New York State Medicaid Update - March 2023 Volume 39 - Number 6

In this issue …

  • All Providers
  • Pharmacy
  • Policy and Billing

    New York State to Resume Eligibility Reviews for Medicaid, Child Health Plus and the Essential Plan; Communications Tool Kit Available to Help Educate Consumers on How to Renew Insurance

    For the duration of the federal Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE), New York State (NYS) was authorized to protect New Yorkers by pausing annual eligibility reviews and providing continuous coverage for Medicaid, Child Health Plus (CHP) and the Essential Plan (EP) members/enrollees. However, on December 29, 2022, the federal Consolidated Appropriations Act updated federal rules to require NYS, in partnership with the Local Departments of Social Services (LDSS), to once again recertify eligibility for members in these public health programs. For additional information regarding the COVID-19 PHE, providers can refer to the United States (U.S.) Department of Health and Human Services (HHS) Administration for Strategic Preparedness and Response (ASPR) "Declarations of a Public Health Emergency" web page. For additional information regarding resumed eligibility reviews, providers can refer to the NY State of Health Important Changes to New York Medicaid, Child Health Plus and the Essential Plan web page.

    There are approximately 8 million New Yorkers enrolled in Medicaid, CH and EP who will need to renew their health insurance. It is imperative that members/enrollees are made aware of these changes as they may risk losing their coverage if appropriate actions to renew are not made.

    Beginning in Spring 2023, renewal notices will be sent to members/enrollees based on their enrollment end dates. Renewal notices will include the deadline to take action to renew their insurance or risk having a gap in coverage. Deadlines will be based on the member/enrollee enrollment end dates and will range from June 30, 2023, through May 31, 2024. During this time, NY State of Health, the Official Health Plan Marketplace (Marketplace), will keep enrollment open to allow consumers who are no longer eligible for Medicaid, CHP or EP to stay covered by enrolling in a Qualified Health Plan (QHP).

    In an effort to minimize the number of New Yorkers at risk of being disenrolled, NY State of Health has developed the Unwinding from the COVID-19 Public Health Emergency: A Communications Tool Kit to Keep New Yorkers Covered, which is available in 14 languages and features resources to help educate consumers about these changes. Resources include the following:

    • a designed poster, fact sheet and infographic available to print and display;
    • pre-written social media posts and images, as well as ad campaign videos that can be shared through social media account(s);
    • drop-in articles for websites and/or newsletters; and
    • drafted email blast messages to send to your partners and distribution lists.

    NYS Department of Health (DOH) encourages all providers, local districts, stakeholders, and advocates to access and use these communication tools and share with members/enrollees.

    NYS DOH thanks providers for their efforts and assistance in reaching all members/enrollees affected by the upcoming changes throughout this renewal process as outreach and cooperative teamwork are crucial during this time. Additionally, NY State of Health appreciates the help of the provider community to ensure New Yorkers are informed and the health insurance of our most vulnerable populations remains safeguarded.

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    Attention Providers: Disclosure of Ownership and Control Information

    This is a reminder that in order to receive payments from New York State (NYS) Medicaid, enrolled providers are required to inform the NYS Department of Health (DOH) within 15 days of any change in direct or indirect ownership or control interest in the enrolled provider. Failure to inform the NYS DOH may result in termination of enrollment. For purposes of NYS Medicaid regulations, an ownership or control interest means a person or corporation that:

    • has an ownership interest totaling five percent or more in a disclosing entity;
    • has an indirect ownership interest equal to five percent or more in a disclosing entity;
    • has a combination of direct and indirect ownership interests equal to five percent or more in a disclosing entity;
    • owns an interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent of the value of the property or assets of the disclosing entity;
    • is an officer or director of a disclosing entity that is organized as a corporation; or
    • is a partner in a disclosing entity that is organized as a partnership.

    Ownership interest is defined as possession of equity in the capital, stock or profits of a provider. Changes of ownership or control interest must be reported to the NYS DOH Office of Health Insurance Programs (OHIP) by filing an amended, signed ownership and control interest disclosure form. Based upon the information supplied, providers may also be required to complete a new NYS Medicaid provider enrollment application to reflect the structural change to their business. Copies of the required disclosure forms can be found on the eMedNY "Provider Enrollment and Maintenance" web page, by selecting the appropriate provider type and billing status, if applicable, then navigating to the "Maintenance Forms" tab of the web page. Individual practitioners can complete and submit this form electronically on the eMedNY "Provider Enrollment Portal" web page. All other provider types must complete and submit the paper form. Providers can also contact the eMedNY Call Center at (800) 343-9000 for assistance.

