New York State Medicaid Update - December 2022 Volume 38 - Number 14

In this issue …

Opioid Overdose Prevention

The New York State (NYS) Department of Health (DOH) has recently released two brochures on Naloxone, the life-saving medication that can reverse opioid overdose, for individuals who are pregnant or who've recently given birth, as well as their support person(s):

Naloxone is available, without a prescription, at most pharmacies throughout NYS. To find a list of participating pharmacies, patients and their families can scan the QR codes provided on the back panels of both brochures using their mobile device.

Both brochures are available as Portable Document Formats (PDFs) on the NYS DOH "Facts about an Opioid Overdose" website, in the following languages: English, Spanish, Italian, Korean, Polish, Russian, Arabic, Bengali, Chinese, Haitian Creole, Yiddish, French, and Urdu. NYS residents and organizations can request to order English and Spanish versions of both brochures, free of charge, by completing the Publication Request Form.

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, Institutional, 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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Reminder to Verify Member Eligibility via Medicaid Eligibility Verification System and Dispensing Validation System

The Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) enable a provider to verify Medicaid member eligibility prior to provision of services and obtain authorization for specific services covered under DVS. The Medicaid member, also known as the client, recipient, or enrollee, must present an official Common Benefit Identification Card (CBIC) to the provider when requesting services. Presentation of a CBIC does not constitute full authorization for provision of medical services and supplies; the eligibility of the Medicaid member must also be verified through eMedNY to confirm eligibility for services and supplies for the Medicaid member. A provider that does not verify eligibility prior to provision of services and supplies will risk the possibility of nonpayment for those services. A provider uses one of the following methods to access the verification process through eMedNY:

  • Telephone verification method: Audio Response Unit (ARU); or
  • Other access methods:
    • Electronic Provider Assisted Claim Entry System (ePACES);
    • eMedNY eXchange;
    • File Transfer Service (FTS) using Simple Object Access Protocol (SOAP); and
    • CORE (Committee on Operating Rules for Information Exchange compliant) Web Services.

The Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) Provider Manual provides information on the CBIC, access methods for verification, a description of eligibility benefit responses, definitions of exception codes, and a list of county/district office codes. Providers can also find the Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) Provider Manual on the eMedNY homepage, under the "Provider Manuals" tab then selecting "MEVS and Supplemental Documentation".

Questions

All questions regarding MEVS or DVS should be directed to the eMedNY Call Center at (800) 343-9000.

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All New York State (NYS) enrolled Medicaid providers must accept the following Health Home consent forms as valid Health Insurance Portability and Accountability Act (HIPAA)-compliant forms that authorize the release and sharing of Personal Health Information (PHI) among identified providers and partners. These consents support the ability of the Health Home Care managers to effectively access, integrate and coordinate services for NYS Medicaid members.

By completing the consent forms above, the NYS Medicaid member is agreeing to enrollment in the Health Home Program and allowing their PHI to be accessed and shared among those partners/providers approved by the NYS Medicaid member and listed within the consent form. This includes information obtained from Regional Health Information Organizations (RHIOs), the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES), and the Tracking and Billing System (TABS)/CHOICES.

NYS and Federal laws and regulations governing shared information include NYS Mental Hygiene Law (MHL) §33.13; NYS MHL §33.16; NYS Public Health Law (PHL) Article 27-F; 42 Code of Federal Regulations (CFR) Part 2; and 45 CFR Parts 160 and 164.

Federal Medicaid confidentiality laws and regulations can be found in the Social Security Act §1902(a)(7); 42 CFR §431.300; and 42 CFR §457.1110.

NYS Medicaid confidentiality laws and regulations can be found in the NYS Social Services (SSL) Law §367(b)(4); SSL §369(4); 10 New York Codes, Rules and Regulations (NYCRR) Part 300 – Statewide Health Information Network for New York (SHIN-NY); and the NYS MHLs §41.05, §41.07 and §41.13.

Questions

All questions regarding this guidance should be directed to the NYS Health Home program at healthhomes@health.ny.gov.

