New York State Medicaid Update - November 2022 Volume 38 - Number 13

In this issue …

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

Update to New York Independent Assessor Initial Assessment Process

Effective December 1, 2022, the New York Independent Assessor (NYIA) will begin conducting the initial assessment process, as defined in the May 2022 Special Edition issue of the Medicaid Update, for adults (18 years of age and older) seeking Personal Care Services (PCS) and/or Consumer Directed Personal Assistance Services (CDPAS) based on immediate need for services.

Individuals seeking PCS and/or CDPAS based on an immediate need for those services will now have two ways to obtain their medical professional's certification of the need for services:

  1. Individuals can provide their Local Department of Social Services (LDSS) with either a Practitioner Statement of Need for Personal Care/Consumer Directed Personal Assistance Services For Adults 18 and Over (for Immediate Needs) form (DOH-5779), or
  2. Individuals can provide their LCSS with a physician's order form [Physician's Order for Personal Care/Consumer Directed Personal Assistance Services form (DOH-4359) or Medical Request for Home Care form (HCSP-M11Q).

The DOH-5779 form requires less documentation from a practitioner and can be completed by a Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), nurse practitioner (NP), or physician assistant (PA).

Regardless of whether the individual provides their LDSS a DOH-5779 form (or physician's order form to substantiate their immediate need for services), they are still required to have a NYIA Independent Practitioner Panel (IPP) clinical appointment and a Practitioner Order completed by an IPP clinician. Once the individual provides their LDSS with a completed Immediate Needs packet, the LDSS will refer their case to NYIA to schedule a community health assessment (CHA) and clinical appointment, to be completed in an expedited timeframe.

Please note: This update does not apply to children under 18 years of age. LDSS will continue to perform the assessments for this population and require a physician's order form (DOH-4359 or HCSP-M11Q).

Questions and Additional Information:

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Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers several online training webinars to providers and their billing staff, which can be accessed via computer and telephone. Valuable provider webinars offered include:

  • Provider Enrollment Portal - Practitioner
  • ePACES for: Dental, Durable Medical Equipment (DME), Institutional, Physician, Private Duty Nursing, Professional (Real-Time), and Transportation
  • ePACES Dispensing Validation System (DVS) for DME
  • eMedNY Website Review
  • Medicaid Eligibility Verification System (MEVS)
  • New Provider / New Biller

Webinar registration is fast and easy. To register and view the list of topics, descriptions and available session dates, providers should visit the eMedNY “Provider Training” web page. Providers are reminded to review the webinar descriptions carefully to identify the webinar(s) appropriate for their specific training needs.

Questions

All questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343-9000.

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eMedNY Provider Training Videos Available

eMedNY offers recorded training videos on a variety of topics that allow providers and staff an alternative learning option that is easy to access and available online. Providers and staff can learn at their own pace and access training content via computer or telephone, at any time. Webinars currently available include, but are not limited to:

  • ePACES: Eligibility Request and Response, User Administration, and Claim Balancing
  • New Provider / New Biller: Edit/Error Knowledge Base (EEKB): Denied and Pended Claims, Keeping up-to-date, Medicaid Partners, Medicaid Update, and Pre-Adjudication Crosswalk (Rejected Claims)
  • eMedNY Provider Enrollment Portal: PE Portal for Practitioners and Wage Parity Attestation

To view the list of recorded training videos, providers should visit the eMedNY “Provider Training Videos” web page. eMedNY strongly encourages providers to continually monitor the web page for new recorded training videos.

Questions

All questions regarding recorded training videos should be directed to the eMedNY Call Center at (800) 343-9000.

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Reminder to Dental Providers on the Use of Antibiotics in Dentistry

The Centers for Disease Control (CDC) has designated Friday, November 18, 2022, through Thursday, November 24, 2022, as United States Antibiotic Awareness Week (USAAW) to highlight the importance of improving antibiotic prescribing and use, also known as antibiotic stewardship.

Dental providers are uniquely positioned to play a role in minimizing antibiotic overuse. According to the Antimicrobial stewardship in dental practice article published on the Journal of the American Dental Association (JADA) website, "dental antibiotic prescribing contributes to approximately 10 percent of all antibiotic prescriptions, and an estimated 80 percent of that prescribing is deemed inappropriate." To limit adverse reactions and drug resistance, the CDC stresses evidence-based prescribing on a documented diagnosis, as well as using the most targeted (narrow-spectrum) antibiotic for the shortest duration possible.

