided to Medicaid members:

• as a stand-alone service when all the criteria specified in this guidance are met and documented.
• in addition to an Evaluation and Management (E&M) or Well Child Visit when all the criteria of the vaccine counseling visit specified in this guidance are met and documented, in addition to all necessary components of the E&M/Well Child visit.
• whether or not a COVID-19 vaccine is administered during the encounter.
• using the Medicaid enrolled child's Client Identification Number (CIN) when counseling is provided to a parent, caregiver, or guardian for the benefit of the child, with or without the child present during the counseling session.
• for up to four counseling visits per vaccine dose recommended by the Centers for Disease Control and Prevention (CDC), when the member has not received and does not have an appointment to receive, the recommended dose, up to a total of 12 visits per member per year.

Additional information regarding COVID-19 vaccines recommended by the CDC can be found on the CDC "Types of Vaccines Available" web page. Qualified providers may provide up to four pre-decisional counseling visits for each dose recommended by the CDC, including booster doses, up to a total of twelve visits per year. Members receiving counseling on an initial dose or subsequent dose, including boosters, must not have already received the dose and must not already have an appointment to receive the dose.

The NYS Medicaid program is designed to provide payment for medical care and services only after all other resources available for payment have been reviewed and used. If a Medicaid member has third-party insurance coverage, the benefits of those coverages must fully be used before billing the NYS Medicaid program. Providers should always ask Medicaid members if they have other or third-party coverage to ensure the proper coordination of benefits. Providers who already receive payments from another source for COVID-19 vaccination counseling (e.g., the New York City COVID-19 Vaccine and Counseling outreach program) are not eligible for reimbursement from Medicaid. Medicaid is the payor of the last resort; federal regulations require that all other available resources be used before Medicaid considers payment.

The COVID-19 vaccine counseling session must be documented in the medical or pharmacy record and must include the following:

• confirming that the patient is not currently "up-to-date" with COVID-19 vaccine dosing, as recommended by the CDC per the CDC "Stay Up to Date with Your Vaccines" web page;
• confirming vaccination status in the New York State Immunization Information System (NYSIIS), whenever possible;
• confirming the patient does not already have an appointment scheduled to receive an initial/first dose;
• confirming patient consent of the parent, guardian or caregiver (if appropriate) to receive the counseling;
• the reasons expressed by the patient, parent, or caregiver for vaccine hesitancy;
• strongly recommending the COVID-19 vaccination (unless medically contraindicated, in which case the counseling session is not billable);
• counseling the patient, along with their parent, guardian, or caregiver (if appropriate) on the safety and effectiveness of COVID-19 vaccines;
• answering any questions that the patient or parent, guardian, or caregiver has regarding COVID-19 vaccination;
• counseling the patient, along with their parent, guardian, or caregiver (if appropriate) for a minimum of eight minutes; and
• arranging for vaccination or providing information on how the patient can get vaccinated for COVID-19.

Questions and Additional Information:

• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at PPNO@health.ny.gov.
• MMC general coverage questions should be directed to the OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by telephone at (518) 473-1134.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

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Office of Health Insurance Programs Announces Launch of 2022 Medicaid Accelerated eXchange (MAX) Workshop Series

The New York State (NYS) Department of Health (DOH) Medicaid Accelerated eXchange (MAX) Series Program is launching the highly rated "MAX Workshop Series" to improve care for individuals whose underlying unmet needs result in high utilization of hospitals and emergency departments. The MAX program, developed under the Delivery System Reform Incentive Payment (DSRIP) program, engages and empowers front-line teams of clinical and social service providers to make changes that are locally relevant and feasible, leveraging available resources. Among the key accomplishments have been creating new on-site workflows incorporating community connections to address root causes of high utilization. Action Teams have reported high worker satisfaction in the redesign of how to care for these complex patients. The MAX program provides a vehicle for front-line provider teams to improve care, reduce the costs associated with avoidable admissions, and benefit under value-based payment (VBP) arrangements.