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Mandatory Compliance Requirements

Effective April 2020, for New York State (NYS) Social Services Law (SSL) §363-d, and effective December 28, 2022, for the corresponding regulations at 18 New York Codes, Rules and Regulations (NYCRR) Subpart 521-1, NYS Medicaid providers shall adopt, implement, and maintain effective compliance programs aimed at detecting fraud, waste, and abuse in the NYS Medicaid program. All NYS Medicaid providers subject to the provisions of Public Health Law (PHL) Articles 28 or 36, providers subject to the provisions of Mental Hygiene Law (MHL) Articles 16 or 31, Medicaid Managed Care (MMC) providers of Managed Long Term Care (MLTC) Plans [collectively, Medicaid Managed Care Organization (MMCOs)], and those providers for which the NYS Medicaid program "constitutes a substantial portion of business operations," are required to have an effective compliance program.

The Office of the Medicaid Inspector General (OMIG) defines "substantial portion of business operations" as claiming or receiving $1,000,000 or more in the aggregate in a consecutive 12-month period, directly or indirectly, from the NYS Medicaid program. OMIG has the responsibility under SOS §363-d and Subpart 521-1 to determine if compliance programs meet the requirements of the law and regulation. An "effective" compliance program is defined in Subpart 521-1 as a compliance program adopted and implemented by the required provider that, at a minimum, satisfies the requirements of Subpart 521-1 and that is designed to be compatible with the provider's characteristics.

A compliance program should include, at a minimum, the following seven elements:

  1. written policies and procedures;
  2. the designation of a compliance officer and compliance committee;
  3. compliance training and education;
  4. lines of communication to the provider's compliance officer or compliance function;
  5. disciplinary policies to encourage good faith participation in the compliance program;
  6. auditing and monitoring compliance risk areas; and
  7. responding to compliance issues.

Effective compliance programs, in meeting the above seven elements, are expected to establish systemic checks and balances to detect and prevent inaccurate billing and inappropriate practices in the NYS Medicaid program; address the requirement to self-disclose, explain, and repay identified overpayments; address the responsibility of the provider to check for excluded persons who may be involved in the provision of NYS Medicaid services; and other obligations that may be specific to the size, complexity, resources, and culture of the provider. The OMIG Bureau of Compliance regularly conducts reviews of providers to ensure they have a compliance program, if required, and that the compliance program is effective.

Required providers who fall under the requirements of the regulation are required to certify upon enrollment and annually using the eMedNY/Medicaid Management Information System – Certification Statement for Provider Billing Medicaid form (EMEDNY 490601). Each year, approximately 45 to 60 days before the enrollment anniversary of a provider, the NYS Department of Health (DOH) mails a package of information and materials to the provider, which includes the EMEDNY 490601 form. This form must be completed and returned by the enrollment anniversary date. Failure to adopt, implement, and maintain an effective compliance program may result in sanctions or penalties, including, but not limited to, the revocation of the provider's agreement to participate in the NYS Medicaid program.

Additional guidance and information on compliance requirements can be found on the OMIG website. Providers can also subscribe to the OMIG LISTSERV, to receive agency updates and announcements.

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NY State of Health Annual Open Enrollment Period to Remain Open for Duration of Public Health Emergency; Expanded Tax Credits and Financial Assistance Continues into 2023

The annual Open Enrollment Period (OEP) for NY State of Health, the Official Health Plan Marketplace (Marketplace), is currently underway for New Yorkers seeking to enroll in a low-cost, quality health insurance plan. NY State of Health is now open for enrollment in Qualified Health Plans (QHP) throughout every county, with free help from in-person certified enrollment assistors New York State (NYS).

NY State of Health offers QHPs from 12 different insurers in 2023, available in four metal tiers: platinum, gold, silver, and bronze, as well as catastrophic coverage. Eligible consumers may also enroll in the Essential Plan, Medicaid or Child Health Plus, which are open all year. All plans through the Marketplace provide free preventive care, such as routine office visits and recommended screenings. They also cover provider visits, hospital stays, emergency care, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, chronic disease management and pediatric dental and vision.