The American Dental Association (ADA) Antibiotic Prophylaxis Prior to Dental Procedures and the American Heart Association (AHA) Prevention of Viridans Group Streptococcal Infective Endocarditis document support premedication for a relatively small subset of patients.

In general, patients with prosthetic joints undergoing dental procedures should not take prophylactic antibiotics to prevent prosthetic joint infection. The ADA recommends a complete health history and consultation with both the patient and orthopedic surgeon, per the ADA management of patients with prosthetic joints undergoing dental procedures document, for patients with a history of complications associated with their joint replacement. In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and when reasonable, write the prescription.

Questions and Additional Information:

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Understanding How Adverse Childhood Experiences Affect Patients' Health Across the Lifespan

Adverse Childhood Experiences (ACEs) are stressful or traumatic events, such as neglect and/or violence during childhood. ACEs are strongly related to brain development and a wide range of health problems throughout a person's lifetime and may include, but are not limited to, physical or sexual abuse, domestic violence, living in poverty, death of a caregiver, exposure to discrimination, or living in a household with someone with mental illness, substance use disorder, or who has experienced incarceration. ACEs research has shown:

  • When families experience historical and systemic racism or live in poverty for generations, the effects of ACEs can add up over time.
  • ACEs are very common in every population group.
  • ACEs can have significant impact on a child's ability to succeed in school, causing a negative impact on their mental health and general well-being.
  • Adults who have experienced ACEs can have higher rates of negative health outcomes, including depression, obesity, substance abuse, anxiety, smoking, and early death.

Parental and child resilience have been shown to reduce the negative impacts of ACEs. Protective factors that may boost child or parental resilience may include, but are not limited to:

  • supportive and caring relationships and social connections;
  • programs that understand a person's background and culture;
  • a healthy lifestyle, which may include regular exercise, mindfulness, getting sufficient sleep, and eating a healthy and nutritious diet;
  • economic support/stability for families; and
  • quality childcare and education early in life.

New York State (NYS) Office of Children and Family Services (OCFS) has developed materials for providers to share this information with adult patients, parents, and caregivers, such as a brochure titled Understanding adverse childhood experiences (ACEs), which is available in multiple languages on the NYS OCFS "Publications" web page.

Additional Information

Visit the NYS OCFS "Adverse Childhood Experiences (ACEs)" web page, for additional information and resources.

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National Cancer Institute-Designated Cancer Centers

New York State (NYS) Social Services Law (SSL) §364-J(4) paragraph (w) requires health plans offering New York State (NYS) Medicaid, Essential Plan (EP) and Qualified Health Plan (QHP) to contract with willing National Cancer Institute (NCI)-designated cancer centers. Effective January 1, 2023, Medicaid Managed Care (MMC) Plans, including mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), and Health and Recovery Plans (HARPs), will be required to contract with willing NCI-designated cancer centers in their service areas. A list of NYS cancer centers can be found on the NCI "Find a Cancer Center" web page by utilizing the "Find Cancer Centers listed by state" feature.

Providers should contact the MMC enrollees' health plan for a list of the NCI-designated cancer centers in the health plan's network.

Questions and Additional Information:

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Reminder: Medicaid Billing Rules for Family Planning and Reproductive Health Services

Providers participating in the provider network of a Medicaid Managed Care (MMC) Plan should bill family planning and reproductive health services to the relevant MMC Plan and not to Medicaid fee-for-service (FFS). All MMC Plans [including mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs) and Health and Recovery Plans (HARPs)] include family planning and reproductive health services within their benefit package.

MMC Plans

MMC Plans should offer provider outreach to ensure contracted providers are aware to bill the MMC Plan for covered services provided to MMC enrollees for benefit package services, including family planning and reproductive health services.

Providers

Medicaid FFS
All providers should ensure that MMC Plans are billed for family planning and reproductive health services provided to MMC enrollees (providers must have a contract with the MMC enrollees MMC Plan in order to do so). Please note: Effective January 1, 2019, Fidelis Care includes family planning and reproductive health services in the benefit package for NYS Medicaid members. Previously, Medicaid FFS had provided this benefit for Fidelis Care members. Effective January 1, 2019, participating Fidelis Care providers should bill family planning and reproductive health services to Fidelis Care, not Medicaid FFS.

