New York State Medicaid Update - July 2022 Volume 38 - Number 8

In this issue …

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

Medicaid Pharmacy Prior Authorization Programs Update

On May 12, 2022, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended changes to the NYS Medicaid pharmacy prior authorization (PA) programs. The Commissioner of Health has reviewed the DUR Board recommendations and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program.

Effective August 11, 2022, PA requirements will change for some drugs in the following PDP classes:

  • Cholesterol Absorption Inhibitors
  • Antimigraine Agents, Other
  • Movement Disorder Agents
  • Antifungals, Topical
  • Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
  • Glucagon-like Peptide-1 (GLP-1) Agonists
  • Antihyperuricemics
  • Anticholinergic/COPD Agents

Effective August 11, 2022, criteria for the following drugs will include:

Spravato® (esketamine) nasal spray

  • PA will be required when Spravato® (esketamine) is prescribed to confirm the following requirements have been met:
    • Before initiating Spravato® (esketamine), prescribers must attest that they have obtained a baseline score using a validated clinical assessment tool for depression [e.g., Hamilton Depression Rating Scale (HAMD-17), Quick Inventory of Depressive Symptomatology (QIDS-C16C), Montgomery-Asberg Depression Rating Scale (MADRS)].
    • Trial of at least two oral antidepressants prior to Spravato® (esketamine) when used for Treatment Resistant Depression.
    • After the initiation of Spravato® (esketamine) therapy, every six months prescribers must attest that Spravato® (esketamine) has resulted in an improvement of depressive symptoms, from baseline, using the same baseline clinical assessment tool for depression (e.g., HAMD-17, QIDS-C16C, MADRS).

Symbicort® (budesonide/formoterol) and Dulera® (mometasone/formoterol)

  • The quantity limit (QL) for Dulera® (mometasone/formoterol) and Symbicort® (budesonide/formoterol) will allow for the dispensing of up to two additional inhalers over a 180-day period.

Questions and Additional Information:

Clarification of Previous Guidance: New York State Medicaid Fee-for-Service Coverage of Practitioner Administered Drugs

New York State (NYS) Medicaid fee-for-service (FFS) has specific policies and billing guidance in place for Practitioner Administered Drugs (PADs) – outpatient drugs administered by providers in a medical office or outpatient clinic setting. This article provides clarification on, and consolidation of, existing guidance.

A list of covered PADs is available on the eMedNY "Physician Manual" web page, within the following manuals:

A list of covered PADs is also available within the Policy and Billing Guidance Ambulatory Patient Groups (APGs) Provider Manual.

NYS Medicaid FFS policy for drugs administered by subcutaneous, intramuscular, or intravenous methods in the practitioner's office are covered for Food and Drug Administration (FDA) approved indications, or where the medically accepted indication is supported in any of the compendia described in Social Security Act §1927(g)(1)(B)(i) for a medically necessary NYS Medicaid-covered service. In the absence of such a recognized indication, an approved Institutional Review Board (IRB) protocol would be required with documentation maintained in the patient's clinical file. Drugs are not covered for investigational or experimental use.

The NYS Medicaid program has also issued policies and billing guidance for certain drugs/drug classes. 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:

  • manufacturer invoice showing the actual acquisition cost of the biologic, including all discounts, rebates, or incentives;
    • the invoice, which must be dated within six months prior to the date of service and/or should include the expiration date of the drug;
  • documentation of the medication administration; and
  • documentation of the criteria listed under the "NYS Medicaid Coverage Policy" sections of the drug-specific policies (issued in the Medicaid Update articles on the NYS DOH "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

Clinical Criteria Worksheets are available for some drugs/drug classes subject to clinical criteria. These worksheets are designed to ensure claim documentation and outline completion as well as provide step-by-step clinical and claim documentation requirements for drugs. Legible, completed worksheets can be submitted in lieu of detailed medical documentation.

Codes Listed "By Report"

There are certain drugs on the Physician Manual Fee Schedule and on the Ordered Ambulatory Fee Schedule that are designated "By Report" ("BR"). For those PADs that are newly FDA-approved or have no assigned Healthcare Common Procedure Coding System (HCPCS) code, the use of an unclassified code may be required when submitting a claim BR. An itemized invoice representing the actual acquisition cost is required with claim submission, inclusive of all discounts and rebates.

