New York State Medicaid Update - March 2022 Volume 38 - Number 3

In this issue …

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

Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit

Effective April 1, 2022, for New York State (NYS) Medicaid fee-for-service (FFS), and effective June 1, 2022, for Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans and Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs)], will reimburse providers for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program when provided to Medicaid members ages 18 years of age or younger. Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP).

Please note: Vaccine counseling visits for Coronavirus Disease 2019 (COVID-19) vaccinations are reimbursed separately. Providers can refer to the Updated COVID-19 Vaccine Counseling Coverage guidance, for more information. Providers may bill for childhood vaccine counseling provided to Medicaid members 18 years of age and younger:

  • 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 recommended vaccine is administered, or vaccine administration is billed for, during the encounter.
  • for up to six counseling visits per member per year for members ages zero through 18 years of age, when the member has not received the ACIP-recommended doses and does not have an appointment to receive the recommended dose.

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

  • confirming with the parent, guardian, caregiver, or patient (if appropriate) that the patient is not currently "up to date" with childhood vaccination doses (according to the ACIP Child and Adolescent Immunization Schedule, recommended for ages 18 years or younger);
  • confirming vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible;
  • confirming the patient does not already have an appointment scheduled to receive the vaccine dose for which they are being counseled;
  • reason(s) expressed by the parent or caregiver for vaccine hesitancy;
  • recommendation of the vaccine(s);
  • counseling the parent, guardian, caregiver, or patient (if appropriate), on the safety and effectiveness of the vaccine(s);
  • answering any questions that the parent, guardian, caregiver, or patient (if appropriate) have regarding the recommended vaccine(s);
  • counseling to the parent, guardian, caregiver, or patient (if appropriate) for a minimum of eight minutes; and
  • arranging for vaccination(s) or providing information to the parent, guardian, caregiver, or patient (if appropriate) on how the patient can get vaccinated.

Clinics, Hospital Outpatient Departments, Physicians, Nurse Practitioners, and Midwives

A provider submitting professional claims should bill Current Procedure Terminology (CPT) code "99401" for preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required.

HCPCS Code Code Description Fee
99401 Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) $12.50

Pharmacists

A pharmacist providing pediatric vaccine counseling for a minimum of eight minutes should bill using the National Council for Prescription Drug Programs (NCPDP) D.0 claim format as outlined in the table below.

NCPDP D.0 Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter the value of "09" [Healthcare Common Procedure Coding System (HCPCS)], which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code*.
407-D7 (Product/Service ID) Enter "99401".
444-E9 (Pharmacist ID) Enter Pharmacist National Provider Identifier (NPI) number.
411-DB (Prescriber ID) Please leave field blank.

*The D.0 Companion Guide can be found on the "eMedNY 501/D.0 Transaction Instructions" web page.

Questions and Additional Information:

  • Fee-for-service (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.
  • Medicaid Managed Care (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 (518) 473-1134.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC Plan.
  • 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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New York State Medicaid Professional Pathology Policy

Effective April 1, 2022, New York State (NYS) Medicaid fee-for-service (FFS) will reimburse participating laboratories and facilities for a consultation on pathology specimens as outlined in this policy. The policy will be effective on June 1, 2022, for Medicaid Managed Care (MMC) Plans, including Mainstream MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs), and Health and Recovery Plans (HARPs). Reimbursement is available for consultations after the initial specimen reading when the following criteria are met:

  • the facility was not the laboratory that initially processed the specimen, and the consulting pathologist is not employed by or affiliated with the original facility; and
  • a pathologist with a specific specialty is necessary for comprehensive evaluation and there is not a pathologist with that specialty available at the initial laboratory; and
  • a consultation will aid in the diagnosis and/or treatment of a Medicaid member; or
  • the member is seeking treatment at the consulting facility.

FFS Billing

CPT Codes
(effective April 1, 2022 for FFS
and June 1, 2022 for MMC)		 Description
80503 Pathology clinical consultation for clinical problem, five to twenty minutes
80504 Pathology clinical consultation for moderately complex clinical problem, 21 to 40 minutes
80505 Pathology clinical consultation for complex clinical problem, 41 to 60 minutes
80506 Pathology clinical consultation, additional 30 minutes

MMC Billing

Providers participating in MMC should check with the individual health plans to determine how each MMC Plan will implement this policy. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee´s MMC Plan.

Reminder:
Pathologists are not payable providers in NYS Medicaid; therefore, reimbursement for this service will be made to the facility.

Questions and Additional Information:

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Attention: New York State Medicaid Fee-For-Service Providers Administering Drugs

The New York State (NYS) Medicaid program has issued policies and billing guidance for certain drugs/drug classes for physicians, nurse practitioners (NPs), and midwives. These drugs are eligible for reimbursement when the clinical criteria outlined on the NYS Department of Health (DOH) "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page, and listed web page Medicaid Update articles, are met. Drug claims must include documentation of clinical criteria as well as the following:

Clinical Criteria Worksheets, located on the NYS DOH "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page, are available for drugs/drug classes subject to clinical criteria. These worksheets outline the clinical and claim documentation requirements, provide a step-by-step outline of the requirements, and are designed to ensure complete claim documentation submission. A completed worksheet and the manufacturer invoice showing the drug acquisition cost, including all discounts, rebates, and incentives, can be submitted with the Health Care Finance Administration (HCFA) 1500 form.

Questions and Additional Information:

  • Fee-for-service (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.
  • Medicaid Managed Care (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 (518) 473-1134.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC Plan.
  • 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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Pharmacy and Medical Billing Guidance for SPRAVATO® (esketamine)

Effective May 12, 2022, for New York State (NYS) Medicaid fee-for service (FFS) and Medicaid Managed Care (MMC) Plans [including Mainstream MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs), and Health and Recovery Plans (HARPs)], the following billing guidance will be implemented for SPRAVATO® (esketamine) in the Medicaid program.

Drug Procured by Medical Provider ("Buy and Bill"):

  • Drug billed by the provider using the appropriate Healthcare Common Procedure Code System (HCPCS) code for esketamine.
  • Medical observation and monitoring are billed using the appropriate Current Procedural Terminology (CPT) code(s) for Evaluation and Management (E/M). See Claim Billing Requirements table provided below.
  • Providers must bill the actual acquisition cost of esketamine, inclusive of all rebates and discounts, per invoice.

Drug Dispensed by REMS-Certified Specialty Pharmacy:

  • Drug billed by the pharmacy and delivered, on behalf of the patient, to the provider.
  • Medical observation and monitoring are billed by the provider using the appropriate CPT code(s) for E/M. See Claim Billing Requirements table provided below.
  • A pharmacy must adhere to the program policy requirements which can be found in the Dispensing of Drugs that Require Administration by a Practitioner article, published in the August 2019 issue of the Medicaid Update.

Claim Billing Requirements

  Information Required on the Claim
HCPCS Code National Drug Code (NDC) CPT E/M Code(s)
Medical Claim for Drug and E/M X X X
Medical Claim for E/M Only N/A N/A X
Pharmacy Claim N/A X N/A

HCPCS Code

HCPCS Code Code Description
S0013 esketamine, nasal spray, 1mg

CPT E/M Codes

Providers may bill the appropriate E/M procedure code(s) that represent the time observing and monitoring the member post administration. See table below for more information:

CPT Codes Code Description
99205 Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and /or examination and high level of medical decision making. When using time for code selection, 60 to 74 minutes of total time is spent on the date of the encounter. For services 75 minutes or longer, use prolonged services code "99417" .
99215 Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40 to 54 minutes of total time is spent on the date of the encounter. For services 55 minutes or longer, use prolonged services code "99417" .
99417 Prolonged office or other outpatient E/M service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (list separately in addition to codes "99205" and "99215" for office or other outpatient E/M services).

Please note: HCPCS codes "G2082" and "G2083" should not be billed to the NYS Medicaid program. These codes are a bundled payment and are not eligible for rebate collection per Federal rule and, therefore, are not listed as covered by the program. These codes are only authorized for use on Medicare crossover claims.

Questions and Additional Information:

  • Fee-for-service (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.
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC Plan.
  • 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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Discontinued Coverage for TerSera Therapeutics LLC Drugs

Effective October 1, 2021, TerSera Therapeutics LLC voluntarily withdrew from participation in the Medicaid Drug Rebate Program (MDRP). As a result, New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) will no longer provide coverage for most drugs manufactured by TerSera Therapeutics LLC.

Pursuant to Social Security Law Sec. 1927 [42 U.S.C. 1396r-8] (a), Centers for Medicare and Medicaid Services (CMS) requires drug manufacturers to participate in the MDRP for their drugs to be eligible for coverage under Medicaid, except in certain circumstances. ZOLADEX® (goserelin implant) is a practitioner-administered drug manufactured by TerSera Therapeutics LLC which is available through a Patient Assistance Program (PAP) from the manufacturer free of charge for those who qualify. For program applications and additional information, providers must visit the ZOLADEX® "Access and support" web page or contact TerSera Support Source at (855) 686-8725.

Coverage of ZOLADEX® will continue to be provided for Medicaid members who are unable to obtain the medication through the PAP and when used under the following conditions:

  • for a Food and Drug Administration (FDA)-approved indication for which there are no alternative options and
  • as a continuation of established therapy if another gonadotropin-releasing hormone (GnRH) product has been tried and failed or if transition to another GnRH is medically contraindicated.

Effective April 14, 2022, providers are to follow the "By Report" billing process for ZOLADEX® and claims will be manually reviewed to validate the above criteria. Additional instructions can be found on the NYS Department of Health (DOH) "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

Questions and Additional Information:

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COVID-19 Testing, Therapeutics, Vaccine Administration and Vaccine Counseling Policy Reminders

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.

The New York State (NYS) Department of Health (DOH) has recently updated Coronavirus Disease 2019 (COVID-19) guidance documents related to COVID-19 testing, specimen collection, therapeutics, and vaccine administration. NYS DOH strongly encourages providers to continually monitor the NYS DOH "COVID-19 Guidance for Medicaid Providers" web page, as these documents are updated regularly. The following is a summary of Medicaid coverage for COVID-19-related services. Billing and guidance materials can be found in the provided links.

COVID-19 Testing, Specimen Collection and Therapeutics

Medicaid covers all types of COVID-19 diagnostic and antigen tests, including "at home" sample collection for over-the-counter (OTC) Food and Drug Administration (FDA)-authorized COVID-19 diagnostic and screening tests that provide "at home" results. Complete coverage criteria and billing guidance can be found on the NYS DOH "NYS Medicaid Pharmacy Policy and Billing Guidance for At Home COVID-19 Testing Coverage" web page. Medicaid covers COVID-19 therapeutics authorized by the FDA for Emergency Use (EUA), including therapeutics recently authorized (bebtelovimab, remdesivir, and tixagevimab/cilgavimab). Additionally, Medicaid has discontinued coverage of therapeutics that are no longer authorized for emergency use by the FDA. Complete coverage and billing guidance can be found on the NYS DOH "New York State (NYS) Medicaid Billing Guidance for COVID-19 Testing and Specimen Collection and Therapeutics" web page.

Medicaid reimburses pharmacies for the administration and dispensing of COVID-19 therapeutics approved or granted an EUA through the FDA. This includes reimbursement for dispensing of COVID-19 antivirals, Paxlovid and molnupiravir. Complete coverage and billing guidance can be found in the NYS DOH "New York State Medicaid Policy and Billing Guidance for Pharmacy Reimbursement of COVID-19 Oral Antivirals" web page. Additionally, Medicaid reimburses pharmacies for the administration of select COVID-19 monoclonal antibodies (mab) by pharmacists per guidance outlined in the Public Readiness and Emergency Preparedness (PREP) Act. Pharmacies dispensing a COVID-19 mab can use policy and billing guidance found on the NYS DOH "NYS Medicaid Policy and Billing Guidance for Reimbursement of COVID-19 Therapeutics Dispensing or Administration at Pharmacies" web page.


COVID-19 Vaccine and Vaccine Administration

Medicaid covers administration of all COVID-19 vaccines approved or authorized by the FDA. This includes administration of the Pfizer-BioNTech vaccine series (12 years of age and older) and a pediatric (five to 11 years of age) booster dose that have recently received FDA EUAs. Complete coverage and billing guidance can be found in the NYS DOH "Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines" web page.


COVID-19 Vaccine Counseling

Medicaid covers up to four counseling visits per vaccine dose recommended by the Centers for Disease Control and Prevention (CDC), up to a total of 12 visits per member per year, as a stand-alone service. Pre-decisional vaccine counseling visits are billable as a separate service even if the counseling is provided on the same date as an Evaluation and Management (E&M) or Well-Child Visit and whether a COVID-19 vaccine is administered during the encounter. Complete coverage and billing guidance for COVID-19 vaccine counseling can be found on the NYS DOH "Updated Coverage Criteria for COVID-19 Vaccine Counseling" web page.


Member Cost Sharing for COVID-19-Related Services is Prohibited

Medicaid members are exempt from co-payments for COVID-19-related services. It is prohibited to charge members a co-payment for COVID-19-related testing, evaluation, and treatment, including preventive therapies and specialized equipment. Providers must ensure claims are properly coded, in accordance with billing guidance, to reflect member co-payments for COVID-19-related services have been waived. Billing guidance to waive co-payments for COVID-19-related services can be found in the article titled Medicaid Members are Exempt from Copayments for COVID-19-Related Treatment and Services, published in the February 2022 issue of the Medicaid Update.

Questions and Additional Information:

  • Fee-for-service (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.
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC Plan.
  • 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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Medicaid Consumer Fact Sheets Now Available

Medicaid consumer fact sheets, focused on prevention, treatment and management of 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, Coronavirus Disease 2019 (COVID-19), 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, Korean, Polish, Yiddish, Arabic and Italian. The four most recently added fact sheets are chronic kidney disease, COVID-19, periodontal disease, and tooth decay.

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Official Launch of eMedNY Provider Enrollment Portal

On April 1, 2022, New York State (NYS) Medicaid practitioners will have access to the new Provider Enrollment Portal (Portal), developed by the NYS Department of Health (DOH) and eMedNY. The easy online process will provide step-by-step instructions to guide practitioners through the accurate completion of transactions. The Portal will enable practitioners to view data and perform numerous maintenance transactions such as:

  • view individual provider file data in real-time, including Electronic Transmitter Identification Numbers (ETINs);
  • submit address changes;
  • perform Drug Enforcement Administration (DEA) updates;
  • affiliate individual providers to groups;
  • add specialties;
  • update electronic funds transfer (EFT) information; and
  • check the status of maintenance transactions.

Register for Portal Webinar Training

Practitioners are strongly encouraged to attend an eMedNY webinar training session to learn more about the functions and features of the Portal. Training sessions will review the following Portal functions:

  • initial log-in/account creation;
  • Multi-Factor Authentication (MFA)/security protocol;
  • provider enrollment portal overview;
  • dashboard functions; and
  • provider profile functions.

Providers can refer to the eMedNY "Provider Training" web page to view all available Portal training webinars. Webinar registration is required for all interested practitioners.

Questions

All questions should be directed to the eMedNY Call Center at (800) 343‑9000.

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New York State Medicaid Launches Emergency Triage, Treat, and Transport Program

On November 24, 2021, New York State (NYS) Medicaid launched its Emergency Triage, Treat, and Transport (ET3) program which mirrors the timing and tenets of the Centers for Medicare and Medicaid Services (CMS) "ET3 Model", allowing qualified participating ambulance providers to treat patients in place or transport to destinations other than the emergency department (ED), as appropriate. Treatment in place must be provided by a licensed healthcare practitioner [physician, nurse practitioner (NP), or physician assistant (PA)], either in person or via telehealth. Non-hospital alternative destinations include Community Mental Health Centers (CMHCs), substance use disorder treatment centers, Federally Qualified Health Centers (FQHCs), physician´s offices, and urgent care facilities. For more information about the ET3 Model in NYS Medicaid, providers can refer to the article titled The CMS Emergency Triage, Treat, and Transport Model with the Department of Health Parallel Model, published in the November 2021 issue of the Medicaid Update.

NYS Department of Health (DOH) is pleased to announce that on February 16, 2022, NYS Medicaid paid its first ET3 ambulance claim for treatment in place. This service and payment model offers flexibility to ambulance providers to best address the care and needs of Medicaid members they treat, in response to 911 calls. ET3 offers the ability to deliver the right care in the right environment and reduce ED overcrowding. Through this model, NYS Medicaid promotes person-centered care by giving members more treatment options as well as encouraging appropriate and efficient utilization of services that reduce strain on EMS systems. All CMS ET3-approved ambulance providers are encouraged to participate in NYS Medicaid´s parallel model. A list of all CMS ET3 Model Selected Applicants is available and includes twenty-five NYS ambulance services.

Questions

All ET3-specific questions should be directed to the NYS DOH, Medical Transportation Unit by telephone at (518) 473‑2160 or by email at MedTrans@health.ny.gov.

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NY State of Health: Affordable Care Act 12th Anniversary; Congress Encouragement to Extend American Rescue Plan Tax Credits; Medicaid Resumes Eligibility Reviews, Disenrolled Members Should Be Directed to the Marketplace

As the Affordable Care Act advances into its 12th year since implementation, NY State of Health, Official Health Plan Marketplace (Marketplace), is reporting record-breaking enrollment numbers. Enabled by the Affordable Care Act, NY State of Health has served as a critical safety net for over 6.5 million New Yorkers during the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE). COVID-19 PHE-related flexibilities and enhanced federal tax credit savings, created under the American Rescue Plan Act of 2021 (ARPA), made coverage even more accessible and affordable.

As New York prepares for the eventual transition out of the PHE, and certain Medicaid/Children´s Health Insurance Program (CHIP) requirements that were waived resume, the move to conduct eligibility reviews could result in many Medicaid/CHIP beneficiaries becoming disenrolled. The availability of affordable coverage through the Marketplace and the ARPA enhanced tax credits is crucial.

In March 2022, NY State of Health released data found in the By the Numbers - Health Insurance Coverage Update document, showing that New Yorkers who receive enhanced ARPA tax credit savings have greatly benefitted. However, without the enhanced tax credit savings and when the PHE ends, individuals who transition from Medicaid and Essential Plan - without a monthly premium - to a Qualified Health Plan (QHP) through the Marketplace, may find coverage too expensive, leading to significant increases in uninsured New Yorkers. Under ARPA, New Yorkers have been receiving enhanced tax credit savings since 2021 that have saved consumers an average of $100 per month on QHP premium costs in 2021, making premiums the lowest they have been in years. If Congress does not extend these savings beyond 2022, consumers could see their monthly premiums rise by 58 percent.

In the By the Numbers - Health Insurance Coverage Update document, NY State of Health reports statistics detailing significant cost and coverage implications across New York´s 27 Congressional Districts, specifically relating to the completion of the PHE. In addition to enrollment data divided by Congressional District, the report also provides statewide information on the negative impact the expiration of ARPA savings would have on New Yorkers, including:

  • 6.4 million New Yorkers who are enrolled in free or low-cost coverage through NY State of Health, who will need to renew their coverage to remain enrolled when the PHE winddown occurs;
  • 138,008 New Yorkers benefitting from enhanced ARPA tax credits will experience an increase in their premiums if these savings are not extended;
  • $1,453 (the annual total among New Yorkers could lose when ARPA subsidies expire at the end of 2022); and
  • 58 percent (the percent by which premiums will increase for New Yorkers who are eligible for tax credits when they come back to enroll in Fall 2022).

Amidst the uncertainty of the pandemic, NY State of Health has been an essential source of stability, with ARPA´s enhanced tax credit savings making coverage more affordable and widely accessible than ever before. The Marketplace has enrolled over 6.5 million New Yorkers in quality health plans and cut the State´s uninsured rate in half since the passage of the Affordable Care Act 12 years ago.

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New York State Department of Health Medicaid Accelerated eXchange (MAX) Workshop Series: Register for Round Two and Upcoming Informational Webinar

To further support provider efforts under value-based payment arrangements, the New York State (NYS) Department of Health (DOH) is pleased to offer Round Two of the highly rated "Medicaid Accelerated eXchange (MAX) Workshop Series," beginning May 2022, to improve care for individuals whose underlying unmet needs result in high utilization of hospitals and emergency departments (EDs). 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 the creation of 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. Previous MAX Workshop Series reports and Symposium proceedings, including participant testimonials, are available on the NYS DOH "Medicaid Accelerated eXchange (MAX) Series and MAX Training Program" web page. As the health care system continues adapting to meet the demands of the Coronavirus Disease 2019 (COVID-19) pandemic, providers and hospitals/organizations can apply their MAX Workshop Series knowledge to reduce avoidable ED and in-patient utilization and preserve bed capacity. Providers and hospitals/organizations can begin applying strategies, adopted by hundreds of teams throughout NYS and across the United States (US), to improve care for multi-visit patients (MVPs).

The MAX Workshop Series is structured as three virtual, rapid-cycle continuous improvement (RCCI) workshops to be convened over an eight-month period with weekly touchpoints alongside each Action Team. All workshops will be led by MVP Method Developer, Dr. Amy Boutwell, with workshop and coaching support provided by Island Peer Review Organization (IPRO). Workshop participants will benefit from previous MAX Workshop Series lessons and receive the guidance, tools, and support needed to achieve results, such as those achieved by earlier participants, which include:

  1. measurable decreases in emergency department and/or hospital utilization and readmissions rates;
  2. development of meaningful collaborations among community partners; and
  3. capacity-building in process improvement.

Round Two Informational Webinar

For more information regarding Round Two of the MAX Workshop Series, safety net providers as well as hospitals/organizations that were MAX Workshop Series and MAXny participants in the past, are encouraged to register to attend the free, informational webinar:

  • Thursday, April 14, 2022
    2 p.m. to 3 p.m. (Eastern Time)

Providers must follow the instructions provided below when registering for the MAX Workshop Series webinar:

  1. Select the following URL or cut and paste the URL into your browser: https://ipro.webex.com/ipro/onstage/g.php?MTID=e7abf85ca3339185e09ba83f8353dd44a
  2. Select "Register"
  3. On the registration form, enter your information, then select "Submit". You will receive a confirmation email message with instructions on how to join the event.

Questions and Additional Information:

  • Providers and hospitals/organizations interested in participating in Round Two of the MAX Workshop Series that would like to know more regarding the process to apply for consideration should contact Shannon Wolanin by email at swolanin@ipro.org or by telephone at (518) 320-3501.
  • To directly apply to participate in Round Two, providers and hospitals/organizations must complete the MAX 2021 Expression of Interest application via Smartsheet. Applications and team selection are subject for NYS DOH review and approval. NYS DOH will prioritize providers and hospitals/organizations that have high Medicaid readmission rates and have not yet participated in previous MAX programs; however, all expressions of interest are welcomed.

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Medicaid Breast Cancer Surgery Centers

Research shows that five-year survival rates are higher for patients who have their breast cancer surgery performed at high-volume facilities. To view the list of all facilities where Medicaid will pay for breast cancer surgery, providers must refer to the NYS DOH Hospitals & Ambulatory Surgery Centers Where Medicaid Will Pay for Breast Cancer Surgery web page.

