New York State Medicaid Update - March 2023 NYRx Pharmacy Benefit Transition - Part Three: Special Edition Volume 39 - Number 4
In this issue …
NYRx Pharmacy Benefit Transition
Pharmacy Providers
Dual Eligible Coverage
Medicare Limited Income Newly Eligible Transition Program (LINET)
Provider Enrollment
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Providers
Information for DMEPOS Providers
Appendix A: Additional PA Guidance
Appendix B: Resources
Appendix C: Member Fact Sheet
Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.
NYRx Pharmacy Benefit Transition
Effective April 1, 2023, New York State (NYS) Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through NYRx, the Medicaid Pharmacy Program [formerly known as Medicaid fee-for-service (FFS)], instead of through their MMC Plan. The pharmacy benefit transition to NYRx does not apply to NYS Medicaid members enrolled in Managed Long-Term Care (MLTC) Plans [e.g., MLTC, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP), the Essential Plan (EP), or Child Health Plus (CHP)].
Transitioning the pharmacy benefit from MMC to NYRx will provide NYS with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiation power, and provide a uniform list of covered drugs with standardized utilization management protocols simplifying and streamlining the drug benefit for NYS Medicaid members. NYS Medicaid members have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers. This guidance provides information in addition to what was provided in the October 2022 Medicaid Update Special Edition - Part One, issued Friday, November 4, 2022, and the January 2023 Medicaid Update Special Edition - Part Two, issued Thursday, February 8, 2023.
Pharmacy Providers
Dual Eligible Coverage
For NYS Medicaid members who are enrolled in a Medicare Part D drug plan or Medicare Advantage Drug Contracting (MAPD) plan, NYRx provides prescription drug coverage only for the drugs listed below. To view all drugs covered by NYRx for Dual Eligible NYS Medicaid members, providers can refer to the NYS Department of Health (DOH) "Drugs Covered by NYRx for Dual Eligible Members Effective 10/22/2020" web page. All other prescription medications should be reimbursed through the Part D drug plan. For the most up to date coverage information for the products below, providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs.
Prescription Drugs:
- Vitamins
- Folic acid - oral
- Hydroxocobalamin - injection
- Vitamin B12 - injection/nasal
- Vitamin D2 - oral
- Vitamin K - oral
- Cough and Cold
- Benzonatate
Please note: NYRx does not provide dual eligible NYS Medicaid members with coverage of compounded prescriptions.
Over-the-Counter Drugs:
- NYRx covers certain over-the-counter (OTC) drugs for dual eligible NYS Medicaid members if coverage is not available under Medicare.
- Only NYRx reimbursable drugs excluded by Medicare law are covered for dual eligible NYS Medicaid members. Therefore, NYRx does not cover OTC insulin and some OTC products which have legend drug substitutes that are covered by Medicare Part D and MAPD drug plans.
- All OTC products covered by NYRx with a prescription or fiscal order can be found using the search tool, located on the Medicaid Member Dashboard "Search for OTC and Prescription Drugs" web page. Please note: Search results may include OTC products in the excluded categories listed above that are not covered for dual eligible NYS Medicaid members.
Resources:
Providers can refer to the web links below regarding drug coverage under Medicare Part B and D:
Medicare Limited Income Newly Eligible Transition Program (LINET)
Medicare Limited Income Newly Eligible Transition Program (LINET) is a Medicare program that provides immediate prescription drug coverage for Medicare beneficiaries who qualify for Medicaid or Extra Help and have no prescription drug coverage. Enrollment in LINET is temporary, usually for one to two months, as this provides time for the beneficiary to choose a Medicare Part D prescription drug plan that best fits their needs. If the beneficiary does not select a plan within this timeframe, Medicare will enroll the beneficiary into a benchmark plan.