When the value of a procedure is to be determined BR, information concerning the nature, extent and need for the procedure or service, time, skill, and the equipment necessary, is to be furnished. Appropriate documentation (e.g., operative report, procedure description, and/or itemized invoices) should accompany all claims submitted, as this will determine medical appropriateness. Itemized invoices must document the acquisition cost, line-item cost from a manufacturer or wholesaler net of any rebates, or other valuable considerations. Additional information is available on the Ordered Ambulatory Fee Schedule and on the Fee Schedule Column Descriptions.


National Drug Code Reporting Requirements

Providers are required to report the National Drug Code (NDC) for all PADs billed by a private practitioner to NYS Medicaid and for all ordered ambulatory claims billed by clinics. If the NDC is not referenced on a claim, NYS Medicaid will not provide reimbursement for the drug.

Drugs obtained via the 340B program must be identified by appending the UD modifier to the 340B drug line on submitted NYS Medicaid FFS-only claims. Providers are required to report the NDC on FFS claims for the reimbursement of 340B drugs. Providers must also include the number of units administered and their actual acquisition cost, by invoice, in the charges field of a claim. Please note: Medicare requires either the JG or TB modifiers be appended to the 340B drug line for Medicare/NYS Medicaid crossover claims (no UD modifier is needed on crossover claims).

An accurate NDC must be reported for all PADs billed to NYS Medicaid FFS on an institutional claim that uses Ambulatory Patient Groups (APGs) payment methodology. Additional guidance is available in the Reporting of the National Drug Code is Required for all Fee-for-Service Physician Administered Drugs article, published in the April 2019 issue of the Medicaid Update.

Use of JW Modifier

NYS Medicaid FFS will reimburse providers for the unused, appropriately discarded, portion of a drug or biologic from a single-use vial/package when providers use the JW modifier. Drug waste from multi-use vials/packages will not be reimbursed. Providers must clearly report on a claim the portion of the drug administered and the portion wasted for a claim to be billable. Payment will not exceed the maximum amount of the drug/biologic as indicated on the single-use vial/package's label. Information should be reported on two lines as follows:

  • Line One: The HCPCS drug code and number of units administered. Providers administering a portion of a unit should round up to the nearest unit. If, through rounding up, the number of units reported on line one equals the total number of units contained in the single-use vial/package, then the JW modifier should not be reported.
  • Line Two: The HCPCS drug code, appended with the JW modifier and number of units not administered/discarded. Units discarded reported on line one (through rounding up to the nearest unit) should not be reported again on line two.

Additional information on the use of the JW modifier can be found in the Clarification of Policy for Practitioner, Ordered Ambulatory, and APG Reimbursement and New Billing Instructions for Wasted Drugs Using JW Modifier article, published in the August 2015 issue of the Medicaid Update.

Paper claim submission and multiple drug procedure codes, including wastage, must be submitted for the same date of service on separate claim forms. Additional information on paper claim submission can be found in the Billing Instructions for Physician-Administered Drugs (J-codes) Submitted on Paper Claims article, published in the December 2008 issue of the Medicaid Update.

Practitioner Billing

Reimbursement for drugs, including vaccines and immune globulins, furnished by practitioners to their patients, is based on the acquisition cost to the practitioner. For all items furnished in this fashion, practitioners are expected to maintain auditable records of the actual itemized invoice cost of the drug. This includes the numbers of doses of the drug represented on the invoice. NYS Medicaid FFS does not intend to pay more than the actual acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to NYS Medicaid for payment, practitioners must limit the NYS Medicaid claim amount to the actual invoice cost of the item administered. The maximum fees for these drugs are adjusted periodically by the State to reflect the estimated acquisition cost. An itemized invoice representing the actual acquisition cost is required with claim submission, inclusive of all discounts and rebates.

Vaccines and the Vaccines for Children (VFC) Program

NYS Medicaid FFS covers medically necessary vaccines as recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). Additional information on ACIP vaccine recommendations and guidelines can be found on the CDC "ACIP Vaccine Recommendations and Guidelines" web page. Additional policy and billing guidance on vaccines, including VFC vaccines, can be found in the Medicaid Fee-for Service Coverage Policy and Billing Guidance for Vaccinations article, published in the July 2020 issue of the Medicaid Update. Additional information on the VFC program is available on the NYS DOH "New York State Vaccines for Children (VFC) Program" web page.