Medicaid
MMC enrollees may obtain family planning and reproductive health services from any qualified Medicaid provider. The following services provided to a MMC enrollee by an out-of-network provider should be billed to Medicaid FFS:

  • birth control drugs and devices, including Intrauterine Devices (IUDs), diaphragms, and other kinds of birth control;
  • emergency contraception;
  • sterilization for men and women;
  • pregnancy testing;
  • an abortion that the patient and provider agree is needed;
  • HIV and sexually transmitted disease (STD) testing, treatment, counseling; and
  • screenings for cancer and other related problems.

Questions and Additional Information:

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System Requirements for Compounded Prescriptions

Effective December 22, 2022, the NYRx Pharmacy program, formerly known as the New York State (NYS) Medicaid Pharmacy program, will require a valid route of administration code for all compounded prescription claims submitted via the National Council for Prescription Drug Programs (NCPDP) D.0 format. NCPDP utilizes Systematized Nomenclature of Medicine -- Clinical Terms (SNOMED CT) terminology for the route of administration, which will be required in field 995-E2 (Route of Administration).

NYS Medicaid will further verify the compound ingredients submitted in NCPDP field 489-TE (Compound Product ID) are valid for the submitted route of administration. Claims submitted with missing or invalid data in these fields will deny with the following message:

eMedNY Edit Number/Message NCPDP Response Code/Description
02337 – Invalid SNOMED to Route Code Mapping

 E2 – M/I Route of Administration

Questions and Additional Information:

  • Questions regarding claim submission should be directed to the eMedNY Call Center at (800) 343-9000.
  • Policy-related questions should be directed to the Medicaid Pharmacy Policy Department at (518) 486-3209 or NYRx@health.ny.gov.

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Mpox (formerly known as Monkeypox) Services No Longer Exempt from Medicaid Copayments

Effective October 28, 2022, in accordance with the expiration of New York State (NYS) Governor Kathy Hochul's Executive Order 20.2 titled Continuing the Declaration of a Statewide Disaster Emergency due the Ongoing Spread of the Monkeypox Virus in the State of New York, mpox (formerly known as the monkeypox) vaccine administration, lab testing, and initial diagnostic evaluations provided to NYS Medicaid fee-for-service (FFS) members and Medicaid Managed Care (MMC) enrollees are subject to NYS Medicaid copayments, when applicable. NYS Medicaid FFS providers should disregard billing instructions provided in the Copayments Waived for Monkeypox Diagnostic Evaluations, Vaccine Administration, and Testing article published in the August 2022 issue of the Medicaid Update.

Questions and Additional Information:

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Updates to Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance

On July 14, 2022, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended coverage policies for several practitioner administered drugs (PADs), which resulted in a meeting summary inclusive of the recommendations and final determination by the Commissioner of Health. Providers can refer to the NYS Department of Health (DOH) "Drug Utilization Review (DUR) Board - 2022" web page, for the full-July 14, 2022 meeting summary. Additionally, NYS Medicaid Pharmacy program prior authorization (PA) changes were announced during the July 14, 2022 meeting, which are outlined in the Medicaid Pharmacy Prior Authorization Programs Update article of the October 2022 issue Medicaid Update.

Effective December 29, 2022, criteria for aducanumab-avwa (Adulhelm®), botulinum toxins (Dysport®, Xeomin®, Botox®, and Myobloc®), infliximab (Remicade®) and its biosimilars, and vedolizumab (Entyvio®) are as follows:

Aducanumab-avwa (Aduhelm®)

Before initiating aducanumab-avwa (Aduhelm®), prescribers must attest that the patient has been diagnosed with mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's dementia by meeting one of the following scores:

  • Clinical Dementia Rating (CDR)-Global Score of 0.5 to 1
  • Mini-Mental Status Exam (MMSE) score between 24 and 30
  • Montreal Cognitive Assessment (MoCA) score of at least 18

Before initiating aducanumab-avwa (Aduhelm®), prescribers must provide medical records for the following pre-treatment testing:

  • genetic testing to assess apolipoprotein E ε4 carrier status, and
  • positron emission tomography (PET) scan or cerebrospinal fluid (CSF) analysis to confirm the presence of amyloid beta deposits.

Before initiating aducanumab-avwa (Aduhelm®), prescribers must attest that the patient does not have evidence of any medical or neurological condition other than Alzheimer's disease that could be contributing to the patient's cognitive impairment.

Before initiating aducanumab-avwa (Aduhelm®), prescribers must attest that the patient does not have a history of a clotting disorder and is not taking any form of antiplatelet or anticoagulant medications other than aspirin ≤325 mg/day.