Enhanced subsidies that were enacted through the American Rescue Plan Act (ARPA) and extended in August 2022 through the Inflation Reduction Act, will continue to be available in 2023. These tax credits have lowered the cost of insurance for many New Yorkers, including higher-income consumers. More than 60 percent of QHP enrollees are not expected to see premium cost increases in 2023, and in some cases, QHP enrollees may be able to find a better deal if they shop for a new plan. To learn more about ARPA, providers can visit the How NY State of Health Enrollees Benefit from the American Rescue Plan and the Inflation Reduction Act web page. To learn more about the Inflation Reduction Act, providers can refer to the Congress "H.R.5376 - Inflation Reduction Act of 2022" web page.

Since the start of the federal Coronavirus 2019 (COVID-19) Public Health Emergency (PHE) in March 2020, coverage has been automatically extended to New Yorkers enrolled in Medicaid, Child Health Plus or Essential Plan. Aligned with the PHE, NYS took action to allow New Yorkers to continuously enroll into QHPs throughout the year. The Open Enrollment Period for 2023 will extend through the duration of the federal PHE.

Individuals and families can enroll in a health plan through the NY State of Health website, by speaking with an enrollment assistor for free personalized help via the NY State of Health "Find a Broker/Navigator" search tool, or by calling the Customer Service Center at (855) 355-5777, available Monday through Friday from 8 a.m. to 8 p.m. and Saturdays from 9 a.m. to 1 p.m. Additionally, individuals and families can use the chat feature for help when completing their application through the NY State of Health website, which is only available during Customer Service Center hours.

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Addition of Incarceration Facility Types for Inmate Inpatient Hospital Claiming

Effective January 1, 2023, New York State (NYS) Medicaid coverage for individuals incarcerated in an Office of Children and Family Services (OCFS) secure or limited secure facility will be suspended with Coverage Code "26" (inpatient hospital only coverage) or Coverage Code "07" (NYS Medicaid Coverage for Treatment of Inpatient Emergency Medical Condition). A provider will be required to submit claims through eMedNY for inpatient hospital services provided to these individuals, similarly to individuals incarcerated in a NYS or local correctional facility. NYS Medicaid coverage is limited to inpatient hospital services provided off the grounds of the correctional facility during the suspension period.

Questions and Additional Information:

  • All questions regarding this guidance should be directed to doh.sm.incarceration@health.ny.gov.
  • The telephone (Audio Response Unit or ARU), VeriFone POS terminal, and Electronic Provider Assisted Claim Entry System (ePACES) response message for individuals with Coverage Code "26" is "Eligible Only Inpatient Services".

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Licensed Clinical Social Worker, Licensed Mental Health Counselor, and Licensed Marriage and Family Therapist Service Coverage

Effective March 1, 2023, for New York State (NYS) Medicaid fee-for-service (FFS), and effective April 1, 2023, for Medicaid Managed Care (MMC) Plans, NYS Medicaid will reimburse Licensed Clinical Social Workers (LCSWs), Licensed Mental Health Counselors (LMHCs), and Licensed Marriage and Family Therapists (LMFTs) in private practice settings. LCSWs, LMHCs, and LMFTs must be enrolled with the NYS Medicaid FFS program to receive reimbursement for services.

To enroll in the NYS Medicaid FFS program LCSWS, LMHCs, and LMFTs must be licensed and registered by the New York State Department of Education (NYSED). LCSWs, LMFTs and LMHCs may submit applications for enrollment beginning February 2023. Additional provider enrollment information can be found on the eMedNY "Provider Enrollment and Maintenance" web page.

LCSWs, LMHCs, and LMFTs may provide all services within their scope of practice, as defined by NYSED. Licensed Master Social Workers (LMSWs) may provide all social work services within their scope of practice when under the supervision of an LCSW, licensed psychologist, or psychiatrist. These licensed professionals will be reimbursed for services provided by LMSWs under their supervision (LMSWs cannot independently enroll in or bill NYS Medicaid for their services). A LCSW may supervise up to six LMSWs. Specific licensure requirements and scope of practice guidelines for LCSWs and LMSWs are contained in NYS Education Law Article 154. Specific licensure requirements and scope of practice guidelines for LMHCs and LMFTs are contained in NYS Education Law Article 163.