Claims Processing for LINET
Pharmacies will submit the claim to LINET for reimbursement. Information on LINET, member eligibility, claims processing, and resources available for pharmacies may be found on the Humana "LINET–Pharmacy resources" web page.
| NEW Billing Option for Pen Needles, Syringes and Lancets |
|---|
| Select pen needles, syringes, and lancets may either be billed to NYRx by pharmacy providers on a pharmacy claim using the 11-digit National Drug Code (NDC) of the product or the Healthcare Common Procedure Coding System (HCPCS) code and will continue to be able to be billed by DMEPOS providers on a medical claim using HCPCS code. Pen needles, syringes, and lancets reimbursable through NYRx are listed on the New York State Department of Health List of Medicaid Reimbursable Drugs. The 11-digit NDC on the package dispensed must match the NDC billing code on the New York State Department of Health List of Medicaid Reimbursable Drugs and the NDC submitted on the claim. In the event an NDC is not found on the list of reimbursable drugs, providers should submit the claim using the HCPCS code found in the NYRx, Medical Supply Codes Billable by a Pharmacy document. Pharmacies and DMEPOS providers many continue to bill for these items using the HCPCS. NYS DOH will continue to evaluate and consider adding select NDCs of medical supplies commonly billed by pharmacies. For more information, providers can refer to the NYRx, Medical Supply Codes Billable by a Pharmacy document Updates to this list will be announced at a later date. The complete list may be found on the NYS DOH NYRx "Information for Providers" web page. |
Prescriptions and Orders by Non-Enrolled Prescribers
NYS Medicaid requires enrollment of all licensed prescribers who serve NYS Medicaid members and MMC enrollees, including prescribing practitioners, as identified on pharmacy prescriptions, per the Centers for Medicare and Medicaid Services (CMS) and federal regulations. * There are two exceptions to the provider enrollment requirement:
- Unlicensed Interns, Residents and Foreign Physicians in training programs.
- Out-of-state (OOS) Licensed Prescribers that are treating NYS Medicaid members for a single instance of emergency care within 180 days. These prescribers must be either enrolled in Medicare with an "approved" status or be enrolled in Medicaid provided by their own State.
Pharmacies will receive a reject code/Point of Service (POS) rejection message for prescriptions written by a non-enrolled prescriber. Prescribers should use the override guidance provided below for the above exceptions specific to NYRx, the Medicaid Pharmacy Program.
For NYRx, the Medicaid Pharmacy Program, please utilize the override instructions provided:
- NEW: Pharmacy claims will initially reject for National Council for Prescription Drug Programs (NCPDP) Reject code "889" - Prescriber Not Enrolled in State Medicaid Program.
- To override above rejection for the unlicensed resident, intern or foreign physician in a training program or OOS prescription situations described above:
- In Field 439-E4 (Reason for Service Code): enter "PN" (Prescriber Consultation)
- In Field 441-E6 (Result of Service Code): enter applicable value ("1A" "1B" "1C" "1D" "1E" "1F" "1G" "1H" "1J" "1K" "2A" "2B" "3A" "3B" "3C" "3D" "3E" "3F" "3G" "3H" "3J" "3K" "3M" "3N" "4A")
- In Field 420-DK (Submission Clarification Code): enter "02" (Other Override)
Provider Enrollment
Providers servicing MMC enrollees must be enrolled in the NYS Medicaid Program by April 1, 2023.
How to Check Provider Enrollment Status
Providers can check their enrollment status by utilizing the tools available on the NYS "Medicaid Enrolled Provider Lookup" web page. Providers can utilize the search tool by entering the Medicaid Provider Identification (ID) or the National Provider Identifier (NPI). Providers should reference to the table shown below to determine current provider enrollment status and the corresponding action necessary, as required from the "Medicaid Type" provided in the result.
| Provider Type | "Medicaid Type" | Enrollment Status | Action Required |
|---|---|---|---|
| Pharmacy Category of Service (COS) 0441 |
FFS | Enrolled (qalified billing provider) | No action |
| No result | Not enrolled | Enroll with Medicaid as billing provider | |
| Durable Medical Equipment COS 0321 and 0442 |
FFS | Enrolled (qualified billing provider) | No action |
| MCO | Not enrolled for NYRx billing (MCO billing only) | Enroll with Medicaid as billing provider | |
| No result | Not enrolled | Enroll with Medicaid as billing provider | |
| Practitioner/ Prescriber Multiple COS |
FFS | Enrolled (qualified billing provider) | No action |
| MCO | Not enrolled for NYRx billing (MCO credentialed as a non-billing provider) | Enroll with Medicaid as billing provider or if eligible as a OPRA provider | |
| OPRA | Enrolled (qualified billing provider) | No action | |
| No result | Not enrolled | Enroll with Medicaid as billing provider or if eligible as a OPRA provider |
Providers who have submitted enrollment applications may check the status of their application in the Medicaid Pending Provider Listing file, updated weekly on the eMedNY "Medicaid Managed Care Network Provider Enrollment" web page.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers
The updated Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider enrollment policy can be found within the New York State Medicaid Program Durable Medical Equipment, Prosthetic, Orthotic, and Supply Manual Policy Guidelines.