Outpatient Clinic Billing

340B Covered Entities and Claim Level Identifiers

All NYS Medicaid FFS-only claims for 340B drugs must be submitted at actual acquisition cost (per invoice), inclusive of all discounts and appended with the UD modifier. Please note: Medicare requires JG or TB modifiers be appended to the 340B drug line for Medicare/NYS Medicaid crossover claims (no UD modifier is needed on crossover claims). Additional information on FFS claims for 340B drugs can be found in the Reminder: NYS Medicaid Requirements for 340B Claim Identification article, published in the June 2017 issue of the Medicaid Update. For ease of reference, regarding the use of modifier codes for APGs, use the following table located on the NYS DOH "NYS APG Modifiers" web page.

Billing APG Group Drugs

Providers should not bill multiple claim lines with the same J-code drugs on the same date of service, even if the drugs administered have different NDCs. Providers should combine all units of the J-code drug administered and bill it on one claim line reporting the NDC that has the highest number of units administered. If the same number of units were administered for each NDC/J-code, providers should choose one NDC to use for the submitted claim.

Billing APG Fee Schedule Drugs

Providers may continue to code multiple lines to denote different NDCs only when billing for PADs through the APG Fee Schedule, located on the NYS DOH "APG and Px-Based Weights History and APG Fee Schedules" web page. Physician services carved out of APG or All Patients Refined Diagnosis Related Groups (APR-DRG) payments for services provided in ambulatory surgery settings, emergency departments (EDs), inpatient settings, and Article 28 hospital outpatient clinics can be found in the Changes to Medicaid fee-for-service reimbursement policy for practitioner services provided in hospital settings article, published in the March 2010 issue of the Medicaid Update.

Additional information on APGs can be found in the Ambulatory Patient Groups (APGs) Medicaid Fee-for-Service Provider Manual Policy and Billing Guidelines. Additional information regarding implementation, weights, and additional web resources pertaining to the APR grouper can be found on the NYS DOH "All Patient Refined Diagnosis Related Groups (APR-DRGs)" web page. The "Never Pay" APGs and procedures lists are available on the NYS DOH "Never Pay Lists" web page.


Free-Standing Diagnostic and Treatment Centers or Hospital-Based Ordered Ambulatory Clinics

Certain drugs [e.g., Chemotherapy (APG 430-434, 441, and 443), Class XIII and XIV Combined Chemotherapy and Pharmacotherapy Drugs (APG 465 and 466), Minor Chemotherapy Drugs (APG 495), and Class IV Therapeutic Radiopharmaceuticals (APG 246)] are carved out of the APG reimbursement methodology. Providers should seek reimbursement for these services via the eMedNY Ordered Ambulatory Fee Schedule. The "Never Pay" APGs and procedures lists are available on the NYS DOH "Never Pay Lists" web page.

Additional information on the reimbursement for carved-out drugs and therapies, such as chimeric antigen receptor (CAR) T-cell therapies, can be found in the New York State Medicaid Fee-for-Service Policy and Billing Guidance for Chimeric Antigen Receptor T-cell Therapy article, published in the October 2021 issue of the Medicaid Update. Codes listed as "BR" on the Ordered Ambulatory Fee Schedule should be submitted as an ordered ambulatory claim on paper (using eMedNY 150003 claim form) and should include the hospital actual acquisition cost by invoice. Additionally, the following documentation must be included with the claim:

  • manufacturer's invoice showing the acquisition cost of the drug/biologic, including all discounts, rebates, and incentives;
  • documentation of the medication administration; and
  • documentation of medical necessity, such as FDA-approved indications and/or Compendia-supported use, must accompany the claim. Ordered ambulatory billing guidelines can be found in the eMedNY NYS 150003 Billing Guidelines - Free Standing or Hospital Based Ordered Ambulatory.

Questions and Additional Information:

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Policy Clarification for Practitioner Dispensing

The following guidance supersedes previous communications on this topic. New York State Education (NYSED) Law, Article 137 §6807, authorizes practitioners, who are authorized to prescribe, to dispense medications directly to their patients. Additional registration or ownership of a pharmacy is not required. This dispensing must be done in accordance with federal, State, and New York State (NYS) Medicaid program policies for dispensing, billing, and record keeping.

The NYS Medicaid program reimburses for drugs furnished by practitioners to their patients on the basis of the acquisition cost to the practitioner of the drug dose provided to the patient. For all drugs dispensed to the patient, regardless of whether an invoice must be submitted to NYS Medicaid for payment, the practitioner must, and is expected to, maintain auditable records of, and limit his/her claim amount to, the actual itemized invoice cost of the drug dispensed. Practitioners may not submit an office visit claim for the sole purpose of dispensing a drug that the member can obtain at a NYS Medicaid enrolled pharmacy.

FFS Billing

NYS Medicaid enrolled practitioners are eligible to bill medications dispensed to a patient via the medical claim format. Practitioners submit using an appropriate Healthcare Common Procedure Coding System (HCPCS) code and corresponding National Drug Code (NDC) when billing for a medication for which they have dispensed. If a specific HCPCS code has not been assigned for an oral medication, the following codes may be utilized:

  • "J8999" - Rx Drug Oral Chemotherapy
  • "J8499" - Rx Drug Oral Non-Chemotherapy

Please note: The use of the codes provided above will require invoice and policy criteria verification. Policy and billing guidelines can be found on the eMedNY "Physician Manual" web page.

MMC Billing

A practitioner participating in Medicaid Managed Care (MMC) should check with the patient's health plan to determine the plan billing policy for prescription drugs dispensed directly to a patient. Reminder: A practitioner that dispenses prescriptions directly to their patient are not considered a pharmacy and, therefore, is not required to be enrolled as a pharmacy provider.

Questions and Additional Information:

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New Attestation Form for New York State Medicaid Members Enrolled in Qualifying Clinical Trials

In December 2021, the Centers for Medicare and Medicaid Services (CMS) issued the UPDATED: Mandatory Medicaid Coverage of Routine Patient Costs Furnished in Connection with Participation in Qualifying Clinical Trials guidance, requiring state Medicaid program coverage of routine costs associated with qualifying clinical trials in which members are enrolled. The NYS Medicaid program has covered and will continue to cover these costs, and is updating policy in compliance with CMS requirements. "Qualifying Clinical Trial" is defined in the referenced guidance above. "Routine costs" do not include any investigational item or service that is the subject of the qualifying clinical trial and is not otherwise covered outside of the clinical trial under the state plan, waiver, or demonstration project.

To comply with CMS' directive, effective immediately, the Medicaid Attestation Form on the Appropriateness of Qualified Clinical Trial must be submitted for each Medicaid member enrolled in a qualifying clinical trial for whom Medicaid reimbursement is requested, prior to providing treatment in the trial. For each trial participant who is enrolled in either NYS Medicaid fee-for-service (FFS) or Medicaid Managed Care (MMC), the form must be completed, in full, and must be:

  • signed by the clinical trial's Principal Investigator (PI),
  • signed by the member's Health Care Provider, and
  • submitted via the Secure File Transfer Application in the Health Commerce System to Medicaid Clinical Trial.

Once a completed form is received, the NYS Department of Health (DOH) will review the attestation and make a coverage determination within 72 hours of its electronic submission. Notification of the coverage determination will be sent electronically to the submitter within 72 hours.

Questions

All questions should be sent to MedicaidClinTrials@health.ny.gov.

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Updated Fees for Physicians, Nurse Practitioners, and Midwives

As part of the New York State (NYS) Enacted Budget for fiscal year (FY) 2022-2023, the NYS Department of Health (DOH) was authorized to benchmark non-facility fees for Evaluation and Management (E&M) and Medicine codes on the NYS Medicaid Physician Drug and Drug Administration Services Fee Schedule to 70 percent of current Medicare rates. Nurse Practitioner (NP) and Midwife (MW) fee schedules are benchmarked to the NYS Medicaid Physician Drug and Drug Administration Services Fee Schedule and will receive commensurate increases. Additionally, the benchmark rate for the Midwife (MW) Fee Schedule will increase from 85 percent to 95 percent of the Physician Fee Schedule. This investment in the physician and primary care workforce is expected to improve access to primary and preventative care for NYS Medicaid members. Effective July 1, 2022, fees for over 500 procedure codes on the NYS Medicaid Physician Drug and Drug Administration Services Fee Schedule have increased.

Questions

All questions should be directed to FFSMedicaidPolicy@health.ny.gov.