For continuation of therapy, providers must attest that the patient's score remained stable or improved, utilizing the same baseline assessment tool as outlined for initiation of therapy.

Botulinum Toxins

Step Therapy (ST) Requirements*

Indication ST
Chronic sialorrhea**

 Glycopyrrolate
Headache prevention in patients with chronic migraine

 Two oral agents FDA-approved or compendia-supported for prevention of migraine
Overactive bladder

 Antimuscarinic agent or beta-3-adrenoceptor agonist
Neurogenic detrusor overactivity***

 Antimuscarinic agent
Urinary incontinence due to detrusor overactivity

 Antimuscarinic agent or beta-3-adrenoceptor agonist

*Requires a trial of a drug to treat a condition before initiating another therapy for the same condition.
**Excludes patients with Parkinson's disease and other neurodegenerative diseases.
***Excludes patients with multiple sclerosis (MS) or spinal cord injury.

Infliximab (Remicade®), infliximab-abda (Renflexis®), infliximab-axxq (Avsola™), and infliximab-dyyb (Inflectra®)

Trial of a disease-modifying anti-rheumatic drug (DMARD) or tumor necrosis factor inhibitor (TNFi) Food and Drug Administration (FDA)-approved for self-administration prior to initiation of infliximab (Remicade®).

Vedolizumab (Entyvio®)

Trial of a DMARD or TNFi prior to initiation of vedolizumab (Entyvio®).

Billing

Fee-for-Service
For NYS Medicaid fee-for-service (FFS), Clinical Criteria Worksheets can be found on the NYS DOH "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

Practitioners
A practitioner can obtain the applicable Healthcare Common Procedure Code System (HCPCS) code for the drug using the Fee Schedule listed in the eMedNY NYS Medicaid Program Physician - Procedure Codes, Section 2 - Medicine, Drugs and Drug Administration manual. The associated National Drug Codes (NDCs) must be included on the claim.

Clinics
Clinics must bill an ordered ambulatory claim as well as submit the claim on paper using the Medical Assistance Health Insurance Claim Form (eMedNY 150003 form). Billing guidelines can be found in the eMedNY New York State 150003 Billing Guidelines - Free Standing or Hospital Based Ordered Ambulatory.

Questions and Additional Information:

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Reminder: Pharmacy Dispensing of Emergency Contraceptives

Per the Pharmacy Reminder: Emergency Contraceptive Coverage article published in the April 2019 issue of the Medicaid Update, New York State (NYS) Medicaid covers both prescription and over-the-counter (OTC) emergency contraception for members enrolled in NYRx, formerly known as the NYS Medicaid Pharmacy program, and Medicaid Managed Care (MMC) enrollees. OTC emergency contraception can be prescribed by a practitioner or dispensed without a fiscal order when requested by the member in accordance with New York Codes, Rules, and Regulations (NYCRR), Title 18, §505.3. OTC emergency contraceptive billing guidance for NYRx can be found in the Reminder: Pharmacy Dispensing Non-Patient Specific Orders article published in the January 2022 issue of the Medicaid Update.

Please note: Prescription-only emergency contraceptives [e.g., ulipristal (ella®)] may be dispensed only pursuant to a patient specific order.

A pharmacy, in compliance with NYS law and regulations, may dispense and submit a claim for emergency contraceptives when the following apply:

  • a prescriber submits a prescription order for either the OTC or prescription-only emergency contraceptive; or
  • a NYRx member or MMC enrollee specifically requests the OTC emergency contraceptive item on the date of service; and
  • a pharmacy submits one course of therapy with no refills; and
  • the drug item(s) are dispensed according to:
    • Food and Drug Administration (FDA) guidelines,
    • NYS laws, rules, and regulations, and
    • NYS Medicaid policy.

The following table illustrates the prescribing requirements of both prescription and OTC emergency contraceptive products.

National Council for Prescription Drug Programs (NCPDP) D.0. Claim Segment Field* Prescription-Only Emergency Contraceptive OTC Emergency Contraceptive
NYRx MMC NYRx MMC
444-E9 (Pharmacist ID)

 Not Applicable

 Consult MMC

 Enter Pharmacist NPI number

 Consult MMC
411-DB (Prescriber ID)

 Qualified Practitioner National Provider Identifier (NPI) number

 Qualified Practitioner NPI number

 Leave Blank or enter Qualified Practitioner NPI number

 Consult MMC

Please note: 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, for guidance on origin code and serial number values that must be submitted on NYRx claims.

Questions and Additional Information:

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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