DMEPOS providers that are located outside NYS may apply for enrollment if they meet the newly established guidelines. DMEPOS providers located in states bordering NYS may enroll if they support NYS Medicaid members in the common medical marketing area. OOS DMEPOS manufacturers and mail-order suppliers may also be considered on a case-by-case basis, as outlined in the New York State Medicaid Program Durable Medical Equipment, Prosthetic, Orthotic, and Supply Manual Policy Guidelines. Information about the DME Supplier application process can be found on the eMedNY "Provider Enrollment and Maintenance Durable Medical Equipment Supplier" web page.
Information for DMEPOS Providers
The following guidance pertains to providers who service NYS Medicaid members with medical supplies. Medical supplies may be provided by a pharmacy or DMEPOS provider. Pharmacies must have Category of Service (COS) "0442"* to provide medical supplies while DMEPOS providers use COS "0321". Supplies may be provided by either provider type. It is recommended that providers be familiar with the specific policy and procedure or medical supply code manual corresponding to their enrolled COS type and reference it for specific information on coding and other provider specific information.
*Pharmacies that choose to bill via the professional or medical claim format need to be enrolled and have a Medicaid COS "0442," assigned to them.
Coverage of DMEPOS
The Scope of Benefits document provides an overview of DMEPOS items subject to the benefit transition. Items that are not subject to the benefit transition will remain the responsibility of the MMC Plans and are listed in "Appendix A: Additional PA Guidance" (see page 10 of this issue).
- Items subject to the benefit transition are listed in Sections 4.1, 4.2, and 4.3 of the DMEPOS - Procedure Codes and Coverage Guidelines document and may be dispensed and billed directly to Medicaid through NYRx or by a FFS DMEPOS provider using the professional claim type. Most items do not require additional authorization prior to dispensing and billing and,
- Items not subject to the benefit transition are listed in Sections 4.4, 4.5, 4.6, and 4.7 of the New York State Medicaid Program Durable Medical Equipment, Prosthetics, Orthotics, and Supplies - Procedure Codes and Coverage Guidelines, and should continue to be billed to the MMC Plan of the enrollee.
- Hearing aid batteries may be dispensed by pharmacies, DMEPOS providers or by hearing aid providers (COS "0322" and "0324"). Audiologists (COS "0325") cannot be reimbursed for batteries and should be referred to an eligible provider.
- Supplies distributed by medical providers at the time of an office visit will continue to be reimbursed by the MMC Plan.
- There are some DMEPOS items subject to the benefit transition, that require pre-approval. To ensure a smooth transition for MMC enrollees, DMEPOS authorization requirements will be temporarily relaxed (e.g., claims will not deny) during the transition period which starts April 1, 2023.
NYS DOH will monitor these claims and outreach to providers to assist them in obtaining the appropriate authorizations for future claims. At a future date, providers will be given notice regarding when prior authorization (PA) requirements will commence. Providers should reference, to "Appendix A: Additional PA Guidance" for PA instructions.
Diabetic Supplies
The Scope of Benefits document, provides a summary of diabetic supply items that are subject to the benefit transition. Diabetic diagnostics, continuous glucose monitors (CGM), glucose testing supplies, insulin syringes, disposable insulin pumps (Omnipod), and infusion supplies will be transitioned to the NYRx program. The NYRx program covers all of these items, some of which are part of the Preferred Diabetic Supply Program (PDSP), located on the Magellan Health, Inc. "NYRx, the Medicaid Pharmacy Program - Preferred Diabetic Supply Program" web page. NYS Medicaid will allow a one-time transition fill from April 1, 2023, through June 30, 2023, for non-preferred diabetic supplies that are not part of the PDSP and will honor PAs already provided by MMC Plans.
Magellan Health, Inc. "NYRx, the Medicaid Pharmacy Program - Preferred Diabetic Supply Program" web page, NYS Medicaid will allow a one-time transition fill from April 1, 2023, through June 30, 2023, for non-preferred diabetic supplies that are not part of the PDSP and will honor PAs already provided by MMC Plans.
Practitioner Visits and Medical Supplies
Medical supplies dispensed during a physician office visit will remain the responsibility of the MMC Plans. To determine if the product or supply is billable to the MMC Plan of the enrollee or subject to the benefit transition, practitioners should reference to the Scope of Benefits document. The Scope of Benefits document includes a high-level summary of the NYS Medicaid outpatient pharmacy benefit and denotes whether the benefit is subject to the transition and whether the MMC Plan should also continue to make the benefit available when provided by a non-pharmacy provider.
Billing Instructions for DMEPOS
The table below provides billing instructions for DMEPOS items subject to the benefit transition.
| DMEPOS Billing Instructions | ||||||
|---|---|---|---|---|---|---|
| Claim Format | Instructions | |||||
| NCPDP and 000301 Paper Claim Form |
When billing electronically for medical supplies:
|
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|
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| When billing by paper, providers can refer to the NYS eMedNY Billing Guidelines – Pharmacy.. | ||||||
| Claim Format | Instructions | |||||
| Professional/ Medical Claim Format 837 (Professional 837-P) or 150003 *Paper Claim Form |
When billing by electronic or paper, providers should refer to the New York State 150003 Billing Guidelines - Durable Medical Equipment, Medical Supplies, Orthopedic Footwear, Orthotic and Prosthetic Appliance. | |||||
| POS | When submitting claims, providers should refer to the ePACES Professional Real Time Claim Reference Guide. | |||||
| Claims Electronic Provider Assisted Claim Entry System (ePACES): Real Time DMEPOS Claims Submissions | ePACES Professional Real Time Claim Reference Guide. | |||||
PA Guidance for DMEPOS
DMEPOS supply information can be found in the New York State Medicaid Program Durable Medical Equipment, Prosthetics, Orthotics, and Supplies – Procedure Codes and Coverage Guidelines. Sections 4.1, 4.2, and 4.3 are subject to the NYRx transition. The manual will provide any necessary medical guidance necessary for each item listed. The manual is coded with information on the type of approval needed (if any) and the quantity and frequency for each item.
Most medical supplies may be reimbursed through claims submissions without any additional approvals. Items that are subject to higher utilization, increased risk for fraud waste and abuse, or require additional review for medical necessity require additional authorizations. There are three methods of requesting authorizations:
- Dispensing Validation System (DVS) used for automated PAs;
- Prior approval; or
- Interactive Voice Response System (IVR)/Web Portal for enteral formula.
Dispensing Validation System Automated PA
Dispensing Validation System (DVS) is a real-time electronic PA obtained prior to provision of services. DVS will provide an authorization if frequency and quantity are within established guidelines. The DVS system can be accessed through ePACES, a web-based application that allows providers to request and receive Health Insurance Portability and Accountability Act (HIPAA)-compliant transactions.
Prior approval
Prior approval is the process of determining if the item(s) requested are medically necessary and appropriate for the condition of the NYS Medicaid member. Prior approval is also required if the fiscal order written by the ordering provider exceeds the quantity or frequency limits found in the New York State Medicaid Program Durable Medical Equipment, Prosthetics, Orthotics, and Supplies - Procedure Codes and Coverage Guidelines.
IVR/Web Portal – Automated Enteral Authorizations
The IVR/Web Portal is the automated system utilized by ordering prescribers and dispensing providers (pharmacies or DMEPOS dealers) for enteral formulas. The ordering prescriber enters medical information into the IVR/Web Portal to medically support enteral formula and receives a PA number to be documented on the fiscal order. The dispenser provider activates the authorization for dispensing and reimbursement. Additional information on the Web Portal can be found on the eMedNY "DME Manual" web page. Training sessions for enteral policy and the Web Portal will be held on March 20, 2023. Providers are encouraged to visit the eMedNY "Provider Training" web page, to sign up for these sessions.
Appendix A: Additional PA Guidance
| Additional PA Guidance | |
|---|---|
| DMEPOS Authorizations | Resources |
| HCPCS code is preceded by a pound sign (#). |
|
| PA | |
| Submitted through the DVS through ePACES. | |
| HCPCS code is underlined |
|
| PA | |
| Submitted on paper, by a HIPAA 278 transaction or electronically using ePACES | |
| HCPCS code is preceded by an asterisk (*) |
|
| DiRAD IVR/Web Portal Enteral Authorization |
|
Appendix B: Resources
| Resources | |||
|---|---|---|---|
| Topic | Description | Contact Information | Website Links |
| Claims Processing for Outpatient Pharmacy Benefits | Questions regarding billing and pharmacy claims processing, lost or stolen medications and remittances. | eMedNY Support: (800) 343-9000, Option 1 | |
| NYRx, the New York Medicaid Pharmacy Program PA criteria | Questions regarding PA or inquiries about quantity/age/day supply and other edits or medication questions. |
|
|
| Preferred Diabetic Supply Program | Questions regarding billing | eMedNY Support: (800) 343-9000, Option 2 | N/A |
| PA requests | Magellan Health, Inc. Clinical Call Center: (877) 309-9493 | N/A | |
| PDSL, etc. | N/A | Magellan Health, Inc. NYRx, the Medicaid Pharmacy Program "Preferred Diabetic Supply Program" web page. | |
| Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (DME) Procedures and Supplies | Questions regarding DME PA criteria; frequency/quantity/durations limits, etc.; and billing information. | OHIP DME:
|
eMedNY "DME Manual" web page |
| LINET | For questions about the LINET program or the retroactive coverage of an individual. | (800) 783-1307 (TTY: 711) Monday through Friday from 8 a.m. to 7 p.m., Eastern time. | Humana "LINET – Pharmacy resources" web page |
| Benefit Transition | |||
| Pharmacy Information for Consumers, Pharmacies, Providers | N/A | N/A | NYS DOH "Welcome to the NY Medicaid Pharmacy Program (NYRx)" web page |
| Pharmacy Frequently Asked Questions (FAQs) | FAQs | N/A | NYS DOH "Transition of the Pharmacy Benefit from Managed Care (MC) to the Medicaid Pharmacy program, NYRx – FAQs" web page |
| Pharmacy Scope of Benefits | N/A | N/A | NYS DOH "Scope of Benefits" web page |
| Eligibility Verification and ePACES | Questions related to ePACES or for assistance with billing and performing MEVS transactions. |
|
|
| Eligibility | |||
| Members Restricted Recipient Program | Providers should direct members to their eligibility location. |
|
N/A |
| Policy and Program Information | |||
| NYRx Preferred Drug List (PDL) | The NYRx PDL contains a full listing of drugs/classes subject to the NYS Medicaid NYRx Pharmacy Programs. | Magellan Clinical Call Center: (877) 309-9493 | Magellan Inc. NYRx, the Medicaid Pharmacy Program homepage |
| Medicaid List of Reimbursable Drugs (Formulary) | Providers may review the Medicaid Pharmacy List of Reimbursable Drugs for products covered. | NYRx@health.ny.gov | eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page |
| Medicaid Pharmacy Program, Policy and Coverage | For questions related to the Pharmacy Program, 340B Billing, Drug Pricing, Lost or Stolen Medications, etc. |
|
NYS DOH "Welcome to NYRx, Medicaid Pharmacy Program" web page |
| Provider Enrollment | Provider enrollment, revalidation and NPI termination questions. |
|
eMedNY "Provider Enrollment & Maintenance" web page |
| Policy and Program Information | |||
| Provider Manuals (Physician, Pharmacy, DME, etc.) and Billing Guidelines | The "Provider Manuals" tab has billing and policy related guidance (e.g., billing guidelines, procedure codes, fee schedules, etc. for each provider type). | N/A | |
| Provider Outreach and Training | Providers may visit the training website to review eMedNY trainings available. | N/A | eMedNY "Provider Training" web page |
Appendix C: Member Fact Sheet
Providers must use the Member Fact Sheet to provide members with the resources and information they need regarding the benefit transition. A print-friendly version of the Member Fact Sheet is available on the Medicaid Member Dashboard homepage.
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