The goal of the "MAX Workshop Series" is to reduce avoidable hospital use, adopting the Multi-Visit Patient (MVP) methodology developed by Dr. Amy Boutwell, a national care transitions subject matter expert and consultant. MVPs are the small percentage of patients with unmet needs that utilize a disproportionately high amount of healthcare services, such as inpatient stays and emergency department visits, often based on non-medical concerns.

The "MAX Workshop Series" is structured over an eight-month period with three virtual, rapid-cycle continuous improvement (RCCI) workshops and weekly coaching calls held for each participating MAX Action Team. In the MAX framework, hospitals form interdisciplinary teams to use RCCI to implement systems to identify MVPs, assess for root causes (drivers of utilization), and connect to more appropriate community supports and services. This ultimately creates a "MVP Care Pathway" for improved care and reduced utilization.

Dr. Boutwell has led past rounds during DSRIP's MAX efforts and will continue to lead MAX Action Teams with virtual workshop and coaching support from Island Peer Review Organization (IPRO). The next cohort will be launched in Spring 2022.

Questions and Additional Information:

• For questions and workshop enrollment assistance, providers are encouraged to contact Shannon Wolanin by email at swolanin@ipro.org or by phone at (518) 320-3501.
• For more information on the "MAX Workshop Series", providers can visit the NYS DOH "Medicaid Accelerated eXchange (MAX) Series and MAX Training Program" web page.

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Medicaid Consumer Fact Sheets Now Available

Medicaid consumer fact sheets, focused on prevention and management of chronic health conditions, as well as relevant Medicaid benefits that can be used to help members stay healthy, are available on the New York State (NYS) Department of Health (DOH) "MRT II Policies and Guidance" web page. Topics include asthma control, chronic kidney disease, diabetes, high blood pressure, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), periodontal disease, sickle cell disease, smoking cessation, and tooth decay. Fact sheets are available in English, Spanish, Chinese, Russian, Haitian Creole, Bengali, and Korean, Polish, Yiddish, Arabic and Italian. The three most recently added fact sheets on chronic kidney disease, periodontal disease, and tooth decay are currently only available in English; however, translations will be made available in the near future.

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Update to Upcoming eMedNY Provider Enrollment Portal

As previously announced in the January 2022 Medicaid Update, the release of eMedNY's upcoming Provider Enrollment Portal (the Portal) will enable practitioners to perform numerous maintenance transactions using an easy online process. Although this will be an alternative to the current paper processes that will significantly reduce turnaround time, paper maintenance forms will continue to be accepted. Group, Business, and Institutional providers will be able to access portal transactions in future releases.

Some of the key maintenance functions of the Portal will include the ability to:

• perform Drug Enforcement Administration (DEA) updates;
• view provider file data in real-time;
• submit address changes;
• affiliate to groups;
• add specialties;
• update electronic funds transfer (EFT) information; and
• check the status of all Portal-based maintenance transactions.

eMedNY is currently developing Provider Enrollment Portal training webinars that will include topics such as how to sign up and how to navigate the Portal. Dates, times, and registration for these webinars will be communicated via eMedNY LISTSERV. Providers are encouraged to subscribe to the eMedNY LISTSERV, for updates and email alerts. Additionally, providers can access all eMedNY trainings and training registration information on the eMedNY "Provider Training" web page.

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Driver's License Requirements

The purpose of this update is to reinforce existing driver's license requirements through the New York State (NYS) Medicaid Program Policy regarding the reporting of vehicle license plate numbers and driver's license numbers on all transportation claims. eMedNY requires the entry of nine characters for driver's license numbers. All NYS driver's licenses have a nine-digit motorist ID. Other states may have fewer or more characters. When reporting an out-of-state driver's license number with more than nine characters, only the first nine characters should be reported. Exhibit 2.4.2-5 shown below features an entry where the driver's license is A123456789B:

22 OTHER (REFERRING/ORDERING) PROVIDER ID/LICENCE NUMBER
	A	1	2	3	4	5	6	7	8

If a driver's license number contains fewer than nine characters, the entry must be right justified and zero-filled to complete the nine characters. Exhibit 2.4.2-6 shown below features an entry where the driver's license is 3456789:

22 OTHER (REFERRING/ORDERING) PROVIDER ID/LICENCE NUMBER
	0	0	3	4	5	6	7	8	9

The basic tenets of this guidance are included in the eMedNY New York State Billing Guidelines - Transportation document.

Questions

All questions should be directed to the NYS Department of Health (DOH) Medical Transportation Unit by telephone at (518) 473-2160 or by email at MedTrans@health.ny.gov.

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Parking and Toll Reimbursement for All Non-Emergency Medical Transportation Providers

The purpose of this guidance is to reinforce existing New York State (NYS) Medicaid Program Policy regarding payments for parking and tolls (Procedure Code "A0170"). NYS Medicaid will provide reimbursement only for the actual costs incurred by a transportation provider while transporting a Medicaid member. When tolls are incurred, the toll is assessed per vehicle, not per rider, and must be billed according to the actual toll charged. Therefore, if a vehicle is transporting more than one rider on the same trip, the provider may bill one unit per charged crossing, not one unit per passenger. E-ZPass® customers, who are charged less per toll than those who pay tolls with cash must bill Medicaid for the actual toll amount charged to their E-ZPass® account while transporting a Medicaid member(s).

Procedure code "A0170" for parking and tolls has an assigned maximum dollar amount that will be accepted by the eMedNY system. A transportation provider may only bill this maximum dollar amount if it represents the actual costs incurred by the transportation provider. When submitting a claim involving parking or tolls, the transportation provider must replace the maximum dollar amount associated with procedure cost "A0170", with the actual costs incurred by the transportation provider while transporting a Medicaid member(s).

The basic tenets of this guidance are included in the New York State Medicaid Program - Transportation Manual Policy Guidelines document.

Questions

All questions should be directed to the NYS Department of Health (DOH) Medical Transportation Unit by telephone at (518) 473-2160 or by email at MedTrans@health.ny.gov.

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Updated Statewide Formulary for Opioid Dependence Agents and Opioid Antagonists

On December 22, 2021, Governor Hochul signed Chapter 720 of the Laws of 2021, which amends Social Services Law and the Public Health Law, in relation to medication for the treatment of substance use disorders. Effective March 22, 2022, prior authorization (PA) will not be required for medications used for the treatment of substance use disorder prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder. Prescriptions written outside of accepted guidelines may be subject to PA.

A Single Statewide Medication Assisted Treatment (MAT) Formulary was implemented on October 1, 2021, in accordance with §367-a (7)(e) of Social Services Law. The Single Statewide MAT Formulary aligns coverage parameters across New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC).

Reminder to Prescribers

Effective March 22, 2022, prescriptions for a brand name multi-source drug will be filled with a generic equivalent, as required by NYS Social Services and Education Law, unless the prescriber indicates "DAW" and "Brand Medically Necessary (BMN)" on the prescription. The prescriber must also make notation in the medical record of the Medicaid member stating that the drug is "BMN" and the reason that a brand name multi-source drug is required.

Questions and Additional Resources:

• The Magellan Health Inc. "Single Statewide Medication Assisted Treatment (MAT) Formulary" website.
• MMC general coverage questions should be directed to the OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by telephone at (518) 473-1134.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans. MMC Plan coverage and contact information can be found on the NYS DOH "New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center" website.
• FFS billing questions should be directed to General Dynamics Information Technology Company (GDIT) at (800) 343-9000.
• FFS coverage questions should be directed to Magellan Health Inc. at (877) 309-9493.
• FFS policy questions should be directed to the Medicaid Pharmacy Policy unit by telephone at (518) 486-3209 or by email at ppno@health.ny.gov.

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

Kathy Hochul
Governor
State of New York

Mary T. Bassett, M.D., M.P.H.
Commissioner
New York State
Department of Health

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

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