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Updated Billing Guidance for Postpartum Maternal Depression Screening

This article supersedes the Postpartum Maternal Depression Screening: Updated Billing Guidance article published in the August 2016 issue of the Medicaid Update. Effective August 1, 2022, for New York State (NYS) Medicaid fee-for-service (FFS), and effective October 1, 2022, for Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs), as well as Health and Recovery Plans (HARPs)], postpartum maternal depression screening using a validated screening tool may be reimbursed up to four times within the first 12 months after the end of the pregnancy. Screening can be provided by the maternal health care provider and/or by the infant's health care provider. This is an increase from the previous limit of three times within the first 12 months postpartum.

This reimbursement is in addition to the payment for an Evaluation and Management (E&M) service when maternal depression screening is provided postpartum. Maternal depression screening can be provided by the maternal health care provider up to 12 months postpartum. This service can be integrated into the well-childcare checkup schedule. Providers of infant health care may bill for postpartum maternal depression screening under the infant's Medicaid identification number (ID). The Current Procedural Terminology (CPT) codes to be used for maternal depression screening include the following:

  • "G8431" [with the HD modifier (Pregnant/parenting)] - Screening for clinical depression is documented as being positive and a follow-up plan is documented.
  • "G8510" [with the HD modifier (Pregnant/parenting)] - Screening for clinical depression is documented as negative; a follow-up plan is not required.

If the mother screens positive for depression, then the mother must be further evaluated for diagnosis and treatment. Medical practices that do not have the capacity to evaluate and treat mothers who screen positive for depression must have a referral process in place for these beneficiaries. Mothers who currently have depression, or have a history of major depression, warrant particularly close monitoring and evaluation. The current standard of care for pregnant persons requires that all pregnant persons receive depression screening as part of their routine antepartum care. Maternal depression screening that occurs antepartum is included in the payment for the E&M service.

A maternal health care provider is defined as a: physician, midwife (MW), nurse practitioner (NP), physician assistant (PA), or other health care practitioner acting within their lawful scope of practice. The infant's health care provider is also defined as a: physician, NP, PA, or other health care practitioner acting within their lawful scope of practice. Additional information is available on the NYS DOH "Medicaid Perinatal Care Standards" web page.

Depression Screening and Referral Tools

There are multiple depression screening tools available for use that can be completed in less than ten minutes. The American Academy of Pediatrics (AAP) shares the following resources and guidance on depression screening tools below:

Additional validated screening tools for maternal depression can be found on the NYS Department of Health (DOH) "Screening for Maternal Depression" web page. Additional guidance on referral information can be found on the following web pages:

Billing Guidance

If maternal depression screening is provided postpartum by the maternal health care provider, the service can be reimbursed in addition to the E&M visit. Providers should continue to bill for this service using CPT code "G8431" in conjunction with the HD modifier for a positive depression screen of the mother and "G8510" in conjunction with the HD modifier when the screening returns a negative result. If maternal depression screening is performed on the same day as the infant's primary care visit (E&M) by the infant's health care provider, one claim can be submitted for both services using the appropriate "G" series code ("G8431" or "G8510") with the HD modifier under the infant's Medicaid ID. Alternatively, providers may bill this service separately under the mother's Medicaid ID.

Questions and Additional Information:

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Updated Identification, Specimen Collection, Testing, Vaccine Administration, and Treatment for Suspected Cases of Orthopoxvirus/Monkeypox

This article supersedes the Identification, Specimen Collection, Testing, Vaccine Administration, and Treatment for Suspected Cases of Orthopoxvirus/Monkeypox article published in the June 2022 Medicaid Update. On July 29, 2022, New York State (NYS) Governor Kathy Hochul signed Executive Order No. 20, declaring a disaster emergency in NYS due to the ongoing spread of the monkeypox virus.

The Centers for Disease Control and Prevention (CDC) is tracking multiple cases of orthopoxvirus/monkeypox that have been reported in several countries that do not normally report orthopoxvirus/monkeypox, including the United States (U.S.). The CDC is urging health care providers in the U.S. to be on alert for patients who have rash illnesses consistent with orthopoxvirus/monkeypox, as explained on the CDC Monkeypox "Clinical Recognition" web page.

An orthopoxvirus/monkeypox rash may look like blisters or pimples, and can appear on the face, inside the mouth, or on other areas of the body such as the genitals, anus, hands, or feet. In addition to a rash, other symptoms may include fever, chills, headache, swollen lymph nodes, exhaustion, muscle aches, and backache. Additional information on the symptoms related to orthopoxvirus/monkeypox can be found on the CDC Monkeypox "Signs and Symptoms" web page. Updated total cases of confirmed orthopoxvirus/monkeypox in NYS can be found on the NYS Department of Health (DOH) "Monkeypox" web page.