Limited Permit Holders

The NYS Medicaid program also reimburses for services provided by individuals who have a limited permit and whose services are provided within NYSED scope of practice. This includes reimbursement to:

  • LCSWs for services rendered by LCSW limited permit holders and LMSW limited permit holders under the supervision of an LCSW,
  • LMHCs for services rendered by LMHC limited permit holders under the supervision of an LMHC, and
  • LMFTs for services rendered by LMFT limited permit holders under the supervision of an LMFT.

Please note: Limited Permit Holders cannot enroll in NYS Medicaid. Additional information on limited permits can be found on the NYSED "Part 74, Licensed Master Social Worker (LMSW)" web page.

Billing

FFS
Licensed professionals providing FFS can refer to the eMedNY Licensed Clinical Social Worker Procedure Codes and Fee Schedule, as well as the eMedNY Licensed Mental Health Counselor and Licensed Marriage and Family Therapist Procedure Codes and Fee Schedule, for billing needs.

Limited Permit Holders

Services provided by an LMSW or an LCSW/LMSW with a limited permit may be claimed by the supervising LCSW with the National Provider Identification (NPI) of the supervising LCSW reported as the attending provider. Services provided by an LMFT or LMHC with a limited permit may be claimed by the supervising LMFT or LMHC, respectively, with the NPI of the supervising provider reported as the attending provider.

Billing Limitations for Services Provided in Article 28 Facilities
NYS Medicaid currently reimburses Article 28 hospital outpatient clinics, as well as free-standing Diagnostic and Treatment Centers (D&TCs) for mental health counseling services provided by LCSWs, LMSWs, LMHCs, and LMFTs. LCSWs, LMHCs, and LMFTs must be enrolled in the NYS Medicaid FFS program as an Ordering, Prescribing, Referring, Attending (OPRA) provider.

In accordance with Public Health Law (PHL) §2807, LCSWs and LMSWs can only provide individual psychotherapy to individuals under 21 years of age and pregnant women up to 12 months postpartum (based on the date of delivery or end of pregnancy) in these settings. LMHCs and LMFTs can provide services within their scope of practice as there are no limitations on the patient population that can receive services in this setting. Payment to the clinic includes the cost of services provided by an LCSW, LMSW, LMHC, and LMFT; a professional claim cannot be billed. Please note: These changes do not affect services provided in Article 16, 29-I, 31, and 32 clinics. LCSW, LMSW, LMHC, and LMFT services may be provided in accordance with the NYS Office of Children and Family Services (OCFS), NYS Office for People With Developmental Disabilities (OPWDD), NYS Office of Mental Health (OMH), and NYS Office of Addiction Services and Supports (OASAS) agency regulations.

When billing for LCSW, LMSW, LMHC, and LMFT services provided in an Article 28 clinic, the NPI of the practitioner should be identified as the attending provider. Additionally, the Article 28 clinic must affiliate the NPI of the practitioner in eMedNY. For affiliation instructions, providers can refer to the eMedNY section of the website where facilities record with NYS Medicaid program NPIs and licenses of practitioners. Additional NYS Medicaid billing guidance can be found on the eMedNY "Information for All Providers" web page.

Billing Limitations for Services Provided in Article 16, 29-I, 31, and 32 Facilities

Additional NYS OASAS, NYS OCFS, NYS OMH, and NYS OPWDD billing guidance can be found at the following web pages:

Questions:

  • FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHP) Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee 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.
  • FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • FFS provider enrollment questions should be directed to eMedNY Provider Enrollment at (800) 343-9000.

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Pharmacy Dispensing Drugs that Require Practitioner Administration

The New York State (NYS) Medicaid program recognizes the need for drugs that must be administered by a practitioner to be billable to NYS Medicaid members through both the Medical Benefit and Pharmacy Benefit. Such practitioner administered drugs (PADs) are listed on the NYS Department of Health (DOH) List of Medicaid Reimbursable Drugs document, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, and may be billed directly to NYRx, formerly known as the NYS Medicaid Pharmacy program, by a pharmacy.

This guidance provides information for the proper dispensing and delivery of such drugs and is not meant to suggest that all PADs must be dispensed as a Pharmacy Benefit. The policy regarding pharmacy billing of drugs that require practitioner-administration can be found in the New York State Medicaid Fee-for-Service Program Pharmacy Manual Policy Guidelines, under the "Delivery" section. The policy regarding PAD billing can be found in the New York State Medicaid Program Physician Policy Guidelines manual, located on the eMedNY "Physician Manual" web page.

PADs dispensed as a Pharmacy Benefit must be delivered by the pharmacy directly to the site of administration. This is considered "white bagging" and is acceptable under the following guidelines:

  • Prior to the delivery of a PAD, the dispensing pharmacy must confirm the delivery address, if the NYS Medicaid member still requires the drug, and that an appointment has been scheduled and confirmed for its administration. Automatic refills are not permitted. The policy regarding refills can be found in the New York State Medicaid Fee-for-Service Program Pharmacy Manual Policy Guidelines, under the "Refills" section.
  • Delivery charges may not be billed to the NYS Medicaid program or the NYS Medicaid member.
  • The pharmacy is responsible for preparing and delivering the drug, in accordance with administration guidelines in the package insert, as well as the replacement of improperly stored, lost, or stolen drugs until there is a confirmed receipt by the authorized agent.
  • The pharmacy is required to obtain documentation of delivery by the receipt of an authorized agent's signature at the site of administration.
  • All NYS Medicaid program claims for drugs that were not deliverable must be reversed within 14 days.
  • Once delivered and signed for, the site of administration is responsible for the replacement of improperly stored, handled, lost, or stolen PADs.

Please note: Drugs should only be dispensed by the pharmacy directly to the patient when they are to be self-administered. The policy surrounding self-administered drug delivery can be found in the New York State Medicaid Fee-for-Service Program Pharmacy Manual Policy Guidelines, under the "Delivery" section.

PADs dispensed directly to a patient by the pharmacy to bring to their practitioner's office for administration is considered "brown bagging". Brown bagging causes concern regarding proper storage or handling, which can affect the drug efficacy and is not acceptable under the NYS Medicaid program.

Clinic Billing Instructions

Clinics [including Federally Qualified Health Centers (FQHCs) that opt into Ambulatory Patient Groups (APGs)] that administer drugs covered through the NYS Medicaid member pharmacy benefit and/or obtained at no-cost are only able to seek reimbursement from the NYS Medicaid program for the administration of the drug. The clinic may not submit a claim to the NYS Medicaid program for reimbursement of the cost of a drug obtained at no-cost.

For NYS Medicaid FFS members, clinics must bill the Current Procedural Terminology (CPT) code of the no-cost drug delivered by the pharmacy for administration, indicate a charged amount of $0.01, and append the drug line with the "FB" modifier (indicating the drug was supplied at no-cost). The clinic will be reimbursed $13.23 for the administration of the drug. No separate or additional administration CPT code is required. FQHCs and Rural Health Clinics (RHCs) opting out of APGs and administering a "white-bagged" or no-cost drug may bill the prospective payment system (PPS) rate when the drug is administered during a comprehensive visit.

Practitioner Billing Instructions

Practitioners in a private practice setting that administer drugs covered through the pharmacy benefit, and/or obtained at no-cost, may only seek reimbursement for the administration of the no-cost drug when the service is performed as part of an office visit. Practitioners must bill the CPT code of the no-cost drug delivered to them by the pharmacy for administration, indicating a charged amount of $0.01, appended with the "FB" modifier (indicating the drug was supplied at no-cost). To be reimbursed for the administration of a no-cost drug, the practitioner must submit the applicable CPT code for the administration of the drug.

Questions and Additional Information:

NYS Medicaid Fee-for-Service Program:

  • NYS Medicaid fee-for-service (FFS) claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid 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.
  • NYRx coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.

NYS Medicaid Managed Care:

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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

James McDonald, M.D., M.P.H.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs