New York State Medicaid Update - January 2023 Volume 39 - Number 2

In this issue …

Medicaid Eligibility Changes Effective January 1, 2023

Effective January 1, 2023, the New York State (NYS) Medicaid program increased income levels for individuals being determined eligible for the Medicare Savings Program (MSP). Individuals with income up to, and including, 138 percent of the Federal Poverty Level (FPL), will be eligible for the Qualified Medicare Beneficiary (QMB) category of the MSP. Due to this change, more individuals qualify for this benefit. Eligibility responses for these individuals, in the Electronic Provider Assisted Claim Entry System (ePACES), will indicate active Medicare and include "QMB" as a suffix to the type of Medicare in which the individuals are enrolled. There are no changes to the billing process for NYS Medicaid members enrolled in MSP at the QMB level.

Additionally, effective January 1, 2023, the Medicaid Medically Needy Income Level (MNIL) has increased to 138 percent of the FPL. As a result, the MNIL for a single individual has increased from $934 to $1,563, and from $1,367 to $2,106 for a couple. Further information can be found in the NYS Department of Health (DOH) Office of Health Insurance Programs (OHIP) General Information System (GIS) 22/Messages (MA) 11 document, which includes a sample of a one-time letter sent to impacted NYS Medicaid members informing them of this change and how to request a budget recalculation from their local department of social services (LDSS). It is expected that the impact to many current NYS Medicaid members with excess income will decrease in the amount of excess income that must be spent on medical expenses prior to NYS Medicaid paying the cost of medical care (e.g., a decrease or elimination of NYS Medicaid members "spenddown" obligation). This includes NYS Medicaid members currently enrolled in a Managed Long Term Care (MLTC) Plan who are currently paying their excess income ("spenddown") amount to the MLTC Plan.

If a refund is due to the MLTC Plan enrollee as a result of a recalculation of income, MLTC Plans should be prepared to issue a refund retroactive to January 1, 2023, when updated spenddown amounts are received by the Plan (through a copy of a Notice with the budget change issued by the LDSS or through an 834 transaction).

Questions and Additional Information:

  • MLTC Plans should direct questions to mltcinfo@health.ny.gov, with the email subject line "MLTC Spenddown Recalculation Refund", or by telephone at (518) 474-6965.
  • NYS Medicaid member-specific questions regarding personal spenddown recalculations should be directed to the LDSS or New York City (NYC) Human Resources Administration (HRA) of the NYS Medicaid member.

|top of page|

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 Supplier (DME), Institutional, Physician; Private Duty Nursing, Professional (Real-Time), Transportation, and Vision Care
  • ePACES Dispensing Validation System (DVS) for Rehabilitation Services
  • ePACES Dispensing Validation System (DVS) for DME
  • 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.

|top of page|

Project TEACH Maternal Mental Health Services

Project TEACH (Training and Education for the Advancement of Children's Health) is a statewide program that supports reproductive, primary care, and pediatric clinicians to deliver quality mental health care in New York State (NYS). The program strives to strengthen and support the delivery of care to children, families and individuals who experience mental health concerns during the perinatal period.

Project TEACH Maternal Mental Health Services Overview

Project TEACH maternal mental health resources address maternal depression and related mood and anxiety disorders, which are increasingly prevalent and can have serious impacts on parents and their children. If identified and treated early, health outcomes are improved. Additional information can be found on the Project TEACH "Maternal Mental Health" web page.

Resources

Phone Consultation Services
Maternal health, primary care, pediatric, and psychiatric providers can access reproductive and/or child psychiatry consultation support via the warmline. Providers can speak to a reproductive or child psychiatrist immediately, within 30 minutes, or can schedule a consultation. Additional information on Project TEACH consultation services can be found on the Project TEACH "Real Time Consultations" web page. Providers can access phone consultation services by telephone at (855) 227-7272, Monday through Friday from 9 a.m. to 5 p.m.

Training and Education
Two in-person (or live, virtual) half-day intensive trainings are offered yearly for maternal health providers, which include a minimum of three one-hour follow-up sessions to provide case-based learning. Additionally, there are three web-based trainings offered yearly, which are archived on the Project TEACH "Courses" web page. Continuing Medical Education (CME) is offered for all live trainings and most archived events.