Testing

Monkeypox testing is available at the NYS DOH Wadsworth Center Biodefense Laboratory and the New York City (NYC) Public Health Laboratory. Specimen collection and submission must be coordinated with the Local County Health Department (LCHD) and/or NYS DOH. Within NYC, coordination must be done in consultation with the NYC DOH.

The NYS DOH Wadsworth Center will accept specimens collected and transported in viral transport media (VTM) or collected and transported dry. Specimens in VTM can be tested for orthopoxvirus, varicella-zoster virus (VZV), and herpes simplex viruses (HSVs): HSV-1 and HSV-2. Specimens collected dry can only be tested for orthopoxvirus. Testing for other viruses should be done locally. Providers can refer to the NYS DOH, Wadsworth Center "Monkeypox Testing Guidance" web page, for additional testing information. The NYC Public Health Laboratory will accept specimens collected and transported in viral transport media (VTM) or collected and transported dry. Specimens will only be tested for orthopoxvirus. Testing for other viruses should be done locally. Providers can refer to the Instructions for Submission of Specimens for Monkeypox Testing to the New York City Public Health Laboratory, for more information.

Additional labs are being approved to support diagnostic orthopoxvirus testing. Effective July 26, 2022, enrolled NYS Medicaid lab providers approved for this testing may bill the Current Procedural Terminology (CPT) code "87593" [Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (e.g., monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each] for testing provided to Medicaid fee-for-service (FFS) members. Providers who are already receiving funding from another source for these tests, are not eligible for reimbursement. A temporary fee of $51.31 has been assigned, until more information is available.

The Food and Drug Administration (FDA) made a recent announcement that test results from commercial laboratories showing orthopoxvirus detected are definitive for monkeypox virus, because it is the only circulating orthopoxvirus in the U.S. Although no longer a requirement, the CDC would like to continue to receive positive samples from commercial laboratories to aid in surveillance. Without confirmation, commercial laboratories must also be clear in their report that the sample was positive for orthopoxvirus and assumed to definitively indicate monkeypox.

Reporting

Health care providers must immediately report suspected cases of orthopoxvirus/monkeypox to their LCHD. Reporting should be to the county where the patient resides. For reporting outside of NYC, contact information can be found on the NYS DOH "County Health Departments" web page. Providers who are unable to reach the LCHD where the patient resides must contact the NYS DOH Bureau of Communicable Disease Control (BCDC) by telephone at (518) 473-4439 during business hours or (866) 881-2809 during evenings, weekends, and holidays. NYC residents suspected of monkeypox infection should be reported to the NYC DOH Provider Access Line (PAL) by telephone at (866) 692-3641.

For additional information including specimen collection and virus images, providers can refer to the Health Advisory: Monkeypox Outbreak, United States, released on June 17, 2022 by the Wadsworth Center, NYC Public Health Laboratory, and CDC.

Vaccines

The CDC is providing two, free immunizations, licensed by the U.S. FDA, JYNNEOS (also known as Imvamune or Imvanex) and ACAM2000. Monkeypox vaccine administration is a covered benefit in both NYS Medicaid FFS and Medicaid Managed Care (MMC). NYS Medicaid FFS and MMC Plans will reimburse providers for the administration of these vaccines. For individuals enrolled in MMC, providers should check with the individual's MMC Plan for billing instructions. LCHD Article 28 clinics may bill NYS Medicaid FFS for the administration of these vaccines to Medicaid FFS members by submitting an ordered ambulatory claim with the following CPT codes effective for dates of service on or after July 26, 2022.

CPT Code Code Description Vaccine Name
90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, nonreplicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous injection JYNNEOS (Imvamune or Imvanex)
90622 Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use ACAM2000

For Medicaid FFS members 19 years of age and older, providers must bill the CPT code "90471" for vaccine administration and the CPT code of the vaccine administered appended with the "FB" modifier (indicating an adult vaccine supplied at no cost). Providers will be reimbursed $13.23 for the administration of the vaccine. For Medicaid FFS members under 19 years of age, providers must bill the CPT code "90460" for vaccine administration and the CPT code of the vaccine administered appended with the "SL" modifier (indicating a child vaccine supplied at no cost). Providers will be reimbursed $17.85 for the administration of the vaccine. Article 28 clinics that partner with LCHDs for vaccine administration should follow the billing guidelines listed above. Similarly, private practitioners [i.e., physicians, nurse practitioners (NPs), and midwives (MWs)] may bill a professional claim for vaccine administration using the billing guidelines listed above.