    Postpartum Period for Pregnant Individuals Increased from 60 Days to 12 Months

    State and federal rules defining the postpartum period for consumers enrolled in Medicaid during have recently changed. Previously in New York State (NYS), the postpartum period started on the last day of pregnancy and ended on the last day of the month in which the 60th postpartum day occurred. Under the new law, the length of the postpartum period is now 12 months. The 12-month postpartum period begins on the last day of the pregnancy and ends on the last day of the 12th month. The change in length of the postpartum period in state statute ensures all pregnant consumers, who are state residents, will receive the same length of coverage at the conclusion of a pregnancy, regardless of their immigration status.

    The 12-month postpartum period is available to all pregnant consumers, regardless of how their pregnancy ends. However, consumers who have been screened by a provider as presumptively eligible for Medicaid, but who have not been determined eligible for ongoing coverage, are not entitled to this coverage extension. The option to provide 12 months of postpartum coverage will be implemented in all instances where a consumer was eligible and enrolled in Medicaid prior to the end of their pregnancy, including any retroactive period.

    Consumers will be renewed at the end of the 12-month postpartum period. If at this renewal, they are determined ineligible for Medicaid, they will continue to be eligible for limited coverage through the Family Planning Extension Program (FPEP) for 24 months calculated from the end of the 60-day postpartum period.

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    Office of the Medicaid Inspector General to Initiate Compliance Program Reviews

    On December 28, 2022, Title 18 of the New York Codes, Rules and Regulations (NYCRR) Part 521, located in the Office of the Medicaid Inspector General (OMIG) Summary of Regulation document, was adopted, outlining the requirements for effective compliance programs in the Medicaid program. Beginning July 2023, OMIG will initiate compliance program reviews to determine if required providers have adopted, implemented, and maintained an effective compliance program as required by 18 NYCRR Part 521, located in the OMIG Summary of Regulation document. Compliance program reviews will be for a defined period and will confirm the following:

    • the adopted compliance program satisfied the regulatory requirements;
    • the adopted compliance program was implemented and continuously operated for the entire review period; and
    • the adopted, implemented, and maintained compliance program was effective.

    Initial compliance program reviews will encompass a three-month review period for months on or after April 1, 2023. Providers are reminded to review the amendments made to 18 NYCRR Part 521, located in the OMIG Summary of Regulation document, and the associated guidance available on NYS OMIG website, and make any necessary changes to their compliance programs.

    Questions and Additional Information:

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    Service Delivery for Managed Long Term Care Enrollees Moving from Adult Homes to Community Residences in Response to O'Toole v. Cuomo

    This article clarifies the March 8, 2016 New York State (NYS) Administrative Health Home Service Agreement (ASA) letter, outlining the responsibility of Managed Long Term Care (MLTC) Plans to support the community transition of individuals residing in adult home facilities. Following a lawsuit in 2013, NYS entered a settlement agreement with disability advocates and the United States (U.S.) Department of Justice. This settlement agreement affords individuals diagnosed with Serious Mental Illness (SMI) in Adult Homes (hereafter referred to as "class members") the opportunity to move to more integrated community housing with Adult Home Plus (AH+) care coordination and services and supports provided through a MLTC Plan.

    Per the settlement agreement, settlement providers, including MLTC Plans, must educate class members about their right to move to community settings and thoroughly document those conversations. These conversations must include a detailed explanation of available services to support the class transition of the member, including all services they are entitled to receive as part of the MLTC benefit package. MLTC Plans may not state that an MLTC benefit is unavailable without providing a written denial to the class member. All efforts to secure said services must be thoroughly documented. MLTC Plans must immediately report any challenges and concerns regarding service delivery for class members to the designated liaison at the NYS Department of Health (DOH) Bureau of MLTC.

    Background

    In 2013, a group of disability advocacy organizations and the U.S. Department of Justice filed a lawsuit (O'Toole v. Cuomo, 13-cv-04166) on behalf of persons diagnosed with SMI residing in twenty-three specific Impacted Adult Homes in New York City (NYC). The lawsuit alleged that NYS was in violation of Title II of the Americans with Disabilities Act (ADA), 42 U.S.C., §12131 et seq., and §504 of the Rehabilitation Act of 1973, 29 U.S.C. §794. The ADA, as interpreted by the Supreme Court in the landmark decision, Olmstead v. L.C., 527 U.S. 581 (1999), mandates that public entities must provide disabled persons, including those individuals diagnosed with serious mental illness (SMI), with services, programs, and activities in the most integrated setting appropriate to their needs.

    The 2014 settlement agreement ensures that class members are given every opportunity to move to the most integrated (community) setting possible. To date, due to the collaborative efforts of MLTC Plans, and providers contracted by the NYS Office of Mental Health (OMH) and the NYS DOH, approximately 1,200 class members have moved out of Impacted Adult Homes to more integrated settings.

    Questions:

    • MLTC policy questions should be directed to the NYS DOH Division of Managed Care, Bureau of MLTC by telephone at (518) 474-6965.
    • Questions regarding the Disability Advocates Inc. (DAI) Settlement should be directed to the NYS DOH Office of Community Transitions by email at CommTran@health.ny.gov or telephone at (518) 485-8781.
    • Questions regarding AH+ care coordination can be directed to the AH+ program by email at AHPlusProgram@health.ny.gov.

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    Medicaid Breast Cancer Surgery Centers

    Research shows that five-year survival rates are higher for patients who have their breast cancer surgery performed at high-volume facilities. A high-volume facility is defined as a hospital or ambulatory surgery center defined averaging 30 or more all-payer surgeries annually over a three-year period. Therefore, it is the policy of the New York State (NYS) Department of Health (DOH) that NYS Medicaid members should receive mastectomy and lumpectomy procedures associated with a breast cancer diagnosis at high-volume facility. Restricted low-volume facilities will not be reimbursed for breast cancer surgeries provided to NYS Medicaid members.

    Effective April 1, each year, NYS DOH reviews facilities and releases an updated list that identifies low-volume facilities. NYS DOH has completed its annual review of all-payer breast cancer surgical volumes for 2019 through 2021 using the Statewide Planning and Research Cooperative System (SPARCS) database. Two hundred restricted low-volume hospitals and ambulatory surgery centers throughout NYS were identified. These facilities have been notified of the restriction, effective April 1, 2023. The policy does not restrict the ability of the facility to provide diagnostic or excisional biopsies and post-surgical care (chemotherapy, radiation, reconstruction, etc.) for NYS Medicaid members. For mastectomy and lumpectomy procedures related to breast cancer, NYS Medicaid members should be directed to high-volume providers in their area.

    For a list of hospitals and ambulatory surgery centers where NYS Medicaid will not pay for breast cancer surgery, providers can refer to the NYS DOH "Hospitals & Ambulatory Surgery Centers Where Medicaid Will Not Pay for Breast Cancer Surgery" web page. Providers can refer to the NYS DOH "Hospitals & Ambulatory Surgery Centers Where Medicaid Will Pay for Breast Cancer Surgery" web page, for the list of facilities approved to provide breast cancer surgery.

    Questions

    All questions should be directed to NYS DOH at hcre@health.ny.gov.

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    Attention Pharmacy Providers: Mifepristone (Mifeprex®) Available to Certified Pharmacies

    The mifepristone (Mifeprex®) Risk Evaluation and Mitigation Strategy (REMS) program was modified by the United States (U.S.) Food and Drug Administration (FDA) in January 2023, and now, certified pharmacies may dispense mifepristone when the prescriber, patient, and pharmacy comply with the Mifepristone REMS program. Mifepristone may be billed by New York State (NYS) Medicaid enrolled pharmacy providers that are certified to dispense mifepristone. Additional information regarding the REMS program, the process to be certified, and the dispensing of mifepristone may be found on the U.S. FDA "Information about Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation" web page.

    In addition to general billing rules applicable to all pharmacy claims, the following rules apply when submitting a pharmacy claim for mifepristone:

    • the pharmacy must be certified* to dispense mifepristone;
    • the pharmacy may only dispense when the prescription is written by a practitioner certified to prescribe mifepristone;
    • the pharmacy must be able to ship mifepristone in a timely manner using a shipping service that provides tracking information;
    • the pharmacy submits a claim for only one course of therapy with no refills; and
    • the drug item is dispensed according to:
      • U.S. FDA guidelines;
      • New York State (NYS) laws, rules, and regulations; and
      • Medicaid Policy.

    *To certify, a pharmacy must have submitted to the manufacturer a completed Pharmacy Agreement form relevant to the product dispensed, either the brand Mifeprex® or the generic mifepristone.

    Questions

    • Questions regarding billing should be directed to the eMedNY Call Center at (800) 343-9000.
    • Questions regarding this policy should be directed to the Medicaid Pharmacy Policy Unit at NYRx@health.ny.gov.

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    Diabetes Self-Management Training Pharmacy Billing

    This article is to notify New York State (NYS) Medicaid fee-for-service (FFS) providers and Medicaid Managed Care (MMC) Plans that NYS Medicaid program will reimburse for diabetes self-management training (DSMT) services provided by a pharmacist, as described in the Expanded Coverage for Diabetes Self-Management Training article published in the January 2023 issue of the Medicaid Update.

    FFS Coverage Policy

    DSMT services are reimbursable when provided by a pharmacy that has been accredited or recognized by a Centers for Medicare and Medicaid Services (CMS)-approved National Accreditation Organization (NAO). The NYS Medicaid program will reimburse pharmacies for DSMT services provided by an affiliated pharmacist operating under the accreditation/recognition of the pharmacy.

    FFS Billing Guidance for Pharmacies

    DSMT claims must include a valid International Classification of Diseases (ICD)-10 code for diabetes mellitus. DSMT services are billed in single-unit increments with one unit equaling 30 minutes of service. DSMT claims should be submitted using the appropriate Current Procedural Terminology (CPT) code from the table below.

    CPT Code CPT Code Description
    G0108 Diabetes outpatient self-management training services, individual, per 30 minutes.
    G0109 Diabetes outpatient self-management training services, group sessions (two to eight patients), per 30 minutes.

    If billing DSMT for a Medicaid FFS-only NYRx member, the claim should be billed in the National Council for Prescription Drug Programs (NCPDP) D.0 claim format. If billing DSMT for a dually eligible (Medicare/Medicaid) member, Medicare should be billed first via the medical claim format using either the 837 Professional or Centers for Medicare and Medicaid Services (CMS) 1500 claim format. A pharmacist providing DSMT to a NYRx member should enter the values in the corresponding NCPDP D.0 fields as described below.

    NCPDP D.0 Claim Segment Field Value
    436-E1 (Product/Service ID Qualifier) Enter the value of CPT code "07", which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code.
    407-D7 (Product/Service ID) Enter the applicable CPT code from the table above.
    442-E7 (Quantity Dispensed) Enter the value "1".
    405-D5 (Days supply) Enter the value "1".
    444-E9 (Pharmacist ID) Enter the pharmacist National Provider Identifier (NPI) number
    411-DB (Prescriber ID) Leave field blank.
    454-EK (Scheduled Prescription ID Number) Enter serial number "99999999".
    419-DJ (Prescription Origin Code) Enter origin code "5".

    The NCPDP D.0 Companion Guide can be found on the eMedNY "5010/D.0 Transaction Instructions" web page.

    MMC

    MMC Coverage Policy
    The "FFS Coverage Policy" section referenced above also applies to all types of MMC Plans. The April 1, 2023 pharmacy benefit transition only applies to the NYS Medicaid pharmacy benefits. MMC Plans will continue to be responsible for providing reimbursement for other medical benefits, such as DSMT.

    MMC Reimbursement
    The "FFS Billing Guidance for Pharmacies" section referenced above is specific to NYS Medicaid FFS. For NYS Medicaid members enrolled in an MMC Plan, providers should check with the MMC Plan of the enrollee for implementation details, reimbursement fees, and billing instructions. Additionally, MMC Plans will reimburse providers no less than the NYS Medicaid FFS rate for DSMT services and must cover the cost of DSMT services when rendered by qualified providers who do not participate in the network of the MMC Plan.

    Questions and Additional Information:

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    Risdiplam (Evrysdi®): Medicaid Prior Authorization Drugs Update

    On December 15, 2022, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended changes to the NYRx, the Medicaid pharmacy program. James McDonald, M.D., M.P.H., Commissioner of the NYS Department of Health (DOH), has approved the DUR Board recommendations resulting in changes to the NYRx coverage criteria for the following drugs.

    Effective April 27, 2023, prescribers must ensure patients do not have an advanced disease (e.g., complete limb paralysis or permanent ventilator dependence) before prescribing risdiplam (Evrysdi®).

    Prior Authorization

    For a full and up-to-date listing of drugs subject to the NYRx Pharmacy Programs and information on NYRx prior authorization (PA) programs, prescribers should refer to the NYRx, the Medicaid Pharmacy Program Preferred Drug List.

    To obtain a PA, prescribers must contact the eMedNY clinical call center at (877) 309-9493. The eMedNY clinical call center is available 24 hours per day, seven days per week, with pharmacy technicians and pharmacists who will work with prescribers and/or prescriber agents, to quickly obtain a PA. NYS Medicaid-enrolled prescribers can also initiate PA requests using PAXpress®. PAXpress® is a web-based pharmacy PA request/response application, accessible through the "PAXpress" button, located on eMedNY homepage, under the "eMedNY Tools Center" drop-down button.

    Additional Information:

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    Nusinersen (Spinraza®): Medicaid Practitioner Administered Drugs Update

    On December 15, 2022, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy prior authorization (PA) programs and coverage criteria for practitioner administered drugs (PADs). James McDonald, M.D., M.P.H., Commissioner of the NYS Department of Health (DOH), has approved the DUR Board recommendations resulting in changes in NYS Medicaid coverage criteria for PADs.

    Effective April 27, 2023, providers must ensure patients do not have an advanced disease (e.g., complete limb paralysis or permanent ventilator dependence) before providing nusinersen (Spinraza®), via the medical benefit. Please note: PAD Clinical Criteria Worksheets are available on the NYS DOH "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

    Fee-for-Service (FFS) Billing

    Drugs listed in the Physician Manual Fee Schedule, with a notation of BR (By Report) under the "Maximum Fee" column, must be submitted on the Health Care Finance Administration (HCFA) 1500 claim form (via paper) with a copy of the itemized invoice as documentation. Additional information can be found in the New York State Medicaid Program Physician Policy Guidelines document.

    Questions and Additional Information:

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    Update to Medicaid Fee-for-Service Practitioner Administered Drug Policy and Billing Guidance

    As previously announced in the Updates to Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance article published in the November 2022 issue of the Medicaid Update, criteria for administering infliximab, and vedolizumab were effective December 29, 2022. The updated coverage criteria for vedolizumab and infliximab is as follows.

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

    A trial of a conventional agent, 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, in accordance with FDA package labeling or compendia-supported use.

    Vedolizumab (Entyvio®)

    A trial of a conventional agent, DMARD or TNFi, prior to initiation of vedolizumab in accordance with FDA package labeling or compendia-supported use.

    Fee-for-Service Billing

    Drugs listed in the Physician Manual Fee Schedule, with a notation of "BR" (By Report) under the "Maximum Fee" column, must be submitted on a paper Health Care Financing Administration (HCFA) 1500 claim form with a copy of the itemized invoice as documentation. Additional information can be found in the New York State Medicaid Program - Physician Policy Guidelines.

    Questions and Additional Information:

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    Applied Behavior Analysis Services Update

    Effective April 1, 2023, the New York State (NYS) Medicaid fee-for-service (FFS) program has added the following Current Procedural Terminology (CPT) codes to the Applied Behavior Analysis (ABA) Fee Schedule:

    CPT Code CPT Code Description
    97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
    97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.

    The ABA Fee Schedule can be found on the eMedNY "Applied Behavior Analysis (ABA)" web page. The New York State Medicaid Fee-For-Service Program – Licensed Behavior Analysts & Certified Behavior Analyst Assistants Policy Manual for Providing Applied Behavior Analysis Services has been updated.

    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

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

    Amir Bassiri
    Medicaid Director
    Office of Health Insurance Programs