To view the latest webinar regarding perinatal mood and anxiety disorders, providers are encouraged to visit the NYS OUD/NAS Project Coaching Call Webinar via Zoom. In this webinar, maternal health clinicians will learn how to utilize Project TEACH for cases in which perinatal mental health issues are present, how to access real-time phone consultation services with a perinatal psychiatrist, access no-cost continuing medical education (CME) in perinatal mental health screening/diagnosis and treatment, and access linkages/referrals for their perinatal patients.

Screening Tools
The Project TEACH "Maternal Clinical Rating Scales" website offers clinical rating scales that can assist providers with screening, diagnosis, and treatment monitoring.

Referrals
Project TEACH partners with local mental health providers, psychiatrists, and support services. Liaison coordinators and consultants help to connect individuals who need specialty mental health care with resources in their community. This could include clinic treatment, care management, or family support. Additional information can be found on the Project TEACH "Referrals" web page.

|top of page|

Update to eMedNY Applied Behavior Analysis Provider Manual

The New York State (NYS) Department of Health (DOH) has updated the eMedNY New York State Medicaid Fee-For-Service - Licensed Behavior Analyst and Certified Behavior Analyst Assistants Policy Manual for Providing Applied Behavior Analysis Services, to include guidance in "Section IV: LBA/CBAA Scope of Practice/Services," which reviews the role of unlicensed individuals, sometimes referred to as "technicians", in assisting with the delivery of applied behavior analysis (ABA) services under the direction of a licensed behavior analyst.

Questions and Additional Information:

  • Medicaid fee-for-service (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.
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee. 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.

|top of page|

Health Equity for People with Disabilities: Provider Training Available to Reduce Disparities

People with disabilities report provider attitude and implicit bias as barriers to obtaining recommended preventive care. The New York State (NYS) Department of Health (DOH) Disability and Health program, in partnership with nine other state Disability and Health programs, is pleased to sponsor two free online trainings for health care providers regarding accessible care and communicating effectively with people with disabilities:

Developed in collaboration with medical staff, researchers, and patient advocates, these trainings help providers recognize barriers to care and acquire strategies and approaches to provide disability-competent, responsive care. These trainings are designed for anyone who works in the health care system (clinicians and non-clinicians) and can be accessed on the NYS DOH "NYS Health Care Providers and Continuing Education Opportunities" web page. Upon completion of these trainings, doctors, nurses, and pharmacists can earn 0.5 and 1.0 Continuing Education Credits (CECs), respectively.

Questions and Additional Information:

|top of page|

Expanded Coverage for Diabetes Self-Management Training

This article is to notify New York State (NYS) Medicaid fee-for-service (FFS) providers and Medicaid Managed Care (MMC) Plans that Diabetes Self-Management Training (DSMT) services may be rendered by the practitioner types shown below. Practitioners must be licensed, registered, or certified in their profession; enrolled in the NYS Medicaid program; and affiliated with a DSMT program that has met the programmatic accreditation/recognition standards from a Centers for Medicare and Medicaid Services (CMS)-approved National Accreditation Organization (NAO), but are no longer required to be Certified Diabetes Educators (CDE). Registered Dieticians (RDs) are unable to enroll in the NYS Medicaid program as billing providers at this time; therefore, RDs must maintain CDE certification and be affiliated with a DSMT program for their services to be billable. Currently, CMS recognizes the American Diabetes Association (ADA), Association of Diabetes Care and Education Specialists (ADCES), and the Indian Health Services (IHS) as approved NAOs.

Eligibility Requirements

NYS Medicaid Members
DSMT is an essential element of diabetes care and may be provided to NYS Medicaid members with:

  • newly diagnosed diabetes;
  • diabetes who are stable; or
  • diabetes who have a medically complex condition such as poor control of diabetes or another complicating factor.

Practitioners
NYS Medicaid-enrolled licensed, registered, or certified practitioners who are affiliated with the DSMT program in one of the following professional disciplines may submit claims to NYS Medicaid for DSMT services:

  • Registered Nurse (RN)
  • RN Practitioner
  • Physician [Medical Doctor (MD), Doctor of Osteopathy (DO)]
  • Pharmacist
  • Physician Assistant (PA)
  • Physical Therapist (PT)
  • Clinical Psychologist
  • Optometrist
  • Occupational Therapist (OT)
  • Podiatrist

DSMT Referral Requirement

Pursuant to the NYS Medicaid-approved State Plan Amendment (SPA), DSMT services are provided as preventive services in accordance with 42 Code of Federal Regulations (CFR) §440.130(c), and must be ordered/referred by a qualified practitioner pursuant to NYS Social Services Law (SOS) §365-a(2)(q). To be eligible to receive services, NYS Medicaid members are required to show proof of referral to the DSMT service provider. The referral must be maintained by the NYS Medicaid-enrolled DSMT service provider.

FFS Billing

DSMT services can be provided in individual sessions or group sessions of no more than eight NYS Medicaid members. Claims must include a valid International Classification of Diseases, Tenth Revision (ICD-10) code for diabetes mellitus. DSMT services are billed in unit increments with one unit equaling 30 minutes of service using the following Healthcare Common Procedure Coding System (HCPCS) codes:

  • "G0108" - Diabetes outpatient self-management training services, individual, per 30 minutes.
  • "G0109" - Diabetes outpatient self-management training services, group (two to eight patients), per 30 minutes.

No more than 10 hours, or 20 units, of DSMT for NYS Medicaid members who were newly diagnosed or have a medically complex condition can be billed during a continuous six-month period. Medically stable NYS Medicaid members can receive up to one hour, or two units, of DSMT in a continuous six-month period. These service limitations pertaining to the amount, duration, or scope may be exceeded based on medical necessity and/or clinical appropriateness.

Instructions
DSMT services are reimbursable to NYS Medicaid-enrolled Article 28 clinics, provider group practices, and sole practitioner practices when provided by one of the NYS Medicaid-enrolled licensed, registered, or certified practitioners shown above. Practitioners must be affiliated with a DSMT program that has achieved programmatic accreditation/recognition standards from a CMS-approved NAOs.

Federally Qualified Health Centers and Rural Health Clinics
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) reimbursed via the federal all-inclusive prospective payment system (PPS) rate are not eligible for reimbursement for group DSMT services; however, FQHCs and RHCs are eligible for reimbursed for a threshold visit for DSMT services rendered during a one-on-one, face-to-face visit with one of the qualifying practitioners referenced above.

Record Retention Requirement
All DSMT billing providers (Article 28 clinics, provider group practices, and individual practitioners) must comply with all NYS Medicaid record-keeping requirements and shall maintain, and promptly provide/furnish, any/all DSMT program accreditation/recognition documentation received from a CMS-approved NAO to the Department of Health (DOH) upon request.

Questions and Additional Information:

  • FFS claims reimbursement and/or provider enrollment questions should be directed to the Computer Sciences Corporation (CSC) or Community Spouse Resource Allowance (CSRA) 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.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee.
  • MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

|top of page|

Clarification of Previous Guidance: New York State Medicaid Fee-for-Service Coverage of United States Preventive Services Task Force A and B Medical Service Recommendations

New York State (NYS) Medicaid fee-for-service (FFS) covers United States Preventive Services Task Force (USPSTF) A and B medical service recommendations. Previous guidance regarding NYS Medicaid coverage of USPSTF medical services can be found in the New York State Medicaid Fee-for-Service: Modifier 33 Waiving Copayment, Deductible, and Coinsurance for United States Preventive Services Task Force A and B Medical Services article, published in the September 2022 issue of the Medicaid Update. USPSTF A and B medical services are exempt from NYS Medicaid FFS copayments. A listing of all the recommendations with either USPSTF A or B medical services can be found on the USPSTF "A & B Recommendations" web page.

When providing a USPSTF A or B medical service, providers should append modifier "33" to the applicable Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code when submitting the claim. Reporting modifier "33" will exempt the claim from all NYS Medicaid FFS copayments. The copayment exemption applies to clinic, ordered ambulatory, and laboratory claims. Please note: Reporting modifier "33" on any claim line [specifically an Ambulatory Patient Group (APG) clinic claim] will exempt the entire claim from a copayment.

Questions and Additional Information:

|top of page|

Psychotherapy Services: Medical Necessity

Two-generational and preventative approaches are critical when supporting and caring for the health and well-being of children and their caregivers. To support these approaches, the following clarification for medical necessity related to individual, group, and family psychotherapy services, allowing for reimbursement for services to be provided to the child and/or the caregiver to prevent childhood behavioral health issues and/or illness.

New York State (NYS) Medicaid fee-for-service (FFS) accepts International Classification of Diseases, Tenth Revision (ICD-10) code "Z65.9" (problem related to unspecified psychosocial circumstances) as an indication of medical necessity on claims for the psychotherapy services listed below when provided by qualified NYS Medicaid-enrolled providers to NYS Medicaid members under 21 years of age. A diagnosis of "Z65.9" is intended for prevention-based services when no other behavioral health diagnosis is present.

Effective April 1, 2023, NYS Medicaid Managed Care (MMC) Plans and providers should ensure claiming systems do not exclude ICD-10 code "Z65.9" in the identification of medical necessity for the psychotherapy services and Current Procedural Terminology (CPT) codes listed below.

Individual/Group Therapy CPT Codes
CPT Code Code Description
90832 Individual Psychotherapy - 30 minutes
90834 Individual Psychotherapy - 45 minutes
90837 Individual Psychotherapy - 60 minutes
90849 Multi-family Group Psychotherapy
90853 Group psychotherapy
Family Therapy CPT Codes
CPT Code Code Description
90846 Family Psychotherapy without patient present - 50 minutes
90847 Family Psychotherapy with patient present - 50 minutes

Questions and Additional Information:

|top of page|

Coverage of Licensed Mental Health Counselor and Licensed Marriage and Family Therapist Services Provided in Article 28 Outpatient Hospital Clinics and Free-Standing Diagnostic and Treatment Centers

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 services provided by Licensed Mental Health Counselors (LMHCs) and Licensed Marriage and Family Therapists (LMFTs), within their scope of practice, as defined by New York State Education Department (NYSED).

Article 28 Hospital Outpatient Departments

Article 28 hospital outpatient departments (OPDs) should use the following rate codes to request reimbursement from NYS Medicaid FFS for mental health counseling when provided by LMHCs and LMFTs. Please note: Free-standing diagnostic and treatment centers (D&TCs) cannot yet bill for these services. State Plan Amendment (SPA) approval from the Centers for Medicare and Medicaid Services (CMS) is pending. Providers will be notified once approval is received.

Rate Code Rate Description Reimbursement
4222 Individual LMHC/LMFT Services 20 to 30 minutes with patient $41.41
4223 Individual LMHC/LMFT Services 45 to 50 minutes with patient $62.62
4224 Family Services LMHC/LMFT with or without patient present $70.70

School-Based Health Centers

School-Based Health Centers (SBHCs) should use the following rate codes when billing NYS Medicaid FFS for mental health counseling when provided by LMHCs and LMFTs.

Rate Code Rate Description Reimbursement
3260 SBHC-Individual LMHC/LMFT Service 20 to 30 minutes with patient $41.41
3261 SBHC-Individual LMHC/LMFT Service 45 to 50 minutes with patient $62.62
3262 SBHC-Family Services LMHC/LMFT with or without patient present $70.70

Federally Qualified Health Centers

Federally Qualified Health Centers (FQHCs) that have opted out of Ambulatory Payment Groups (APGs) should bill the Prospective Payment System (PPS) rate. For additional information regarding mental health counseling provided in Article 28 outpatient hospital clinics, providers may refer to the Licensed Clinical Social Worker, Licensed Mental Health Counselor, and Licensed Marriage and Family Therapist Service Coverage article, published in the December 2022 issue of the Medicaid Update.

Questions and Additional Information:

|top of page|

Reminder to All Non-Emergency Medical Transportation Providers: Parking and Toll Reimbursement

The purpose of this guidance is to reinforce existing New York State (NYS) Medicaid program policy regarding payments for parking and tolls (procedure code "A0170"). Regardless of the dollar value associated with the prior authorization (PA), NYS Medicaid will provide reimbursement only for the actual costs incurred by a transportation provider, while transporting a NYS Medicaid member.

Additionally, tolls are assessed per vehicle, not per rider, and must be billed according to the actual toll charged. Therefore, if a vehicle is transporting more than one rider on the same trip, the provider may bill one unit per charged crossing, not one unit per passenger. E-ZPass® customers who are charged less per toll than those who pay tolls with cash must bill NYS Medicaid for the actual toll amount charged to their E-ZPass® account while transporting NYS Medicaid member(s). When submitting a claim involving parking or tolls, the transportation provider must input the actual costs incurred with procedure code "A0170".

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

Questions

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

|top of page|

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