School Based Health Centers (SBHCs) would follow the ordered ambulatory billing instructions above and append the "HA" modifier to both the CPT code for the vaccine administered (in addition to the appropriate "FB" or "SL" modifier) and CPT code for vaccine administration.

Federally Qualified Health Centers (FQHCs), including SBHCs designated as FQHCs (SBHC/FQHC), may submit a Prospective Payment System (PPS) threshold clinic claim if the vaccine is administered as part of an encounter in which a significant procedure and/or medical visit accompanies the vaccination. FQHCs and SBHC/FQHCs that bill under the PPS rate should not submit a claim for reimbursement seeking the PPS threshold clinic visit rate when the only service provided to a member is a vaccine administration. Instead, FQHCs should seek reimbursement for vaccine administration as an ordered ambulatory service following the ordered ambulatory billing instructions above. SBHC/FQHC must append the "HA" modifier to both the CPT code for the vaccine administered (in addition to the appropriate "FB" or "SL" modifier) and CPT code for vaccine administration when billing an ordered ambulatory claim.

Please note: Executive Order No.20 suspends consent requirements for reporting monkeypox vaccinations and requires providers to report monkeypox vaccine administrations with 72 hours of administration to the New York State Immunization Information System (NYSIIS) or Citywide Immunization Registry (CIR). Additional Information on NYSIIS is located on the NYS DOH "New York State Immunization Information System (NYSIIS)" web page. Additional information on CIR is located on the City of NY "Citywide Immunization Registry (CIR)" web page.


Pharmacy Billing

A pharmacist may administer vaccinations against monkeypox pursuant to a patient specific or non-patient specific order. Pharmacies must submit the vaccine claim via the National Council for Prescription Drug Program (NCPDP) D.0 format as described below.

  • Submit the CPT code of the vaccine in field 407-D7 [Product/Service Identification Number (ID)] with a value of $0.00 in field 409-D9 (Ingredient Cost Submitted).
  • Medicaid members 19 years of age and older:
    • Submit the CPT code "90471" for vaccine administration in field 407-D7 (Product/Service ID).
  • Medicaid members under 19 years of age:
    • Submit the CPT code "90460" for vaccine administration in field 407-D7 (Product/Service ID).

Billing Instructions

NCPDP D.0 Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code
407-D7 (Product/Service ID) Enter the applicable procedure codes listed above
409-D9 (Ingredient Cost Submitted) Enter a value of $0.00
442-E7 (Quantity Dispensed) Enter the value of "1" for the procedure administration code
405-D5 (Day Supply) Enter the value of "1"
411-DB (Prescriber ID) Enter prescriber National Provider Identifier (NPI) number

For guidance on origin code and serial number values that must be submitted on the claim, providers can refer to the Matching Origin Codes to Correct Prescription Serial Number in Medicaid Fee-for-Service article published in the July 2020 issue of the Medicaid Update.

Please note: Executive Order No.20 suspends consent requirements for reporting monkeypox vaccinations and requires providers to report monkeypox vaccine administrations with 72 hours of administration to the New York State Immunization Information System (NYSIIS) or Citywide Immunization Registry (CIR). Additional Information on NYSIIS is located on the NYS DOH "New York State Immunization Information System (NYSIIS)" web page. Additional information on CIR is located on the City of NY "Citywide Immunization Registry (CIR)" web page.

Treatment

Tecovirimat, also known as TPOXX or ST-246, is FDA-approved for the treatment of human smallpox disease caused by Variola virus in adults and children. Tecovirimat is used for other orthopoxvirus infections, including monkeypox, and is not FDA-approved; therefore, the CDC holds non-research expanded access Investigational New Drug (EA-IND) protocol that allows for the use of tecovirimat for primary or early empiric treatment of non-variola orthopoxvirus infections, including monkeypox, in adults and children of all ages. TPOXX is available through the Strategic National Stockpile (SNS). To request TPOXX, clinicians and care facility pharmacists can contact their state/territorial health department or CDC by calling the Emergency Operations Center at (770) 488-7100 or by emailing Poxvirus@cdc.gov. Additional CDC information for providers regarding obtaining TPOXX can be found on the CDC Monkeypox "Information for Healthcare Providers on Obtaining and Using TPOXX (Tecovirimat) for Treatment of Monkeypox" web page.

Questions and Additional Information:

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New York State Department of Health Launches Health Care Worker Bonus Program

In July 2022, the New York State (NYS) Department of Health (DOH) launched the Health Care and Mental Hygiene Worker Bonus (HWB) program, an incentive program for the purpose of recruiting, retaining, and rewarding health care and mental hygiene workers who participate in the NYS Medicaid program and meet specified eligibility requirements.

The new HWB provision is authorized under Part ZZ of the NYS Enacted Budget for State Fiscal Year (SFY) 2022-23 Education, Labor, Family Assistance Health and Mental Hygiene Bill, which allocated $1.2 billion for the payment of retention bonuses to certain health care and mental hygiene workers, with the goal of increasing the NYS health care workforce by 20 percent over the next five years. Bonuses will be awarded to workers in the NYS Medicaid program who make less than $125,000 annually and remain in their positions for one year. Disbursements will be commensurate with the number of hours worked during designated vesting periods for up to a total of $3,000 per employee.

Employers eligible for the HWB program funding include providers participating in Medicaid with at least one employee, and other providers, facilities, pharmacies, and school-based health centers licensed under NYS Public Health Law, Mental Hygiene Law, or Education Law, as well as certain programs funded by the Office of Mental Health (OMH), Office for the Aging (OFA), Office of Addiction Services and Supports (OASAS), and the Office for People with Developmental Disabilities (OPWDD). Employees eligible for HWB payments provide hands-on health care services and can include certain front line health care, home care and mental hygiene practitioners, technicians, assistants, and aides. Eligible employees must currently receive an annualized base salary (excluding any bonuses or overtime pay) of $125,000 or less, and can be full-time, part-time, temporary, or an independent contractor.

Bonuses for employees will be determined by specific "vesting periods," or hours worked during a consecutive six-month period between October 1, 2021, through March 31, 2024. Qualified employees who work:

  • at least 20 hours but no more than 30 hours per week are eligible for a bonus of $500.
  • at least 30 hours but no more than 35 hours per week are eligible for a bonus of $1,000.
  • at least 35 hours per week are eligible for a bonus of $1,500.

A qualified employee is entitled to a maximum of $3,000 in total bonus payments over two vesting periods. Employees may not receive bonuses if they have ever been suspended or excluded from the NYS Medicaid program. Employees must be enrolled in the HWB program by their employer. Providers who are not enrolled in NYS Medicaid, or provide both non-NYS Medicaid and Medicaid services, will need to verify their Statewide Financial System (SFS) ID. Once providers confirm that they are actively enrolled in NYS Medicaid or provide their active SFS ID, they can prepare information for submission of reimbursement for eligible employees.

Employers must submit claims for bonus payments within 30-days after the NYS DOH publishes a vesting schedule for completed vesting periods, and thereafter, within 30-days after the end of each additional vesting period. Employers are required to pay bonuses within 30-days of receipt of payment on a claim for each qualified employee. Eligible employers can submit employees who qualify for HWB payments by creating an account on the HWB online portal.

Additionally, employers must be currently enrolled and maintain an active Medicaid Management Information Systems (MMIS) ID with eMedNY. Eligible employers without an MMIS ID can enroll on the eMedNY website. The Office of the Medicaid Inspector General (OMIG) will audit eMedNY payments to ensure funds were appropriately claimed and dispersed by the employer. Claims determined to have been inappropriately paid may be subject to recovery and may also, depending on the facts and circumstances, result in the imposition of penalties and sanctions [see, SSL Section 367-w (5)(a)]. An eligible employer who fails to identify, claim, and pay any bonus for more than 10 percent of workers eligible for HWB payments may be subject to additional penalties [see SSL Section 367-w(5)(b)].

Additional Information

For more information on the HWB program and HWB online portal, providers should contact the HWB Call Center at (866) 682-0077.

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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 Arabic, Bengali, Chinese, English, Haitian-Creole, Italian, Korean, Polish, Russian, Spanish, Urdu, and Yiddish. The most recently added fact sheet provides information on COVID-19 vaccination, testing, and treatment. Fact sheets are available in Arabic, Bengali, Chinese, English, Haitian-Creole, Italian, Korean, Polish, Russian, Spanish, Urdu, and Yiddish.

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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

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs