New York State Medicaid Update - May 2023 Volume 39 - Number 10

In this issue …

New York State Medicaid Program Ends Provisional Temporary Provider Enrollment

Pursuant to §1135(b)(1)(B) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) allowed states to temporarily waive and/or suspend some of the requirements for providers who wanted to temporarily enroll in Medicaid for the purpose of assisting with the Coronavirus Disease 2019 (COVID-19) public health emergency (PHE). The New York State (NYS) Department of Health (DOH) Bureau of Provider Enrollment acted by implementing a Provisional Temporary Provider Enrollment (PTPE) process that allowed certain provider types to rapidly enroll on a temporary basis during the PHE.

With the expiration of the federal PHE on May 11, 2023, the PTPE process also officially ended, and the online PTPE portal closed as of May 11, 2023. Since inception of the PTPE process, the eMedNY COVID FAQs page, has stated: "Within six months of the federal public health emergency being lifted, New York State will cease payments to providers who are temporarily enrolled unless a provider has submitted an application that meets all requirements for New York State Medicaid participation, and the application was reviewed and approved by the New York State Department of Health within six months of the federal public health emergency being lifted."

Providers who temporarily enrolled via the PTPE process must complete the full enrollment process by November 11, 2023, to continue participation in the program. Temporarily enrolled providers will be terminated and their NYS Medicaid payments will cease if they do not complete the enrollment process by November 11, 2023. It can take up to 120 days to complete processing of an application; therefore, it is suggested that applications be submitted with enough time to ensure that they are processed by the November 11, 2023 deadline.

To complete an application for full enrollment, providers should visit the eMedNY "Provider Enrollment & Maintenance" web page. From there, providers can navigate to the enrollment pages for their provider type where they will find instructions and a list of documents that must be submitted as part of a complete application.

Questions

Questions regarding the temporary-to-full enrollment process should be directed to providerenrollment@health.ny.gov.

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New York State Reminds Members/Enrollees in Medicaid, Child Health Plus and the Essential Plan to Renew Their Health Insurance; Eligibility Redetermination Notices are Being Distributed to New Yorkers Enrolled in Public Insurance Programs; NY State of Health Marketplace Assisting Consumers to Renew and Maintain Open Enrollment to Help Ensure a Continuation of Coverage

With the passage of the federal Consolidated Appropriations Act, eligibility reviews that were paused during the federal Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE) are now resuming for over 9 million New Yorkers enrolled in Medicaid, Child Health Plus (CHPlus) and the Essential Plan (EP). The renewal process is currently underway, and members/enrollees will continue receiving renewal notices in advance of their coverage end dates with detailed instructions on how to stay covered and their deadline to take action. For more information regarding the COVID-19 PHE, providers should refer to the Administration for Strategic Preparedness and Response (ASPR) "Declarations of a Public Health Emergency" web page.

The New York State (NYS) Department of Health (DOH) has reviewed federal government guidance, developed plans to enhance systems, increased resources and added staff to prepare for this renewal process. Additionally, NYS DOH has collaborated with participating health insurance plans, health care providers, and thousands of certified enrollment staff across the state to help keep New Yorkers covered.

Throughout the next year, current members/enrollees will receive renewal notices based on their coverage end date. Members/enrollees with coverage end dates of June 30 have already received their renewal notices. Enrollees should follow the instructions on their renewal notices and take any needed actions ahead of the deadlines to renew their coverage.

New Yorkers whose public insurance eligibility was affected by a change in income or other family circumstances, will continue to have a broad range of free or low-cost health insurance options. New York's EP for low-income individuals will smooth the transition for New Yorkers who no longer qualify for Medicaid and enhanced federal tax credits, making coverage more affordable for individuals transitioning to a Qualified Health Plan (QHP). NY State of Health enrollment in a QHP will remain open through May 2024. For more information regarding enhanced federal tax credits, providers should refer to the NY State of Health "How NY State of Health Enrollees Benefit from the American Rescue Plan and the Inflation Reduction Act" web page.

New York thanks providers for their efforts and assistance in reaching all members/enrollees affected by this renewal process and encourage all providers, stakeholders, and advocates to access the NY State of Health Unwinding from the COVID-19 Public Health Emergency: A Communications Tool Kit to Keep New Yorkers Covered, to educate consumers and help them renew. New Yorkers who need more information should reach out to their LDSS office by visiting the NYS DOH "New York State Local Departments of Social Services (LDSS)" web page. Additional information can be found on the NY State of Health "Important Changes to New York Medicaid, Child Health Plus and the Essential Plan" web page, and the NYS DOH Medicaid website.

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Update to Clinic Billing for Denture Codes

Effective July 1, 2023, reimbursement of Current Dental Terminology (CDT) denture codes "D5110", "D5120", "D5211", "D5212", "D5213", "D5214", "D5225", and "D5226" will transition to reimburse via the Ambulatory Patient Group (APG) "Procedure-Based Weights file for services rendered in Article 28 Hospital Outpatient Departments (HOPDs), free-standing Diagnostic and Treatment Centers (D&TCs), and Federally Qualified Health Centers (FQHCs) that opted into APG reimbursement. This update is being made to create payment parity among clinic providers for the delivery of denture services rendered to New York State (NYS) Medicaid members with either commercial insurance coverage as primary, or for members with only straight NYS Medicaid fee-for-service (FFS) coverage. This update will allow the clinic to utilize the units field on the claim line to seek reimbursement from NYS Medicaid FFS for the number of visits the member was seen before they were allowed to bill the primary commercial insurer.

To ensure proper NYS Medicaid payment for NYS Medicaid members with third-party commercial insurance, the clinic should utilize the "units" field on the claim line to indicate the number of visits required to reach the decisive appointment set forth by the primary/commercial insurer of the NYS Medicaid member before they were able to bill for services. For example, if the clinic was not able to bill the primary insurer for a denture until the fourth visit of the NYS Medicaid member, the clinic (when submitting their claim to NYS Medicaid) would indicate the payment received from the primary/commercial insurer by inserting a "4" in the "units" field on the claim line for one of the CDT codes referenced above. The line-level payment is multiplied by the number of units submitted on the line, which reflects the number of visits needed to reach the primary payer's decisive appointment. The number of units required to complete billing for dentures reimbursement should not exceed five.

When the NYS Medicaid member has NYS Medicaid FFS without third-party commercial insurance, the clinic may seek reimbursement for every visit in which the NYS Medicaid member crosses the threshold by indicating a "1" in the "units" field. The number of units required to complete billing for dentures reimbursement should not exceed five. Providers should refer to the NYS DOH APG-Based Weights History File, located on the NYS Department of Health (DOH) "APG and Px-Based Weights History and APG Fee Schedules" web page.

Questions and Additional Information:

  • FFS claims reimbursement and/or provider enrollment questions should be directed to the Computer Sciences Corporation (CSC or CSRA) at (800) 343-9000.
  • FFS dental 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 dentalpolicy@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.

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Update to New York State Medicaid Fee-for-Service Pharmacy Billing Instructions for Coordination of Benefits Submission

NYRx, the New York State (NYS) Medicaid Pharmacy program, needs to ensure accurate Coordination of Benefits (COB) submissions are recognized and other patient responsibility amounts are accepted. This is an update to previous guidance issued in the Update on Medicaid Fee-for-Service (FFS) Pharmacy Billing Instructions for Coordination of Benefits (COB) Submission article published in the July 2017 issue of the Medicaid Update.

Federal regulations require that all other available resources be used before Medicaid considers payment. If there is a responsible third-party that should be paying for the patients' health benefits, such as a health insurance provider, the responsible third-party should pay first. NYS Medicaid pays the lesser of Patient Responsibility (PR) or the NYS Medicaid fee, regardless of the PR amount. For pharmacies, this rule applies to all PR amounts, which includes deductible, co-insurance, copay, and other patient responsibility.

The following list of values reported in field 308-C8 (Other Coverage Code) are considered acceptable. This field is used by the pharmacy to indicate whether the patient has other insurance coverage. Valid entries for field 308-C8 are:

  • 0 = Not Specified
  • 1 = No Other Coverage Identified
  • 2 = Other Coverage Exists, Payment Collected
  • 3 = Other Coverage Exists, This Claim Not Covered
  • 4 = Other Coverage Exists, Payment Not Collected

The following updates will be made to the specified values submitted in field 308-C8 when the Other Coverage Code of "4" is submitted:

  • If value code of "4" is submitted in field 308-C8 for situations where the prior payer did not make a payment, the system will enforce that the following conditions are met:
    • National Council for Prescription Drug Programs (NCPDP) field 431-DV (Other Payer Amount Paid) is equal to zero; and
    • NCPDP fields 351-NP (Other Payer-Patient Responsibility Amount Qualifier) and 353-NR (Other Payer-Patient Responsibility Amount Count) are present from the primary payer; and
    • 352-NQ segment (Other Payer-Patient Responsibility Amount) is included from the primary payer.

If any of the above conditions are not met, the system will deny the claim and return response code "193": OTHER PAYER PAT RESPO VALUE NOT SUPPORTED.

As a reminder, the following is a list of values in field 351-NP (Other Payer Patient Responsibility Amount Qualifier) when the Other Coverage Code of "4" is submitted. These values are considered as acceptable for payment when qualifying PR amounts are reported in field 352-NQ (Other Payer Patient Responsibility Amount) for claims involving third-party liability (TPL) other insurance. All payments paid by any/all third parties, including Medicare, should be included on the claim. Qualifier values Accepted- Field 351-NP:

  • Blank = Not Specified
  • 01 = Deductible
  • 04 = Amount reported from previous payer as Exceeding Periodic Benefit Maximum
  • 05 = Copay Amount
  • 06 = Patient Pay Amount
  • 07 = Coinsurance Amount
  • 09 = Health Plan Assistance Amount
  • 12 = Coverage Gap Amount

Questions and Additional Information:

  • NYS Medicaid fee-for-service (FFS) claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid FFS Pharmacy 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.

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Base Rate Fees for Emergency Ambulance Trips

Effective for dates of service on or after July 1, 2023, recognizing the higher costs associated with providing emergency ambulance trips, as well as advances in pre-hospital emergency medical care, New York State (NYS) Medicaid base rate fees (shown in the table below) will be automatically applied to emergency ambulance trips completed by NYS Medicaid-enrolled providers. Providers will not need to change the way they bill to receive these updated fees.

Procedure Code Description Fee
A0429 Basic Life Support, emergency (BLS- Emergency) $250.00
A0427 Advanced Life Support, emergency, Level 1 (ALS1- Emergency) $296.00
A0433 Advanced Life Support, Level 2 (ALS2) $429.00
A0434 Specialty Care Transport (SCT) $507.00

Please note:

  • There will be no changes to the base rate fees for non-emergency ambulance trips.
  • There will be no changes to ambulance loaded mileage fees ("A0425").
  • If the county of fiscal responsibility for a NYS Medicaid member currently pays a value greater than those shown in the table, there will be no reduction in payments.

Questions

NYS Medicaid Transportation questions should be directed to medtrans@health.ny.gov.

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Updated Billing Guidance for Vagus Nerve Stimulators

Effective July 1, 2023, for New York State (NYS) Medicaid fee-for service (FFS), vagus nerve stimulator (VNS) devices will be carved out of Ambulatory Patient Group (APG) rate codes. Reimbursement for the device will remain limited to the following Food and Drug Administration (FDA)-approved indications:

  • use VNS devices as an adjunctive therapy in reducing the frequency of seizures in patients four years of age and older with partial onset seizures that are refractory to antiepileptic medications;
  • use VNS devices for treatment-resistant depression in adults that have not shown improvement after trying four or more medicines or electroconvulsive therapy (ECT), or both; and
  • use VNS devices for stroke therapy in conjunction with rehabilitation to recover function in hands and arms after an ischemic stroke.

FFS Billing

Claims for VNS devices must be billed using Current Procedural Terminology (CPT) code "64999" (unlisted procedure, nervous system), and must be submitted, on paper, to eMedNY with the following documentation:

  • copy of the operative report showing implantation of the device; and
  • copy of the invoice showing the acquisition cost to the facility, less any manufacturer rebates.

Please note: Physicians will continue to submit a professional claim for their services using the appropriate CPT codes for the insertion, revision, or removal of the device and/or leads.

Questions and Additional Information:

  • 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.
  • NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • Medicaid Managed Care (MMC) general coverage questions may be directed to OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by telephone at (518) 473-1134.
  • MMC reimbursement and/or billing requirements questions should be directed to the MMC Plan of the enrollee. Providers can refer to the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

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Pharmacy Program Integrity Spotlight

The Pharmacy Program Integrity Spotlight is a regular monthly series intended to reinforce pharmacy program requirements and share program integrity information with providers.

Pharmacist Supervision Requirements for In-State New York State Medicaid-Enrolled Pharmacies

Operating a pharmacy without a pharmacist present and/or without an enrolled supervising pharmacist is considered an unacceptable practice under the Medical Assistance program. Pharmacies, pharmacy owners, and/or supervising pharmacists operating a pharmacy without the required pharmacist's supervision may be terminated from the New York State (NYS) Medicaid program and/or sanctioned pursuant to 18 New York Codes, Rules and Regulations (NYCRR) §515.2 and 18 NYCRR §515.3.

NYS Medicaid-enrolled pharmacies are required to have a supervising pharmacist currently licensed and registered with the New York State Education Department (NYSED), Board of Pharmacy. The supervising pharmacist must be enrolled in NYS Medicaid. For additional information, providers should refer to the NYRx, The NY Medicaid Pharmacy Program Pharmacy Manual - Policy Guidelines.

As a NYS Medicaid provider, the supervising pharmacist is responsible for fulfilling the duties outlined in the "Duties of the Provider" section of the New York State Medicaid Program: Information for All Providers - General Policy document. This includes adherence to all federal and NYS laws, rules and regulations, and policies that govern the NYS Medicaid program, including NYS pharmacy law. Responsibility for conformance with all laws and regulations applicable to the conduct of a pharmacy is placed upon the ownership of the pharmacy and upon a licensed pharmacist who is designated by the owner as the supervising pharmacist (i.e., pharmacist in charge)*. A supervising pharmacist must adhere to the following responsibilities:

  • The supervising pharmacist is responsible for the proper conduct of the pharmacy.
  • The supervising pharmacist oversees the practice of other employed pharmacists and ensures that those unlicensed persons do not engage in unlawful activity.
  • The supervising pharmacist must have an active role in the conduct of the pharmacy and not a passive role.
  • The supervising pharmacist may not assign their responsibility to others.
  • The supervising pharmacist must be aware of all laws and regulations and must instruct and direct others to ensure compliance.
  • The supervising pharmacist must work full-time (at least 30 hours per week). If the establishment is operating less than 30 hours per week, the supervising pharmacist must work the majority of the hours.
  • If the supervising pharmacist is to be absent from a pharmacy at any time, the supervising pharmacist must ensure another qualified pharmacist is present in their absence.
  • The supervising pharmacist cannot supervise more than one pharmacy establishment at a time.
  • The supervising pharmacist will notify NYS Department of Health (DOH) Bureau of Enrollment of any change in their supervising pharmacist status.

*Per the NYSED "Supervising Pharmacist" web page.

Additional Information:

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Update to Pharmacy Dispensing Non-Patient Specific Orders

Effective June 22, 2023, NYRx, the New York State (NYS) Medicaid Pharmacy program, will now require the National Provider Identifier (NPI) of the dispensing pharmacy be submitted in the prescriber field. This guidance supersedes the Reminder: Pharmacy Dispensing Non-Patient Specific Orders article published in the January 2022 issue of the Medicaid Update, advising to leave the prescriber field blank for certain non-patient specific orders. NYS law and regulation allow some drugs (i.e., emergency contraception) to be dispensed to a patient without a patient-specific prescription or fiscal order from their practitioner. This change does not apply to standing orders where practitioners authorize the dispensing or administration of select therapies (i.e., naloxone and vaccines). Providers can refer below for details for non-patient specific orders.

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

  • a NYS Medicaid fee-for-service (FFS) member or Medicaid Managed Care (MMC) enrollee specifically requests the item on the date of service;
  • a pharmacy submits one course of therapy with no refills; and
  • the drug item(s) are dispensed according to:
    • Food and Drug Administration (FDA) guidelines;
    • NYS laws, rules, and regulations; and

NYS Medicaid FFS Billing Instructions:

When billing NYS Medicaid FFS, providers should:

  1. enter a value of "5" in the Prescription Origin Code field 419-DJ to indicate pharmacy dispensing;
  2. enter a value of "99999999" in the Serial Number field 454-EK; and
  3. submit the prescriber identification field 411-DB with the dispensing pharmacy's NPI number.

Questions and Additional Information:

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Clarification Regarding Pharmacy and Practitioner Dispensing of Drugs Requiring Administration by a Practitioner

New York State (NYS) Medicaid recognizes that certain drugs require administration by a practitioner and may be billed to NYS Medicaid by either a practitioner or a pharmacy. Practitioner administered drugs (PADs) billed directly to NYRx, the NYS Medicaid Pharmacy program, by a pharmacy, are listed on the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page. The intent of this article is to provide guidance for proper dispensing and delivery of such drugs. Nothing in this policy is meant to suggest that any or all practitioner-administered drugs must be dispensed by a pharmacy.

PADs Billed by a Practitioner

PADs billed by a practitioner using medical claims format should refer to the policy and guidance regarding PAD billing located on the eMedNY "Physician Manual" web page. Additional information regarding PAD drug policies and billing guidance is located on the NYS Department of Health (DOH) "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

Medicaid Managed Care (MMC) Plans are required to make PADs available when billed as a medical or institutional claim (e.g., outpatient hospital, clinic, physician office). Reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee.

PADs Billed by a Pharmacy

"White bagging" occurs when the pharmacy delivers the medication directly to the site of administration. PADs are available in the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, and are billed using the National Council for Prescription Drug Programs (NCPDP) format. Additional information regarding PADs and billing guidance is located in the Pharmacy Dispensing Drugs that Require Practitioner Administration article published in the December 2022 issue of the Medicaid Update. This delivery modality is acceptable by NYRx, under the following guidelines:

  • prior to delivery of a PAD, the dispensing pharmacy must confirm the delivery address, that 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 surrounding refills can be found in the NYRx, the NY Medicaid Pharmacy Program: Pharmacy Manual - Policy Guidelines;
  • delivery charges may not be billed to the NYS Medicaid member or NYS Medicaid;
  • 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 confirmed receipt by the authorized agent;
  • the pharmacy is required to obtain documentation of delivery by the receipt of a signature of an authorized agent at the site of administration;
  • all NYS Medicaid claims for drugs that were not deliverable must be reversed within 60 days; and
  • once delivered and signed for, the site of administration is responsible for replacement of improperly stored, handled, lost, or stolen PADs.

"Brown bagging" is when drugs designated for self-administration or practitioner administration are dispensed directly to a patient by the pharmacy. Brown bagging PADs causes concern regarding proper storage or handling, which can affect the efficacy of the drug. Brown bagging is acceptable only when the drug is intended, prescribed, or labeled for self-administration. Prescribers should use their professional judgement to determine the best method for NYS Medicaid members to obtain PADs. It is the responsibility of the pharmacist to ensure white or brown bagged drugs are appropriately dispensed.

Providers must follow NYS Medicaid policy for delivery of medications, including proof of delivery documentation. Information regarding delivery requirements may be found in the NYRx, the NY Medicaid Pharmacy Program: Pharmacy Manual - Policy Guidelines. This policy refers to any drug being dispensed by a pharmacy for practitioner-administration, including those billed as a secondary payment.

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.

MMC:

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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