Each year, NYS DOH reviews the list of low-volume restricted facilities and releases an updated list, effective April 1, 2022. NYS DOH has completed its annual review of all-payer breast cancer surgical volumes for 2018 through 2020 using the Statewide Planning and Research Cooperative System (SPARCS) database. One hundred eighty hospitals and ambulatory surgery centers throughout NYS were identified as low volume. These facilities have been notified of the restriction, effective April 1, 2022. The policy does not restrict a facility´s ability to provide diagnostic or excisional biopsies and post-surgical care (chemotherapy, radiation, reconstruction, etc.) for NYS Medicaid members. For mastectomy and lumpectomy procedures related to breast cancer, Medicaid members should be directed to high-volume and/or "Low-Allow" facilities.

NYS DOH will annually re-examine all-payer SPARCS surgical volumes to revise the list of low-volume facilities. The annual review will also allow previously restricted providers meeting the minimum three-year average all-payer volume threshold to provide breast cancer surgery services for NYS Medicaid members.

To view the list of all facilities where Medicaid will not pay for breast cancer surgery, providers must refer to the NYS DOH "Hospitals and Ambulatory Surgery Centers Where Medicaid Will Not Pay for Breast Cancer Surgery" web page. To view the list of all facilities where Medicaid will pay for breast cancer surgery, providers must refer to the NYS DOH "Hospitals and Ambulatory Surgery Centers Where Medicaid Will Pay for Breast Cancer Surgery" web page.

Questions

All questions should be directed to NYS DOH at hcre@health.ny.gov.

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Update on Pharmacy Billing for Compound Prescriptions

Effective April 21, 2022, New York State (NYS) Medicaid will implement system enhancements regarding compound billing. Medicaid compound policy can be found in the article titled Pharmacy Billing Changes for NCPDP D.0, published in the February 2011 issue of the Medicaid Update, as well as the article titled Compound Policy: A Reminder and Clarification, published in the December 2020 issue of the Medicaid Update.

Per Medicaid policy, when billing a compound via National Council for Prescription Drug Programs (NCPDP) D.0 transaction, providers must submit a minimum of two ingredients, or National Drug Codes (NDCs), in the Compound Segment, field 489-TE (Compound Product ID). Providers can submit up to 25 NDCs using this field. Providers must also submit a compound code of "02–Compound" in field 406-D6 (Compound Code) in the Claim Segment. Claims with NDCs listed in the Compound Segment submitted as a compound code "01-Not a compound" will not be accepted. A new claim edit has been developed to ensure this requirement.

eMedNY Edit Number/Message NCPDP Response Code/Description
"70420" – Compound Segment found when compound drug code is not compound "8D" – Compound Segment present on a non-compound claim

Compound-Only Ingredients

Items intended for compound use only such as suspending agents, additives, or bulk powders, will only be reimbursed as part of a compound claim. These items will not be reimbursed when submitted as a single ingredient claim and will deny when compound code "01−Not a compound" is submitted in field 406-D6 (Compound Code) in the claim segment. A new claim edit has been developed to ensure this requirement.

eMedNY Edit Number/Message NCPDP Response Code/Description
"02326" – Drug only covered in compound "8H" – Product/service only covered on compound claim

Non-Reimbursable Ingredients

As previously communicated, payment will only be issued for drugs found on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page. If an ineligible drug or drug product is included in the compound, the claim will deny. The pharmacy provider may then elect to receive payment only for those reimbursable drugs by resubmitting the claim with of "08−Process Compound for Approved Ingredients" in field 420-DK (Submission Clarification Code).

Please note: Submission Clarification Code of "08" should only be utilized in accordance with NYS Medicaid policy. The NYS Department of Health (DOH) will monitor the use of these codes.

Questions and Additional Information:

  • Fee-for-service (FFS) claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • 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.
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC Plan.
  • 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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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